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Based on observation and staff interview, the facility failed to ensure the staff were properly trained in the set up and use of emergency equipment on two of three patient care units and on one of the three patient care units the tubing was not available for assembly of the emergency equipment.

Findings include:

On 6/11/15 at 8:27 A.M., Surveyor #2 reviewed the emergency equipment/code cart on Unit 5 with RN #1. At 8:40 A.M. RN #1 was unable to connect the tubing to the suction machine properly in order to demonstrate operation of the suction machine in the event of an emergency. RN #1 said that he was not aware of how to connected the tubing properly and then stated that it is probably a good idea to have the tubing connected to the suction machine and be "ready to go" in the event of an emergency.

Surveyor #2 then proceeded to Unit 4 where Surveyor #2 reviewed the emergency equipment/code cart with RN #2. RN #2 began to initiate connecting the tubing to the suction machine at 8:50 A.M. At 8:55 A.M., she was unable to connect the tubing properly to the suction machine because there was no tubing available in the suction machine case. At 8:55 A.M., Surveyor #2 and RN #2 proceeded to the 4th floor treatment room to obtain the suction tubing. RN#2 was unable to locate any spare suction tubing. RN#2 was able to demonstrate the proper set up of the suction machine in the event of an emergency, however, the equipment (tubing) was unavailable.

Surveyor #2 then proceeded to Unit 8 where Surveyor #2 reviewed the emergency equipment/code cart with RN #3 at 9:02 A.M. At 9:10 A.M. RN #3 was still unable to connect the tubing to the suction machine properly in order to demonstrate operation of the suction machine in the event of an emergency. RN #3 said that she was not aware of how to connected the tubing properly and then stated that it is probably a good idea to have the tubing connected to the suction machine and be "ready to go" in the event of an emergency.

An emergency cart content check list, located on all of the code carts, indicated that the equipment/code cart was checked every Thursday for correct operation and supplies by the 11:00 P.M. to 7:00 A.M. Nurse (although Unit #4's emergency cart did not have any suction tubing on the cart).

Review of the facility Inservice Records indicated that inservices were held between 6/2014 and 8/2014 for the Nursing Department on the Vacumax Aspirator (suction machine). An additional inservice was held on 1/6/15 for RN #1. There was no evidence that RN #3 had attended training on the Vacumax Aspirator.

The Director of Nursing (DON) said on 6/11/15 at 9:25 A.M. that the facility failed to ensure the staff had been properly trained in the set up and use of emergency equipment and that the equipment (tubing) was available for assembly of the emergency equipment.

Based on record review and staff interviews, the hospital failed to adequately justify the repeated and extensive use of restraints as the primary intervention for the safety for 1 patient (#18), who had a history of harming him/herself and others, in a total sample of 30 patients.

Findings include:

Patient #18 had diagnoses that included Antisocial Personality Disorder and Borderline Personality Disorder, history of drug and alcohol abuse, hypertension, hepatitis C, tachycardia with an unknown etiology, anemia, headaches and irritable bowel syndrome. The Patient had a history of sexual, physical and emotional abuse/trauma, gender identity issues and a severe, chronic and frequent history of harming him/herself and aggressive behavior towards others.

Review of the medical record indicated that the patient had been either inpatient in a psychiatric hospital or incarcerated for the past 5 years. The patient had spent the past 2 years in a psychiatric facility and had encounter legal charges after assaulting staff at the facility. While at the court house the Patient was transferred and admitted to the hospital on a legal Section 12 (e) for emergency hospitalization of persons posing risk of serious harm by reason of mental illness in 5/2015.

The medical record indicated the patient had difficulty in problem solving and was overly sensitive to his/her surroundings, which resulted in the loss of control and violence directed at self and/or others. The hospital's initial plan for safety included placing the patient in the seclusion room, provide supervision at a 2 to 1 ratio, no utensils, finger foods and ensure the patient's hands were above the sheets while in bed (to prevent from self harm).

