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Based on the citation at 0144 cited for this survey the facility remains out of compliance with the Condition of Participation for Patient Rights since the survey ending on 7/12/12. The facility failed to provide care in a safe setting on the Behavioral Health Services (BHS) Intensive Psychiatric Care [IPC] unit housed on the East Campus of the facility. The facility has 2 campuses The East Campus is located approximately 1 mile from the main Medical/Surgical West Campus For this survey the facility was found to still be out of compliance for failure to provide care in a safe setting for 1 of 2 sampled patients (Patient 29) selected from the 2 BHS units This failure placed the 6 patients that were on the BHS - IPC unit at potential risk for injury. On the day of entrance the census for both West and East Campus was 67 with 8 patients on the BHS units. Findings are:

One patient was selected for review on each of the BHS units housed on the East Campus. The patient selected on the IPC unit was selected due to a reported history by the nursing staff that the patient had required use of "Dr. Strong" on 3 occassions. A "Dr. Strong" refers to a policy and procedure developed to handle psychiatric emergencies in the hospital. It is a code that is called to summon staff trained in Crisis Prevention Intervention (CPI). The patient selected was Patient 29, who was 1 of 6 patients that were on the IPC unit at the time. The third "Dr. Strong" for Patient 29 was called on 9/7/12. This incident included calling the Norfolk Police Department to come to serve as back up for the staff to have a "show of force" as a means to get the patient to accept an ordered medication for agitation and anxiety.

Review of Patient 29's medical record, interviews of the nurse working on the unit on 9/7/12, and the clinical nurse consultant led to the determination that the facility remained out of compliance with this condition.

Refer to the citation at 0142 and 0144 for additional information.

Based on record review and interview the facility failed to ensure care was provided in a safe setting for 1 of 2 sampled patients (Patient 29) selected from Behavioral Health Services (BHS). This failure placed the 6 patients that were on BHS Intensive Psychiatric Care (IPC) at potential risk for injury. On the day of entrance the census for both the West and the East Campus was 67. 8 of those patients were located on the BHS East campus. Findings are:

Review of the medical record for Patient 29 revealed an admission date of 8/18/12. The patient was admitted as an Emergency Protective Custody order (EPC) patient by the Madison County Sheriff's office as a danger to himself or others. An EPC is an involuntary admission order arranged by law enforcement following some type of bizarre and aberrant behavior in the community. Patient 29 was placed under the EPC because his father had visited him and found him to be acting confused, having mixed his oral medication with fluids and injecting it as well as taking amphetamines. He was acting delusional and the father called the police. The patient was committed to the facility by the Board of Mental Health for Madison County. Patient 29 had diagnoses of schizophrenia, paranoid type, amphetamine and Seroquel abuse (a medication used for schizophrenia), antisocial personality disorder, narcissistic personality traits, and impulse control disorder. Schizophrenia is defined as a mental disorder characterized by a breakdown of thought processes and by poor emotional responsiveness. It commonly features auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and is accompanied by significant social or occupational dysfunction. Antisocial personality disorder is defined as being characterized by a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood. A narcissistic personality is defined as a condition in which a person has an inflated sense of self-importance and an extreme preoccupation with themselves. Impulse control disorder is a psychiatric disorder characterized by impulsivity, failure to resist a temptation, urge or impulse that may harm oneself or others. Review of treatment notes, progress notes, psychological testing, social history, and nursing documentation found the patient was refusing to attend groups, refusing to have individual therapy, and acting out, threatening and cursing routinely on the unit.

The BHS units are contained on a separate campus from the acute care medical/surgical campus. The BHS units are on the East Campus approximately 1 mile from the acute medical/surgical West campus. The facility had a policy and procedure to deal with psychiatric emergencies called "Dr. Strong"with the last revision in effect dated 8/2012. Review of the hospital's "Dr. Strong" policy and procedure defined the purpose of the policy was "To provide guidelines for therapeutic intervention to de-escalate patient/visitor hostile/aggressive behavior in order to protect patients, visitors and staff from injury while maintaining an environment that fosters safety, dignity, and respect to all involved." When a "Dr. Strong" would be called it indicated that a patient was out of control, and all available staff trained to manage this type of emergency were expected to respond to the unit indicated. The policy also would lead to an automatic call to the local police to respond to the BHS units on the hospital's East Campus. If the staff felt the police were not needed for backup they would notify the dispatcher that the police did not need to come.

