HospitalInspections.org

Based on observation, interviews and record review the facility failed to:
-Provide care in a safe setting for vulnerable patients from a patient who was known to be physically and verbally aggressive.
-Provide sufficient staffing specific to patient acuity and not merely based on the number of patients.
-Provide first aid training for restraints to 22 Security Officers as required to provide patient safety.
-Immediately report an incident of abuse in the Emergency Department.
-Follow Policy and Procedure directing the facility to thoroughly, promptly and objectively investigate reported abuse and analyze and take appropriate corrective disciplinary action.
-Conduct Employee Disqualification Lists checks on 22 contracted Security employees since their hire on 04/20/12.

The facility census was 292 with 57 in behavioral health unit.

These deficient practices and systemic failures had the potential to place all patients at continued risk and in immediate jeopardy to those patient's health and safety.

The cumulative result of these findings resulted in non compliance with the Condition of Participation: Patient Rights and an Immediate Jeopardy situation. The facility was informed of the Immediate Jeopardy on 03/28/13. The facility was able to provide an acceptable plan of correction on 03/28/13 to implement corrective actions and abate the immediate Jeopardy. Please see A0144, A0145 and A0206 related to the Immediate Jeopardy.

Based on observations, interviews and policy review, the facility failed to:
-Post the correct contact information for patients and/or their representative to file a complaint and/or grievance with the appropriate State Agency.
-Ensure admission packets given to patients and/or their representatives listed the correct contact information to file a complaint/grievance to the appropriate State Agency. The facility census was 292 with 57 being on the Behavioral Health Unit. This had the potential to affect all patients seeking care at the facility.

Findings included:

1. Record review of the facility's Policy and Procedure titled, "Patient Grievance Policy" revised 09/01/12 gave the following direction:
- Alternate Grievance Process: In addition to the above mentioned processes, patients are advised in the Patient rights document that they may also direct grievances to:
Missouri Department of Health and Senior Services at 573 751-0293.

The telephone number listed is incorrect and when called identified the Missouri Division of Professional Registration and not the Missouri Department of Health and Senior Services (DHSS).

2. Record review of the facility's admission packet showed the following information:
-Patient Rights and Responsibilities: The telephone number to contact the Bureau of Health Services Regulation is listed as 573-751-0293. This telephone number is incorrect and is for the Division of Professional Registration and not the Missouri Department of Health and Senior Services-Bureau of Health Services Regulation.

3. During an interview on 03/25/13 at 2:45 PM, Patient #7 stated that he was admitted to the facility on 03/22/13 and did not recall what information he received during the admission process. He stated that if he had concerns he did not know who or how to contact to report concerns. He stated that he did not know how to contact the State Agency if he had concerns to report.

4. During an interview on 03/25/13 at 3:00 PM, Patient #8 stated that she was admitted to the facility on 03/11/13 and does not remember getting information related to patients' rights during the admission process. She stated that she did not know who to report concerns to and did not know how to contact the State Agency if she had concerns to report.

5. Observation on 03/27/13 at 9:00 AM, showed on the First Floor Adult Unit of the behavioral health campus that staff had posted signage in the day room directing patients and concerned others to call the Missouri Department of Health and Senior Services (DHSS) at 573-751-0293 if they have questions regarding patient rights. The telephone number listed is incorrect.

6. Observation on 03/27/13 at 9:45 AM, showed on 2A Unit of the behavioral health campus that staff had posted signage in the day room directing patients and concerned others to call DHSS at 573-751-0293 if they have questions regarding patient rights. The telephone number listed is incorrect.

7. Observation on 03/27/13 at approximately 11:00 AM on the 2C Unit of the Behavioral Health building showed staff posted signage directing patients and concerned others to call the DHSS at 573 751-0293, an incorrect number.

8. Observation on 03/27/13 at 2:00 PM showed signage posted in the main facility visitor elevator, located in the lobby, directed patients and concerned others to call the DHSS at 573 751-0293 (an incorrect number) if there were questions regarding patient rights.

9. Record review of documents from the admission packet titled "Welcome Packet" provided during the survey by Staff LL, Charge Nurse on 2C showed the following:
-A document titled "Protective Services" that directed "for questions and/concerns about a health care provider's state survey results, certification or licensure, contact the DHSS at 573 751-6279 (not a working number);
-A booklet titled, "Behavioral Health Patient Handbook", page 14, directed patients and concerned others to call 573 751-0293. The number is incorrect.

10. Observation on 03/28/13 at 10:00 AM in the Emergency Department (ED) showed a large Patient's Rights notice taped to the top of each admission's desk. The information directed patients and concerned others to call the DHSS at 573 751-0293 (an incorrect phone number) if there were questions regarding patient rights.

11. During an interview on 03/28/13 at 4:00 PM Staff XX, Director of Building Services, stated he was unaware that the documents provided to the patients and/or their representatives for complaints/grievances were varied and contained incorrect information. He stated that the documents were all provided by different sources and at different times and that they had not been checked for current, accurate information. He stated he was also unaware that the policy and procedure, titled "Patient Grievance Policy" dated 09/01/12 contained incorrect information.


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Based on interview and record review the facility behavioral health staff failed to ensure the patient and/or designated representative participated in developing and implementing a plan of care for two patients (#4, #6) of six patient care plans reviewed. The facility census was 292 with 57 of those at the behavioral health unit. This deficient practice had the potential to affect care of all patients at the behavioral health unit.