Review of the medical record from 5/6/15 through 5/26/15, indicated the patient had 5 episodes of violence and aggression towards others. The hospital staff treated the patient with the use of chemical and physical restraints. Review of the plan of care and progress notes from care plan meetings for the patient's risk of self harm and aggression indicated the care plan was revised to include the use of of restraints, 2 to 1 supervision (that included the presence of Campus Police Officers) and restrictions of activities and attendance at social and therapeutic groups.

On 5/28/15, the patient assaulted a staff member while under 2 to 1 supervision. The nurses' note indicated the incident occurred without provocation. The hospital staff initiated restraints on 5/28/15, that included the use of seclusion, physical hold, medication and 4 point restraints. The patient was maintained in 4 point restraints from 5/28/15 through 5/31/15.

Review of the medical record (including physician orders, progress notes, restraint monitoring and assessment logs) from 5/28/15 through 5/31/15 indicated the hospital staff had followed the hospital's policy and procedures for the initiation and use of restraints. The staff obtained physician orders and renewal orders in accordance with policy. The orders indicated the need for the restraints was the patient was a danger to others and had to contract for safety for release.

The progress notes dated 5/30/15, indicated that on 5/29/15, a plan had been discussed with administrative staff to ensure patient safety. The progress notes indicated, after extensive discussion, that the staff were to maintain the patient in 4 point restraints around the clock (including when the patient was not exhibiting behaviors). The progress notes indicated the patient would be allowed to walk around his/her room (the seclusion room) and staff were to reapply the restraints "roughly" every 2 hours. The staff were to ensure there would be enough staff in the area to support placing the patient back into restraints if the patient's behavior warranted increased staff. The progress notes indicated the patient had been cooperative and had no complaints from 5/29/15 through 5/31/15. In fact, the notes indicated that the patient had refused to get up out of bed and receive care during several of scheduled 15 minute breaks, but had not attempted to harm self or others. The progress notes indicated that staff thought that his/her refusals might indicate the patient was angry, but had not observed anything else except the patient's refusal.

On 6/1/5, after the patient had been managed with 4 point restraints for 72 hours, the plan for safety was revised from 4 point restraints (under a 2 to 1 ratio in the seclusion room) to 2 point restraints. The order was to alternate the 2 point restraints from arms to legs, while under 2 to 1 supervision. The order indicated the reason for the restraints was that the patient was at high risk to engage in assaultive and self destructive behavior. There was no criteria for release of the restraints, only to maintain the patient with the continuous use of restraints for the patient's safety.

The documentation (including progress notes from all disciplines, restraint notes, assessments, monitoring sheets and physician orders) from 6/1/15 through 6/7/15 indicated the hospital staff, maintained the patient in physical restraints for an additional 120 hours or a total of 9 days. There was no other interventions developed to address the patient's high risk behaviors and there was no supportive documentation adequately justifying (as the patient had not exhibited self injurious behaviors to self or others) the use of the physical restraints for extensive periods. The orders and notes indicated that the restraints were being maintained in accordance with the administration treatment plan.

During interview on 6/8/15 at 10:45 A.M., Registered Nurse (RN) #3 said Patient #18 had recently been maintained in restraints for an extensive period of time. She said the patient had a history of severely harming self and others. She said the unit had been restraint free for many months, but shortly after the patient's arrival he/she had required restraints for assaulting others. She said that after several episodes of the patient assaulting others, the unit staff had been directed to use continuous restraints to prevent the patient from harming self and staff (including when not exhibiting any behaviors). RN #1 said it was unusual for any of the patients to remain in restraints for long periods and that 9 days was especially rare situation. She said, however, that it had been a directive from the hospital administration for patient safety. RN #3 could not provide documentation to clinically justify the continuous use of the restraints.

During interview on 6/15/15 at 11:00 A.M., Social Worker #2 said that the patient was considered a high risk to harm self and others. She said that she was advocating for wrist and and/or ankle restraints for the patient so that he/she would be able to walk around (the restraints were later described as cuffs that were metal, locked with keys and had a chain that staff could hold onto). She said she had a discussion with the administration and had been given permission to use them, but that the decision had been changed.

