HospitalInspections.org

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Based on Observations, Interviews, and Record reviews the facility failed to ensure patient's Exercise of Rights A0129; Participation in Care Planning A0130; Personal Privacy A0143; Care in Safe Setting A0144; Free from Abuse/Harassment A0145; and Restraint or Seclusion A0166 were met.

The facility was out of complance with the Condition during the investigation.

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Based on observation of video, interview, and record review the facility failed to ensure 3 patients (#1,3,4) were treated with personal dignity and respect out of 9 active patients reviewed. This failed practice denied the patients their right to be afforded respectful treatment and created a risk for a nontherapeutic environment. Findings:

Patient #1

Observation during the survey on 3/30/18 at 1:35 pm, Psychiatric Nursing Assistant (PNA) #2 told Patient #1 "Don't use you hands, it's in appropriate, Go sit down. Keep your hands to yourself. Go sit down!". Patient #1 responded by swearing at the PNA, the PNA replied in a condescending tone "That's okay, I'll be here for targets." Patient #1 stated "I'm sorry, I'm sorry", to which PNA stated "You can display your sorry by changing your behaviors."

Review of Patient #1's treatment plan, dated 5/27/18 revealed the "Targets" were a system used for scoring areas if the Patient's behavioral objectives objectives were met. Thereby earning the Patient various rewards or privileges.

Patient #3

Record review on 5/30-31/18 revealed Patient #3 had diagnoses that included Schizophrenia (mental disorder characterized by abnormal social behaviors, false beliefs, hearing voices, hallucinations) and Fetal Alcohol Syndrome.

Video review with facility staff on 5/31/18 at 2:00 pm, of a seclusion event that happened 5/22/18 , revealed during the event Patient #3 yelled one of the male PNA's, of the 4 male PNA's present, had raped her. The 4 male PNA's surrounded the bed while the nurse gave two injections in the Patient's buttocks. The patient then pointed to PNA #3 and stated "I didn't want him here."

After the injection, the PNA #3 continued to remain in the area outside the seclusion room, visible to the patient through the window in the door.

During an interview with the ADON on 5/31/18 at 2:29 pm, when asked why the PNA remained in the area, despite the Patient's request, the ADON replied "They didn't swap him out." The ADON stated the facility staff had not been providing trauma informed care.


Patient #4

Record review on 5/30-31/18 revealed Patient #4 had diagnoses that included Schizoaffective Disorder (prominent delusions. disorganized thoughts and behaviors, and hallucinations) and Posttraumatic Stress Disorder (a traumatic event can trigger symptoms such as: flashbacks, frightening thoughts, avoidance, outbursts, being startled easily).

Review of a video, with facility staff on 5/31/18 at 2:00 pm, of a seclusion event that happened on 5/6/18 at 9:38 am, Patient #4,after spitting on a peer, then spitting on a PNA, the Patient was escorted by facility staff to the seclusion room (called the oak room), and placed in seclusion. Observation of the video seclusion event revealed the Patient stood on the bed and urinated on it. A few minutes later the Patient asked facility staff if h/she could use the bathroom (located outside the door), a bed pad was provided for the Patient to use in the room. Further review revealed the Patient was provided a change of clothing over an hour after urinating in her clothing and was given a bagged lunch. The Patient was not offered the opportunity to shower or wash hands, and ate lunch with soiled hands.

During an interview on 5/31/18 with the ADON, who was present during the video review, when asked why facility staff provided a bed pan to an ambulatory patient (on camera) and why facility staff did not offer the opportunity for the Patient to wash up, the ADON stated he didn't know.

Review of the facility policy "Notice of Rights and Responsibilities Alaska Psychiatric Institute", revised 8/16, revealed "Psychiatric hospitals accredited by The Joint commission (TJC) must assure the following standards are met in serving consumers: 1. Personal dignity and services considerate and respectful of personal values and beliefs."

Review of the facility policy "Conduct Involving Patients", effective date 10/13/18, revealed "All patients will be treated in a respectful and culturally sensitive manner at all times."

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Based on record review and interview, the facility failed to ensure the interdisciplinary team allowed 1 patient (#8), out of 10 sampled patients, to exercise his/her right to participate in care plan reviews on 3 separate occasions. This failed practice violated the patient's right to participate in the development and implementation of their plan of care. Findings:

Record review from 5/30-31/18 revealed Patient #8 was admitted to the facility on 4/17/18 with a diagnosis of Unspecified Psychosis not due to a Substance or Known Physiological Condition.

