HospitalInspections.org

Based on interview and document review, the hospital failed to ensure patients were only admitted by practitioners granted admitting privileges by the governing body for 3 of 30 patients (P26, P30, P10) reviewed.

Findings include:

P26 was admitted to the hospital on 7/22/12. The history and physical (H&P) and the initial admitting orders were completed by nurse practitioner (NP)-A. No other admitting orders by a physician were documented on the Physician Order Forms according to the original computer entries.

P30 was admitted to the hospital on 9/17/12. The initial orders were completed by NP-A. No other admitting orders by a physician were documented on the Physician Order Forms according to the original computer entries.

P10 was admitted to the hospital on 7/27/12. The initial orders were completed by NP-B. No other admitting orders by a physician were documented on the Physician Order Forms according to the original computer entries.

On 10/18/12, at 10:00 a.m. the nursing supervisor (director of nursing) stated 1 of the 3 Community Behavioral Hospital's (CBH) statewide psychiatrists (MDP) will accept each patient for admit to one of the CBHs.

The Preadmission Triage worksheets identified this process, however, the accepting psychiatrist did not authenticate an admission order on these worksheets.

On 10/18/12, at 10:20 a.m. MDP-A verified this practice. MDP-A added the accepting psychiatrist would delegate the H & P and initial orders to a LIP (licensed independent practitioner) that included other physicians and nurse practitioners.

On 10/19/12, at 11:40 a.m. the chief executive officer indicated that there are only 4 physicians that have admitting privileges at the hospital. He further clarified that nurse practitioners and physicians assistants do not have admitting privileges. He stated he would expect to see the physicians writing an admission order in the record.

The Medical Staff Bylaws dated September 30, 2011, page 4 identified, "Admitting privileges means the authority to authorize admission to a licensed hospital. Admitting privileges are granted to physicians who may serve as attending clinicians." Section 3 of the by medical staff bylaws indicated advanced practice registered nurses do not have admitting privileges.




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Based on interview and document review, the hospital failed to follow their own policy including providing written responses for 7 of 18 grievances reviewed that involved 2 patients (P40, P41) who had filed grievances in the hospital.

Findings include:

A review of the eighteen grievances filed between 4/1/12 and 10/15/12, was conducted on 10/18/12. Documentation did not reflect whether a written notice of the hospital's decision was provided to the patient after a grievance was filed.

A Grievance Form had been completed for each grievance. The form identified the date of concern, the specific concern identified by the patient, and if the grievance had been resolved for the patient after staff had responded to the concern at the time it had been filed. The form identified if the grievance was not resolved, additional action taken on the grievance would be documented within 72 hours. If the grievance continued to be unresolved, it would be faxed to the chairperson of the grievance committee for resolution.

On 4/1/12, P40 filed a grievance form that identified concerns that the facility was "lousy" and wouldn't send P40's dog. The form also identified P40 felt the county case worker had lied regarding the smoking policy in the facility. The form identified a staff person had discussed the grievance with P40, however, P40 felt the grievance had not been resolved. The form lacked further documentation of follow up with P40 to resolve the grievance and lacked documentation the grievance had been faxed to the grievance committee for further follow up.

On 4/4/12, P41 filed a grievance form that identified concerns with trauma from another patient repeatedly exposing private body parts to P41. P41 identified she was disgusted, traumatized and very hurt by this behavior. The form identified P41 felt this grievance was unresolved, however, the form lacked documentation of discussion by the staff person who received the grievance and of further follow up in the hospital or by the grievance committee. Further, the form lacked documentation of a written response provided to the patient after investigation of the grievance.

On 4/9/12, P41 filed a grievance form with concerns that she felt harassed and did not feel safe around a specific staff member. The form identified a staff person had discussed the grievance with P41, however, the patient felt the grievance had not been resolved. The form lacked further documentation of follow up with P41, and lacked documentation of further follow up by the hospital or by the grievance committee.

On 4/9/12, P41 filed a grievance form with concerns regarding a specific patient who had made threats of harm, and staff was aware of the conflict. The form identified P41 did not feel the grievance was resolved, but lacked documentation of further follow up or action taken by the hospital or by the grievance committee.