During interview on 6/15/15 at 11:30 A.M., the Chief Operating Executive said that she acknowledged that the patient status was unusual and had not followed the usual course of assessment and treatment. The Chief Operating Executive said that because the patient had a history of significantly harming him/herself and others that it had impacted the care. However, no documentation could be provided to clinically justify the continuous use of restraints.

Based on record review and staff interviews, the hospital failed to ensure a nursing care plan was developed with goals and individualized interventions for problems identified in the nursing assessment for 1 sampled patient (#18) in a total sample of 30 patients.

Findings include:

Patient #18 was admitted in 5/2015 and had diagnoses that included Antisocial Personality Disorder and Borderline Personality Disorder, history of drug and alcohol abuse, hypertension, hepatitis C, tachycardia with an unknown etiology, anemia, headaches and irritable bowel syndrome (including constipation). The Patient had a history of sexual, physical and emotional abuse/trauma, gender identity issues and a severe, chronic and frequent history of harming him/herself and aggressive behavior towards others.

Review of the medical record indicated that the patient had been either inpatient in a psychiatric hospital or incarcerated for the past 5 years. The patient had spent the past 2 years in a psychiatric facility and had encounter legal charges after assaulting staff at the facility. While at the court house the Patient was transferred and admitted to the hospital on a legal Section 12 (e) for emergency hospitalization of persons posing risk of serious harm by reason of mental illness in 5/2015.

Upon admission to the facility, the psychiatrist was unable to complete a history and physical, as the patient either refused to participate and/or the psychiatrist indicated the patient had a notable history of trauma and violence towards caregivers, but completed a psychiatric assessment on 5/6/15. However, the transferring admission paper work and the patient's prior admission information indicated the patient had identified medical issues that included problems with his/her heart rate, bowels, anemia and weight

The psychiatric assessment identified that the patient's behavioral history of violence against others, as well as self injury were difficult to be controlled. In addition, the assessment identified problems with his/her transgender identity issues, difficulty with interpersonal relationships and that the patient feels alone, unwanted, discarded and without a place (discharge location).

Review of the current (6/9/15 and initiated on admission 5/6/15) nursing plan of care indicated 2 problems;
(1) Risk of self harm and aggression, as evidence by extensive history of self cutting and assaulting others.
(2) Health/Wellness, as evidence by tachycardia and obesity.

Although, the current care plan identified 2 of the problems the patient was experiencing they lacked individual interventions and appropriate goals. For example the problem of risk of self harm and aggression focused on the use of restraints and lacked interventions and objectives towards patient's goal to gain self behavioral control. The care plan did not include any of the other identified problems such as, transgender identity issues, difficulty with interpersonal relationships, self isolation and feelings of being alone abandon, legal issues, discharge planning, etc. In addition, the interventions were focused on treatment of restraints and medication and lacked interventions that offered the patient therapeutic services to control his/her behaviors.

The health/wellbeing care plan lacked interventions to address his/her medical condition, including bowels, tachycardia, and weight.

Review of the care plans progress notes (5/18/15, 5/26/15, 6/5/15. 6/8/15 and 6/9/15) indicated that on 5/11/15, the patient, who was being supervised, on a staff 2 to 1 basis and residing in a private room, had assaulted a staff and was placed in restraints. On 5/21/15, the Patient swallowed batteries, while on a 2 to 1 supervision, and was aggressive towards self and others on 5/25/15, 5/28/15 and 5/29/15 and was placed in physical restraints.

