HospitalInspections.org

Based on review of facility documents and staff interviews (EMP) it was determined the facility failed to take all reasonable steps to conform with all applicable State Law.

The following State regulation has been deemed non-compliant:

The Meadows Psychiatric Center was not in compliance with the following State law related to The Medical Care Availability and Reduction of Error Act, 40 P.S.? 1303.101 et seq.
Chapter 3 Patient Safety Section 1303.301. Scope. This chapter relates to the reduction of medical errors for the purpose of ensuring patient safety. Section 1303.302. Definitions. The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise: ... Incident. An event, occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury require the delivery of additional health care services to the patient. The term does not include a serious event. Infrastructure. An undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient safety, ... Medical facility. An ambulatory surgical facility, birth center or hospital ... Serious event. An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient, the term does not include an incident. ... 1303.307 Patient Safety Plans. a. Development and compliance. -- A medical facility shall develop, implement and comply with an internal patient safety plan that shall be established for the purpose of improving the health and safety of patients. ... (b) Requirements. A Patein safety plan shall: ... (3) Establish a system for the health care workers of a medical facility to report serious events and incidents which shall be accessible 24 hours a day, seven days a week. ... Section 1303.309. Patient safety officer. A patient safety officer of a medical facility shall do all of the following: (1) serve on the patient safety committee. (2) Ensure the investigation of all reports of serious events and incidents. (3) Take such action as is immediately necessary to ensure patient safety as a result of any investigation. (4) Report to the patient safety committee regarding any action taken to promote patient safety as a result of investigations commenced pursuant to this section. Section 1303.310. Patient safety committee. ... (b) Responsibilities. A patient safety committee of a medical facility shall do all of the following: (1) Receive reports from the patient safety officer pursuant to section 309. (2) Evaluate investigations and actions of the patient safety officer on all reports. (3) Review and evaluate the quality of patient safety measures utilized by the medical facility. A review shall include the consideration of reports made under sections 304 (a) (5) and (b), 307 (b) (3) and 308 (a). (4) Make recommendations to eliminate future serious events and incidents. (5) Report to the administrative officer and governing body of the medical facility on a quarterly basis regarding the number of serious events and incidents and its recommendations to eliminate future serious events and incidents. ... "

This is not met as evidenced by:

Based on review of facility documents, medical records(MR), and interviews with staff (EMP), it was determined that the Patient Safety Officer failed to submit reports of serious events and infrastructure failures according to the definitions set forth, and failed to ensure that the Patient Safety Committee meeting minutes reflected analysis and investigation of serious events and infrastructure failures.

Findings include:

Review of "The Meadows Psychiatric Center Universal Community Behavioral Health Title: Patient Safety Plan ... Date Reviewed/Revised: ... 1/10 Overview and Purpose Attention to maintain and improving patient safety and well being is inherent in The Meadows Psychiatric Center and Universal Behavioral Health's commitment to the improvement in the quality of life to those in the community it serves. In committing ourselves to safeguarding individuals, The Meadows/UCBH must fully understand the processes and systems that are utilized by the organization to deliver patient care. From this deeper understanding, The Meadows/UCBH will be able to analyze, evaluate, develop, and implement changes that will continuously improve the way we deliver care to patients. ... Principles: The Meadows/UCBH patient safety plan is based on the following principles. Improvement in patient safety will not occur unless there is a commitment by The Meadows/UCBH Board of Governors and senior management and an overt, clearly defined, and ongoing effort on the part of the hospital leaders. physicians, managers and employees to sustain the organization's interest and focus on patient safety. The leadership of the Meadows/UCBH will keep the hospital Board of Governors apprised of any adverse outcomes, safety problems, and efforts directed at improving patient safety. ... Punitive approaches towards individuals involved in various events pushes reporting and disclosure underground, thereby preventing an opportunity for the organization to appropriately intervene to correct the underlying problems. The Meadows/UCBH is committed to developing ways to reward rather than discourage reporting of errors or patient safety concerns and will celebrate successes at improving the reporting of patient safety concerns and errors and how such information has been used to make improvement in hospital processes, systems and care delivery. Patients are encouraged to actively participate in care decisions. ... In the event of a serious event, the disclosure will be made in writing to the patient or patient's family within seven days of the occurrence or discovery of the serious event. ... Key Definitions ... Serious Event - An Event, occurrence, or situation involving the clinical care of a patient in a medical facility (hospital, ambulatory surgery facility, or birthing center) that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient.{Pennsylvania Act 13, Medical Care Availability and Reduction of Error Act} Serious events are reportable to the Patient Safety Authority and Department of Health under Act 13. Incident - An event, occurrence, or situation involving the clinical care of a patient in a medical facility (hospital, ambulatory surgery facility, or birthing center) which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient.{Pennsylvania Act 13 of 2002, Medical Care Availability and Reduction of Error Act} Incidents are reportable to the Patient Safety Authority and Department of Health under Act 13. Infrastructure Failure - An undesirable or unintended event, occurrence, or situation involving the infrastructure of a medical facility (hospital, ambulatory surgery facility, or birthing center) or the discontinuation or significant disruption of a service, which could seriously compromise patient safety. (sic)Pennsylvania Act 13 of 2002, Medical Care Availability and Reduction of Error Act}Department of Health under Act 13. Infrastructure failures are reportable to the Pennsylvania Department of Health under Act 13. ... Disclosure ... External Reporting - Depending on the severity of the event or incident, the appropriate authorities, including the Patient Safety Authority and/or the Department of Health will be notified utilizing the required reporting format. (Refer to The Meadows/UCBH policy on Healthcare Peer Review (HPR) Occurrence Reporting System and on Conducting a Root Cause Analysis for Sentinel Event) Authority and Responsibility Board of Governors - The overall authority for direction of the patient safety improvement and management program rests with The Meadows/UCBH Board of Governors. The Board of Governors delegates its authority to implement and maintain the various components of the patient safety improvement and management program to the chief executive officer of the Meadows/UCBH. Chief Executive Officer - The chief executive officer in collaboration with administrative, managerial, and clinical staff ensures that the patient safety improvement and management program is implemented throughout the organization and integrated appropriately with other activities within the organization which contribute to the maintenance and improvement of patient safety, such as performance improvement, environment safety and risk management. The Chief executive officer will designate a qualified individual in the organization to mange the organization-wide patient safety improvement and management program at The Meadows/UCBH. Patient safety Officer-An individual designated by the president of the medical staff and chief executive officer who is responsible for the organization-wide patient safety improvement and management program and is accountable directly to The Meadows/UCBH Board of Governors and Chief executive officer. The patient safety officer will: Oversee the creation, review, and refinements to the patient safety improvement and management program. Coordinate and prioritize the activities of the patient safety council. Develop and implement adequate information and management systems to support the activities of the patient safety improvement and management program. Identify and secure the necessary resources to fully implement the patient safety improvement and management program. Ensure compliance with sentinel event, serious event, incident, and infrastructure failure reporting requirements as mandated by law/regulations or meet accreditation standards. Oversee the investigation of serious events and as appropriate identified incidents. Ensure that disclosure of serious events and as appropriate identified incidents. Ensure that disclosure of serious events to patients and/or families is carried out in accordance with organizational policy and law/regulations. Devise strategies to enlist medical staff, employee, and patient family input into the organization's patient safety improvement and management plan. Serve as a direct link to the Board of Governors and chief executive officer on all matters related to patient safety. Ensure that the organization conducts proactive hazard analyses. ... Hospital Employees-The Meadows/UCBH employees are responsible for actively participating in The Meadows/UCBH patient safety improvement and management program. An active participant will: Assume responsibility for identifying process or systems that could potentially lead to errors and adverse events."

