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Based on observations and interviews, the hospital failed to ensure the requirements for the Condition of Participation for Governing Body were met as evidenced by the governing body failing to ensure that services offered and provided met the Medicare Conditions of Participation. Areas of noncompliance included Patient Rights (Refer to A-115, A-0144, and A-0154).

Based on observation, document review, and staff interview the hospital failed to assure equipment and furnishings were of a type (i.e. anti-ligature) to prevent injury to patients at risk for harmful behavior (refer to A-0144) and failed follow their policy and ensure patients are free from restraint or seclusion unless they are an immediate danger to themselves or others (refer to A-0154).
These deficient practices have the potential to create an unsafe patient environment.

At approximately 11:00 AM on 11/10/2016 during an observation of the patients rooms the following ligature risks were identified and communication with the Center for Medicare and Medicaid) Regional Office representative was notified and an Immediate Jeopardy (IJ). Survey staff notified administrative staff members (A, B, and L) of the Immediate Jeopardy situation. The Hospital provided the following plan of correction on 11/10/2016: on 11/10/2016 the facility will Replace Non-Tamper resistant screws with tamper resistant screws, Remove toilet paper holders, Shorten bathroom and shower curtains, remove box light fixtures in each patients room and they will place 2 additional hospital staff members on the units to serve as Safety Observers and they will conduct safety rounds every 15 minutes on every patient to ensure no patient is at risk and when a patient foes to the bathroom, staff will be present inside the patients bathroom. It was determined the Hospital abated the Immediate Jeopardy situation on 11/15/2016 at 10:30 AM Condition level noncompliance continued post abatement.

The hospital reported a current census of 44 patients. Based on observation, interview and document review, the hospital failed to assure equipment and furnishings were of a type (i.e. anti-ligature) to prevent injury to patients at risk for harmful behavior in four of four units (A, B, C, and D). This deficient practice has the potential to place all current and future patients at risk for injury or death.

Findings include:

- Unit A observed on 11/10/2016 at 9:35 AM revealed 14 lightweight chairs that are easily lifted and can be thrown by patients. A hallway cabinet observed was unlocked and contained plastic utensils, papers and other miscellaneous items. The unit has eight rooms (1-8) with two beds each and an attached bathroom. All rooms in unit A contained two bookcase type shelves with square tops, multiple outlet and light switch covers with non-tamper proof screws securing them in place and one approximately 24inch long horizontal light. The bathrooms contained faucet fixtures that were non-anti-ligature, a square box covering the toilet fixtures with a flat top surface, toilet paper holder, and non-anti-ligature shower fixtures.

- Unit B observed on 11/10/2016 at 9:50 AM revealed nine lightweight chairs that are easily lifted and can be thrown by patients. A hallway cabinet observed was unlocked and contained plastic utensils, papers and other miscellaneous items. The unit has eight rooms (9-11, and 13-16) with two beds each and an attached bathroom. All rooms in unit A contained two bookcase type shelves with square tops, multiple outlet and light switch covers with non-tamper proof screws securing them in place and one approximately 24inch long horizontal light. The bathrooms contained faucet fixtures that were non-anti-ligature, a square box covering the toilet fixtures with a flat top surface, toilet paper holder, and non-anti-ligature shower fixtures.
Room 12 revealed a painted wall with large areas of paint peeled from the wall, multiple outlet and light switch covers with non-tamper proof screws securing them in place and one approximately 24inch long horizontal light.
Administrative Staff I interviewed on 11/10/2016 at 10:15 indicated room #12 was the room they are currently in the process of constructing to be ligature risk free.

- Unit C observed on 11/10/2016 at 10:10 AM revealed seven lightweight chairs that are easily lifted and can be thrown by patients. A hallway cabinet observed was unlocked and contained plastic utensils, papers and other miscellaneous items. The unit has six rooms (17-22) with two beds each and an attached bathroom. All rooms in unit A contained two bookcase type shelves with square tops, multiple outlet and light switch covers with non-tamper proof screws securing them in place and one approximately 24inch long horizontal light. The bathrooms contained faucet fixtures that were non-anti-ligature, a square box covering the toilet fixtures with a flat top surface, toilet paper holder, and non-anti-ligature shower fixtures.

- Unit D was observed on 11/10/2016 at 11:50 AM revealed six lightweight chairs that are easily lifted and can be thrown by patients. A hallway cabinet observed was unlocked and contained plastic utensils, papers and other miscellaneous items. The unit has four rooms (23-26) with two beds each and an attached bathroom. All rooms in unit A contained two bookcase type shelves with square tops, multiple outlet and light switch covers with non-tamper proof screws securing them in place and one approximately 24inch long horizontal light. The bathrooms contained faucet fixtures that were non-anti-ligature, a square box covering the toilet fixtures with a flat top surface, toilet paper holder, and non-anti-ligature shower fixtures.

- All four units (A, B, C, an D) have an emergency exit door with a metal bar going across the middle of the door that would allow an item to be looped around it, cabinet handles that would allow for looping, a whiteboard with a ledge, all door handles and door hinges, and furniture that is light enough to be easily moved.

