HospitalInspections.org

The hospital failed to ensure the Condition of Participation: CFR 482.13 Patient's Rights was met as evidenced by:

A122- Failed to ensure 1 patient's (#3) grievances were reviewed and investigated within the time frames specificied by the facility policy and 2 of the patient's grievances were allegations of abuse.

A123 - Failed to ensure 1 patient (#11) had received written notice of the steps taken and resolution of his/her written grievance.

A145- Failed to ensure: 1) all allegations of abuse, neglect or mistreatment were investigated in a timely and thorough manner for 1 patient (#3); 2) incidents of potential abuse, neglect or mistreatment were reported to the state agency for 1 patient (#13); and 3) substantiated incidents of staff abuse, neglect or mistreatment by staff (Psychiatric Nurse Assistant) (PNA) #s 3 and 4) and Licensed Nurse (LN) #s 1 and 2) against patient (#s 2, 7, 14) had appropriate corrective, remedial and/or disciplinary action implemented.

A167 - Failed to ensure seclusion was implemented for 1 patient (#7) per the facility's policy.

A168- Failed to ensure a Time-Out that became seclusion for 1 patient (#7), had physician orders for implementation.

The cumulative effect of these systemic problems resulted in failure of the facility to ensure patients were receiving quality care in a safe manner that promoted the rights of the patients and afforded them due process.
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Based on record review, interview and policy review the facility failed to ensure 1 patient's (#3) grievances were reviewed and investigated. This failed practice denied the patient due process and having concerns about staff mistreatment addressed in a timely manner. Findings:

Record review on 8/16-17/17 revealed Patient #3 was admitted to the facility with a diagnosis that included Schizophrenia.

During an interview on 8/17/17 at 12:40 pm - 1:00 pm, Recovery Support Specialists (RSS) #'s 1 and 2 were asked for their log or list of patient grievances. RSS #1 said there was a log, but it was not current. He/she continued to say that there was a stack of written grievances in their office that had not been documented in the grievance log.

Review of the stack of unlogged written grievances revealed Patient #3 had written 3 separate grievances/complaints.

During the interview, RSS #1 was asked if there were any grievances or complaints from Patient #3. RSS #1 stated, "No, I don't think so. That name does not ring a bell." After showing RSS #1 Patient #3's written grievances/complaints, he/she disclosed he/she had not seen them and confirmed they had not been reviewed or investigated. The 3 written grievances/concerns were:

1. Dated 5/31/17 at 3:04 pm revealed, Patient #3 wrote "Too much abuse observed which are done by API staff...";

2. Dated 6/1/17 at 8:45 pm revealed, "...[another Patient's name]...located on [a unit] was left to suffer through agonizing pain with no emergency services/911 called...she is vomiting and shivering with gnashing teeth in obvious pain..."; and

3. Dated 6/2/17 at 6:45 am, revealed Patient #3 had concerns regarding his/her admission.

During the interview on 8/17/17 at 12:40 pm - 1:00 pm RSS #'s 1 and 2 stated patients can call, fill out a complaint form (located on the units), and/or verbally tell staff to file grievances for them. RSS #1 stated since starting his employment last May, he/she had not been able to keep up with a log tracking the patients' grievances and resolutions.

RSS #1 was unable to provide evidence Patient #3's grievances had been investigated, 2 of which were allegations of abuse/and or neglect.

Review of the facility's policy and procedure "No: PRE 030-03", dated 8/15/16, revealed "...LEVELS OF RESPONSE TO GRIEVANCES...an RSS, NSS or designee will...immediately report to the Chief Executive Officer (CEO) or designee any grievance that alleges abuse, neglect or serious staff misconduct...See to resolve with the patient...(immediately or within three business days)."


Review of the facility's policy and procedure "No: PRE 030-03", dated 8/15/16, revealed " ...LEVELS OF RESPONSE TO GRIEVANCES...an RSS, NSS or designee will...immediately report to the Chief Executive Officer (CEO) or designee any grievance that alleges abuse, neglect or serious staff misconduct...See to resolve with the patient...(immediately or within three business days)."