1) Review of The Meadows Risk Management Incident Analysis Report for August, September and October, revealed that 13 patients had eloped from the Meadows; four of the 13 patients that eloped were gone for greater than 24 hours. It was also revealed that 370 physical confrontations had occurred which included; patients attacked staff 77 times; patients attacked another patient 62 times. Of the 62 attacks, patients were injured 26 times. The Incident Analysis report also revealed that 25 sexual allegations occurred during the three month period; and there were12 patient self inflicted injuries, including six suicide attempts.

2) Review of the Pennsylvania Department of Health Reporting System revealed that for the past year (2010) the Meadows submited three reports (two serious events reported on November 2, 2010 & March 16, 2010 and one infrastructure failure reported on March 18, 2010).

3) Review of the "UHS Patient Safety Council Report Facility: The Meadows Psychiatric Center Date of Meeting: 10/20/10 Members present: ... Members Absent: ... Primary Initiative ... Discharge Process Reviewed ... Observation Rounds ... " There is no documentation in the Patient Safety council meeting minutes that indicates a review of incidents, infrastructure failures or serious events.
Review of the "UHS Patient Safety Council Report Facility: The Meadows Psychiatric Center Date of Meeting: 9/15/10 Members present: ... Members Absent: ... Primary Initiative ... Discharge Process Reviewed ... Observation Rounds ... " There is no documentation in the Patient Safety council meeting minutes that indicates a review of incidents, infrastructure failures or serious events.

4) Review of the Meadows bed capacity by census and date report revealed that on October 25, 26, 27 and 28, 2010, the facility exceeded it licensed bed capacity with a census of 102 patients. The licensed bed capacity for the Meadows Psychiatric Center is 101 beds.

5) A review of incident reports for three months was performed and a sample of medical records was selected from the incident reports for review.

a. Review of MR1 revealed a 14 year old ... (patient) admitted on September 11, 2010. Review of the Discharge Summary it is documented that the patient was seen by the physician assistant on September 19, 2010 after alleged sexual intercourse with a peer. The patient stated peer forced (self) on them and ejaculated inside them. ... Review of the Interdisciplinary Progress Notes dated September 18, 2010, ... Pt was distressed regarding an incident of the previous evening stating that they and a M peer had sexual relations during the overnight shift. ... Pt became verbally agitated of the previous night stating that (they) had no choice when peer held me down and put their penis in me. Pt was expansive and dismissive about the situation and fails to recognize the significance. ...

b. review of MR2 revealed a 15 year-old ... who was admitted on a 201 commitment on September 28, 2010 and discharged on November 4, 2010. A review of the Psychiatric Discharge Summary revealed ... The patient had a difficult weekend. They were locked in seclusion after they punched an RN. Pt also used a weapon. Apparently patient got the weapon from their room. Pt took wooden moulding down with nails in it and apparently tried to attack other staff members. Pt also managed to choke a peer. ... After I met with the patient I was called by staff. Staff informed me that the patient spontaneously, without provocation, jumped onto the back of another patient and tried to kill them. .... We do not have reason for that behavior. On 10/26/2010 after threatening staff. ... Pt had another episode of unprovoked rage and aggression towards a peer. Pt was placed in seclusion because of this. ...
Upon further review it was revealed Seclusion/Restraint Observation record. 1:1 Must Be Maintained During Seclusion Or Restraint ...18:15 Pt had a approx. four foot long wooden piece broken off from their closet, patient walked out with the wooden weapon and seemingly about to strike a nurse in the back of her head. At this point staff grabbed the wooden piece and a second staff member restrained and escorted the pt. to the saferoom. ... On 10/24 at 18:55 Pt exited bathroom with shower curtain rod, put staff in headlock, assaultive escorted to saferoom.
Review of the Interdisciplinary Progress Notes dated 10/10 22:30 ... Pt verbally / physically aggressive with both peers and staff . ... 10/11 19:50 Pt agitated most of the shift. ... Pt went after another pt and was choking other pt. ...10/24 22:48 Spoke with ... Updated them on severity of aggression and assaultive behaviors tonight. Staff reported to myself patient took a shower curtain rod and took a female staff member to the ground in a choke hold. Staff was able to get a hold and back-up was called. ... 10/27 15:00 Pt choked and had a peer in the scissors hold. Pt was held for 5 minutes walked to safe room. ...

