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Based on observation, document review and interview it was determined that the Hospital failed to ensure the patients' rights were protected, including the rendering of care in a safe manner. As result, the Condition of Participation, Patient Rights (42 CFR 482.13) was not met. This potentially affected all 47 patients on census in the Behavioral Health Unit.

Findings include:

1. The Hospital failed to ensure the complaint was investigated through to resolution, in accordance with the complaint/grievance policy. (A-119)

2. The Hospital failed to ensure patient safety rounds were conducted in accordance with policy. (A-144)

3. The Hospital failed to ensure a physician's restraint order was obtained. (A-168)

4. The Hospital failed to ensure proper de-escalation techniques for a patient with disruptive behavior (A-199)

Based on document review and interview it was determined that for 1 of 1 (Pt#1) clinical record reviewed that contained documentation of a patient complaint, the Hospital failed to ensure the complaint was investigated through to resolution, in accordance with policy.

Findings include:

1. Hospital policy entitled, "Patient Complaints/Grievances" (Revised 4/2014) required, "Definitions: Complaint: A...verbal concern ...from a patient regarding the quality or appropriateness of patient care that can be effectively addressed and resolved by informal means. Grievance ....verbal complaint that is made to the hospital by a patient ...regarding patients care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the Hospital's compliance with the CMS Hospital Condition of Participation... Patient Representative: An individual who is authorized to act on the behalf of the patient for purposes of resolving complaints or grievances involving the patient. Staff present: Includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location to resolve the patient complaint."

"If a patient care complaint cannot be resolved at the time of the patient complaint by staff present, is postponed for a later resolution, is referred to staff for a later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance. ...Procedure: 2. ...Representatives shall document the complaint or grievance in the Clarity event reporting system under "Patient/Visitor Compliments or Concerns."


2. Pt#1 was a 55 year old female admitted to the Behavioral Health Unit (BHU) on 6/8/15 with a diagnosis of depression.

Pt#1's nurses' progress notes were reviewed from 6/8/15-6/12/15. On 6/9/15 at 2:00 PM E #3 (Registered Nurse) documented "MHS (Mental Health Specialist) worker (E #1) came by and pt (Pt#1) said, 'is the black girl with the yellow dress gonna keep slapping people...'"

3. On 10/27/15 at 2:31 PM E#1 (MHS) was interviewed. E #1 stated "I remember Pt#1 had said I was slapping patients."

4. On 10/29/15 at approximately 7:09 AM the MHS (E#6) was interviewed. E#6 stated " the patient (Pt#1) told me that a staff member prior to my interaction assaulted and slapped her. I told the patient (Pt#1) that I would talk to my supervisor and patient's relations to resolve the issue and she thanked me. E#6 stated he notified the Manager (E#2).

5. On 10/29/15 at approximately 9:15 AM the Manager of the Behavioral Health Unit (E#2) was interviewed. E#2 stated to be aware of Pt#1 allegations. Pt#1 was delusional." E#2 stated he reviewed the footage (surveillance video) that are located in the unit hallways and common areas for the entire shift (6/9/15) . E#2 stated "this is a psychiatric unit and patients are delusional."E #2 stated he did not notice anything in these videos to be inappropriate therefore did not deem the allegation of E#1 slapping patients valid.

6. On 10/29/15 at approximately 10:30 AM the Vice President and Chief Nursing Officer (E#8) stated any of the staff that were made aware of Pt#1 allegation should have reported it: E#1 (MHS), E#2 (Manager of the Behavioral Health Unit), E#3 (Registered Nurse) and E#7 (MHS). E#2 stated if the complaint is not entered in Clarity (Electronic occurrence reporting system), there is no trigger for the Chief Experience Officer (E#9) to be made aware and for her to notify the appropriate staff to initiate an investigation.

7. On 10/30/15 at approximately 9:30 AM E #9 (Chief Experience Officer) was interviewed. E #9 stated she had received a complaint that involved Pt#1 but it was not in reference of staff slapping patients. E #9 stated she was not aware of this allegation.

8. On 10/30/15 at 11:00 AM the Complaint/Grievance log was reviewed from 6/9/15-10/29/15. The allegation regarding slapping Pt. #1, was not included in the log.

Based on document review and interview, it was determined that for 17 of 32 patients (Pt. #s 10-26), on the psychiatric unit (3 West) reviewed for safety rounds, the Hospital failed to ensure the patient safety rounds were conducted in accordance with policy.

Findings include:

1. Hospital policy entitled, "Patient Safety Rounds" (Revised 1/2015) indicated "It is the policy of... Department of Psychiatry, that the patient safety rounds occur every 15 minutes and these rounds are documented. This includes identifying all patients on the unit on a pre-designed room list of all patients on the unit. Procedure: ... The rounds are completed by identifying each patient individually and noting location, behavior, activity and by checking each exit door..."

2. On 10/28/15 at approximately 1:45 PM the "High risk precaution/observation flowsheet" of the 3 West in-patient psychiatric unit was reviewed. The form lacked documentation from 1:15 PM to 1:45 PM ( a total of 30 minutes) for the following patients, who required monitoring every 15 minutes:

-Pt. #10, a 36 year old male admitted on 10/14/15 with a diagnosis of bipolar disorder, was on assault, suicide and sexual acting out precautions.

- Pt. #11, a 37 year old male admitted on 10/23/15 with a diagnosis of schizoaffective disorder, was on assault precaution.

-Pt. #12, a 23 year old male admitted on 10/22/15 with a diagnosis of schizophrenia paranoid, was on assault and suicide precautions.

-Pt. #13, a 42 year old male admitted on 10/26/15 with a diagnosis of bipolar disorder, was on assault precaution.

