HospitalInspections.org

Based on observation, interview, record review, policy review, and review of digital video recording, the hospital's Governing Body failed to:
- Ensure the Chief Executive Officer (CEO, appointed by the Governing Body) effectively managed the hospital in order to meet applicable regulatory requirements.
- Recognize an internal policy, used to guide Security Officers, gave direction for security staff to use law enforcement techniques, including Oleoresin Capsicum (OC, also known as pepper-spray, a compound spray that irritates the eyes to cause a burning sensation, pain and temporary blindness typically used by law enforcement) spray, hand cuffs, the use of wrist-to-waist locking restraints (W2, restraint devices used by law enforcement), and four and five-point locking restraints (medical cuffs which require a key to unlock, applied to both arms and both legs to prevent someone from causing harm to themselves or others) on patients.
- Recognize that the use of law enforcement techniques were law enforcement actions and not a health care intervention.
- Ensure nursing staff maintained responsibility of patients when security responded to an event.
- Ensure the least restrictive method was used to control behavioral symptoms for three patients (#1, #95, #96) who were OC sprayed and placed in restraints.

These failures had the potential to affect all patients in the hospital. The hospital census was 478.

The severity and cumulative effect of these systemic practices resulted in the hospital's noncompliance with 42 CFR 482.12 Condition of Participation: Governing Body, and resulted in the hospital's failure to ensure quality health care and safety.

Refer to A 0057 for further details.

Based on observation, interview, record review, policy review, and review of digital video recording, the Governing Body failed to ensure the Chief Executive Officer (CEO, also referred to as President) was responsible for the management and oversight of the entire hospital, and included accountability for the effective oversight of staff to comply with the requirements under the Conditions of Participation for Patient's Rights. These failures had the potential to adversely affect all patients in the hospital. The hospital census was 478.

Findings Included:

1. Review of the hospital's document titled, "Leadership - MUHC Governing Body and Management," dated 04/07/16, showed the following:
- As the governing board of the University, the Board of Curators was ultimately responsible for all of the University's activities, including University of Missouri Health Care (UMHC) at the University of Missouri-Columbia.
- The President of the University was responsible to the Board of Curators for administering the University within the collected rules and regulations established by the Board of Curators. In addition, the President had been delegated governance responsibilities for UMHC, including but not limited to patient safety and the quality of care, treatment, and services provided.
- As delegated authority for UMHC through the President, Chancellor of University of Missouri-Columbia, Vice Chancellor of Health Sciences; the CEO establishes policies, promotes performance improvement, and provides for organizational management and planning.
- UMHC's CEO responsibilities included the development, interpretation and implementation of policies, and to work with the Medical School Dean and appropriate campus and University Management in establishing hospital polices and procedures.
- The Vice Chancellor provided for coordination and integration among the hospital leaders through the delegated authority of the CEO and Chief Operation Officer (COO), the establishment of policy, maintenance of quality care and patient safety, and provision for necessary services.

Review of the hospital's document titled, "Medical Staff Bylaws," dated 09/09/20, showed the following:
- The purpose of the Medical Staff was to bring qualified physicians, dentists, podiatrists and psychologists, who practice or were appointed to faculty, together into a cohesive body to promote good care and to offer advice, recommendations, and input to the CEO, CCO, and the governing authority.
- The primary duty of the Medical Staff was to provide health care that meets accepted quality standards for patient-and family-centered care, education, and research to improve the health of the people of Missouri and beyond.
- All interactions would model generally recognized standards of professional ethics.
- Responsibility in the health sciences included adherence to ethical standards and placed patient needs at the center of their work.

The CEO failed to:
- Recognize an internal policy, used to guide Security Officers, gave direction for security staff to use law enforcement techniques, including Oleoresin Capsicum (OC, also known as pepper-spray, a compound spray that irritates the eyes to cause a burning sensation, pain and temporary blindness typically used by law enforcement) spray, hand cuffs, the use of wrist-to-waist locking restraints (W2, restraint devices used by law enforcement), and four and five-point locking restraints (medical cuffs which require a key to unlock, applied to both arms and both legs to prevent someone from causing harm to themselves or others) on patients.
- Recognize that the use of law enforcement techniques were law enforcement actions and not a health care intervention.
- Ensure the least restrictive method was used to control behavioral symptoms for three patients (#1, #95, #96) who were OC sprayed and placed in restraints.
- Ensure nursing staff maintained responsibility of the patient when security responded to events requiring restraints.

During an interview on 09/23/20 at 2:40 PM, Staff AAAAAA, CEO, stated that:
-The governing body delegated authority to the CEO.
- All policies and procedures were reviewed by the Executive Director of the Medical Staff and he serves on the Executive Medical Staff. He had the ultimate review of all policies.
- He was not aware that security applied locking restraints in the hospital, or that restraint procedures differed in the Missouri Psychiatric Center (MUPC).
- If nursing asked security officers to leave during the care of a patient, he expected them to leave.
- He was not aware that security officers were in charge of, and applying four and five point locking restraints on patients.
- He agreed that the areas of concern were the locking restraints, the law enforcement techniques including the use of pepper spray and handcuffs.
- None of these areas of concern were escalated to the Quality Assurance and Performance Improvement (QAPI) Committee.

The lack of oversight of patient care and safety by the CEO resulted in the hospital's failure to ensure quality healthcare and safety.

Based on interview, record review, policy review, and review of digital video recording, the hospital failed to provide a safe environment, free from abuse, when they failed to:
- Recognize and ensure that staff provided a safe environment on the adult psychiatric unit, when non-psychiatric safe screws (safe screws are tamper resistant) were accessible in the smoke detector in the seclusion room. (refer to A-0144)
- Recognize and ensure that staff provided a safe environment on the adult psychiatric unit, by not protecting patients from a smoke detector that was reachable, and placed patients in danger (risk of burns, shock, fire or electrocution [death or severe injury by electric shock with electric current passing through the body]). (refer to A-0144)
- Prevent one patient (#1) from being placed in wrist-to-waist locking restraints (W2, restraint devices used by law enforcement) of one patient reviewed. (refer to A-0152)
- Prevent three patients (#1, #95 and #96) from being pepper-sprayed (Oleoresin Capsicum [OC] spray, a compound spray that irritates the eyes to cause a burning sensation, pain and temporary blindness typically used by law enforcement) by hospital security, of three patients reviewed.(refer to A-152)
- Prevent one patient (#96) from being handcuffed by hospital security prior to placing him in locking restraints, of one record reviewed. (refer to A-0152)
- Ensure that nursing staff were accountable and responsible for the restraint process for two patients (#95 and #96) of three patient records reviewed. (refer to A-152)

These deficient practices resulted in the hospital's non-compliance with the specific requirements found under 42 CFR 482.13 Condition of Participation: Patient's Rights. The hospital census was 478.

The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 09/23/20 at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ for all in-patient areas and the Emergency Departments (EDs), excluding University of Missouri Psychiatric Center (MUPC), by implementing the following:
- All patients in locking limb restraints will have a one-to-one (1:1, continuous visual contact with close physical proximity) patient observer assigned for the entire time locking restraints are in use. The observer will maintain the key on his/her person.
- A "just-in-time" training document will be provided to all patient observers outlining observer's roles and responsibilities when observing patients in locking restraints.
- All house managers and STAT nurses (nurses trained to respond immediately) will be re-educated on the application of violent restraints (any manual method used to contain aggressive attacking behavior using a physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) currently in use beginning 09/23/20. House managers and STAT nurses will respond to in-patient units for all episodes of violent restraint application. Application of violent restraints will be the primary responsibility of nursing staff as overseen by house managers and STAT nurses on in-patient units.
- All ED nurses will be re-educated on the application of violent restraints currently in use beginning 09/23/20, utilizing in-services at all shift huddles (a quick meeting used to share and discuss important information). ED nurses will apply all violent restraints in the ED. Application of violent restraints will be the primary responsibility of the nursing staff.
- Education to all nursing and security staff will be performed utilizing tiered huddles. A Situation-Background-Assessment-Recommendation (SBAR, a communication technique used between members of a healthcare team about a patient's condition) addressing use of least restrictive measures for restraint, nursing responsibility for application of violent restraints, and presence of a staff member with locking restraint key will be shared at all tiered huddles for nursing and security staff for 14 days beginning on 09/23/20.
- The organization will procure nylon restraints with "quick release" feature. The organization is working to source appropriate restraints beginning on 09/23/20.
- Appropriate restraints with a "quick release" feature are expected to be delivered on 09/25/20. Once obtained, the "quick release" restraints will replace the locking restraint stock currently in use. Locking restraints will be discarded upon receipt of "quick release" restraints.
- House managers, STAT managers and ED nurses will be educated on the use of new "quick release" restraints via in-service beginning on 09/25/20.
- Web-based training will be provided to all nursing staff on use of the new "quick release" restraints beginning 09/25/20. The training module will emphasize use of the least restrictive measures, de-escalation (reduction of the intensity of a conflict or potentially violent situation), and nursing's authority in the restraint process.
- Application of violent restraints will be performed by nursing staff. Security staff will assist nursing in holding limbs at the nurse's request, but restraint application will be the primary responsibility of nursing staff.
- The Security-Use of Force Policy has been revised to exclude its application to patients in the clinical setting. The new title of the policy is, "Security-Use of Force, Non-Patient Policy."