On 4/9/12, P41 filed an additional grievance form with concerns that one patient had punched another patient and made threats of further harm. The grievance identified P41 felt scared and frightened by the other patient. The form identified the administrator had briefly discussed the concern with P41, however, the form lacked documentation of further follow up or actions taken by the administrator or by the grievance committee.

On 4/9/12, P40 filed a grievance form with concerns that he was Catholic and was not allowed to wear a Crucifix. The request was declined because of the potential for harm. However, the form lacked documentation the team decision had been discussed with P40, and any further follow up by the hospital or grievance committee.

On 4/13/12, P41 filed a grievance form with concerns related to her discharge plan from the facility. The form identified staff referred the concern on to social services to discuss the discharge plan with P41. The form lacked documentation of any follow up of the concern by the hospital social worker or grievance committee.

Review of the policy titled Grievance and Complaint Process, effective 6/16/12, identified if a complaint cannot be resolved at the time, a grievance form would be completed. If the grievance could not be resolved by the hospital, the grievance would be forwarded to the grievance committee and a response would be recorded on the grievance form and provided to the patient.

On 10/18/12, at 9:41 a.m., the nursing supervisor (director of nursing) confirmed the above findings and hospital policy. She stated the hospital considered all written concerns grievances. She stated they would expect that all grievances in the hospital would be investigated in an attempt to resolve the grievance. If unable to resolve the grievance, the grievance committee would address the grievance response in writing. The nursing supervisor confirmed the patients had not received a written response to their individual grievances.

Based on interview and document review, the hospital failed to ensure adequate staffing to manage each patient's behavioral symptoms in order to provide care in a safe environment for 2 of 3 patients (P19, P23) identified to receive assistance during behavioral emergencies by law enforcement personnel.

Findings include:

Review of the incident reports for the hospital from 9/29/11 to 9/10/12, revealed the following:

The incident report dated 5/3/13, at 7:40 p.m., revealed R23 had become aggressive and started fighting with another patient in the facility. R23 sustained multiple scratches on the face, chest, and wrists. Review of the progress note dated 5/3/12, identified R23 also yelled at staff members and hit a staff member in the head and face. The progress note identified staff present could not manually restrain R23, and police were called to the hospital to help get R23 into a restraint chair. Law enforcement had informed R23 she would not be taken to jail, but placed in the restraint chair, given medication and would "stay here." R23 hit law enforcement staff in the leg, and was finally restrained and given an intramuscular injection for aggressive behavior.

The incident report dated 9/10/12, at 3:43 p.m. indicated R19 became agitated, yelling, swearing, very angry, and verbally and physically threatening. The incident report identified 5 law enforcement officers came to unit. Review of the progress note dated 9/10/12, identified R19 refused injections for mood, became verbally abusive, threatening, put finger in staff faces yelling loudly and making gestures with his fist, and threatening violence. Law enforcement came to facility to and talked to R19 about taking his medications. R19 requested hand cuffs and law enforcement placed the hand cuffs on R19 briefly, intramuscular injections were given and he was placed in the restraint chair. R19 did not resist, and followed the officers' orders.

Review of the facility policy titled Responding to Criminal Behavior, effective 6/2/11, identified the decision to involve law enforcement in the management of aggressive behavior must ONLY be made when there is an emergency that includes substantial risk of serious injury or death to person and or substantial property damage that compromises safety and constitutes criminal behavior. The policy lacked identification of other personnel resources for these emergency situations in the hospital.

On 10/18/12, at 12:55 p.m., the nursing supervisor (director of nursing) confirmed the current hospital policy and the usual staffing patterns on the station was 4 staff for each shift. She confirmed part of the crisis plan would be to call law enforcement for assistance to manage a patient's behavioral symptoms (crisis) that would require additional staff.

On 10/18/13, at 2:02 p.m., licensed practical nurse (LPN)-A stated if a patient became aggressive, the physician or nurse practitioner are contacted to assist in determining a plan for immediate care of aggressive behavior. LPN-A stated the nurse practitioner was present during R19's recent aggressive behavior and determined law enforcement was to be called and had "determined need more manpower." She stated the usual hospital staffing was 4 staff on per shift, and the hospital had recently added 1 more staff person on the weekend to assist with cares.