Potential Environmental Risk document reviewed on 11/10/2016 at 11:00 AM revealed the facility had identified the following ligature risks on 1/13/2016 during a walk through conducted by Risk Management Staff on all four patient care units (A, B, C, and D):
YWC cabinets unlocked, Toilet paper dispensers, Water knobs for skin/showers, Room doors, Non-tamer resistant screws, Toilet seats, Patient storage shelves, uncovered outlets, exit door handles, fire door handles, YWC tables/chairs in hallways, Multi-purpose room furniture, light weight chairs, YCW cabinet handles, Whiteboard ledge, and protruding water fountain.
Sanctuary Status Sheet document reviewed on 11/10/2016 at 12:00 PM revealed an observation document with times prefilled in and at regular intervals for the 7:00 AM until 2:45 PM. This practice of prefilling in times decreases the accuracy of documentation and does not represent an irregular pattern of safety checks.

Risk Manager Staff A interviewed on 11/10/2016 at 1:00 PM revealed the facility is currently assigning two additional staff members to provide a security rounds check for each unit until all ligature risk items are removed. Staff A indicated all screws would be replaced with tamper resistant screws today (11/10/2016), All shower curtains will be hemmed to ensure staff can see the lower legs and feet of every patient while they are showering to ensure their safety, and toilet paper holders will be removed. Staff A reported staff members would accompany patients to the bathroom until all ligature risks are removed.
Hospital Data indicated the hospital is accredited by the Joint Commission, this was confirmed by Risk Manager Staff A on 11/15/2016 at 9:35 AM.

Policy titled " Safety Monitoring Orders "with an effective date of 6/2015 reviewed on 11/10/2016 at 10:45 AM directed "...All patients should be observed a minimum of four times per hour. Staff must document the patient ' s activity and location in an irregular pattern. For example, one check might be done 5-6 minutes early followed by checking again in 10 minutes followed exactly at 15 minutes ..."

The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with the Joint Commission patient safety goals as well as the current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).

Based on medical record review and staff interview the facility failed to follow their policy and ensure patients are free from restraint or seclusion unless they are an immediate danger to themselves or others. This deficient practice has the potential to create an unsafe patient environment.

Findings include:

- Patient #1's medical record reviewed on 11/7/2016 at 11:00 AM revealed the patient was admitted on 10/23/2016 with the following diagnosis: Autism, ADHD (Attention Deficit Hyperactivity Disorder, schizoaffective disorder (by history), Generalized Anxiety disorder, and PTSD (Posttraumatic stress disorder) and discharged on 10/26/2016. Medical record documentation revealed the patient was placed in a physical hold (restraint) on 10/24/2016 at 7:27 Am and was released at 7:38 AM.

- Outpatient therapist Staff H, interviewed on 11/7/2016 at 2:35 PM via telephone reported Patient #1 and their mother reported the following incident during their first appointment on 10/29/2016:
Staff H revealed when Patient #1 and their mother came in s/he reported they had a sore rib.
Staff H stated they asked the patient what happened and was told that their rib was broken. The patient stated that while they were at the hospital they had been restrained the morning after they arrived. The patient indicated two staff members tried to wake them up and they did not get up right away. Then staff pulled the mattress off the bed so s/he began somewhat kicking around, waving their arms and legs around. The patient said that one of the staff members got them on the ground and restrained them and put so much pressure under their arm area. The patient indicated to Staff H there was bruising and they had complained to staff about having pain, but all they did was just gave the patient an aspirin.
The patient's mother told Staff H that the patient was seen on Friday (10/28/2016) at an urgent care clinic and they confirmed the broken rib. The patient indicated there were not any other incidents that would have caused that type of injury.

- Family and Youth Specialist Staff C's Milieu Notes revealed, "Client was not willing to get up from the bed this morning. Staff made all efforts to help without restraining him, and had to call the supervisor in. Yet client refused to work with staff and as a result, client was restrained at this time. S/He was then forced out of their room".
Family and Youth Specialist Staff C interviewed on 11/9/2016 between 10:05 AM and 10:25 AM revealed the incident occurred between 7:00 AM and 7:15 AM he went to Patient # 1 ' s room and said his/her name twice but s/he would not talk so I thought s/he was still asleep. Staff C indicated they called another staff member to help because they thought that maybe their accent was too hard for the patient to understand. Staff C stated, "Patient #1 rolled off the bed and was kicking and in order to protect ourselves we had to try to get their legs so s/he doesn't kick". Staff C indicated that their documentation might not have reflected what s/he meant to say because they implied the incident was not considered a hold. Staff C acknowledged there was documentation and an order confirming it was a hold, but they did not agree that it actually was. Staff C agreed that this situation became more physical because the patient was not talking and then was kicking and being aggressive.
- Family and Youth Specialist Staff J interviewed on 11/10/2016 between 3:14 PM and 3:50 PM revealed they went into the patient's room because s/he did not want to get up, which indicated to staff that something was wrong with the patient. Staff J reported they went into the room to start processing (communicating) with the patient, but s/he was curled up in a ball and was ignoring staff and the questions they were asking. Staff J revealed the patient was non-verbal during the incident and the patient did not report or verbalize pain at any time.
Staff J indicated they went to the head of the patient's bed. The patient had their glasses in their hands, and staff believed they were broken so they went to grab them from the patients hand and that is when the patient started to kick. Staff J indicated the patient kicked Staff C who was located at the foot of the bed. Staff J revealed that is when they decided to initiate a hold claiming it was for safety reasons.
Staff J confirmed they begin waking patients up at 7:15 AM and believed the time of 7:27 AM was accurate for the initiation of the hold. Staff J confirmed they spent approximately 5 minutes trying to talk to the patient prior to the escalation and initiation of the hold and the only non-restrictive technique used was verbal communication by staff telling the patient repeatedly it was time to get up.
Staff J confirmed the patient did not attempt to move toward staff in an attempt to kick them nor did they make any gestures or motions to self-harm. Staff J confirmed Staff C did not try to step away from the patient to avoid their legs as they kicked. Staff J denied knowledge of the patient's medical history as they were assisting another staff member (Staff C) and they had no knowledge of the patient ' s diagnosis of PTSD, Autism, and past physical abuse.

