HospitalInspections.org

20638


Based on records review and interviews, the hospital failed to meet the Condition for Participation for Nursing Services by:

1) failing to ensure a Registered Nurse supervised and evaluated the care of each patient as evidenced by:
1a) failing to ensure that a suicidal patient, post suicidal gesture, was observed 1:1 as ordered by the physician for 1 of 8 sampled patients (Patient #F2). See findings cited at A0395.
1b)failing to ensure that a patient who fell in the hospital was assessed and evaluated by the Registered Nurse, as per hospital policy. A patient refused to get out of bed at 5:45 a.m. on 10/12/11 due to complaints of right ankle pain for 1 sampled patient out of a total of 8 sampled patients, (Patient #F1). X-rays on 10/13/2011 revealed the patient had (#F1) a fractured ankle. See findings cited at A0395.
1c) failing to ensure that the physician was notified of a significant change in condition of a patient, as per hospital policy. A patient had fallen the night before and refused to get out of bed due to right ankle pain for 1 sampled patient out of a total of 8 sampled patients, (Patient #F1). See findings cited at A0395.

2) failing to develop and implement a system to ensure all employees were assessed for competency and current certification in Cardio Pulmonary Resuscitation(CPR) and Crisis Prevention Intervention (CPI). In 5 of 6 employees reviewed that worked on 10/23/2011 from 7:00 p.m. - 7:00 a.m. (FS18, FS19, FS20, FS21, and FS22) and 2 of 6 (FS8 and FS17) employees reviewed that worked on 10/24/2011 from 7:00 a.m. - 7:00 p.m. there were no evidence of competency assessment or verification of certification before these employees were assigned to provide patient care. (See findings cited at A0397).

The immediate jeopardy that remained in place from the survey conducted on 9/28/2011 was removed on 10/21/2011 at 3:00 p.m. The hospital changed their observation levels to a two level system and instructed Mental Health Techs on the two level system. Interviews and Observations of Mental Health Techs illustrated understanding and compliance with the two level observation system. A new policy regarding Homicidal Patients was developed and being taught to oncoming nurses at the beginning of each shift. No Homicidal Patients had been admitted for record review. All new patients had admission assessments regarding Side Effects of Medications and the new hospital orientation and skills competency fair addressed identifying, treating, and monitoring of patients with side effects to include EPS (Extrapyramidal Symptoms) of anti-psychotic medications. No patients with EPS symptoms had been admitted to the hospital for record review.

The deficiency remains at a Condition Level.






26458

26351




20177




20638


Based on records review and interviews the hospital failed to ensure a Registered Nurse supervised and evaluated the care of each patient as evidenced by:

1) failing to ensure that a suicidal patient, post suicidal gesture, was observed 1:1 as ordered by the physician (Patient #F2) for 1 of 8 sampled patients (Patient #F2),

2) failing to ensure that a patient who fell in the hospital was assessed and evaluated by the Registered Nurse, as per hospital policy. A patient refused to get out of bed at 5:45 a.m. on 10/12/11 due to complaints of right ankle pain for 1 of 8 sampled patients, (Patient #F1). X-rays on 10/13/2011 revealed the patient had (#F1) a fractured ankle,

3) failing to ensure that the physician was notified of a significant change in condition of a patient, as per hospital policy. A patient who had fallen the night before refused to get out of bed due to right ankle pain for 1 sampled patient out of a total of 8 sampled patients, (Patient #F1), and

4) failing to ensure that the hospital policy regarding vital signs was followed. Patients with abnormal vital signs taken by Mental Health Techs were not re-assessed by a nurse as per hospital policy for 2 of 2 patients (Patient #F6 and #F7)out of a total sample of 8. The nurse failed to re-assess a patient with a change in condition (facial flushing and head ache) as per policy for 1 of 8 sampled patients (Patient #F3).