Review of the medical record revealed Patient 29 had 3 "Dr. Strong's" that were called due to aggressive, agitated and threatening behavior.

An interview with RN (Registered Nurse)-A on 9/10/12 at 4:45 PM revealed that staff were "scared" of Patient 29, especially on the third "Dr. Strong" that was called on 9/7/12. RN-A related the patient threatened to punch the nurse in the face if staff tried to give him an injection. RN-A said they wanted the police there for a show of force to get the patient to back down and take the ordered medication without anyone getting hurt. RN-A stated they "didn't feel safe." When asked if staff didn't feel safe, how could the patients be provided care in a safe setting? She responded she "never thought of that." There were 6 patients on the unit at the time this incident occurred, placing all 6 patients (including Patient 29) at risk for injury.

Review of the care plan for Patient 29 revealed the care plan was initiated on the date of admission [8/18/2012]. The staff did not make any changes to the interventions in the patients care plan following the initial date of 8/18/12 to assist staff in dealing with the patient's ongoing and increasing aggressive behaviors. The hospital had contracted with a consulting firm since the previous survey ending 7/12/2012. A clinical consultant had come on site to evaluate the program for Behavioral Health just 2 weeks before this survey. An interview with the consultant on 9/10/12 occurred between 3:00 and 4:30 PM. The consultant had found the facility depending on the police to back up staff to manage patient behaviors. The nurse consultant confirmed the staff's depending on the police was not appropriate. The consultant agreed police are trained to deal with criminal behavior on the streets, not psychiatric behaviors in a mental health hospital setting. The consultant said she had already started rewriting the policy and procedure for "Dr. Strong" that would eliminate calling the police. She was not planning to initiate it until the staff could be trained on the new policy and their confidence built up in their CPI skills. The consultant confirmed at the time of this survey the staff still did not have the necessary confidence in their skills to manage patients that were out of control and had violent or aggressive behaviors.

Refer to citation at 0144 for additional details.

Based on record review and interview the facility failed to ensure care was provided in a safe setting for 1 of 2 sampled patients (Patient 29) selected from Behavioral Health Services (BHS). This failure placed the 6 patients that were on BHS Intensive Psychiatric Care (IPC) at potential risk for injury. On the day of entrance the census for both the West and the East Campus was 67. 8 of those patients were located on the BHS East campus. Findings are:


Review of the medical record for Patient 29 revealed an admission date of 8/18/12. The patient was admitted as an Emergency Protective Custody (EPC) patient by the Madison County Sheriff's office. An EPC is an involuntary admission order arranged by law enforcement following some type of bizarre and aberrant behavior in the community. Patient 29 was placed under the EPC because his father had visited him and found him to be acting confused, having mixed his oral medication with fluids and injecting it as well as taking amphetamines. He was acting delusional and the father called the police. The patient was committed to the facility by the Board of Mental Health for Madison County. Patient 29 had diagnoses of schizophrenia, paranoid type, amphetamine and Seroquel abuse (a medication used for schizophrenia), antisocial personality disorder, narcissistic personality traits, and impulse control disorder. Schizophrenia is defined as a mental disorder characterized by a breakdown of thought processes and by poor emotional responsiveness. It commonly features auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and is accompanied by significant social or occupational dysfunction. Antisocial personality disorder is defined as being characterized by a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood. A narcissistic personality is defined as a condition in which a person has an inflated sense of self-importance and an extreme preoccupation with themselves. Impulse control disorder is a psychiatric disorder characterized by impulsivity, failure to resist a temptation, urge or impulse that may harm oneself or others. Review of treatment notes, progress notes, psychological testing, social history, and nursing documentation found the patient was refusing to attend groups, refusing to have individual therapy, and acting out, threatening and cursing routinely on the unit.

The BHS units are contained on a separate campus from the acute care medical/surgical campus. The BHS units are on the East Campus approximately 1 mile from the acute medical/surgical West campus. The facility had a policy and procedure to deal with psychiatric emergencies called "Dr. Strong"with the last revision in effect dated 8/2012. Review of the hospital's "Dr. Strong" policy and procedure defined the purpose of the policy was "To provide guidelines for therapeutic intervention to de-escalate patient/visitor hostile/aggressive behavior in order to protect patients, visitors and staff from injury while maintaining an environment that fosters safety, dignity, and respect to all involved." When a "Dr. Strong" would be called it indicated that a patient was out of control, and all available staff trained to manage this type of emergency were expected to respond to the unit indicated. The policy also would lead to an automatic call to the local police to respond to the BHS units on the hospital's East Campus. If the staff felt the police were not needed for backup they would notify the dispatcher that the police did not need to come.

