HospitalInspections.org

27457

Based on record review, interview, and policy review, the provider failed to:
*Protect and promote patients rights' for 4 of 4 reviewed patients (15, 16, 17, and 18) that were alleged to have been sexually abused.
*Ensure care and treatments were provided in a safe environment for 7 of 19 reviewed patients (1, 2, 3, 15, 16, 17, and 18).
Findings include:

1. Review of the mandatory reports dated 12/15/09 involving patient 15 revealed investigation for allegations of sexual abuse by patient 1. Refer to A115, finding 1 and A144, finding 1a.

2. Review of the mandatory report dated 11/15/09 involving patient 16 revealed investigation for allegations of sexual abuse by patient 1. Refer to A115, finding 2 and A144, finding 1b.

3. Review of the mandatory report dated 4/8/08 involving patient 17 revealed investigation for allegations of sexual abuse by patient 1. Refer to A115, finding 3 and A144, finding 1c.

4. Review of the mandatory report dated 12/16/06 involving patient 18 revealed investigation for allegations of sexual abuse by patient 1. Refer to A115, finding 4 and A144, finding 1d.

5. Review of the medical records, policies, procedures, and mandatory reports for patients 1, 2, 3, 15, 16, 17, and 18 revealed care and treatments were not provided in an safe environment. Refer to A144, finding 1a, 1b, 1c, 1d, 1e, 2, and 3.

Based on interview and record review, the provider failed to maintain an environment free from alleged sexual abuse for four of four reviewed patients (15, 16, 17, and 18) records. Findings include:

1. Review of the mandatory report dated 12/15/09 involving patient 15 revealed investigation for allegations of sexual abuse by patient 1. Refer to A144, finding 1a.

2. Review of the mandatory report dated 11/15/09 involving patient 16 revealed investigation for allegations of sexual abuse by patient 1. Refer to A144, finding 1b.

3. Review of the mandatory report dated 4/8/08 involving patient 17 revealed investigation for allegations of sexual abuse by patient 1. Refer to A144, finding 1c.

4. Review of the mandatory report dated 12/16/06 involving patient 18 revealed investigation for allegations of sexual abuse by patient 1. Refer to A144, finding 1d.

Based on record review, interview, and policy review, the provider failed to maintain a safe environment for 7 of 19 sampled patients (1, 2, 3, 15, 16, 17, and 18) receiving treatment and care. Findings include:

1a. Review of the five day mandatory report from an incident that had occurred on 12/15/09 involving patient 1 and patient 15 revealed:
*Patient 1 was found at 6:47 a.m. standing over the top of patient 15 in their shared room. Patient 1 did not have any clothes on from the waist down and patient 15's pajama pants and "pull-up" were pulled down.
*Nursing assessed patient 15 that morning and had found his rectal area was "moist and sticky." No rectal bleeding was noted at the time of that assessment.
*Patient 1 had three prior incidents of "inappropriate boundaries" on 12/16/06, 4/8/08, and 11/15/09.
*Patient 1 was discharged on 12/15/09 as a result of the 12/15/09 occurrence.
*Patient 1 was not under direct supervision at the time the incident had occurred.

b. Review of the five day mandatory report from an incident that had occurred on 11/15/09 involving patient 1 and patient 16 revealed:
*Patient 1 by was found by direct support professionals at 11:10 p.m. in bed naked from the waist down in the bed of patient 16. Patient 16 was also found naked from the waist down.
*Nursing staff were notified of the incident.
*Staffing ratio at the time of the incident was one support staff person to every eight patients.
*Patient 1 was not under direct supervision at the time the incident had occurred.

c. Review of the mandatory report from an incident that had occurred on 4/8/08 involving patient 1 and patient 17 revealed:
*Patient 1 had been found by direct support professionals at 10:20 p.m. directly next to patient 17 in patient 17's bedroom. Patient 17 was found hanging off the side of the bed with her jeans around her knees and her underwear pulled down. Patient 17 was also reported to have tears in her eyes at the time she was found.
*Nursing was notified by staff of the incident and an assessment of patient 17 revealed no abnormal findings.
*Staff were reminded that patient 1 was to be in the line of sight during waking hours.
*Patient 1 was not under direct supervision at the time the incident had occurred.