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Based on record review, interview and policy review the facility failed to ensure 1 patient (#11) had received written notice of the steps taken and resolution of his/her written grievance. This failed practice denied the patient written knowledge of the steps and actions taken on his/her behalf. Findings:

Review of a stack of written grievances with Recovery Support Specialist (RSS) #'s 1 and 2 on 8/17/17 revealed Patient #11 had filed a written grievance with the facility.

Review of the grievance written by Patient #11, dated 4/17/17, revealed "I got attacked by one of the staff ... [he/she] pushed me twice for no reason..."

During an interview on 8/17/17 at 12:40-1:00pm, RSS #'s 1 and 2 were asked to provide a copy of the letter sent to Patient #11 notifying him/her of the facility's resolution, RSS #1 was unable to provide it. Furthermore RSS #1 stated the facility had not had an RSS in place for 4 months prior to him/her (RSS #1) starting the job in May.

Further review of the same policy revealed, "...If attempted resolution takes longer than seven (7) days, the patient, or individual acting on patient's behalf, will be informed of the need for additional time. The written response is due no later than fourteen (14) business days post receipt of grievance."
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Based on record review, interview and policy review the facility failed to ensure: 1) all allegations of abuse, neglect or mistreatment were investigated in a timely and thorough manner for 1 patient (#3); 2) all incidents of potential abuse, neglect or mistreatment were reported to the state agency for 1 patient (#13); and 3) substantiated incidents of staff abuse, neglect or mistreatment by staff (Psychiatric Nurse Assistant) (PNA) #s 3 and 4) and Licensed Nurse (LN) #s 1 and 2) against patients (#s 2, 7, 14) had appropriate corrective, remedial and/or disciplinary action implemented. These failed practices placed vulnerable patients at risk for delayed investigations, further abuse or neglect, delayed responses to identified concerns, lack of supervision of staff and no state agency oversight. Findings:

Record review was from 8/16-31/17.

Investigation

Record review revealed Patient #3 was admitted to the facility with a diagnosis that included Schizophrenia.

During an interview on 8/17/17 at 12:40 pm -1:00 pm, Recovery Support Specialists (RSS) #'s 1 and 2 were asked for their log or list of patient grievances. RSS #1 said there was a log, but it was not current. He/she continued to say that there was a stack of written grievances in their office that had not been documented in the grievance log.

Review of the stack of unlogged written grievances revealed Patient #3 had written 3 separate grievances/complaints.

During the interview, RSS #1 was asked if the RSS had any grievances or complaints from Patient #3. RSS #1 stated, "No, I don't think so. That name does not ring a bell." After showing RSS #1 Patient #3's written grievances/complaints, he/she disclosed he/she had not seen them and confirmed they had not been reviewed or investigated. The 3 written grievances/concerns were:

1. Dated 5/31/17 at 3:04 pm revealed, Patient #3 wrote "Too much abuse observed which are done by API staff..."

2. Dated 6/1/17 at 8:45 pm revealed, "... [Another Patient's name]...located on [a unit] was left to suffer through agonizing pain with no emergency services/911 called...she is vomiting and shivering with gnashing teeth in obvious pain..." and

3. Dated 6/2/17 at 6:45 am, revealed Patient #3 had concerns regarding his/her admission.

During the interview on 8/17/17 at 12:40 pm - 1:00 pm RSS #'s 1 and 2 stated the patients can call, fill out a complaint form (located on the units) and/or verbally tell staff to file grievances for them. Furthermore, RSS #1 stated since starting in May, he/she had not been able to keep up with a log tracking the patients' grievances and resolutions.
RSS #1 was unable to provide evidence Patient #3's grievances, 2 of which were allegations of abuse/and or neglect, had been investigated.

Review of the facility's policy and procedure "No: PRE 030-03", dated 8/15/16, revealed "...LEVELS OF RESPONSE TO GRIEVANCES...an RSS, NSS or designee will...immediately report to the Chief Executive Officer (CEO) or designee any grievance that alleges abuse, neglect or serious staff misconduct...See to resolve with the patient...(immediately or within three business days)."

