HospitalInspections.org

Based on document review and interview the facility failed to ensure a patient received care in a safe setting related to
a transfer in one instance. (Patient # 5).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview the facility failed to ensure a patient received care in a safe setting related to a transfer in one instance. (Patient # 5).

Findings include:

1. Review of policy Patient Rights and Responsibilities, Policy Stat ID 13517670, indicated on page 1, under PROCEDURE, 1. Receive respectful care; on page 3, 18. Receive safe care. Last approved 4/2023.

2. Review of policy Advanced Directives in Hospital, Policy Stat ID 13517664, indicated on page 1, under PROCEDURE, 11. If the patient is transferred to another organization, the existence of any Advance Directives for care is communicated to the receiving organization. Last approved 4/2023.

3. Review of policy Patient Care Management, Policy Stat ID 12197166, indicated on page 4, under Safety, Standard of Care I: Pertinent patient medical information is communicated to ensure safe delivery of care. Last approved 8/2022.

4. Review of MR for patient # 5, reflected the following:
a. Patient # 5, an 84 year old; admitted on 6/1/2025 for Psychosis with paranoid behaviors.
b. DNR (Do not resuscitate) documentation noted. Dated 10/18/2023.
c. Admission orders on 6/1/2025 at 11:20 pm reflected Code Status: DNR.
d. H&P (History & Physical) on 6/2/2025, by NP # 51 (Nurse Practitioner - Medical) reflected Code Status: Do not Resuscitate.
e. Provider order on 6/6/2025 at 7:31 am, by NP # 50 (Nurse Practitioner - Medical) - send patient to the hospital - indication: Hypoxia & Failure to thrive.
f. Nurse note on 6/6/2025 at 9:00 am, by N # 1 (Licensed Practical Nurse) reflected patient's vitals were BP (Blood pressure) = 101/61, Pulse = 35, Respirations = 26, Temperature = 96.7 F (Fahrenheit) and O2 (oxygen) saturation = 62%. NP # 50 ordered the nurse to send the patient out to AH # 60 (Acute Care Hospital) via 911 (Emergency Medical Services). Paramedics transported patient to AH # 60.
g. MR lacked documentation by N # 1 for the following
1. For any return call from AH # 60's ER provider for information requested.
2. That the wrong patient medical record information (patient # 11 - was a full code) was sent with EMS for patient # 5 to AH # 60's ER/ED, and that N # 1 then faxed over to AH # 60's ER/ED the correct patient medical record information for patient # 5, after the call with the ER provider.

5. Review of MR for patient # 5 from AH # 60 (Acute Care Hospital) reflected the following:
a. ER/ED (Emergency Room/Emergency Department) provider note on 6/6/2025 reflected that patient # 5 who presents with altered mental status. Here on arrival, he/she is on a nonrebreather from EMS (Emergency Medical Services); tachypnea, using accessory muscles, not responsive to verbal stimuli or ED nurses placing IV (Intravenous) lines. He/she does have slight gag but is not making any purposeful movements. Per EMS, patient is a full code. Per review of paperwork from sending facility, patient is also full code. No family or emergency contact listed in paperwork and when ER/ED provider called the sending facility (APH # 40 - Acute Psychiatric Hospital); was placed on extensive hold. At this time, patient is in respiratory distress, unable to protect his/her airway, he/she was intubated for airway protection. Later told by ED staff that the paperwork that was sent was incorrect and they are now putting information in the computer for the correct patient. APH # 40 able to send in paperwork and he/she is a DNR. Will discuss case with family.
b. ED course: note at 8:25 am, after patient intubated, ED clerk informed ER/ED provider that she/he talked to sending facility and they said they had given the wrong paperwork with wrong name. Says they are sending over patient's correct information now.

6. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (Licensed Practical Nurse), confirmed the following:
a. Might have forgot to send copy of transfer form.
b. Received call from AH #60 ER nurse; realized had sent wrong paperwork for patient.

Based on document review and interview, the facility failed to ensure the patient care units were adequately staffed to provide nursing care to all patients as needed on two patient care units. (100 unit & 200 unit).

Findings include:

1. The facility policy titled: Clinical Staff (Nurse) Staffing Plan, policy number: none listed, indicated on page one (1) - Section - Purpose - This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multidisciplinary patient care that is consistent with the assessed needs of the population served. Last revised 09/2024.

