HospitalInspections.org

Based on observation, document review, and interview, the Governing Body failed to:


1. ensure all patients and family had the ability to participate in the interdisciplinary care planning in 3 of 3 (#10, 2, and 4) charts reviewed.

2. ensure Nursing participated in the Treatment Plan team meetings, documented problems, interventions and goals, and ensured nursing maintained accurate records for the treatment team involvement in 3 of 3 (#10, 2, and 4) charts reviewed.

Cross Refer to Tag A0130


3. provide a safe environment and protect vulnerable suicidal patients from potential harm by utilizing safety measures such as a 1:1 monitoring or continuous line of sight observation in 3 of 3 (#4, 10, and 13) charts reviewed.

4. provide adequate staffing to ensure a safe, respectful, and comfortable environment allowing basic needs while monitoring patients in 3 of 3 (#4, 10, and 13) charts reviewed.

5. ensure physician orders were obtained when restricting patient rights in 1 (4) of 3 (#4, 10, and 13) patient charts reviewed.

6. ensure physician progress notes were written concerning changes in observation levels, legal status, and safety of patients in 3 of 3 (#4, 10, and 13) charts reviewed.

7. ensure staff completed appropriate training to maintain patient and staff safety during altercations, behavioral outbursts, and use of restraints in 7 of 7 (7, 8,19, 20, 28, 32, and 47) employee files reviewed.


Cross Refer to Tag A0144



8. ensure there was documentation in the physician orders/progress notes concerning Chemical Restraint/Emergency Behavioral Medications on why the order was necessary, what other less intrusive forms of treatment, if any, that the psychiatrist has evaluated but rejected, and the reasons those treatments were rejected in 3 of 3 (#4, #5, and #10) patient charts reviewed.

9. staff documented less restrictive interventions attempted prior to administering chemical restraints, document patient assessments for safety and effectiveness, performed a face to face assessment, document staff involvement, and document in the patients Medication Administration Record (MAR) or nursing notes that the chemical restraints were administered in 3 of 3 (#4, #5, and #10) patient charts reviewed.

10. nursing administered chemical restraints as ordered by the physician and failed to ensure nursing staff administered NOW orders for chemical restraints in a timely manner. Nursing administered chemical restraints an hour or more later or not at all, for staff convenience in 3 out of 3 (#4, #5, and #10) charts reviewed.

11. monitor the use and effectiveness of chemical restraints in QAPI, and monitor treatment plans for chemical restraint usage, and patient education in 3 (#4, #5, and #10) of 3 charts reviewed.


Cross Refer to Tag A0160



12. have a qualified individual that was appointed by the governing body as the Infection Preventionist that was responsible for the infection prevention and control program.

Cross Refer to Tag A0748



13. maintain a clean and sanitary environment to prevent the transmission of infectious and communicable disease in 5 (Units #200, #300, #400, #600, and the kitchen) of 5 areas observed.

14. have an active and ongoing infection control program to prevent and control the transmission of infections.

15. follow facility policies on Infection Control Measures and transmission precautions, CDC guidelines for Coronavirus, Persons Under Investigation (PUI) for Covid-19

Cross Refer to Tag A0749




It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.




16. ensure safe staffing levels by providing adequate Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Mental Health Technicians (MHT's) to meet the needs of the patients in a safe manner in 5 (200, 300, 400, 500, and 600) of 5 patient care units.

17. provide each nursing unit with a basic staffing grid which considers the unique needs of the patients' services, acuity levels, and admission and discharge fluctuations for 5 (200,300,400,500, and 600) of 5 patient care units.

18. ensure the Director of Nurses (DON) appropriately monitored the staffing schedule and made staffing adjustments to patient and staff needs on 5 (200, 300, 400, 500, and 600) of 5 patient care units.

19. ensure that nursing staff advisory committee meetings were being conducted to discuss staffing needs and unsafe staffing practices.

20. provide safe staffing levels and protect vulnerable suicidal patients from potential harm by utilizing safety measures such as a 1:1 monitoring or continuous line of sight observation in 2 (#4 and 13) of 2 charts reviewed.

Refer to Tag A0392

Based on review and interview the facility failed to:

A. ensure all patients and family had the ability to participate in the interdisciplinary care planning in 3 of 3 (#10, 2, and 4) charts reviewed.

B. ensure Nursing participated in the Treatment Plan team meetings, documented problems, interventions and goals, and ensured nursing accurately documented the treatment team involvement in 3 of 3 (#10, 2, and 4) charts reviewed.

Refer to Tag A0130


C. provide a safe environment and protect vulnerable suicidal patients from potential harm by utilizing safety measures such as a 1:1 monitoring or continuous line of sight observation in 3 of 3 (#4, 10, and 13) charts reviewed.

D. provide adequate staffing to ensure a safe, respectful, and comfortable environment allowing basic needs while monitoring patients in 3 of 3 (#4, 10, and 13) charts reviewed.

E. ensure physician orders were obtained when restricting patient rights in 1 (4) of 3 (#4, 10, and 13) patient charts reviewed.

F. ensure physician progress notes were written concerning changes in observation levels, legal status, and safety of patients in 3 of 3 (#4, 10, and 13) charts reviewed.

G. ensure staff had appropriate training to maintain patient and staff safety during altercations, behavioral outbursts, and use of restraints in 7 of 7 (7, 8, 19, 20, 28, 32, and 47) employee files reviewed.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Refer to Tag A0144


H. Indicate in the physician orders/progress notes concerning Chemical Restraint/Emergency Behavioral Medications on why the order was necessary, what other less intrusive forms of treatment, if any, that the psychiatrist has evaluated but rejected, and the reasons those treatments were rejected in 3 of 3 (#4, #5, and #10) patient charts reviewed.

I. Document less restrictive interventions attempted prior to administering chemical restraints, document patient assessments for safety and effectiveness, performed a face to face assessments, document staff involvement, and document in the patients Medication Administration Record (MAR) or nursing notes that the chemical restraints were administered in 3 of 3 (#4, #5, and #10) patient charts reviewed.

J. Administer chemical restraints as ordered by the physician and failed to administer NOW orders for chemical restraints in a timely manner. Nursing administered chemical restraints an hour or more later or not at all for staff convenience in 3 out of 3 (#4, #5, and #10) charts reviewed.

K. Educate staff, monitor the use and effectiveness of chemical restraints in QAPI, and monitor treatment plans for chemical restraint usage and patient education in 3 (#4, #5, and #10) of 3 charts reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Refer to Tag A0160

Based on review and interview, the facility failed to:

A. ensure safe staffing levels by providing adequate Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Mental Health Technicians (MHT's) to meet the needs of the patients in a safe manner in 5 of 5 (200, 300, 400, 500, and 600) patient care units.

B. provide each nursing unit with a basic staffing grid which considers the unique needs of the patients' services, acuity levels, and admission and discharge fluctuations for 5 of 5 (200, 300, 400, 500, and 600) patient care units.

C. ensure the Director of Nurses (DON) appropriately monitored the staffing schedule and made staffing adjustments to patient and staff needs 5 of 5 (200, 300, 400, 500, and 600) patient care units.

D. ensure that nursing staff advisory committee meetings were being conducted to discuss staffing needs and unsafe staffing practices.

E. provide safe staffing levels and protect vulnerable suicidal patients from potential harm by utilizing safety measures such as a 1:1 monitoring or continuous line of sight observation in 2 of 2 (#4 and 13) charts reviewed.

Refer to Tag A0392

Based on observation, document review, and interview, the facility failed to:

A. take measures to contain and/or prevent the transmission of a highly suspected contagious Coronavirus (COVID-19), and failed to follow CDC guidelines and their own policies to provide care to 1 of 1 (#5) patients under investigation.

B. have an active and ongoing infection control program to prevent and control the transmission of infections.

C. maintain a clean and sanitary environment to prevent the transmission of infectious and communicable disease in 5 (Units #200, #300, #400, #600, and kitchen) of 5 areas observed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Cross Refer to Tag A0749


D. have a qualified individual that was appointed by the governing body as the infection preventionist that was responsible for the infection prevention and control program.

Cross Refer to Tag A0748

Based on review and interview, the facility failed to:

A. ensure all patients and family had the ability to participate in the interdisciplinary care planning in 3 of 3 (#10, 2, and 4) charts reviewed.

B. ensure Nursing participated in the Treatment Plan team meetings, documented problems, interventions and goals, and ensured nursing documented accurately the treatment team involvement in 3 of 3 (#10, 2, and 4) charts reviewed.


Review of Patient #10's chart revealed, she was a 29 y/o female admitted to the facility on 2/25/20 as an involuntary patient. Patient #10 was brought into the facility by the police for suicidal ideation with a plan to shoot or cut herself.


Review of the Interdisciplinary Treatment Team Notes dated 2/26/20 at 1530 revealed that the patient did not participate with her treatment plan. There is no further information that the patient was allowed to participate in her care. Review of the plan revealed there was no documentation concerning the patients behavior requiring a line of sight and a 1:1 observation. There was no documentation addressing the patient's outbursts and multiple orders for chemical restraints.

There was no documentation that an effort to communicate with family members in the care planning process was performed.

Confidential interviews with staff were conducted from 4/14/20 - 4/16/20 with nursing staff concerning patient treatment team meetings. Staff stated they did not have enough staff to cover, so they could not attend the treatment team meetings. Nursing staff was asked by the Medical Director, DON, and Administrator to sign the treatment plan to show they were in the meetings and active in the process. Staff stated they were not told what happened in the meetings but were instructed to sign the document regardless.


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PATIENT #2

A review of Patient #2's medical record revealed, he was a 43-year-old male, voluntarily admitted to the facility on 3/10/2020, with a diagnosis of Major Depressive Disorder and Methamphetamine Use Disorder. He was placed on suicide precautions with Q 15-minute observations.

A review of the Interdisciplinary Treatment Plan dated 3/10/2020 revealed Patient #2 did not participate with his treatment plan. There is no further information that the patient was allowed to participate in his care. There was no diagnosis, patient strength, weaknesses, or patient stated goals documented on the plan. Further review revealed no discharge criteria or preliminary discharge plan was discussed with the patient or family.

There was no documentation that an effort to communicate with family members in the care planning process was performed.


Patient #2 did not sign the Interdisciplinary Treatment Plan nor was there any documentation of a refusal to sign. Nursing and the Psychiatric Provider failed to sign the Treatment plan. The Psychiatric Provider failed to document any short-term goals or interventions.




PATIENT #4

Patient #4 was a 35-year-old male admitted involuntarily on 3/31/2020 at 10:54 AM. Patient #4 was brought into the facility by the police for suicidal and homicidal ideation.

A review of the Interdisciplinary Treatment Plan dated 4/1/2020 at 7:00 AM revealed no safety precautions were documented. Patient stated goals, strengths, and weaknesses were left blank. The problem list, to include psychiatric and medical, was blank. Documentation by staff of patients refusal to sign and be involved was not dated, timed, or signed by staff member initiating the Treatment Plan. Further review revealed no documentation addressing the patients outbursts and need for seclusion and a chemical restraint.

Nursing did not participate in the treatment plan. A review of the Treatment Plan revealed nursing did not initiate any goals or interventions. Nursing failed to sign the Treatment Plan.

The facility failed to follow their own policy.



A review of the facility policy titled, "Treatment Plan Acute Inpatient, #1200.9" was as follows:

" ...POLICY

Each patient admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapist, recreational therapists and other health professions as indicated. Patients are involved in the treatment planning process and sign their treatment plans. The treatment planning process is continuous, beginning at the time of admission and continuing discharge.

PROCEDURE

Master Treatment Plan

1. Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. The Master Treatment Plan should be initiated within 8 hours and completed within 72 hours of the patients admission.

2. Short term objectives should also be reviewed and added to throughout the treatment course, if appropriate or indicated.

3. Interventions should be completed, and the name of the responsible person identified as well as the date of implementation of specific disciplines interventions ..."

Based on review and interview, the facility failed to:

A. provide a safe environment and protect vulnerable suicidal patients from potential harm by utilizing safety measures such as a 1:1 monitoring or continuous line of sight observation in 3 of 3 (#4, 10, and 13) charts reviewed.