Findings:

1) Patient #F2 was admitted to the hospital as a transfer from another facility on 10/17/2011 with diagnoses of Psychosis Not Otherwise Specified, Mood Disorder Not Otherwise Specified, and Post Traumatic Stress Disorder. Review of Patient #F2's Physician's Emergency Certificate (PEC) from the sending facility, signed by the sending physician on 10/17/2011 at 4:30 a.m., revealed in part, "C/O (complained of) 'I don't want to live anymore' - made suicidal gesture in ER (Emergency Room) wrapped cord around neck). I am of the opinion that the above person named (Patient #F2) is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering from substance abuse so that he/she is dangerous to self and unwilling to seek voluntary admission." Review of Patient #F2's Observation Form at St. James Behavioral Hospital revealed the patient was admitted to the hospital on 10/17/2011 at 12:15 p.m.

Review of Patient #F2's Suicide Risk Assessment with no date, time, or authentication signature revealed in part, "Has the patient identified a method/weapon? Yes, Hanging. Has the patient attempted suicide in the past? Multiple hanging, OD (over dose), wrists. Has the patient ever attempted suicide while hospitalized? Yes, In ER (Emergency Room)- cord on neck. Have any family members or loved ones committed suicide? Yes, Aunt. Has the patient experienced a recent significant loss, such as a spouse, child, job etc? Yes, child. Does the patient allow suicidal thoughts to preoccupy him/her? Yes, was this a.m. (morning). Does the patient deny having a support system? Unknown. Does the patient experience frequent periods of withdrawal, depressed affect, lethargy, short attention span, insomnia, difficulty concentrating, and /or anorexia? Yes. . . ."

Review of Patient #F2's Nursing Notes dated 10/17 (2011) 2p (2:00 p.m.) completed by Registered Nurse FS6 (former Director of Nursing) revealed in part, "Assessment complete (1 hour and 45 minutes after arrival to the hospital), Disheveled, poor eye contact, per pt (patient) she tried to kill self at ER with a cord around neck. Multiple hx (history) of attempts by hanging, OD, wrists. . . Pt states PTSD (Post Traumatic Stress Disorder) from childhood sexual, physical, emotional , and drug abuse by parents."

Review of Patient #F2's physician orders dated 10/17/2011 signed by the physician at 1400 (2:00 p.m.) revealed in part, "Q15 (every 15 minute) checks, 1:1 AL (arm's length)."

Review of Patient #F2's Observation Form at St. James Behavioral Hospital revealed the patient was placed on "Q15 (Every 15 minute) Observation" from 1215 (12:15 p.m.) through 1900 (7:00 p.m.) on 10/17/2011. Review of Suicidal Patient #F2's entire medical record revealed no documented evidence that the patient (#F2) had been monitored/observed one to one at arm's length as ordered from 12:15 p.m. through 7:00 p.m. on 10/17/2011.

During a face to face interview on 10/21/2011 at 9:50 a.m., Mental Health Technician, FS13, indicated she (FS13) had been the tech assigned to monitor Patient #F2 on the 10/17/2011 during the 7 a.m. to 7 p.m. shift. FS13 further indicated the patient (#F2) had been monitored every 15 minutes as documented on the Observation Flow sheet from 12:15 p.m. until 7:00 p.m.. FS13 indicated she (FS13) had never been told to place the patient (#F2) on 1:1 arm's length. FS13 indicated at the change of shift someone told the oncoming Mental Health Tech that the patient (#F2) should be 1:1 arm's length; however, she (#FS13) had never been given those instructions and had never provided more than 15 minute observations to Patient #F2.

During a face to face interview on 10/21/2011 at 10:00 a.m., Registered Nurse, FS6, indicated he (FS6) had been the nurse that had received the request for admission of Patient #F2 to St James Behavioral Hospital from the sending facility. FS6 confirmed the packet with the request for admission contained a copy of the PEC which indicated Patient #F2 had wrapped a cord around her neck in the Emergency Department as a suicidal gesture while located at the sending facility. FS6 indicated he (FS6) had not noticed the documentation in the packet that Patient #F2 had made a suicidal gesture in the Emergency Room of the sending facility. FS6 indicated St James Behavioral Hospital had two levels of observation: 1) Every 15 minute observations and 2) 1:1 arm's length. FS6 further indicated a nurse could place any patient on the higher level of observation if deemed necessary and then contact the patient's physician for an order. FS6 indicated he (FS6) would have informed the Mental Health Tech assigned to Patient #F2 that the patient should be on 1:1 arm's length from the point of admission if he (FS6) had noticed the documentation indicating Patient #F2 had made a suicidal gesture prior to arrival at the hospital. FS6 further indicated he (FS6) had not been aware that Patient #F2 had never been placed on 1:1 arm's length on 10/17/2011 from 12:15 p.m. through 7:00 p.m.. Mental Health Tech FS13 was called to the room and in the presence of FS6, re-stated that she (FS13) had never been instructed to place Patient #F2 on 1:1 Arm's Length on 10/17/2011. FS6 indicated he (FS6) had told someone that the patient (#F2) needed to be on 1:1 Arm's Length but did not recall who he (FS6) had told.