d. Review of the mandatory report from an incident that occurred on 12/16/06 involving patient 1, patient 18, and patient 19 revealed:
*Patient 1, 18, and 19 were found by direct support professionals at 12:40 p.m. in a dorm room under a blanket. Patient 1 and 18 were found to be partially undressed. Patient 19 was found to be fully clothed.
*The action plan for that event was to separate the patients and to have staff keep each patient in their line of sight during all waking hours.
*Patient 1 was not under direct supervision at the time the incident had occurred.

Review of patient 1's treatment and care plan last revised on 11/21/08 revealed:
*The patient had a history of aggression towards others that included swearing, threatening others, teasing, and provoking others.
*The patient's target behaviors were aggression and noncompliance.
*Under the specific treatment and procedures section it stated staff "should" always have patient 1 in their sight. Patient 1 should never be left unsupervised.

Review of patient 1's treatment and care plan revised on 11/17/09 revealed:
*The patient had a history of aggression towards others that included swearing, threatening others, teasing, and provoking others.
*The patient had a history of inappropriate social behavior that included getting too close to another person and/or grabbing/touching private areas of others.
*The patient's target behaviors were aggression, noncompliance, and inappropriate social behavior.
*Under the specific treatment and procedures section it stated staff "must" always have patient 1 in their sight. Patient 1 should never be left unsupervised.

e. Multiple interviews on 8/19/10 starting at 9:30 a.m. with operations director 1 regarding the above mentioned incidents revealed:
*He was aware of the incidents that had occurred with patient 1 on 12/15/09, 11/15/09, 4/8/08, and 12/16/06.
*He was aware and the facility was aware of patient 1's history of sexual inappropriateness.
*He agreed according to the patient's treatment and care plan staff should have always had the patient in sight, and the patient should have never been left unsupervised. However he stated at night the direct support staff ratio would have been 1 to 7 or 1 to 8 with one nurse for each unit. Staff would not be able to follow what was outlined in the treatment and care plan. When asked why that had not been followed as written he was unable to answer.
*A bed alarm had been placed on patient 1's bed after the incident that had occurred on 11/15/09, as part of the provider's action plan.
*The provider had not trained all staff on bed alarms until after the 12/15/09 incident had occurred.
*The provider did not have a policy and procedure for bed alarms until after the 12/15/09 incident.
*The direct support professional supervisor on duty on 12/15/09 had moved the patient's bed to a different location in the room and had disabled the alarm.
*The direct support professionals on duty on 12/15/09 were found documenting bed checks for each other and had been disciplined for that.
*The provider did not currently have a policy and procedure for direct support staff regarding night time bed checks or proper documentation for clinical records.
*He agreed during the interview he now saw the need for policies and procedures related to documentation.
*He agreed lack of policies and procedures and training were likely contributing factors to the 12/15/09 incident.

2. Review of the incident report dated 8/10/10 involving patient 2 revealed:
*The report was submitted to the South Dakota Department of Health and South Dakota Child Protective Services alleging abuse by a staff member. The report detailed how a staff member had improperly transported and then held the patient on the toilet after the patient had urinated and defecated on the floor.
*The patient had a history of urinating and defecating on the floor.

Interview and record review on 8/17/10 at 10:15 a.m. with direct support professional 2 revealed:
*She had worked for the provider for three weeks.
*She had not completed all of her training for her current position.
*She had worked with patient 2 without a mentor.
*When direct support professional 2 was asked by this surveyor how she knew how to intervene when patient 2 urinated and defecated on the floor she stated one of the other staff had told her.
*When direct support professional 2 was asked by this surveyor what written information would she look at in regards to behaviors she took me to a closet that contained what she called programming binders. In reviewing patient 2's programming binder with direct support professional 2 no behavioral programming was found. Direct support professional 2 stated she did not know why no behavioral programing was available for patient 2.

