HospitalInspections.org

Based on policy and procedure reviews, medical record reviews, staff personnel file reviews, hospital timeline documentation reviews, video surveillance review, staff assignment reviews, job description reviews, patient and staff interviews the hospital's Governing Body failed to provide oversight and assure the male adolescent unit was staffed ensuring a safe environment free from patient to patient abuse and patient to staff abuse.

The findings include:

1. The hospital failed to protect the rights of a patient by failing to maintain a safe environment free from patient to patient abuse and patient to staff abuse.

~Cross refer to 482.13 Patients' Rights, Condition Tag A0115.

2. Nursing services failed to staff the male adolescent unit (2 E) with adequate number of staff and adequately trained staff to ensure that the male adolescent was a safe environment free of patient to patient and patient to staff abuse.

~Cross refer to 482.23 Nursing Services, Condition Tag A0385.

3. The Quality Assessment Performance Improvement program failed to monitor the Code One process ensuring an effective process was in place for psychiatric emergencies with violent behaviors.

~Cross refer to 482.21 Quality Assessment Performance Improvement, Condition Tag A0263.

4. The hospital failed to ensure the safety and well-being of patients as referenced in the Life Safety survey completed 4-28-2010 .

~Cross refer to 482.41 Physical Environment, Condition Tag A0700.


10A NCAC 27 D .0304
10A NCAC 27 G .0201

Based on medical record reviews, hospital documentation timeline review, policy and procedure reviews, staff interviews and review of video surveillance the hospital failed to protect the rights of a patient by failing to maintain a safe environment free from patient to patient abuse and patient to staff abuse.

The findings include:

1. The hospital failed to provide a safe environment by the staff failing to maintain control of a psychiatric emergency on the male adolescent unit (2 E) in 9 of 9 patient medical records reviewed (#1, #3, #4, #5, #9, #10, #11, #12 and #13).

~Cross refer to 482.13(c)(2) Patients' Rights, Standard Tag A0144.

2. The hospital administration failed to ensure an environment free of abuse by failing to adequately staff the male adolescent unit.

~Cross refer to 482.13(c)(3) Patients' Rights, Standard Tag A0145.


10A NCAC 27D .0304

Based on policy and procedure reviews, medical record review, staff interviews and review of video surveillance the hospital failed to provide a safe environment by the staff failing to maintain control of a psychiatric emergency on the male adolescent unit (2 E) in 9 of 9 patient medical records reviewed (#1, #3, #4, #5, #9, #10, #11, #12 and #13).

The Findings include:

Review of the hospital policy "Code One Psychiatric Emergency date reviewed 9/09" revealed "In the event that the number of personnel at the site is not adequate to handle a psychiatric emergency without risk to the patient or staff, a Code One will be paged...In the event that the situation is so out of control that staff is unable to contain it and there is risk of injury, the police may be called...The Code One Leader is the person who will oversee the crisis and give all instructions to the members of the team dealing with the out of control patient. The Code One Leader is usually the person who has already been involved in the situation...It is essential that the person who is assuming this role clearly identifies him/herself as the leader to avoid confusion...When the team arrives, designate those you will need to participate in providing physical assistance with the patient. Ask others to check with the staff members managing the milieu for directions, such as providing assistance with other patients...The Code One Leader is the only one person to communicate with the patient...Staff member managing the Milieu. This person, designated by the nurse in charge is responsible for overseeing all other activities on the unit...Assign someone to be with the other patients away from the Code One activity...Lesser restrictive Interventions: removal from the stimulating situation, the offering of PRN medications, verbal intervention and taking the patient to his/her room with a staff member...When the code leader determines the patient will not respond to lesser interventions and has been given ample opportunity to do so, he/she will explain to the patient the need to escort him/her to the seclusion area. If the patient continues to resist and excalates his/her behaviors, the code leader will direct staff to physically intervene."

Open record review of patient #1 revealed an 11 year-old male admitted to the male adolescent unit on 02-11-2010 with "cyclothymia" (bipolar disorder). Record review revealed the patient had a history of violent behavior.