During a face to face interview on 10/21/2011 at 10:20 a.m., Director of Nursing FS2 indicated a patient; such as Patient #F2, who had expressed Suicidal Ideation and made a Suicidal Gesture prior to admission to the hospital should have been placed on 1:1 immediately upon arrival to the hospital. FS2 further indicated the patient should have been assessed by the Registered Nurse ASAP (as soon as possible) when the patient arrived at the hospital.

Review of the hospital policy titled, "Suicide Precautions, #8.33 last reviewed December 2011" revealed in part, "Upon admission to the Hospital, every patient will be evaluated for suicidality. . . All patient admitted following a suicide attempt will be considered at high risk. For these patients, suicide precautions will be initiated upon arrival to the hospital. An order for suicide precaution will be written by the attending psychiatrist. Suicide precaution may be instituted prior to securing a written order as determined by nursing staff. The order will follow as soon as practical precautions are in effect. . .Guidelines for Suicide Assessment: Level I: Close Observation . . . Level II: Visual Contact. . . Level III: One to One Arm's length Observation: Patient is in imminent danger of implementing suicide. Patient Behavior: verbalizing, clear intent for self harm, concrete and viable plan, delusions of self mutilation, command hallucinations, unable to commit to safety, poor impulse control, no insight into existing problems, and past attempts by lethal method. Nursing intervention: 1:1 Constant observation at arm's length twenty four hours a day . . ."

Review of the hospital policy titled, "Suicide Precautions #8.33 revised on 10/17/2011" revealed a change in the Levels of Observation from 3 levels to 2 levels: "Level I: q 15 minute observations" and "Level II One to One Arm's length Observations".

2) Review of the medical record for Patient #F1 revealed she was admitted on 10/11/11 with the diagnosis of Bipolar Disorder. Review of the "Nursing Assessment" Notes dated/timed 10/11/11 at 10:00 p.m. (2200) written by FS11, LPN (Licensed Practical Nurse), revealed the patient fell in the day room and had complaints of right ankle pain. Further review of the Nursing Notes documented by FS11 revealed in part, ". . . No injuries or bruises noted. Pt (patient) c/o (complained of) R (right) ankle pain and RN (no name identified) arrived, V/S (vital signs) taken, Assisted pt (patient) to wheelchair and then to bed. Tylenol given for "c/o (complaints of) R (right) ankle pain but there was no swelling. MD (no name identified) was notified. Will monitor...".

Review of the "Nursing Assessment" for Patient #F1 dated/timed 10/11/11 at 5:45 a.m. (0545/ ) read in part, "...the patient (#F1) does not want to get up to have labs drawn due to right ankle pain...". Review of the entire medical record revealed no documented evidence of a Registered Nurse assessment of Patient #F1 immediately post fall and/or at 5:45 a.m. when the patient would not get out of bed due to right ankle pain. Further review of the record revealed no documented evidence as to the patient level of pain, pedal pulses, capillary refill, temperature of extremity, absence of and/or presence of swelling, absence of and/or presence of deformity post fall on 10/11/2011 at 10:00 p.m. (2200) or when Patient #F1 refused to get out of bed due to ankle pain the following morning on 10/12/2011 at 5:45 a.m.. Further review of the medical record revealed no documented evidence that the patient's physician was notified of the patient's refusal to stand due to ankle pain at 5:45 a.m. on 10/12/11.