The care plan progress notes focused on the use of restraints and lacked revision of interventions and services to treat the patient's behaviors. The 6/5/15 progress note indicated that the Department of Mental Health administration had decided the treatment plan had been to maintain the patient on 2 to 1 supervision and in 4 point restraints with 15 minute breaks every 2 hours. During the 15 minute breaks the campus police would be present. The progress note indicated that going forward, the continuous use of restraints would be reduced to 2 point with a 15 minute break and then reduce to 30 minute breaks, while on 2 to 1 supervision. The plan of care lacked interventions, treatment and assessment that would assist the patient in obtaining control of his/her behaviors, or an indication for the continuous use. In addition, the other identified problems, that were mentioned above and issues associated with the patient remained undressed.

During interviews with multiple staff during the survey process (6/8/15 - 6/15/15), staff acknowledged that the use of physical restraints for extensive periods for any patient and including this patient, was unusual. The staff indicated that they had not followed the usual course of assessment and treatment, as the administration had directed the use of restraints in place of staff completing comprehensive assessments and implementing therapeutic treatment.

On 6/15/15 at approximately 11:30 A.M., the Chief Operating Executive said that the patient had not been provided the treatment in accordance with the hospital's usual practice. The Chief Operating Executive said that because the patient had significantly harmed him/herself and others that the plan of care had not been developed and revised. She said that as of 6/5/15, she and the staff were obtaining services, so that they could complete the assessments and develop an individualized and comprehensive plan of care for the patient.

Based on documentation and staff interview, the facility failed to have complete planned menus to meet the needs of patients on Vegetarian Diets. The findings include:

1. On 6/10/15, Surveyor #3 reviewed the "diet sheets" which listed the prescribed diet order for each patient. The diet sheets indicated three patients had diet orders for a "Vegetarian" Diet.

2. Review of the Menu for the weeks of 6/7/15 and 6/14/15 indicated that the Vegetarian Menus did not always provide appropriate substitutions of the House Menus.

a) For the week of 6/7/15:

The Sunday House Menu listed Salisbury Steak as the Dinner entree. The Vegetarian Menu omitted the Salisbury Steak and substituted Pasta with Tomato Sauce. The alternative entree did not provide an equivalent protein substitution for the Salisbury Steak.

The Monday House Menu listed Meatballs/Tomato Sauce/Spaghetti as the Dinner entree. The Vegetarian Menu omitted the meatballs and did not provide a meatless protein substitution for the meatballs.

The Tuesday House Menu listed American Chop Suey as the meal alternative at Lunch and Dinner. The Vegetarian Menu did not provide a meatless alternative meal.

The Wednesday House Menu listed Baked Chicken as the meal alternative at Lunch and Dinner. The Vegetarian Menu did not provide a meatless alternative meal.

The Thursday House Menu included Clam Chowder at Lunch. The Vegetarian Menu omitted the clam chowder but did not provide an alternative soup.

The Thursday House Menu listed Spanish Rice as one of the side dishes at Dinner. The Vegetarian Menu omitted the Spanish Rice but did not provide an alternative side dish.

The Friday House Menu listed pizza as the meal alternative at dinner. The Vegetarian Menu listed "veg pizza" as the main entree at dinner and "Pizza" as the alternative meal as well.

The Saturday House Menu listed Chicken, Broccoli, Ziti as the meal alternative. The Vegetarian Menu did not provide a meatless alternative meal.

b) For the week of 6/14/15:

The Sunday House Menu listed Baked Chicken as the meal alternative at Lunch and Dinner. The Vegetarian Menu did not provide a meatless alternative meal.

The Tuesday House Menu listed American Chop Suey as the meal alternative at Lunch and Dinner. The Vegetarian Menu did not provide a meatless alternative meal.

The Wednesday House Menu included Chicken Rice Soup at Lunch. The Vegetarian Menu omitted the Chicken Soup but did not provide an alternative soup.

The Wednesday House Menu listed Baked Chicken as the meal alternative at Lunch and Dinner. The Vegetarian Menu did not provide a meatless alternative meal.

The Thursday House Menu listed Baked Stuffed Shells as the meal alternative at Lunch and Dinner. The Vegetarian Menu listed Baked Stuffed Shells as the entree at lunch and Baked Stuffed Shells as the alternative meal as well.