Security will refrain from using law enforcement techniques with patients except in extreme circumstances as defined in the newly created policy titled, "Patient Care-Management & De-Escalation of Disruptive or Violent Patients Policy." The new policy will outline the following management of violent or disruptive patient behaviors:
- Nursing is responsible for the management and de-escalation of patient behaviors in the clinical setting.
- Nursing will be the first level of response for disruptive or violent patients. At all times, nursing will have authority over the techniques used and parties involved in de-escalation incidents.
- De-escalation techniques used will be those approved for use in the clinical setting as determined by the Workplace Violence Prevention and Control Committee. The current approved technique is Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement).
- Nursing will use and direct the use of progressive measures as included in the annual training received regarding restraints (least restrictive means) and as taught during CPI certification courses (recognizing patterns of escalation and appropriate responses; levels of physical engagement including disengagement skills).
- In emergency circumstances where a patient presents a risk of imminent death or severe injury to another patient, staff, or visitor, nursing may deviate from approved clinical techniques or direct the use of non-clinical intervention techniques to save life, limb, or bodily function as a last resort.
- An SBAR outlining the policy changes above will be shared with all in-patient and ED nursing staff utilizing tiered huddles and staff meetings beginning on 09/24/20. The same SBAR will be shared with all security staff prior to beginning their next shift beginning 09/24/20.
- Nursing staff are already trained on use of least restrictive measures and de-escalation techniques. Nursing staff in higher risk areas (for example, ED, Medicine Units, ICUs) have already completed CPI training. CPI refresher content is provided on the hospital intranet site. Additional in-service refreshers will be provided to nursing staff in higher risk in-patient units.

Based on interview, record review, and policy review, the hospital failed to provide a safe environment for one discharged patient (#1) of one discharged patient observed, when they failed to recognize and ensure that staff provided a safe environment on the adult psychiatric unit, when non-psychiatric safe screws (safe screws are tamper resistant) were accessible in the smoke detector in the seclusion room and by not protecting the patient from a smoke detector that was reachable by the patient that placed him in danger (risk of burns, shock, fire or electrocution [death or severe injury by electric shock with electric current passing through the body]). These failures by the hospital created an unsafe environment and had the potential to place all patients seeking care and treatment at risk. The hospital census was 478.

Findings included:

1. Review of the hospital-provided undated document titled, "Initial Competency Assessment Environmental Searches," gave staff the direction for a seclusion room search that included review of bolts on wall units.

Review of Patient #1's medical record showed the patient was a 24-year-old male with Autism (developmental disorder that impairs communication and social interaction) and admitted for homicidal ideation (HI, thoughts or attempts to cause another's death) toward his parents (guardians, documentation provided in the medical record). The patient was brought in due to increasing agitation and threatening to kill his parents and animals in their sleep. The patient has a history of aggression (behaviors that cause psychological or physical harm to another individual) and had been refusing to take his medication.

Review of the document titled, "Case Report," dated 08/06/20 at 2:45 PM, documented by Staff EEEEE, Security Officer, showed that:
- He was dispatched to Missouri Psychiatric Center (MUPC) 2 South with Staff KKKKK, Security Officer, Staff LLLLL, Security Officer, and Staff MMMMM, Security Officer, for report of Patient #1 having metal screws in his possession.
- Upon arrival to the 2 South seclusion room, they were told by MUPC staff to "handle it."
- Patient #1 was beating the glass window on the door with a plastic cover from a smoke detector.
- He told the patient to stop beating the door and to drop the screws in his hand.
- The patient continued to yell and would not drop the screws.
- Once the patient stepped away from the door, he opened the door and entered the seclusion room.
- While in the room, the patient took a defensive stance with the smoke detector cover in his right hand and the screws in his left hand.
- He told the patient that if he did not drop the screws that he would spray him with the pepper spray.
- The patient refused to comply, cursed, and took a step toward him.
- He then administered a burst of pepper spray to the patient's face.
- The patient raised his right arm up and took another step toward him.
- He then was able to complete a modified shoulder pin neck restraint (a low-level restraint used to pin a subject to the ground), placed the patient against the wall, then took him to the ground between the bed and the wall in the seclusion room.
- Staff LLLLL then forcefully removed the four metal screws from the patient's hands.
- Once the screws were retrieved, the patient became compliant, security officers assisted the patient onto the bed and held him down while MUPC staff placed the patient in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others).

During an interview on 09/22/20 at 2:08 PM, Staff RRRRR, MUPC Registered Nurse (RN), stated that she took over care for Patient #1 on 08/06/20, after his original nurse, Staff OOOOO, RN, was injured by the patient. She stated that there was a sitter with the patient for one-to-one (1:1, continuous visual contact with close physical proximity) observation in the seclusion room. who called out to her about the patient scratching the window of the seclusion room with the metal screws.

During an interview on 09/22/20 at 2:30 PM, Staff I, Clinical Manager for MUPC, stated that the environmental rounds/contraband room checks performed daily did not include checking for the psychiatric safe screws or if the smoke detector was covered. The staff were expected to inspect the rooms for anything that was changed or out of place.

Staff failed to recognize the unsafe environment in which Patient #1 was placed. The patient was vulnerable (in need of special care and protection) and mentally challenged and he relied on the hospital to protect him. These failures had the potential for injury and/or death.

Based on interview, record review, policy review, and review of digital video recording, the hospital failed to:
- Prevent one patient (#1) from being placed in wrist-to-waist locking restraints (W2, restraint devices used by law enforcement) of one patient reviewed.
- Prevent three patients (#1, #95 and #96) from being pepper-sprayed (Oleoresin Capsicum spray [OC], a compound spray that irritates the eyes to cause a burning sensation, pain and temporary blindness typically used by law enforcement) by hospital security of three patients reviewed.
- Prevent one patient (#96) of one patient record reviewed, from being handcuffed by hospital security prior to placing him in locking restraints.
- Ensure that nursing staff were accountable and responsible for the restraint process for two patients (#95 and #96) of three patient records reviewed.
- Ensure that four and five-point locking restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) had a quick release mechanism.
These failures had the potential to place all patients at risk for their safety. The facility census was 478.

Findings included:

Review of the hospital's document titled, "Missouri University Psychiatric Center (MUPC, also referred to as Missouri Psychiatric Center) W2 Restraint Appropriate Use Policy," dated 04/06/20, showed:
- Restraints may only be utilized to ensure the immediate physical safety of the patient, staff, or other patients.
- The use of restraints must be discontinued as soon as possible based on an individualized patient assessment, re-evaluation, and current plan of care.
- W2 restraints can be considered for use when a patient shows a pattern of aggression that is unpredictable and/or frequent in nature that constitutes an imminent risk of harm to self or others and is not amenable to de-escalation efforts or proactive psychopharmacology (the scientific study of the effects of drugs on the mind and behavior).
- Utilization of W2 restraints must be pre-authorized by the Chair/Medical Director for the Department of Psychiatry or by their designee.
- Authorization must be documented via nursing communication.
- Using W2 restraints requires a physician order and a modification to the patient's treatment plan.
- Upon successful completion of established goals (contract for safety, engage with others without threats, intimidation, or violence, medication compliance and a decrease in the psychiatric symptoms that influence the level of violence) restraints will be discontinued.

Review of Patient #1's medical record showed the patient was a 24 year old male with Autism (developmental disorder that impairs communication and social interaction) and admitted for homicidal ideation (HI, thoughts or attempts to cause another's death) toward his parents (guardians, documentation provided in the medical record).The patient was brought in due to increasing agitation and threatening to kill his parents and animals in their sleep. The patient had a history of aggression (behaviors that cause psychological or physical harm to another individual) and had been refusing to take his medication.