Closed record review of patient #3 revealed a 17 year-old male admitted to the male adolescent unit on 04-13-2010 with "oppositional defiant disorder, mood disorder and attention deficit hyperactive disorder." Record review revealed the patient had a history of "cutting and assaultive behavior".

Open record review of patient #4 revealed a 15 year-old male admitted to the male adolescent unit on 04-05-2010 with "cyclothymia, oppositional defiant disorder and borderline mental retardation". Record review revealed the patient had a history of aggressive behavior.

Closed record review of patient #5 revealed a 16 year-old male admitted to the male adolescent unit on 04-16-2010 with "bipolar schizophrenia". Record review revealed the patient had a history of aggressive/violent behavior.

Closed record review of patient #9 revealed a 15 year-old male admitted to the male adolescent unit on 03-25-2010 with "adjustment disorder with disturbance in conduct". Record review revealed the patient had a history of oppositional behavior and assaultive behavior.

Closed record review of patient #10 revealed a 14 year-old male admitted to the male adolescent unit on 04-13-2010 with a "cyclothymia and attention deficit disorder with hyperactive conduct". Record review revealed the patient had a history of assaultive and criminal behavior.

Closed record review of patient #11 revealed a 16 year-old male admitted to the male adolescent unit on 04-14-2010 with a "mood conduct disorder, polysubstance abuse and major depression". Record review revealed the patient had a history of gang activity with assaultive and criminal behavior.

Closed record review of patient #12 revealed a 13 year-old female admitted to the female adolescent unit on 04-07-2010 with a "cyclothymia". Record review revealed the patient had a history of self injurious behavior, violence and aggression.

Closed record review of patient #13 revealed a 16 year-old male admitted to the male adolescent unit on 04-16-2010. Record review revealed the patient had a history of assaultive behavior.

Interview with administrative risk management staff on 4-27-2010 at 1400 revealed the hospital had identified an incident on 4-18-2010 as "Grave" and started an investigation of the incident on 4-19-2010. The interview revealed on the 2 E unit (male adolescent unit) on 4-18-2010 at approximately 1800 a patient became agitated and assaulted another patient. The interview revealed a Code One (overhead page requesting assistance for phychiatric emergency) was "called". The interview revealed the agitated and violent behavior continued to escalate with 5 patients (patients #3, 5, 9, 10, and 11) becoming aggressive and violent. The interview revealed the incident required the assistance of the Police Department. The interview revealed this was the first time that they remembered the Police being involved in an incident at the hospital. The interview revealed one patient sustained injuries, three staff members had injuries, 1 MHT (Mental Health Technician sustained injuries, 1 security officer sustained injuries and third unknown). The interview revealed three patients were arrested and taken to jail. The interview revealed there had been"gang like behavior" with "1-2 ring leaders". The interview revealed the staff had identified areas of concern, the investigation was ongoing and no actions were taken since the investigation was still ongoing.

Review of hospital video surveillance for 4-18-2010 revealed at 1810 on the 2 E unit patients in the hallway in front of the nursing station and patient #9 at the nursing station talking with RN #1. The video revealed the patients pacing in front of the nurses station and grouping together (#s9, 3, 5, and 11) unsupervised in the ante room for the seclusion room for 56 seconds. At 1814 patient #9 was observed attacking patient #4 in front of the nursing station and joined by patient #11 and #10. RN #1 is observed pushing the Code One button and within seconds MHT #1 was observed jumping over the nursing station into the group of patients. MHT #2 came and pulled the patients apart from MHT #1 and Patient #4. Staff from other units were observed coming into camera view at this time ( less than 40 seconds after Code One paged). At 1815 Patient #9 and #11 were observed trying to attack MHT #1 and MHT #2 pulling the patients off of MHT #1. At 1815 physician #1 was observed sitting at the nursing station and patient #9 pacing around the nursing station without a shirt. Patient #11 was observed following closely with patient #9. Patient #9 was observed for approximately 4 minutes pacing the hall shirtless, making threatening gestures and appeared to be in an agitated state before the house supervisor arrived. When the supervisor arrived at 1818 she took patient #9 down the "long hall" outside of camera view. Patient #11 was observed to follow the supervisor. Video review revealed from 1814 to 1821 (7 minutes) patients #9, #11, and #10 displayed escalating and assaultive behavior with no effective staff intervention. At 1821 patient #9 was observed running from the long hall into the nursing station tackling MHT #1. Patient #11 shirtless was immediately running behind patient #9 along with patients #3 and 5. Patients #9, 3, 5 and 11 jumped on MHT #1 and went out of camera view. The physician was observed at the nursing station from 1815 through the last attack (1821) on MHT #1. Review of the video did not reveal staff member taking a lead role after the Code One was initiated. Review of the video did not reveal patients #9, 11, 3 and 5 displaying aggressive/violent behaviors being removed from the escalating situation. Video review revealed physician #1 was present from 1815 through 1821 and failed to engage or respond to the Code One psychiatric emergency.