Review on 5/31/18 at 10:20 am of the Patient # 8's Master Treatment Plan (MTP) (identifies the patient's diagnosis, specific problems, specific goals, and specific interventions to be addressed during hospitalization), dated 4/20/18, revealed Strengths/Assets identified as General Fund of Knowledge (information that a person has stored in memory about people, places, and things), mobility, and resilience.

Review of the Patient # 8's MTP Reviews (weekly re-evaluations of the MTP), dated 4/27/18, 5/4/18, and 5/11/18, revealed there was no documentation indicating the interdisciplinary team offered the patient the opportunity to participate in treatment planning.

During an interview on 5/31/18 at 12:50 pm, RN #1 stated the social worker or RN should invite the patient to the treatment planning meetings and document whether they refuse or are unable to attend. RN #1 agreed this documentation was not completed on Patient #8's 3 MTP Reviews and therefore could not state whether this offer was made.

Review on 5/31/18 at 2:00 pm of the facility policy "Treatment Planning", with an effective date of 8/30/17, revealed: "Section I: Treatment Team Meetings. Section F. The patient will attend the meeting in which the MTP is finalized and any subsequent Treatment Plan reviews. G. The patient will be encouraged to provide input and asked to sign the MTP, indicating involvement and agreement to plan.
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Based on video review, interview, and record review the facility failed to ensure 1 patient (#3), out of 10 patients, was offered and/or received personal privacy when receiving injections in her buttocks. This failed practice denied the patient the right to privacy and placed the patient at risk from psychological harm. Findings:

Video review of a seclusion event that happened 5/22/18 at 8:00 am, revealed Patient #3 being secluded in the Oak Room by 4 male Psychiatric Nursing Assistants (PNAs). When Nurse #6 asked the Patient to lower her pants, so she could receive 2 injections, the Patient responded by removing her pants and underwear and tossing them on the floor and proceeded lying face down on the bed, naked from the waist down. During the administration of the medication, in which 4 male PNAs surrounded the Patient while the nurse gave the infection, facility staff did not offer to cover Patient #3's buttocks.

During an interview on 5/31/18 at 2:29 pm, the Assistant Director of Nursing, who was present during the review, stated the Patient was not treated in a dignified manner.
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Based on record review and interview the facility failed to implement measures for the protection of 1 patient (#2) from sexual assault by another patient. This failed practice had the potential to cause the patient undue trauma from potential physical and/or psychological harm. Findings:

Record review on 5/30-5/31/18 revealed Patient #2 was admitted to the facility with a diagnoses that included Shizoaffective Disorder and a history of traumatic brain injury.

Review of a nurses note, dated 5/30/18, revealed "It was reported by PNA [psychiatric nursing assistant] staff to this writer that patient had been engaging in sexual activity with another patient in the TV room."

During an interview on 5/30/18 from 1:52-2:04 pm, Patient #2 had disorganized thought process and stated she was being raped by "Ghosts". The Patient was unable to remember the event that had occurred occurred 11 days before.

Observation of the TV room on 5/30-31/18 revealed a large common room with multiple seating and large glassed windows. the room was visible from the nursing desk located on the unit.

Review of the facility's investigation revealed no staff were present at the nurse's desk during the time of the event.

During an interview on 5/31/18 at 12:00 pm, the Medical Director stated Patient #2 was sexually assaulted. The MD stated all evidence had been turned over to the police. The Medical Director stated the Patient was unable to consent to a sexual assault exam.

Review of the facility policy on abuse and neglect revealed the policy was still being revised and not complete.

Review of the facility policy "Conduct Involving Patients", effective date 10/13/18, revealed "Neglecting or endangering a patient is the failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any patient when that failure presents either immediate danger to the health, safety, or well being of a patient..."

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Based on record review and interview the facility failed to protect a vulnerable patient (#2) from sexual assault, of 10 patients reviewed, by another patient, and failed to report the event to the State Agency as per AS 47.24.013. This failed practice placed vulnerable patients at risk for further psychological and physical harm. Findings:

Record review on 5/30-5/31/18 revealed Patient #2 was admitted to the facility with a diagnoses that included Shizoaffective Disorder and a history of traumatic brain injury.