- Physical Hold Order reviewed on 11/9/2016 at 3:00 PM revealed Physician Staff E signed a hold order on 10/24/2016 at 12:30 PM after it was initiated at 7:27 AM and discontinued at 7:38 AM.

- Physician Staff E interviewed on 11/9/2016 between 1:10 PM and 1:30 PM acknowledged they signed the Physical Hold Order and indicated they were informed of the incident that occurred on the unit on 10/24/2016. Staff E indicated they are not aware of any facility policy that requires a patient to get up and go to group. Staff E stated they have had discussions about not forcing a patient to come to group and stated "we do not want to put our hands on somebody to force them to participate when they are not dysregulated (unable to control emotional responses) and let them have that time to become more comfortable and go to group a little later."

- Family and Youth Manager Staff D interviewed on 11/9/2016 between 10:30 Am and 10:50 AM indicated they were called to assist with the hold involving patient #1 on 10/24/2016. Staff D indicated that when they arrived to patient #1's room s/he was already on the floor with two other staff members and in a hold, but the staff members were struggling with the patient. Staff D indicated they assessed the situation and took over the hold. Staff D indicated some of the methods they use to get patients up are by being annoying telling the patient "hey you need to get up" and being repetitive. Staff D confirmed we should not force a patient to get up because they can just have a staff member stay down the hallway with them.
Staff D indicated they had no concerns with the hold itself, but acknowledged they did not investigate what started the situation because they were told the patient had become aggressive when staff tried to wake the patient up. Staff D revealed they had been told at shift change that the patient was potentially aggressive so they did not question staff about the circumstances of the hold.

- Registered Nurse Staff F interviewed on 11/9/2016 between 3:05 PM and 3:18 PM acknowledged they observed Patient #1 in a hold but did not witness the start of the incident. Staff F indicated they were told the patient had been aggressive and was kicking. Staff F agreed a patient lying on the floor kicking was not a danger to self or staff and confirmed staff could have stepped away from the patients legs and allowed him/her to calm down.

- Registered Nurse Staff B interviewed on 11/9/2016 between 9:40 AM and 10:00 AM indicated they followed up with the well-being check after the restraint/hold was discontinued and had obtained the order, but did not witness the hold or the situation that caused it. Staff B stated if they had a patient that did not want to get up they would talk to the patient, turn the light on, tell them they cannot stay in bed all day, talk to them, strongly encourage them but stated they would not be physical with a patient or force them out of bed.

- Policy titled Restrain/Seclusion Use for Violent/Self-Destructive Behavior reviewed on 11/7/2016 at 10:15 AM directed "...Restraints or seclusion will be used only after all less restrictive measures have been considered and deemed inadequate to meet the need for patient safety. The benefit of placing a patient in restraint or seclusion must outweigh the risk of the intervention ..."

Based on interview and record review the Psychiatric Hospital failed to ensure that a medical history and physical must be completed and documented no more than 30 days before or 24 hours after admission and placed in patient ' s medical record within 24 hours after admission or registration for 1 of 19 records reviewed (Patient #4). Failure to ensure the processing of all patients' records in a timely manner according to applicable policies and procedures resulted in potential delay of medical record retrieval and medical information.


Findings included:


- Review of Medical Records #1 through 19, the medical records initially provided to the surveyors for review that could be reviewed on 11/9/2016 at 2:30 PM, revealed and identified that chart #4 (Patient # 4) did not have a History and Physical in the chart as a complete medical record. Patient #4 had an admission date of 5/11/2016


Administrative Staff I, Interviewed on 11/10/2016 at 8:20AM revealed that the facility had a policy in place regarding the History and Physical. Policy also acknowledges this is a deficient practice and produced policy on 11/10/2016 at 08:26 AM.


Policy titled, "Completion of the History and Physical," reviewed on 11/10/2016 directed staff that "...The history and physical must be available in the patient medical record on all inpatient/observation encounters within twenty-four (24) hours of admission ..."