Review of the right foot three views X-ray done on 10/13/11 at 12:34 p.m. (1234/second day post fall) and the report written on 10/13/11 at 1:01 p.m. (1301) read in part, " ...Impression: ...Fracture of the distal right fibula ... " . Further review of the right ankle three views X-ray done on 10/13/11 at 12:31 p.m. (1231) and the report written on 10/13/11 at 12:59 p.m. (1259) read in part, " ...Impression: ...Fracture line suggesting acute fracture without displacement within the right fibula or lateral malleolus, with associated soft tissue swelling ... "
Review of the "Physicians Orders" dated/timed 10/13/11 at 4:00 p.m. (1600) read in part, "...Transfer to hospital "a" for evaluation of R (right) ankle...".
The policy titled, "Nursing Documentation Guidelines", Policy 2.14, Originated date of March 2010; with no revised and/or reviewed dates; presented as the hospital's current "Assessment of Patients" policy for October of 2011 was reviewed. The policy indicated a Registered Nurse shall be responsible for completing the initial patient assessment. Nurses are to document every shift on the patient daily records. Changes in the patient status will result in reassessment. The reassessment is to be documented in the patient's daily record and communicated to the physician involved in the patient's care.

During an interview on 10/20/11 at 11:10 a.m., Patient #F1 requested to speak in private with the surveyor. Patient #F1 indicated she was admitted into the hospital the Tuesday prior to the interview (10/11/11) and she (#F1) fell that night in the day room. She indicated she broke her ankle that night. She (#F1) further indicated no X-ray was done on her foot (right ankle) until the Thursday (about 3 days later). Patient #F1 indicated she was in severe pain during this time from the Tuesday (10/11/11) through Thursday (10/13/11).

In an interview on 10/20/11 at 3:50 p.m. (1550), FS11 confirmed Patient #F1 fell in day room on 10/11/11 at 10:00 p.m. (2200). Further the FS11 confirmed that Patient #F1 fractured her right fibula. FS11 verified that Patient #F1 complained of right ankle pain after she fell that night. FS11 indicated Patient #F1 refused to move her right ankle at 5:45 a.m. on 10/12/11. Further, FS11 indicated this was a change in the patient's condition.

During an interview on 10/20/11 at 7:45 a.m., FS12, Registered Nurse (RN), verified Patient #F1 fell at 10:00 p.m. (2200) on 10/11/11. Further, FS12 verified at 5:45 a.m. Patient #F1 refused to get out of bed due to right ankle pain. The FS12 indicated this was a change in the patient's condition requiring an assessment and evaluation as per policy. FS12 indicated she had not been informed that Patient #F1 had not been able to stand the following morning due to right ankle pain. FS12 denied re-assessing and re-evaluating Patient #F1's right ankle at 5:45 a.m. on 10/12/11 as per policy.

An interview was held on 10/21/11 3:55 p.m. with S2, DON (Director of Nursing). S2 verified there was no documented evidence that FS12 re-assessed and re-evaluated Patient #F1 at 5:45 a.m. on 10/12/11 after the patient's condition changed as per policy. S2 stated that FS12 failed to follow the policy to assess and document the assessment of Patient #F1 at 5:45 a.m. on 10/12/11.

3) Patient #F1: Review of the Nursing Assessment for Patient #F1 by FS11 dated/timed 10/11/11 at 5:45 a.m. (0545) read in part, "...the patient (#F1) does not want to get up to have labs drawn due to right ankle pain...". Further review of the record revealed there was no documentation FS11 (assigned to the care of Patient #F1) or FS12 (Charge Nurse on duty) notified the physician of Patient #F1's refusal to get up due to her right ankle pain at 5:45 a.m. (0545) on 10/11/11.

The policy titled, "Care of the Patient", Policy 3.13, Originated date of June 2006; Reviewed date(s) of May 2007, June 2008, January 2010; Revised date of May 2009, presented as the hospital's current" Notification to Physician of Significant Changes" policy was reviewed. The policy read in part, "...It is the Policy of the Psychiatric Program that Physicians must be notified of...the following circumstances regarding their patients:...Pertinent changes in condition...4. Any unusual occurrences involving the patient...Procedure 1. Contact the physician via pager, answering service, cell phone or at home...2. Document the time the call was placed, the number called, and the response...".