c. Review of MR3 revealed a 20 year-old ... voluntarily committed on September 27, 2010, and discharged on October 4, 2010. Review of the Meadows Psychiatric Center Daily Progress Note date: 10-1-10 - ... Pt is extremely agitated, confrontational, oppositional and defiant today. Pt is kicking and punching female staff members and fighting with and threatening physically and verbally their peers. ...

d. Review of MR4 revealed 22 year old ... who was admitted on September 23, 2010. Review of the Seclusion/Restraint Observation record. 1:1 Must Be Maintained During Seclusion Or Restraint ... 14:30 Pt was yelling and screaming, charged staff nurse and punched them in the face. Pt restrained. ...

e. Review of MR5 revealed a 13 year old ... admitted on November 3, 2010 and discharged on November 9, 2010. Review of a consult report dated November 7, 2010, revealed Consult to evaluate patient, after pt was attacked and repeatedly [punched in the head by peers ...
Further review of MR5 revealed Physician Progress Notes 11/08/2010 ... Subjective: ... The patient verbalized frustration about three peers jumping pt over the weekend. Pt says they do not get along with these three peers and they jumped on pt and that pt called the police and pressed charges. Mother called and requested discharge because of this situation and feels that pt may not be safe here. ...

6) Review of the crossboarding data revealed that from June 1, 2010 to November 24, 2010 the Meadows crossboarded patients 1,334 times. A sample month was reviewed and revealed that from June 1 through June 30, 2010, the Meadows crossboarded patients 202 times.
32 patients admitted to the Adult Unit slept on the Stabilization Unit;
Nine patients admitted to the Stabilization Unit slept on the Adult Unit;
34 patients admitted to the Adolescent Unit slept on the Adult Unit;
27 patients admitted to the Childrens Unit slept on the Adolescent Unit;
74 patients admitted to the Adult Unit slept on the Adolescent Unit;
27 patients admitted to the Adolescent Unit slept on the Childrens Unit.
The Meadows failed to submit any reports of crossboarding to the Pennsylvania Safety Authority or the Department.

7) An interview was conducted with EMP1 on December 21, 2010, at approximately 3:00 PM, "I was unaware that we needed to report until this complaint investigation."

8) An interview was conducted with EMP3 on December 21, 2010, at approximately 3:15 PM, "I'm new to this position, I was not aware of the reporting requirements. Since our last conversation, I have attended the training."
The list of Risk Management Analysis report was reviewed with EMP3. EMP3 stated "these events should have been reported."

Based on review of facility documents it was determined the Governing Body failed to ensure that the Meadows followed their adopted Patient Safety Plan by ensuring that the activities of the Patient Safety Council were reported to the Governing Body, and by failing to ensure adequate housing for the population served, and by failing to ensure that the facility followed their adopted staffing guidelines.

Findings include:

Review of Meadows Hospital, Board of Advisors By-Laws, dated May , 2010, revealed "... The Governing Body of Universal Health Services hereby designates the Board of Advisors of Meadows Hospital to be the Board of Directors of Meadows Hospital ... Article VIII Administration of Hospital. 8.1. The Hospital Administrator ... 8.2 Authority and Duties: The authority and responsibility of the Administrator is granted by the Governing Body which reviews and approves all fiscal and operational activities taken for Universal as part of the duties noted below. Duties include: A. implementation, in the day-to-day operation of the Hospital, of all policies established by the Governing Body, and advising the Board and the Governing Body on the formulation of future policy; B. organizing the administrative functions of the Hospital, delegating duties, and establishing formal means of accountability on the part of subordinates through written reports, and periodic meetings with department heads and through attendance, in person or through a duly authorized representative, at departmental and inter-departmental meetings, and developing and submitting for approval of the Governing Body a plan of organization for the conduct of hospital operations and for evaluation of departmental performance in patient care and for fiscal accountability on a departmental basis ... Article X Quality of Professional Services: 10.1 Governing Body Responsibility: After considering the recommendations of the Medical Staff and other professional staffs, the Governing Body shall conduct a review and evaluation of activities on a continuing basis to assess, preserve and improve the over-all quality and efficiency of patient care in the Hospital. The Governing Body shall, within the reasonable capabilities of the Hospital, provide whatever administrative assistance is reasonable [sic] necessary to support and facilitate the implementation and the on-going operation of these monitoring and evaluation activities, including utilization review and monitoring of the quality of patient care. The Governing Body shall receive, consider, and where necessary, act upon documentation of the monitoring and evaluation activities above described and the recommendation arising therefrom and shall give such monitoring and evaluation activities due consideration ... G. that the Medical Staff and other clinical department services to implement and report activities and mechanisms for monitoring and evaluating the quality of patient care for identifying and resolving problems and identifying opportunities to improve patient care. The Board approves the Hospital Performance Improvement plan and reviews summary Quality Improvement reports from all clinical departments and services. The Board gives these activities due consideration and, as appropriate, acts upon their recommendations ... ."