Interview with risk analyst staff during the review of the video on 4-27-2010 at 1150 revealed the hospital had identified that the staff did not follow the Code One policy by staff not taking a leadership/control role "sooner after the first attack".

Interview with MHT #4 on 4-29-2010 at 1110 revealed he had been called in on 4-18-2010 at 1951 by the Assistant Director of Nursing to come and assist with a situation that was "out of control" on the 2 E unit. The interview revealed the lead MHT was also a hospital CPI (Crisis Prevention Institute - non violent crisis intervention) instructor. The interview revealed when there is a potential aggressive patient the staff are to verbally redirect the patient 1-2 times. If this does not de-escalate the patient the staff are then to redirect with setting limits such as removal of privileges. The interview revealed if redirection does not de-escalate the patient, then the patient should be removed from stimulating circumstances. The interview revealed when he arrived the police were present on the unit. Two officers were standing one each at entrances into the day room. The interview revealed two patients in the day room were still agitated/excited and another patient was in hand cuffs. The interview revealed the nursing station was considered a secured area and patients are not allowed in the station area. The interview revealed the staff member was asked on Tuesday 4-27-2010 to review the surveillance video of the incident on 4-18-2010. The interview revealed areas of concern were identified and staff needed to have education reinforcing the Code One policy and the CPI protocol.

Telephone interview with the nursing house supervisor on 4-29-2010 at 1455 revealed the supervisor was making rounds in the north area of the hospital when a Code One was called on 4-18-2010. The interview revealed the supervisor had worked on Friday 4-16-2010 and there had been a "fight" that day on the 2 E unit. The interview revealed the Code One may be connected to the Friday event. The interview revealed when she arrived on the unit there was no identified Code leader, she was told what had occurred and that patient #9 wanted to talk to her. The interview revealed patient # 10 was "egging" patient #9 on about a spitting incident. The interview revealed she talked patient # 9 to come down the hall with her so they could talk. The interview revealed within "few minutes" patient #11 came down towards her and patient #9. The interview revealed 5 to 6 other patients came down the hall. The interview revealed patient #11 was yelling. The interview revealed MHT #1 came into view in the nursing station and patient #11 while taking his shirt off said " there he is". The interview revealed patient #9 and #11 ran down the hall followed by two other patients. The interview revealed the patients jumped "on top of " MHT #1. The interview revealed she heard a Code One paged overhead about 4-5-6 times during the this time. The interview revealed the patients pushed through the door behind the nursing station and three patients ended up on the 2 W girls unit. The interview revealed patient #11 and #3 got onto the 2 W unit and patient #10 was on 2 W yelling at female patients in the day room. The interview revealed the staff got the three patients back to the 2 E unit. The interview revealed she called the "Respond" unit and requested male counselors to respond to 2 E and the Police needed to be called for assistance. The interview revealed the supervisor knew the staff assigned to the 2 E unit on second shift was "short".

In summary, staff failed to ensure a safe environment for patients and staff by failing to implement measures to decrease escalation exhibited by patients with a known history of aggressive, assaultive and or violent behaviors. Consequently, patient demonstrations of agitative and aggressive behavior progressed to patient to patient abuse and patient to staff abuse resulting in injury.






10A NCAC 27G .0202, .0204

Based on review of hospital investigative findings(timeline), staffing assignment reviews and staff interviews the hospital administration failed to ensure an environment free of abuse by failing to adequately staff the male adolescent unit.