Findings included:

1. Review of the facility's policy titled "Plan of Care - Inpatient Nursing", revised 11/02/11 and provided during the survey by Staff A, Behavioral Health Unit Executive Director showed the following:
-The purpose was to provide a standardized, critical thinking framework for professional nursing practice;
-The Registered Nurse (RN) collected comprehensive data pertinent to the patient's health or situation;
-The RN involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection;
-{The nurse} documents relevant data in a retrievable format.

2. Record review of current Patient #4's admission history and physical showed the physician admitted the patient on 03/13/13 with diagnoses of depression and planned to provide medication, treatment and suicide precautions.

Record review of the patient's form titled "Multidisciplinary Treatment {care} Plan (Problem List)" dated 03/13/13 showed the staff assessed the patient with problems including suicidal ideation (thinking about taking one's own life) with no specific plan (no exact method of how to commit suicide). Further review of the form showed staff signed their own names in the column titled "Person(s) Responsible (Patient/Staff Name/Discipline)". No patient or patient representatives signatures were found on the form to indicate the patient's knowledge/involvement in the planning of care.

Record review of the patient's treatment plan showed staff included a
pre-printed form for treatment of anxiety dated 03/13/13 with the following:
-No treatment or care plan for suicidal ideation;
-No objectives, interventions, timeframe's or designated staff identified as responsible for the completion;
-Signatures of attendees included only the social worker, recreation therapist and nurse;
-Signatures of attendees did not include the patient.

3. During an interview on 03/25/13 at approximately 3:30 PM Staff B, Director of Nurses, Behavioral Health Unit reviewed the care plan and stated the following:
-Staff should care plan for each identified problem;
-The problem list did not include anxiety;
-The problem list did include suicide;
-Staff failed to develop a care plan for suicide as indicated on the problem list;
-The physician's admission history and physical included direction for staff to implement suicide precautions;
-Staff B would expect staff to develop and implement a care/treatment for suicide ideation with the patient.

4. Record review of current Patient #6's admission history and physical showed the patient was admitted on 03/20/13 with diagnoses including dementia with anxiety and depression; depression with psychosis, panic and anxiety. Further review of the history and physical showed the patient had problems including: making suicidal comments; was threatening and confrontational with others in her apartment building; was confused, was wandering, was confusing day and night and was at risk of burning herself; burning the carpet with cigarettes and stealing cigarettes/butts; and had poor appetite causing weight loss.

Review of the patient's past medical history, included on the admission history and physical showed the patient had gastrointestinal reflux (stomach fluids come back into the swallowing tube from the stomach into the mouth); chronic deafness; significant degenerative joint disease (wear and tear of the joint tissue) and basilar artery aneurysm (weakening of the wall of an artery in the base of the skull).

Record review of the patient's two treatment/care plan forms showed the first one titled, "Multidisciplinary Treatment {care} Plan (Problem List)" dated 03/20/13 on which staff documented a problem list including only psychosocial problems and none of the patient's numerous physical medical problems listed in the admission history and physical were mentioned.

Record review of the patient's second form titled "Multidisciplinary Treatment Plan" showed staff:
-Failed to plan any individualized objectives, interventions, timeframe's or designated staff or the patient identified as responsible for the completion;
-Failed to complete the form (form was blank) and sign (Signatures of attendees was blank).

5. During an interview on 03/25/13 at 4:00 PM Staff K, Charge Nurse stated she could not find a care/treatment plan for the patient.

6. During an interview on 03/25/13 at 4:05 PM Staff J, Nurse Supervisor reviewed the patient's blank care/treatment documents. She stated she would expect staff to develop a care plan with the patient and confirmed the staff failed to develop one.

7. During an interview on 03/27/13 at 3:00 PM, Staff PP, Recreational Therapist, stated that the patients were not invited to the care plan meetings unless they requested it or if there was a concern which the staff wanted to discuss.



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Based on interview and record review the facility failed to:
-Provide care in a safe setting and ensure one patient (#12), who was physically assaulted and suffered a concussion and one patient (#16), who was verbally harassed, were both protected from a patient (#13), who was known to be an aggressor;
-Provide sufficient staffing not only based on census but also on patient acuity (symptoms or conditions such as a likely hood for violence).

The facility census was 292 with 57 of those in the Behavioral Health Unit (BHU.) This deficient practice had the potential to affect all patients receiving care at the facility.

Findings included:

1. Review of the facility's policy titled Abuse and Neglect: Child, Domestic Partner, Adult and Patient" revised 03/28/12 showed the following direction for staff:
-The facility assured patients have the right to be free from physical and/or mental abuse or neglect, have the right to be treated with respect and have the right to protective oversight while a patient;
-1. C. Definition of the term physical abuse included the willful infliction of injury ... and intimidation ... resulting in physical harm ... of an adult by another individual;
-1. D. Definition of the term mental abuse included the use of oral ...gestured language that threatened a patient's well being and included willful intimidating, disparaging and derogatory terms. Mental abuse also included ... harassment, humiliation and threats of punishment.

