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Based on medical record review, policy review and staff interview, the facility failed to obtain vital signs as ordered for one of one patient medical records reviewed with orders for vital signs every shift (Patient 4) and failed to ensure consults were completed per policy for two (Patient 23 and 14) of 30 medical records reviewed. The total census at the time of the survey was 228 patients.

Findings include:

1. The medical record for Patient 4 was reviewed on 08/13/13 and revealed the patient was admitted to the facility on 09/30/10 with diagnosis of schizoaffective paranoid type. The most recent comprehensive recovery treatment plan completed on 07/25/13 identified hypertension as a problem and directed daily monitoring of vital signs. The intervention ordered Patient 4 to have vitals monitored and documented Q shift.

On 08/13/13 at 10:39 AM Staff B revealed there are three shifts that run from 7:30 AM-3:30 PM, 3:30 PM-11:30 PM and 11:30 PM-7:30 AM. Staff B confirmed, per the above noted treatment recovery plan, Patient 4 was to have his/her vital signs, including pulse oximetry, taken three times a day.

Review of the corresponding flow sheets for the period of time beginning 07/25/13 and ending 08/12/13 lacked evidence of vital signs being completed more than twice a day. For the 16 days reviewed, Patient 4 had 32 documented instances of vital signs recorded in the medical record instead of 48 (3 times a day x 16 days).

Staff B and Staff F (nurse manager) confirmed this finding on 08/13/13 at 10:39 AM.

On 08/13/13 at 10:00 AM, the facility's 02.91 Shift Responsibility policy was reviewed. The policy stated nursing staff should take vital signs per policy or if the patient has unusual symptoms.





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2. The review of the medical record for Patient 23 was completed on 08/14/13 at 2:00 PM. Patient 23, a forensic patient, was admitted to the psychiatric hospital 5/23/13 with a court order for restoration to competency and a diagnosis of history of head injury resulting in dementia and seizures. Review of the medical record revealed a physician's order dated 05/23/13 for a Substance Abuse Mental Illness (SAMI) consult with the social worker. The medical record lacked documentation the SAMI evaluation was completed. In an interview with Staff L on 08/14/13 at 3:40 PM, Staff L verified this finding and stated he/she was unable to determine if the social work department ever received the order for the SAMI consult, but nonetheless the SAMI consult was not done.

3. Review of the medical record for Patient 14 was completed on 08/14/13. Patient 14 was admitted to the hospital on 06/13/13. The diagnoses on admission included Psychosis, Mood Disorder, Alcohol and PCP Dependence. On 06/13/13, the interdisciplinary treatment plan recommended for Patient 14 to be placed in the substance abuse and mental illness (SAMI) program. The substance abuse and mental illness assessment was not completed until 08/06/13.

Interview with Staff C on 08/14/13 at 1:55 PM revealed the SAMI counselors had not received the initial referral, after the initial recommendation by the treatment team on 06/13/13.

On 08/15/13 at 10:00 AM, the hospital's policy entitled 02.17A - SAMI Services Substance Abuse/Mental Illness Services Integrated Dual Diagnosis Treatment was reviewed. The policy stated, "Once a referral is sent to SAMI Services, the assessment is to be completed within 3 business days - for civil patients and 10 business days for forensic patients."

Based on medical record review, staff interview and review of facility policy, the facility failed to complete the recovery service plan (care plan) in a timely manner, to ensure it encompassed all current patient problems and that all recovery team members participated in the development of the plan. This affected one of four medical records reviewed for care plans on unit McKee 4 (Patient 1). The total census at the time of the survey was 228 patients.

Findings include:

The medical record for Patient 1 was reviewed on 08/12/13 and revealed the patient was admitted to the facility on 07/12/13 with diagnoses of psychosis and rule out schizophrenia. Per review of the initial nursing assessment (dated 08/07/13) and physician' order (dated 07/12/13), Patient 1 was on assault precautions with 15 minute checks to be completed by staff.

Review of the corresponding "Admission Recovery Service Plan" (initial nursing care plan) failed to identify the assault precautions as a "problem" with appropriate intervention(s) and goal(s) for Patient 1. Staff B and D (registered nurse) were made aware of and confirmed this finding on 08/12/13 at 3:22 PM. At that time, Staff D stated the assault precautions should have been addressed on the initial "Comprehensive Recovery Service Plan" and confirmed this was not done.

The initial "Comprehensive Recovery Service Plan" (treatment team care plan) for Patient 1 appeared to have been initiated on 07/12/13 and was signed by the registered nurse on 07/13/13. Patient 1 signed the plan on 07/14/13, after initially refusing to do so on 07/13/13. There was no documentation to indicate the other members of the treatment team, including social worker and psychiatrist, participated in the development of the service plan or met to review the plan. The first signed comprehensive recovery plan available for review was dated 07/30/13.

Staff C (nurse manager) was interviewed on 08/12/13 at approximately 3:22 PM regarding the process for completion of the Comprehensive Recovery Service Plans. Staff C stated for newly admitted patients, the process consists of the treatment team (registered nurse, psychiatrist, social worker and patient) meeting initially within 72 hours after the patient is admitted to develop and review appropriate interventions and goals for the patient. The treatment team is then supposed to meet weekly for eight weeks then on a monthly basis for stable patients.

Staff D was interviewed at approximately 4:40 PM and confirmed there was no documented evidence the social worker and psychiatrist had participated in the initial meeting and plan development within the 72 hour required time frame.

Facility policy, 02.21A Individual Recovery Plan - Admitting and Comprehensive, was reviewed on 08/14/13. Per policy, "a comprehensive recovery service plan shall be created by the treatment team within 72 hours or two working days of admission." Members of the core recovery team include " the physician, a nurse and a social worker."

Based on observations, staff interviews and policy review, the facility failed to ensure staff followed policy and procedure for the safe handling, storage and administration of medications, including controlled substances. This affected three of three units observed. The total census at the time of the survey was 228 patients.

Findings include:

1. Observations of medication administration were started on 08/13/13 at 8:07 AM on Unit McKee 4. Upon arrival to the unit, the door to the medication room was noted to be open and Staff E (licensed practical nurse) was standing inside. Staff E was observed removing medications from the automated medication dispensing system (ADS). Following introductions, Staff E was asked to explain the process for administering "morning" medications to the patients. Staff E stated he/she "pulls" all of the scheduled medications (from the ADS) for each of the patients first.

Staff E was observed removing medications for Patient 34 from the automated system, placing them into a plastic cup, unopened, and then placing the cup inside a drawer (on one of the medication carts) labeled with Patient 34's name on it. The drawers to the two medication carts were observed to be unlocked at that time.

Staff E continued in this manner until all of the morning medications were pulled for all of the 38 patients on McKee 4 unit. Staff E then proceeded to begin dispensing medications to patients on the unit. Patients' 31-36 were observed to individually walk up to the medication window and one by one be handed their "cup" of medication(s). Staff E asked each patient his/her full name but failed to review the medication administration record (MAR) for each medication dispensed at that time. Staff E also did not sign off the medications on the MAR as they were dispensed to patients.

During the course of medication administration, Staff E was also observed to use a pill cutter multiple times in order to split pills in half. Staff E failed to clean the pill cutter between uses and at 8:32 AM returned the pill cutter, dirty, to a cupboard located above the sink.

Eight cups of prune juice were also observed, prior to the start of medication administration, on the countertop adjacent to the sink. Staff E was observed to wash his/her hands in the same sink, without awareness of the risk for splash, during the course of medication administration. All eight cups of prune juice were observed to be ingested by patients.

Prior to leaving the unit on 08/13/13 at approximately 9:50 AM, Staff E was made aware of the above noted issues. Staff E stated he/she reviewed the MAR when the medications were removed from the ADS. Staff E was noted to be signing off medications on the MAR for unit McKee 4 patients at that time.