Review of "The Meadows Psychiatric Center Universal Community Behavioral Health Title: Patient Safety Plan ... Date Reviewed/Revised: ... 1/10 Overview and Purpose. Attention to maintain and improving patient safety and well being is inherent in The Meadows Psychiatric Center and Universal Behavioral Health's commitment to the improvement in the quality of life to those in the community it serves. In committing ourselves to safeguarding individuals. The Meadows/UCBH must fully understand the processes and systems that are utilized by the organization to deliver patient care. From this deeper understanding, The Meadows/UCBH will be able to analyze, evaluate, develop, and implement changes that will continuously improve the way we deliver care to patients. ... The leadership of the Meadows/UCBH will keep the hospital Board of Governors apprised of any adverse outcomes, safety problems, and efforts directed at improving patient safety. ... Authority and Responsibility Board of Governors - The overall authority for direction of the patient safety improvement and management program rests with The Meadows/UCBH Board of Governors. The Board of Governors delegates its authority to implement and maintain the various components of the patient safety improvement and management program to the chief executive officer of the Meadows/UCBH. Chief Executive Officer - The chief executive officer in collaboration with administrative, managerial, and clinical staff ensures that the patient safety improvement and management program is implemented throughout the organization and integrated appropriately with other activities within the organization which contribute to the maintenance and improvement of patient safety, such as performance improvement, environment safety and risk management. The Chief Executive Officer will designate a qualified individual in the organization to manage the organization-wide patient safety improvement and management program at The Meadows/UCBH. Patient safety Officer-An individual designated by the president of the medical staff and chief executive officer who is responsible for the organization-wide patient safety improvement and management program and is accountable directly to The Meadows/UCBH Board of Governors and Chief Executive Officer. The patient safety officer will: ... Ensure compliance with sentinel event, serious event, incident, and infrastructure failure reporting requirements as mandated by law/regulations or meet accreditation standards. ... ."

Review of " Performance Improvement Plan, Reviewed 12/2009, revealed " 1.0 Philosophy: The Meadows Psychiatric Center/Universal Community Behavioral Health is dedicated to providing quality care and services for all patients in a safe, clean and therapeutic environment. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its system and processes. 2.0 Purpose The performance improvement program is designed to provide a coordinated, objective and systematic approach to organization-wide performance improvement activities. The program is based upon an integrated and collaborative approach to increase the probability of desired patient outcomes and patient safety by assessing and improving those governance, managerial, safety, clinical and support processes that most affect patient outcomes. ... 3.6 To promote patient safety and prevent untoward occurrences through systematic monitoring of the treatment environment. 4.0 Scope. The performance improvement program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care/safety and organizational functions. Data are systemically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care, patient safety, and clinical performance, whether or not problems are suspected. Assessment findings are used to study and improve the processes that affect patient care outcomes and patient safety, identify educational needs and evaluate clinical competence of employees, medical staff and health care professional affiliate staff. Organization wide performance activities include utilization management, management of information, infection control, medication use and management, safety, patient safety, risk management and quality control activities. Assessment findings are communicated to the Medical Executive Committee and the governing body at least quarterly. 5.0 Organization. 5.1 Governing Body. The Governing Body has the ultimate responsibility and authority to establish, maintain and support an effective performance improvement program. The Governing Body assures that the necessary structures are established and processes are implemented to assess and continually improve the overall quality and efficiency of patient care. It receives and acts upon recommendations regarding quality assessment and improvement activities. 5.2 Medical Staff and Management Staff. Medical staff and management staff provide leadership for actively participate in performance improvement activities and establish criteria for measuring, assessing and improving organization performance of both clinical and non-clinical processes and patient outcomes. ... Performance Improvement Committee. The Quality Council is the steering committee for the Performance Improvement Program and is responsible to oversee and accomplish the following: ... 5.3.3 Design, maintain, support and document evidence of an ongoing program to systematically measure, assess and improve patient outcomes, patient safety, and organizational performance. The program will include measures related to: ... 5.3.3.4 Monitor performance of processes that involve risk or may result in sentinel events ... 5.3.4 Receive reports of performance improvement activities from process improvement teams, committees as assigned, patient/family satisfaction surveys, staff satisfaction, and staff input regarding performance improvement activities. 5.3.5 Assure that intensive assessment is initiated when statistical analysis indicates undesirable variations in performance, when a sentinel event has occurred, when conducting a proactive safety project, or when specific clinical events have occurred (Significant adverse drug reaction, significant medication errors, or hazardous conditions) ... 6.0 Medical Staff functions ... 6.4 Safety and Infection Control Function. The Medical Executive Committee delegates the safety functions to the Environment of Care, which is responsible for measuring and assessing all aspects of the safety/Environment of Care management program. The safety officer is responsible for carrying out the functions of the safety program on a daily basis. The risk manager provides reports on data collected from risk identification reports related to environmental safety, noting any trends, significant variances from clinical practice or issues of concern relating to the safety of patients, staff or visitors in accordance with the risk management program. ... 6.6 Patient Safety. ... 6.6.6 Conduction of thorough and credible root cause analyses that focus on process and system factors whenever a sentinel event or other serious patient safety incident occurs. ... "

1) Review of Governing Body Meeting Minutes, dated February 9, 2010, May 21, 2010, August 24, 2010, and November 22, 2010, failed to reveal documented evidence of reporting of activities by the Patient Safety Council related to the reporting and analysis of serious events or infrastructure failures.

