Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 11/03/2011
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0395 RN SUPERVISION OF NURSING CARE
CFR(s): 482.23(b)(3)

A registered nurse must supervise and evaluate the nursing care for each patient.


This STANDARD is not met as evidenced by:
Based on observation, staff interview, and medical record review, the facility failed to provide consistent monitoring for 3 of 3 patients (#5, #6, #10) in the Behaviorial Health Services (BHS) unit who were assessed as needing close observation. In addition, the facility failed to ensure a safe environment for patient #5 who was at risk for self injury. The findings were: Interview on 10/31/11 at 4 PM with RN #1, who was the nurse on duty in the BHS unit revealed patients #5, #6, and #10 required close monitoring. The RN stated staff were to observe the patients every fifteen minutes and document the observations on a form called the "Behavioral Health Daily Graphics Sheet" (BHDGS). The following concerns were identified: 1. Observation in the BHS unit on 10/31/11 from 3:35 PM to 4:50 PM revealed the bathroom flush valves and plumbing hardware on the sinks in all of the patients' rooms could potentially be used in a harmful manner by patients who were assessed as high suicidal risks. Interview with the director of the unit on 11/1/11 at 3:15 PM revealed he had identified this as one of the areas that made the unit environmentally unsafe for patients at risk for self injury. He stated replacement hardware was ordered and measures to ensure safety had been implemented until the existing parts could be replaced. He further stated the safety measures included surveillance and close monitoring of the patients. Review of the 10/29/11 multidisciplinary treatment plan for patient #5 showed the "reason for admission" was "danger to self." Review of the care plan showed interventions included monitoring to evaluate, maintain and assess safety issues. However, review of the 10/31/11 BHDGS for the patient showed documentation from 1:30 PM to 3 PM (one and a half hours) was lacking. 2. Review of the 10/31/11 BHDGS for patient #6 showed staff determined the patient needed to be monitored every fifteen minutes due to "Clinical Institute Withdrawal Assessment" (CIWA) precautions. Further review showed documentation was lacking from 1:00 PM to 2:45 PM (one hour and forty-five minutes). 3. Review of the 10/31/11BHDGS for patient #10 showed staff determined the patient needed to be monitored every fifteen minutes due to CIWA precautions. Further review showed the lack of documentation from 11:45 AM to 3 PM (three hours and fifteen minutes). 4. Interview with the director on 11/1/11 at 3:30 PM revealed the facility had not developed a policy and procedure regarding when to initiate the BHDGS protocol and how to complete it, but the expectation was that the patient was to be observed every fifteen minutes and the observation should be documented. He further stated incomplete documentation on the BHDGS for patients #5, #6 and #10 was not an acceptable practice.