B. provide adequate staffing to ensure a safe, respectful, and comfortable environment allowing basic needs while monitoring patients in 3 of 3 (#4, 10, and 13) charts reviewed.

C. ensure physician orders were obtained when restricting patient rights in 1 (4) of 3 (#4, 10, and 13) patient charts reviewed.

D. ensure physician progress notes were written concerning changes in observation levels, legal status, and safety of patients in 3 of 3 (#4, 10, and 13) charts reviewed.

E. ensure staff had appropriate training to maintain patient and staff safety during altercations, behavioral outbursts, and use of restraints in 7 of 7 (7, 8, 19, 20, 28, 32, and 47) employee files reviewed.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Findings:

PATIENT #4

Patient #4 was a 35-year-old male admitted involuntarily on 3/31/2020 at 10:54 AM with a diagnosis of bipolar disorder, current manic episode severe with psychotic features. Precautions on admission were Self Harm, Assault Precautions-Perpetrator, and Suicide Precautions with a Q (every) 15-minute Level of observations.

A review of the Intake Screening Assessment revealed, Patient #4 called the crisis hotline on 3/31/2020 and reported Suicidal Ideations (SI) and Homicidal Ideation (HI) with a plan. Patient was in possession of a knife and put it down when police responded. He was transported by the police department to the facility for further evaluation.

A review of the Nursing Progress Note dated 3/31/2020 at 2240 (10:40 PM) was as follows:

"Found by MHT to have his sheet rolled up and was tying it to his desk - told them he planned to asphyxiate himself. Linens removed from room." The staff signature was illegible. There was no physician order to restrict the patients' rights by removing his linens.

No further documentation was found where the incident was reported to the Psychiatrist/MD. Patient remained on a Q 15-minute observation. This placed the patient at very high risk of death by suicide. The staff failed to alert the physician for a 1:1 observation allowing the patient to have bed linen and sleep comfortably. Instead the staff removed his linen and forced him to sleep on a bare mattress, with no covers, and no 1:1 monitoring. There was no nursing documentation that addressed the patients reason for attempting a suicidal act or what was done to address the patient's needs.

A review of the MHT Patient Observations form revealed a note dated 4/1/2020 at 6:15 AM by Staff #28. The note was as follows:

"Pt was asleep most of the shift. Pt was compliant and had no issues. Pt took medication and went to bed. 0000 Pt tried to tie bed sheet over his head and around his neck pt had no attempt after that or issues and remained asleep. Incident was reported to nurse but no LOS (line of sight) or 1:1 was needed."

Review of the staffing schedule for 3/31/20 7:00 PM to 7:00 AM revealed there was only 1 RN and 1 MHT scheduled.

A review of the Psychiatric Progress Note dated 4/2/20 at 11:45 AM by Staff #15 was as follows:

" ...Pt A&O X 4 (alert and oriented X 4). Agitated, restless, punching wall at nursing window before visit, shouting-demanding meds change. Upon seeing pt bargaining he will quit smoking if I increase his Ativan. States anxiety is so bad "I tried strangling myself a couple nights ago. Did you know that!?!?" Pt redirected and calmed with visit with POC (plan of care) concordance achieved except Cluster B traits ..."

No further documentation was found where the incident was reported to the Psychiatrist/MD. However, Staff #3 did cosign behind Staff #15 because she is currently in the role of a Student PMHNP (Psychiatric Mental Health Nurse Practitioner.) Staff #15 is a FNP-C (Family Nurse Practitioner-Certified) but was not treating Patient #4 as a medical patient on this day. Staff #3 counter signed Staff #15's Psychiatric Progress Note, however it was timed 4 hours and 19 minutes before she clinically saw the patient. No further documentation was located within the medical record where Staff #15 reported the incident to the Psychiatrist/MD.

During an interview in the afternoon of 4/16/20 Staff #1, 2, 3, 5, and 7, were asked if they were aware Patient #4 attempted suicide in his room during his stay? All staff confirmed they were not aware.



32143


Patient #13

Review of Patient # 13's chart revealed he was admitted on 4/6/20 at 10:00 PM with suicidal ideation. A physician order for a 1:1 observation was found dated as an addendum to the admissions orders dated 4/6/20 at 2056. The physician signed the addendum on 4/7/20 at 2:38 AM. The Mental Health Technician (MHT) started the 1:1 documentation on 4/6/20 at 11:00 PM.

Review of the nursing schedule revealed there was only one MHT and one RN for the 600-unit. Patient #13 was on a 1:1 but there was no MHT assigned to the patient.

Review of the House Supervisor (H.S.) notes dated 4/6/20 stated that Patient #13 was on a 1:1 but there was no information found on who was called in for the 1:1. Review of the H.S. notes revealed, H.S. was assigned to the 400 unit as the only RN. There was no available H.S. to assist with the 1:1.

Review of Patient #13's 1:1 patient observation sheet revealed Staff #40 MHT documented on the sheet. There was no documentation of Staff #40 being called in or on the schedule for 4/6/20 7:00 PM to 7:00 AM shift. There was no documentation on who relieved Staff #40 for breaks.

A time card was pulled for Staff #40 on 4/6/20 and 4/7/20. The card revealed that Staff #40 worked on the 7:00 PM to 7:00 AM shift for 12 hours. There was no documentation of any breaks on the time card.

Review of the chart revealed Patient #13 was removed from the 1:1 observation and put on q 15-minute checks on 4/7/20 at 9:30 AM. A nurse's note was noted on 4/7/20 at 7:00 AM. The note stated, "Upon my arrival on the unit Pt was in the day room with the rest of the group. At the morning vitals patient is awake, A&O x 3, V/S are stable. Pt denies SI/HI/AVH presently. Dr. _____ (Staff#3) is aware. Pt is medication compliant. Pt is tolerating all meds well. Pt. Appetite is intact, Pt is programming with the group. Pt is in a pleasant mood. Pt is sleeping well. Pt is showing moderate depression and anxiety today. Patient is still withdrawn. Dr. _____ (Staff #3) is aware. Pt is showing no signs and symptoms of distress."

There was no further nursing documentation noted until 7:25 PM (10 hours later). The nurse failed to document the date and time the 1:1 ended, an assessment of the patient, and the patient's response.

Review of the physician's order revealed a physician order signed by Staff #3 was found to end the 1:1 on 4/7/20 at 9:22 am. There was no physician progress note found dated for 4/7/20. There was no physician documentation that discussed the 1:1 or the discontinuation of the 1:1. Review of the progress note for 4/8/20 revealed there was no mention of the 1:1 or the end of the 1:1.

Review of the policy and procedure "Levels of Observation" stated, "

One to One Observation: This is the only and sole assignment of one staff member who documents the location, behavior, and activities of the patient every 15 minutes. The staff member assigned is in constant visual range of the Patient (including bathing/toileting) and is within arm's length of the patient at all times, including bathing and hours of sleep unless otherwise specified in the physician order.

Procedure:

A. Physician responsibilities and documentation:

1. A physician's order is required for any increased level of observation; however, nursing staff may initiate a higher level of observation after assessing the patient until such time the physician may be reached. A Risk Assessment must be done at this time by a qualified clinical staff member.

a. Any patient on 1:1 or close observation will be evaluated daily. If the physician is not on-site, the RN will evaluate and communicate the results to the physician. An order should be obtained at that time to continue or discontinue the observation level. The RN will document the assessment, patient's response and justification in the patient's progress note.

b. The physician must document the justification and response in the progress note.

c. Decrease in the level of observation requires a verbal/written physician's order and assessment of the patient is documented in the medical record.

2. The physician is to be notified as soon as possible and an order written. The Risk Assessment score aids in identification of a high-risk patient, however the score is not the requirement that mandates the physician's order. The patient automatically goes on 15-minute checks. The physician will specify type of observation required during sleep hours (i.e.; 1:1, LOS, or 15-minute checks).


Review of the policy and procedure revealed,

"Levels of Observation" revealed under definitions,

"Fifteen-minute observation is required for all patients. Staff observes and documents location, behavior, and activities of the patient every 15 minutes. Close observation (Line of sight observation): The assigned staff maintains a full, unobstructed view of the patient at all times including bathing/toileting. The staff is within a proximity that allows them to implement immediate action if necessary. Staff observes and documents location, behavior, and activities of the patient every 15 minutes. Up to three patients may be observed by one staff during Close Observation status as long as the patients are in an area whereby the staff can monitor all patients on a continuous basis."


Confidential interviews with staff were conducted from 4/14/20-4/16/20 concerning 1:1, close observations, and staffing. Staff reported MHT's were given multiple close observation patients at a time and may be the only MHT on the unit. Staff Reported that they may have to assist with meals, patient care needs, disruptive patients, and general care while trying to observe more than one close observation. Staff reported that they have 1:1 patients and MHT's get called into the facility for the 1:1's but they can't take breaks because there is no one to relieve them for breaks. Multiple staff members reported the staffing is unsafe. Staff reported that there has been patient and staff injuries due to poor staffing. Staff reported that administration had called and requested to send staff home this am (4-14-20) but changed their minds when the state surveyors had entered the building. Nursing staff and MHT's stated they feel there was and still is a high possibility of patient or staff injury. Staff stated that many times the Administrator, Director of Nursing (DON) or Chief Financial Officer (CFO) would call down to the unit and tell the staff to discontinue 1:1's, and close observations. Staff reported they would have to call the physician for orders to discontinue care due to lack of staff or because the administrative staff insisted. Staff reported that sometimes orders are not written and the 1:1 or LOS is discontinued by the Administrator.


An interview was conducted on 4/15/20 in the afternoon with Staff #1 and #2 concerning the policy and procedure "Levels of Observation." Staff #1 was asked how 1 staff member could monitor up to three patients on a close observation and if that was a practice at the facility? Staff #1 stated, "yes. Our policy says they can have up to 3 patients." Staff #1 was asked what happened when one of those patients needed to go to the restroom or a patient became aggressive or acting out. Who would be monitoring the other two patients? Staff #1 reported there would be other staff available to watch the patients. Staff #1 stated, "There is plenty of staff and we are meeting every day to talk about patient acuity. The staff are just use to working with excess staff. They have to tell us why extra staff is needed and most of the time they can't." Staff #1 was unable to provide written proof or give an explanation on what staff was available and how the patients were to be monitored. Staff #1 was asked about the staff grid and how that was used. Staff #1 was unable to provide a staffing grid. Staff #1 stated, "you just need to get past numbers it's about the needs of the patient and acuity." Staff #1 was unable to provide any guidance on acuity levels.


Review of the policy and procedure " Hospital Plan for Provision of Nursing Care" stated, " Each nursing unit will have a basic staffing pattern which considers the unique needs of the patient services. This factor in the greater level of need on the part of patients' assigned to the units. Staffing pattern is the responsibility of the CNO/DON."


Staff #2 was asked by the surveyor how he was involved in staffing? Staff #2 reported that he attends the flash meetings daily concerning the patient's acuity, staffing, and general information for the day. Staff #2 was asked if he was making staffing decisions based on financial reasons instead of patient safety. Staff #2 stated, "No. I am never involved in sending people home. I am not involved in that part of patient care. I don't decide about patient acuity and staffing."


Review of emails provided by staff revealed Staff #2 sent out an email on 3/23/20 at 8:40 AM, "We need five techs to go home. We currently have 10 techs working. _____ (MHT) worked overnight but is still clocked in. Can you have him clock out."

3/24/20 at 8:40 AM. Staff #2 documented, "Do we still have the 1 on 1? We have 7 techs, 1 needs to go home. Are all the wings open? If not another tech needs to leave as well. Why is ___ and ___ working overtime they are still on the clock?"

3/24/20 at 8:56 AM Staff #7 responded, "Yes a new 1:1 as of this morning." The DON was included in the chain of emails but no indication that the DON made any staffing decisions. The staffing coordinator responded to the emails and followed direction from Staff #2.