2. The facility Staffing Grid by shift, indicated nurses work a twelve (12) hour shift and BHA's (Behavioral Health Associate) work eight (8) hour shifts. For Day shift - for Nurses - 7:00 am to 7:00 pm & BHA's - 7:00 am to 3:30 pm. For Evening shift - BHA's - 3:00 pm to 11:30 pm; for Night shift for Nurses - 7:00 pm to 7:00 am.
Required staff for census-patients of 22 for Day shift = 2 Nurses & 3 BHA's; Night shift = 2 Nurses & 1 BHA.
Required staff for census-patients of 23 for Day shift = 2 Nurses & 4 BHA's; Evening shift = 2 Nurses & 4 BHA's; Night shift = 2 Nurses & 1 BHA.
Required staff for census-patients of 24 for Day shift = 2 Nurses & 4 BHA's; Night shift = 2 Nurses & 1 BHA.
Required staff for census-patients of 25 for Day shift = 2 Nurses & 4 BHA's; Evening shift = 2 Nurses & 4 BHA's; Night shift = 2 Nurses & 2 BHA's.

3. Review of staffing data worksheet for 100 unit & 200 unit, for weeks of 6/1/2025 - 6/7/2025 & 6/8/2025 - 6/14/2025, indicated the following:
a. 100 unit - total 15 shifts were noted as short:
1. Day shift: 6/2/2025: Census = 22 patients; Staff = 1 Nurse & 2 BHA's. Short 1 Nurse.
2. Day shift: 6/3/2025: Census = 24 patients; Staff = 1 Nurse & 4 BHA's. Short 1 Nurse. Night shift: Census = 24 patients; Staff = 2 Nurses and 0 BHA's. Short 1 BHA.
3. Day shift: 6/6/2025: Census = 23 patients; Staff = 1 Nurse (a LPN {Licensed Practical Nurse}) & 4 BHA's. Short 1 Nurse. Night shift: Census = 23 patients; Staff = 1 Nurse & 1 BHA. Short 1 Nurse.
4. Evening shift: 6/7/2025: Census = 23 patients; Staff = 2 Nurses & 3 BHA's. Short 1 BHA.
5. Evening shift: 23 patients; Staff = 2 Nurses & 3 BHA's. Short 1 BHA. Night shift: 6/8/2025: Census = 23 patients; Staff = 1 Nurse & 1 BHA. Short 1 Nurse.
6. Day shift: 6/9/2025: Census = 23 patients; Staff = 1 Nurse (a LPN) & 4 BHA's. Short 1 Nurse. Evening shift: Census = 23 patients; 1 Nurse & 3 BHA's. Short 1 Nurse & 1 BHA. Night shift: Census = 23 patients; Staff = 1 Nurse & 2 BHA's. Short 1 Nurse.
7. Evening shift: Census = 25 patients; Staff 2 Nurses & 3 BHA's. Short 1 BHA. Night shift: 6/11/2025: Census = 25 patients; Staff = 1 Nurse & 2 BHA's.
8. Evening shift: Census = 25 patients; Staff 2 Nurses & 3 BHA's. Short 1 BHA. Night shift: 6/13/2025: Census = 25 patients; Staff = 1 Nurse & 2 BHA's. Short 1 Nurse.
b. 200 unit - total 3 shifts were noted as short:
1. Night shift: 6/3/2025: Census = 21 patients; Staff = 1 Nurse & 1 BHA. Short 1 Nurse.
2. Night shift: 6/4/2025: Census = 21 patients; Staff = 1 Nurse & 2 BHA's. Short 1 Nurse.
3. Night shift: 6/13/2025: Census = 21 patients; Staff = 1 Nurse & 2 BHA's. Short 1 Nurse.

4. In interview on 7/1/2025 at approximately 2:10 pm, with A # 3 (Director Quality), confirmed/
verified staffing shortages for 100 unit and for 200 unit for weeks reviewed. Staffing grid not followed.

Based on document review and interview the hospital failed to provide nursing services supervised by a registered nurse for 2 of 28, unit 100, Nursing (12 hour shifts) shifts reviewed. (Day shift 6/6/2025 & Day shift 6/9/2025).