On 10/18/12, at 2:46 p.m., registered nurse (RN)-B stated that "no less than 4 staff " were required for safe management of aggressive patients, and 1-2 staff were needed to manage other patients on the unit during the intervention. RN-B stated the usual hospital staffing was 4 staff per shift, and when staff felt they were unable to physically manage the situation due to possible harm to staff or patients, law enforcement were called to assist with subduing the patient.

On 10/19/12, at 12:20 p.m., the nursing supervisor stated there are times the usual staffing is not adequate, such as when there is an increase in patient behaviors requiring increase in interventions, increase in observation levels of patients, and assaultive, aggressive behavior that requires more staff redirection. She stated when "explosive" behaviors occur such as verbal or physical assaultive and are unable to de-escalate, and staff can not contain the situation, law enforcement is called to assist. She added the hospital support staff are trained to assist with crisis situations, however, after business hours and weekends and holidays, the support staff are not available.

Further, she stated the hospital does not employ security guards or maintenance staff after usual business hours. The nursing supervisor stated the hospital has on occasion called a maintenance staff member that lives close to the hospital, however, it is not part of the crisis plan to consistently call the maintenance personnel in after hours to assist with emergency management of aggressive behaviors. The nursing supervisor confirmed law enforcement is called to the hospital to assist to contain behavioral emergency situations, and not to arrest and remove the patient.

Based on interview and document review, the hospital failed to provide education related to organ/tissue donation (OPO) for 9 of 13 direct care staff (DSC-A, DSC-B, DSC-C, DSC-D, DSC-E, DSC-F, DSC-G, DSC-H, DSC-I) reviewed.

Findings include:

Personnel record review indicated DSC-A, DSC-B, DSC-C, DSC-D, DSC-E, DSC-F, DSC-G, DSC-H, and DSC-I, did not receive education related to organ/tissue donation. The direct care staff included three registered nurses, one occupation therapist, four licensed practical nurses and one human service technician.

The nursing supervisor (director of nursing) interviewed on 10/19/12, at approximately 2:40 p.m., stated she was unsure if all direct care staff received organ/tissue donation education. She indicated registered nurses received education on OPO sometime during the first year of hire. In addition, the facility on-line education program included a review of the policy for organ/tissue donation.

No other documentation or information related to this review was provided.

The policy on Death of Patient dated September 2008, indicated the charge registered nurse would notify the Organ Donor Coordinator of the death of a patient.

Interview with the chief executive officer on 10/19/12, at 12:15 p.m. indicated he knew that the director of nurses (nursing supervisors) met in St Cloud to discuss OPO, but was unsure how other direct care staff were educated.

Based on interviews and record reviews, the facility failed to assure that patients on the inpatient unit who were required to attend a court hearing related to involuntary commitment were treated with dignity, and that nursing staff were able to treat seriously agitated patients without requiring the aid of outside law enforcement officials. Specifically:

1. The Medical Director failed to assure that patients who required court appearances related to involuntary commitment were treated with dignity. Patients were usually transported to court hearings at various county courts by law enforcement and in handcuffs, in a manner similar to that used for persons involved in criminal hearings. (Refer to B144)

2. The Director of Nursing failed to assure that nursing staff were adequately prepared to treat potentially assaultive patients; instead the facility relied on armed law enforcement officers, who came onto the inpatient unit and took part in restraint of patients, although these patients were not involved in criminal actions which would require the involvement of law enforcement and which would have resulted in arrest. (Refer to B148)

Based on interviews, the Medical Director failed to assure that patients who require commitment hearings are treated with dignity. Although there is an Interactive TV on the Inpatient Unit that is used for court hearings for some patients, most are transported from the facility to various county courts for commitment hearings, without staff escort and not in a manner that maintains patient dignity. Patients are transported to the county in which the court hearing occurs in the custody of law enforcement agents, who are usually under the law enforcement agency's policy of always transporting patients in handcuffs. Patients may also be in shackles going to or coming from court. These procedures compromise the dignity of patients, ad expose them to additional psychological trauma.

Findings include:

1. In an interview with RN 2 at 10:00 AM on 10/18/12, she stated that, although the facility has the set-up for Interactive TV to allow involuntary patients to appear in court for commitment hearings via TV from the hospital, most involuntary patients are transported to the county where the hearing is to occur, and are transported by law enforcement. No staff from the hospital accompany the patients.