Review of the facility's policy titled "Precautions/Safety Checks/Environmental Check" revised 04/01/12 showed the following direction for BHU staff:
-The BHU policy was to provide a safe and secure environment for patients;
-The procedure included the Registered Nurse (RN) or physician would determine the level of risk associated with each new admission and throughout an admission based on past behavior, affidavits, present situation, present behavior and current mental status;
-During the course of treatment, a RN may determine that intensified patient supervision was warranted and clinically necessary;
-Defined precautions included: Assault Precautions which were appropriate for those patients who were at risk to assault or harm others;
-Documentation would include the presence/absence of assault behaviors, nursing interventions as appropriate and the patient's response.

Review of the facility's policy, "Staffing - Nursing" revised 05/01/12 showed the following direction:
-Nurse staffing was based on the level and scope of care needed (acuity), the frequency of the care provided and a determination of the level of staff that can most appropriately and competently provide the type of care needed.
-A combination of "In Quality Staffing" (an internal process using full time, part time, as needed personnel with appropriate licensure for staffing), guidelines per census and hours per unit of service (budgeted hours) were used to determine the number of staff needed.

2. Record review of the facility staffing grid for the BHU - 2 C (a twelve bed unit) showed the following:
-For a census of one to ten patients, staffing was planned as one RN and one Mental Health Technician (MHT, an aide);
-For a census of 11 or 12 patients, planned staffing should be one RN, one Licensed Practical Nurse and one MHT;
-No parameters for additional staff based on acuity were defined (for example additional staff needed for a one patient to one staff instance).

3. Record review of discharged Patient #13's Clinical Summary (done in the Assessment and Referral department) dated 02/08/13 showed the following:
-The 25 year old patient was admitted to the BHU for homicidal ideation (thoughts of killing others);
-The 6' 2" tall, 256 pound patient had a legal guardian;
-Prior to admission he was living in a Residential Care Facility (RCF);
-He left the RCF without the guardians permission, visited a friend, smoked marijuana, returned to the RCF and when he tested positive for marijuana and he left the RCF again in a very angry state;
-He again returned to the friend's home and refused to leave;
-Police were called, the police returned him to the RCF and the patient punched holes in the walls there;
-He was transferred to the facility BHU and on 02/08/13 was admitted with problems including homicidal ideation and anger issues.

4. Record review of current Patient #16's Clinical Summary dated 02/08/13 at 12:58 PM showed the following:
-The patient was admitted to the BHU for self inflicted stab (knife) wound;
-The patient was assessed by staff as somewhat anxious with delayed responses to questions;
-Staff assessed the patient as not capable to make decisions for himself;
-Staff assessed he was not able to keep himself safe;
-On 02/12/13 staff assessed, while hospitalized on the BHU, the patient again stabbed himself in the upper abdomen with a pencil;
-This second stab wound required exploratory surgery (while on the surgical unit staff assessed him as paranoid and catatonic at times);
-The patient was returned to the BHU on 02/18/13 for continued psychiatric care.

Record review of Patient #16's re-admission history and physical dated 02/19/13 showed the physician assessed the following:
-The patient was a 5' 1" tall, 113 pounds;
-He appeared anxious with inappropriate affect and delayed speech;
-He was slowed, withdrawn and inattentive;
-He's not combative or aggressive.

5. Record review of discharged Patient #12's admission history and physical showed the patient was admitted on 02/20/13 with diagnoses including major recurrent severe depression; anxiety; alcohol and drug abuse.

Record review of the patient's Daily Assessment Flow sheet Data dated 02/20/13 showed staff assessed the patient was 5' 6" tall and weighed 178 pounds.

Review of the patient's nurse's notes dated 02/22/13 showed he was attacked by another patient. Patient #12 was knocked to the floor; struck several times in the head and body; sustained a lump on the head; had headache; had right jaw pain and dizziness. The 2 C unit staff assessed there was no loss of consciousness. The patient's vital signs were taken, the physician was called. The physician ordered staff to take the patient to the Emergency Department (ED) for evaluation.

Record review of the Patient #12's Event/Occurrence Executive Summary dated 03/24/13 showed Patient #12 asked the aggressor (Patient #13) to not make fun of a peer patient.

6. During an interview on 03/26/13 at 2:05 PM Staff T BHU Nurse Supervisor stated the following:
-She was on duty on 02/22/13;
-A "Mr Strong" code was called (a call for additional assistance and manpower for a special incident);
-She went to BHU - 2 C unit and found Patient #12 on the floor;
-Staff and security had Patient #13 in the hallway;
-Staff were removing Patient #13 to another unit;
-Patient #13 was previously admitted to another unit and had been unstable on that unit;
-Patient #13's instability had lessened so, was brought to 2 C because it was a quieter unit with less census;
-Patient #13 (the aggressor) was verbally mocking Patient #16 in the dining room after breakfast;
-Patient #12 asked Patient #13 to stop mocking Patient #16;
-Patient #13 ran across the dining room and physically attacked Patient #12;
-Census/staffing on 2 C on 02/22/13 was as planned; two staff for ten patients.