Findings include:

1. Review of policy Clinical Staff (Nurse) Staffing Plan, policy number: none listed, last revised 9/2024, indicated on page 4. under Staffing Plan, B., first point - There must be at least one (1) RN (Registered Nurse) on every unit at all times. C. The hospital utilizes twelve (12) hour shifts for nurses.

2. Review of APH # 40's (Acute Psychiatric Hospital) unit 100 Staffing Sheets, indicated the following:
a. Day shift on 6/6/2025 - 1 LPN (N # 1) and 4 BHA's. Lacked 1 RN on unit.
b. Day shift on 6/9/2025 - 1 LPN (N # 1) and 4 BHA's. Lacked 1 RN on unit.

3. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (LPN), confirmed the following:
a. That has worked 100 unit by herself/himself - the only nurse for the shift.
b. That this has occurred more than once; worked with no RN on unit.
c. It was a busy morning on 6/6/2025; I was the only nurse for 20 + patients.
d. Not enough help on unit.

4. In interview on 7/1/2025 at approximately 2:10 pm, with A # 3 (Director of Quality), confirmed the following:
a. That the 100 unit was short staffed on 6/6/2025 & 6/9/2025.
b. That there was only one (1) nurse a LPN - on day shift for 6/6/2025 & 6/9/2025, with no RN staffed on unit.

Based on document review and interview, the nursing services failed to complete a transfer/transport report form per policy/procedure for 1 of 10 MRs (Medical Records) reviewed. (Patient # 5).

Findings include:

1. Review of policy Transfer of Patient, Policy Stat ID 10623375, indicated on page 1, under PURPOSE, guidelines to follow to help assure continuity of care and communication of vital patient information. Definition: Transport: when a patient is sent to either another health care institution for medical services. Appropriate patient information will accompany the patient during transfer/transport. Last reviewed 6/2023.

2. Review of MR for patient # 5, reflected the following:
a. Patient # 5, an 84 year old; admitted on 6/1/2025 for Psychosis with paranoid behaviors.
b. Provider order on 6/6/2025 at 7:31 am, by NP # 50 (Nurse Practitioner - Medical) - send patient to the hospital - indication: Hypoxia & Failure to thrive.
c. MR lacked documentation by N # 1 for the following:
- The completion of a Patient Transfer/Transport Report form for patient # 5's send out to AH # 60's (Acute Care Hospital) ER/ED (Emergency Room/Emergency Department) on 6/6/2025 am (morning).

3. Review of Transfer log binder on 100 unit for June 2025, lacked an entry by N # 1 for patient #5's transfer/transport to AH # 60 on 6/6/2025 am (morning).

4. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (Licensed Practical Nurse), confirmed that N # 1 might have forgot to send copy of transfer/transport report form.

Based on document review and interview, nursing services failed to complete and submit an incident report per policy/procedure, for a patient send out to Acute Care Hospital via EMS (Emergency Medical Services) for 1 of 10 MRs (Medical Records) reviewed. (Patient # 5).

Findings include:

1. Review of policy Incident Reports, Policy Stat ID 13033981, indicated on page 1, under PROCEDURE, A. hospital staff must complete and submit an incident report as soon as possible, but no later than twenty-four (24) hours from the time the event occurred, and on page 2. under Completing an Incident Report: A. This should be done by the employee who witnessed or was informed of the incident; under Responsibilities: Supporting documentation will by ready for review by the Risk Manager within 7 days of the incident. The Administrator On-call is to be notified as soon as possible after any incident. Last revised 1/2023.

2. Review of incident/event logs for June 2025, lacked an entry for the incident/event report for patient # 5's send out to AH # 60 (Acute Care Hospital) on 6/6/2025.

3. In interview on 6/30/2025 at approximately 4:05 pm, with A # 2 (LCSW {Licensed Clinical Social Worker} - Director of Clinical Services), confirmed that no incident report for patient # 5, for send out to ER at AH # 60 on 6/6/2025. There should have been one completed by nurse. Policy not followed.

4. In interview on 6/30/2025 at approximately 4:10 pm, with N # 1 (Licensed Practical Nurse), confirmed the following:
a. Would - suppose to fill out incident report, but not done; forgot and exhausted; was short staffed, and forgot then next day to complete one.
b. Thought texted A # 5 (Chief Executive Officer), but must have not.