Per review of facility policy 02.06 Administration of Oral Medications, after a medication has been removed from the ADS staff are to "recheck the label with the medication administration record." When administering medications staff are to "check the following two (2) out of three (3) identifications of patient. Picture, ID Number, Name." After individual administration, "charting on medication administration record is dome before proceeding to administer meds for the next patient."

2. Observations and tour of the medication room on unit McKee 2 were started on 08/13/13 at 2:00 PM. Upon arrival to the unit the door to the medication room was observed to be wide open. After entering the room, all of the drawers on the unlocked medication cart were opened and inspected for the presence of medication. One drawer was observed to contain two 500 milligram Depakote pills (antiseizure medication) and one 300 milligram Quetiapine pill (antipsychotic medication). Staff G (registered nurse) was asked to explain why these medications were left unattended in the drawer and stated it appeared the patient was scheduled to receive the medications at 2:00 PM but was currently off the floor for group.

At approximately 3:01 PM, the same medication room was entered again for observations with Staff G. The above noted Depakote and Quetiapine were no longer in the drawer. Upon reviewing the MAR for the patient, the 2:00 PM dose of Quetiapine had been signed off but the 2:00 PM dose of Depakote was not signed off for 08/12/13 or 08/13/13. Staff G was asked to explain this and after talking to the nurse indicated the nurse had forgotten to sign it off. Staff G was then asked to explain how one knows for certain the patient received the 2:00 PM dose of Depakote on 08/12/13 and was unable to say. Staff G confirmed Depakote had been removed from the ADS on 08/12/13 at 1:17 PM for this patient.

3. Observations of medication administration were started on unit 22E on 08/14/13 at 7:55 AM. Upon arrival to the unit the door to the medication room was observed to be closed. Staff B stated that the computers were down, including the automated dispensing systems (ADS). Staff B stated the unit was waiting on someone from the pharmacy department to come and unlock the drawers to the ADS so that medications could be passed.

At approximately 8:12 AM Staff B was asked to unlock the door to the medication room so that observations could be made. Staff H (registered nurse) was observed to be within the room and unattended with all the drawers to the ADS unlocked and open. He/she continued to pull medications from the ADS for patients based on the paper MAR (medication administration record).

At approximately 8:18 AM Staff I (registered pharmacist) arrived to the unit to assist with the medication dispensing. Together Staff H and Staff I worked to remove the "morning:" medications from the ADS, using the MAR as reference. This process continued until all of the medications had been removed for the entire unit patients scheduled to receive "morning" medications. The door to medication room remained open throughout this process, with multiple patients observed to stand directly outside of the doorway. One patient was observed to step into the room.

At approximately 9:05 AM Staff I proceeded to open the door to the cabinet on the ADS in which the controlled substances (medications) were stored. Staff I asked Staff H to get a piece of paper and record the medications that were removed. After looking at the MAR, Staff H informed Staff I that one Klonopin (antiseizure medication) for Patient 37 was needed. Staff I proceeded to remove one table of Klonopin from the cabinet. Staff H recorded this information on a blank piece of copy paper. Staff H then informed Staff I one Percocet (pain medication) for Patient 38 was needed. Staff I proceeded to remove one Percocet from the cabinet and Staff H recorded the information on the same blank piece of copy paper. Again the door to the medication room remained opened during this time.

Staff I left the unit after all of the medications had been removed from the ADS. Staff I closed the cabinet door where the controlled substances were kept. All of the remaining drawers on the ADS remained opened after Staff I left the unit.

Review of facility policy 07.09 Pharmacy Emergency Backup Plan revealed that during "short term outages campus wide" the following procedures are to be followed:

i) For (immediate) drug procurement, the Director may give permission for the ADM drawers to be opened by a staff pharmacist, allowing nursing to access medications as needed during the outage. In this case, the pharmacist will monitor and nursing will record each drug pulled on a printed Active Medication list from PCS.

ii) The UDM dispensers will NOT be opened to the nurses. Controlled medications will be dispensed one at a time to the nurse as the need for each medication arises (each pill patient-labeled in a small plastic bag), or a supply may be sent to the ward along with an accountability record.

Staff J (registered pharmacist) was present during the review of this policy on 08/14/13 at 3:02 PM. Staff J was interviewed regarding the removal of controlled medications from the ADS and confirmed the policy did not specify the pharmacist was allowed to remove them in the manner that was observed on unit 22E this morning.

Staff J confirmed the Active Medication lists had not been printed out. Staff J stated the entire system was down and he/she had to call Columbus and request someone there fax the lists to the hospital pharmacy. Staff J stated it took approximately 45 minutes for all of the lists to be faxed to the hospital. Staff J confirmed these lists were not observed being utilized on unit 22E this morning.

Staff J stated he/she felt confident that when the system was down, physicians were not writing new orders during this time period and if there were any new orders staff would know they needed to call the pharmacy with the order during the time period when the system was down.

Based on medical record review, staff interview and policy review, the facility failed to ensure physicians followed policy and procedure for the signing of telephone/verbal orders. This affected one of 30 patient medical records reviewed for orders (Patient 1).The total census at the time of the survey was 228 patients.

Findings include:

The medical record for Patient 1 was reviewed on 08/12/13. Review of the orders revealed unsigned telephone orders for the following dates: 07/19/13, 07/31/13 and 08/03/13. Policy 04.01b - Telephone and Verbal Orders read, "it is the authorized prescribers responsibility to sign, date and time the order within seventy two (72) hours."

Staff B was made aware of confirmed the above findings on 8/12/13 at approximately 3:22 PM.

Based on medical record review, staff interview and policy review, the facility failed to ensure the initial nursing assessment was completed within the required timeframe for one of 30 patient medical records reviewed (Patient 1). The total census at the time of the survey was 228 patients..

Findings include:

The medical record for Patient 1 was reviewed on 08/12/13 and revealed the patient was admitted to the facility on 07/12/13 with diagnoses of psychosis and rule out schizophrenia. The initial nursing assessment appeared to have been completed on 08/07/13, as indicated by the electronic signature of the registered nurse.

Staff B was interviewed on 08/12/13 at approximately 1:58 PM and stated the initial nursing assessment was required to be completed within eight hours of admission.

Interview at 3:22 PM on 08/12/13 of Staff C revealed the nurses are able to electronically fill out a "draft" or "final" version of the assessment. Patient 1's assessment appeared to be the "draft" version and was started on 07/12/13 at 4:14 PM. Staff C explained the "final" version of the assessment would prompt staff, via an error message, when the assessment was incomplete. The "draft" version of the assessment would not generate such an error message. Staff B and C confirmed it was possible to submit or generate a "draft" version of the assessment that was incomplete. Staff C further confirmed it was not possible to determine whether or not the initial assessment of Patient 1 that began on 07/12/13 was completed within the eight hour time frame.

Facility policy 02.43 Assessment of Patients - Admitting and Annual was reviewed on 08/14/13. Per said policy, "The admitting Assessment is to be completed within eight (8) hours of admission."

Based on observation, interview, and policy review, the hospital failed to ensure safe practices for food handling in regard to disposing of unlabeled and expired foods, cleanliness of the kitchen area, and storage of cleaning supplies near patient food. The had the potential to affect all staff, visitors and patients. The total census at the time of the survey was 228 patients..


Findings Included:

1. On 08/12/13, during a tour of the 22C nursing unit at 2:00 PM, an observation was made of the staff break room. Cases of applesauce, bottled water, and bottled juice were stored directly on the floor. Observation was made of a dry storage cabinet with cleaning solution stored in with the coffee and straws. The solution Virex Tb is a tuberculocide, fungicide, and virucide and the label stated, "do not contaminate water, food, or feed by storage."