Review of Patient #1's treatment plan dated 08/02/20 through 08/19/20 showed that the discharge goals throughout his stay were to remain free from aggressive behaviors for at least 48 consecutive hours prior to discharge.

Review of the physician's orders for Patient #1's medical record dated 08/12/20, showed that Staff FFFFFF, Physician, ordered wrist-to-waist locking restraints (W2, restraint devices used by law enforcement) for the patient. On 08/12/20, the patient was placed in W2 restraints for travel to his guardian's home and returned back to the hospital.

During an interview on 09/02/20 at 1:10, Staff I, Clinical Manager for MUPC, stated that 08/12/20 was not a discharge but was a drive to the guardian's house to make contact with the guardian. She also stated that when the guardian was not found at the home, they returned to the hospital.

The patient was transported outside of the hospital by hospital staff in W2 restraints when his discharge plan was to remain free of aggressive behaviors for at least 48-hours consecutively. The staff believed that the patient was safe to transport yet believed that he was aggressive enough to place in W2 restraints. These measures were not just a process to treat the patient for his aggressive behaviors prior to leaving the hospital, instead the patient was placed in W2 restraints for transportation purposes.

2. Review of the hospital's policy titled, "Security - Handcuff and Weapons," reviewed 06/26/18, showed the following:
- Weapons included pepper spray, night sticks, collapsible batons, Tasers, stun guns, pistols, and other such devices.
- Handcuffs, manacles (metal bands, chains, or shackles for fastening someone's hands or ankles), shackles, and other chain-type devices were considered law enforcement restraint devices and would not be considered safe, appropriate healthcare restraint interventions for use by hospital staff to restrain patients.
- Care should be taken to use only necessary force in subduing a person.
- Weapons and/or handcuffs are only to be used in reaction to criminal action and should be reported to law enforcement.

Review of the hospital's document titled, "Security - Use of Force - Policy," dated 09/06/18, showed that pepper-spray (Oleoresin Capsicum spray, a compound spray that irritates the eyes to cause a burning sensation, pain and temporary blindness typically used by law enforcement) will be carried and/or used by security staff members in the performance of their assigned duties and used as a defensive weapon to ward off attacks on the security personnel or another person, and shall be used in accordance with training.

Review of the document titled, "Case Report," dated 08/06/20 at 2:45 PM, documented by Staff KKKKK, Security Officer, showed that:
- He was dispatched to MUPC 2 South with Staff LLLLL, Security Officer, Staff MMMMM, Security Officer, and Staff NNNNN, Security Officer, for report of Patient #1 having metal screws in his possession.
- Upon arrival to the 2 South seclusion (confinement of a patient alone in a room from which free exit is prevented) room they were told by MUPC staff to "handle it."
- Patient #1 was beating the glass window on the door with a plastic cover from a smoke detector.
- He told the patient to stop beating the door and to drop the screws in his hand.
- The patient continued to yell and would not drop the screws.
- Once the patient stepped away from the door, he opened the door and entered the seclusion room.
- While in the room, the patient took a defensive stance with the smoke detector cover in his right hand and the screws in his left hand.
- He told the patient that if he did not drop the screws that he would spray him with the pepper spray.
- The patient refused to comply, cursed, and took a step toward him.
- He then administered a burst of pepper spray to the patient's face.
- The patient raised his right arm up and took another step toward him.
- He then was able to complete a modified shoulder pin neck restraint (a low-level restraint used to pin a subject to the ground), placed the patient against the wall, then took him to the ground between the bed and the wall in the seclusion room.
- Staff LLLLL, Security Officer, then forcefully removed the four metal screws from the patient's hands.
- Once the screws were retrieved, the patient became compliant, security officers assisted the patient onto the bed and held him down while MUPC staff placed the patient in four-point restraints.

During an interview on 09/22/20 at 9:00 AM, Staff GGGGGG, Security Sergeant, stated that security officers carried pepper spray with them at all times and only deployed it when the patient had a weapon.

The staff failed to protect Patient #1 from being placed in W2 restraints and being pepper-sprayed. The patient was vulnerable (in need of special care and protection) and mentally challenged and he relied on the hospital to protect him. These failures had the potential for injury.

3. Review of the hospital's policy titled, "Violent Restraint and Seclusion - Policy," stated:
- The use of violent restraint (any manual method used to contain aggressive attacking behavior using a physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) or seclusion was based on the assessed needs of the patient and used in conjunction with or after exploring other less restrictive alternatives.
- For locked restraints, assure immediate availability of restraint keys at all times.
- A registered nurse (RN) can make the decision to place the patient in a violent restraint or seclusion.

Review of Patient #95's medical record showed the following:
- The patient was a 29-year-old male who presented to the ED, on 02/20/20 at 6:22 PM, by local law enforcement for alcohol intoxication.
- He was found by police, stumbling, and was clearly a danger to himself.
- After an hour and a half in the Emergency Department (ED), he was deemed clinically sober and was discharged.
- When the patient left, he wandered into the ambulance bay and was helped back into the ED by emergency medical services (EMS) after they determined he was not behaving normally.
- During his stay in the ED, he became verbally aggressive, causing security to come to his bedside, which escalated his behavior.
- He was redirectable when security was not present, and he became agitated when he saw them.
- Nursing successfully verbally redirected him to his bed and he was calm.
- Security entered the room with consent from their supervisor, without consulting the ED healthcare staff or physician, and sprayed pepper spray into the patient's face. He was then physically restrained.

Review of the hospital's untitled video, dated 02/20/20, showed that for more than two hours, there were anywhere from five to eight security officers in the hallway just outside Patient #95's room. Multiple security staff members entered the patients room between 8:56 PM and 9:02 PM and out of camera view.

Review of the hospitals internal investigation stated that Patient #95 was pepper sprayed on 02/20/20 at 9:02 PM.

Review of the hospital's document titled, "Patient Safety Report," dated 02/20/20, documented by Staff PPPPP, RN, stated the following:
- Patient #95 was brought into the ED by local law enforcement on 02/20/20.
- He was treated in the ED for about an hour and a half and then discharged.
- The patient stumbled on his way out of the ED, and it was determined he should stay longer.
- The patient agreed to stay in the ED longer, but had reservations about putting hospital scrubs back on.
- Security insisted that the patient be put back into hospital scrubs.
- When Patient #95 could not see security staff he was cooperative and could be redirected; however, when he could see the security officers he would escalate.
- Security was asked by nursing staff to leave more than once, but they would not leave.
- There were roughly eight security guards in the area, and the patient was cornered in his room.
- Security physically pulled the RN out of the room so that they could pepper spray the patient because he would not listen to them.
- Security sprayed Patient #95 several times without provocation.
- Security restrained Patient #95 despite previous efforts when the patient was able to be redirected.
- At one point during the restraint process, one of the security officers was sitting on Patient #95's chest.

During an interview on 09/21/20 at 2:15 PM, Staff PPPPP, RN, stated that:
- Security was there to provide safety, but on 02/20/20, they were escalating Patient #95.
- She had requested that everyone leave the room.
- Security removed her from the room so they could pepper spray Patient #95.
- When the security office placed his knee in the chest, it was beyond what was appropriate.
- The whole event on 02/20/20 with Patient #95 could have been avoided.

During an interview on 09/21/20 at 2:55 PM, Staff QQQQQ, Emergency Services Representative, stated the following:
- She very clearly remembered the incident on 02/20/20 with Patient #95.
- Patient #95 was redirectable, especially with female staff.
- Security would walk by and upset Patient #95, and they were antagonizing him.
- At one point there were six or seven security officers in the room and the hallway, the more security that showed up the more upset the patient became.
- It was a yelling contest between security officers and Patient #95.
- Nursing staff asked security to leave because there were too many of them, but they would not leave.
- If security had cooperated, the whole event could have been avoided.
- She remembered that one of the security officers was on the patient's chest while the patient was being placed in restraints.

During an interview on 09/21/20 at 3:27 PM, Staff RRRRR, Security Supervisor, stated the following:
- The hospital used four and five-point restraints that locked at the wrist and to the bed. All security officers carried a key and nursing had a key available to them.
- Security officers were not trained in Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement).
- All the security officers were trained to verbally de-escalate patients.
- Security officers applied the restraints only, they did not stay with the patients after they were restrained..
- Restraints required an order from a nurse.