Review of a nurses note, dated 5/30/18, revealed "It was reported by PNA [psychiatric nursing assistant] staff to this writer that patient had been engaging in sexual activity withy another patient in the TV room."

During an interview on 5/30/18 from 1:52-2:04 pm, Patient #2 had disorganized thought process and stated she was being raped by "Ghosts". The Patient was unable to verbally articulate she could remember the event that had occurred occurred 11 days before.

Observation of the TV room on 5/30-31/18 revealed a large common room with multiple seating and large glassed windows. The room was visible from the nursing desk located on the unit.

Review of the facility's investigation revealed no staff were present at the nurse's desk during the time of the event.

During an interview on 5/30/18 at 11:37 am, the Director of Quality Improvement stated the facility had called the police but had not reported it to the State Agency as they had only been reporting cases of staff to patients abuse and neglect.

During an interview on 5/31/18 at 12:00 pm, the Medical Director (MD) stated Patient #2 was sexually assaulted by Patient #6, The MD stated all evidence had been turned over to the police.

Review of the facility's policy "Conduct Involving Patients", effective date 10/13/17, revealed "a. If there is reasonable cause to believe the physical, sexual, or verbal abuse, neglect, or serious misconduct by staff towards patient or patients, has occurred the CEO, SO, or designee will immediately complete mandatory reporting to 1. State of Alaska Certification and Licensing."
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Based on record review and interview, the facility failed to ensure the interdisciplinary team modified the care plan that reflected the treatment plan for 1 patient (#2), out of 3 events reviewed, after a seclusion occurred. Without appropriate and current care plan problems, interventions, and goals patients are at risk for not receiving the necessary and/or appropriate care and services. Findings:

Record review on 5/30-31/18 revealed Patient #2 was admitted to the facility with a diagnosis of Schizoaffective Disorder, Unspecified (a mental disorder characterized by abnormal though processes and disturbance in the person's mood).

Review of Patient #2's chart revealed a seclusion (the act prohibiting a patient from leaving an area) had occurred on 5/20/18 at 1:06 pm.

Review of Patient #2's Master Treatment Plan (MTP-identifies the patient's diagnosis, specific problems, specific goals, and specific interventions to be addressed during hospitalization), dated 3/31/18, was not updated with a "Restraint-Seclusion Problem Sheet."

In addition, review of Patient #2's MTP Reviews (timely re-evaluations of the MTP) revealed the last review occurred on 5/5/18.

During an interview on 5/31/18 at 12:50 pm, the Registered Nurse (RN) #1 stated the Restraint-Seclusion Problem Sheet is required to be completed after a seclusion or restraint and added to the MTP. The RN started it was not always completed and was not compliant with policy.

Review on 5/31/18 at 2:00 pm of the facility policy "Treatment Planning", with an effective date of 8/30/17, revealed: "Section III: Master Treatment Plan (MTP). Section F: When a patient requires seclusion or restraint, the MTP will be updated with Restraint-Seclusion Problem sheet. The problem will remain open for the duration of the patient's admission and will be closed upon discharge."

Further review of the policy revealed: "Section IV: Treatment Plan Reviews. Section A: The MTP is reviewed using the MTP Review Form, and each objective is measured for progress toward goals at the following times: 5. When a patient requires seclusion or restraint..."

During an interview on 5/31/18 at 2:00 pm, the Assistant Director of Nursing stated that seclusions and restraints would not be on the care plan.

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Based on record review and interview, the facility failed to ensure an interdisciplinary team developed care plans that:
1) identified all problems with specific interventions during review of the care plans for 2 patients (#2 and 7) out of 4 sampled patients;
2) identified an established behavioral plan within the care plan interventions for 1 patient (#7); 3) reviewed and signed the initial care plan within 24 hours of admission for 1 patient (#8) out of 4 sampled patients; and
4) reflected a review of the care plan due to a significant event for 1 patient (#2) after a sexual assault occurred. Without appropriate and current care plan problems, interventions, and goals residents are at risk for not receiving the necessary and/or appropriate care and services. Findings:

1) All problems reflected with specific interventions on care plans;

Patient #2

Record review on 5/30-31/18 revealed Patient #2 was admitted to the facility with a diagnosis of Schizoaffective Disorder, Unspecified (a mental disorder characterized by abnormal though processes and disturbance in the person's mood).