2. In an interview with RN1 at 10:00 AM on 10/19/12, she confirmed that involuntary patients are transported to the county court where the hearing occurs, with law enforcement escort, and without hospital staff accompanying. She stated that the hospital is advised by the court of the date and time of the hearing, and that the hospital had no input into the transportation arrangements, and she did not know why the Interactive TV was not used more. She stated that the hospital staff often asked the law enforcement person transporting the patient to not use handcuffs, but that in most cases, the law enforcement personnel do not have the option to not use handcuffs, but are required by policy in their own department to handcuff anyone they transport. She stated that patients sometimes are also in shackles, and that some patients, when they return, report that they felt "humiliated."
She also stated that patients usually were given daytime meds before going to court or after return, since there was no one to carry the meds and administer to the patient while the patient was away. Some hearings were up to three or more hours away each direction, and so the patient would be away all day, and the facility did provide the patients with a sack lunch to take along.

3. In an interview at 11:05 AM on 10/19/12, the Administrative Asst., who sits at the front desk in the waiting area where patients go when escorted from the facility, stated that "all patients" who are transported for hearings are handcuffed. She started that they do not go in shackles, but may come back in shackles. The Administrative Asst. stated that for the patients who went to the local county court, that it was about two blocks away, and yet the patients were escorted by law enforcement and always in handcuffs.

4. In an interview with a state agency surveyor at 11:00 AM on 10/19/12, she reported that a facility social worker told her that patients go to hearings in handcuffs, and often complain because they are not "criminals."

5. In a joint interview with the facility administrator and the Medical Director on 10/19/12 at 1:30 PM, they both acknowledged that patients are handcuffed when transported, and agreed this was a matter of intrusion on patient dignity. The Medical Director stated that he welcomed the inclusion of these findings, since the facility did have Interactive TV available, which could be used in place of transporting the patient. The administrator stated that attorneys for the patients state it is the patients right to be in court "face-to-face," but agreed he did not know if the attorneys ever offered the patients the option of court via Interactive TV vs. appearing face-to-face. Both the administrator and the Medical Director agreed that in cases where the patient might be assaultive or an elopement risk, use of Interactive TV was a suitable alternative to escort by law enforcement. The Medical Director stated that he believed the Interactive TV would be much less traumatic to the patient.

Based on record reviews, document reviews, and staff interviews, the Director of Nursing (DON) failed to ensure that nursing staff was properly prepared to de-escalate and manage aggressive and assaultive patients without calling in outside law enforcement. The failure resulted in patients being managed and behaviorally controlled by individuals who are not hospital staff.

Findings are:

A. Record Review

1. Patient 9, admitted on 07-27-12 and discharged on 9-24-12, was restrained on 9-10-12.
The seclusion and restraint record for Patient 9, written on 9/10/12 states, "Required call to 911 for LE (law enforcement) assistance" and "[Patient's name] placed into restraint chair with assistance by LE."
Progress note dated 9-10-12 states: "... [Patient Name] continued to yell and make threats of violence,... [s/he] continued to refuse the offer of medication. Law enforcement did come, they spoke with [him/her] about taking medication..... [s/he] was then placed in the restraint chair. [s/he] did not resist, [s/he] followed the officers orders."
A hospital document, entitled, "List of Incident Reports By Programs" for the period of 4-1-12 through 10-31-12 states that on 9-10-12, Patient 9 had a "verbal/non-verbal threat." Documentation reads: "[Patient 9 Name] was approached by staff at approximately 3 p.m. that injections of Prolixen (sic) Decanoate and Invega Sustenna were ordered per Jarvis [Minnesota State law regarding court ordered medication]. [Patient 9] became loud and yelling out, demanding discharge and refusing of medications..... Law enforcement presented, applying manual restraint and handcuffs at 3:43 p.m. Handcuffs removed at 3:50 p.m. when placed in restraint chair and brought to seclusion room with door open." (In an interview on 10-19-12 at 10:00 a.m., Nurse Practitioner (NP1) stated, "I asked that law enforcement be called to assist." See full interview in Section C3 below.)