7. During an interview on 03/26/13 at 3:16 PM Staff KK, Mental Health Technician (MHT) stated the following:
-Patient #13 had made inappropriate comments or mocking sounds to Patient #16. "Patient #13 was in his face";
-Patient #12 had witnessed the exchange and said "that's real smart" and "you shouldn't have done that";
-Patient #13 was at the desk receiving medication and Patient #12 was at the opposite end of a dining room table;
-The two patients were not yelling and the verbal exchange did not seem angry. There was probably ten feet between the two of them;
-Patient #13 pushed away from the desk and struck the seated Patient #12, pushing him out of the chair to the floor and sliding six to eight feet on the floor;
-Patient #13 continued to strike Patient #12 while on the floor;
-Staff KK and a recreation therapist tried to pull Patient #13 off of Patient #12;
-Patient #13 shook both staff off of him and continued to strike Patient #12;
-The RN was at the desk called a "Mr Strong" code;
-Help came (staff from other units responding to the Mr Strong code) and we all pulled Patient #13 off of Patient #12;
-Patient #16 was not able to defend himself and may have been described as a victim. He didn't know what was going on around him;
-Patient #13 had been on the most acute unit for his propensity (likely hood) for violence so maybe he should not have been on 2 C;
-Patient #12 was much smaller than Patient #13. Patient #13 was two of Patient #12;
-Unit 2 C was not my usual unit, but there was nothing going on that would make anyone feel that a physical incident would happen.

8. During an interview on 03/27/13 at 9:00 AM Staff LL, Charge Nurse stated the following:
-She was not usually assigned to 2 C unit;
-She knew that AP meant assault precautions but could not relate any specific interventions;
-She did not know where to find the facility policy listing the definitions of the precautions and the list of actions to take for a specific precaution level;
-She looked for progress notes and nursing notes regarding an altercation involving Patient #16 however could not find any mention of verbal harassment of the patient on 02/22/13;
-She felt staff should have documented regarding the verbal harassment of the patient.

9. During an interview on 03/27/13 at approximately 10:30 AM Staff II, Licensed Practical Nurse (LPN) stated the following:
-The more acute patients go to another unit, usually not here on 2 C;
-Patient #12 was a smaller man who could be described as shy and guarded;
-Patient #12 was well known to staff due to previous admissions to the unit;
-Patient #13 was a much larger man and not known to staff because he'd never been admitted here before;
-Patient #13 could be described as a bully or intimidating.

10. During an interview on 03/27/13 at 10:46 AM Staff JJ, RN Charge Nurse on the day of the incident on 2 C stated the following;
-Patient #13 just woke up in a bad mood on 02/22/13;
-She had given Patient #13 his medication, he said he wanted to go home and he knew "they" were not sending him home;
-Patient #13 said something to another patient and Patient #12 said "leave him alone";
-Patient #13 said "don't tell me what to do" and ran across the room and started striking Patient #12;
-I was behind the nurse's station and called Mr Strong;
-A recreation technician who just happened to be there, had to help the MHT get Patient #13 off Patient #12;
-Patient #13 was transferred from a more acute unit. He had been violent on the previous unit and on the outside prior to admission;
-I'm not sure if he was on special precautions or had any special care planned;
-Patient #13 was just looking for someone/anyone to "get" that day;
-We had nine patients and I had one technician (MHT);
-We don't get a third staff person until we have 11 patients;
-Everyone does everything to keep it going;
-We do not use patient acuity to determine the staffing on the units.

11. During an interview on 03/28/13 at 8:50 AM Staff QQ, Licensed Clinical Social Worker (LCSW) in the Assessment and Referral (A & R) department stated the following:
-She screened walk-in and referred persons for possible admission to the BHU;
-Persons who report homicidal ideation (HI) may or may not be admitted because she felt that was "only one piece of the puzzle";
-For those who reported HI, she also looked for history of mental illness;
-If she felt a person required admission to the BHU, she called information to a psychiatrist who would give a verbal order to her for admission based on the information she had gathered and assessed;
-If a person was admitted she would write the order for admission;
-No psychiatrist were present and made a firsthand assessment or clinical judgment for admission of any patients who may have the potential to harm self or others.

12. During an interview on 03/28/13 at approximately 9:12 AM Staff B, Director of Nurses for the BHU and Staff T stated the following:
-Normal staffing on the BHU units was two staff for ten patients;
-The nurse supervisor on duty would listen to the unit staff to determine if more staff were needed (an after the fact determination and not a planned decision/change);
-Each unit has different staffing;
-The facility's policy, "Staffing - Nursing" revised 05/01/12 was used to determine how many staff were needed to care for patient;
-The policy did not include any consideration for patient acuity (patient's symptoms/ conditions) to decide numbers of staff required.

Based on record review, interview and Missouri Revised Statute review, facility staff failed to:
-Immediately report an incident of abuse of one (Patient #15) of one psychiatric patient in the Emergency Department (ED);
-Follow their internal policy on abuse investigation;
-Conduct Employee Disqualification List (EDL) checks (as directed by state statute Chapter 660.315 Employee Disqualification List) on 22 contracted Security employees;
-Proactively identify and screen one (Patient #13) of one patients known to be aggressive;
-Protect one (Patient #16);
-Investigate a patient to patient altercation (Patients #12 and #13) in a timely manner.

These failures had the potential to affect all patients in the facility. The facility census was 292. The behavioral health unit census was 57.

Findings included:

1. Missouri Revised Statutes RSMO Chapter 198 Section 198.070. 1. When any adult day care worker; chiropractor; Christian Science practitioner; coroner; dentist; embalmer; employee of the departments of social services, mental health, or health and senior services; employee of a local area agency on aging or an organized area agency on aging program; funeral director; home health agency or home health agency employee; hospital and clinic personnel engaged in examination, care, or treatment of persons; in-home services owner, provider, operator, or employee; law enforcement officer; long-term care facility administrator or employee; medical examiner; medical resident or intern; mental health professional; minister; nurse; nurse practitioner; optometrist; other health practitioner; peace officer; pharmacist; physical therapist; physician; physician's assistant; podiatrist; probation or parole officer; psychologist; social worker; or other person with the care of a person sixty years of age or older or an eligible adult has reasonable cause to believe that a resident of a facility has been abused or neglected, he or she shall immediately report or cause a report to be made to the department.