Further review of the same policy revealed, "...If attempted resolution takes longer than seven (7) days, the patient, or individual acting on patient's behalf, will be informed of the need for additional time. The written response is due no later than fourteen (14) business days post receipt of grievance."

Report Patient Neglect Incident

Record review on 8/24/17 revealed Patient #13 was admitted to the facility with a diagnosis that included neurodevelopmental disorder with fetal alcohol effects. The Patient was admitted to the unit with close observation status scale (COSS) 1st degree (Patient is to be checked every 15 minutes x 24 hours, and noted on the patient safety checklist).

Review of a facility unusual occurrence report revealed an incident which occurred on 8/4/17 at 2200 (10:00 pm). Patient #13 was found sitting in a corner in his/her room with blood oozing from a self-inflicted laceration on his right upper arm, "possibly due to a punctured or lacerated Basilic vein. Patient conscious and coherent but pale ...It also appear that the patient may have banged the back of [Patient] head against the wall as some blood were present on the wall and on [Patient] head...the patient was transported to the ED at around 2225 [10:25 pm]."

Review of the locator checks on the patient safety checklist, dated 8/4/17, revealed Patient #13 was checked every 15 minutes on 8/4/17, including the time of the incident.

During an interview on 8/24/17 at 12:45 pm, the Quality Improvement Coordinator (QIC) said the verification of the 15 minute locator checks were reviewed by video. The documentation of the 15 minute locator checks on the patient safety checklist did not match what was seen on the video. The QIC said the 15 minute locator checks were falsified by the staff doing the checks. The Patient was not checked every 15 minutes. The times missed between checks ranged from 16 minutes up to 83 minutes.

Review of the State survey agency's facility reported incidents log revealed a report regarding the neglect of Patient #13 had not been reported to the State agency.

Disciplinary, Remedial, and/or Reeducation Action Did Not Occur

PNA #3

Record review on 8/17/17 revealed Patient #7 had diagnoses that included schizophrenia and a history of traumatic brain injury.

Review of the State agency's facility's report of harm, dated 4/14/17, revealed a facility incident report of an allegation by PNA #3, which occurred on 4/12/17. The incident was reviewed on video by the Safety Officer/Risk Manager and the State survey team. The allegation stated PNA #3 restrained and escorted Patient #7 to the Oak Room (seclusion room). PNA #3 was observed preventing the Patient from leaving the seclusion room. After the second event of the PNA pushing the Patient, the Patient could be heard on audio/video yelling at the PNA #3 "Stop hitting me, stop hitting me." During the Patient's time in the seclusion room Patient #7 urinated on the floor, due to the fact he/she was prevented from the leaving the seclusion room. Further review revealed the abuse towards Patient #7 was substantiated.

Review of the medical record revealed no evidence Patient #7 had a physician's order or assessment for seclusion.

Record review on 8/16-31/17 revealed a letter of warning (LOW), dated 6/14/17, was given to PNA #3 by the Interim CEO through the Assistant Director of Nursing. The LOW revealed "...determined that the allegations were substantiated and discipline is warranted...I am also directing you to attend a 1:1 session with the API Safety officer to review the differences between and protocols relating to time outs and seclusions; and continue with your weekly sessions with your clinical supervisor for the next six months." further review revealed no evidence of the weekly sessions with a clinical supervisor"

Review of PNA #3's record on 8/17/16, revealed no evidence the PNA had received any weekly supervision visits with a supervisor after the abuse and illegal restraint had been substantiated by the facility.

During an interview on 8/16/17 at 3:30 pm, when asked about the discipline and education of nursing staff, the Director of Nursing replied, the supervision was assigned to the clinical lead and she was "out of the loop."


Review of an email, dated 8/22/17 at 10:51 am from the Director of Nursing to the Safety Officer/Risk Manager, revealed the weekly supervision had not started for PNA #3.