Patient #10

Review of Patient #10's chart revealed she was a 29 y/o female, admitted to the facility on 2/25/20 as an involuntary patient. Patient #10 was brought into the facility by the police for suicidal ideation with a plan to shoot or cut herself.
Review of the Intake Screening Assessment dated 2/25/20 at 1655 stated, "Pt was brought in due to SI with a plan to cut herself. Pt stated she has not slept in 24 hours and was very upset. Pt broke a pen and started to try to cut herself. Pt stated that they have taken off some of her medication and does not feel right." The LMSW documented that the patient was able to contract for safety. There was no further documentation of patient outburst or inappropriate behavior.


Review of the facility's policy and procedure Seclusion and Physical or Chemical Restraint revealed,

"2. Rock Prairie Behavioral Health will utilize nonphysical interventions in an effort to prevent restraint or seclusion. The use of verbal de-escalation (i.e., calming techniques, redirection, refocus, etc.) are utilized. Restraint or seclusion is used only when non-physical interventions are not effective or not viable and when there is an imminent risk of a patient physically harming himself or herself, staff or others.

4. The use of restraint or seclusion shall always be implemented, utilizing the least restrictive measures to prevent a patient from injuring self or others in an emergency safety situation. Any use of Restraint or Seclusion requires clinical justification by a registered nurse after attempts at least restrictive approach to reduce the possibility of seclusion or restraint have occurred and are documented and must have a psychiatrist's order."


Review of Patient #10's chart revealed a verbal physicians order dated 2/25/20 at 1753 for "Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM." There was no indication on why this medication was ordered. Hand written out to the side of the physician order stated, "admin LA 1805 per C_ (illegible letter) RN." The nurse had written that the medication was administered in the LA (left arm) at 1805 but did not legibly write by whom. There was no documentation on the patient's Medication Administration Record (MAR) or nursing notes that the medication was given. There was no restraint packet done on the chart that addressed de-escalation techniques, chemical restraint, face to face assessment, staff involvement or assessment of the patient after the medication was administered. There was no physician progress report that addressed the patient's behavior or chemical restraint ordered for 2/25/20.


Review of patient #10's chart revealed a verbal physician order dated 2/25/20 at 2027 that stated, "Place patient on LOS while awake for safety."


Review of Patient #10's chart revealed a "Patient Observation" (PO) sheet filled out by the MHT. The documentation revealed from 1700 to 1800 Patient #10 was in the assessment area "lying/sitting." At 1815 was eating and drinking. There was no documentation of any behavioral issues or a restraint being administered. 2 1/2 hours later, on 2/25/20 at 2045, a RN documented on top of the Initial Nursing Assessment sheet, "pt. refused admit nursing assessment, stating she was going asleep." There was no nursing documentation on the patient till 9:00 AM on 2/26/20.


Review of patient #10's chart revealed she was seen by admitting physician Staff #43 (Psychiatrist) on 2/27/20 at 7:46 AM. Staff #43 stated, "Reports that she opened up more and groups were helpful. Reports mood remains down and depressed. Continues to have SI. Reports continued anxiety impacting her during the day."


Review of Patient #10's chart revealed a verbal physician order dated 2/27/20 at 7:55 AM (9 minutes after seen by primary psychiatrist). The verbal order was from Staff #3 (Psychiatrist) to "DC LOS." There was no progress note found that Staff #3 had evaluated Patient #10, determined in the last 9 minutes that the patient was no longer suicidal and no longer needed to have a continued LOS for safety. There was no progress note found that Staff #3 consulted with Staff #43 concerning his patient and current safety needs before ordering to discontinue the line of sight for safety.


A physician verbal order from Staff #3 dated 2/27/20 at 1:35 PM stated, "sign in as voluntary." Review of Patient #10's chart revealed her Apprehension by Peace Officer Without Warrant (APOWW) had expired and was signed in as a voluntary patient. There was no progress note from Staff #3 that he had evaluated Patient #10. There was no documentation that the patient was stable, progressing with treatment, or had conversed with the patient's primary psychiatrist.


Review of Patient #10's chart revealed Staff #43 had written a progress note on 2/29/20 at 11:59 AM. Staff #43 documented, "Pt was agitated on the unit, unable to be redirected. I ordered 10 mg Zydis w/ 7 mg Ativan which calmed the patient. Pt reports bad mood is 'pissed off'. Pt endorses depressed mood, denies SI. Pt endorsed HI towards 'Staff' but refuses to specify who pt reports good sleep and appetite. Denies AVH."


Review of patient #10's chart revealed, Staff #43 wrote another order to put Patient #10 back on a line of sight. The physician order dated 2/29/20 7:45 PM stated, "Start line of sight." Under the order written at 7:45 PM (1945) a nurse wrote another verbal physician order from Staff #46 (Psychiatrist) dated 2/29/20 at 1912 (7:12 PM), "LOS while awake only."The nurse documented the order at 1912 however it was written after the physician's hand-written order at 7:45 PM (1945).


There was no documentation/progress note from Staff #46 that he had assessed Patient #10 and determined that the patient should only be on a LOS while awake. There was no note that the primary psychiatrist was aware his original order had been changed 33 minutes after he wrote the original order.


Review of Patient #10's chart revealed, Staff #43 wrote an order on 3/1/20 at 0745 (7:45 AM). The order stated, "Change to 1:1 observation for increased SI."


Review of Patient #10's chart revealed, nurses notes dated 3/1/20 at 1930. The notes stated, "A&Ox4 Pt is very agitated, angry and having explosive outburst. She is cursing and threatening staff, going in room and slamming the door. Dr. ____ (Staff #3) called for emergent medication by house supervisor _____. Order received. Bang fist on bathroom wall" [SIC].


Review of Patient #10's chart revealed a verbal physician order on 3/1/20 at 1930 for "Haldol 5 mg IM x 1, Ativan 2 mg IM x 1, Benadryl 50 mg IM x 1 for severe agitation."


Review of the patient MAR revealed no documentation that the medication was administered. Review of the nurse's notes dated 3/1/20 at 2000 (8:00 PM) stated, "Pt refused to receive IM medications, report that she is getting calm, in room talking with MHT's." Review of the MHT's observation record revealed the patient was on a 1:1. The MHT had documented on 3/1/20 at 1930 (7:30 PM), "Pt. was talking to nurse abt cellphone. 1945 Pt. was talking to nurse abt cellphone. 2000 Pt gave us her cellphone that was hidden." [SIC]


Confidential interviews with staff were conducted from 4/14/20 - 4/16/20 concerning contraband and the cell phone incident with patient #10 on 3/1/20. Staff stated, when patients arrived to the facility they are to be "wanded" for items on their person and body check by the admissions nurse. The patient items are gone through and a written inventory is completed. Staff reported that "multiple patients have contraband on them that we have found and we report it but it keeps happening." Staff reported that Patient #10 had her cell phone and was hiding it in her bra. When the staff realized she had a cell phone in her possession for 5 days they asked her to hand it over. She became irate and angry. "The nurses just call the doctor and get a shot ordered. Nobody tried to talk to the patient except the MHT."


Review of the chart revealed no nursing documentation on finding the cell phone or any de-escalation techniques performed. Review of the chart revealed no documentation that the nurse called the physician and obtained an order to discontinue the chemical restraint. The nurse failed to follow physician orders and decided not to administer ordered medication. The nurse failed to document any interventions attempted to deescalate the situation or use other form of restraint before obtaining the most stringent restraint.


Review of Patient #10's chart revealed a verbal physician order on 3/2/20 at 1100 (11:00 AM) by Staff #43. The order stated, "decrease observation to LOS x 24 hours for safety."


Review of Patient #10's nurses notes dated 3/2/20 at 1100, "A&Ox4. Pt denies SI, HI,& AVH. Labile, easy agitated & very intrusive with peers and staff. Pt is verbally aggressive and about to physical altercation. Pt can easily calmed. Refused to take calm down medicine [SIC]. 1245 pt again attempted to attack staff, hit staff, refused to take medications. Pt states during emergency med administration time, 'I calmed. I don't need meds. I can control my mood [SIC]." There was no documentation of the patients behaviors reported to the physician.


Review of Patient #10's chart revealed a verbal physician order dated 3/2/20 at 1255 (12:55 PM), "Haldol 5 mg po now, Ativan 2 mg now, Benadryl 50 mg po now aggression, agitation, and assaultive behavior. If patient refuses po, give above medication IM." The physician's order left it up to the RN to decide if the patient would require a chemical restraint. It is not in the scope of practice for an RN to make medical judgements. There was no nursing documentation that the physician was contacted concerning the patient's mood, behavior, or refusal to take po medications.


Review of Patient #10's chart revealed a verbal physician orders form Staff #3. The physician orders dated 3/2/20 at 1311 revealed, "cancel now medications. Discharge AMA." The physician signed the order on 3/2/20 at 1300, 11 minutes before the order was written. Nursing documentation dated 3/2/10 at 1300 stated, "N.O. received AMA discharge. Pt is medically stable for discharge." There was no documentation concerning the patient's behavior, however, 15 minutes prior the patient was aggressive, agitated, with assaultive behavior.


Review of the nurse's notes dated 3/2/20 at 1300 stated, "N.O. received AMA discharge. Pt is medically stable for discharge." There was no further nursing documentation.


Review of Patient #10's chart revealed, Staff #3 wrote the Physician Discharge Summary on 3/31/20 at 11:50 AM stated,

"Psychiatric Discharge Summary

History of Present Illness: This patient was discharged against medical advice. This was her 17th admission to Rock Prairie. This admission was similar to previous admission. The patient had come back to the facility with a report of suicidal ideation and significant distress in her community. Like other admissions, this patient plans to act out on the unit, in order to get one-to-one. It was during the stay, that the patient smuggled a cellphone into the facility and proceeded to use it throughout the week. The patient also made several threats towards staff and peers. These threats escalated when the phone was found and she threatened to kill or harm people that tried to pick her phone. The patient refused to program during this stay, was somewhat medication compliant and was not programming in our facility. Due to her excessive agitation, her ongoing threats to harm herself and others despite no indication that she would harm herself, this patient was administratively discharged. We spent several days trying to work with this patient, support her to get her to program and get her medications adjusted. However, during the stay, the patient absolutely refused to do any type of treatment and reported that she was only staying here in order to have some place to stay because she did not want to be at home. Due to the patient's lack of acute symptoms in regards to self-harm and due to her ongoing threats and aggression towards our staff, we felt that the patient had met all of the treatment goals while being here and due to our safety, we felt that she would do better in the community. We did also work with her, work on outpatient, but the patient refused to accept any outpatient appointments. She refused to take any medications and she was discharged against medical advice.

Mental Status Examination: Mental status exam was not completed as this patient was discharged after hours. She was very angry and agitated, making threats towards staff, but denied any thoughts of hurting herself.

Diagnosis at Discharge: Borderline personality disorder as well as unspecified mood disorder.

Discharge Plan: She was not discharged any medications as this was against medical advice. The patient also has significant conduct disorder. She was offered appointments as an outpatient, but refused."


Review of the Interdisciplinary Treatment Team Notes dated 2/26/20 at 1530, revealed that the patient did not participate with her treatment plan. There is no further information that the patient was allowed to participate in her care. Review of the plan revealed no documentation concerning the patients behavior requiring a line of sight, a 1:1 observation, or chemical restraints.


Patient #10 had a shunt in her brain due to hydrocephalus and was on seizure medication. There was no documentation if she had access to her seizure medication.


The nurse documented vital signs on the "AMA Discharge Note" dated 3/2/20 with no time. The note stated, "A&Ox4. Pt is medically stable for discharge. Denies SI, HI, or AVH. Received order AMA discharge with no medications /prescriptions." The nurse signed the note but did not date or time signature. The nurse documented that the "patient refused to sign." The note stated, "Request for Discharge form was completed and signed by patient" was blank. Patient's plan after discharge, assessment of patient's mental status, notifications, recommended follow up and referrals, patient provided with prescriptions upon AMA discharge, patient has access/means to acquire prescribed medications, goals and all belongings returned was left blank.