Interview and record review on 8/17/10 at 1:30 p.m. with behavioral therapist 3 and clinical directors 4 and 5 revealed:
*The main rational for patient 2's admission to the facility on 5/25/10 was for control of behaviors with the main ones being urinating and defecating on the floor.
*No written documentation existed for staff training regarding the behaviors exhibited by patient 2. Behavioral therapist 3 had talked to staff about patient 2's behaviors, but he was unsure as to dates, times, and personnel involved in those conversations.
*Patient 2 did not have a developed treatment and care plan. However an interim plan had been put in place for urinating and defecating on the floor on 8/13/10 as a result of the 8/10/10 incident. Behavioral therapist 3 and clinical director 4 stated they were still in the process of collecting data prior to development of the care plan.
*All agreed the programming binder shown to this surveyor by employee 2 should have contained the 8/13/10 programming.
*No toileting program existed for patient 2.

Interview and record review on 8/17/10 at 1:50 p.m. with direct support professional supervisors 6 and 7 revealed:
*Both of them directly supervised direct support professionals.
*Both were unable to find any behavior programming information in the programming binder.
*Both agreed that behavior programming should have been in the binder.

Interview and observation on 8/17/10 at 3:00 p.m. with direct support professional 8 revealed:
*She had worked for the provider for one month prior to the incident that had occurred on 8/10/10.
*She had not completed all of her training for the position prior to that incident.
*She had been assigned without a mentor to patient 2 at the time of the 8/10/10 incident.
*She was not aware of any formal or informal behavioral programming for patient 2's behavior of urinating or defecating on the floor.
*When direct support professional 8 was asked by this surveyor how she knew how to intervene when patient 2 urinated and defecated on the floor she stated one of the other staff had told her.
*At the time of the incident it made her feel uncomfortable, but she was not sure if she should have reported it to the supervisor.
*She had not reported the incident to her supervisors until the afternoon of 8/11/10 after attending a behavior management class conducted by the provider.

Interview on 8/18/10 at 9:05 a.m. with program manager 9 revealed:
*She was a licensed social worker and case manager for patient 2. That meant she coordinated care for patient 2 with the health care team and patient 2's parents.
*The main rational for the admission to the facility was patient 2 had been urinating and defecating on the floor at school and at home over the past year or so.
*She had been made aware of the 8/10/10 incident on 8/16/10 by another staff member but had not taken any actions regarding that matter yet.
*No formal behavioral programming existed for patient 2.
*She was unable to state exactly why formal behavioral programming was not in place for patient 2.
*Nurses or the case manager would report an incident like that to the parents. She was unaware if the parents had been notified of the 8/10/10 incident.

Interview on 8/18/10 at 9:35 a.m. with clinical director 4 revealed:
*Staff would not know for sure how to address patient 2's behaviors without a treatment and care plan.
*No time frames existed in the policy and procedure for the implementation of treatment and care plans.
*She agreed not having staff knowing how to properly intervene with a behavior could have posed a risk to the patient.




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3. Review of patient 3's nurses' notes dated 7/9/10 to 7/10/10 revealed:
*On 7/9/10 at 4:40 p.m. patient 3 fell while on a shopping outing outside the facility.
*Neurological checks were within normal limits (WNL).
*Injures included a:
-Quarter size contusion on the middle of the back of the head.
-One centimeter (cm) x 1/2 cm abrasion and/or bruise on the right shoulder.
-One and three quarter cm x three quarter cm abrasion on the right shoulder.
-Three inch (in) x 1 1/2 in abrasion on the middle upper back.
-One in. abrasion on the right knee.
*The injuries were cleansed with soap and water, the physician was notified, and an order was received to transport the patient to the emergency room (ER).
*On 7/9/10 at 7:30 p.m. the patient returned from the ER, was alert, and "Back to normal self."
*Will monitor while awake every 2 hours and complete neurological checks for 24 hours. The physician would be notified if there were complaints of nausea, vomiting, and drowsiness.
*Tylenol could be administered for complaints of a headache.
*Received a physician order to hold medications due to injury.
*At 8:40 p.m. neurological checks were WNL.
*At 9:42 p.m. the patient was awakened, she complained "I hurt", and had a large emesis. An assessment and vital signs were completed and all were WNL.
*At 9:56 p.m. the on-call physician was updated on the patient's status. An order was received to have the patient evaluated at a hospital ER that night.
*At 10:40 p.m. the patient was transferred to an ER. Patient was alert, oriented to person, place, and time, pupils were equal and reactive to light, and she answered questions appropriately. Vital signs stable, gait steady, denied pain, and no further emesis.
*On 7/10/10 at 3:20 a.m. patient 3 was admitted into the hospital.