Review of an email, dated 8/22/17 at 2:16 pm from the Director of Nursing to LN #1 and the Assistant Director of Nursing Cc'd, revealed "[PNA #3] will receive weekly clinical supervision for a period of six months. The clinical supervisor will provide Quality Improvement Coordinator/Safety Officer with a supervision plan; the clinical plan supervisor will provide written documentation of the clinical supervision, documentation the review of events, restraints and seclusions, assaults that occur; discussions of de-escalation techniques; discussions of specific patients and their illness, learning about symptoms, manifestations, treatment modalities, etc. Copies of the clinical supervisor notes will be provided to Quality Improvement Coordinator/Safety Officer for review on a monthly basis."

PNA #4

Record review revealed Patient #2 had diagnoses that included Autism spectrum disorder (a developmental disorder that affects a wide range of skills, symptoms, and disabilities) and mild-moderate retardation. The Patient had been discharged and readmitted to the facility several times.

Review of an incident occurrence, dated 12/24/16, revealed PNA #4 was providing 1:1 observation for Patient #2. During the incident the Patient had aggressive behavior towards PNA #4. When the "Patient dropped the chair and fell to the floor...[PNA #4] charged at the Patient, tackling the patient to the ground. While restraining the Patient [PNA #4] pulled the Patient's hair, and moments later, during the fluid restraint, [PNA #4] right arm ended up around the Patient's neck and the Patient was placed briefly in a choke hold. [PNA #4] did not follow [his/her] training, physically responded to the patient when having other options."

Further review revealed the use of more force than necessary against Patient #2, by PNA #4, was substantiated by the facility.

PNA #4 returned to work on 1/28/17. Review of a letter revealed PNA #4 was to receive clinical supervision for at least 1 year with a clinical supervisor and meet regularly with his/her clinical supervisor for a mininum of 30 minutes per supervision session.


Review of the "2015 Supervision Log", provided as evidence of PNA #4's supervision, revealed the PNA had supervisory visits, following the incident, conducted by LN #1 on 1/2/17; 1/7/17; 1/19/17; 1/21/17; and 2/2/17.


No further information regarding PNA #4's supervisory visits since 2/2/17 was provided prior to the exit on 8/31/17.

LN #1

Review of the State agency's facility's report of harm, on 4/14/17, revealed a facility incident report of an allegation, by LN #1, of abuse/neglect/exploitation/serious staff misconduct, dated 4/12/17. This incident was the same one that PNA #3 was involved in. The incident was reviewed on video by the Safety Officer/Risk Manager and the State survey team. The allegation stated the LN #1 instructed Patient #7 to clean up her/his own urine from the Oak Room (seclusion room) and gave the Patient a towel to use to clean her/his urine. Patient #7 was not given any gloves or booties to cover his slippers when he/she was stepping on the towel to clean the urine off the floor. At no time was the Patient offered any help from the staff to assist in cleaning up the urine. The allegation of abuse was substantiated against LN #1. The facility's report stated LN #1 had received a letter of instruction (LOI) and resigned from API.

Observation on 8/16/17 revealed LN #1 was currently working as a clinical lead with patients on 1 of the patient care units.

During an interview on 8/16/17 at 9:50 am, LN #1 stated he/she was "clinical lead" and "nurse manager" and functioned as the "charge nurse" in the morning.

Record review revealed LN #1 was a lead nurse on one of the units. There was no documentation found of the LN's LOI or any education, training or employee supervision after the allegation of abuse was substantiated against LN #1.

During an interview on 8/23/17 at 12:45 pm, the Quality Improvement Coordinator (QIC) was asked about LN #1 LOI for the 4/12/17 incident. The QIC said there was no Letter of Instruction or Letter of Warning given to LN #1 for the 4/12/17 incident, but there should have been. The QIC stated that a letter was now being drafted (in process) for the 4/12/17 incident that LN #1 was involved in.

LN #2

During an interview on 8/16/17 at 2:14 pm -2:45 pm, the Safety Officer (SO) stated the facility had substantiated LN #2 spit and yelled at Patient #14, 2 years ago (December 2013). The SO stated although the abuse was substantiated and although LN #2 was initially fired, the facility had to hire him/her back last year.