There was no documentation on how the patient left, when the patient left, There was no 4 hour request for discharge in the chart, no documentation that the patient requested discharge, no discharge plan, the therapy discharge note was blank, the discharge safety plan was blank, the discharge follow-up authorization was blank, and the discharge continuing care plan was blank. There was no evidence that the patient was discharged safely.


Review of Staff employee files revealed the following staff did not have the appropriate training in the employee folder:

Staff #7 failed to have a job description, no evaluation since 2016, no patients-age appropriate training, no monitoring for patient safety training, and no abuse and neglect training. Staff #26 assisted in looking for items in Staff #7's chart. An interview with Staff #26 was conducted on 4/15/20 revealed that she had recently taken over the role of HR Director. Staff #26 stated that she was aware the charts were poorly organized. Staff #26 was unable to find the items required for Staff #7.


Staff #8 no patient-age appropriate training, no monitoring for patient safety training, and no abuse and neglect training.
Staff #19 no current nursing license, No CPI, no age appropriate training, no monitoring for patient safety training, and no abuse and neglect training.


Staff #20, 28, 32, and 47 personnel files were so disorganized that the surveyor was unable to find current training of any kind. Except CPI training.

Based on review, observation, and interviews, the facility failed to:

A. Indicate in the physician orders/progress notes concerning Chemical Restraint/Emergency Behavioral Medications on why the order was necessary, what other less intrusive forms of treatment, if any, that the psychiatrist has evaluated but rejected, and the reasons those treatments were rejected in 3 of 3 (#4, #5, and #10) patient charts reviewed.

B. Document less restrictive interventions attempted prior to administering chemical restraints, document patient assessments for safety and effectiveness, perform a face to face assessment, document staff involvement, and document in the patients Medication Administration Record (MAR) or nursing notes that the chemical restraints were administered in 3 of 3 (#4, #5, and #10) patient charts reviewed.

C. Administer chemical restraints as ordered by the physician and failed to administer NOW orders for chemical restraints in a timely manner. Nursing administered chemical restraints an hour or more later or not at all for staff convenience in 3 out of 3 (#4, #5, and #10) charts reviewed.

D. Educate staff, monitor the use and effectiveness of chemical restraints in QAPI, and monitor treatment plans for chemical restraint usage and patient education in 3(#4, #5 and #10) of 3 charts reviewed.


Findings:

Patient #10

Review of Patient #10's chart revealed that she was a 29 y/o female admitted to the facility on 2/25/20 as an involuntary patient. Patient #10 was brought into the facility by the police for suicidal ideation with a plan to shoot or cut herself.


Review of the Intake Screening Assessment dated 2/25/20 at 1655 stated, "Pt was brought in due to SI with a plan to cut herself. Pt stated she has not slept in 24 hours and was very upset. Pt broke a pen and started to try to cut herself. Pt stated that they have taken off some of her medication and does not feel right." The LMSW documented that the patient was able to contract for safety. There was no further documentation of patient outburst or inappropriate behavior.


Review of the facility's policy and procedure Seclusion and Physical or Chemical Restraint stated, "2. Rock Prairie Behavioral Health will utilize nonphysical interventions in an effort to prevent restraint or seclusion. The use of verbal de-escalation (i.e., calming techniques, redirection, refocus, etc.) are utilized. Restraint or seclusion is used only when non-physical interventions are not effective or not viable and when there is an imminent risk of a patient physically harming himself or herself, staff or others.

4. The use of restraint or seclusion shall always be implemented, utilizing the least restrictive measures to prevent a patient from injuring self or others in an emergency safety situation. Any use of Restraint or Seclusion requires clinical justification by a registered nurse after attempts at least restrictive approach to reduce the possibility of seclusion or restraint have occurred and are documented and must have a psychiatrist's order."


Review of Patient #10's chart revealed a verbal physician's order dated 2/25/20 at 1753 for "Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM." There was no indication on why these medications were ordered. Hand written out to the side of the physician order stated, "admin LA 1805 per C_ (illegible letter) RN." The nurse had written that the medication was administered in the LA (left arm) at 1805 but the signature was not legible. There was no documentation on the patients Medication Administration Record (MAR) or nursing notes that the medication was given. There was no restraint packet done on the chart that addressed de-escalation techniques, chemical restraint, face to face assessment, staff involvement, or assessment of the patient after the medication was administered. There was no physician progress report that addressed the patients behavior or chemical restraint ordered for 2/25/20.


The facility failed to follow their own policy on Chemical Restraints. A review of the Policy titled, "Seclusion and Physical or Chemical Restraint, #1000.57, Page 19 was as follows:

" ... Physician Order for Restrictive Interventions for Behaviors

For orders for chemical restraints, the following additional information must be provided from the ordering psychiatrist:

Why the order is necessary

What other generally accepted, less intrusive forms of treatment, if any,

That the psychiatrist has evaluated but rejected; and

The reasons those treatments were rejected ...

Seclusion and Physical Restraint, #1000.57, page 20" was as follows:

" ...Time Limitation

3. Once a physical/chemical restraint or seclusion has been implemented the qualified RN shall conduct a face-to face assessment using the Seclusion/Restraint Hourly flow sheet. Assessment will include evaluation of patient's immediate situation; reaction to the intervention; physical assessment including skin integrity, respiratory/circulation status, nutrition/hydration, pain, and review of medications; and lab results. This Seclusion/Restraint Hourly Flow Sheet shall be continued whereby the above parameters are documented for the patient every 5 minutes for physical restraints or episodes of seclusion for the duration of the event and, for chemical restraints, for one consecutive hour ..."


Review of Patient #10's chart revealed a "Patient Observation" (PO) sheet filled out by the MHT. The documentation revealed from 1700 to 1800 Patient #10 was in the assessment area "lying/sitting." At 1815 was eating and drinking. There was no documentation of any behavioral issues or a restraint being administered. On 2/25/20 at 2045 (2 1/2 hours later), a RN documented on top of the Initial Nursing Assessment sheet, "pt. refused admit nursing assessment, stating she was going asleep." There was no nursing documentation on the patient till 9:00 AM on 2/26/20.


Review of Patient #10's chart revealed nurses notes dated 3/1/20 at 1930. The notes stated, "A&Ox4 Pt is very agitated, angry and having explosive outburst. She is cursing and threatening staff, going in room and slamming the door. Dr. ____ (Staff #3) called for emergent medication by house supervisor _____. Order received. Bang fist on bathroom wall" [SIC].


Review of Patient #10's chart revealed a verbal physician order on 3/1/20 at 1930 for "Haldol 5 mg IM x 1, Ativan 2 mg IM x 1, Benadryl 50 mg IM x 1 for severe agitation."


Review of the patient MAR revealed no documentation that the medication was administered. Review of the nurse's notes dated 3/1/20 at 2000 stated, "Pt refused to receive IM medications, report that she is getting calm, in room talking with MHT's."

Review of the MHT's observation record revealed the patient was on a 1:1. The MHT had documented on 3/1/20 1930, "Pt. was talking to nurse abt cellphone. 1945 Pt. was talking to nurse abt cellphone. 2000 Pt gave us her cellphone that was hidden." [SIC]


Confidential interviews with staff were conducted from 4/14/20-4/16/20 concerning contraband and the cell phone incident with patient #10 on 3/1/20. Staff stated when patients arrive to the facility they are to be wanded for items on their person and body check by the admissions nurse. The patient items are gone through and a written inventory is completed. Staff reported that "multiple patients have contraband on them that we have found, and we report it, but it keeps happening." Staff reported that Patient #10 had her cell phone and was hiding it in her bra. When the staff realized she had a cell phone in her possession for 5 days they asked her to hand it over. She became irate and angry. "The nurses just call the doctor and get a shot ordered. Nobody tried to talk to the patient except the MHT."


Review of the chart revealed no nursing documentation on finding the cell phone or any de-escalation techniques performed. Review of the chart revealed no documentation that the nurse called the physician and obtained an order to discontinue the chemical restraint. The nurse failed to follow physician orders and decided not to administer ordered medication. The nurse failed to document any interventions attempted to deescalate the situation or use other form of restraint before obtaining the most stringent restraint.


Review of Patient #10's nurses notes dated 3/2/20 at 1100, "A&Ox4. Pt denies SI, HI, & AVH. Labile, easy agitated & very intrusive with peers and staff. Pt is verbally aggressive and about to physical altercation. Pt can easily calmed. Refused to take calm down medicine [SIC]. 1245 pt again attempted to attack staff, hit staff, refused to take medications. Pt states during emergency med administration time, 'I calmed. I don't need meds. I can control my mood [SIC]."


Review of Patient #10's physician orders revealed a verbal order for Haldol 5 mg po now, Ativan 2 mg now, Benadryl 50 mg po now aggression, agitation, and assaultive behavior. If patient refuses po, give above medication IM." The physician order left it up to the RN to decide if the patient would require a chemical restraint. It is not in the scope of practice for an RN to make medical judgements. There was no nursing documentation that the physician was contacted concerning the patient's mood, behavior, or refusal to take po medications.


Review of the physician orders dated 3/2/20 at 1311 revealed a telephone order was written by the RN. The order read, "cancel now medications. Discharge AMA." Nursing documentation dated 3/2/10 at 1300 stated, "N.O. received AMA discharge. Pt is medically stable for discharge." There was no documentation concerning the patient's behavior, however, 15 minutes prior the patient was aggressive, agitated, with assaultive behavior.


Review of the Interdisciplinary Treatment Team Notes dated 2/26/20 at 1530 that the patient did not participate with her treatment plan. There is no further information that the patient was allowed to participate in her care. Review of the plan revealed there was no documentation concerning the patients behavior requiring a line of sight and a 1:1 observation.


There was no documentation addressing the patient's outbursts and multiple orders for chemical restraints. Confidential interviews with staff were conducted from 4/14/20-4/16/20 with nursing staff concerning patient treatment team meetings. Staff stated they did not have enough staff to cover so they could not attend the treatment team meetings. Nursing staff was asked by the Medical Director, DON, and Administrator to sign the treatment plan to show they were in the meetings and active in the process. Staff stated they were not told what happened in the meetings but were instructed to sign the document regardless.


An interview was conducted with Staff #5 on 4/16/20 concerning restraints and how restraints are being monitored in QAPI. Staff #5 stated that he has been watching for restraints and making sure they have been entered on the restraint log. Staff #5 confirmed there was no performance improvement currently for chemical restraints and no incidents were reported from Nursing.


Confidential interviews with staff was conducted from 4/14/20-4/16/20 with nursing staff concerning chemical restraints/emergency behavioral medication and court ordered medications. Staff reported that they were instructed by previous nursing administrators that when a patient was acting out or having behavioral issues that they could get an order for po meds or IM meds. If the patient "willingly" took the IM medication, then it was not considered a chemical restraint and they did not have to fill out a restraint packet. Staff also reported that they were instructed that if a patient had a court order for medications that they could administer any medication for any issues as long as there was a physician order and not document it as a chemical restraint or emergency behavioral medication. Staff members were unfamiliar with the facility's policy and procedure "Seclusion and Physical or Chemical Restraints."


40989


PATIENT #4

A review of Patient #4's medical record revealed the following:

Patient #4 was a 35-year-old male, involuntary admitted on 3/31/2020 at 10:54 AM with a diagnosis of Bipolar 1 Disorder, Depressed, severe with mixed features. Patient #4 was placed on Self Harm, Assault Precautions-Perpetrator, and Suicide Precautions and the level of observations were Q (every) 15 minutes.


Review of physician orders revealed Staff #3 gave a verbal order to Staff #8 on 3/31/2020 at 1:17 PM for Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM (intramuscular) X 1 NOW for agitation. No documentation was found in the medical record that Patient #4 was a serious threat to himself or others at this time and there was no documentation that this medication was given at that time.


A review of Patient #4's medical record and facility video on 4/16/2020 after 10:00 AM with Staff #1, #5, and #38 revealed the following documentation discrepancies:


According to the video surveillance, on 3/31/2020 at 2:00 PM, Patient #4 was seen kicking the door at the nurses station and he was taken to the seclusion room. The seclusion room door was closed, and staff was stationed outside the door. Patient #4 was released from seclusion at 2:17 PM. No order was found within the medical record for seclusion from any provider. At no time during the viewing of the video was any staff seen administering an intramuscular injection.