Review of patient 3's physician's progress notes dated 7/9/10 revealed:
*The patient fell off another person's shoulder's around 4:00 p.m. and hit her head and back.
*A 1.5 cm contusion was noted on the right occipit (head) area, mild abrasion on the upper back and right shoulder, but no joint pain.
*There was no loss of consciousness, but she was quite groggy for about 20 minutes.
*The patient was better now and back to her usual self according to her caregiver.
*There was no nausea, vomiting, was alert, and cooperative.
*Pupils were equal and reactive to light, neck and back with full range of motion, and had no complaints of pain.
*The patient was ambulatory, active, and was returned to the facility.

Interview on 8/17/10 at 3:30 p.m. with direct support professional 13 revealed:
*On 7/9/10 around 4:00 p.m. she had been responsible for the care of patient 3 and two other patients while on a shopping outing. Two other staff members were on the shopping outing with her and had patients of their own. A total of three staff and six patients were on that shopping outing. One co-worker had been assigned one-to-one patient care and the other coworker was responsible for two patients. Her coworkers exited the bus and went into the shopping center.
*One of her patients was in a wheelchair and one of the wheels had malfunctioned and lifted off the ground, the other patient was trying to get away from her, and she had placed patient 3 around her neck on her shoulders.
*When she leaned forward to fix the wheelchair patient 3 fell backwards and hit her head on the parking lot.
*Patient 3 began crying and saying her head hurt.
*She had attempted to send a text message asking for help to her coworkers that had gone into the shopping center for help. Those coworkers had not answered her text message.
*She had entered the shopping center, saw her coworkers at the check-out, and informed them of the fall.
*After returning to the facility a debriefing was completed, and she was instructed patients were not placed on the shoulders of staff or placed in dangerous situations.
*On 7/14/10 she had been terminated because of the incident but was rehired after the investigation two weeks later.
*She had been off several days prior to the shopping outing on 7/9/10.
*The direct support professional supervisor had not provided her adequate preparation and information regarding her assigned patients prior to going on the shopping outing.
*When asked what information should have been provided to her before going on the shopping outing she replied:
-Information about the patient's wheelchair malfunction since that was not the first time that had happened.
-Two of the patients had been hyperactive and one of them had not slept for three days.
*She had been informed by other coworkers that it was okay to give patient piggyback rides. She agreed a piggyback ride was different than placing a patient around your neck.

Interview on 8/17/10 at 5:00 p.m. with direct support professional 14 revealed:
*She had been on the shopping outing on 7/9/10 with direct support professional 13.
*Upon arrival at the shopping center the team had divided into two groups.
*She had been assigned a patient that required one-to-one supervision. Should another co-worker on that shopping outing require assistance she would not have been available to provide that assistance.
*She had missed the text message from direct support professional 13, because the shopping center was busy and there was a lot going on.
*The shopping outing had not been well planned for, because information had not been shared with the staff members going on the shopping outing. The patients assigned on that shopping outing were difficult patients. The team did not know one of the wheels on the patient's wheelchair had not been fixed, one of the patients had not slept for three days, and another was in a pre-crisis status.

Interview on 8/19/10 at 9:00 a.m. with the director of human rights and protections revealed:
*Direct support professional 13 had violated the provider's lifting, transferring, and transporting policy. That policy informed employees about the most appropriate method for transferring patients.
*That policy provided weight limits for when one staff, two staff, or more staff were needed when lifting or transferring patients or objects.
*At no time were staff trained to provide patients with piggyback rides or carry them on their shoulders.
*Direct support professional 13 had been rehired after information had been discovered during the investigation that a supervising staff member had informed staff it was appropriate to give patients piggyback rides.