During an interview on 8/24/17 at 9:00 am, the Quality Improvement Coordinator was asked for any retraining, action plans or oversight of LN #2 and PNA #4 after they were reinstated at the facility.

The facility did not provide any information to the State survey agency prior to exit on 8/31/17.

Review of the "Notice of Rights and Responsibilities" provided to patients on admission, last dated 8/17, and revealed "1. Receive personal dignity and services considerate and respectful of personal value and beliefs...8. To receive care in a safe setting...12. To be free from restraints or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff."

Review of the facility's policy, "Conduct Involving Patients", dated 8/15/17, revealed "All known or suspected incidents and all complaints of abuse, neglect, and other serious misconduct by API employees, student interns, or contractors towards patients must be reported and investigated...Physical abuse includes, but is not limited to: a. hitting, slapping, kicking, pinching, shoving, spitting on, or beating a patient; b. depriving a patient of a needed medical services or treatment, necessary biological needs...c. using more force than is reasonable for a patient's control, treatment, or management...d. the improper or illegal restraint or seclusion of a patient...4. Emotional abuse includes humiliation of a patient and threats of corporal punishment."







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Based on record review, video review, interview and policy review the facility failed to ensure seclusion was implemented for 1 patient (#7) per the facility's policy. Specifically, facility staff implemented a Time-Out (a voluntary seclusion) that became seclusion for the patient (involuntary seclusion) when the facility staff denied the patient the right to exit the room. This failed practice caused the patient to be illegally detained in seclusion and created a risk for psycological harm. Findings:

Record review on 8/16-17/17 revealed Patient #7 was admitted to the facility with diagnoses that included Schizophrenia (a brain disorder that causes on to suffer delusions and/or hallucinations) and Post Traumatic Brain Injury.

Record review on 8/16/17 revealed the facility had conducted an investigation of an incident that occured on 4/12/17 with Patient #7.

Review of the 4/12/17 incident on the video, on 8/16/17 with the Safety Officer, revealed Patient #7 was observed launching across the nursing desk and then being escorted to the seclusion room (Oak room-a room with a bed, no windows, and a secure door capable of being locked) by PNA #3. The Patient was placed in the room and the door was left unlocked. During the review the Patient was observed attempting to exit the room 3 times. All 3 times the PNA prevented the Patient from exiting the room by pushing the Patient back into the room, the PNA then forcfully closed the door. At one point the Patient briefly looked around and voided in the corner. The seclusion lasted almost 15 minutes.

Review of the "Seclusion & Restraint Initial Order Activity" revealed no physician's order for Patient #7 being placed in seclusion that day.

During an interview on 8/16/17 at 9:50 am, Licensed Nurse #1 stated only a nurse could initiate seclusion or a restraint.

During an interview on 8/16/17 at 3:30 pm, when asked about the incident, the Director of Nursing (DON) stated the Time-Out is voluntary and the patient needs to feel they can leave the room. The DON stated the incident with Patient #7 (on 4/12/17) should have been treated as seclusion.

Review of the facility policy "Seclusion and or Restraint Time-Out, Patient Safety Equipment (PSE)", effective date 8/15/16, revealed "Seclusion: The involuntary confinement of a patient alone in a room or in an area whereas he/she is physically prevented from leaving that room or area. The room or area may be locked or unlocked..."

"Time-Out: A voluntary procedure used to assist the patient to regain emotional control..When a patient is physically prevented from leaving the Time-Out, or given the impression that they are no longer allowed to leave the intervention is no longer a Time-Out and instead becomes seclusion."

"The following applies to any use of physical or mechanical restraint(s) or seclusion...Seclusion or physical or mechanical restraint will be documented on appropriate hospital forms."
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Based on record review, video review and interview the facility failed to ensure a Time-Out that became seclusion for patient #7, had physician orders for implementation. The failed practice placed the patient in seclusion without an order and denied the patient oversight of a providers care. Findings:

Record review on 8/16-17/17 revealed Patient #7 was admitted to the facility with diagnoses that included Schizophrenia (a brain disorder that causes on to suffer delusions and/or hallucinations) and Post Traumatic Brain Injury.