Staff #1, #5 and #38 confirmed the above findings.


Review of the documentation on the Q 15-minute Patient Observations by the Mental Health Tech, dated 3/31/2020, from 2:00 PM to 2:30 PM revealed Patient #4 was in the consultation room with the Doctor/NP. This is the same time Patient #4 was seen in the seclusion room on video.


Further review of the Patient Observations documentation revealed a written note on the back of the observation worksheet that was not dated, timed, or signed by any staff member. The note was as follows, "Patient came from 400 unit to 300 unit after he made a big disturbance about coming here and his lady friend was stealing all of his money off his bank card. Nurse talked with pt he calmed down and took shot."


A review of the document titled "NURSING ASSESSMENT" on 3/31/2020 by Staff #8 was as follows:

" ... Patient #4 is A&OX4 (alert and oriented X 4) appears medically stable. VSWNL (Vital signs within normal limits). He is very agitated, having difficulty controlling himself, screaming, punching the wall, threatening to murder the people who stole his credit card with his money on it. Given Haldol 5 mg, Ativan 2 mg, Benadryl 50 mg IM (intramuscular to L (left) deltoid ..." Signed by Staff #8 on 3/31/2020 at 2:35 PM. There was no documentation of patient #4 being in seclusion or why medication was given after the patient was released from seclusion.


Staff #3 gave a telephone order for Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM Now for agitation on 3/31/2020 at 1:17 PM and Staff #8 administered the emergency medications at 2:25 PM. That was 1 hour and 8 minutes after the order was given for a "NOW" dose of a behavioral medication. Staff #8 failed to follow physician orders and administer the "NOW" medication when ordered at 1:17 PM.


There was no documentation within the medical record of less restrictive interventions attempted prior to seclusion and/or administering the medication. Also, there was no documentation of patient assessment for safety or effectiveness after medications were given.


No restraint/seclusion packet was located within Patient #4's medical record. Further review of Patient #4's medical record did not reveal a 1-hour face to face had been completed.


Staff #1 and Staff #5 confirmed the above findings.




PATIENT #5

Patient #5 was a 79-year-old male, admitted involuntary on 3/16/2020 with a diagnosis of Bipolar 1 Disorder, Manic, with Psychotic Features.

A review of the medical record was as follows:

Staff #23's written progress note dated 3/26/2020 at 2:30 AM was follows:

" ...Patient took coffee pot and went into room and hit light. Patient banging on windows, throwing **** (illegible writing) at staff. Call made to doctor. Order for IM given. Patient had to be restrained due to refusing medication. Patient medically stable ..."


A telephone order given from Staff #3 for "Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM X 1 now-agitation-destruction of property" was given to Staff #23 on 3/25/2020 at 2:45 AM. The Medication Administration Record revealed Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg was administered on 3/26/2020 at 3:00 AM by Staff #23.




A review of the document titled, "PHYSICIAN ORDERS FOR RESTRICTIVE INTERVENTIONS (RI) FOR BEHAVIORS" revealed the documentation was incomplete. The required PHYSICIANS SECTION, at the bottom of the page was not completed by Staff #3.


Staff #42 completed the One Hour Face to Face on Patient #5 on 3/26/2020 at 4:00 AM on Unit 200.


A review of the Schedule and Assignment document for staff dated 3/25/2020, Night Shift, revealed Staff #42 was assigned to Unit 400 as the only Registered Nurse.

No further documentation was provided to show who the Registered Nurse was giving patient care on Unit 400 while Staff #5 was completing the face to face on Unit 200.


Again, the facility failed to follow their own policy Chemical Restraints. A review of the Policy titled, "Seclusion and Physical or Chemical Restraint, #1000.57, Page 31 was as follows:

" ...Restraint or seclusion Debriefing:

1. The use of an emergency safety intervention shall be discussed with the patient face to face and be documented as a Patient and Staff Debriefing, on the Patient and Staff Debriefing form within 24 hours of the emergency safety intervention. This form is to remain in the patients record. This form must include the full names of staff who were present for the debriefing, and indications of those staff who were present and or excused from this Patient and Staff Debriefing ..."

Staff #30 confirmed no Patient and Staff Debriefing document was in the medical record of Patient #5 for the chemical restraint given on 3/26/2020.


Further review of Patient #5's medical record revealed a telephone order from Staff #43 was given to Staff #8 for Ativan 1 mg IM Now on 4/3/2020 at 2:00 PM. Staff #8 failed to follow the physicians order for a "Now" medications.


A review of the documentation on the Nursing Progress Note was as follows:

" ...12:00 Pt appears agitated. Constantly redirected by nurse to stay in room and wear mask, refuses to stay in room, wears mask occasionally ..." Staff failed to sign this entry on the progress note.

However, a review of the Patient Observations form dated 4/3/2020 at 12:00 PM, Staff #44 documented the Patient #5 was in the cafeteria eating/drinking at this time.

An additional telephone order was given to Staff #8 for Haldol 2.5 mg and Benadryl 50 mg IM agitation by Staff #3 on 4/3/2020 at 3:04.


A review of the documentation on the Nursing Progress Note and Patient Observations documents was as follows:

"14:05 (2:05 PM) Pt observed pacing the lobby. Becomes agitated after a peer discharged. Heard muttering to himself why am I still here. Pt redirected to stay calm. Refuses redirection." Staff failed to sign this entry on the progress note. However, Staff #44 documented on the Patient Observations form dated 4/3/2020 at 2:00 PM and 2:15 PM that Patient #5 was in his room lying/sitting at this time.

1420 (2:20 PM) c/o (complains of) of having a heart attack. VS WNL (vital signs within normal limits). Becomes increasingly agitated yelling and shouting at the nurse. Staff failed to sign this entry on the progress note. However, on 4/3/2020 at 2:15 PM, Staff #44 documented Patient #5 was in his room lying/sitting. Although Patient #5 was noted to be screaming and yelling at the nurse and complaining of a having a heart attack, there was no nursing documentation until 9:00 PM.


1534 (3:34 PM) Pt carries a chair and threatens to hit anyone that comes close. Emergency meds Haldol 2.5 mg, Ativan 1 mg, and Benadryl 50 all IM given at this time ..." Staff failed to sign this entry on the nursing progress note.


A review of the Medication Administration Record was as follow:

"Ativan 1 mg IM Now X 1, Benadryl 50 mg, Haldol 2.5 mg IM, court ordered". However, while the court order for medication administration allowed the use of these medications for treatment of the patient's condition, records show that the medication was given as "Emergency meds" and not a part of routine treatment. Medications given as emergency medication administrations do not require consent or court order as they are for behavioral emergencies when the patient has been identified as risk to self or others. Staff #8 administered the medications at 3:34 PM. The Ativan 1 mg IM Now order from Staff #43 was given 1 hour and 34 minutes late. Staff #8 failed to follow physician orders.


A review of the policy titled, "Seclusion and Physical Restraint, #1000.57, page 4" was as follows:

" ...13. Restraint or seclusion must not result in harm or injury to the patient and must be used only:

a. To ensure the safety of the patient or others during an emergency situation. An emergency safety situation means unanticipated patient behavior which places the patient or others at serious threat of violence or injury if no intervention occurs and it calls for an emergency safety intervention as defined in this policy.

b. Until the emergency safety situation has ceased and the patient's safety and safety of others can be ensured, even if the restraint or seclusion order has not expired ..."


Further review of the medical record for Patient #5 did not include the following required elements per the facility policy titled, "Seclusion and Physical or Chemical Restraint, #1000.57" when administering the chemical restraint dated 4/3/2020.

1. PHYSICIANS ORDER FOR RESTRICTIVE INTERVENTIONS (RI) FOR BEHAVIORS

2. RESTRICTIVE INTERVENTION REPORTING FORM

3. RESTRICTIVE INTERVENTION OBSERVATION/ASSESSMENT FLOW SHEET

4. ONE HOUR FACE TO FACE

5. PATIENT SELF DE-BRIEFING FORM

6. STAFF DEBRIEFING FOLLOWING A SECLUSION OR RESTRAINT EPISODE

7. INTERDISCIPLINARY PATIENT TREATMENT PLAN FOR SECLUSION OR RESTRAINT
INTERVENTIONS."

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

A. ensure safe staffing levels by providing adequate Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Mental Health Technicians (MHT's) to meet the needs of the patients in a safe manner in 5 of 5 (200, 300, 400, 500, and 600) patient care units.

B. provide each nursing unit with a basic staffing grid which considers the unique needs of the patients' services, acuity levels, and admission and discharge fluctuations for 5 of 5 (200, 300, 400, 500, and 600) patient care units.

C. ensure the Director of Nurses (DON) appropriately monitored the staffing schedule and made staffing adjustments to patient and staff needs 5 of 5 (200, 300, 400, 500, and 600) patient care units.

D. ensure that nursing staff advisory committee meetings were being conducted to discuss staffing needs and unsafe staffing practices.

E. provide safe staffing levels and protect vulnerable suicidal patients from potential harm by utilizing safety measures such as a 1:1 monitoring or continuous line of sight observation in 2 of 2 (#4 and 10) charts reviewed.


Review of the policy and procedure "Hospital Plan for Provision of Nursing Care" stated, "_____ (the facility name) is a 72-Bed, private hospital in College Station, Texas specializing in psychiatric and dual diagnosis services for geriatric, adult, and adolescent patients at an acute, partial hospitalization, and DP level. The Department of Nursing is a professional organizational department which provides nursing care services to inpatients and outpatients and their families. Nursing care is defined and delivered in accordance with the laws of the State of TEXAS, federal requirements, the Joint Commission, the mission of ______ (the facility name) (CBH), and the philosophy and standards of the Department of Nursing."


A tour of the facility was conducted on 4/15/20. The facility had the following patient care units.

Unit 200 - was the Geriatric Unit that recently had been changed to a child and adolescent unit. This was a locked unit and away from the other units in the building.

Unit 300 - 400 - were two separate locked units that shared 1 nurses station and seclusion area. Unit 300 had acute adults and 400 had adults and geriatric patients.

Unit 500 - 600 - were two separate locked units that shared 1 nurses station and seclusion area. Both units had child and adolescent patients. Unit 500 was closed at this time due to census.


Review of the staff Schedule and Assignment sheets revealed information at the top of the page as follows:

The Date

Nursing Supervisor

AOC (Administrator on call)

Shift (Day shift 7:00 AM-7:00 PM. Night shift 7:00 PM -7:00 AM)

MD on Call and phone number.

The page had columns with each unit census, what RN, LVN, and MHT were scheduled to work, and what staff member was assigned to a Line of Sight (LOS) or One to One (1:1) observation.


Review of the sheets revealed no information documented on the following:

On top of the schedule there was no documentation except the date and shift.

No census on 11 out of 25 shifts from 4-1-20 to 4-12-20.

The code teams were blank in 10 out of 25 shifts from 4-1-20 to 4-12-20.

The staffing was difficult and at times unable to follow due to mark throughs and no clear identifiers of who was working and on what unit from 4-1-20 to 4-12-20.

Line of sights and 1:1's assignments were unclear. No documentation found on what patients were on a line of sight or a 1:1.


Review of the policy and procedure "Levels of Observation" stated,

"One to One Observation: This is the only and sole assignment of one staff member who documents the location, behavior, and activities of the patient every 15 minutes. The staff member assigned is in constant visual range of the Patient (including bathing/toileting) and is within arm's length of the patient at all times, including bathing and hours of sleep unless otherwise specified in the physician order.

Close observation (Line of sight observation): The assigned staff maintains a full, unobstructed view of the patient at all times including bathing/toileting. The staff is within a proximity that allows them to implement immediate action if necessary. Staff observes and documents location, behavior, and activities of the patient every 15 minutes. Up to three patients may be observed by one staff during Close Observation status as long as the patients are in an area whereby the staff can monitor all patients on a continuous basis."