2. Patient D5, admitted on 4-13-12 and discharged on 7-19-12, was restrained on 5-3-12. Progress note dated 5-3-12 states: "[Patient Name] refused the injections each time asked. Due to [patient name]'s assaultive behavior staff could (sic) not manually restrain [her/him] for injection and upon Dr. order law enforcement were called. " A seclusion and restraint record for Patient D5, written on 5-3-12 states, "Patient refused IM medication. Per Dr. [dr. name] call police have [him/her] put in restraints and give IM (intra-muscular)."

B. Document Review

State Operated Services Policy 2150 entitled "Client Care: Responding to Criminal Behavior" (June 2, 2011) states: ".... the decision to involve law enforcement in the management of aggressive behavior must only (bold type in original document) be made when there is an emergency that includes substantial risk of serious injury or death to persons and/or substantial property damage that compromises safety and constitutes criminal behavior."

C. Interviews:

1. In an interview on 10-18-12 at 2:00 p.m., the hospital administrator stated that the local police department is called to the hospital to assist in the behavior management of patients whom the staff does not feel "confident" to control. He stated that staff members have been physically hurt and "traumatized" in the past year by assaultive patients. He furthermore stated the staff does not think of law enforcement as an "extension of the staff" but that law enforcement can be helpful when patients are "really scary." He stated that law enforcement will take part in the physical restraint of the out-of-control patient. The hospital administrator also stated that, while staff can be increased to meet the needs of a particularly difficult patient group, sometimes staff are not available to do so; thus making it necessary to call law enforcement to the unit. He stated that specifically, on 9-10-12 law enforcement were called to the unit to assist with the restraint of Patient 9. According to the hospital administrator, the police entered the unit via the back door, using their own access key. He stated that the staff was surprised at the policemen's abrupt and somewhat unannounced entry.

2. In an interview on 10-18-12 at 12:15 p.m., the Director of Nursing stated that law enforcement are called to the unit to assist nursing staff when there is concern that not doing so could cause physical harm to the staff or patient. She stated that the hospital would prefer not to have to call in the law enforcement for assistance, but that sometimes it is necessary. Furthermore, she stated that law enforcement have not been cooperative with the hospital's request to leave their weapons in the weapon lock box off the unit.

3. In an interview on 10-19-12 at 10:00 a.m., Nurse Practitioner (NP1) stated, "I asked that law enforcement be called to assist (in restraint of Patient 9)." She further stated that the police were called to assist in the restraint of Patient 9 on 9-10-12 because the patient was "demanding and escalating" and that law enforcement was "needed to help calm [him/her] down." When questioned why law enforcement was needed for this patient when other escalating patients are managed by staff, NP1 stated that Patient 9 is a "large [man/woman]" and that the "hospital did not have a large number of people available." She stated that they were unable to use the maintenance man whom they had used in the past to assist with restraints because he had a dislocated shoulder, that there was only one male nurse on duty, and that the remaining nursing staff were smaller females. She stated that the patient was so escalated that [s/he] was "beyond staff to use their own de-escalation skills." She furthermore stated that when the police came to the unit, they refused to leave their guns in a locked box off the unit. They wore their weapons onto the patient unit. In reviewing the hospital policy with her about calling outside law enforcement to the unit for criminal behavior, she stated that on that day, the patient had not committed any crime, but that staff thought "for the safety of the patients and the staff, that law enforcement should be involved." She stated that because staff have been injured in the past, they did not want to "take chances" with staff being injured again. She stated that because a number of staff members were injured by patients last year, staff is now "more cautious."

4. In an interview with the hospital administrator and the Director of Nursing on 10-19-12 at 11:00 a.m., surveyors were told that at the end of 2011, the unit had a "rash of complex, assaultive, and psychotic patients" that resulted in 13 staff being injured during a 2-month period. The administrator stated that the hospital is in the process of "developing competency and confidence regarding personal safety." He stated the serious injuries that occurred last year have created fear and "psychological secondary trauma" and that the staff is now "recovering." The hospital administrator furthermore stated that the hospital does not have a policy for calling law enforcement when criminal behavior is not apparent. He stated that Patient 9's behavior on 9-10-12 was "approaching" criminal behavior.

5. In an interview with RN4 on 10-19-12 at 12:30 p.m. regarding law enforcement being called on 5-3-12 to restrain Patient D5, surveyors were told that staff could not control Patient D5 and that they could not do anything to re-direct the patient; thus the charge nurse called the medical director to get an order to call law enforcement to assist with restraining the patient.