The patient refrigerator was in the break room and contained 33 cartons of 0.5 pint fat free milk, 21 of these milk cartons expired on 08/09/13 and two four ounce containers of orange juice with no expiration date. A foil pan partially full of lasagna that belonged to the staff was observed in the patient refrigerator that was labeled for patient food storage only. Staff B immediately disposed of the expired items and removed the cleaning solution from the cabinet. At the completion of the tour of the unit, the cases of applesauce, bottled water, and bottled juice remained on the floor. In an interview with Staff B on 08/12/13 at 2:15 PM, Staff B verified these findings and stated the food service workers, the Infection Control staff and the nursing staff should work together to ensure that food and drinks are not outdated and stored properly. Staff B stated staff food should not be stored in the patient refrigerator.

2. On 08/13/13 during a tour of the Rehabilitation Department at 10:00 AM, an observation was made in the kitchen area, where patient cooking classes are held. The refrigerator had an opened 24 ounce container of sour cream with an expiration date of 08/10/13, an opened 16 ounce package of chopped ham with an expiration date of 07/22/13 and an opened 15 ounce bottle of lime juice with an expiration date of 12/07/12. In the cabinet was a zip lock bag which appeared to be potato flakes, unlabeled, with no date, an opened 35 ounce container of popcorn salt with an expiration date of 07/03/13 and an opened container of popcorn oil, with no date. Staff A and Staff N verified these finding in an interview on 08/13/13 at 10:30 AM.

3. On 08/13/13 during an environmental tour of the kitchen from 1:30 PM to 3:00 PM, several observations were made: In the dry food storage area, a case of Raisin Bran cereal, a case of Boost nutritional supplement, and a case of canned apricots stored directly on the floor. In the main walk-in cooler: individual containers of applesauce, mixed fruit, and cottage cheese with pineapple with no label and no date, a stainless steel pitcher of a dark liquid with plastic wrap over the top with no label and no date, a one gallon container of strawberry pie filling expired 07/02/13, a box of orange fruit with no label and no date, a box of honeydew melons with no date, a box of cantaloupes with no date, and box of broccoli opened on 08/01/13, an opened box of tomatoes with no date, an opened bag of diced potatoes, unsealed, with no date, one box with one head of cabbage dated 07/11/13 and visibly brown, one box with two heads of cabbage dated 06/13/13 and visibly brown, an opened 16 ounce plastic container of chicken base with no date, an opened 16 ounce plastic container of pork base with no date, an opened package of provolone cheese, unsealed, opened on 07/16/13, a package of pressed tortillas, opened, expired on 05/04/13, a package of hard salami opened 07/08/13. In the freezer, there was an opened bag of egg rolls, unsealed, with no date and overhead condensation dripping down onto the food stored underneath the fans in the freezer. In the room labeled Cart Cooler 116, a stainless steel cart with unwrapped, unlabeled food items (cheeseburgers, tomatoes, salads) with no dates. In the food prep area, there was a double door refrigerator with visible food build-up on the handles and with three Styrofoam containers stored directly on the floor of the refrigerator with unidentified food, unlabeled, with no dates. In the tray preparation area, there was visible dust and dead insects in the window sills and visible dead insects in the light fixtures directly above the tray preparation area. There was a one quart spray bottle of Ster-Bac Blu cleaning spray stored on a counter top adjacent to the tray preparation area. In the Cleaning Chemicals Storage Room, adjacent to the dishwashing area, there was a mop bucket containing dirty mop water. These findings were verified with Staff A and Staff K in an interview 08/13/13 at 3:00 PM. Staff K stated he/she thought that produce should be used within 3-5 days after it was opened.

On 08/14/13 at 11:51 AM, the hospital's policy entitled Nutrition Services (effective 09/01/08 and last reviewed 2012) was reviewed. The policy stated, "Food stock expiration dates are checked in the Dietary Department by the Infection Control Nurse on monthly rounds."

On 08/14/13 at 1:00 PM, the hospital's policy entitled Food Storage (last reviewed 12/10/12) was reviewed. The policy stated, "At all times food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, hair, flooding, drainage and overhead leakage or overhead dripping from condensation." "Containers of food shall be stored a minimum of six inches above the floor." "All food stored in the refrigerator or freezer must be properly sealed in clean, dated zip locked bags, plastic containers or the original wrapper." "Once an item has been opened or prepared, it must be put in a clean, sealed container and dated." "Opened or prepared potentially hazardous food must be eaten or removed after 72 hours. Food that is not classified as potentially hazardous is to be discarded according to the expiration date on the package." "All cleaning supplies are to be stored in a locked cabinet." "All refrigerators will be kept clean at all times."

Based on staff interview, observations, maintenance inspection reports, and facility evacuation floor plan review the facility failed to maintain the environment safe from fire in regard to patient room doors not resisting the passage of smoke, vertical openings, exit signs, smoke barriers, smoke barrier doors, delayed egress locks and exit pathways, exit discharge lighting, smoke detector locations, sensitivity testing of smoke detectors, spare sprinkler heads and wrench, heating and air conditioning, space heaters, weekly generator inspections, and use of extension cords (A710) and failed to ensure supplies were maintained with an acceptable level of safety and quality by not identifying and removing expired supplies from patient care areas (A724). The cumulative effect of these systemic practices resulted in the facility's inability to ensure a safe environment for all patients, staff, and visitors. The census on the first survey day was 228 patients.

Findings include:

Refer to A710 and A724.

Based on staff interview, observations, maintenance inspections, and facility evacuation floor plan review, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association, related to patient room doors not resisting the passage of smoke, vertical openings, exit signs, smoke barriers, smoke barrier doors, delayed egress locks and exit pathways, exit discharge lighting, smoke detector locations, sensitivity testing of smoke detectors, spare sprinkler heads and wrench, heating and air conditioning, space heaters, weekly generator inspections, and use of extension cords. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 228 patients.

Findings include:

During this visit, 08/14/13 between 10:00 A.M. and 5:00 P.M., and on 08/15/13, between 8:30 A.M. and 12:00 P.M., tour was conducted in the facility with
Staff A1, B2, C3, E5, and Staff Y. Observations were conducted in the main campus buildings and offsite locations. During this visit, the following were identified and verified by facility staff:

Corridor doors failed to close and latch into the frame. Please refer to the life safety code finding at K18.

The facility could not determine fire resistance or smoke control in a vertical shaft in one laundry room. Please refer to the life safety code finding at K20.

The facility lacked directional exit signs in the path of egress. Please refer to the life safety code finding at K22.

The facility failed to ensure smoke barriers were intact and without penetrations. Please refer to the life safety code finding at K25.

Smoke barrier doors failed to close when released from the automatic hold open device. Refer to K27.

The facility was equipped with 2 to 4 delayed egress doors in the path of exit. One staff member was unaware of having a key to unlock exit access and exit access doors. Exit discharges lacked a paved hard surface to the public way. Refer to K38.

Exit discharges were not adequately illuminated. Refer to K45.

Smoke detectors were located less than 36 inches from air supply and returns. Refer to K52.

The facility lacked documentation of sensitivity of smoke detectors. Please refer to the life safety code finding at K54.

One of two buildings lacked spare sprinkler heads and a wrench. Please refer to the life safety code finding at K62.

Heating and air distribution was working improperly in one of two buildings. Please refer to the life safety code finding at K67.

Space heaters were observed in patient sleeping areas and offices. Please refer to the life safety code finding at K70.

The facility lacked documentation of weekly generator inspections. Please refer to Life safety code finding at K144.

Daisy chain of extension cords were observed in one of two buildings. Please refer to the life safety code finding at K147.

Based on observation, interview and policy review the facility failed to ensure expired medical supplies were unavailable for patient use. This had the potential to affect all of the facility's 228 active patients.