Review of the staff "Schedule and Assignment" sheets revealed under each unit, who was assigned to respond to the "Code Blue, Purple, Black, Green, and Red team.

There was no documentation for admissions or discharges performed during the shift or patient acuity on the assignment sheets.


An interview was conducted with Staff #27 on 4/15/20. Staff #27 stated that she schedules staff according to the new guideline set by this administration. Staff #27 stated that its to be 1 nurse to 12 patients and 1 MHT to 8 patients. Staff #27 was asked where her staffing grid was to allow a change in staff to patient ratio and acuity. Staff #27 stated, "We don't have one. If the staff needs to be increased, we have to call the Administrator or AOC to increase or decrease any staffing levels."


Staff #27 reported that she was instructed by administration that the staffing was counted by the whole census of the building as a total. Based off that, you get 1 RN per unit and 1 MHT. However, there may only be 2 patients on unit 200 with 1 RN and 1 tech but the other units are full, with up to 18-20 pts. Staff #27 was asked how she staffed the unit when there is a 1:1 or LOS patient observation. Staff #27 stated, "administration really doesn't want LOS or 1:1's for long. We are supposed to have MHT's on call to come in if we need them, but it is difficult to get them, if they are not scheduled to work. Staff #27 stated it was a battle daily to get the minimal staff much less any extra. The staff get mad because they are scheduled and then staff #1 or 2 sends them home. Staff #27 was asked to give the surveyor an example. Staff #27 stated, "well yesterday we had a total of 34 patients on the 300 - 400 units. There was 1 RN for each unit, an extra RN to take patients from both units, and 4 MHT's. The patients on unit 300 were pretty acute. Staff #2 wanted to send the 3rd RN home. That would have left the RN on 300 with 18 acute adult patients. The RN on 400 with 16 patients. Staff #2 also wanted to send home a MHT. That would have left 1 MHT on the floor and 1 float. I was trying to explain to them that this was not good, and the nurses could not take that kind of patient load safely. Then you came into the building, so they decided to leave the staff in place." Staff #27 was asked if the DON made these staffing decisions and Staff #27 reported that sometimes she does but its usually Staff #1 and #2. Staff #27 confirmed that there had been times that there was no staff to perform 1:1's and administration would call down to the nurse's station and cancel the 1:1.


An interview was conducted with Staff #7 on 4/15/20 concerning staffing. Staff #7 stated that she was just an interim DON. Staff #7 stated, she did not want to take on this role but there was no one else to do it. Staff #7 confirmed that she is aware of staffing and staffing needs but Staff #1 and #2 work closely with Staff #27. "They really decide how many staff are needed." Staff #7 was not familiar with any staffing grid or the staff to patient ratio. Staff #7 denied conducting any Nursing Advisory Committee Meetings to discuss staffing. Staff #7 confirmed there has been no nurse staffing meetings since January of 2020. Staff #7 denied taking staffing issues to QAPI. Staff #7 stated they talk about staffing in QAPI sometimes but had no information on what and when.


Review of the policy and procedure "Hospital Plan for Provision of Nursing Care" stated, Patient Classification System

1. Each nursing unit will have a basic staffing pattern which considers the unique needs of the patients' service. This factor in the greater level of need on the part of patients assigned to the units. Staffing pattern is the responsibility of the CNO/DON.
a. In order to evaluate the patient care needs on a daily basis, for inpatient units, The CNO/DON and the House Supervisors adjust the staffing each day based on the acuity needs of the individual patients as well as how these patients meld together in the milieu."


An interview was conducted on 4/15/20 in the afternoon with Staff #1 and #2 concerning the policy and procedure "Levels of Observation." Staff #1 was asked how 1 staff member could monitor up to three patients on a close observation and if that was a practice at the facility? Staff #1 stated, "yes. Our policy says they can have up to 3 patients." Staff #1 was asked what happened when one of those patients needed to go to the restroom or a patient became aggressive or acting out. Who would be monitoring the other two patients? Staff #1 reported there would be other staff available to watch the patients. Staff #1 stated, "There is plenty of staff and we are meeting every day to talk about patient acuity. The staff are just used to working with excess staff. They have to tell us why extra staff is needed and most of the time they can't." Staff #1 was unable to provide written proof or give an explanation on what staff was available and how the patients were to be monitored. Staff #1 was asked about the staff grid and how that was used. Staff #1 was unable to provide a staffing grid. Staff #1 stated, "you just need to get past numbers it's about the needs of the patient and acuity." Staff #1 was unable to provide any guidance on acuity levels or needs.


Staff #2 handed a piece of paper to the surveyor and stated that this was the staffing grid. The paper had 1 RN to 12 patients and 1 MHT to 8 patients. There was no standard for increasing staff due to increase of patient load past 12 or 8. The surveyor asked if the census is over 12 would another nurse be placed on the unit. He stated "Not necessarily it would depend on the acuity. He was asked what is the acuity levels? Staff #2 reported that it would depend, and they would have to get administrative approval. Staff #2 was unable to clarify the process.

Staff #2 was asked by the surveyor how he was involved in staffing? Staff #2 reported that he attends the flash meetings daily concerning the patient's acuity, staffing, and general information for the day. Staff #2 was asked if he was making staffing decisions based on financial reasons instead of patient safety. Staff #2 stated, "No. I am never involved in sending people home. I am not involved in that part of patient care. I don't decide about patient acuity and staffing."


Review of emails provided by staff revealed Staff #2 sent out an email on 3/23/20 at 8:40 AM, "We need five techs to go home. We currently have 10 techs working. _____ (MHT) worked overnight but is still clocked in. Can you have him clock out."

3/24/20 at 8:40 AM. Staff #2 documented, "Do we still have the 1 on 1? We have 7 techs 1 needs to go home. Are all the wings open? If not another tech needs to leave as well. Why is ___ and ___ working overtime they are still on the clock?"

3/24/20 at 8:56 AM Staff #7 responded, "Yes a new 1:1 as of this morning." The DON was included in the chain of emails but no indication that the DON made any staffing decisions. The staffing coordinator responded to the emails and followed direction from Staff #2.


Confidential interviews with staff was conducted from 4/14/20-4/16/20 concerning 1:1 observation, close observations, and staffing. Staff reported MHT's were given multiple close observation patients at a time and may be the only MHT on the unit. Staff Reported that they may have to assist with meals, patient care needs, disruptive patients, and general care while trying to observe more than one close observation. Staff reported that they have 1:1 patients and MHT's get called into the facility for the 1:1's but they can't take breaks because there is no one to relieve them for breaks. Multiple staff members reported the staffing is unsafe. Staff reported that there has been patient and staff injuries due to poor staffing. Staff reported that administration had called and requested to send staff home this am (4-14-20) but changed their minds when the state surveyors had entered the building. Nursing staff and MHT's stated they feel there was and still is a high possibility of patient or staff injury. Staff stated that many times the Administrator, Director of Nursing (DON) or Chief Financial Officer (CFO) would call down to the unit and tell the staff to discontinue 1:1's, and close observations. Staff reported they would have to call the physician for orders to discontinue care due to lack of staff or because the administrative staff insisted. Staff reported that sometimes orders are not written and the 1:1 or LOS is discontinued by the Administrator.


Review of an email dated 3/14/20 revealed, the house supervisor (HS) had sent out a house supervisors report. Staff #27 stated, the report revealed the CEO had ordered a 1:1 to be discontinued without a physician's order on the night shift. Staff #27 stated that it happened frequently. The email was sent back out from Staff #1 stating, "The CEO did not request the 1:1 to be discontinued. The CEO spoke with the DON and requested the policy be followed and that clear documentation of behaviors of the need for 1:1 justify the need. The CEO did not speak with the RN supervisor so please adjust the report attached as necessary." Staff #27 stated, there was no more house supervisors as of 4/11/20. Staff #1 confirmed, she had eliminated the HS positions and would eventually replace them with unit managers.


Review of multiple emails revealed, Staff #1 requested to send staff home on 4/7/20 at 8:35 AM. Staff #2 documented, "One MHT needs to come off the clock and DR. ____ Staff #3 will see the 1:1 on the adolescent then d/c at which case another MHT needs to clock out." There was no documentation that Staff #7 was involved in this decision.


Nursing staff reported they are afraid to talk about all the serious issues due to retaliation. Confidential interviews were performed from 4-14-20 to 4-16-20. The Nurses stated they are given 15 to 18 patients at a time with only 1 MHT. Nursing staff stated the patients are high acuity and have had incidents where staff and patients have been injured from acute patient behaviors. Staff stated that a staff member was hurt a week ago and was on leave from her injuries. Nurses stated that there are no more house supervisors. If they are the only nurse on the floor and a code happens there is no one to send to help. Staff stated if they are on unit 300 or 400 the nurse can come over from his/her unit to help but that leaves the unit unattended by an RN. Nursing staff reported that they don't get to take lunches due to no one to watch the unit. Staff stated that if they do, the other nurses have to watch two units at a time. Each unit is locked, and you do not know what's happening on one unit when you are on the other. Multiple nursing staff stated they are afraid for their safety and safety of the patients. Staff stated they have voiced their concerns to administration but have been told that "this is the staffing from now on." Staff #27 stated that one of the nurses refused to take 15 patients on two different units (500-600) with an LVN to pass medications. The nurse refused to take two units and stated that was not safe. The nurse was unable to supervise the patients, MHT's and LVN on both units. Staff #7 became upset and sent the nurse home for refusing to take patients in an unsafe condition. Nurses stated that if there is no nurse working in admissions, they must leave their units unsupervised, to go get patients being admitted.


Findings:

PATIENT #4

Patient #4 was a 35-year-old male, admitted involuntarily on 3/31/2020 at 10:54 AM with a diagnosis of Bipolar, current manic episode severe with psychotic features. Precautions on admission were Self Harm, Assault Precautions-Perpetrator, and Suicide Precautions with a Q (every) 15-minute Level of observations.


A review of the Intake Screening Assessment revealed Patient #4 called the crisis hotline on 3/31/2020 and reported Suicidal Ideations (SI) and Homicidal Ideation (HI) with a plan. Patient was in possession of a knife and put it down when police responded. He was transported by the police department to the facility for further evaluation.


A review of the Nursing Progress Note dated 3/31/2020 at 2240 (10:40 PM) was as follows:

"Found by MHT to have his sheet rolled up and was tying it to his desk - told them he planned to asphyxiate himself. Linens removed from room." Staff signature illegible. There was no physician order to restrict the patient's rights by removing his linen.

No further documentation was found where the incident was reported to the Psychiatrist/MD. Patient remained on a Q 15-minute observation. This placed the patient at very high risk of death by suicide. The staff failed to alert the physician for a 1:1 observation allowing the patient to have bed linen and sleep comfortably. Instead the staff removed his linen and forced him to sleep on a bare mattress, with no covers, and no 1:1 monitoring. There was no nursing documentation that addressed the patients reason for attempting a suicidal act or what was done to address the patient's needs.


A review of the MHT Patient Observations form revealed a note dated 4/1/2020 at 6:15 AM by Staff #28. The note was as follows:

"Pt was asleep most of the shift. Pt was compliant and had no issues. Pt took medication and went to bed. 0000 Pt tried to tie bed sheet over his head and around his neck pt had no attempt after that or issues and remained asleep. Incident was reported to nurse but no LOS (line of sight) or 1:1 was needed."


Review of the staffing schedule for 3/31/20 7:00 PM to 7:00 AM revealed there was only 1 RN and 1 MHT scheduled.


A review of the Psychiatric Progress dated 4/2/20 at 11:45 AM by Staff #15 was as follows:

" ...Pt A&O X 4 (alert and oriented X 4). Agitated, restless, punching wall at nursing window before visit, shouting-demanding meds change. Upon seeing pt bargaining he will quit smoking if I increase his Ativan. States anxiety is so bad "I tried strangling myself a couple nights ago. Did you know that!?!?" Pt redirected and calmed with visit with POC (plan of care) concordance achieved except Cluster B traits ..." No further documentation was found where the incident was reported to the Psychiatrist/MD. However, Staff #3 did cosign behind Staff #15 because she is currently in the role of a Student PMHNP (Psychiatric Mental Health Nurse Practitioner.) Staff #15 is a FNP-C (Family Nurse Practitioner-Certified) but was not treating Patient #4 as a medical patient on this day. Staff #3 counter signed Staff #15's Psychiatric Progress Note, however it was timed 4 hours and 19 minutes before she clinically saw the patient. No further documentation was located within the medical record where Staff #15 reported the incident to the Psychiatrist/MD.