2) Review of the Minutes failed to reveal documented evidence that cross boarding activities or that the facility had exceeded their bed capacity had been reported to the Governing Body.

3) Review of staffing schedules for the month of June 1 - June 30, 2010, revealed that staff were often pulled to other units from their initial unit assigned.
For this time period, it was noted that 56 of 360 shifts were not staffed according to the facility's staffing guidelines.

Cross Reference with:

482.11 Compliance with Federal, State and Local Laws
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (b) Staffing and Delivery of Care

Based on review of facility documents and staff interviews it was determined that the Meadows failed to provide care in a safe setting by failing to provide adequate housing for the populations it serves, according to their adopted admission criteria.

Findings include:

Review of " The Meadows Psychiatric Center Written Plan of Clinical Services Children's Service. Children's Program ... Revised 1/10 ... V. Population Served. The Meadows Psychiatric Center was designed as therapeutic environment where a child and family could obtain services in a private, peaceful and secure setting. ... The Children's Program serves boys and girls between the ages of four (4) and thirteen (13). The Children's Unit is divided into A-side and B-side within one building, providing a structured and supportive community for daily living while the children participate in various therapies. The facility operates 24 hours per day and seven days a week. ..."

Review of " The Meadows Psychiatric Center Written Plan of Clinical Services Adolescent Service. Adolescent Program ... Revised 1/10 ... V. Population Served. The Adolescent Program manages adolescent boys and girls between the ages of twelve (12) and seventeen (17). The males and females are housed separately at opposite ends of the hall as feasible with current census. ..."

Review of " The Meadows Psychiatric Center Written Plan of Clinical Services Adult Program ... Revised 1/10 ... V. Population Served. The Adult Program Treatment Service at The Meadows Psychiatric Center consists of a 28-bed service located in Building D. Patients above 18 years of age are accepted for admission. ..."


Review of " The Meadows Psychiatric Center Written Plan of Clinical Services Stabilization Program ... Revised 1/10 ... V. Population Served ... Patients admitted to the Stabilization Unit must be at least eighteen (18) years of age, and suffering from severe psychiatric impairments. ... "

Review of " The Meadows Psychiatric Center Policies & Procedures Section: III Policy: # 8 Function: Provision of Care Treatment and /services Subject: Crossboarding of Patients Issued: 2/96 Revised: 1/09 I. Purpose: To define guidelines for sleeping patients on another unit during times of high census. II. Policy: All patients will be provided appropriate sleeping accommodations and bathroom facilities. III. Implementation: A. All patients will be provided appropriate sleeping accommodations and bathroom facilities. 1. Sleeping accommodations will include bed frame, mattress, sheets, blankets, and a pillow. 2. Patients will have access to bathroom facilities including a sink, toilet, and shower/tub. B. Patients may be assigned sleeping accommodations and bathroom facility in another patient building. 1. Patient will room with a patient of same gender and appropriate age. 2. Patients attend all programs and activities on their home unit. 3. Staff will escort patient(s) from their home unit to the sleeping unit with Kardex, medication sheets, identification picture, medications and belongings needed for overnight stay. Patient's on AWOL Precautions who are crossboarding will be escorted by the code team. 4. On all transfers (back and forth) the charge nurse will provide a report for all patients to receiving nurse in charge. 5. Staff on the sleeping unit will document in the medical record during the time that the patient is under their care. 6. Patient ' s belongings will be secured on their home unit. C. A hospital safe room may be used as a patient room on a temporary emergency basis only, on the condition that the patient can be transferred to a regular patient room within twenty-four (24) hours. Must be approved by the Unit Nurse Manager/Supervisor. D. One safe room will be kept open in each building at all times for uses as a safe room only. E. Patients considered for sleep over will be carefully evaluated and meet the following criteria: Adolescents to sleep on Children's unit should be female. Adolescents to sleep on Adult unit should be male. Adults to sleep on Adolescent unit should be female. Patients will have been on the unit for 3 or more days or may sleep over at the direction of the physician. Decision to be made during regular hours if at all possible. Identify patients on Friday for potential sleep over during weekend. Must be off checks for self harm. History of being a perpetrator will be evaluated. Preference is given to patients who are willing to move. The attending physician/MOD must be notified and an order given and documented to sleep the -patient on another unit. Order will be obtained to discontinue sleepover status as appropriate. Any exceptions to the policy should be decided by the CEO, the Medical director, and the Director of Nursing. "
This was the policy in effect for crossboarding until October 2010.

1) Review of the crossboarding data revealed that from June 1, 2010 to November 24, 2010 the facility crossboarded patients 1,334 times. A sample month was reviewed and from June 1 through June 30, 2010, the Meadows crossboarded patients 202 times.
32 patients admitted to the Adult Unit slept on the Stabilization Unit;
Nine patients admitted to the Stabilization Unit slept on the Adult Unit;
34 patients admitted to the Adolescent Unit slept on the Adult Unit;
27 patients admitted to the Childrens Unit slept on the Adolescent Unit;
74 patients admitted to the Adult Unit slept on the Adolescent Unit;
27 patients admitted to the Adolescent Unit slept on the Childrens Unit.

2) An interview was conducted with EMP2, on December 21, 2010, at 11:00 AM, "We do not have specific criteria for unit other than age".

3) A interview was conducted with EMP1, on November 18, 2010, at 9:20 AM, " We did run over our bed capacity. One hundred one is our licensed bed count and for four days we were at 102."