In an interview on 10/20/11 at 3:50 p.m. (1550), FS11 confirmed that Patient #F1 fell in day room on 10/11/11 at 10:00 p.m. (2200). FS11 indicated this was a significant change in Patient #F1's condition that required physician notification as per policy. Further, FS11 denied contacting the physician regarding Patient #F1's change in condition on 10/12/11 as per policy. FS11 confirmed there was no documented evidence the physician was notified regarding the change in Patient #F1's condition by FS12 on 10/12/11 as per policy. FS11 recalled reporting Patient #F1's refusal to get out of bed due to right ankle pain to the FS12 that same morning.

During an interview on 10/20/11 at 7:45 a.m., FS12 verified that Patient #F1 fell at 10:00 p.m. (2200) on 10/11/11. Further, FS12 verified that Patient #F1 refused to get out of bed at 5:45 a.m. on 10/12/11. FS12 indicated that this was a significant change in Patient #F1's condition that should have been reported to the physician as per policy. FS12 denied calling the physician regarding Patient #F1's refusal to get out of bed due to right ankle pain during her shift from 7:00 p.m. on 10/11/11 through 7:00 a.m. on 10/12/11 as per policy.

In interview on 10/21/11 1:55 p.m., S2 verified there was no documented evidence that the physician was notified regarding Patient #F1's refusal to get out of bed due to right ankle pain at 5:45 a.m. on 10/12/11 as per policy. S2 indicated that this was a significant change in the patient's (#F1's) condition that should have been reported to the physician, immediately as per policy. Further, S2 indicated the physician notification must be documented in the patient's medical record as per policy.

4)Review of the hospital policy titled, "Vital Signs-Blood Pressure, Temperature, Pulse, Respiration #3.23, Revised October 2011" presented by the hospital as current revealed in part, "Vital Signs are routinely taken by the MHT (Mental Health Tech) and recorded on the Vital Sign Worksheet. They are then recorded on the vital signs record of the chart by the MHT. Abnormal vital signs are re-checked by the registered nurse manually and appropriate action is taken. . . If second recheck remains out of range, notify physician. . . Abnormal Parameters: Pulse > (greater than) 100 or < (less than) 60. Systolic > 140 or < 100. . ."

Patient #F6 was admitted to the hospital on 10/22/2011 with diagnoses that included Chronic Paranoid Schizophrenia. Further review revealed abnormal vital signs as recorded by the Mental Health Tech on the patient's (#F6) graphic Flowsheet as follows:

10/22/2011 at 1600 (4:00 p.m.) - blood pressure 99/72
10/23/2011 at 2400 (12 midnight) - blood pressure 99/63, pulse 55
10/23/2011 at 0400 (4:00 a.m.) - blood pressure 98/62, pulse 55
10/23/2011 at 1200 (12:00 p.m.) - pulse 57

Review of Patient #F6's entire medical record revealed no documented evidence that Patient #F6's abnormal vital signs were re-assessed by a nurse on 10/22/2011 at 1600 or 10/23/2011 at 2400, 0400, and 1200.

Patient #F7 was admitted to the hospital on 10/22/2011 with diagnoses that included Major Depression. Further review revealed abnormal vital signs as recorded by the Mental Health Tech on the patient's (#F7) graphic Flowsheet as follows:

10/23/2011 at 0400 (4:00 a.m.) - blood pressure 98/60
10/23/2011 at 1200 (12:00 p.m.)- blood pressure 89/52

Review of Patient #F7's entire medical record revealed no documented evidence that Patient #F7's abnormal vital signs were re-assessed by a nurse on 10/23/2011 at 0400 or 1200.

During a face to face interview on 10/24/2011 at 1055 (10:55 a.m.), S2 indicated the nursing staff on duty; when Patient #F6 and #F7 had abnormal vital sign readings documented on the graphic flow sheet by the Mental Health Tech, should have re-evaluated/re-assessed the patients' (#F6 and #F7) vital signs as per hospital policy and should have documented their assessment and evaluation of findings in the patients' (#F6 and #F7) medical records.

Review of the medical record revealed Patient #F3 was admitted to the hospital on 10/11/11 at 8:25 p.m. (2025) with the diagnosis of Major Depressive Disorder. Review of the "Nursing Assessment AM Shift" dated/timed 10/21/11 at 9:30 a.m. (0930) read in part, "...Patient c/o (complains of) flushing, cheeks slightly red. VS good...". Review of the "Nursing Assessment AM Shift" dated/timed 10/21/11 at 10:55 a.m. (1055) read in part, "...Patient cheeks not as red stated flushing is better but c/o headache...".