During an interview in the afternoon of 4/16/20 Staff #1, 2, 3, 5, and 7 was asked if they were aware Patient #4 attempted suicide in his room during his stay? All staff confirmed they were not aware.


Patient #13

Review of Patient # 13's chart revealed, he was admitted on 4/6/20 at 10:00 PM with suicidal ideation. A physician order for a 1:1 observation was found dated as an addendum to the admissions orders dated 4/6/20 at 2056. The physician signed the addendum on 4/7/20 at 2:38 AM. The Mental Health Technician (MHT) started the 1:1 observation documentation on 4/6/20 at 11:00 PM.


Review of the nursing schedule revealed there was only one MHT and one RN for the 600-unit. Patient #13 was on a 1:1 observation but there was no MHT assigned to the patient.


Review of the House Supervisor (H.S.) notes dated 4/6/20 stated that Patient #13 was on a 1:1 observation but there was no information found on who was called in for the 1:1 observation. Review of the H.S. notes revealed, H.S. was assigned to the 400 unit as the only RN. There was no available H.S. to assist with the 1:1 observation.


Review of Patient #13's 1:1 patient observation sheet revealed, Staff #40 MHT documented on the sheet. There was no documentation of Staff #40 being called in or on the schedule for 4/6/20, 7:00 PM to 7:00 AM shift. There was no documentation on who relieved Staff #40 for breaks.


A time card was pulled for Staff #40 on 4/6/20 and 4/7/20. The card revealed that Staff #40 worked on the 7:00 PM to 7:00 AM shift for 12 hours. There was no documentation of any breaks on the time card.


Review of the chart revealed, Patient #13 was removed from the 1:1 observation and put on q 15-minute checks on 4/7/20 at 9:30 AM. A nurse's note was noted on 4/7/20 at 7:00 AM. The note stated, "Upon my arrival on the unit Pt was in the day room with the rest of the group. At the morning vitals patient is awake, A&O x 3, V/S are stable. Pt denies SI/HI/AVH presently. Dr. _____ (Staff#3) is aware. Pt is medication complaint. Pt is tolerating all meds well. Pt. Appetite is intact, Pt is programming with the group. Pt is in a pleasant mood. Pt is sleeping well. Pt is showing moderate depression and anxiety today. Patient is still withdrawn. Dr. ____ (Staff#3) is aware. Pt is showing no signs and symptoms of distress." There was no further nursing documentation noted until 7:25 PM (10 hours later). The nurse failed to document the date and time the 1:1 ended, an assessment of the patient, nor the patient's response.

A physician order was found to end the 1:1 on 4/7/20 at 9:22 am. There was no physician progress note found dated for 4/7/20. There was no physician documentation that discussed the 1:1 or the discontinuation of the 1:1. Review of the progress note for 4/8/20 revealed there was no mention of the 1:1 or the end of the 1:1.

Based on interview and document review, the facility failed to have an individual appointed as the infection control preventionist.

This deficient practice had the likelihood to cause harm to all patients by exposing patients and all staff to possible hospital acquired infections and infectious diseases. This could possibly lead to death during a public health emergency and/or pandemic without proper monitoring and oversight of the infection control program.


Findings:


An interview was conducted with Staff #1 after 10:00 AM on 4/15/2020. Staff #20 was asked who was the Infection Control Preventionist. Staff #1 stated, "Staff #7 is the Infection Control Nurse."

An interview was conducted with Staff #7 on 4/15/2020 after 12:00 PM. Staff #7 was asked how long she had been the Infection Control Nurse. Staff #7 replied, "I am not the infection control nurse. I do not feel comfortable nor do I have the experience to be the infection control nurse and I have told administration that. I was told I would be the Infection Control Nurse since Staff #9 left." Staff #7 was asked if she continued to complete the infection control rounds weekly and if she was the one responsible for the state reportable diseases? Staff #7 replied, "No, I do not do the rounds nor do I report things to the state. I do not have the experience and I have not been trained on any of those things."

A review of an email document given to this state surveyor was as follows:

" ...Infection Control

From: Staff #7

Tues 3/31/2020 3:59 PM

To: Staff #18

I have told Staff #1 that I do not feel comfortable picking up infection control. I have no access to the annual plan or surveillance plan that Staff #9 developed. As of April 11 there are no nursing supervisors. We do not have a nurse educator or infection control nurse ..."


An interview was conducted with Staff #1 on 4/15/2020 after 12:00 PM. Staff #1 was asked again who the Infection Control Nurse was and if she had the required experience and had signed a job description for Infection Control Nurse. Staff #1 stated, "Staff #7 is the infection control nurse and she is also the DON. Our infection control nurse quit a couple weeks ago and we made Staff #7 the infection control nurse at that time."

An interview was conducted with Staff #26 on 4/16/2020 after 11:30 AM. Staff #26 was asked if Staff #7 was the infection control nurse. Staff #26 stated, "Yes, I think she is. Our infection control nurse quit about 3 weeks ago and I think they made Staff #7 the infection control nurse. We tried to get Staff #9 to come to work because we didn't have an infection control nurse, but she told us it was unsafe for the patients and the staff and she would not do that. She had been told to self-quarantine for 14 days with her child due to exposure to COVID-19. I told her it was important that she finds a babysitter and come into work because she didn't have any symptoms and it left us without an infection control nurse during a pandemic."


A review of Staff #7's employee file did not reveal a signed job description for infection control preventionist.


A review of a document provided by Staff #9 to self-quarantine was as follows:

" ...To Whom It May Concern,

Please be aware that due to recent contact with family members who have a positive travel history and now have developed symptoms of COVID-19, **** and his mother, Staff #9, require self-quarantine for 14 days.

Sincerely,

******** ****, MD ..."



Staff #26 confirmed the above findings.

Based on observation, document review, and interview, the facility failed to:

A. take measures to contain and/or prevent the transmission of a highly suspected contagious Coronavirus (COVID-19) and failed to follow their own policies to provide care to 1 of 1 (#5) patients under investigation.

B. have an active and ongoing infection control program.

C. maintain a clean and sanitary environment in 5 (Units #200, #300, #400, #600, and kitchen) of 5 areas observed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.



Findings:

A. The facility failed to take measures to contain and/or prevent the transmission of a highly suspected contagious Coronavirus (COVID-19) and failed to follow their own policies.

A review of Patient #5's medical record revealed the following:

Patient #5 was a 79-year-old male, admitted on 3/16/2020 with a diagnosis of Bipolar 1, Manic, with Psychotic features.

A review of the nurses notes dated 4/1/20 on the 7 A-7 P shift revealed, Patient #5 had a temperature of 99.2 and generalized body aches of a 10 on a pain scale of 1-10, with 10 being the most severe.


A review of the Medical Progress note dated 4/2/20 at 7:56 AM by Staff #13 was as follows:

" ...Pt with low grade temp yesterday (99.8) Pt c/o sinus congestion and joint aches. Pt said he felt bad all day yesterday. Low grade fever with slight cough and exposure to lab tech. ER exposure. Discussed with Health Department and *** ******testing. Discussed with Facility #2. Will transfer for testing..."


A review of the Physicians order dated 4/2/2020 at 9:38 AM by Staff #13 was as follows:

"Transfer to Facility #2 for COVID-19 testing secondary to fever, cough, exposure."


A review of Patient #5's Discharge Instructions from Facility #2 was as follows:

" ...SPECIAL NOTES
You are advised to self-quarantine per CDC guidelines ..."



A review of the Physicians order dated 4/2/2020 at 1:08 PM by Staff #13 was as follows:

"1. Isolate (with a line drawn through this word) Block patients room

2. Keep patient in room until Covid results available.

3. Patient to wear mask when out of room.

4. Vitals QID (4 times a day)"

Further review of the medical record of Patient #5 revealed no physician order for isolation precautions pending results for COVID-19.


An interview was conducted with Staff #8 on 4/15/2020 after 10:00 AM.

Staff #8 was asked how they ensured Patient #5 stayed in his room. Staff #8 replied, "We could not keep him in his room. As soon as he got back from the hospital he started screaming and yelling saying he was not going to stay in his room and he did not have to. When Patient #5 would come out of his room, most of the time he would not be wearing a mask and we would have to tell him to put it on and sometimes he would and sometimes he wouldn't. His observation level was never increased to a 1:1 or even a line of sight so we could monitor him better because we did not have the staff. He stayed on a q (every) 15-minute observation so sometimes it was hard to stop him if he came out of his room not wearing his mask. Staff #8 was asked if they were wearing their personal protective equipment when they went into Patient #5's room. Staff #8 stated, "We only wear a mask and we will put on gloves if we are going to be touching him for any reason."


An interview was conducted with Staff #7 on 4/15/2020 After 10:00 AM.

Staff #7 was asked how they ensured Patient #5 was isolated from other patients and how the staff protected themselves from a highly contagious respiratory virus/suspected COVID-19. Staff #7 said he only ran a fever for a couple days, and it was a low fever and just had a slight cough, so the staff just wore a mask. It was hard to get him to wear a mask because he refused or would take it off once he started watching television."


Staff #7 and Staff #8 confirmed the above findings.


A review of the policy titled,

"Transmission Based Precautions; Policy and Procedure 1600.18; Reviewed/Revised Governing Board 2/2019" was as follows:

"DROPLET PRECAUTIONS

A. Private Room

B. Change protective attire and perform hand hygiene between contacts with patients in the same room.

C. Wear a mask

D. Staff should move or transport patients from the room for medically necessary purposes only.

E. Isolation: Isolation can be considered whenever a patient has infectious disease.
The potential negative effects isolation may have on mental health should be strongly considered.
Every effort should be made to gain voluntary compliance with isolation.
If a patient refuses to isolate, efforts should be made to have the patient wear a mask, sit away from other patients
etc., or other actions which will mitigate the risk of exposure to others."


A review of the policy titled, "Management of Coronavirus (2019n-CoV)" was as follows:

" ...V. PROCEDURE:

All patients, visitors, and vendors shall be screened for possible coronavirus infection upon arrival to the facility using Center for Disease Control recommended screening tool. Employees shall be screened on a daily basis and as needed per CDC recommendations. Screenings shall include the following clinical features and epidemiology risks:

1. Fever

2. Signs/symptoms of lower respiratory illness (e.g. Cough, shortness of breath.)

3. Close contact with a laboratory confirmed 2019-nCOV patient within 14 days of symptom onset.

4. A history of travel within 14 days of symptom onset.

F. Suspected Coronavirus Infection

2. Any post admission patient reasonably suspected of coronavirus based on signs and symptoms will immediately be donned with a surgical mask over the mouth and nose and will be isolated in a designated isolation space with the door closed.

*Entry and exit to this room should be limited and should occur only when necessary. Only the number of staff required to maintain patient safety should be allowed in the room ..."

Further review of the policy revealed the policy was only approved by the Infection Control Committee March 2020. No Infection Control Meeting minutes were provided dated later than 1/13/2020 to include the approval of this policy after several requests. No further documentation was provided of an approval by the Medical Staff or the Governing Body.


A review of the CDC Guidelines for patients with suspected Coronavirus Disease (COVID-19) were as follows:

" ...Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
Update April 13, 2020

Summary of Changes to the Guidance

Below are changes to the guidance as of April 13, 2020:

To address asymptomatic and pre-symptomatic transmission, implement source control for everyone entering a healthcare facility (e.g., healthcare personnel, patients, visitors), regardless of symptoms.

This action is recommended to help prevent transmission from infected individuals who may or may not have symptoms of COVID-19.

Cloth face coverings are not considered PPE because their capability to protect healthcare personnel (HCP) is unknown. Facemasks, if available, should be reserved for HCP.

