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Based on documentation review and interview the medical staff failed to review pertinent patient care conditions and requirements prior to admission , provide adequate G-tube feeding orders and/or supplies, and colostomy care orders and/or supplies for 1 of 10 medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Criteria for Admission", no policy number, last revised 03/2024, indicated exclusionary criteria includes patients that cannot be managed safely and adequately at the hospital due to his/her medical problems as determined by his/her medical doctor.

2. After Visit Summary documentation provided by H2 (Acute Care Hospital) to H1 (Psychiatric Hospital) for Pre-Admission Screening on 3/15/24 indicated discharge instructions for enteral supplies set up through H2 along with the instructions and contact information for services to be set up for P1 upon discharge of H2, indicated the patient's diet required tube feedings and a regular diet. Discharge Summary documentation indicated the patient was s/p colostomy placement in 10/2024, underwent a G-tube (Gastrostomy tube) placement on 3/10/24, started G-tube feedings 3/11/24, feeding was advanced to 50 ml (milliliters)/h (hour) with a plan on moving towards bolus feeding at the time of discharge. P1 was discharged from H2 on 3/15/24 then admitted to H1 on 3/15/24 at 7:55 pm.

3. Pre-Admission Patient Screening documentation, completed by H1, dated 3/15/23 indicated P1 was referred to H1 (Psychiatric Hospital) by H2 (Acute Care Hospital) d/t (due/to) unspecified psychosis with a wish to harm him/herself or others. Pre- Admission Patient Medical Evaluation indicated P1 required minimal assistance, was ambulatory, used a wheelchair, required a medical psychiatric bed, could take medication by mouth whole, and had a foley catheter. This medical evaluation did not indicate the patient had either a colostomy and/or PEG (Percutaneous endoscopic gastrostomy)/G-tube present requiring medical supplies and/or enteral nutritional needs.

4. In an interview on 4/2/24 at approximately 2:00 pm with A1 (Chief Executive Officer) confirmed H1 did not get clarification on G-tube feeding and/or ostomy care needs prior to the admittance to H1 on 3/15/23 and should have preventing adequate care of P1. Supplies that H1 lacked for P1's medical care included replacement colostomy bags and enteral feeding supplies.

Base on document review and interview the facility failed to adequately staff per the facilities policy for one inpatient unit (Unit 200) for 7 of 14 days reviewed.

Finding include:

1. The facility policy titled, "Clinical Staff (Nurse) Staffing Plan", PolicyStat ID 12279065, last revised 08/2022, indicated the core staffing matrix per inpatient unit was to be staffed with one (1) clinical staff member for every four (4) patients from 7:00 am - 11:00 pm.

2. The Staffing Pattern Worksheet was reviewed for the dates 3/10/24 - 3/23/24 indicated the following:
a. 3/10/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 13.
b. 3/11/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 13.
c. 3/12/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 14.
d. 3/14/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 13.
e. 3/16/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 14.
f. 3/17/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 14.
g. 3/122/24 lacked 1 clinical staff member from 7:00 am -11:00 pm with a patient census of 15.

3. In an interview on 4/2/24 at approximately 3:15 pm with A4 (Director of Nursing) confirmed the facility was understaffed by lacking one clinical staff member for 7 of 14 days reviewed on the staffing.

Based on documentation review and observation, facility nursing staff failed to complete an incident report by no later than 24 hours after a patient transfer, send all appropriate patient documents with the ambulance service at the time of transfer for 1 of 10 medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Incident Reports", PolicyStat ID 13033981, last revised 01/2023, indicated an incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether and actual injury is involved or not. After providing for the care needs of the individuals involved, hospital staff must complete and submit an incident report as soon as possible. Preferably, the report should be submitted before leaving the hospital at the end of the work shift, but no later than twenty-four (24) hours from the time the event occurred.

2. The facility policy titled, "Transfer of Patient", PolicyStat ID 10623375, last revised 06/2023, indicated copies of all of the following inpatient admission will include, but are not limited to: Face Sheet, Advance Directives, H&P, Psychiatric Evaluations, Care Plan, Laboratory and Radiology Reports, Medication Administration Record, Physician progress notes, Medication Reconciliation, Patient Belonging Inventory List were provided to the transporting entity in order to be given to the accepting facility at the time of arrival.

3. Patient Transfer/Transfer Report documentation dated 3/17/24 for P1 indicated paperwork provided to S1 (Ambulance Service)at the time of transfer to H2 (Acute Care Hospital) included P1's psychiatric evaluation, History & Physical (H&P), Medication Administration Records, Medication Reconciliation, and Face Sheet. P1's EDO, Care Plan, Laboratory and Radiology Reports, and a Patient Belonging Inventory List documents were not included in the transfer documents given to S1 at the time of discharge

4. The facility's incident report log was observed to lack an incident report for the transfer of P1 from H1 to H2 on 3/17/24.

5. In an interview on 4/2/24 at approximately 3:00 pm with N1 (Registered Nurse) confirmed transfer paperwork sent with the patient on 3/17/24 included a face sheet, medication administration record, but does not remember if EDO paperwork was included.

6. In an interview on 4/2/24 at approximately 2:00 pm with A4 (Director of Nursing) confirmed no incident report was completed by nursing staff for the transfer of P1 from H1 to H2 on 3/17/24 when there should have been.