During an interview on 09/21/20 at 4:00 PM, Staff SSSSS, Security Officer, stated the following:
- The nurse did not want security officers to be involved in the encounter with Patient #95.
- The physician was the one who ordered the four-point locked restraints on Patient #95.
- When they became involved in the restraint process, security was in charge of the restraints while medical staff monitored the patient for medical issues.
- Security was in charge of getting patients on the bed and the restraints applied, medical staff would do what they could.
- Security officers did not stay with the patients after they were restrained.

4. Review of the hospital's untitled video, dated 04/25/20, showed that there were six security officers in a semi-circle formation around Patient #96's room. The patient stood in his doorway, surrounded by security, and he appeared to make verbal gestures and swing his arms. Security advanced towards the patient and at approximately 11:46 PM, discharged OC spray directly in the patient's face. The patient stepped backward into his room, the security officers followed after the patient, at which point, both the patient and security were out of the camera's view.

Review of Patient #96's medical record showed the following:
- The patient was a 58 year old male with a psychiatric history and a diagnosis of paranoid schizophrenia (a mental illness that involves mistaken beliefs that one or more people are plotting against them or their loved ones).
- He presented to the ED on 04/25/20 at 9:06 PM, voluntarily for evaluation and needing psychotropic medication (any drug that affects behavior, mood, thoughts, or perception).
- He had documented disorganized thinking on examination.
- Psychiatry was contacted and the patient was to be further evaluated at the MUPC, which was on the hospital grounds.
- He became combative when attempting to transfer the patient to the MUPC, and the patient was returned to the ED.
- Upon return to the ED, he became verbally aggressive with the psychiatry resident that came to evaluate him, and a 96-hour hold (a temporary hold against a patient's will when it is deemed that a person presents with a likelihood of serious harm to themselves or others) was ordered.
- The patient was pepper sprayed and restrained by security officers.
- After he was restrained, Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) and Ativan (a medication that has a calming effect, used to treat anxiety or sleep difficulty) were administered intramuscularly (IM, situated in, occurring in, or administered by entering a muscle).
- The patient was then transferred to MUPC after being chemically sedated and placed on a 96-hour hold.

Review of the document titled "Case Report," dated 04/25/20 at 11:40 PM, documented by Staff YYYYY, Security Officer, showed that:
- He was dispatched to escort Patient #96 from exam room 10 of the ED to the MUPC for a mental health evaluation.
- During the escort, the patient became confused, disoriented, and aggressive, having changed his mind about wanting to go to MUPC.
- He yelled and cursed at the nursing staff, but was agreeable to return to the ED.
- Upon return to the ED, Staff XXXXX, Psychiatry Resident, ordered the patient to be placed on a 96-hour hold, and additional security officers were called to assist.
- The patient stood in the doorway of exam room 10 and he continued to yell and curse at staff.
- Hospital policy was that all patients who were placed on a 96-hour hold turn over their personal belongings and be changed into purple scrubs.
- Security requested that his personal belongings be handed over to them and for him to change into purple scrubs.
- The patient refused to hand over his belongs and he said that he was leaving.
- Staff WWWWW, ED Physician Resident, then ordered him to be placed into four-point nylon locking restraints due to his violent statements and aggressive behaviors.
- The patient began to "posture" (positioning of body in an aggressive manor) his body which prompted security to draw his OC from his belt and place it behind his back.
- The patient continued to refuse to go back to his bed, and remained in the doorway of his room.
- Security officers began to approach the patient in an attempt to place him back in his room but the patient continued to yell, and took a step toward officers, which resulted in the deployment of OC successfully into the patient's eyes and on part of his facial area.
- Security officers then made entry into the patient's room to restrain the patient, in which he fought and resisted the security officers' commands.
- They then utilized their handcuffs and handcuffed the patient's hands behind his back, double locking them.
- The patient was then placed into four-point nylon locking restraints and was no longer resisting security officers.
- Medical staff then administered IM medications.

During an interview on 09/22/20 at 08:40 AM, Staff TTTTT, RN, stated the following:
- Patient #96 was initially cooperative and had presented to get psychiatric medications.
- Hospital practice was for security to escort nursing on all transports when it was a mental health patient, so security was contacted to escort them as the patient was escorted to MUPC.
- The patient became agitated when he visualized the MUPC, he had changed his mind and did not want to go.
- Nursing staff and the patient made their way back to the ED, and security stayed with them.
- He felt like he could have deescalated the patient but security took over.
- He felt like security "provoked" the patient by threatening to restrain him.
- When the psychiatrist arrived on the scene, he made it worse, and quickly ordered a 96-hour hold.
- There had been at least five or six security officers present and he did not understand why so many were surrounding the patient.
- He had stepped back as security took control of the situation, which ended in the patient being pepper sprayed, handcuffed, and placed in a locking restraint.
- He did not understand why pepper spray was needed when there were so many security officers present.
- He felt the pepper spray was not right to use in a medical setting, and that this patient had been pre-judged based on his past history of violence.
- He did not keep a key for the nylon locking restraints and he did not know where they were located at the nursing station.

During an interview on 09/22/20 at 11:30 AM, Staff XXXXX, Psychiatry Resident, stated the following:
- He did not remember this case.
- If a patient was threatening, his interview would not take very long.
- It was possible to order a 96-hour hold quickly, if a patient exhibited homicidal ideations.
- He did not know where the restraint keys were located.
- He would expect that a nurse manager could tell staff where the keys were located.

During an interview on 09/22/20 at 10:53 AM, Staff WWWWW, ED Physician Resident, stated the following:
- This patient had a psychiatric history and came in for his medications.
- He remembered he was agitated upon arrival and required deescalation by nursing staff.
- He believed this patient had made homicidal comments.
- He was placed on a 96-hour hold due to his verbal aggression and disorganized thinking.
- He had ordered four-point restraints due to his verbal aggression and resistance after the patient was placed on a 96-hour hold.
- He did not typically think that pepper spray was needed, but if a weapon was involved, that would be different.
- He recalled a security officer stating that he thought the patient was reaching for his bag and they were unsure if he had a weapon in the bag.
- He did not know where the keys to the locking restraints were located.

During an interview on 09/23/20 at 12:35 PM, Staff YYYYY, Security Officer, stated the following:
- He received threat pattern recognition (TPR) training annually and did not do the CPI training.
- He had applied both four and five-point restraints on patients.
- He did not know how to assess for respiratory difficulty in patients, he would leave that to nursing.
- Security officers did not typically stay with the patients after restraints were placed.
- He had worked at this hospital approximately two years and had deployed his OC spray on two different occasions that he could recall.
- He recalled this patient screaming and yelling threatening words.
- The psychiatry resident was in the room with the patient for a couple of minutes and then told them he was on a 96-hour hold.
- The patient was still in street clothes and had his personal belongings with him.
- Security officers asked the patient to hand over his personal belongings and to change into purple scrubs.
- The patient was in the doorway of exam room 10, and would not comply.
- He deployed his OC spray into the patient's face, when the patient reached for his personal bag.
- Security advanced into the room, handcuffed the patient to get him onto the bed, and then placed him into four point nylon locking restraints.

During an interview on 09/21/20 at 3:27 PM, Staff RRRRR, Security Supervisor, stated the following:
- The hospital used four and five-point restraints that locked at the wrist and to the bed. All security officers carried a key and nursing had a key available to them.
- Security officers were not trained in CPI.
- Security staff were trained in TPR techniques annually.
- All the security officers were trained to verbally de-escalate patients.
- Security officers applied the restraints only, they did not stay with the patients after they were restrained.
- Restraints required an order from a nurse.
- If nursing asks security to leave, they should do so.

During an interview of 09/22/20 at 10:02 AM, Staff UUUUU, RN, House Manager, stated the following:
- In the ED, the security officers brought the four and five-point locked restraints with them.
- Security stayed with the patients when they were in locked restraints (multiple interviews revealed that security officers did not stay after they place the patient in locked restraints).
- The nurses were probably not familiar with four and five-point locked restraints.
- A patient should never be handcuffed.
- If a nurse asked security to leave then that security officer should leave.
- She did not know where the key for the locked restraints was located.

During concurrent interviews on 09/22/20 at 1:00 PM, Staff ZZZZZ, Security, Safety and Emergency Management Director, and Staff DDDDDD, Support Services Executive Director, stated the following:
- Nursing staff ordered restraints and then security applied or would assist with the application of restraints.
- Security had locking restraints, nursing did not have locking restraints.
- Once restraints were applied, security would leave and nursing stayed with the patients.
- Nursing had keys to restraints readily available, but they did not know where those were located. That information would be part of the handoff from security.
- Some units kept the restraint keys in the same location, other units did not.
- Neither staff member knew where the restraint key was located in the ED.
- Antagonizing patients was never a good thing.
- Regarding the incident on 02/20/20, they believed that Staff PPPPP, RN, was directing her angst toward security, and that was what got Patient #95 "all fired up."