The policy titled, "Nursing Documentation Guidelines", Policy 2.14, Originated date of March 2010; with no revised and/or reviewed dates; presented as the hospital's current "Assessment of Patients" policy for October of 2011 was reviewed. The policy indicated a Registered Nurse shall be responsible for completing the initial patient assessment. Nurses are to document every shift on the patient daily records. Changes in the patient status will result in reassessment. The reassessment is to be documented in the patient's daily record and communicated to the physician involved in the patient's care.

Review of the hospital policy titled, " Vital Signs-Blood Pressure, Temperature, Pulse, Respiration", Policy #3.23, last revised October 2011, revealed in part, " ...Vital Signs are taken anytime there is a sudden apparent change in the patient's condition... " .

Review of the "Graphic Flowsheet" revealed vital signs-blood pressure, temperature, pulse and respirations were recorded for Patient #F3 on 10/21/11 at 7:00 a.m. (0700) and at 7:00 p.m. (1900). Further review revealed there was no documented evidence vital signs-blood pressure, temperature, pulse, or respirations were taken for Patient #F3 when she exhibited a change in condition at 9:30 a.m. (0930) and/or 10:55 a.m. (10:55) on 10/21/11 as per policy.

During an interview on 10/24/11 at 11:25 a.m., S2 verified Patient #F3 complained of flushing at 9:30 a.m. and complained of a headache at 10:55 a.m. on 10/21/11. S2 indicated this was a significant change in Patient #F3's condition. S2 further indicated vital signs-blood pressure, temperature, pulse, or respirations should had been taken for Patient #F3's sudden apparent change in condition as per policy. S2 verified there was no assessment of Patient #F3's vital signs-blood pressure, temperature, pulse, or respirations at 9:30 a.m. and/or at 10:55 a.m. as per policy. Further S2 indicated the Registered Nurse should have assessed Patient #F3's vital signs-blood pressure, temperature, pulse, or respirations at 9:30 a.m. and at 10:55 a.m. on 10/21/11 as per policy.












25059





25065

20638


Based on records review and interviews, the hospital failed to develop and implement a system to ensure that all employees were assessed for competency and current certification in Cardio Pulmonary Resuscitation(CPR) and Crisis Prevention Intervention (CPI). In 5 of 6 employees reviewed (FS18, FS19, FS20, FS21, and FS22) that worked on 10/23/2011 from 7:00 p.m. - 7:00 a.m. and 2 of 6 employees reviewed (FS8 and FS17) that worked on 10/24/2011 from 7:00 a.m. - 7:00 p.m. there were no evidence that competency evaluation was completed or certification verified. Findings:

Review of the Daily Schedule and Assignments for 10/23/2011 from 7:00 p.m. through 7:00 a.m. revealed 1 Registered Nurse, 2 Licensed Practical Nurses, and 7 Mental Health Techs were on duty. Six (6) of the ten (10) employees that worked the night shift on 10/23/2011 personnel files were reviewed (FS18, FS19, FS20, FS21, FS22, and FS23) with Staff Development Coordinator SFS5. Review revealed:

Registered Nurse FS18 (Date of Hire 8/25/11) failed to have any documented evidence of current competency evaluation, CPR certification, or CPI certification.

Licensed Practical Nurse FS19 (Date of Hire 4/20/11) failed to have any documented evidence of current CPI.

Licensed Practical Nurse FS20 (Date of Hire 1/28/11) failed to have any documented evidence of current competency evaluation.

Mental Health Tech FS21 (Date of Hire 9/13/11) failed to have any documented evidence of current CPR certification or CPI certification.

Mental Health Tech FS22 (Date of Hire 9/01/11) failed to have any documented evidence of current competency evaluation, CPR certification, or CPI certification.

Review of the Daily Schedule and Assignments for 10/24/2011 from 7:00 a.m. through 7:00 p.m. revealed 2 Registered Nurses, 2 Licensed Practical Nurses, and 8 Mental Health Techs were on duty. Six (6) of the twelve (12) employees that worked the date shift on 10/24/2011 personnel files were reviewed (FS8, FS9, FS17, FS24, FS25, FS26, ) with Staff Development Coordinator SFS5. Review revealed:

Mental Health Tech FS17 (Date of Hire 8/16/11) failed to have any documented evidence of current competency evaluation or CPI certification.