Review of Nurses Notes documentation for 8/22/12 at 11:55 AM found Patient 29 was talking on the phone with a parent, and became increasingly loud, yelling vulgar language. Patient 29 was slamming his hand on the shelf near the phone repeatedly. The documentation revealed staff removed the other patients from the area, and gathered around the patient (a "Dr. Strong" procedure had been called). The patient was told that if he was going to continue to be so agitated he would have to end his phone call. The patient slammed the phone down and let it dangle from the cord. The patient then stood up quickly and walked to his room yelling all the way about how evil the staff were and that they didn't care about anyone. The staff followed him into his room and informed him they had a medication for him to take. The patient took the pill from the nurse and continued to yell at the staff. The nurse encouraged Patient 29 to take the pill, and he did take the medication while the staff were standing there in their "show of force." The patient was then left in his room.

Review of Psychiatric Technician Notes on 8/31/12 at 6:15 PM found documentation by a psychiatric tech [BHT-B] of circumstances leading to a second "Dr. Strong" incident. The notes stated the patient was being escorted by 2 staff from his room to the south quiet area [an area with tables and chairs] for "supper" at 6:00 PM. The notes describe the whole time Patient 29 was yelling and swearing at staff, calling them "M F's" and other things. There is nothing documented about redirection or de-escalation efforts being taken by staff. Even though he continued yelling and swearing he was allowed to sit and eat with the other peers. After eating his supper, Patient 29 returned to his room. [The patient rooms have cameras that cover the room but not the patient bathrooms. All patients are informed of this on admission.] While monitoring him by the camera in his room, the staff saw the patient go to the camera in his room and flip his finger at the camera, and he was seen yelling things at the camera. He would move away from the camera, then return, and then he came back to the camera and smeared something on it. A "Dr. Strong" was called. The staff approached him with their "show of force" and tried to give him an ordered prn (as needed) intramuscular (IM) injection of medication (Haldol-an antipsychotic, Ativan-an anti-anxiety medication, and Benadryl-an anti-histamine with sedative effects) to decrease his agitation. There is nothing charted about trying to give him oral medications that were also ordered for agitation and anxiety that may have been beneficial if given prior to his eating his evening meal. They were able to give him the IM medication with the team of staff present, and then the patient was left in his room. Nurses Notes documented on 8/31/2012 at 6:30 PM by the RN on the shift noted the patient had been yelling and swearing at and about staff during the meal with the other patients confirming the patient was allowed to eat with peers while displaying agitated and angry behaviors.

Review of the medical record's Physician Progress Notes dated 9/7/12 found documentation that the patient was being seen for medication adjustments. The psychiatrist noted the patient was non compliant with taking medications as prescribed when not being supervised in a controlled setting. To manage this behavioral problem of non compliance with medications, the psychiatrist had started the patient on a drug that is given 1 time per month (Invega Sustena-a long acting drug for schizophrenia). The notes reveal when the psychiatrist talked to the patient about starting this drug initially, she did not inform the patient that after the first injection is given, a second injection needs to be given a week later. Then following that injection, the medication is given by injection monthly. The patient had believed the medication would not be given again for a month. On 9/7/12 Patient 29 was due to receive the second injection. When the psychiatrist told the patient this, he became very angry and agitated. The Progress Notes document "the patient was coming quite rapidly down the hall, looking furious with his fists balled up and extremely angry, and he loudly banged on the door, demanding to have a phone call now. The nurse opened the door and asked for the number he would like to have called. He continued to escalate. She was writing the number down to call, and he stated he was going to 'beat the shit' out of the nurse, punch her in the face. He continued to escalate. The patient had a history of getting on the phone and escalating even more. He would contact his parents and scream and yell and slam the phone and disrupt the unit, frightening the other patients."