Staff EEEEEE, Security Officer, was unavailable for an interview.

Staff IIIIII, ED Physician, was unavailable for an interview.





41474






36473

Based on observation, interview, record review, and policy review, the hospital failed to:
- Provide complete, thorough, and timely assessments for seven current patients (#11, #16, #44, #45, #46, #51 and #55) of 80 current patient records reviewed, and 4 discharged patients (#91, #92, #93 and #94) of 14 discharged patient records reviewed.
- Identify safety risk and secure two medical supply carts (a durable mobile cart used in medical facilities for storing and transporting medications, emergency equipment, and medical supplies) of two medical supply carts observed. One cart was located in patient (#84) room, and one was located at the nurse's station.
- Follow the physician's orders for Pneumatic Compression Devices (PCD, a therapeutic device used to improve circulation in the legs of patients with swelling, who are at risk of deep vein thrombosis [DVT, the formation of a blood clot in a blood vessel that is deep under the skin] or at risk for pulmonary edema [an abnormal buildup of fluid in the lungs]) for three patients (#13, #14 and #48) of three patients observed.
- Dated, timed, and initialed on peripheral intravenous (IV) dressings (sterile dressings which covers the entrance of a small flexible tube placed into a vein in order to administer medication or fluids) for nine patients (#13, #25, #28, #47, #49, #50, #57, #82, and #85) of 23 patients observed.

Findings included:

1. Review of the hospital's policy titled, "Patient Care - Needle and Syringe Safety Policy," dated 10/18/19, showed that needles and syringes should have been secured in locked rooms, cabinets, or carts to prevent access to patients, visitors and unauthorized staff.

Observation on 09/02/20 at 2:30 PM, in Patient #84's room, showed an unsecured, unattended medical supply cart with needles and syringes open to patients and visitors.

During an interview on 09/02/20 at 3:23 PM, Staff PPP, Registered Nurse (RN), stated that she should have locked the supply cart.

During an interview on 09/02/20 at 3:47 PM, Staff N, Orthopedic Clinical Manager, stated that the supply carts were used for emergencies and should have been locked at all times.

Observation on 09/01/20 at 10:00 AM, showed an unsecured, unattended medical supply cart that contained needles and syringes in an alcove of the 4 West nurses station. The cart was located next to a hallway where visitors and patients could gain access to the cart.

During an interview on 09/01/20 at 10:05 AM, Staff MM, 4 West Clinical Manager, stated that the supply cart was not locked because it was considered to be in the nurses' station.

2. Review of the hospital's policy titled, "Patient Care - Pneumatic Compression Device Clinical Guidelines," dated 07/19/19, showed that the PCDs should be worn at all times when the patient was inactive lying in bed, ordered on bedrest, or sitting up in a chair for long periods of time.

Review of Patient #13's medical record showed physician orders dated 08/24/20, ordered for the PCDs to be placed on the patient's bilateral (both right and left) lower extremities (legs) when in bed.

Observation and concurrent interview on 08/31/20 at 3:45 PM, in Patient #13's room, showed the patient lying in bed without her PCDs on. The patient stated that she had been in bed the entire day and hadn't had them on.

During an interview on 09/01/20 at 10:00 AM, Staff SS, Licensed Practical Nurse (LPN), stated that he thought Patient #13 had been back and forth to the restroom, and staff forgot to put them back on.

Observation on 08/31/20 at 4:00 PM, in Patient 14's room, showed the patient lying in bed without his PCDs on.

During an interview on 09/01/20 at 9:55 AM, Staff QQ, RN, stated that the patient refused to wear his PCDs.

Review of Patient #14's medical record showed no documentation that the patient had refused the PCDs.

Review of Patient #48's medical record, showed physician orders dated 08/29/20, for PCDs to be placed on the patient's bilateral lower extremities when in bed.

Observation on 09/01/20 at 9:18 AM, in Patient #48's room, showed the patient lying in bed without her PCDs on.

During an interview on 09/01/20 at 9:55 AM, Staff QQ, RN, stated that the Patient #48's PCDs should have been on while the patient was in bed.

3. Review of the hospital's undated document titled, "Skills - Intravenous Therapy: Maintenance and Dressing Change" showed the direction for staff to label IV dressings with the date, time of application, and staff initials.

Observation on 08/31/20 at 3:55 PM, in Patient #13's room, showed the patient had a right forearm IV dressing with no date, time, or initials.

During an interview on 09/01/20 at 10:00 AM, Staff SS, LPN, stated that staff should have labeled the IV dressing when it was placed.

Observation and concurrent interview on 09/01/20 at 10:20 AM, in Patient #47's room, showed the patient had a right forearm IV dressing with no date, time, or initials. Staff RR, RN, stated that she didn't put the dates on the IV dressings and that the Emergency Department (ED) staff were responsible for that.

Observation and concurrent interview on 09/02/20 at 3:30 PM, in Patient #85's room, showed the patient had a right upper arm IV dressing with no date, time, or initials. Staff QQQ, RN, stated that the IV dressing should have been dated.

Observation on 09/01/20 at 9:20 AM, in Patient #49's room, showed the patient had a right forearm IV dressing with no date, time, or initials.

Observation on 09/01/20 at 9:45 AM, in Patient #50's room, showed the patient had a right forearm IV dressing with no date, time, or initials.

Observation on 09/01/20 at 10:00 AM, in Patient #57's room, showed the patient had a right forearm IV dressing with no date, time, or initials.

During an interview on 09/01/20 at 10:00 AM, Staff FFF, RN, stated that if there was no date, time, or initials on the IV site, it would be documented in the computer. She attempted to locate the documentation in the electronic medical record, but was unsuccessful. She stated that nursing staff should initial, date, and time and she would check the policy for verification.

Observation on 08/31/20 at 4:00 PM, in Patient #28's room, showed the patient had a right hand IV dressing with no date, time, or initials.

Observation on 09/02/20 at 9:10 AM, in Patient #25's room, showed the patient had a right lower arm IV dressing with no date, time, or initials.

Observation on 09/02/20 at 2:15 PM, in Patient #82's room, showed the patient had a right forearm IV dressing with no date, time, or initials.

4. Review of the hospital's document titled, "Nursing Admission Assessment - Guidelines," dated 08/16/19, showed that a RN will begin the initial nursing assessment at the time of admission and it must be completed within 24 hours.

Review on 09/02/20, of Patient #55's adult nursing intake assessment form dated 08/21/20 at 1:35 AM, showed that the assessment was incomplete with the presenting problems and previous medical history sections left blank.

Review on 09/02/20, of Patient #11's adult nursing intake assessment form dated 08/27/20 at 5:49 PM, showed that the assessment was incomplete with the information given by, language, orientation, guardianship, and presenting problem sections left blank.

Review on 09/02/20, of Patient #51's adult nursing intake assessment form dated 08/29/20 at 3:30 PM, showed that nursing was unable to get the assessment completed at the time of admission due to patient sedation and that there were no further attempts made to complete the assessment.

Review on 09/01/20, of Patient #16's behavioral health unit adult nursing intake assessment form dated 08/22/20 at 7:21 PM, showed that the assessment was incomplete with the information patient agrees to, the referral source, mode of arrival, admit status, accompanied by, referral facility, communicable disease risk, fall scale, self-harm and suicide (to cause one's own death) risk assessment, Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self inflicted harm and desire to end one's life), violence risk assessment, behavioral concerns, and the anticipated discharge needs sections left blank.

Review on 09/01/20, of Patient #44's behavioral health unit adult nursing intake assessment form dated 08/27/20 at 9:48 AM, showed that the assessment was incomplete with the information preferred language, patient agrees to, referral source, mode of arrival, admission status, accompanied by, employment, previous mental health diagnosis, history of abuse, history of abusing others, edema, wound, pregnancy, communicable disease risk, assistive device used at home, dressing, toileting, continence, feeding, fall scale, family behavior health history, usual hours of sleep, recent homicide (thoughts or attempts to cause another's death) or assault attempt, behavior concerns, and anticipated discharge needs sections left blank.