Findings include:

1. On 08/12/13 at 2:35 PM, observation was made of the multipurpose room on the 22C nursing unit. The room had two expired intravenous cannulas, a 22 gauge lot # 42296VM with an expiration date of 05/2011 and a 20 gauge lot#47709 with an expiration date of 10/2011. The room had an 18 gauge angiocath autoguard lot #0057170 with an expiration date of 03/2013. The findings were shared with Staff C and verified.

2. A tour of the patient treatment room on Mckee 2 unit was completed on 08/13/13 at approximately 2:00 PM. An unopened bottle of Providone Iodine 16 ounces with an expiration date of June, 2013 was observed located on the treatment cart. This was verified by Staff B on 08/13/13 at approximately 2:00 PM.

On 08/13/13 at 8:58 AM, the facility's 12.12 Storage of Medical Supplies policy was reviewed. The policy stated designated staff shall check medical supplies for expiration dates and remove them from shelves when noted.

Based on observation, interview and policy review, the facility failed to ensure sharps containers were emptied according to policy.

Findings include:

1. On 08/12/13 at 2:50 PM, observation was made of a sharps container on the 22C nursing unit. The container had syringes stored more than 3/4 full and above the container's fill line. Staff O was interviewed and stated he/she was unaware the container had a fill line marking.

On 08/15/13 at 2:35 PM, the facility's policy entitled 02.24 Disposal of Contaminated Needles, Syringes and Lancets was reviewed. The policy stated the property management department was to be notified for pick up and proper disposal of sharps containers when the containers are 3/4 full.

On 08/15/13 at 2:35 PM, the facility's Infectious Waste Management Program policy was reviewed. The policy stated the sharps container will be disposed of when the container is filled to the fill line.

Based on observations, policy review and interview the facility failed to ensure the hospital-wide quality assessment and performance improvement program addressed problems identified by the infection control officer. This had the potential to affect 25 of the 25 active patients on the 22C nursing unit.

Findings include:

On 08/12/13 at 2:45 PM, observation was made of the unit's shower/bath room on the 22C nursing unit. The room had one functional shower. Two bath tubs were observed. One tub had dust and a dirty towel on it. The other tub had dust, socks and a rag on it. The findings were shared with Staff C and confirmed.

On 08/15/13 at 2:20 PM, the facility's custodial duties schedule was reviewed. The document stated the patient's tub was to be cleaned daily.

On 08/13/13, the facility's Infection Prevention and Control Report from June 2013 was reviewed. The report showed observations had been made on Unit 22C. The report stated the unit had heavily soiled bathroom tubs.

Based on interview and record review, the facility failed to:

I. Revise the treatment plans for 4 of 4 patients (1 of 9 active sample patients: C15; and 3 of 3 active non-sample patients reviewed for restraint use: A2, B21 and D10) after use of restraints (chemical or mechanical). This results in lack of guidance to assist the team members in assisting patients to control behaviors which led to use of these procedures. (Refer to B118)

II. Ensure the proper use and documentation of chemical restraints that is supported by facility policy and procedures for the control of patients' agitation and/or threatening behaviors, for 1 of 9 active sample patients (Patient C15) and 2 non-sample active patients (Patients A2 and B21) whose treatment was reviewed for the use of medications. There was no documented evidence that the staff attempted to deescalate the patients other than "redirection." There was no evidence of 1 hour face-to-face evaluations following medication use, no evidence of on-going assessments until the effects of the medications ended, and no revision of the treatment plans. These deficiencies result in the imposition of medication restraint with potentially serious side effects without proper justification and documentation for their usage. (Refer to B125, Section I)

III. Ensure that assessments for and use of mechanical restraints on patients is performed by qualified clinical personnel. Non-clinical personnel (hospital police officers/security staff) assessed patients for the need and type of mechanical restraints and were granted authority to use mechanical restraints (usually wrist to waist) when escorting patients outside the buildings/units to other areas on or off hospital grounds. This results in a risk for all patients in the hospital to be restrained without an appropriate physician assessment, and patients' treatment being delegated to non-clinical support personnel (security). (Refer to B125, Section II)

IV. Ensure that use of mechanical wrist to waist restraints was based on an immediate threat of harm to self/others and used in an area that protects the privacy of 1 of 1 patient (D10) added to the sample for wrist to waist mechanical restraint review. Patient D10 was continued in wrist to waist restraints without documented justification and "walked about" in the day room. Staff reported that this wrist to waist restraint has been used for other patients who have been allowed in the day room areas while in restraint. This results in violation of patients' rights for privacy and freedom of movement without documented justification. (Refer to B125, Section III)

Based on medical record review and staff interview it was determined that the facility failed to provide psychiatric evaluations that included an assessment of patient assets that would be used in treatment for 6 of 9 sample patients (Patients A5, C5, E5, E15, F5 and G16). The failure to identify those patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapeutic endeavors.

Findings include:

A. Medical Record Review:

1. Patient A5: The Psychiatric Evaluation dated 4/19/13 stated the sole asset of the patient was "Supportive family."

2. Patient C5: The Psychiatric Evaluation dated 7/25/13 stated the sole asset of the patient was "Family connection."

3. Patient E5: The Psychiatric Evaluation dated 8/8/13 stated the assets of the patient were "[S/he] is linked to services. [S/he] has an income. [S/he] has a place to live."

4. Patient E15: The Psychiatric Evaluation dated 4/4/12 had no description of any patient assets.

5. Patient F5: The Psychiatric Evaluation dated 8/12/13 stated the assets of the patient were "Some education. Employment history."

6. Patient G16: The Psychiatric Evaluation dated 4/19/13 stated the assets of the patient were "SSI. Family relationship."


B. Staff Interview:


On 8/22/13 at 10:45 a.m. the facility's clinical director was presented the findings for Patients A5, F5 and G16; he agreed that these were not descriptive of patient assets and stated that the psychiatric staff would have to take a look at this matter and improve their performance.

Based on interview and document review there was failure to revise the treatment plans for 4 of 4 patients (1 of 9 active sample patients- C15, and 3 of 3 active non-sample patients - A2, B21 and D10) after use of restraints (chemical or mechanical). This results in lack of guidance to assist the team members in assisting patients to control behaviors which led to use of these restrictive procedures.

Findings include:

A. Patient findings:

1. Patient A2 was admitted 8/15/2013.

a. The review of physician Orders disclosed that STAT (immediate) usage of Haldol, Benadryl and Ativan had been administered daily on 8/15, 8/16, 8/17, 8/18, 8/19, 8/20 and 8/21/13. Review of Patient A2's Master Treatment Plan (8/19/13) revealed no additional interventions to address the behavior that led to the use of chemical restraint for this patient.

b. In an interview on 8/22/13 at 3:55 p.m. the attending psychiatrist (MD#2) for Patient A2 concurred that there was no physician intervention on the plan and that there was no identification of the patient's daily agitated behavior as a problem to be addressed.

2. Patient B21 was admitted on 7/31/13.

a. According to the "Emergency, Stat, and PRN (as needed)" Medications record, Patient B21 received the following Stat medications:

1). On 8/2/13 at 8:15 a.m., 8/5/13 at 8:15 a.m. and on 8/12/13 at 8:35 a.m.-- "Prolixin 5 mg, Ativan 1 mg and Benadryl 50 mg IM for agitation."

2). On 8/10/13 at 9:00 a.m., 4:05 p.m. and 5:50 p.m.-Thorazine 200 mg for agitation.

3). On 8/15/13 at 3:15 p.m.-Thorazine 200 mg po for agitation.

b. Review of Patient B21's Master Treatment Plan (8/23/13) revealed no additional interventions to address the agitation that led to the use of chemical restraint for this patient.