The Findings include:

Interview with administrative staff on 4/28/2010 at 1400 revealed an initial review of an incident identified as "Grave" occurring on 4/18/2010 had been completed. The interview revealed the review indicated the staff did not take control of the incident in a timely manner and the staff did not remove the aggressive behavior patients or remove the rest of the patients from the escalating incident.

Review of the 1600 to 2400 (second shift) staff assignments for the male adolescent unit for 4-18-2010 revealed one Registered Nurse (RN #1), and two Mental Health Technicians (MHT#1 and 2). Review of the assignment revealed a contract staff (MHT #5) was assigned to patient #14 requiring 1: 1 (one staff to one patient only). The 2 E unit had a census of 22 patients including patient #14.

Interview on 4-29-2010 at 0930 with the staffing coordinator revealed the hospital has a matrix that denotes the number of staff in ratio to the number of patients on a unit. The interview revealed the matrix numbers do not include any variances such as special precaution patients or increased acuity level of the patients. The interview revealed staff would be added to the matrix if the acuity level increased. The interview revealed on the 2 E unit with a census of 22 would require one RN and three MHT's per the staffing matrix (excluding any one to one staff). The interview revealed based on a review of the assignment sheets for 4-18-2010 the 2 E unit was "short" one MHT per the matrix.

Telephone interview on 4-29-2010 at 1455 with RN #4 (House Supervisor assigned 4-18-2010 on second shift) revealed the she knew they were understaffed on the number of staff to the number of patients on the 2 E unit. The interview revealed MHT #5 assigned to 1:1 patient #14 did not have training in CPI and could not provide assistance during the incident. The interview revealed she told him to stay out of the hall for his protection.

In summary, the male adolescent unit failed to have adequate staff available to provide and maintain an abuse free environment. Therefore, facility staff failed to ensure a safe environment for patients and staff by failing to assess, supervise and implement measures to decrease escalation exhibited by patients with a known history of aggressive, assaultive and or violent behaviors. Consequently, patient demonstrations of agitative and aggressive behavior progressed to patient to patient abuse and patient to staff abuse resulting in injury.




10A NCAC 27D .0304

Based on incident report reviews, staff interviews and hospital documentation reviews the hospital failed to develop and maintain an effective monitoring system for the Code One process (process to request assistance needed for emergency psychiatric events) ensuring a safe patient environment.

The findings include:

1. The hospital failed to monitor the Code One process (process to request assistance needed for emergency phychiatric events) ensuring its effectiveness for providing a safe patient environment.

~Cross refer to 482.21(b)(2)(i) Quality Assessment and Performance Improvement, Standard Tag A0275.

2. The hospital failed to timely investigate a psychiatric emergency of patient to patient abuse and patient to staff abuse and implement corrective actions to promote a safe environment in 5 of 5 patient patients with incident reports reviewed (#3, #5, #9, #10 and #11).

~Cross refer to 482.21(c)(1) Quality Assessment and Performance Improvement, Standard Tag A0285.

Based on staff interviews and hospital documentation reviews the hospital failed to monitor the Code One process (process to request assistance needed for emergency psychiatric events) ensuring its effectiveness for providing a safe patient environment.

The Findings include:

Review of the hospital documentation of "Code One Drill Critique" revealed a drill was completed on first shift at 1444 on 4/7/2010, second shift at 1727 on 4/14/2010 and third shift at 0744 on 4/16/2010. Review of the critiques revealed the first drill conducted for first shift on 4/7/2010 had educational needs for the staff identified, the critique of the second drill on 4/14/2010 on second shift revealed the staff in the cafe "eating" did not respond to the drill and review of the critique for the third shift drill on 4/16/2010 revealed educational needs were identified regarding the staff's response when a patient "comes toward them." Review of the critiques revealed education was provided during the drill to the staff that responded to the specific drill.

Interview with administrative staff on 4/28/2010 at 1400 revealed an initial review of an incident identified as "Grave" occurring on 4/18/2010 had been completed. The interview revealed the review indicated the staff did not take control of the incident in a timely manner and the staff did not remove the aggressive behavior patients or remove the rest of the patients from the escalating incident.