Review on 09/01/20, of Patient #45's behavioral health unit adult nursing intake assessment form dated 08/27/20 at 10:44 PM, showed that the assessment was incomplete with the information patient agrees to, referral source, mode of arrival, admission status, accompanied by, referral facility, relationship status, housing, employment, presenting problems, history of psychiatric diagnosis, previous mental diagnosis, history of psychiatric hospitalization, previous psychiatric hospital, history of abuse, history of sexually abusing others, current or previous involvement with law enforcement, edema, wounds, pregnancy, communicable disease risk, assistive device used at home, activities of daily living evaluation index, fall scale, self-harm and suicidal risk assessment, complete the C-SSRS, violence risk assessment, behavioral concerns, and anticipated discharge needs sections left blank.

Review on 09/01/20, of Patient #46's behavioral health unit adult nursing intake assessment form dated 08/24/20 at 1:54 PM, showed that the assessment was incomplete with the information patient orientation, referral source, mode of arrival, admission status, accompanied by, referral facility, presenting problems, previous mental illness diagnosis, edema, pregnancy, communicable disease risk, breath alcohol, activities of daily living index, dressing, bathing, toileting, fall scale, self-harm and suicide risk assessment, recent life events, family behavior health history, sleeping, behavioral concerns, and anticipated discharge needs sections left blank.

Review on 09/02/20, of Patient #93's behavioral health unit adult nursing intake assessment form dated 04/17/20 at 11:12 PM, showed that the assessment was incomplete with the information referral source, mode of arrival, admission status, accompanied by, presenting problems section, activities of daily living assessment, fall scale, self-harm and suicide risk assessment, violence risk assessment, behavioral concerns, and anticipated discharge needs sections left blank.

Review on 09/02/20, of Patient #94's behavioral health unit adult nursing intake assessment form dated 04/23/20 at 5:51 PM, showed that the assessment was incomplete with the information orientation to unit, relationship status, activities of daily living evaluation, fall scale, self-harm and suicide risk assessment, violence risk assessment behavioral concerns section, and anticipated discharge needs sections left blank.

Review of the hospital's document titled, "Abuse and Neglect Investigations," dated 04/28/20 showed that Patient #93 and Patient #94 (neither of whom had a violence risk assessment completed on their nursing intake assessment)were roommates, and each had accused the other of attacking them.

During an interview on 09/03/20 at 9:00 AM, Staff I, Behavioral Health Unit Clinical Manager, stated that initial assessments were important for patient and staff safety, and she expected an initial assessment be completed upon the patient's admission.

During an interview on 09/03/20 at 9:28 AM, Staff CCCCC, RN, stated the following:
- She filled out as much as she could on an initial assessment to assist the treatment team.
- She believed the initial nursing assessments were very important and should be filled out completely.
- She did not feel that any section on the intake form should be left blank or skipped.
- She filled out both the Broset scale (a tool used to assess the level of violent behavior with one being mild and six being extreme) and the violence risk assessment because they were good indicators to future violence against roommates.

Review of the hospital's document titled, "Fall Prevention Policy," dated 02/17/20, showed:
- Post fall management included a nurse would notify their immediate supervisor and the provider when a fall occurred.
- Complete the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) post-fall risk assessment tool.
- Complete a patient safety report in the patient safety network.

Review on 09/03/20, of Patient #91's post-fall patient safety report summary dated 04/20/20 at 12:05 AM, showed that the assessment was incomplete with the categorization of the type of fall, was the fall observed by an employee, severity of injury, was a fall debrief completed, risk level, was the charge nurse/supervisor/manager notified the fall occurred, and the JHFRAT sections left blank.

Review on 09/03/20, of Patient #92's post-fall patient safety report summary dated 04/23/20 at 3:00 PM, showed that the assessment was incomplete with the categorization of the type of fall, was the fall observed by an employee, severity of injury, was a fall debrief completed, risk level, was the charge nurse/supervisor/manager notified the fall occurred, and the JHFRAT sections left blank.

During an interview on 09/03/20 at 12:00 PM, Staff Z, Chief Nursing Officer (CNO), stated that she felt nursing assessments were important to complete in their entirety.



36473











39562





40710




39089

Based on interview, record review and policy review, the hospital failed to ensure that patients with guardians (a person appointed by a judge to take care of and manage the property and rights of a person who, because of age, understanding or self-control, is considered incapable of administering his or her own affairs) and durable power of attorney for health care (DPOA, a legal document that lets a person name someone else to make decisions about their health care in case they were not able to make those decisions themselves) were notified and engaged in the development of the patient's discharge evaluation and plan for two current patients (#26 and #39) of 40 current patients whose charts were reviewed, and one discharged patient (#4) of four discharged patients whose charts were reviewed. The hospital also failed to re-evaluate the availability of appropriate treatment to provide a safe discharge and post-hospital plan for follow-up care, for one Autistic (developmental disorder that impairs communication and social interaction) discharged patient (#1) admitted with homicidal ideation (HI, thoughts or attempts to cause another's death) and aggressive behavior, of four discharged patients whose charts were reviewed.

These failures had the potential to lead to unsafe discharges, inappropriate transition of care, and result in poor discharge outcomes for all patients in the hospital. The hospital census was 478.

The severity and cumulative effects of these systemic failures resulted in the hospital being out of compliance with 42 CFR 482.43 Condition of Participation: Discharge Planning.













36473

Based on interview, record review, and policy review, the hospital failed to re-evaluate the availability of appropriate treatment to provide a safe discharge and post-hospital plan for follow-up care, for one Autistic (developmental disorder that impairs communication and social interaction) discharged patient (#1) admitted with homicidal ideation (HI, thoughts or attempts to cause another's death) and aggressive behavior. These failures had the potential to lead to the inability to recognize those patients in need of continued care resulting in poor discharge outcomes for all patients at the hospital. The hospital census was 478.

Findings included:

1. Review of the hospital's policy titled, "Care Coordination - Assessment Patient and Family- Policy," dated 09/25/19, showed that assessments should ensure:
- Appropriate support was provided to ensure an appropriate, safe discharge plan was developed.
- Assessment/discharge evaluation for information specific to needs, capabilities, and motivation of the patient and family, barriers to discharge, and anticipated discharge planning options.
- Assistance in determining an appropriate discharge plan based on information from the patient and family.
- Reassessment/re-evaluation that was ongoing during the hospital stay and included any change of medical and/or plan and when there was a deterioration in the patient's coping abilities.

Review of the hospital's policy titled, "Care Coordination - Discharge Planning - Policy," dated 04/17/17, showed that:
- The discharge planning definition included transition planning that was essential in solidifying a safe discharge plan which extended beyond the walls of the hospital.
- The case manager was to implement the patient's discharge plan and transition of care to home that provided the appropriate continuing level of care.
- There was an appropriate identification of a destination which was best suited to meet the patient's level of care and safety needs which the patient or designee (guardian) had agreed to.

Review of Patient #1's medical record showed the patient was a 24-year-old male with Autism and admitted for homicidal ideation toward his parents (guardians, documentation provided in the chart).
The patient was brought in due to increasing agitation and threatening to kill his parents and animals in their sleep. The patient had a history of aggression and had been refusing to take his medication.

Review of Patient #1's treatment plan dated 08/02/20 through 08/19/20 showed that:
- The discharge goals throughout his stay were to remain free from aggressive behaviors for at least 48 consecutive hours prior to discharge.
- On 08/19/20 at 12:45 PM, Staff WW, Master of Social Work (MSW), documented that the patient was unable to return home with his guardians due to their concerns.
- Staff WW also documented that the patient was to be discharged to home or a Residential Care Facility (RCF) was to be determined (TBD), along with follow-up care by outpatient psychiatric services.

Review of Patient #1's Broset scale (a tool used to assess the level of violent behavior with one being mild and six being extreme) showed that the patient's Broset scale on 08/19/20 at 9:55 AM (three hours prior to his discharge) was a level five (meaning the presence of verbal threats, irritable, physical threats, boisterous and attacked objects).

The patient failed to remain free from aggressive behaviors for 48-hours prior to the discharge.