Mental Health Tech FS8 (Date of Hire 4/12/11) failed to have any documented evidence of current competency evaluation.

During a face to face interview on 10/24/2011 at 11:30 a.m., FS5 confirmed the above findings. FS5 further indicated that although she had been working greater than 40 hours a week training and evaluating employees at the hospital, she had not yet been able to train and evaluate all employees. FS5 indicated the goal of the hospital was to ensure all clinical staff received certification in CPR and CPI and maintained current status with certification. FS5 further indicated all hospital employees should have been evaluated and deemed competent in skills annually.

Review of the hospital policy titled, "Competency Assessment, #9.8 reviewed 8/2011" presented by the hospital as their current policy revealed in part, "Competency of all hospital employees, contracted personnel and volunteers will be assessed during orientation and the introductory period, as well as periodically throughout the course of a year and during annual performance evaluations. . . Performance assessments and proficiency demonstration will occur during orientation and the introductory period, as well as periodically throughout employment as appropriate per hospital policy and procedure. . . Each employee is subject to an annual performance evaluation, during which the employee's competence in performing the duties as delineated in there respective job description shall be evaluated.

Review of the hospital policy titled, "Management of Human Resources, #9.13, June 2006" presented by the hospital as current revealed in part, "Clinical staff are additionally responsible for attendance at: CPR recertification prior to expiration of current certification. . . . CPI recertification prior to expiration of current certification."





25059




25065




26351

20638


Based on records review and interviews, the hospital failed to ensure all medical record entries were dated, timed, authenticated, and complete for 2 of 8 medical records reviewed (Patient #F2). Findings:

Patient #F2 was admitted to the hospital as a transfer from another facility on 10/17/2011 with diagnoses of Psychosis Not Otherwise Specified, Mood Disorder Not Otherwise Specified, and Post Traumatic Stress Disorder. Review of Patient #F2's Registered Nurse Admission and Suicide Risk Assessment revealed no documented evidence of the date and time the assessment had been done and no documented signature to reveal who had performed the assessment.

During a face to face interview on 10/21/2011 at 10:00 a.m., FS6 indicated he (FS6) had been the nurse that had completed the Registered Nurse Admission Assessment and Suicide Risk Assessment for Patient #F2. FS6 confirmed that he had failed to date, time, and authenticated the documentation.

During a face to face interview on 10/21/2011 at 10:20 a.m., FS2 indicated all entries in the Medical Records of patients should be dated, timed, and authenticated.

Patient #F1: Review of the medical record for Patient #F1 revealed she was admitted on 10/11/11 with the diagnosis of Bipolar Disorder. Review of the Nursing Assessment Notes dated/timed 10/11/11 at 10:00 p.m. (2200) by FS11 revealed that the patient fell in the day room and had complaints of right ankle pain. Review of the entire medical record revealed no documented evidence of a Registered Nurse assessment of Patient #F1 immediately post fall.
During an interview on 10/20/11 at 7:45 a.m., FS12 indicated she had assessed Patient #F1 immediately post fall on 10/11/2011 around 10:00 p.m.; however, she had not documented the assessment. FS12 further indicated she (FS12) should have documented.
The policy titled, "Nursing Documentation Guidelines", Policy 2.14, Originated date of March 2010; with no revised and/or reviewed dates; presented as the hospital's current "Assessment of Patients" policy for October of 2011 was reviewed. The policy indicated a Registered Nurse shall be responsible for completing the initial patient assessment. Nurses are to document every shift on the patient daily records. Changes in the patient status will result in reassessment. The reassessment is to be documented in the patient's daily record and communicated to the physician involved in the patient's care.






26351

20638



Based on record reviews and interviews, the hospital failed to meet the Condition of Participation of Special Provisions Applying to Psychiatric Hospitals because it failed to be in compliance with one (CoP of Nursing Services at ?482.23) of the Conditions of Participation specified in ?482.1 through ?482.23 and ?482.25 through ?482.57.