4) An interview was conducted with EMP6 on November 19, 2010, at approximately 2:00 PM, " ... We do not have adequate staffing on the Adolescent Unit. ... I feel that it is unsafe for staff and patients. When we cross-board, the staff goes with the patient. The staff is not replaced. It is a problem because if a patient wants to lay down there is no place for them. Some times it is 10:00 PM before we can take the patients to the other unit. Some times two staff will have to go, they are not replaced. There was a specific incident that really bothers me, they were sending children to the adolescent unit. The adolescent unit had two known pedophiles on the unit, that really bothered me. We have a lot of kids right now that are not to have roommates because of their sexual outbursts. I feel at times that nothing is done and they (administration) do not investigate allegations that we bring to their attention. We had an elopement in August, when the Adults were occupying building C and D. Staff was taking the patients out to smoke in the C building and a female patient walked around the corner and ran. The patient came back approximately a half hour later. We had another elopement when an adolescent ran, we had to call the State Police to find them. The patient went to someone's house and called their family. The patient was gone for a couple of hours."


Cross Reference with:
482.11 Compliance with Federal, State amd Local Laws
482.12 Condition of Participation: Governing Body
482.21 QAPI

Based on review of facility documents and interviews with staff (EMP), it was determined that the Governing Body failed to ensure that the hospital analyzed quality indicators, which included adverse patient events, and other aspects of care (A286, A287),and failed to ensure that the governing body, medical staff, and administrative officials followed the facility's adopted Performance Improvement Plan. (A310)

Findings include:

Review of "The Meadows Psychiatric Center Universal Community Behavioral Health Title: Patient Safety Plan ... Date Reviewed/Revised: ... 1/10 Overview and Purpose. Attention to maintain and improving patient safety and well being is inherent in The Meadows Psychiatric Center and Universal Behavioral Health's commitment to the improvement in the quality of life to those in the community it serves. In committing ourselves to safeguarding individuals. The Meadows/UCBH must fully understand the processes and systems that are utilized by the organization to deliver patient care. From this deeper understanding, The Meadows/UCBH will be able to analyze, evaluate, develop, and implement changes that will continuously improve the way we deliver care to patients. ... Principles: The Meadows/UCBH patient safety plan is based on the following principles. Improvement in patient safety will not occur unless there is a commitment by The Meadows/UCBH Board of Governors and senior management and an overt, clearly defined, and ongoing effort on the part of the hospital leaders. physicians, managers and employees to sustain the organization's interest and focus on patient safety. The leadership of the Meadows/UCBH will keep the hospital Board of Governors apprised of any adverse outcomes, safety problems, and efforts directed at improving patient safety. ... Authority and Responsibility Board of Governors - The overall authority for direction of the patient safety improvement and management program rests with The Meadows/UCBH Board of Governors. The Board of Governors delegates its authority to implement and maintain the various components of the patient safety improvement and management program to the chief executive officer of the Meadows/UCBH. Chief Executive Officer - The chief executive officer in collaboration with administrative, managerial, and clinical staff ensures that the patient safety improvement and management program is implemented throughout the organization and integrated appropriately with other activities within the organization which contribute to the maintenance and improvement of patient safety, such as performance improvement, environment safety and risk management. The Chief Executive Officer will designate a qualified individual in the organization to mange the organization-wide patient safety improvement and management program at The Meadows/UCBH. Patient safety Officer-An individual designated by the president of the medical staff and chief executive officer who is responsible for the organization-wide patient safety improvement and management program and is accountable directly to The Meadows/UCBH Board of Governors and Chief Executive Officer. The patient safety officer will: Oversee the creation, review, and refinements to the patient safety improvement and management program. Coordinate and prioritize the activities of the patient safety council. Develop and implement adequate information and management systems to support the activities of the patient safety improvement and management program. Identify and secure the necessary resources to fully implement the patient safety improvement and management program. Ensure compliance with sentinel event, serious event, incident, and infrastructure failure reporting requirements as mandated by law/regulations or meet accreditation standards. Oversee the investigation of serious events and as appropriate identified incidents. ... Serve as a direct link to the Board of Governors and chief executive officer on all matters related to patient safety. Ensure that the organization conducts proactive hazard analyses. ... Hospital Employees-The Meadows/UCBH employees are responsible for actively participating in The Meadows/UCBH patient safety improvement and management program. An active participant will: Assume responsibility for identifying process or systems that could potentially lead to errors and adverse events. ... ."