For visitors and patients, a cloth face covering may be appropriate. If a visitor or patient arrives to the healthcare facility without a cloth face covering, a facemask may be used for source control if supplies are available.

Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility.
Recommendations

3. Patient Placement

For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization. If hospitalization is not medically necessary, home care is preferable if the individual's situation allows.

If admitted, place a patient with known or suspected COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom.

Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)

As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift.

Determine how staffing needs will be met as the number of patients with known or suspected COVID-19 increases and HCP become ill and are excluded from work.

It might not be possible to distinguish patients who have COVID-19 from patients with other respiratory viruses. As such, patients with different respiratory pathogens might be housed on the same unit. However, only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should ideally not be housed in the same room as a patient with an undiagnosed respiratory infection.

Limit transport and movement of the patient outside of the room to medically essential purposes.

Consider providing portable x-ray equipment in patient cohort areas to reduce the need for patient transport.

To the extent possible, patients with known or suspected COVID-19 should be housed in the same room for the duration of their stay in the facility (e.g., minimize room transfers).

Patients should wear a facemask or cloth face covering to contain secretions during transport. If patients cannot tolerate a facemask or cloth face covering or one is not available, they should use tissues to cover their mouth and nose while out of their room.

Personnel entering the room should use PPE as described above ..."


An interview was conducted with Staff #1 on 4/15/2020 after 11:00. Staff #1 was asked who was doing the employee screening before the employee was allowed in the building to work. Staff #1 stated, "The employees take their own temperature and write it down." Staff #1 was then asked what if the employee did not take their temperature and just wrote a number down. Staff #1 replied, "They would never do that."

Staff #7 and Staff #8 confirmed they complete their own screening including taking their own temperature when they arrive at the facility.


B. The facility failed to have an active and ongoing infection control program.


A review of the document titled, "Infection Prevention and Control Plan January 2020" revealed the following:

" ...Goal 4: Limit the spread and/or occurrence of infections through promotion of actions that are designed to limit the spread and/or prevent the occurrence of hospital acquired or community acquired infections and as measured by the accomplishment of the following:

A. Identify and reduce the risk of acquiring and transmitting infections among patient, employees, physicians, students, and visitors by completing ongoing surveillance of organisms in patients as well as infection risks within the environment.

GENERAL SURVEILLANCE PROCEDURES:

1. Indicators and thresholds to be measured:

i. Environmental surveillance of the hospital using a designated assessment sheet will be evaluated on a minimum of a monthly basis or more often, as needed to ensure compliance with infection control standards ..."


A review of the documents titled, " ...Infection Control Nurse Environmental Monitoring Report" revealed the following:

January 7, 2020
Other issues:
Mold on drywall around AC vents throughout the hospital, EVS Director aware.

January 16, 2020
Other issues:
Mold on drywall around AC vents throughout the hospital, EVS Director aware.

January 20, 2020
Other issues:
Mold on drywall around AC vents throughout the hospital, EVS Director aware.

January 27, 2020
Other issues:
Mold on drywall around AC vents throughout the hospital, EVS Director aware.

February 15, 2020
Other issues:
Mold on drywall around AC vents throughout the hospital, EVS Director aware.

February 19, 2020
61. Dish room vent has cracks in drywall around it. Cafeteria vent with mildew above soda dispenser. EVS aware ..."


A review of the document titled,

" ...Infection Control Committee Minutes" was as follows:

Discussion/Recommendations
Environment of Care

Action/Conclusions
RN-IC noting frequent mold/mildew throughout the facility. Staff #6 has 2 quotes for duct cleaning.

Follow-up (To include person responsible & date)
Staff #6 to send Staff #1 proposal for approval this week ..."


An interview was conducted with Staff #6 on 4/15/2020 after 12:00 PM. Staff #6 was asked how long there had been a problem with the mildew around the vents throughout the building. Staff #6 replied, "We don't have a problem with mildew in the building." The mildew in room #305 wasn't there and it is a new problem. No one has come to me about any mildew or mold." Staff #6 was asked if he completed any infection control rounds. Staff #6 stated, "When I do my EOC (Environment of Care) rounds it only includes patient safety items. I don't have the knowledge to look at infection control issues."


An interview was conducted with Staff #7 on 4/15/2020 after 12:00 PM. Staff # 7 was asked if she had completed any infection control rounds since the infection control nurse left. Staff #7 state, "No, I have not completed any." Staff #7 confirmed the last time any infection control rounds were completed was February 20, 2020.


During an observation tour on 4/15/202 after 10:00 AM with Staff #6 and Staff #12 the following was observed.

Findings:


UNIT 200

Inside the patient nutrition refrigerator, all shelves and the inside of the door shelves, dirt, dust, debris, and human hair were noted. Inside the refrigerator were the following items: an open Gatorade bottle with no patient label, two 3.5 ounces of orange juice readily available for patient use that expired 4/09/20. In the door shelf was a Monster Energy drink that Staff #8 confirmed belonged to an employee. Under the nurses desk, closest to the day area of the unit, was a three-drawer rolling cart. In the top drawer was multiple oranges, two unopened pretzel bags, and a single pack of crackers. The bottom of the top drawer was noted to be covered with dirt and dust. The other two drawers were filled paper products.

An interview with Staff #8 was conducted on 4/15/2020 after 10:00 AM. Staff #8 was asked who was responsible for the cleaning of the refrigerator and the patient items in the refrigerator. Staff #8 stated, "I guess we should be wiping it down and checking for expired items." Staff #8 was asked how long the oranges had been in the drawer and ready to be given to a patient. Staff #8 replied, "I really don't know when or how long they have been in there. We keep them there for patient snacks because sometimes they complain about not getting a snack and being hungry."

Staff #6, #8, and #12 confirmed the above findings.


UNIT 300

During a tour of Unit 300 the following was observed:

A closed room, not identified as a storage room, was located at the end of the hall on Unit 300. Inside the room, on a shelf (cubicle), was a white paper sack labeled, "4/14/20 300 18". Inside the sack was two "Dannon Light and Fit" yogurts; one blueberry and one strawberry. In the next cubicle to the right was a plastic container. On the outside of the container written in a black was "SNACKS 300". Inside the container was an empty white paper sack and two 3.5-ounce containers of apple juice. The plastic bin was noted to have dirt, dust, and trash lining the bottom of the inside. Next to the plastic bin was personal hygiene items for patient use.

A review of the manufacturing guidelines for Dannon Yogurt was as follows:

" ...Dannon recommends that yogurt be refrigerated at all times. Recommended temperature for refrigeration of Dannon products is 40 degrees; While you should always use your best judgment, we'd suggest you discard any yogurts that have not been properly refrigerated ..."

Staff #7 and Staff #12 confirmed the above findings.



UNIT 400

During the observation tour, a day room was observed to have graffiti on the wall. The countertops were soiled with a dried liquid, dust, and dirt. Styrofoam cups were on the soiled countertop uncovered and readily available for patient use. Missing metal covers to the door openings under the sink and the drawer beneath the cabinet were exposing the porous surface. The porous surface could not be properly sanitized to prevent the transmission of infectious diseases. A wooden chair next to the far wall, noted to be missing the cushion and had an empty cup of a snack that had been eaten and paper trash in the chair.

Staff #6 confirmed the above findings.


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A tour of the facility was performed on 4/15/20 at 10:40 AM. The following issues were found:

KITCHEN

Two insulated, portable, patient food tray, holding carts were found sitting together in the soiled dish room. The 1st cart was covered in plastic. The second cart was soiled with dirt, hair, food particles, and dust. Kitchen Staff #11 and #6 confirmed the cart coved in plastic was clean and the other was dirty and needed to be cleaned. Staff #8 and #11 confirmed there was no clean vs dirty area in the dish room and all items in the room would be considered dirty.


UNIT 300

During a tour of patient unit 300, a female, Patient #8, approached the surveyor. Patient #8 reported that she had been assigned to room 305. She reported that the room was full of mold and no one would believe her. She stated, "they just think you're crazy here and won't do anything about this mold and its making me sick." The female patient stated that she was moved out of the room but wanted to show me. Upon arrival to the room, 2 other female patients were sharing the room. The smell of mildew was very strong from the door entrance. The carpet was stained as if it had been wet recently in the bedroom adjacent to the bathroom. Inside the bathroom was mildew and mold on the ceiling. The floor molding had separated from the wall exposing damaged sheetrock. The shower curtain was soiled and there was exposed sheetrock on the wall. Patient #8 stated, she had told multiple staff about the problem.

Along the bedroom wall a wooden shelving system for patients was found to store their personal items. The top of the shelves was heavily dusty. The surveyor was able to write the letter S in the dust.

An interview with Staff #6 was conducted on 4/15/20 at 11:35 AM. Staff #6 was asked about the mildew and mold in the bathroom. Staff #6 stated, he was not aware that the bathroom was mildewed and moldy. Then he reported that there was a previous patient that was in that room and would turn on the shower and just let it run and run. Staff #6 stated, it ran until it flooded the room multiple times and that's where the mildew was coming from. He also stated he knew about the floor molding loose from the flooding of the bathroom and it was on the list to be fixed.

The facility was aware there was mold in the patient room and bathroom of 305 and continued to assign patients to the room exposing them to potential health risk.


STORAGE ROOM #1 (end of hall 300)

On the end of unit 300 was a storage room. There was no signage on the outside of the room. The following items were found inside:

10 soiled chair cushions piled up next patient medical supplies.

An open container of adult depends were found dusty. Lids to specimen cups were found loosely sitting on a dusty and dirty shelf uncovered.

Old coffee cups and trash were found sitting alongside patient medical supplies.

Medical supplies sitting on dirty shelving and containers opened with dust and hair found on paper scrubs.

Clean bed linen and towels was found open on dirty shelves next to patient medical supplies.

The floor was soiled with dust, hair, and dried spilled liquids. The ceiling vent was rusted.


STORAGE ROOM #2 ON UNIT 300

An unidentified room on unit 300 was opened and the following items were found:

Patient personal items (hygiene) were found.

Medical supplies.

Trash.

Employee drinks and employee belongings.

Patient records.

Patient snacks. The yogurt snacks had come to room temperature.


The room was heavily soiled with dust and dirt on the shelves. The floor had large clumps of human hair, dirt, paper, trash, and old patient stickers. Inside the trash was empty cigarette boxes, Kleenex, wadded up paper, and soda bottles. Inside the trash bag, patient information was found; History and physicals, rosters, and various forms with patient identifiers. The MHT confirmed it was trash but didn't know why patient information was in there.

Employee belongings that were brought from home were stored in the same room with patient belongings and could potential expose the patients to potential hazards during the COVID 19 pandemic.

An interview with Staff #12 and #32 was conducted on 4/15/20 at 11:50 AM. Staff #32 stated, the snacks were brought into this room and stored for the patients but was not aware how the snacks were picked up or disposed of. Staff #12 confirmed, there was a problem with the process in distributing, storing, and disposing of snacks in a safe manner.


STORAGE 400

A room was found with signage that stated Electrical/Storage on Unit 400. The following items were found:

Inside the room was patient belongings and patient hygiene boxes.

Dirty laundry.

Wheel chairs and desk chairs.

Patient Snacks.

In the same cabinet space employee belongings, employee drinks and food (brought from home). Those employee items were sitting next to and exposing patient belongings during the COVID 19 pandemic.

In a paper sack with toiletries was patient snacks. Yogurt was left in the sack and was at room temperature. The food was available for consumption.

There was only one wheelchair labeled as clean from 1/20. There was no other proof that the equipment in the room had been properly cleaned.


UNIT 600

A storage room was found on unit 600. Inside the storage room was the following items:

Paperwork with patient names and information sitting exposed on the cabinet.

Two baskets of dirty laundry.

Patient personal hygiene boxes.

Patient linen and towels.

Gym equipment (balls)

Soiled cushions from chairs in the patient dayroom.

Open drinks and employee belongings (back packs, purses and jackets).

Next to the employee belongings was a sack for the patient's snacks. Inside the sack dated on 4/15/20 was cookies available for consumption.