Record review of the Missouri Revised Statute (RSMO) Chapter 660.250 directed the following:
-660.250. As used in sections 660.250 to 660.321, the following terms mean:
-(5)"Eligible adult", a person sixty years of age or older who is unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs or an adult with a disability, as defined in section 660.053, between the ages of eighteen and fifty-nine who is unable to protect his or own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs;

Record review of the Missouri Revised Statute (RSMO) Chapter 198 Section 198.070 directed facility staff to immediately report abuse or neglect of a patient sixty years of age or older or an eligible adult where there was cause to believe that the resident of the facility had been abused or neglected should immediately report that abuse or neglect to the department.

Record review of the Missouri Revised Statute Chapter 660 Section 660.315 Employee Disqualification List directed the following:
-The department shall provide the list maintained pursuant to this section to other state departments upon request and any other person, corporation, organization, or association who is licensed as an operator under chapter 198;
-No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) ... of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.

Record review of the facility's policy titled, "Abuse & Neglect: Child, Domestic Partner, Adult and Patient" revised 03/28/12, directed staff to the following:
-The facility assures that patients have the right to be free from physical and/or mental abuse or neglect, have the right to be treated with respect, and have the right to protective oversight while a patient at the facility.
-Definition of the term physical abuse included the willful infliction of injury ... and intimidation ... resulting in physical harm ... of an adult by another individual;
-Definition of the term mental abuse included the use of oral ...gestured language that threatened a patient's well being and included willful intimidating, disparaging and derogatory terms. Mental abuse also included ... harassment, humiliation and threats of punishment.
-Mandated reporters: Missouri law mandates that persons having cause to believe or suspect that an elderly or dependent adult or a child has been physically or mentally abused or neglected or is at risk of being physically or mentally abused or neglected must report their concerns to the Missouri Department of Health and Senior Services (DHSS) for qualified adults.
- All personnel of the facility are mandated reporters of abuse, neglect or exploitation of qualified adults and children.
-Procedure: Emergency Department:
- Any employee who suspects or witnesses physical and/or mental abuse of an elderly or dependent adult patient will report the situation to their immediate supervisor and to the Social Service/Care Management Department. During regular business hours, the patient will be referred to the Social Worker who will interview the patient.
- If the real or suspected abuse or neglect involves a facility employee, the witness to the incident will report it to the manager of the division where it occurred. The manager will report incident to the Social Services Department. The patient will be referred to the Social Worker who will interview the patient and follow the check list protocol. Evenings and weekends the Division Manager will contact the on-call Social Worker through the Operator and the on-call Social worker will interview the patient.
-In all of these examples, if the Social Worker's interview establishes real or reasonable suspicion of abuse or neglect, she/he will document the interview on the Social Services Assessment or the Social Service Progress Note form in the patient's medical record. She/he will call a report to DHSS.
Management Procedural Checklist for Internal Allegation of Abuse:
-Notify Social Service/Care Management appropriate to location of patient.
-Notify Security to meet with patient (Social Services and Security should work together to interview patient and investigate).
-Social Service will work with Security and ask patient if they want to file a police report.
-Notify Administrator of the Day.
-Notify Risk Management.
-Document incident as appropriate.
-Notify family and employee about necessary reporting to agencies who may need to follow up.
-Offer family counseling or pastoral care support to family and patient.
-Social Worker will call the appropriate agency with a Hotline call as required.
Notification of Authorities:
-Determine patient's desire or willingness to prosecute.
-Call report to the age appropriate hotline.
Examination:
-Physician will perform a complete physical exam.
Referrals:
-Referrals to resources appropriate to age and nature of abuse to assist patient with legal recourse, counseling, etc.
Documentation - Multidisciplinary:
-Identity information of the attacker should be included in the documentation (in the patient's words).
-Documentation must include thorough description of injuries, both old and new.
-Documentation must include any treatment provided.
-Documentation must also include a Social Service intervention and that appropriate referrals were made and resource information provided. Refusal of Social Service intervention must be noted.
-Documentation must also include notification of proper authorities if contacted at patient's request.

2. Record review of the facility's self report received by DHSS on 03/06/13 showed the following:
-The incident regarding Patient #15 occurred on 02/21/13 in the ED.
-The patient had cut his wrists in an attempt to commit suicide.
-The police brought the patient to the ED for treatment after the patient had been tased (a brand name for a gun-like device that uses propelled wires or direct contact to electrically stun and incapacitate a person temporarily) two times before reaching the facility.
-Upon entering the ED the patient was placed in four point restraints (the application of limb restraints on both arms and legs at once).
-Four ED personnel, one policeman and one security guard witnessed the physician put his hands around the patient's neck and press on his throat shutting off his airway and stated that he will stop fighting now, I am restricting his airway.
-The security guard reported the incident to his supervisor on 02/24/13.
-The ED Medical Director was notified of the incident by the Director of Security on 02/24/13.
-The Risk Manager was notified of the incident on 02/26/13.
-The incident was reported to DHSS on 03/06/13.