Interview on 8/19/10 at 11:10 a.m. with direct support professional supervisor 15 on duty on 7/9/10 revealed:
*Prior to a patient going on an outing she would have completed an outing sheet. The registered nurse responsible for the patient would have also signed that form to indicate the patient's health status did not prevent the patient from participating in the proposed activity.
*She had prepared the staff on 7/9/10 for the shopping outing. When preparing a team to take patients on outings into the community she would ask the team if there was anything they needed, talked to them about where they were going, and what they needed to get.
*The staff on 7/9/10 were long term employees. They had at least been on the job more then six months. All staff on that outing had taken patients on outings into the community before.
*When asked how staff were trained to take patients on outside outings she replied patients were assigned to staff members that were familiar with their care.
*She had asked the staff if they felt comfortable going on that shopping outing, and they had responded "Yes."
*She felt the shopping outing was adequately staffed.
*She had been asked in the past by another staff member if staff were allowed to give patients piggyback rides. She had responded it was age appropriate to give a five year old a piggyback ride. She had never told staff it was all right to give piggyback rides or to put them on their shoulders.

Interview on 8/19/10 at 11:00 a.m. with operations director 1 revealed the provider did not have a policy and procedure for patient outings. He would have to review direct support professional 13's personnel file to determine if she had received training for community outings with patients.

Review of direct support professional 13's personnel file with operations director 1 confirmed there was no documentation in that personnel file for training on community outings with patients.

Based on observation, interview, record review, and policy review, the provider failed to ensure plans of care were developed and kept current for 4 of 14 sampled patients (2, 4, 5, and 6) receiving care. Findings include:

1. Review of patient 2's entire medical record revealed:
*The resident had been admitted to the facility on 5/25/10 for the treatment of behavioral issues.
*The resident had a nursing care plan dated 5/25/10 but did not have the treatment and care plan the provider utilized for behavioral issues.

Interview and record review on 8/17/10 at 1:30 p.m. with behavioral therapist 3 and clinical directors 4, and 5 revealed:
*Nursing staff were responsible for medical care plans, and the behavior therapist was responsible for the treatment and care plan addressing behaviors.
*The main rational for patient 2's admission to the facility on 5/25/10 was for control of behaviors with the main ones being urinating and defecating on the floor.
*No written documentation existed for staff training regarding the behaviors exhibited by patient 2. Behavioral therapist 3 had talked to staff about patient 2's behaviors, but he was unsure as to dates, times, and personnel involved in those conversations.
*Patient 2 did not have a developed treatment and care plan. However an interim plan had been put in place for urinating and defecating on the floor on 8/13/10. Behavioral therapist 3 and clinical director 4 stated they were still in the process of collecting data prior to development of the care plan.
*All agreed the programming binder shown to this surveyor by direct support professional 2 should have contained the 8/13/10 programming plan.
*No toileting program existed for patient 2.

Interview and treatment and care plan policy review on 8/18/10 at 9:35 a.m. with clinical director 4 revealed:
*Staff would not be able to know for sure how to address patient 2's behaviors without a treatment and care plan.
*No time frames existed in the policy and procedure for the implementation of treatment and care plans.
*She agreed not having staff knowing how to properly intervene with a behavior could pose a risk to the patient.

2. Review of patient 5's nursing care plan revealed the last time the care plan had been updated was on 2/16/10.

Interview and nursing care plan policy review on 8/19/10 at 10:15 a.m. with director of nursing 17 revealed:
*She agreed patient 5's care plan was not documented as reviewed or revised since 2/16/10.
*She agreed the provider's policy for nursing care plans called for care plans to be reviewed on a quarterly basis.
*She agreed patient 5's care plan was not documented as reviewed and revised per the provider's policy.