According to the nursing documentation on 9/7/2012 at 11:30 AM by a Licensed Practical Nurse [LPN], the patient knocked on the door, yelling and cursing at staff and wanting to make a phone call to his parents. Further nursing documentation for 9/7/12 at 11:30 AM by the RN (Registered Nurse)-A notes that the "patient is very hostile and pointing at the psychiatrist rocking back and forth on his feet and with his hands balled into fists. He sees a nurse in the nurses station drawing up an injection and yells 'If you give me a shot, I'll punch you in the face'." The patient continued to stand at the nurse's station doorway staring at the staff through the window and threatening. The documentation continued with the statement that the Norfolk Police were called to come to assist with the patient due to his continuing threatening and aggressive behavior.

According to the "Dr. Strong" form for debriefing following this event, the unit had a total of 8 staff who responded and were available on the unit trained in Crisis Prevention Intervention (CPI) to manage this patient, including a trained security officer, but they still did not feel "safe" in dealing with the patient until the police arrived. With 2 police officers present Patient 29 backed down and allowed staff to give him the injection.

An interview with RN (Registered Nurse)-A on 9/10/12 at 4:45 PM revealed that staff were "scared" of Patient 29, especially on the third "Dr. Strong" that was called on 9/7/12. RN-A related the patient threatened to punch the nurse in the face if staff tried to give him an injection. RN-A said they wanted the police there for a show of force to get the patient to back down and take the ordered medication without anyone getting hurt. RN-A stated they "didn't feel safe." When asked if staff didn't feel safe, how could the patients be provided care in a safe setting? She responded she "never thought of that." There were 6 patients on the unit at the time this incident occurred, placing all 6 patients (including Patient 29) at risk for injury.

Review of the care plan for Patient 29 revealed the care plan was initiated on the date of admission [8/18/2012]. The staff did not make any changes to the interventions in the patients care plan following the initial date of 8/18/12 to assist staff in dealing with the patient's ongoing and increasing aggressive behaviors.

The hospital had contracted with a consulting firm since the previous survey ending 7/12/2012. A clinical consultant had come on site to evaluate the program for Behavioral Health just 2 weeks before this survey. An interview with the consultant on 9/10/12 occurred between 3:00 and 4:30 PM. The consultant had found the facility depending on the police to back up staff to manage patient behaviors. The nurse consultant confirmed depending on the police was not appropriate. The consultant agreed police are trained to deal with criminal behavior on the streets, not psychiatric behaviors in a mental health hospital setting. The consultant said she had already started rewriting the policy and procedure for "Dr. Strong" that would eliminate calling the police. She was not planning to initiate it until the staff could be trained on the new policy and their confidence built up in their CPI skills. The consultant confirmed at the time of this survey the staff still did not have the necessary confidence in their skills to manage patients that were out of control and had violent or aggressive behaviors.

Based on medical record review, and interview the facility failed to ensure 1 of 2 sampled inpatients (Patient 29) selected from the Behavioral Health Services [BHS] on the East Campus had updates to the plan of care. The facility failed to develop nursing interventions to manage the patient's increasing aggressive behavioral issues, non compliance with attending groups, and refusing individual therapy. On the day of entrance the hospital census was 67 with 8 patients on the Behavioral Health Services program. Findings are:

Review of the medical record for Patient 29 revealed an admission date of 8/18/12. The patient was admitted as an Emergency Protective Custody (EPC) patient by the Madison County Sheriff's office. An EPC is an involuntary admission order arranged by law enforcement following some type of bizarre and aberrant behavior in the community. Patient 29 was placed under the EPC because his father had visited him and found him to be acting confused, having mixed his oral medication with fluids and injecting it as well as taking amphetamines. He was acting delusional and the father called the police. The patient was committed to the facility by the Board of Mental Health. Patient 29 had diagnoses of schizophrenia, paranoid type, amphetamine and Seroquel abuse (a medication used for schizophrenia), antisocial personality disorder, narcissistic personality traits, and impulse control disorder. Schizophrenia is defined as a mental disorder characterized by a breakdown of thought processes and by poor emotional responsiveness. It commonly features auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and is accompanied by significant social or occupational dysfunction. Antisocial personality disorder is defined as being characterized by a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood. A narcissistic personality is defined as a condition in which a person has an inflated sense of self-importance and a extreme preoccupation with themselves. Impulse control disorder is a psychiatric disorder characterized by impulsivity, failure to resist a temptation, urge or impulse that may harm oneself or others. Review of treatment notes, progress notes, psychological testing, social history, and nursing documentation found the patient was refusing to attend groups, refusing to have individual therapy, and acting out, threatening and cursing routinely on the unit.