3. Record review of Patient #15's medical record showed on 02/21/12 at 4:14 PM the patient was combative and was tased and handcuffed by the police (prior to the ED visit). The patient had multiple cuts on his left wrist. The handcuffs were removed and the bleeding was controlled. The patient was transported to the facility ED at 5:06 PM.

4. Record review of ED documentation by Physician Z for Patient#15, dated 02/21/13 at 5:46 PM showed that the patient was screaming and tearing out large chucks of his hair. When he was asked to stop he became extremely angry. The patient stated that he was not a man after he was called Sir. The patient started calling me names such as a queer and a fat piece of shit and tried to throw a pan of his spit on me and tried to spit on me. The patient was placed in four point restraints and then spit on me and the police officer. He stated that he eventually would get out of the restraints, come to my house and cut off my dick and shove it down my throat. He stated that he would kill me in a most painful way he could think of and would get away with it because he had a head injury. There were police, multiple security and nursing at the bedside during this time.

5. Review of the facility's job description for Staff R, the Director Risk Management/Assistant General Counsel showed the following responsibilities:
-The Director of Risk Management/Assistant General Counsel is responsible for the risk management and legal functions of the facility and it's affiliates. The Director Risk Management/Assistant General Counsel shall also assist departments with regulatory compliance of legal and risk management issues.
-Risk Management: Provides risk management consulting and education to employees, physicians and affiliates. This includes responding to patients, families and collaborating with other departments. Also provides regulatory and insurance reporting as required by appropriate statute and coverage.
-Compliance - Conduct: Be truthful in communication and avoid any information that is misleading.
-Accountability: Takes responsibility for his/her own actions, including the impact of own decision on patients and others. Also takes responsibility for actions of any direct reports. Takes appropriate action when anyone in the organization violates standards or regulations.
Service Standards: Enforces and adheres to facility policies.
-Safety: Takes responsibility for patient safety. Complies with National Patient Safety Goals and other regulatory standards as well as rules designed for personal protection and environmental safety. Looks for potential safety risks, speaks up promptly, and encourages patients, co-workers and family members to do the same if they see safety is a concern.
-Compliance: Conduct patient care and service within established standards of quality and ethics throughout the campus.

6. Record review of the facility's Policy and Procedure titled, "Incident Report" revised 02/11/09, showed the following:
-The incident report is a risk management tool that is created to factually and objectively document the incident in anticipation of litigation.
-An incident report is to be completed as soon as practical after an incident involving a patient or visitor. An incident is described as: "Any happening which is not consistent with the routine operation of the facility or the routine care of a particular patient." It may be an accident or situation that might result in bodily injury or a claim.

7. During an interview on 03/25/13 at 10:00 AM Staff R, Director of Risk Management/Assistant General Counsel, stated that she was a mandated reporter. Staff R stated she did not do any follow up about the abuse/neglect reporting (concerning the incident with Patient #15) but the Security Department and the ED were supposed to. She stated that she asked the two departments to please try and do some education. She stated that Staff V, Security Supervisor reported the incident to her and on 03/25/13 and she conducted another investigation. She stated that she interviewed everyone but the police and the patient (#15).
She stated that she did not report the event as an incident even though there were six witnesses that confirmed the event.

During an interview on 03/26/13 at 12:20 PM Staff R, stated that she should have reported the event internally as an incident (did not complete an incident report.)

8. Review of Staff R's investigation notes showed that Staff V, Security Supervisor, stated that Patient #15 couldn't breathe and his face was turning red. The investigation notes for the ED RN stated that the physician (Staff Z) was taunting the patient and stated that the patient is a transgender male in the final stages of transformation. She stated the patient was dressed as a woman and the physician refused to address him as a female and stated that you have a penis don't you?

9. During an interview on 03/26/13 at 2:05 PM Staff CC, RN, ED Nursing Manager, Staff SS, ED Director and Staff ZZ, ED Medical Director agreed that the ED practices did not follow the facility policy on abuse and neglect.

10. During a telephone interview on 03/26/13 at 2:29 PM Staff V, Security Supervisor, stated that he was in Patient #15's room during the event. He stated that he witnessed Staff Z, MD, put his hands around the neck of the patient.

11. During a telephone interview on 03/27/13 at 11:00 PM Staff AA, Emergency Medical Technician (EMT), stated he witnessed Staff Z, ED physician, put his hands around Patient #15's neck.

12. During an interview on 03/27/13 at 8:35 AM Staff RR, RN, Director of Nursing Resources and Professional Practices, stated that she conducts all the education in the facility. She stated she was never told about the event with Patient #15 until 03/25/13 when the survey began. She stated she was never told the names of the staff in the room and was not aware that none of them reported the incident until now. No education related to abuse and neglect had been provided to the ED.

13. During a telephone interview on 04/02/13 at 10:15 AM, Staff Z, ED physician stated that he could not speak to the medical treatment of Patient #15 because he did not have the medical chart to review. He stated that he remembered the patient because of the circumstances of his ED presentation. He stated that he called the patient sir, the patient said he wasn't a man and the physician stated that you have a penis so you are a man. He stated he didn't remember what the patient asked him to call him, but whatever it was that's what he called him because that's what he does for all his patients. He stated that he did not put his hands on the man's throat and he did not try to choke him.