15036

3. Review of patient 6's nursing notes revealed:
*On 11/26/09 at noon (late entry) the patient had winced when his right leg was moved. An assessment by registered nurse (RN) 12 of the patient's right leg revealed no edema, redness, or warmth. The staff would continue to monitor.
*On 11/27/09 at 11:00 a.m. the patient was up in the wheelchair. RN 12 palpated his right knee and upper leg. No patient distress, swelling, or redness was noted.
*On 11/27/09 at 5:00 p.m. the direct support professional reported when the patient's right leg was moved he flailed his arm as if in pain. An assessment by RN 12 revealed the patient's right leg appeared bigger than the left leg, but no redness or temperature difference was noted.
*On 11/27/09 at 7:45 p.m. the patient was transported to Sanford emergency room and was diagnosed with a right femur fracture.

Review of the radiology report dated 11/27/09 confirmed a right femur fracture.

Review of the emergency room physician's orders dated 11/27/09 revealed a knee immobilizer was to be worn at all times, could be removed for bathing, and use caution with extremity movement. Tylenol with codeine had been ordered for pain.

Review of patient 6's medical record revealed:
*There was no care plan addressing the right femur fracture, mobility, or pain monitoring.
*There were care plans for impaired gas exchange, alteration in nutrition, potential risk for injury (relating to seizure activity), potential alteration in skin integrity, and potential alteration in bowel pattern.
*The review dates for the care plans listed above were 8/20/09, 11/18/09, 3/26/10, 5/29/10, and 8/5/10. There was no information on those care plans addressing a right femur fracture nor the application of a knee immobilizer.

Interview on 8/19/10 at 3:55 p.m. with operations director 1 confirmed patient 6 did not have a care plan that addressed the right femur fracture and the use of the knee immobilizer. Operations director 1 revealed the knee immobilizer had been listed on the patient's November 2009 treatment flow sheet used by nursing.




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4. Review of patient 4's nursing notes revealed:
*On 9/6/09 at 4:00 p.m. patient 4's mother was at the facility to visit the patient. The patient's mother requested "(word not clear) child to stay in bed until 11:00 a.m. on weekends and holidays."
*On 9/13/09 at 9:00 a.m. patient 4's mother called the facility "to see if child was still in bed. Explained to mom child ask to have her stay in bed until 11:00 a.m. Told mom staff gave child the option of staying in bed but child wanted to get up. Mom con't to sound unhappy about situation."
*On 10/30/09 at 6:45 p.m. the nurse was approached by the support supervisor and asked to contact patient 4's mother and physician. They were to be informed the patient was in bed until approximately 11:00 a.m. after the awaking at 7:30 a.m. and requesting to get up.
*On 11/3/09 at 8:45 p.m. patient 4's mother visited and requested "that child's sign in room be changed to allow child out of bed at 11:00 a.m. on weekends if child wants to."

Review of patient 4's undated behavior cardex revealed there were no written instructions related to the mother's request for the patient to remain in bed on weekends and holidays.

Review of an incident report dated 11/2/09 revealed support specialist 16 was assigned to patient 4's room. Patient 4 was reported to be awake at 7:30 a.m. and requested to get out of bed. It was reported support specialist 16 would not assist patient 4 in getting up. Support specialist 16 stated it was her understanding patient 4's mother wanted her to stay in bed until 11:00 a.m. on days when she was not in school.

Review of interviews of support staff and nursing staff conducted on 10/30/09 for the incident report dated 11/2/09 revealed support specialist 16 stated patient 4's mother and nursing staff wanted the patient to stay in bed until 11:00 a.m.

Interview on 8/19/10 at 11:45 a.m. and at 1:40 p.m. with direct support supervisor 1 revealed:
*After the 10/30/09 incident a sign had been posted in patient 4's room with instructions about getting the patient out of bed on weekends and holidays.
*The information about the mother's instructions recorded in the nursing notes was passed on verbally to the care technician for the unit.
*The care technician would then train the direct support personnel about the information so appropriate care could be provided to the patient.
*The information provided by the nurse to the care technician might or might not be written down into the behavior cardex.

Interview on 8/19/10 at 1:30 p.m. with director of nursing (DON) 17 revealed patient 4's mother had wanted the patient to stay in bed until 11:00 a.m. on weekends and holidays. DON 17 stated there had been conversations with the mother to explain the patient had the right to get out of bed earlier if that was what the patient had desired.