Review of " Performance Improvement Plan Reviewed12/2009. 1.0 Philosophy: The Meadows Psychiatric Center/Universal Community Behavioral Health is dedicated to providing quality care and services for all patients in a safe, clean and therapeutic environment. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its system and processes. 2.0 Purpose The performance improvement program is designed to provide a coordinated, objective and systematic approach to organization-wide performance improvement activities. The program is based upon an integrated and collaborative approach to increase the probability of desired patient outcomes and patient safety by assessing and improving those governance, managerial, safety, clinical and support processes that most affect patient outcomes. 3.0 Goals and Objectives. The goal of the performance improvement program is to assure continuous and incremental performance improvement in the delivery of quality health care that is efficient and cost effective and consistent with the facility's mission. The program promotes an organization- wide commitment to continually meet and/or exceed standards in the delivery of quality and safe health care and services. The program emphasizes ongoing assessment of the dimensions of performance, including surveillance of health care delivery involving the qualifications of performance of those managing and delivering services, the outcomes of care and services delivered, the availability and utilization of support resources, facilities, staff, equipment and the environment to assure efficiency, cost effectiveness and accountability for both professional and paraprofessional staff. Objectives are: ... 3.6 To promote patient safety and prevent untoward occurrences through systemic monitoring of the treatment environment. 4.0 Scope. The performance improvement program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care/safety and organizational functions. Data are systemically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care, patient safety, and clinical performance, whether or not problems are suspected. Assessment findings are used to study and improve the processes that affect patient care outcomes and patient safety, identify educational needs and evaluate clinical competence of employees, medical staff and health care professional affiliate staff. Organization wide performance activities include utilization management, management of information, infection control, medication use and management, safety, patient safety, risk management and quality control activities. Assessment findings are communicated to the Medical Executive Committee and the governing body at least quarterly. 5.0 Organization. ... 5.2 Medical Staff and Management Staff. Medical staff and management staff provide leadership for actively participate in performance improvement activities and establish criteria for measuring, assessing and improving organization performance of both clinical and non-clinical processes and patient outcomes. They assure implementation of appropriate performance improvement activities and report the results to the Governing Body through the Medical Executive Committee and Performance Improvement Committee. ... The Medical Staff is delegated the authority and accountability necessary for the delivery and assessment of all processes that contribute to the prevention of problems and the continual improvement of the quality, appropriateness, safety, and efficiency of patient outcomes. ... Performance Improvement Committee. The Quality Council is the steering committee for the Performance Improvement Program and is responsible to oversee and accomplish the following: ... 5.3.3 Design, maintain, support and document evidence of an ongoing program to systematically measure, assess and improve patient outcomes, patient safety, and organizational performance. The program will include measures related to: ... 5.3.3.4 Monitor performance of processes that involve risk or may result in sentinel events ... 5.3.4 Receive reports of performance improvement activities from process improvement teams, committees as assigned, patient/family satisfaction surveys, staff satisfaction, and staff input regarding performance improvement activities. 5.3.5 Assure that intensive assessment is initiated when statistical analysis indicates undesirable variations in performance, when a sentinel event has occurred, when conducting a proactive safety project, or when specific clinical events have occurred (Significant adverse drug reaction, significant medication errors, or hazardous conditions) ... 6.4 Safety and Infection Control Function. The Medical Executive Committee delegates the safety functions to the Environment of Care, which is responsible for measuring and assessing all aspects of the safety/Environment of Care management program. The safety officer is responsible for carrying out the functions of the safety program on a daily basis. The risk manager provides reports on data collected from risk identification reports related to environmental safety, noting any trends, significant variances from clinical practice or issues of concern relating to the safety of patients, staff or visitors in accordance with the risk management program. ... 6.6 Patient Safety. The Patient Safety Council is responsible to the Medical Executive Committee for the following: 6.6.1 Review of major patient safety issues based on claims history, probable claims reports, incident reports trends, risk issues identified from annual assessments, and/or any other areas identified as high risk through data analysis. 6.6.2 development of corrective actions to decrease and prevent similar issues/incidents from occurring in the future. ... 6.6.6 Conduction thorough and credible root cause analyses that focus on process and system factors whenever a sentinel event or other serious patient safety incident occurs. ... "

Review of "The Meadows Psychiatric Center and Universal Community Behavioral Health Medical Staff Bylaws" dated May 21, 2010, The Bylaws stated, " ... Article IX: Committees, Section 1: Structure of the Medical Staff Committees/Functions. The Medical Staff maintains oversight of all appropriate committees/functions relative to patient care ... The Patient Safety Council, Environment of Care Committee, and Performance Committees are held as separate committees reporting to the Medical Executive Committee ... ."

A review of "The Meadows Psychiatric Center Management of Environment of Care Plan. A. Overview. I. Purpose. The purpose of the Management of the Environment of Care Plan is to provide a safe environment free of hazards for patients, employees and visitors by monitoring the hospital environment. For this function to operate, the hospital leadership and administration, with support from the Governing Body, plan for the design of this program. ... Performance standards have been developed to measure member and organization effectiveness in the application of this plan. Through the functions of the EOC Committee, Performance Improvement/Risk Management Committee, Patient Safety Council and other processes, information gathered to evaluate the effectiveness of the program, provide a reporting mechanism to Medical Staff and Governing Body, and continue a cycle of organization improvement for the Environment of Care. The Safety Program includes the reporting and review of all incidents, injuries and safety hazards. II. Scope. The EOC Plan encompasses all functions and departments of the hospital in order to minimize, eliminate or control events that have adverse safety effects on patients, employees, visitors and property. The program will identify and resolve the hazards associated with the operation of the facility, ensure activities are comprehensive and coordinate and appropriately report and disseminate information. III. Objectives. To provide written plans for each of the seven elements of managing the EOC, Which include ICES Information Collection Evaluation System. > Maintain a system for reporting and investigating all incidents involving patient, employees, visitors, occupational illness and property damage. ... A. Governing Body - has the final authority and ultimate responsibility for providing resources and support systems for EOC Plan. B. Hospital Administration- The CEO, through the management and administrative staff, will provide support for the establishment and maintenance of EOC Plan. C. Safety Officer-Will be responsible for the following: 1. Authority to take corrective action when a hazardous condition exists that could result in personal injury to patients, visitors, employees, medical staff or damage to equipment and buildings. 2. Provide a safe environment for patients, employees and visitors by systematically monitoring the hospital environment. ... V. EOC Committee. The purpose of the EOC Committee is to identify, evaluate and when possible, correct/eliminate potential risks exposures for patients, employees and visitors. Functions: > Review, monitor and evaluate patient, employee and visitor safety incidents and provide recommendations for resolution and follow up on incident trends. ... ."