14. 660.315 "Employee Disqualification List" showed the EDL is maintained by the DHSS and is a listing of individuals who have been determined to have abused or neglected a resident, patient, client or consumer. These acts must have occurred while the individual was employed or by reason of their employment by a long term care facility, an in-home services provider agency, by the hospital, home health agency, hospice, or an ambulatory surgical center, or by a consumer or vendor.

Long-term care facilities, in-home services provider agencies, hospitals, home-health agencies, hospices and ambulatory surgical centers are prohibited from employing a person, in any capacity, whose name appears on the EDL. These providers are required to check the EDL before hiring an individual and they may not continue to employ a person whose name appears on the EDL.

15. Record review of the facility's policy and procedure titled, "Employee Disqualification List Checks" revised 10/01/09 gave the following direction:
- To ensure no current facility employees have been added to the list, Human Resources will review the list quarterly.
- EDL reports will be maintained as part of the employee's permanent record.

16. Record review of the contracted Security personnel files showed the following:
- Staff V, Security Supervisor, showed no EDL checks.
- Staff X, Security Officer, showed no EDL checks.
- Staff Y, Security Officer, showed no EDL checks.
- Staff BB, Director of Security, showed no EDL checks.

17. During an interview on 03/27/13 at 1:15 PM Staff BB, Director of Security, stated that the facility contracted for 22 Security personnel. He stated that none of the employees have been checked for EDL's. He stated he had never heard of an EDL check until now and wasn't aware this was a required check at least annually.

18. During an interview on 03/27/13 at 3:00 PM Staff WW, Human Resources Business Partner, stated that the contracted security employees had not been in the facility system for EDL checks since the contract began on 04/20/12. She stated she was not aware that the EDL checks pertained to contracted employees.

19. Review of the facility's policy titled "Precautions/Safety Checks/Environmental Checks" revised 04/01/12 showed the following direction for BHU (Behavioral Health Unit) staff:
-The BHU policy was to provide a safe and secure environment for patients;
-The procedure included the registered nurse (RN) or physician would determine the level of risk associated with each new admission and throughout an admission based on past behavior, affidavits, present situation, present behavior and current mental status;
-During the course of treatment, a RN may determine that intensified patient supervision was warranted and clinically necessary;
-Defined precautions included: Assault Precautions which were appropriate for those patients who were at risk to assault or harm others;
-Documentation would include the presence/absence of assault behaviors, nursing interventions as appropriate and the patient's response.

20. Record review of discharged Patient #13's Clinical Summary (completed in the Assessment and Referral, A&R department) dated 02/08/13 showed the following:
-The 6' 2", 256 pound, 25 year old patient was admitted to the BHU for homicidal ideation (thoughts of killing others);
-He eloped from the Residential Care Facility (RCF), went to a friend's home and refused to leave. Police were called, the police returned him to the RCF where he punched holes in the walls;
-He was transferred to the facility BHU and on 02/08/13 was admitted with problems including homicidal ideation and anger issues.

21. Record review of current Patient #16's Clinical Summary (completed in the A&R department) dated 02/08/13 at 12:58 PM showed the following:
-The patient was admitted to the BHU for self inflicted stab (knife) wound;
-He was assessed as somewhat anxious with delayed responses to questions, not capable of making decisions for himself and not able to keep himself safe;
-On 02/12/13, while hospitalized on the BHU, the patient again stabbed himself in the upper abdomen with a pencil;
-While on the surgical unit, recovering from the second stab wound, staff assessed him as paranoid and catatonic at times;
-The patient was returned to the BHU on 02/18/13 for continued psychiatric care.

Record review of Patient #16's re-admission history and physical dated 02/19/13 showed the physician assessed the following:
-The 5' 1" tall, 113 pounds patient appeared anxious with inappropriate affect and delayed speech;
-He was slowed, withdrawn and inattentive and not combative, aggressive or combative.

22. Record review of discharged Patient #12's admission history and physical showed the patient was admitted on 02/20/13 with diagnoses including major recurrent severe depression; anxiety; alcohol and drug abuse.

Record review of the patient's Daily Assessment Flow sheet Data dated 02/20/13 showed staff assessed the patient was 5' 6" tall and weighed 178 pounds.

Review of the patient's nurse's notes dated 02/22/13 showed he was attacked by another patient. Patient #12 was knocked to the floor; struck several times in the head and body; sustained a lump on the head; had headache; had right jaw pain and dizziness. The 2 C unit staff assessed there was no loss of consciousness. The patient's vital signs were taken, the physician was called. The physician ordered staff to take the patient to the Emergency Department (ED) for evaluation.

Record review of the Patient #12's Event/Occurrence Executive Summary dated 02/22/13 showed Patient #12 asked the aggressor (Patient #13) to not make fun of a peer patient.

23. During an interview on 03/26/13 at 9:45 AM Staff R, Director of Risk Management/Assistant General Counsel, stated the following:
-She had probably received a telephone call regarding the physical altercation between Patient #12 and #13.
-Since Patient #12 had received care in the Emergency Department after the altercation, Staff R felt nothing more was required (no further investigation, interviewing or reporting).

24. During an interview on 03/26/13 at 2:05 PM Staff T, BHU Nurse Supervisor, stated the following:
-Patient #13 was admitted to another unit and had been unstable on that unit;
-Patient #13's instability had lessened, so, was brought to 2 C because it was a quieter unit with less census;
-Patient #13 (the aggressor) was verbally mocking Patient #16 in the dining room after breakfast;
-Patient #13 ran across the dining room and physically attacked Patient #12.