Review of Patient #1's Social Work Narratives between 08/03/20 and 08/19/20 were as follows:
- On 08/03/20 at 4:10 PM, Staff TTTT, Licensed Clinical Social Worker (LCSW), documented that she spoke with the patient's mother (guardian) on the phone and the mother told Staff TTTT that she was concerned about her and her husband's health and did not think they could have him back home as he had threatened to kill them in their sleep.
- On 08/05/20 at 12:33 PM, Staff TTTT, LCSW, documented that she spoke with the patient's mother and the mother requested that they wanted the patient to be placed at a facility rather than return home, as they did not feel safe.
- On 08/07/20 at 3:15 PM, Staff TTTT, LCSW, documented that she spoke with the patient's mother and the mother stated that the patient would need a higher level of care than they could provide.
- On 08/11/20 at 1:06 PM, Staff TTTT, LCSW, documented that she spoke with the patient's mother and informed her that the treatment team wanted to discharge the patient home the next day and the mother stated that she would not pick him up and bringing him home. Staff TTT then told the mother that she attempted to explain that most hospitals would likely not accept the patient and referrals had been sent for the patient's placement, and declined. The mother continued to express worry about their safety.
- On 08/11/20 at 3:53 PM, Staff TTTT, LCSW, documented that she contacted the mother and informed her that the patient would be discharging home the next day. The mother stated that they were on their way to the courthouse to file paperwork that would relieve them of guardianship.
- On 08/12/20 at 9:40 AM, Staff TTTT, LCSW, documented that she left a message on the mother's phone informing her that if she did not return the call and didn't pick the patient up, that they would be transporting the patient home.
- On 08/12/20 at 11:02 AM, documented that the patient's mother called Staff TTTT and told her that due to the patient's aggression and violence, she was advised by her lawyer to file a 96-hour hold to have the patient placed. Staff TTTT informed the clinical nursing manager, supervisor, attending physician, and the risk management and performance improvement director and she was advised that they would be moving forward with the discharge.
- On 08/12/20 at 2:30 PM, documentation showed that the patient was placed in waist-to wrist restraints (W2, restraint devices used by law enforcement) and taken to the guardian's home. Since the guardian did not answer the door, the patient was taken back to the hospital.
- On 08/17/20 at 9:54 AM, Staff WW, MSW, documented that she spoke with the mother and advised her of the patient's discharge that day. The mother stated that she had a meeting with her attorney at 3:30 PM.
- On 08/17/20 at 11:16 AM, documentation showed that the mother called Staff WW to let her know that she could not accept the patient back in her home and that she and her husband could not care for him due to they were still in recovery from when the patient attacked them previously. The mother asked Staff TTTT to find placement for him.

There were several contacts between the social workers and the guardian without resolution regarding a discharge plan. The patient was placed in waist-to-wrist restraints and transported to the home on 08/19/20 at 2:15 PM. The patient was left on the porch without direct face-to-face contact of staff with the guardian, which prevented the patient medication list and directions for the patient's care, to be provided to the guardian. These discharge failures placed the patient in potential harm as he was a person with an intelligence quotient (IQ, a number used to express the relative intelligence of a person) of 49 (moderately intellectually disabled) and incapable of caring for himself.

During an interview on 09/03/20 at 9:22 AM, Staff T, LCSW, stated that Patient #1 was her patient for the first week of his admission and that the patient came in with aggressive behavior, so his goal was to remain aggression-free for 48 hours prior to discharge. She also stated that she was aware of the patient being in restraints prior to his discharge and attempted to address this with the patient's team.

During an interview on 09/03/20 at 9:30 AM, Staff WW, MSW, stated that they followed the goals for all patients throughout their hospital stay. She stated that she recalled the patient being in restraints prior to discharge and spoke of this in the team meeting. The team felt that the environment was causing the patient to behave poorly and agreed to discharge.

During an interview on 09/02/20 at 1:10, Staff I, Clinical Manager for the Missouri Psychiatric Center (MUPC), stated that on 08/19/20 at 2:15 PM, the patient was discharged and transported to his parent's home and dropped off on the front porch. She stated that the attorneys spoke and she was given the go ahead to transport the patient home. She also stated that she didn't see the patient open the front door of the house or make contact with his family.

During an interview on 09/03/20 at 9:05 AM, Staff BB, Staff Representative (Driver), stated that he drove Patient #1 and Staff I to the patient's home on 08/19/20 at 2:15 PM, and they dropped him off with his belongings. He stated that there were cars in the driveway but there was no contact made with the parents.

During an interview on 09/03/20 at 10:12 AM, Staff AA, Executive Director and Director of Nursing for MUPC, stated that it was the preference for staff to have an in-person handover directly to the guardian, but the family ceased communication with the hospital and chose to go through their legal counsel. She also stated that the goals written on the patient's admission were not always the same as on the discharge day, and that meeting the goals were not always possible.

During an interview on 09/03/20 at 9:10 AM, Staff R, Medical Director of MUPC, stated that:
- He was aware of Patient #1 being placed in restraints two hours prior to discharge.
- He was not aware of the staff not making contact with the patient's guardian in-person at the patient's drop-off.
- If a patient had diminished capacity, it was expected for there to be in-person contact with the guardian at the time of drop-off.

Based on interview, record review and policy review, the hospital failed to ensure that patients with guardians (a person appointed by a judge to take care of and manage the property and rights of a person who, because of age, understanding or self-control, is considered incapable of administering his or her own affairs) and durable power of attorney for health care (DPOA, a legal document that lets a person name someone else to make decisions about their health care in case they were not able to make those decisions themselves) were notified and engaged in the development of the patient's discharge evaluation and plan for two current patients (#26 and #39) of 40 current patients whose records were reviewed, and one discharged patient (#4) of four discharged patients whose records were reviewed. These failures had the potential to lead to unsafe discharges and inappropriate transition of care when the guardian/DPOA was not involved or updated during the patient's hospital admission.

Findings included:

1. Review of the facility's policy titled, "Determination of Decisional Incapacity and Surrogates for Patients," dated 08/17/15, showed the following:
- An incapacitated person was someone who was unable by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to such an extent that he/she lacks capacity to meet essential requirements for food, clothing, shelter, safety or other care such that a serious physical injury, illness or disease is likely to occur.
- For adult patients who lack decisional capacity, a surrogate shall be identified and this surrogate shall make health care decisions for the patient in accordance with any advance directive given by the patient.
- A surrogate is someone who speaks on behalf of anther and may include a guardian and a DPOA for Health Care.
- A guardian is a person appointed by the Court to have the care and custody of a minor or an incapacitated person; a copy of the document from the court should be provided and kept in the patient's medical record.
- A DPOA for Health Care is a signed, dated and notarized document naming an individual to act as an agent for health care; this person would make health care decisions when the patient is no longer able to make decisions for himself/herself; this designated person has the authority to accept or refuse health care for the patient.

Review of the hospital's policy titled, "Care Coordination - Discharge Planning," dated 04/17/17, showed that discharge planning will occur on an ongoing basis during the course of the patient's hospital stay, and will engage the patient, patient identified caregivers, guardian, or patient representative.

Review of the hospital's policy titled, "Care Coordination - Assessment Patient and Family," dated 09/25/19, showed the following directives for Care Coordination Department case managers/social workers:
- Assess patients and their families on an ongoing basis to obtain relevant information for appropriate intervention.
- Assessments will ensure that appropriate support is provided to the patient during the hospital stay and that an appropriate safe discharge plan is developed.
- Obtain information from the patient and family; the consult is acknowledged within 24 hours by documentation of chart review or conference with the patient and/or family.
- Follow the patient's clinical progression in multi-disciplinary rounds or daily interaction with attending team, interaction with patient and family, chart review and/or consultation with other health care providers to determine needs and timeliness for specific case management interventions to facilitate the discharge plan.
- The patient and family must be given the opportunity to participate in the assessment and discharge planning evaluation.

Review of discharged Patient #4's History and Physical (H&P) and physician progress notes, showed the following:
- He was a 37 year old male with a past medical history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), seizure disorder, intellectual disability (ID, below average intellectual functioning and problems with functioning independently) and asthma (a condition in which the airways narrow and swell making it difficult to breathe).
- He was admitted to the hospital on 07/30/20 for acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system) from a Covid-19 (highly contagious, and sometimes fatal, virus) infection, which required intubation (the insertion of a tube into a persons trachea for ventilation when a person is not breathing on their own).
- A phone consent for intubation was obtained with the patient's guardian, by the physician.

Review of Patient #4's Care Coordination notes showed the following:
- On 07/31/20, recognition that the patient had a guardian, guardian's name and phone number (there was no documentation that the guardian was contacted and aware of patient's admission).
- On 08/10/20, the patient was extubated (removal of breathing tube). (There was no documentation that the guardian was notified of change in condition.)
- On 08/12/20, Physical Therapy recommended inpatient rehabilitation (rehab) at discharge; spoke to group home manager and nurse and they requested two facilities (there was no documentation that the guardian was notified).
- On 08/13/20, the patient was transferred out of the Intensive Care Unit (ICU) to the Progressive Care Unit (PCU). (There was no documentation that the guardian was notified of change in condition.)
- On 08/14/20, the patient was to be discharged to an inpatient rehab facility on 08/17/20 at 1:00 PM (there was no documentation of discussion of plan with the guardian).
- On 08/17/20, the patient was discharged to an inpatient rehab facility (there was no documentation that the guardian was notified).

