Summit Oaks Hospital

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 49828 Based on review of the facility Master Staffing Grid, review of facility documents, and staff interviews, it was determined the facility failed to provide an adequate number of licensed staff on three of the seven days reviewed. Findings include: On 3/20/24 at 10:09 AM, a tour of the facility with Staff (S)3, Director of Clinical Education, was conducted. The tour included the following units: TU4, Child/Adolescent, TU3 Detox, and TU1 Adult Psychiatric. On 3/20/24 at 10:15 AM, on TU4, an interview with S12, Mental Health Assistant (MHA), was conducted. He/she stated that staffing can be “a little short at times, and sometimes we must pull staff from other units to get to where we have to be.” On 3/20/24 at 10:23 AM, on TU4, an interview with S13, Registered Nurse (RN), was conducted. He/she stated the unit is short staffed most days. On 3/20/24 at 10:30 AM, on TU4, an interview with S9, was conducted. This surveyor requested the previous shifts’ Safety Huddle Sheet, used to document events or behavioral concerns of patients on the unit. He/she stated there was only one nurse on the unit overnight from 11 PM -7 AM, and he/she was unable to fill out the Safety Huddle Sheet for the morning shift. On 3/20/24 at 10:45 AM, on TU3, an interview with S14, RN, was conducted. He/she stated there are times where there is only one nurse on the unit. S14 stated that on 3/18/24, he/she was the only registered nurse assigned on the unit during the 7 AM-7 PM shift. On 3/20/24 at 11:58 AM, a review of the Summit Oaks Hospital Staffing Grid was completed and compared to one week of Patient Care Assignment Sheets (used to record the staff assigned to the unit, and which patients the staff are assigned to). Review of the staffing grid for TU3 revealed the 7 AM-3 PM, and 3 PM-11 PM shift should have a minimum of one registered nurse (RN), and one licensed practical nurse (LPN) for a patient census of 11-18 patients. On 3/15/24, during the 7 AM-3 PM, and 3 PM-7 PM shift, there was only one RN listed on the Patient Care Assignment Sheets with a patient census of 14. On 3/18/24, during the 7 AM-3 PM, and 3 PM-7 PM shift, there was only one RN listed on the Patient Care Assignment Sheets with a patient census of 12. Review of the staffing grid for TU4 revealed the 11 PM-7 AM shift should have a minimum of two RNs for a patient census of 13-22 patients. On 3/19/24 during the 11 PM-7 AM shift, there was only one RN on the assignment sheet with a patient census of 16. On 3/20/24 at 2:11 PM, the above findings were confirmed with S15, Chief Nursing Officer (CNO). S15 stated that on days they are short staffed, the units nurse manager would “help” on the unit. S15 confirmed the availability of the nurse manager for assistance, is not reflected on their staffing sheet.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48414 Based on staff interview, review of facility documents, and review of one of ten medical records, it was determined the facility failed to ensure 1) a patient with a head injury receives neurological checks and 2) nursing reassessments are documented, in accordance with facility policy. Findings include: 1) Reference facility policy titled, “Fall Prevention/Reduction Program” (effective 7/20), states “ ...Definition A fall is a sudden, unplanned event resulting in a person coming to rest on the ground/floor, lower level surface or object from a standing, sitting, or lying position not due to any intentional movement. ...Post-Fall Management ...fall with suspicion of minor head trauma, the nurse will: ...2. Conduct neurological checks at least: i. Every 2 hours for the first 12 hours ii. Every 3 hours for the next 24 hours iii. Every 4 hours for the next 24 hours ...”. On 3/20/24 at 12:00 PM, medical record review of Patient (P)1 revealed, he/she was admitted on 1/4/24 with a diagnosis of Attention Deficit Disorder (ADD), Oppositional Defiant Disorder (ODD), and Disruptive Mood Dysregulation Disorder (DMDD). The Nursing Progress Note on 1/8/24 at 6:30 PM, stated, “Pt was sent to [Emergency Department] for evaluation of head and neck injury. ...Transfer to [Emergency Department]. The RN Transfer Document from 1/8/24 at 6:00 PM, stated, “ ...s/p [status/post] physical altercation, evaluate for head and neck trauma. Pt got hit on the head and neck by peer and sustained a brief unconsciousness. ...”. The Return From Facility form from 1/9/24 at 4:41 AM, stated “ ...New Medical Diagnosis: Injury of head ...Current Physical Status/Medical Problems: status post “injury of head” drowsy with unsteady gait ...”. The Emergency Department [ED] Provider Note from 1/8/24 stated, “ ...[P1] presents to the emergency department from [facility name] for evaluation after being assaulted. [His/her] head is atraumatic vital signs are normal. Based on [his/her] physical exam and mechanism of injury PERCAN [Algorithm used to determine need for brain imaging after pediatric head injury] does not recommend CT at this time. Observation is recommended. [He/she] was observed in the emergency department .... [He/she] is medically stable for discharge back to [facility]. ...”. P1 was discharged from the facility on 1/9/24 at 1:00 PM. P1’s incident report from 1/9/24 at 6:08 PM, stated, “Patient was hit in head and kicked by peer while [he/she] was on ground. ...”. On 3/20/24 at 12:15 PM, a policy related to neurological checks for a patient who sustained a head injury was requested. S2 stated the “only policy related to neurological checks was within the falls policy.” P1 returned from the ED on 1/9/24 at 6:01 AM and was discharged home on 1/9/24 at 1:00 PM. The medical record lacked documentation that neurological checks were performed. S2 confirmed there were no neurological checks documented for P1 upon return from the ED. 2) Reference facility policy titled, “Assessment/Reassessment” (effective 5/20) states, “ ...Policy All patients admitted to [facility name] will be assessed and reassessed for their psychological, physical, and social status. ... Procedure ...4. Reassessments take place when there is a significant change in a patient’s conditions or change in diagnosis. ...Assessment/Reassessment Criteria: RN ...Reassessment Q [every] shift or with change of status of care setting Format ...nursing progress note ...”. Reference facility policy titled, “Daily Nursing Progress Note/Suicide Risk Assessment (effective 6/20), states, “ ...The Daily Nursing Progress Note/Suicide Risk Reassessment form is utilized to document the nursing assessments and reassessments of patients’ responses to interventions and treatment. ...3. The nursing progress includes but is not limited to the following clinical information: 1. Individual behaviors especially those behaviors necessitating hospitalization. ...7. Significant interactions with staff, family/guardian, peers ... 4. The following events require an additional nursing progress note: 1. Presence of patient crisis or significant event in the course of treatment ...3. Medial emergency and/or problem ...6. Events which significantly impact a patient’s status whether positively or negatively. ... On 3/20/24 at 12:00 PM, medical record review of P1 was conducted. The Nursing Progress Note on 1/8/24 at 6:30 PM, stated, “Pt was sent to [Emergency Department] for evaluation of head and neck injury. [Grandpa/Grandma] made aware assault to patient. Transfer to [Emergency Department].” The Nursing Progress Note on 1/8/24 at 6:30 PM, lacked documentation of clinical information in accordance with the facility policy. On 3/20/24 at 12:35 AM, these findings were confirmed with S2.”