The Friday House Menu included Seafood Gumbo at Lunch. The Vegetarian Menu omitted the Seafood Gumbo but did not provide an alternative for the Gumbo.

The Saturday House Menu listed Chicken, Broccoli, Ziti as the meal alternative. The Vegetarian Menu did not provide a meatless alternative meal.


3. On 6/15/15 at 10:15 A.M., Surveyor #3 reviewed the above concerns about the Vegetarian Menu with the Dietitian, the Food Service Director and the District Manager.

Based on observation and documentation review, the Hospital failed to maintain equipment and supplies in the Food Service Department at an acceptable level of safety and quality. Findings include:

1. During the tour of the Food Service Department on 6/9/15 at 9:20 A.M., the following equipment and supplies were not maintained at an acceptable level of safety and quality.

In the ware washing area, pans were stacked wet and not air dried as per facility policy. The pot/pan storage shelves were dusty. Six beverage pitchers had lids with sticky labels affixed to them even after being washed and sanitized. The sticky residue from the labels did not allow for adequate cleaning and sanitizing.

The cutting boards were worn with scratched surfaces. The base of the table mounted manual can opener had a build up of food debris. The covers to the rice and flour bins had food debris.

In the food storage room and the bottled water storage room, floor edges and baseboards were not kept clean and free of debris. In the emergency food storage room, not all supplies and equipment were stored 6 inches off the floor. The storage room was cluttered and all areas of the floor were not accessible for cleaning and pest control inspection.

In the food production area, the bottom shelves of the reach-in freezer and the reach-in refrigerator were dirty with food debris. The tray assembly line and a food service cart used to hold containers of lettuce, tomato and cheese were not clean and free of food debris. The pipe under the hand wash sink leaked when the water was turned on.

The light bulbs in the reach-in refrigerator by the tray line and the walk-in refrigerator were burnt out. A ceiling light in the production area was not working. The hood light covers in the main kitchen and the cafeteria were dirty.

In the Cafeteria, the floor and the ceiling behind the serving line were dirty. The following was in need of cleaning: floor, floor edges, ceiling and the ceiling light covers. A metal table behind the serving line was dirty and a steam table lid kept on the table was laden with dust. A decoration kept behind the serving line was dust laden. The floor behind the serving line had evidence of mouse droppings.


2. In the nourishment kitchens on the 4th, 5th and 8th floors, the refrigerator light bulbs were either burnt out or missing. In the 5th floor nourishment kitchen, the interior of the microwave oven was stained. The faucet mounting on the handwash sink was loose. On the 8th floor, a small refrigerator in the dining room had no thermometer.


3. Review of the weekly pest control service reports from 3/13/15 to 6/9/15 indicated that broken and/or missing door strips in the kitchen and the dining area "create a gap to allow rodents to come in". The pest control report indicated that the Hospital should take action to "fix it soon".

On 6/11/15 at 9:00 A.M., observation of the cafeteria door and the kitchen receiving door indicated that the broken and/or missing door strips had not been fixed.

4. On 6/15/15 at 10:00 A.M., Surveyor #3 reviewed concerns about the Food Service Department with the Food Service Director, the District Manager, the Director of Safety and Security and the Dietitian.

Based on record review and staff interviews, the facility failed to include an accurate discharge planning evaluation in the patient's record and failed to discuss and update the patient with the results of the discharge planning evaluation.

Findings include:

Patient #18 had diagnoses that included Antisocial Personality Disorder and Borderline Personality Disorder, history of drug and alcohol abuse, hypertension, hepatitis C, tachycardia with an unknown etiology, anemia, headaches and irritable bowel syndrome (including constipation). The Patient had a history of sexual, physical and emotional abuse/trauma, gender identity issues and a severe, chronic and frequent history of harming him/herself and aggressive behavior towards others.