Review on 5/31/18 at 10:30 am of the Patient's Master Treatment Plan (MTP) (identifies the patient's diagnosis, specific problems, specific goals, and specific interventions to be addressed during hospitalization), dated 3/31/18, revealed a second problem of "Grave Disability" (a condition in which a person, as a result of a mental disorder and unable to provide basic personal needs for food, clothing, or shelter) was added on 5/4/18.

Review of the Patient #2's MTP Review (timely re-evaluations of the MTP), dated 5/5/18, revealed no documentation of the participation/progress for any of the 6 objectives (goals) for this problem of "Grave Disability."

During an interview on 5/31/18 at 12:50 pm, the Registered Nurse (RN) #8 stated the second problem of "Grave Disability" was not addressed on the MTP Review dated 5/5/18. The RN stated this was not in compliance with policy and should have been addressed.

Review on 5/31/18 at 2:00 pm of the facility policy "Treatment Planning", with an effective date of 8/30/17, revealed: "Section IV: Treatment Plan Reviews. Section C: Process of Review: 5. Document Participation/Progress and Changes in Therapeutic Interventions. a. All objectives must be reviewed and scored."

Patient #7

Record review on 5/30-31/18 revealed Patient #7 was admitted to the facility with a diagnosis of Unspecified Dementia (mental deterioration but the exact cause is unknown).

Review of the Patient's MTP original start date of 7/1/17, revealed a problem list reflecting 1 problem (primary psychiatric/behavioral/social problems that will be addressed during hospitalization) of "Danger to Others" (demonstrated behavior through acts, attempts, or threats to harm others). Further review revealed this problem was deferred (suspended) on 11/6/17 and replaced with the problem "Cognitive/Memory Deficits" (memory problems and a decline in the ability to live independently). A third problem of "Multiple Medical Problems" was added on 4/14/18. The changes were not reflected on the problem list of the MTP.

During an interview on 5/31/18 at 11:40 am, the RN# 12 stated the "Multiple Medical Problems" was still an active problem and was not addressed on the Patient #7's the MTP Review dated 5/13/18. The RN stated the MTP Problem List did not accurately reflect the Patient's current problems.

Review of the facility policy "Treatment Planning", with an effective date of 8/30/17, revealed: "Section III: Master Treatment Plan (MTP). Section E: Problems may be identified by any discipline beginning at the time of admission and continuing throughout hospitalization. The MTP Problem List includes each identified active and deferred problem: 1. Numbered Problems. 2. A brief problem statement. 3. Documented if a discharge barrier. 4. Documented date the problem was initiated and/or solved. 5. Any problems identified but deferred for treatment and the reason for deferral ....6. All objectives include target completion date."

Further review of the policy revealed: "Section IV: Treatment Plan Reviews: Section C: Process of Review: 4. Document the problem number and name for each problem listed on the MTP. 5. Document Participation/Progress and Changes in Therapeutic Interventions. a. All objectives must be reviewed and scored."

2) Behavioral Plan Interventions in the Treatment Plan:

Review of Patient #7's established individual behavioral plan (IBP) labeled "[Patient's Name] Daily Routine", most recently dated 5/3/18, revealed multiple interventions available to staff to help target maladaptive behaviors (behaviors that inhibit your ability to adjust healthily to particular situations) exhibited by the Patient.

Review of the Patient #'s MTP and subsequent Reviews, from 6/28/17 to 5/13/18, revealed no documentation reflecting Patient #7's IBP. Further review revealed no documentation that the IBP was discussed during treatment team meetings.

During the interview on 5/31/18 at 11:40 am, RN #12 stated the Patient #7's behavior plan was attached to the Daily Nursing Communication Report for the nurses to review and is posted on a bulletin board in the nurse's station for all Psychiatric Nursing Assistants (PNAs) to review.

Review on 5/31/18 at 2:00 pm of the facility policy "Treatment Planning", with an effective date of 8/30/17, revealed: "Section V. Individual Behavioral Plans. 3. The IBP will specifically target maladaptive behaviors and positively provide interventions to help the patient be safe...."