3. Patient C15 was admitted on 7/25/13.

a. As documented in the comprehensive psychiatric evaluation (7/25/13) this patient had been charged with Domestic Violence and Criminal Damaging and diagnosis was listed as "Depression NOS (not otherwise specified) vs Adjustment Disorder with Depressed Mood."

b. As documented in a nursing note on 8/10/13 at 12:37 a.m., Patient C15 "was very agitated on the 2nd shift (8/9/13). The patient refused to take PO (oral) meds (medications) ...At some point in the shift, the patient was loud and was using profanity." According to the note, the RN called Physician 6, telling him about the patient's threatening and agitated behavior. Based on an order given by MD#6, Patient C15 was manually held and given Ativan 1mg IM, Diphenhydramine 50 mg IM and Haloperidol 5 mg IM (not typical medications for the patient's diagnoses) on 8/9/13 at 11:40 p.m.

c. A physician progress note on 8/10/13 at 12:13 a.m. for Patient C15 stated "[S/he] made threats towards nursing staff...demonstrated a crescendo of agitation. [S/he] was believed to be an imminent risk of harm to others....continued to escalate [his/her] behavior, and became increasingly psychomotor agitated. [S/he] was given STAT IM medications of Ativan 1 mg, Haldol 5 mg and Benadryl 50 mg to lower agitation to prevent imminent harm to others."

d. Review of Patient C15's Master Treatment Plan (8/16/13) revealed no additional interventions to address the agitated and threatening behavior that led to the use of chemical restraint for this patient.

4. Patient D10 was admitted to the hospital on 2/1/13 with a diagnosis of Schizophrenia, chronic, undifferentiated type.

a. As documented in the comprehensive psychiatric evaluation, Patient D10 was admitted for "attacking and assaulting [his/her] peers, became combative and aggressive with caregivers..." His/her diagnoses were listed as "Schizophrenia, chronic, undifferentiated type and Chronic and Personality disorder not otherwise specified."

b. Review of RN Seclusion or Restraint Progress notes revealed Patient D10 was placed in "w/w (wrist to waist restraints) for protections of self + (and) others" on 7/10/13 from 10:50 a.m. to 4:15 p.m. (5 hours and 25 minutes).

c. Review of Patient D10's Master Treatment Plan (8/19/13) revealed no additional specific interventions to address the aggressive behavior that led to the use of wrist to waist restraint for this patient other than placing this patient on 1:1 supervision. The only intervention for this problem, "Staff will monitor pt (patient) for aggressive behavior," was listed on the 7/8/13 treatment plan prior to the restraint and was continued on the 8/19/13 treatment plan.

B. Staff Interview:

On 8/23/13 at 9:30 a.m. the clinical director was interviewed. In the discussion of Patient A2's treatment he acknowledged that no revision to the treatment plan dated 8/19/13 occurred following any of these daily IM STAT combinations of medications.

Based on medical record review and staff interview, for 6 of 9 active sample patients (Patients A5, E5, F5, F11, G16 and I38) the facility failed to ensure that treatment plans included patient-related short-term and long-term goals stated in measurable and behavioral terms. This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the treatment team to modify plans in response to patient needs.

Findings include:

A. Medical Record Review:

1. Patient A5: The Treatment Plan dated 7/15/2013 had the following goals: "[Patient A5] will become competent to stand trial. [Patient A5] will comply with [his/her] medications; exhibit decreased symptoms and be able to function on the unit. [Patient A5] will have improvement or resolution of neurological symptoms. [Patient A5]'s cardiovascular problems will be managed to eliminate or minimize complications. Pt. (Patient) will be able to communicate effectively prior to discharge."

2. Patient E5: The Treatment Plan dated 8/9/2013 had the following goals "[Patient E5] will recognize reality such that [s/he] can function in a less restrictive environment. [Patient E5]'s blood sugar will be under control and the complications of diabetes will be minimized. [Patient E5] will identify needs and resources needed to support [his/her] recovery in the community. To eliminate behavioral difficulties [sic]," and "[Patient E5] will have improvement or resolution of neurological symptoms."

3. Patient F5: The Treatment Plan dated 8/13/2013 had the following goals: "[Patient F5] will comply with [his/her] medications; exhibit decreased symptoms and be able to function on the unit. [Patient F5] will have resolution or improvement of [his/her] chronic pain. [Patient F5] will develop and practice coping strategies to deal with high risk situations, skills for meeting needs in ways other than using substances and techniques for balanced mental health. [Patient F5] will identify needs and resources needed to support [his/her] recovery in the community."

4. Patient F11: The Treatment Plan dated 8/20/2013 had the following goals: "[Patient F11] will recognize reality such that [s/he] can function in a less restrictive environment. [Patient F11] will identify needs and resources needed to support [his/her] recovery in the community" and "[Patient F11] will have resolution or improvement of [his/her] pain."

5. Patient G16: The Treatment Plan dated 12/17/2012 had the following goals: "[Patient G16] will recognize reality such that [s/he] can function in a less restrictive environment," "[Patient G16] will identify needs and resources needed to support [his/her] recovery in the community" and "[Patient G16], will engage with staff to establish a working alliance for addressing SAMI [sic] issues."

6. Patient I38: The Treatment Plan dated 7/30/2013 had the following goals: "[Patient I38] will learn alternate methods for managing [his/her] frustration and not engage in aggressive behavior, as well as, participate actively in [his/her] behavioral plan. [Patient I38] will demonstrate ability to maintain placement in the community with the absence of verbally and physical aggressive behavior. [Patient I38]'s blood sugar will be under control and the complications of diabetes will be minimized. [Patient I38] will verbalize knowledge and ability to manage own recovery by expressing symptoms of [his/her] illness. [Patient I38] will receive treatment for sleep apnea while [s/he] is hospitalized. [Patient I38] will learn to identify and manage thought disturbances of Auditory hallucination, paranoid [sic] and delusions. [Patient I38] will have improvement or resolution of symptoms. [Patient I38] will develop fitness skills and consider behavioral changes that, if made, may result in a healthy lifestyle. [Patient I38] will greet staff and peers appropriately when entering a room."

B. Staff Interview:

On 8/23/13 at 9:05 a.m. the facility's Director of Quality Assurance and Performance Improvement reviewed the Treatment Plans of Patients A5, E5, G1 and I38 and agreed that the goals were not written in a manner to be measured or expressed behaviorally.

Based on medical record review and staff interview the facility failed to develop treatment plans that identified clearly delineated medical staff interventions to address specific patient problems. This failure resulted in routine, generic discipline functions inappropriately listed as individualized interventions for 8 of 9 sample patients (Patients A5, C10, E5, E15, F5, F11, G16 and I38).

Findings include:

A. Medical Record Review:

1. Patient A5: The Treatment Plan dated 7/15/2013 had the following medical staff interventions: "[Patient A5] will be prescribed medications to help [his/her] mood disorder; [MD #2] will prescribe medications and monitor for effectiveness 30 minutes weekly. [Patient A5]'s medical condition will be monitored by [MD#7] as needed. [Patient A5] will be prescribed medications and monitored by [MD#7] to treat [his/her] hypertension."

2. Patient C10: The Treatment Plan dated 8/20/2013 had the following medical staff intervention: "[MD#8] will assess [Patient C10]'s pain and will prescribe medications and/or treatments as needed."

3. Patient E5: The Treatment Plan dated 8/9/2013 had the following medical staff interventions: "[MD#9] will order special precautions to reduce the likelihood of assaultive behaviors and meet with patient daily to evaluate mood, effectiveness of treatment, and assess willingness to contract for safety; [MD#10] will monitor condition (history of hypertension) and prescribe treatment as needed; [MD#10] will evaluate condition (neuropathy) and order treatment as needed."