Throughout Patient #4's 18-day hospital stay, there was only one documented note in the medical record that the guardian was updated or informed of his condition. There was no documentation that the guardian was given the opportunity to participate in the assessment and discharge planning evaluation of Patient #4.

During an interview on 09/03/20 at 4:15 PM, Public Administrator IIIII, stated the following:
- She was the guardian for Patient #4.
- She initially received calls from physicians when Patient #4 was in the ICU; after his transfer to the PCU, the calls stopped.
- She received no calls from a case manager/social worker.
- She called the hospital on 08/19/20 to inquire about Patient #4 and found that he had been discharged to an inpatient rehab facility on 08/17/20.
- The hospital gave the inpatient rehab facility incorrect information regarding her guardianship and contact information. The hospital relayed to the inpatient rehab facility, Public Administrator IIIII's first name only, that she was Patient #4's mother, and gave them a fax number, and therefore was unable to contact her.
- The lack of communication with discharge planning caused problems.

During an interview on 09/02/20 at 11:00 AM, Staff YYY, Case Manager, stated the following:
- He was the primary case manager for Patient #4.
- He was aware that Patient #4 had a guardian.
- Guardians should be contacted when a patient was admitted, change in patient condition, consents, transferring from one unit to another, updated every couple days or a couple times a week to keep them involved in the loop, and when the patient was discharged.
- He recalled Patient #4's guardian contacted him the day after discharge and asked for an update.
- He made a mistake not contacting Patient #4's guardian throughout Patient #4's hospitalization.

Review of current Patient #26's H&P and medical record showed the following:
- She was a 67 year old female with a history of intellectual disability, chronic hypoxic respiratory failure, tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) and dystonia (a movement disorder where muscles contract involuntarily, causing repetitive or twisting movements).
- She was admitted to the hospital on 08/09/20 for new oxygen requirements in the setting of ventilator (a machine that supports breathing) dependence, likely secondary to pneumonia (infection in the lungs).
- She was recently discharged from the hospital on 07/15/20 after being admitted for bacteremia (bacteria in the bloodstream) and pneumonia.
- On 08/25/20, the patient was scheduled to be discharged, she developed a fever and was tested for Covid-19. The discharge was canceled and the test came back negative for Covid-19.
- The patient was scheduled to be discharged on 08/31/20. An asymptomatic Covid-19 test was ordered by the physician on 08/30/20 prior to the patient being discharged to the residential facility in which she lived. (This test was not requested by the residential facility staff)
- The patient was discharged to the residential facility on 08/31/20.
- On 09/01/20 at 7:10 PM, a physician was informed that Patient #26's Covid-19 test results came back positive.
- The physician notified the patient's residential facility director of the results and Patient #26 was readmitted to the hospital on 09/01/20, one day after discharge.

Review of Patient #26's Care Coordination notes showed the following:
- On 08/10/20, recognition that the patient had a guardian, guardian's name, and phone number (there was no documentation that the guardian was contacted and aware of patient's admission).
- On 08/13/20, Gastrostomy-Jejunostomy tube (GJ, flexible tube inserted through the skin of the abdomen and into the stomach) exchanged (one was removed and replaced by the other) yesterday (there was no documentation that the guardian was notified of change in condition or consent obtained).
- On 08/16/20, nursing notes showed that the patient's tracheostomy tube was exchanged (there was no documentation that the guardian was notified of change in condition).
- On 08/18/20, guardian updated.
- On 08/24/20, probable discharge to the patient's residential facility. Nurses notes showed that the patient's GJ tube was exchanged (there was no documentation that the guardian was notified or consent obtained).
- On 08/25/20, patient discharge was canceled there was no documentation that the guardian was notified).
- On 08/26/20, the patient was transferred out of the ICU to the Medical Unit (there was no documentation that the guardian was notified of change in condition).
- On 08/28/20, guardian was updated of patient's probable discharge on 08/31/20.
- On 08/31/20, the patient was discharged to the residential facility she resided in prior to hospital admission. There was no documentation that a Covid-19 test was obtained on 08/30/20 and still pending (there was no documentation that the guardian was notified of actual discharge and that the residential facility manager was notified of the pending Covid-19 test).

Throughout Patient #26's 22-day hospital stay, there were only two documented notes in the medical record that the guardian was updated or informed of the patient's condition. Also, due to the lack of communication of pending Covid-19 test results, the patient was readmitted to the hospital on 09/01/20, one day after discharge, due to a positive Covid-19 test result.

During an interview on 08/31/20 at 3:30 PM and on 09/03/20 at 9:45 AM, Staff GG, Case Manager, stated the following:
- She was Patient #26's primary case manager after she transferred to the medical unit.
- She was aware that Patient #26 had a guardian.
- Guardians should be contacted when the patient was admitted to confirm guardianship and with any change in the discharge plan.
- Although she contacted the guardian regarding discharge three days prior to her discharge, when Patient #26 was discharged, she did not call the guardian to let her know the patient had been discharged.
- She did not recall if Patient #26's residential facility's Clinical Director HHHHH, requested a Covid-19 test prior to the patient's return to the facility.
- Physicians had been ordering Covid-19 tests on patients that lived in residential facilities and nursing homes as a precaution.
- If a residential facility requested a Covid-19 test prior to return, she would inform the physician and the patient would not be discharged until the test results were known.

During an interview on 09/03/20 at 12:24 PM, Staff FFFFF, Physician, stated the following:
- She ordered the Covid-19 test for Patient #26.
- She did not speak to anyone at the residential facility before ordering the test.
- Many facilities required a Covid-19 test prior to discharge; she thought it was required.
- The case manager informed her that the patient's facility did not require a Covid-19 test and that the ambulance had arrived to transport her to the residential facility.

During an interview on 09/03/20 at 3:15 PM, Patient #26's residential facility's Clinical Director HHHHH, stated that if she had known there was a pending Covid-19 test result, she would not have accepted the patient until the results were known. The failure to communicate this at discharge, risked the health of the other residents and staff at the residential facility.

Review of current Patient #39's H&P and medical record showed the following:
- She was a 57 year-old female with a history of bipolar disorder and cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood).
- She was admitted to the hospital on 08/23/20 for altered mental status (AMS, changes in the way the brain functions, such as confusion, memory loss, loss of alertness, judgement, thoughts and emotions), leftward gaze and sepsis (life threatening condition when the body's response to infection injures its own tissues and organs).
- The patient was recently discharged from the hospital on 08/20/20 to a nursing home.
- A signed/notarized Durable Power of Attorney for Decisions Regarding Health Care and Health Care Directive was in the medical record.
- She was inconsistently oriented (understanding of person, place and time) or oriented to self only.

Review of Patient #39's Care Coordination notes showed the following:
- There was no recognition that the patient had a DPOA for health care or that the DPOA was notified of admission and altered mental status.
- On 08/25/20, the plan for discharge was to return to the nursing home when the patient was medically stable (there was no documentation that the DPOA was notified or updated).
- On 08/28/20, problems include continued workup to determine the cause of the patient's altered mental status (there was no documentation that the DPOA was updated).
- On 09/01/20, the DPOA contacted the case manager with questions about the patients discharge plan and financial resource concerns.

Patient #39 was admitted on 08/23/20 with altered mental status. There was no communication with the DPOA for decisions regarding the patient's health care until 9 days later on 09/01/20, when the DPOA reached out to the hospital case manager.

During an interview on 09/03/20 at 10:10 AM, Staff DDDDD, Case Manager, stated the following:
- She was the primary case manager for Patient #39 during this hospital admission.
- A DPOA for healthcare was someone that had been identified to make medical decisions for a person when they were not able to.
- Patient #39 was confused during this admission.
- She was unaware that Patient #39 had a DPOA until she received a phone call from her.
- Her process was to call the DPOA and/or guardian on admission and on day of discharge, if the patient was confused.

During an interview on 09/01/20 at 3:15 PM, Staff HH, Care Coordination Director, stated the following:
- Care Coordination staff viewed guardians and DPOA's for healthcare as very important. They were the decision makers for the patient.
- Her expectation of Care Coordination staff, was to notify the guardian/DPOA within 24 hours of admission and verify guardianship/DPOA status.
- Staff were also expected to communicate with the guardian/DPOA any significant change in patient condition, consents, updates on discharge plan, and when the patient leaves the hospital.
































41474