Further review of this policy section revealed: "4. The IBP will need to be reflected in the MTP through clear goals, objectives, and interventions. The success of the program elements can also be used as part of discharge planning ....5. The IBP will be attached to the Daily Nursing Communication Report for each patient, every day, to be reviewed by staff as they receive report and arrive on the unit."

Further review of policy revealed: "Section B: While it is in effect, the IBP will be reviewed at least weekly during the Treatment Team meeting. This Treatment Plan will be revised as needed to reflect the patient's response to the plan."

During an interview on 5/31/18 at 2:50 pm, PNA #5 stated the treatment plan in the chart was the primary means to review Patient #7's plan of care. The PNA had no knowledge of a behavioral plan available to help assist in Patient #7's care and could not recall being shown an IBP for the Patient.

During an interview on 5/31/18 at 3:15 pm, PNA #6 stated the care plan in the chart was the primary means to review Patient #7's plan of care. The PNA stated there was a Behavioral Plan on a bulletin board in the nurse's station, however hadn't looked at it in a long time. PNA #6 stated that the IBP was never discussed during shift change overs.

3) Reviewed and Signed the Initial Treatment Plan within 24 Hours:

Record review from 5/30-31/18 revealed Patient #8 was admitted to the facility on 4/17/18 with a diagnosis of Unspecified Psychosis not due to a Substance or Known Physiological Condition.

Review of the Patient's "Initial Treatment Plan" (plan completed within 24 hours that included physician orders written to address problems identified as a result of initial assessment and treatment orders), dated 4/17/18, revealed the On-Coming RN, Licensed Individual Practitioner (LIP), and Clinical Services Department had reviewed and signed this plan on 4/23/18 (6 days after its initial completion).

During an interview on 5/31/18 at 12:50 pm, the RN #7 stated the signatures on the initial treatment plan for Patient #7 were late.

Review of the facility policy "Treatment Planning", with an effective date of 8/30/17, revealed: "Section II: Initial Treatment Plan. Section H: This plan will be reviewed and signed off by the LIP, Social Worker, and on-coming RN within 24 hours of admission."

4) Review of Care Plan after a significant event

Record review on 5/30-31/18 revealed Patient #2 was admitted to the facility on 3/29/18 with a diagnosis of Schizoaffective Disorder, Unspecified (a mental disorder characterized by abnormal though processes and disturbance in the person's mood).

Review of the Patient's MTP dated 3/31/18, revealed identified problems (primary psychiatric/behavioral/social problems that will be addressed during hospitalization) as being Disturbance of Thought (disorganized thinking) and Grave Disability (a condition in which a person, as a result of a mental disorder, is unable to provide for his/her basic personal needs for food, clothing, or shelter).

Review of the Patient #7's chart revealed "History of Risk Factors and Significant Events" sheet stated the Patient was a "[possible] victim of sexual assault ..." on 5/19/18.

Further review revealed the Patient's MTP, dated 3/31/18, was not updated to include this change in the patient's condition.

A review of the Patient #7's MTP Reviews (timely re-evaluations of the MTP) revealed the last review occurred on 5/5/18.

During an interview on 5/31/18 at 1:00pm , Advanced Nurse Practitioner #1 stated a sexual assault was deemed a significant event and a review of the treatment plan was warranted during the next treatment team meeting following the incident.

Review on 5/31/18 at 2:00 pm of the facility policy "Treatment Planning", with an effective date of 8/30/17, revealed: "Section IV: Treatment Plan Reviews. Section A: The MTP is reviewed using the MTP Review Form, and each objective is measured for progress toward goals at the following times:
3. When there is a significant change in patient's condition or diagnosis."
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Based on record review and interview the facility failed to ensure the out-patient treatment provider was notified of the patient's impending discharge for 1 patient (#6), out of 3 discharge plans reviewed. This failed practice denied the patient the ability to safely integrate back into the community, potentially placed the community at risk, and denied the patient the necessary wrap around services needed for a successful recovery. Findings:

Record review on 5/30-31/18 revealed Patient #6 was admitted to the facility with a diagnosis of schizophrenia. The Patient was initially diagnosed with schizophrenia in 2011. The Patient had 5 previous admissions to the facility with a primary diagnosis of schizophrenia.