4. Patient E15: The Treatment Plan dated 8/21/2013 had the following medical staff interventions: "[Patient E15] will meet with [MD#11] at least once a week focusing on medications, including side effects, and behaviors. Monitoring for effectiveness and building trust and rapport. [MD#11]/alt (alternate) will evaluate and make recommendations for treatment and medications at least twice a month and as needed; [MD#11] will invite [Patient E15] to team meetings monthly, to build rappor [sic] and evaluate effectiveness of medications. [MD#10]/alt will monitor and make recommendations as needed for hypertension, lipids, diabetes, obesity, anemia and medication efficiency." Patient E15 had "long history of reflux issues" and "[MD#10]/alt will monitor effectiveness of medications and order medications as needed." For the issue "has several complications of diabetes" the intervention was "[MD10]/alt will evaluate, monitor, order medications and make referrals as needed."

5. Patient F5: The Treatment Plan dated 8/13/2013 had the following medical staff interventions: "[MD#11] will order special precautions to reduce the likelihood of a suicide attempt. [MD#11] will prescribe medications to treat [Patient F5]'s Mood D/O (disorder)."

6. Patient F11: The Treatment Plan dated 8/20/2013 had the following physician intervention: "[MD#12] will prescribe medications to treat [Patient F11]'s thought disorder."

7. Patient G16: The Treatment Plan dated 12/17/2012 had the sole psychiatrist intervention "[MD#13] will order special precautions to help redirect potentially violent behavior and increase monitoring for [Patient G16] [sic] to prevent or contain violent incidents."

8. Patient I38: The Treatment Plan dated 7/30/2013 had the following physician interventions: "[PatientI38] will work with [MD#14]/Alt. on adherence to [his/her] behavioral plan. [MD #8] will prescribe medications to treat [Patient I38]'s Diabetes Mellitus. [MD#8] will prescribe a diet and medication to help [Patient I38]'s hypertension."


B. Staff Interview:


On 8/23/13 at 9:05 a.m. the facility's Quality Assurance/Performance Improvement Director reviewed the Treatment Plans of Patients A5, E5, G16 and I38 as described in Section I above. He agreed that the stated interventions were generic and routine medical staff responsibilities.

Based on interview and document review the facility failed to:

I. Ensure the proper use and documentation of chemical restraints that is supported by facility policy and procedures for the control of patients' agitation and/or threatening behaviors for 1 of 9 active sample patients (Patient C15) and 2 active non-sample patients (Patients A2 and B21) whose treatment was reviewed for the use of medications. There was no documented evidence that the team attempted to deescalate the patients other than "redirection." There was no evidence of 1 hour face-to-face evaluations following medication use, no evidence of on-going assessments until the medications' effects ended, and no revision of the treatment plans. These deficiencies result in the imposition of medication restraint with potentially serious side effects without proper justification and documentation for their usage.

II. Ensure that assessments for and use of mechanical restraints for patients is performed by qualified clinical personnel. Hospital policy allowed non-clinical personnel (hospital police officers/security staff) to assess patients for the need and type of mechanical restraints and granted these security staff authority to use mechanical restraints (usually wrist to waist) when escorting patients outside the buildings/units to other areas on or off hospital grounds. This results in a risk for all patients in the hospital to be restrained without an appropriate physician assessment, and patients' treatment being delegated to non-clinical support personnel (security).

III. Ensure that use of mechanical wrist to waist restraints was based on an immediate threat of harm to self/others and used in an area that protects the privacy of 1 of 1 patient (D10) added to the sample for wrist to waist mechanical restraint review. Patient D10 was continued in wrist to waist restraints without documented justification and "walked about" in the day room. Staff reported that wrist to waist restraint has been used for other patients who have been allowed in the day room areas while in restraint. This results in violation of patients' rights for privacy and freedom of movement without documented justification.

Specific findings include:

I. Failure to ensure proper use and documentation of chemical restraints:

A. Patient Reviews

1. Patient A2:

a. During interview on 8/22/13 at 12:35 p.m., RN 1 reported that Patient A2 was brought into the admission office on 8/15/13 by Rocky River police in metal handcuffs, transferred from the metal handcuffs to wrist to waist leather restraints by the support team upon verbal directions by the psychiatrist, and was transferred to 4-point bed restraints upon arrival in Unit A.

b. On 8/22/13 at 3:55 p.m. the attending psychiatrist (MD#2) for Patient A2 was interviewed. The review of physician Orders disclosed that STAT (immediate) usage of Haldol, Benadryl and Ativan had been administered on 8/15, 8/16, 8/17, 8/18, 8/19, 8/20 and 8/21/13. MD#2 verified that there was no physician intervention in the Treatment Plan dated 8/19/2013 addressing the use of medications or addressing the rationale for imposition of STAT medication combinations prescribed. It was further verified that these STAT Orders were administered because of Patient A2's "agitated" behaviors. There was no documented evidence that staff members attempted to deescalate the patient. No documentations of physician assessments within 1 hour of administration of any of the sets of medications were present. The attending psychiatrist did not acknowledge that these interventions were a use of chemical restraint; but did state that Patient A2 did not attend his/her treatment planning session on 8/1/13 because "[S/he] was too sleepy."

c. On 8/23/13 at 9:30 a.m. Patient A2's chart was reviewed with the clinical director. The review of physician Orders disclosed that STAT (immediate) usage of Haldol, Benadryl and Ativan had been administered on 8/15, 8/16, 8/17, 8/18, 8/19, 8/20 and 8/21/13. The clinical director agreed that there was no documentation that would evidence a physician assessment of need or response to these medications within 1 hour of their use. The clinical director stated that he did not consider these STAT Orders as a type of chemical restraint.

d. On 8/23/13 at 9:30 a.m. Patient A2 was interviewed with the clinical director present. Patient A2 stated that s/he had no idea why s/he was requiring daily STAT Orders and said "I have no idea. I just want to go home to my family. I don't know why they are giving me shots."

e. The revised Treatment Plan (dated 8/22/13, during the survey) was reviewed. The following interventions by the psychiatrist were found: "[MD#2] will order special precautions to increase supervision of [Patient A2]" and "Based on [MD#2]'s recommendation NBH (the facility) will petition to court for involuntary medication administration for [Patient A2]. [Patient A2] will order special precautions to reduce the likelihood of an assault [sic]." The Treatment Plan did not address the daily usage of STAT Orders that had occurred or what future interventions, medication or otherwise, would be used.

2. Patient B21 was admitted on 7/31/13.

a. The comprehensive psychiatric evaluation (8/1/13) stated, "Thought process was disjointed, disorganized and tangential...at times [s/he] threatened staff with vague threats. [S/he] was grandiose. [S/he] was paranoid."

b. According to the "Emergency, Stat, and PRN" Medications record, Patient B21 received the following Stat medications:

1) On 8/2/13 at 8:15 a.m., 8/5/13 at 8:15 a.m. and on 8/12/13 at 8:35 a.m.-- "Prolixin 5 mg, Ativan 1 mg and Benadryl 50 mg IM for agitation."

2) On 8/10/13 at 9:00 a.m., 4:05 p.m. and 5:50 p.m.-Thorazine 200 mg for agitation.

3) On 8/15/13 at 3:15 p.m.-Thorazine 200 mg po for agitation.

As documented in the medication administration record, Patient B21 received several additional STAT doses of Prolixin or Ativan, but not in combination form.

c. During interview on 8/22/13 at 11:15 a.m., RN 8 reported that Patient B21's response to the Stat medications was "always different. Sometimes [s/he] was more pleasant. On a couple of occasions [s/he] may sleep [sic]."

d. During interview on 8/22/13 at 11:30 a.m., Patient B21 stated that s/he remembered getting the medication injections, but no specifics about getting them.

e. Review of Patient B21's Master Treatment Plan (8/23/13) revealed no additional interventions to address the agitated behavior that led to the use of chemical restraint for this patient.