Review of the medical record indicated that the patient had been either inpatient in a psychiatric hospital or incarcerated for the past 5 years. The patient had spent the past 2 years in a psychiatric facility and had encounter legal charges after assaulting staff at the facility. While at the court house the Patient was transferred and admitted to the hospital on a legal Section 12 (e) for emergency hospitalization of persons posing risk of serious harm by reason of mental illness in 5/2015.

On 5/6/15, the social worker initiated a Social Work Discharge Plan. The plan indicated the patient was admitted under a legal Section 12 and that it expired on 5/9/15. The assessment indicated the patient was followed by the Department of Mental Health (DMH) community services, but not actively due to ongoing institutionalization. The social worker indicated that the community services would be contacted for involvement for community integration services and placement when needed.

Subsequent to the 5/6/15 assessment, the patient consented to a voluntary commitment on 5/9/15, so that he/she could receive treatment and care.

On 5/14/15, the social worker's progress note indicated that she had met with the Patient's community services and that they were to try to locate an outside DMH placement for the patient. The social worker indicated in her progress note that the Patient's DMH worker was reluctant to see the patient and did not meet with him/ her. The social worker indicated the patient wanted to know what was discussed. The social worker indicated that she would request that the community providers not come weekly, but failed to indicate why. In addition, the note failed to indicate what was communicated to Patient #18.

Subsequent, to the social worker's progress note on 5/14/15, there was minimum information to review in relationship with the Patient's discharge planning. The Hospital staff had initiated a plan, but it lacked a thorough, clear and comprehensive plan. The initial discharge plan failed to map out the course of treatment and there were subsequent interim progress notes about the patient's discharge.

During the survey process on 6/12/15, the Director of Quality of Care/Risk Management provided information, that included electronic mail (email) about Patient #18. Review of the documents indicated that on 5/18/15 and 5/19/15, the Hospital's Medical Director and DMH administration had formulated a discharge plan for the patient. They indicated that the long term discharge plan was for the patient to be placed on an 8 week rotation schedule among the different DMH inpatient hospitals in the state, until DMH was able to come up with a final placement. In the email, the Medical Director indicated he knew it would take a long time to find the final and appropriate discharge placement, but that he did not want his hospital caught in the middle and be responsible for housing the patient indefinitely. The email indicated the plan, to rotate the resident placement among the different DMH facility's, on an 8 week rotation, was developed due to patient assaultive behaviors and likelihood to assault again. The Medical Director indicated that the patient would be transferred to the next facility on 7/1/15.

During interviews on 6/15/15 at approximately 10:45 A.M., Registered Nurse (RN) #3 said she was aware that the administration of DMH had discussed the rotation plan, but had not been informed about its implementation. Social Worker #2 said that she was also aware of the administration's plan on 6/15/15 at approximately 11:00 A.M. She said that she did not think the patient was aware of this plan, but had assaulted a staff because he/she had felt that he/she was not wanted by the staff for treatment and feared he/she would be sent somewhere else. The Social Worker said that the Patient sometimes requested to go back to the facility he/she had lived in during the past 2 years, but felt that the Patient was testing staff, as he/she was sensitive, insecure and tested staff relationships.

During interviews on 6/15/15 at approximately 11:30 A.M., the Chief Operating Executive said the situation with the patient's status was unusual and had not followed the usual course of assessment and treatment. The Chief Operating Executive said that because the patient had significantly harmed him/herself, that DMH administration had directed the development of the plan. She said this impacted the hospital's development of plan of care for discharge planning. She said that as of 6/5/15, she and the staff were obtaining services, so that they could complete the assessments and develop an individualized and comprehensive plan of care for the patient (including appropriate discharge planning). She said that a rotation placement was not an appropriate treatment, as it lacked therapeutic value.

Based on observation, interview and record review, the facility failed to provide active treatment measures that included the provision of therapeutic efforts to address the patient's identified problems and goals for 1 of 8 sampled active patients (#18). This failure resulted in a restriction of patient rights with the repeated use of physical restraints for extensive periods without adequate justification. No interventions were developed to address issues identified during the patient assessment as possibly contributing to the patient's combativeness and self injurious behaviors. These failures potentially delayed improvement in the patient's condition.