Review of Patient #6's initial treatment plan (ITP), dated 5/17/18, revealed the Patient's reason for admission was "The Patient is being admitted due to Grave Disability {a condition in which a person, as a result of a mental disorder is unable to provide basic personal needs for food, clothing, or shelter]." In addition, the impact on health status included "...is known to become acutely psychotic with paranoia and delusions." Additionally, the initial treatment plan revealed that Patient #6 had been medication non-compliant.

Review of the Master Treatment Plan (MTP) dated 5/19/18 revealed discharge planning problem list as "grave disability and disturbance of thought." Discharge criteria was "reduction of life-threatening/endangering symptoms to within safe limits and stabilization of mood/thinking and/or behavior." Discharge Planning section revealed "pt [patient] has guardian, own apt [apartment], + CHOICES for follow-up."

Review of the LIP (Licensed Independent Practitioner) Progress Note dated 5/21/18 revealed in section "Changes since last encounter: Today, patient continues to present with disorganized thought processing, paranoid, delusional thought content, says he feels safe at API, does not want to be discharged due to everyone being out to get him. Patient denies having a mental illness, says he does not want to take psychotropic medications. Over the weekend, patient apparently had sexual intercourse with another patient [an elderly female]. Patient with recent h/o [history of] alleged indecent exposure to a minor prior to recent incarceration, this admission to API."

Review of the LIP Discharge Summary dated 5/22/18 revealed "Prognosis as poor as patient has no insight into the severity of his mental illness, as patient with chronic substance abuse history, chronic legal history... Final diagnosis: Antisocial personality disorder [According to the Diagnostic and Statistical Manual of Mental Disorders V- Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others]."

Review of the SW(social work) Discharge Planning Note dated 5/21/18 revealed in a conversation with Quyana [Q] Clubhouse staff "I worry about him. If he is not taking medications, I don't know how to engage him...would like to see patient on medications and stable before he leaves so he can engage patient at Q House...will come to meet patient at API, to connect with him on 5/22/18 @ 1 PM."

Review of the SW Discharge Planning Note dated 5/22/18 revealed Patient #6 "did not like Q House because it was located in a 'dangerous place'."

Review of the SW Discharge Summary dated 5/22/18 revealed Patient #6"...will be cabbed at discharge to his apartment...declined psychiatric medications during is stay and is declining medications post discharge...Safety statement: did exhibit predatory behavior during this stay, resulting in a sexual encounter with an elderly patient...has active services with both CHOICES and Southcentral Foundation Quyana Clubhouse." Communication with Patient #6's outpatient provider CHOICES was not documented. Further review of the medical record revealed the facility had a ROA (release of information) with both CHOICES and Q (Quyanna) house."

During an interview 5/31/18 at 1:17 pm, Protective Service Specialist #1 (PSS) stated, when asked about follow up with the Patient's outpatient provider, she did not call CHOICES to let them know about his immediate discharge. When asked how long PSS #1 had been working with the Patient, she stated that she was covering for another PSS and that she had only met with with Patient once during the meeting prior to the last minute discharge.

In addition, PSS #1 stated the patient had a history of sexual assault 1. When further questioned the PSS #1 demonstrated on Courtview (public court database) listed the Patient's name with a Sexual Assault in the first Degree conviction in 2001. When questioned about the patient's age in 2001 (patient would have been 10 years old) she recognized the convicted party was not the Patient and he did not have a history as a sex offender. When asked if that would have changed the last minute discharge, she stated no.

When asked why Q house had been notified of the sudden discharge and not CHOICES, since the Patient did not want to use Q House, the PSS stated the Guardian preferred the Patient utilize Q house.

During an interview on 5/31/18 at 1:52 pm, the discharging physician stated that Patient #6 had a chronic history of sexual assaults. When notified that they had incorrect criminal history information, the physician stated the patient had a history of exposure, his behavior [regarding the sexual behavior] was premeditated, voluntary, had an agenda and that patient was "gaming the system". When asked how long he had been treating the patient he reported he had first met the Patient at discharge. Review of the medical record revealed the Physican had examined the Patient on 5/21/18 and 5/22/18.

Review of the facility's policy, Discharge Planning, efective date 6/15/17, "The social worker is responsible for notifying the following people of anticipated discharge (transfer)...iii. Outpatient Providers (if ROI) in place."

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