3. Patient C15 was admitted on 7/25/13.

a. As documented in the comprehensive psychiatric evaluation (7/25/13) this patient had been charged with Domestic Violence and Criminal Damaging and diagnosis was listed as "Depression NOS (not otherwise specified) vs Adjustment Disorder with Depressed Mood."

b. As documented in a nursing note on 8/10/13 at 12:37 a.m., Patient C15 "was very agitated on the 2nd shift (8/9/13). The patient refused to take PO (oral) meds (medications) ...At some points in the shift, the patient was loud and was using profanity." According to the note the RN called MD#6, telling him about the patient's threatening and agitated behavior. Based on an order given by MD#6, Patient C15 was manually held and given Ativan 1mg IM, Diphenhydramine 50 mg IM and Haloperidol 5 mg IM (not typical medications for the patient's diagnoses) on 8/9/13 at 11:40 p.m.

c. A physician progress note on 8/10/13 at 12:13 a.m. for Patient C15 stated "[S/he] made threats towards nursing staff... demonstrated a crescendo of agitation. [S/he] was believed to be an imminent risk of harm to others...continued to escalate [his/her] behavior, and became increasingly psychomotor agitated. [S/he] was given STAT IM medications of Ativan 1 mg, Haldol 5 mg and Benadryl 50 mg to lower agitation to prevent imminent harm to others."

d. A nursing note (8/10/13 at 6:05 a.m. stated, "The patient was given the IM STAT medication and tolerated the injection with no problems. The medication was effective as the patient went into [his/her] room and slept throughout the night without incident."

e. Review of Patient C15's Master Treatment Plan (8/16/13) revealed no additional interventions to address the aggressive/assaultive behavior that led to the use of chemical restraint for this patient.

f. During interview on 8/22/12 at 10:15 a.m., MD#6 stated that he ordered a combination of drugs such as that ordered for Patient C15 (Haldol, Ativan and Benadryl) when a patient "is acutely agitated, has psychosis or mania." He added, "I order Haldol for psychosis, Benadryl to prevent side effects and Ativan as it is well known for its use for agitation. I sometimes use other combinations." He stated that he was unaware that this may be a chemical restraint for some patients. When asked how often he orders a combination of these medications for patients, he replied, "If the nurse calls about a patient, I ask questions such as, Is the patient agitated? Has the patient refused medications? If so, I usually order these medications."

The Medical Director, after joining the interview at 10:25 a.m., stated that the hospital has guidelines for use of medications. He reported that he was not aware that this combination of medications may be a chemical restraint for some patients.

C. Pharmacy Review Findings

To ascertain the prevalence facility-wide for usage of the STAT mixture (Haldol, Benadryl and Ativan), the week 8/12/13-8/18/13 was reviewed with Pharmacist #2 on 8/22/13 at noon. During the defined period of 1 week, 9 patients had received the combination.

D. Policy Review

A review of the Northcoast Behavioral Healthcare policy and procedure, "06.12- Seclusion or Restraint," revealed that this policy failed to address the use of chemical restraints.

II. Failure to ensure that assessments for and application of mechanical restraints on patients are performed by qualified clinical personnel and applied by qualified clinical staff, who also make the determination as to removal based on the clinical situation:

A. During interview on 8/21/13 at 11:30 a.m., the Director of Nursing (DON) stated that the hospital police make rounds on the patient units and the hospital grounds and are trained and assist with seclusion/restraint of patients.

B. During interview on 8/21/13 at 4:00 p.m. in presence of Acting Chief Executive Officer and Director of Nursing, Northcoast Behavioral Healthcare Chief of Police stated that he reports to the hospital CEO and that the role of his department (total of 11 security officers) is "to support clinical staff." He reported, "We help as needed in holds (patient restraint), stand by for treatment team meetings (in case assistance is needed), help if an incident occurs such as assault, allegation of sexual contact, and make daily rounds on every unit. There is always an officer on days and p.m.'s (evenings) in the 22 and McKee buildings. We assist with patient admissions and wand and search patients, clothing--not cavity search. We assist in codes on the units. "

The Chief of Police reported that one of the officers' roles is to escort patients when out of the units. He stated that the officers use waist to wrist leather cuffs if they feel that these are needed. When asked about a physician order, he replied, "The decision to restrain (when escorting a patient out of the unit) is up to the officer. Handcuffs may be used." When asked for an example of handcuff use, he replied, "We were assisting with a code. Both patients involved required a manual hold. A third patient had an outburst and attacked staff during this time. The officer cuffed (handcuffs) this patient."
He reported that there was no documentation or administrative log regarding patients that are escorted in restraints by the police officers (hospital security staff).

C. Policy Review:

1. Review of the Northcoast Behavior Healthcare Policy and Procedure, "06.12-Seclusion or Restraint," states the following:

a. "Hospital Security Personnel means police and security officers of the Hospital who furnish protection and security for the persons, grounds and buildings of the hospital."

b. "Steel handcuffs or other control devices may be used by NBH (Northcoast Behavioral Healthcare) police staff for custody, detention, and public safety reasons and are not considered restraints."

The above policy statement fails to define the term, "control devices"

2. Review of the Northcoast Behavior Healthcare Police Policy and Procedure, "05.23-Restraint Definitions and Procedure" states, "Administrative Restraints...applied to a patient usually through an administrative decision. This type of restraint can be used in conjunction with special circumstances and/or due to a patient's special classification or statute (forensic, arrested, etc...) These types of restraints are usually, but not exclusively, hard and/or metal such as handcuffs and/or leg shackles and primarily used by the hospital policy agency (refers to hospital security staff)."

3. Review of the Northcoast Behavior Healthcare Police Policy and Procedure, "03.15-Use of Handcuffs" states the following:

a. "Waist Restraint Belts are authorized for use on forensic patients and flight/assault precaution patients only when on an off grounds escort. Waist Restraint belts can only be used in other situations with Police Supervision approval."

b. Conditions for Use:

1). "Emergency situation where an impending or crisis situation which creates circumstances demanding immediate action for the preservation of life or prevention of serious bodily harm to the person or others as determined by the police officer."

2). "Escorting forensic and flight or assault precaution patients off grounds and only off grounds. When it appears there is a need to cuff or restrain a patient for an on grounds escort, a Police Supervisor is to be notified prior to the escort."

D. During interview on 8/22/13 at 9:00 a.m., the Acting Chief Executive Officer reported that after review of the Patients' Rights interpretive guides, he now understood that the Northcoast police officers are security staff of the hospital, rather than law enforcement police and cannot handcuff patients. He stated, "This policy (use of handcuffs) is gone."



III. Failure to ensure that use of mechanical waist to wrist restraints is based on an immediate threat of harm to self/others and used in an area that protects patient privacy:

A. During interview on 8/22/13 at 10:55 a.m., the Assistant Director of Nursing (ADON) stated "Occasionally wrist to waist cuffs (leather) are used for a patient who is allowed out in the day area. The use of cuffs gives the patient more freedom."

B. During interview on 8/22/13 at 12:35 p.m., RN 1 reported that the patient in wrist to waist restraint may be taken to the dayroom area with 1:1 supervision.

C. Patient D10 was admitted to the hospital on 2/1/13 with a diagnosis of Schizophrenia, chronic, undifferentiated type.

1. As documented in the comprehensive psychiatric evaluation, Patient D10 was admitted for "attacking and assaulting [his/her] peers, became combative and aggressive with caregivers..." His/her diagnoses were listed as "Schizophrenia, chronic, undifferentiated type and Chronic and Personality disorder not otherwise specified."

2. Review of RN Seclusion or Restraint Progress notes revealed Patient D10 was placed in "w/w (wrist to waist restraints) for protections of self + (and) others" on 7/10/13 from 10:50 a.m. to 4:15 p.m. (5 hours and 25 minutes).