Record review on 8/16/17 revealed the facility had conducted an investigation of an incident that happened to Patient #7 on 4/12/17.

Review of the 4/12/17 incident on video on 8/16/17 with the Safety Officer, revealed Patient #7 was observed launching across the nursing desk and then being escorted to the seclusion room (Oak room-a room with a bed, no windows, and a secure door capable of being locked) by PNA #3. The Patient was placed in the room and the door was left unlocked. During the review the Patient was observed attempting to exit the room 3 times. All 3 times the PNA prevented the Patient from exiting the room by pushing the Patient back into the room, the PNA then forcefully closed the door. At one point the Patient briefly looked around and voided in the corner. The seclusion lasted almost 15 minutes.

Review of the "Seclusion & Restraint Initial Order Activity" revealed there was no physician or nursing order for Patient #7 being placed in seclusion that day.

During an interview on 8/16/17 at 3:30 pm, when asked about the incident, the Director of Nursing (DON) stated the Time-Out was considered voluntary and the patient needs to feel they can leave the room. The DON stated the incident (on 4/12/17) should have been treated as seclusion.

Review of the facility policy "Seclusion and or Restraint Time-Out, Patient Safety Equipment (PSE)", effective date 8/15/16, revealed "Seclusion: The involuntary confinement of a patient alone in a room or in an area whereas he/she is physically prevented from leaving that room or area. The room or area may be locked or unlocked..."

Review of the facility's procedure flow chart, "RN & LIP [licensed independent practitioner] Documentation & Monitoring", revised 3/22/12, revealed "At initiation of ES/R [go to] LIP written or [Telephone] order..."
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Based on interview, meeting minutes review and policy review the facility failed to have an adequate number of licensed nurses (LN) and psychiatric nurse assistants (PNA) available to meet the needs of the patients. This failed practice placed staff at risk for injury and/or burnout and placed patients at risk for abuse and/or neglect. This had the potential to effect all patients residing in the facility. Findings:

During an interview on 8/16/17 at 9:40 am, LN #1 stated staffing was a "big problem" at the facility and LN and PNAs were frequently mandated to work mandatory overtime. During the interview the LN stated some patients require closer monitoring because of their behaviors. LN #1 stated the staff can work 12 hour shifts, 14 hour shifts and/or 8 hour shifts.

During an interview on 8/16/16 at 10:00 am, PNA #3 stated 1 patient in the facility had assaulted 24 different staff and some of the staff were currently out on medical leave.

During an interview on 8/16/17 at 10:45 am, PNA #5 stated some facility staff work 12 hours and some work 8 hours. The PNA stated staff frequently end up working overtime.

Review of the list overtime hours provided by the facility for the pay period ending 7/15/17 and 7/31/17 revealed several PNAs and LNs had worked upward of 20 hours to 135 hours beyond their regularly scheduled hours in the approximate 2 week time period.

During a telephone interview on 8/22/17 at 10:10 am, Physician #1 stated the facility was often short staffed on the weekends. The Physician stated poor scheduling had contributed to some staff working 100 hours of overtime. During the interview, Physician #1 stated about 3 weeks ago, when there was not enough staff to help, a staff member was assaulted by a patient.

Review of the Safety Committee Meeting, dated 1/18/17, revealed "Staff asleep during working." The "Discussion" was Staff who work NOC [night] shift are falling asleep when staff need to be alert and attentive to the patient;s and support one another's safety, and the safety of patients, is critical to the culture of safety." The "Action", revealed "...Discussion on how staff coverage may be affecting staff falling asleep when staff is working multi staff (14-16 [hour] shift s mandatory). Option: staff should be restricted when taking on extra shifts like every other day not every day."

Review of the Safety Committee Meeting minutes dated 4/19/17, "Discussion about Susitna; Discussion about the fact staffing is too low with only three nurses and three PNA staffing."

Review of the Safety Committee Meeting minutes, dated 8/2/17, revealed "Discussion about Susitna; Discussion about the fact staffing is to low with only three nurses and three PNA staffing."