-Pt. #14, a 37 year old male admitted on 10/21/15 with a diagnosis of bipolar disorder, was on fall and suicide precautions.

-Pt. #15, a 60 year old male admitted on 10/19/15 with a diagnosis of severe major depressive disorder, was on suicide precaution.

-Pt. #16, a 45 year old male admitted on 10/22/15 with a diagnosis of bipolar disorder, was on assault precaution.

-Pt. #17, a 31 year old male admitted on 10/24/15 with a diagnosis of schizophrenia, was on suicide precaution.

-Pt. #18, a 26 year old male admitted on 10/21/15 with a diagnosis of paranoid schizophrenia, was on suicide precaution.

-Pt. #19, a 48 year old male admitted on 10/21/15 with a diagnosis of schizoaffective disorder, was on suicide precaution.

-Pt. #20, a 21 year old male admitted on 10/26/15 with a diagnosis of bipolar disorder, was on assault precaution.

-Pt. #21, a 30 year old male admitted on 10/23/15 with a diagnosis of major depression, was on assault and suicide precautions.

-Pt. #22, a 58 year old male admitted on 10/25/15 with a diagnosis of bipolar disorder, was on suicide precaution.

-Pt. #23, a 49 year old male admitted on 10/16/15 with a diagnosis of schizoaffective disorder, was on suicide precaution.

-Pt. #24, a 41 year old male admitted on 10/26/15 with a diagnosis of major depression, was on assault, fall, suicide and seizure precautions.

-Pt. #25, a 57 year old male admitted on 10/13/15 with a diagnosis of schizophrenia, was on assault, suicide, and sexual acting out precautions.

- Pt. #26, a 42 year old male admitted on 10/23/15 with a diagnosis of bipolar disease. Pt# 26's "High Risk Precaution/Observation Flowsheet" dated 10/28/15 indicated the patient was on assault and suicide precautions. The form lacked documentation from 1:15 PM to 1:45 PM (total of 45 minutes).

3. On 10/28/15 at approximately 1:46 PM the Mental Health Specialist (MHS) (E#1) stated she did not conduct the patient safety rounds because she was discharging a patient.

4. On 10/28/15 at approximately 1:50 PM findings were discussed with the Unit Manager of the Behavioral Health Unit (E#2). E#2 stated the assigned MHS to do the patient safety rounds had left the unit to take a patient to radiology and had endorsed the task to E#1. E#2 stated E#1 did not conduct the patient safety rounds.

Based on document review and interview, it was determined that for 1 of 2 (Pt#9) clinical records reviewed for restraints, the Hospital failed to ensure a physician's restraint order was obtained.

Findings include:

1. Policy entitled "Use of Restraints and Seclusion (Revised 9/2013), indicated "Addendum B..Restraints and Seclusion... The following sets forth the procedures for the use of Restraint or Seclusion is for behavioral health reasons in the Medical Center...Orders for Restraints or Seclusion: 3. The order should be entered before the initiation of Restraint or Seclusion except in an emergency. 4. In an emergency, a patient may be placed in Restraint or Seclusion to eliminate the immediate risk, and then an order obtained within one (1) hour of the application of the Restraints or Seclusion."

2. On 10/29/15 the clinical record of Pt#9 was reviewed. Pt#9 was a 65 year old male admitted on 9/22/15 to the Behavioral Health Unit with a diagnosis of Bipolar Disorder.
On 10/4/15 Pt#9 was placed in "4 point locked restraint" due to combativeness and not able to redirect. The "Restraint Care Flow Sheet" indicated Pt#9 remained in restraint from 1:30 PM to 2:45 PM. Pt#9's clinical record lacked a signed physician's order for the implementation of the restraint.

3. On 10/29/15 at approximately 10:38 AM, the above findings were discussed with E#6 (Vice President and Chief Nursing Officer). E#6 stated Pt#9's clinical record (electronic and hard copy) lacked a signed physician's order for restraints.

Based on interview and document review, it was determined that for 1 of 1 patient (Pt#1) reviewed for disruptive behaviors, the Facility failed to ensure the staff used proper de-escalation technique with a disruptive patient, and provide a safe environment to prevent harm. This resulted in Pt. #1 reportedly hitting her head on a rail.

Findings include:

1. On 10/28/15 at approximately 3:45 PM, the Director of Public Safety (E#5), was interviewed. E#5 stated he reviewed the surveillance video to verify the patient allegation of hitting her head after he was called d up to the unit to intervene due to disruptive behavior.. E#5 stated " It did appear she hit her head on the guard (hall side rail). E#5 stated " In the video I saw the patient (Pt#1) hit her head against the side rail and her head bounce off of it. " E#5 stated the staff used improper CPI techniques. E#5 stated " the way they grabbed her (Pt#1) that's how her head shifted. I am the CPI instructor and that is not what I teach in my class. "

2. Pt#1 was a 55 year old female admitted to the Behavioral Health Unit (BHU) on 6/8/15 with a diagnosis of depression. The Nurse Notes were reviewed from 6/8/15-6/12/15. On 6/9/15 at 2:00 PM the Registered Nurse, RN (E#3) indicated in his notes that Pt#1 had become threatening and aggressive to the staff.

3. On 11/13/15 at 11:30 AM the "Non-Violent Training Crisis Intervention Program Objectives" (reprinted 2014) were reviewed. The objectives indicated "Units I-VII 5. Provide for the Care, Welfare, Safety and Security of all those involved in a crisis situation."

4. On 11/13/15 at 10:57 AM E#8 (Vice President Chief of Nursing) stated there is no de-escalation policy or protocol.