Findings include:

Patient #18 was admitted to the Hospital on May 6, 2015,committed by the Court. where the patient was facing charges for assaulting staff at a hospital where the patient received inpatient care for the past two years. The patient was evaluated to be at risk of serious harm to self and others by reason of mental illness and committed by the Court. The patient's assaultive behavior to staff and self could not be managed at the prior hospital.

Review of the medical record indicated that Patient #18 has an extensive history of severe and chronic physical and emotional abuse since childhood. The patient's diagnoses include PTSD (post-traumatic stress disorder) and Borderline Personality Disorder, and psychiatric assessments completed on admission on 5/6/15 and consultant neuro-psychiatric evaluation dated 6/5/15 indicated the patient exhibited an inability to quickly generate alternate problem solving strategies which could result in the loss of control and repeated violence directed at self and/or others. Additional issues included gender identity issues, legal issues, hypersensitivity to rejection and discharge planning.

The problem: Risk of Self Harm and Aggression was entered on the patient's plan of care on admission and remains current. The long term goal is: (Patient #18) "states his/her goal is to gain behavioral control and not self harm or assault to gain more privileges and to be more communicative." The interventions for this problem are all related to the use of restraints, 2:1 constant observation, the presence of Campus Police Officers for the breaks from restraints. The OT interventions of using a sensory box for the patient to use at times of dysregulation has been restricted due to self harming incidents from ingesting batteries from the Wii game and crayons (while on 2:1 observation.) The Social Work interventions include meeting with the patient twice a week to "discuss maintaining safety on the unit". Progress notes dated 5/22/15 indicated that all scheduled activities and groups will cease in the event of any assaultive or self-injurious behaviors.

Specifically, the patient was placed on 2:1 observation until 5/22/15 when the patient became combative and received chemical restraints and 4 point restraints for 6 hours. On 5/26/15 the patient again required restraint use. Beginning 5/28/15 at 4 PM the patient was placed on continuous 4-point physical restraint, according to the examining physicians: due to: "ongoing management plan of danger to others due to repetitive/unpredictable assaultive behavior". On 5/31/15, the patient's psychiatrist, who was the DOC (Doctor on Call) to justify the continuation of 4-point restraints, documented that she wanted to reduce the patients' 4-point restraints to 2-point restraints, but was prohibited from doing so by the Department of Mental Health Boston Area Medical Director because "nothing had changed and until a new treatment plan was formulated, the patient needs to remain in 4-point restraint." The continuation of restraints was not based on the assessment by the physician conducting the actual face to face evaluation of the patient. Not until 6/5/15 was a new plan developed to gradually wean the patient off 4-point restraint, once the Chief Operating Officer (COO) of the facility decided that they could not support the current DMH (Department of Mental Health) plan for this patient.

Other than the use of seclusion, restraint, and constant observation, no active treatment was provided to address the patient's behaviors. Occupational Therapy and therapy groups and activities were discontinued; the focus was on safety only, without attempting to improve the patient's internal control of his/her behavior.

On interview with RN #3 on 6/9/15, she stated that Patient # 18 was hypersensitive to rejection and seemed to become combative or self-injurious when feeling unwanted. She indicated that the goal right now was to keep everyone safe. When asked about active treatment. she stated that normally the psychology intern would address the patient's behaviors, but the interns were not meeting with him/her because they were afraid. No one had been assigned to replace the intern.

Review of documentation and interview with the COO on 6/15/15 at 10:30 AM confirmed that the plan for the patient was developed by the Department of Mental Health with a focus on safety only, with a plan to have the patient rotate between various DMH facilities until a final plan was developed by DMH The COO reported that she could not implement that plan and on 6/5/15 determined that the patient needed the facility to commit to assess and treat the patient. However, as of 6/15/15, no active treatment was included in the patient's plan of care to address the patient's behaviors.