Review of the Psychological Consultation completed on 8/29/12 revealed testing showed that Patient 29 had diagnoses of psychosis, schizophrenia, antisocial narcissistic personality disorder, drug and alcohol abuse. The report goes on to state "Further results suggest he is chronically maladjusted and is experiencing a high level of stress at this time. He is experiencing low morale and a depressed mood. Additionally, the results suggest he is immature and self indulgent, manipulating others for his own ends. He often behaves in an obnoxious, hostile, and aggressive ways. He rebels against authority figures and then refuses to accept responsibility for his own problems. He has an exaggerated and grandiose idea of his own capabilities and own personal worth. He is likely to be hedonistic and overuse alcohol and drugs. He appears to be quite impulsive and may act out against others without considering the consequences."

During his hospitalization, review of nursing notes, and physician progress notes documented he routinely demonstrated aggressive and threatening behaviors. Review of the progress notes, nursing documentation and the "Dr. Strong" debriefing report forms, Patient 29 had 3 episodes of aggressive and threatening behavior that led to staff calling a "Dr. Strong" (a procedure utilized to obtain extra assistance of staff to manage a psychiatric emergency situation with an out of control patient) to manage the patient's behavior. A "Dr. Strong was called for management of Patient 29's behaviors on 8/22/12, 8/31/12, and 9/7/12.

Review of the interdisciplinary care plan initiated on 8/18/12 (the day of admission) found the goals, (stated as "Care Plan Outcomes") were identified as safety of patient, thought processes return to baseline, social behavior appropriate, aggressive behavior controlled, and follow up care arranged at time of dismissal. The interventions for each of these problem goals were all dated 8/18/12. Progress notes and nursing documentation revealed the patient was: refusing to go to assigned groups; refused to meet for individual therapy; at times refused to cooperate with the medication regimen; and had aggressive and threatening behavior requiring 3 separate instances of calling a "Dr. Strong." Even though the staff were aware that when the patient called his parents he would become more agitated with his screaming and cursing them on the phone. The staff failed to address any of these specific behavior problems and failed to develop any additional interventions to try to manage these behaviors in the patient's plan of care.

An interview was completed on 9/18/12 at 3:45 PM with the new Director of Behavioral Health Services (DBHS) and the Clinical Director of Behavioral Health, Acute Rehab, & Home Health Services (CDBHS) regarding the care plan for Patient 29. CDBHS indicated there could be some notes in the computer documentation system that did not print out and she would check to see if there was any additional information that she could find regarding the care plan. The DBHS reviewed the plan of care and agreed it did not contain any indication of ongoing efforts to develop interventions to deal with increasing behaviors. In discussing the care plan, we also discussed triggers and calmer's or soothers that can be used to help de-escalate, or prevent escalation from occurring. The CDBHS indicated she was not aware that they had ever utilized the triggers and soothers concept. The new DBHS indicated he was very familiar with this technique, but had only been here for 2 days and had not had much time to become familiar with the programs. Both confirmed the care plan failed to meet the behavioral control needs of the patient. On 9/19/12 at 10:00 AM, CDBHS indicated no additional care plan information was found and confirmed the care plan was not updated to deal with the increasing behaviors presented by Patient 29.

Based on a review of the current policy regarding potentially infectious blood and blood components, staff interview and a lack of additional documentation, the laboratory failed to develop all the required elements of the HIV and HCV lookback policy.

A. A review of the current lookback policy lacked evidence of :
- a fully funded plan to transfer these records to another hospital, if this facility ceases operation;
- who will be responsible for notifying the patients attending physician and if the attending physician refuses to make the notification to the patient, who will accept responsibility for notifying the patient, legal guardian or relative;
- how this information will be documented in the patient's medical record;
- if the hospital is unable to locate the patient, how this will be documented in the patient's medical record and specify why the timeframe of 12 weeks has been exceeded. In addition, the hospital must complete these actions within one year;
- a basic explanation of the need for HIV or HCV testing and counseling, including enough information so that an informed decision can be made by the patient;
- a list of programs or places where the person can obtain HIV or HCV testing and counseling, including any requirements or restrictions the program may impose;
- for deceased patients, the physician or hospital must notify a legal representative or relative. If the recipient is a minor, the parents or legal guardian must be notified.

B. An interview, conducted with the Immunohematology Supervisor and the General Supervisor on 9/12/12 at 9:30 AM confirmed the above specified elements were lacking in the current policy.