25. During an interview on 03/26/13 at 3:16 PM Staff KK, Mental Health Technician (MHT) stated the following:
-Patient #13 had made inappropriate comments or mocking sounds to Patient #16. "Patient #13 was in his face";
-Patient #12 had witnessed the exchange and said "that's real smart" and "you shouldn't have done that";
-Patient #13 ran over to Patient #12 and struck him several times;
-The RN was at the desk calling a "Mr Strong" code;
-Patient #16 was not able to defend himself and could have been described as a victim. "He didn't know what was going on around him";
-Patient #13 had been on the most acute unit for his propensity for violence so "maybe he should not have been on 2 C";
-Patient #12 was much smaller than Patient #13. "Patient #13 was twice the
size of Patient #12".

26. During an interview on 03/27/13 at 10:46 AM Staff JJ, RN Charge Nurse on 2 C stated the following;
-Patient #13 was transferred from a more acute unit. He had been violent on the previous unit and on the outside prior to admission;
-She was not sure if he was on special precautions or had any special care planning.

27. During an interview on 03/27/13 at 12:58 PM Staff MM Clinical Manager of the Assessment and Referral (A&R) department stated the following:
-Her department employed 19 Licensed Clinical Social Workers (LCSWs);
-Her department had staff on duty 24 hours a day, seven days a week;
-The staff assessed 25 to 30 patients per day and approximately 50% of those were admitted;
-If a LCSW assessed a person required admission, the LCSW telephoned the on-call psychiatrist for a verbal order to admit;
-If a person was admitted and they had verbalized a propensity to harm self or others the LCSW would tell the nursing staff on the unit assigned;
-If there was a danger to harm others, that statement would be in the A&R documentation;
-Patients who were a risk to harm self or others would be assigned to 2 A, the acute unit.

28. During an interview on 03/28/13 at 8:50 AM Staff QQ, LCSW in the A&R department stated the following:
-She had been in position for approximately six years;
-Prior to this position she had been a Social Worker on a regular hospital unit;
-She currently screened walk-in and referred persons for possible admission to the BHU;
-She had received training for her current position from a previous LCSW;
-Persons who report homicidal ideation (HI) may or may not be admitted because she felt that was "only one piece of the puzzle";
-For those who reported HI, she also looked for history of mental illness;
-If she felt a person required admission to the BHU, she called information to a psychiatrist who would give a verbal order to her for admission based on the information she had gathered and assessed;
-If a person was admitted, she would write the verbal order for admission;
-No psychiatrists were present and/or made a firsthand assessment or clinical judgment for admission of any patients who may have the potential to harm self or others.

29. Record review of the undated job description, titled "Assessment and Referral Clinician" showed the following:
-The position summary was: An assessment and Referral Clinician is a professional who has responsibility and accountability for evaluating patient treatment needs and patient treatment disposition. The responsibilities will be in accordance with the policies and procedures of the Assessment and Referral department, {the facility} and Federal and State laws concerning duty to warn, reports of abuse, guardianship, COBRA, involuntary admission and confidentiality;
-License required: Licensed Clinical Social Worker in the state;
-Education: Masters degree required.
-The position description did not require any specialized education, training, credentialing or experience in psychiatry, psychology or counseling.





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Based on interview and record review the facility failed to provide 22 of 22 Security employees with First Aid Training in Restraints as required to ensure patient safety. This had the potential to affect all patients in restraints. The facility census was 292.

Findings included:

1. Record review of the facility Policy and Procedure titled, " Restraint/Seclusion" revised 04/01/12 showed the following:
- Training and Education: All staff involved in the assessment implementation and monitoring of seclusion and restraint are required to complete training and display competency during orientation and annually thereafter.
- This training includes: Safe application of restraint/seclusion, including how to recognize and respond to physical and psychological distress.
- Monitoring physical and psychological well-being of patient (e.g. respiratory and circulatory status, skin integrity, and vital signs) and any special requirements specified by hospital policy associated with the one hour face-to-face evaluation.
- All staff who applies restraint or seclusion, monitors, access or provide care for a patient in restraint or seclusion will receive education and training in the use of first aid techniques as well as training and certification in the use of cardiopulmonary resuscitation (CPR).
- Trainers must be qualified by education, training and experience. Training and competencies must be documented in staff records.

2. Record review of the contracted Security personnel files showed the following:
- Staff V, Security Supervisor, showed no First Aid Training in Restraints education.
- Staff X, Security Officer, showed no First Aid Training in Restraints education and no CPR.
- Staff Y, Security Officer, showed no First Aid Training in Restraints education and no CPR.
- Staff BB, Director of Security, showed no First Aid Training in Restraints education.

3. During an interview on 03/27/13 at 1:15 PM Staff BB, Director of Security, stated that the facility contracted for 22 Security personnel. He stated that none of the employees had received First Aid Training in Restraints education. He stated he was not aware that it was a requirement. He stated that cardiopulmonary resuscitation was not a requirement for security employees and was not in their job description.

4. During an interview on 03/27/13 at 3:00 PM Staff WW, Human Resources Business Partner, stated that the contracted personnel files were not audited by Human Resources and was not aware that they did not receive First Aid Training in Restraints education or were required to have training and certification in the use of cardiopulmonary resuscitation.