Review of "The Meadows Psychiatric Center Universal Community Behavioral Health Title: Patient Safety Plan ... Date Reviewed/Revised: ... 1/10 Overview and Purpose. Attention to maintain and improving patient safety and well being is inherent in The Meadows Psychiatric Center and Universal Behavioral Health's commitment to the improvement in the quality of life to those in the community it serves. In committing ourselves to safeguarding individuals. The Meadows/UCBH must fully understand the processes and systems that are utilized by the organization to deliver patient care. From this deeper understanding, The Meadows/UCBH will be able to analyze, evaluate, develop, and implement changes that will continuously improve the way we deliver care to patients. ... Principles: The Meadows/UCBH patient safety plan is based on the following principles. Improvement in patient safety will not occur unless there is a commitment by The Meadows/UCBH Board of Governors and senior management and an overt, clearly defined, and ongoing effort on the part of the hospital leaders. physicians, managers and employees to sustain the organization's interest and focus on patient safety. The leadership of the Meadows/UCBH will keep the hospital Board of Governors apprised of any adverse outcomes, safety problems, and efforts directed at improving patient safety. ... ."


1) Review of the Patient Safety Council Meeting Minutes, dated June 30, 2010, July 27, 2010, August 18, 2010, September 15, 2010, and October 20, 2010, failed to reveal documented evidence of review or analysis of serious events, incidents, or infrastructure failures.

Review of Performance Improvement Meeting Minutes, dated June 16, 2010, July 21, 2010, August 18, 2010, September 15, 2010, October 20, 2010, November 17, 2010, and December 15, 2010, revealed risk management incident analysis and/or risk management report for sexual allegations. Review of the "action" section of the minutes, revealed "continue to monitor" and either report monthly or report quarterly.

Review of Environment of Care Committee Meeting Minutes, dated May 25, 2010, June 29, 2010, July 27, 2010, August 31, 2010, September 28, 2010, and October 28, 2010, failed to reveal documented evidence that all incidents were reviewed by the Environment of Care Committee. A standing report in the meeting minutes included Risk Management. Discussion under each month stated either nothing to report or no incidents to report. The action for each of the months, either stated continue to report findings monthly or continue to monitor.

2) A review of Medical Executive Committee Meeting Minutes dated January 22, 2010, February 26, 2010, March 26, 2010, April 23, 2010, May 28, 2010, June 25, 2010, July 23, 2010, August 27, 2010, September 24, 2010, and October 22, 2010, failed to reveal documented evidence that performance improvement activities were reported to the Medical Executive Committee as stated in the facility's Performance Improvement Plan, or evidence that the Patient Safety Council and the Environment of Care Committee reports their activities to the Medical Executive Committee.

Interview with EMP7, on December 21, 2010, stated that Performance Improvement Committee reports go to the Medical Director, and that they [EMP7] do not report Performance Improvement Committee activities to the Executive Committee.

Interview with EMP8, on December 21, 2010, revealed that they record the minutes for Medical Executive Committee, and is not aware of a Performance Improvement Committee report going to the Medical Executive Committee.

Interview with EMP9, on December 21, 2010, revealed that the Environment of Care Committee Meeting Minutes go to only the Governing Board.

Cross Reference with:
482.11 Compliance with Federal, State, Local Laws
482.12 Condition of Participation: Governing Body
482.13 (c) (2) Patient Rights: Care in Safe Setting

Based on review of facility documents and interviews with staff (EMP), it was determined that the facility failed to follow adopted staffing guidelines for 56 of 360 shifts.

Findings:
" The Meadows Psychiatric Center Policies and Procedures, Function: Care Of The Patient, Subject: Staffing/ Nursing Care " dated April 2010, The policy stated, " ... III. Implementation A. Nursing care is provided by a team of registered nurses, licensed practical/vocational nurses and mental health technicians with specialized training to meet the needs of the population(s) being served ... B. Nursing care is provided by sufficient numbers of nursing staff members to meet the identified needs of the patients/family members twenty-four hours a day. Scheduling the program assignment of nursing personnel is anticipated and based on the identified needs of the patient population and professional qualifications of nursing staff members. Staffing grids are used as a guideline. Utilization is at the discretion of Supervisors, UNM [Unit Nurse Manager], and DON [Director of Nursing]. C. The Unit Nurse Manager and or/charge nurse will evaluate patient needs and make appropriate adjustments to the number of nursing care personnel to improve delivery of optimal patient care. Nursing supervisors are assigned during the evening, night, and weekend shifts adjust staffing in accordance with changing patient needs. "


1) A review of staffing schedules for the month of June 1 - June 30, 2010, revealed that staff were often pulled to other units from their initial unit assigned. A total of 360 shifts for all four units were documented from June 1 - June 30, 2010. 56 shifts were not staffed according to the facility's staffing guidelines.

2) An interview was conducted with EMP2, December 21, 2010, at 11:00 AM. EMP2 was queried regarding staffing on the Children's, Adolescent, Adult, and Stabilization Units. A review of staffing schedules for the month of June 1 - June 30, 2010, was conducted with EMP2. EMP2 confirmed that the facility failed to follow their staffing grid for 56 of 360 shifts. EMP2 confirmed staffing requirements for each unit are based on census. Staff guidelines were inclusive for each unit: Registered Nurse(s), Licensed Practical Nurse(s), Mental Health Technician(s)(MHT(s)), Mental Health Technician II (s)(MHT2(s), and a day shift secretary.

Cross Reference with:
482.12 Condition of Participation: Governing Body