3. An RN note at 1:50 p.m. stated, "Pt (patient) threatening to hit others @ (at) this time. Not able to contract for safety." An RN note at 3:50 p.m. stated, "Pt (Patient) is not able to contract for safety. MD present. Renewal order obtained. Pt (Patient) able to walk about the unit."

4. The "Seclusion or Restraint Observations" sheet completed during the time the patient was in restraint failed to show any threatening behavior reflective of an immediate threat to self/others. In addition, this observation sheet noted that Patient D10 was "In the day area" from 1:00-1:30 p.m. while in wrist to waist restraints.

5. As documented in #2 and #3 above Patient D10 failed to show aggressive behaviors to self/others other than one statement at 3:50 p.m. which was accompanied with allowing this patient to walk in the dayroom; such action was a risk of harm to others and prohibited privacy for Patient D10 while in restraints.

D. During interview on 8/23/13 at 9:15 a.m., Patient D10 described being in wrist to waist restraints. S/he reported walking out on the unit while being in these restraints.

E. Review of Patient D10's Master Treatment Plan (8/19/13) revealed no additional specific interventions to address the aggressive behavior that led to the use of wrist to waist restraint for this patient other than placing this patient on 1:1 supervision. The only intervention for this problem, "Staff will monitor pt (patient) for aggressive behavior," was listed on the 7/8/13 treatment plan prior to the restraint and was continued on the 8/19/13 treatment plan.

F. Review of the policy, "06.12-Seclusion or Restraint," revealed the following statements:

1. "Seclusion and/or restraints are utilized only as a last resort when patients are in imminent risk of harming themselves or others."

2. "S/R (Seclusion/Restraint) shall not be used in place of more appropriate treatment interventions or longer than is necessary."

3. "While restrained or secluded, a patient shall receive appropriate, humane, personal, and safe treatment."

Based on interview and document review, the facility failed to assure that the Medical Director monitored active treatment and took needed corrective actions. Specifically,

The Medical Director failed to provide adequate medical leadership. The Medical Director failed to ensure that:

1. Psychiatric Evaluations contained assessment of patient assets in descriptive, not interpretive fashion;

2. Treatment Plans were revised when the clinical state of the patient necessitated use of chemical restraints;

3. Treatment Plans had measurable long and short term goals for staff consideration of progress or lack of progress in treatment;

4. Treatment Plans had physician interventions that were patient specific and were not simply the listing of routine discipline tasks;

5. When chemical restraints were used a physician face-to-face assessment occurred within 1 hour to evaluate patient response to effectiveness of STAT IM medications written to lessen patient dangerousness to self or others;

6. When mechanical restraints were used the necessity for such was assessed by a clinical member of the staff and not the facility's law enforcement staff;

7. Use of mechanical wrist to waist restraints was based on an immediate threat of harm to self/others and used in an area that protects the privacy of patients;

8. Hospital policy restricted the use of law enforcement restraints (steel handcuffs) on patients by hospital security staff (Northcoast Police Officers); and

9. Patients on hospital grounds were free of the potential use of a Tazer by Northcoast Behavioral Healthcare Police Officers.

These deficiencies result in treatment that is not clinically driven, treatment that is not evaluated in a timely manner, a lack of revision of treatment plans after the use of restraints, violation of patients' rights without proper justification and a potential safety risk for patients and staff. (Refer to B144.)

Based on interview and document review, the clinical director failed to ensure that for 8 of 9 active sample patients (Patients A5, C5, C15, E5, E15, F5,G16, and I38) and for 3 of 3 non-sample patients (Patients A2, B21 and D10 ) that:

1. Psychiatric Evaluations contained assessment of patient assets to be used in treatment for 6 of 9 sample patients (Patients A5, C5, E5, E15, F5 and G16). Assets noted were general and not related to the treatment plan. (See B117 for details.)

2. Treatment Plans were properly developed and revised. Treatment plans were not revised when the clinical state of the patient necessitated use of chemical restraints for 4 of 4 patients (active sample patient C15, and non-sample patients A2, B21 and D10). This results in lack of guidance to assist the team members in assisting patients to control behaviors which led to use of these restrictive procedures (See B118 for details). Treatment Plans did not have measurable long and short term goals for staff consideration of progress or lack of progress in treatment for 6 of 9 active sample patients (Patients A5, E5, F5, F11, G16 and I38) (See B121 for details.) Treatment Plans did not have physician interventions that were patient specific but rather were simply the listing of routine discipline tasks for 8 of 9 sample patients (Patients A5, C10, E5, E15, F5, F11, G16 and I38.) (See B122 for details)

3. Restraints were properly used. When chemical restraints were used, there was a failure to treat them as restraints and to provide a physician face-to-face assessment within 1 hour to evaluate patient response to effectiveness of STAT IM medications written to lessen patient agitation or dangerousness to self or others. (See B125 Part I for details). When mechanical restraints were used, the assessments for and use of mechanical restraints for patients is performed by qualified clinical personnel. (See B125 Part II for details.) When mechanical wrist to waist restraints were used, there was a failure to assure their use was based on an immediate threat of harm to self/others and they were used in an area that protects the privacy of patients. (See B125 Part III for details.)
These deficiencies result in a potential safety risk for patients and staff.

In addition there was failure to ensure that patients, when out of the patient buildings on the hospital grounds, are free of the potential use of a Tazer used by Northcoast Behavioral Healthcare Police Officers. The facility allows the police staff to carry a Tazer while making rounds on the hospital grounds.

Findings include:

A. During interview on 8/21/13 at 4:00 p.m. in the presence of Acting Chief Executive Officer and Director of Nursing, the Northcoast Behavioral Healthcare Chief of Police stated that his department's role (total of 11 security officers) is "to support clinical staff." He stated that one of the duties of the officers is to make rounds of the hospital for safety purposes.

B. When asked what the officers carry, he replied "hand radio and handcuffs." He added, "There is one Tazer available. It is kept in the police squad room. When making rounds on the hospital grounds at night, the officer can check it out in case protection is needed. The Tazer is not to be taken into the patient units."

C. The Northcoast Behavioral Healthcare Policy and Procedure, "05.29-Electronic Control Device (Tazer)" stated "NBH Police Officers...will be provided access to an Electronic Control Device (ECD) for the purpose of exterior perimeter and grounds patrol."

Based on interview and document review, The Director of Nursing failed to provide appropriate monitoring and corrective action to:

I. Ensure the proper use and documentation of chemical restraints for the control of patient's agitation and/or threatening behaviors for 1 of 9 active sample patients (Patient C15) and 2 non-sample active patients (Patients A2 and B21) whose treatment was reviewed for the use of medications. Nursing staff accepted and implemented physician orders for chemical restraint without hospital policy/procedures to support this practice. There was no documented evidence that the nursing staff attempted to deescalate the patients other than "redirection." There was no evidence that nursing provided on-going assessments until the medications' effects ended and there were no revisions of the nursing interventions in the treatment plans. The only alternative intervention documented by nursing was "attempted to redirect" the patient. These deficiencies result in the imposition of medication restraint with potentially serious side effects without proper justification and documentation for their usage. (Refer to B125, Section I)

II. Ensure that use of mechanical wrist to waist restraints was based on an immediate threat of harm to self/others and used in an area that protects the privacy of 1 of 1 patient (D10) added to the sample for wrist to waist mechanical restraint review. Nursing staff continued wrist to waist restraints for Patient D10 without documented justification and allowed the patient to go into the day room while restrained. Staff reported that wrist to waist restraint has been used for other patients, sometimes allowing them to go to the day room or hallway while in restraint. This results in violation of patients' rights for privacy and freedom of movement without documented justification. (Refer to B125, Section III)