(See findings at A0385, A0395, and A0397 ).





26458

20638



Based on record reviews and interviews, this hospital failed to meet one the Conditions of Participation specified in ?482.1 through ?482.23 and ?482.25 through ?482.57 specifically the Condition of Participation requirements for Nursing Services.

Services at ?482.23 (See findings at A0385, A0395, and A0397).






26458

20638



Based on record reviews and interviews the hospital failed to ensure an adequate number of competent clinical staff to provide patient care as evidenced by the lack of system to ensure all clinical employees were assessed for skills competency and current certification in Cardio Pulmonary Resuscitation(CPR) and Crisis Prevention Intervention (CPI). In 5 of 6 employees reviewed that worked on 10/23/2011 from 7:00 p.m. - 7:00 a.m. (FS18, FS19, FS20, FS21, and FS22) and 2 of 6 employees reviewed that worked on 10/24/2011 from 7:00 a.m. - 7:00 p.m. (FS8 and FS17), there were no evidence found that skills competency were done or certifications verified before these employees were assigned to provide patient care. Findings:

Review of the Daily Schedule and Assignments for 10/23/2011 from 7:00 p.m. through 7:00 a.m. revealed 1 Registered Nurse, 2 Licensed Practical Nurses, and 7 Mental Health Techs were on duty. Six (6) of the ten (10) employees that worked the night shift on 10/23/2011 personnel files were reviewed (FS18, FS19, FS20, FS21, FS22, and FS23) with Staff Development Coordinator SFS5. Review revealed:

Registered Nurse FS18 (Date of Hire 8/25/11) failed to have any documented evidence of current competency evaluation, CPR certification, or CPI certification.

Licensed Practical Nurse FS19 (Date of Hire 4/20/11) failed to have any documented evidence of current CPI.

Licensed Practical Nurse FS20 (Date of Hire 1/28/11) failed to have any documented evidence of current competency evaluation.

Mental Health Tech FS21 (Date of Hire 9/13/11) failed to have any documented evidence of current CPR certification or CPI certification.

Mental Health Tech FS22 (Date of Hire 9/01/11) failed to have any documented evidence of current competency evaluation, CPR certification, or CPI certification.

Review of the Daily Schedule and Assignments for 10/24/2011 from 7:00 a.m. through 7:00 p.m. revealed 2 Registered Nurses, 2 Licensed Practical Nurses, and 8 Mental Health Techs were on duty. Six (6) of the twelve (12) employees that worked the date shift on 10/24/2011 personnel files were reviewed (FS8, FS9, FS17, FS24, FS25, FS26, ) with Staff Development Coordinator SFS5. Review revealed:

Mental Health Tech FS17 (Date of Hire 8/16/11) failed to have any documented evidence of current competency evaluation or CPI certification.

Mental Health Tech FS8 (Date of Hire 4/12/11) failed to have any documented evidence of current competency evaluation.

During a face to face interview on 10/24/2011 at 11:30 a.m., Staff Development Coordinator, FS5, confirmed the above findings. FS5 further indicated that although she had been working greater than 40 hours a week training and evaluating employees at the hospital, she had not yet been able to train and evaluate all employees. FS5 indicated the goal of the hospital was to ensure all clinical staff received certification in CPR and CPI and maintained current status with certification. FS5 further indicated that all hospital employees should have been evaluated and deemed competent in skills annually.

Review of the hospital policy titled, "Competency Assessment, #9.8 reviewed 8/2011" presented by the hospital as their current policy revealed in part, "Competency of all hospital employees, contracted personnel and volunteers will be assessed during orientation and the introductory period, as well as periodically throughout the course of a year and during annual performance evaluations. . . Performance assessments and proficiency demonstration will occur during orientation and the introductory period, as well as periodically throughout employment as appropriate per hospital policy and procedure. . . Each employee is subject to an annual performance evaluation, during which the employee's competence in performing the duties as delineated in there respective job description shall be evaluated.

Review of the hospital policy titled, "Management of Human Resources, #9.13, June 2006" presented by the hospital as current revealed in part, "Clinical staff are additionally responsible for attendance at: CPR recertification prior to expiration of current certification. . . . CPI recertification prior to expiration of current certification."


26458