Interview with nursing administrative staff and administrative quality/risk management staff on 4-27-2010 at 1130 revealed the hospital had an incident in March 2010 with a Code 1 in which a patient on the male adolescent unit (2E) had broken a window in the day room with his head and hand. The interview revealed the hospital did not have a system or process in place monitoring/evaluating the effectiveness of the response and process of a Code One. The interview revealed after this incident the staff requested that Code One drills be completed because the staff did not feel the Code One's were effective and questioned the appropriateness of the staff's response from other units. The interview revealed a Code 1 drill for each shift in April, 2010 had been completed. The interview revealed the initial results of the drills appeared that on day shift the staff on meal breaks did not respond to the Code One. The interview revealed no actions had been taken on results of the Code One drills. The interview revealed a critique of the drills had not been completed. The interview revealed the administrative staff had not decided exactly what the plans were for future monitoring of the Code One process. The interview revealed the administrative staff was not aware of the educational needs identified and if the educational needs had been addressed with all staff.

Based on incident report reviews, hospital documentation timeline review, staff interviews and observations the hospital failed to timely investigate a psychiatric emergency of patient to patient abuse and patient to staff abuse and implement corrective actions to promote a safe environment in 5 of 5 patient patients with incident reports reviewed (#3, #5, #9, #10 and #11).

The Findings include:

Review of an incident report dated 04-18-2010 for patient #3 revealed "pt (patient) as part of the mob attacked staff and damaged property". Further review revealed the patient threatened to punch staff, attacked a security guard, attempted to elope and pulled metal ceiling framing for use as a weapon resulting in patient injury. Review revealed the patient was placed in police custody and charged with assault.

Review of an incident report dated 04-18-2010 for patient #5 revealed "pt (patient) as part of the mob attacked staff and damaged property using damaged property to attack and threaten staff". Further review revealed the patient attacked and injured the security guard, attempted to elope and pulled metal ceiling framing for use as a weapon resulting in patient injury. Review revealed the patient was placed in police custody and charged with assault.

Review of an incident report dated 04-18-2010 for patient #9 revealed "pt (patient) attacked (patient #4). When staff intervened, staff was also attacked."

Review of an incident report dated 04-18-2010 for patient #10 revealed "pt (patient) was part of initial attack on staff when two peers went after male MHT. Pt was highly agitated due to peers being spit on by female peer".

Review of an incident report dated 04-18-2010 for patient #11 revealed "pt (patient) as part of the mob attacked staff and damaged property, using damaged property and threatened staff". Further review revealed the patient threatened girls on the female adolescent unit, attacked the security guard and used metal ceiling supports as weapons. Review revealed the patient was placed in police custody and charged with assault.

Review of the hospital "Grave Incident 4/18/2010 Initial Timeline" documentation revealed on on 4-18-2010 an incident of patient to patient abuse and patient to staff abuse occurred. Review of the documentation revealed a male adolescent patient (#9) became agitated after seeing a female adolescent patient (#12) in the courtyard that had "spit" on him earlier that day. Patient #9 demanded from the 2 E staff to see the House Supervisor. The patient's behavior continued to escalate. Review of the documentation revealed at 1814 patient #9 hit patient #4 and patient #10 joined in the fight (first attack). RN #1 initiated a Code One (overhead page requesting assistance from other areas for an emergent/violent situation). At the same time MHT #1 "went to break up the fight". MHT #1 was attacked while breaking up the fight (second attack). Patient #4 sustained injuries and was removed from the area. Patient #9's behavior continued to escalate. Review of the timeline revealed four other patients displaying agitated behavior (refusing to do as staff asked and encouraging others). Patient #9 and three other patients attacked MHT #1 (third attack). During the attack the patients gained entrance to the adjoining female adolescent unit (2 W). The patients continued with aggressive and threatening behaviors against the female adolescent patients that were locked in a day room with staff. Staff intervened and got the patients back to the 2 E. Timeline review revealed the staff did not gain control of the patients resulting in three patients getting metal frames from ceiling tiles and using them as "weapons". Timeline review revealed a security officer was attacked and sustained injuries (fourth attack). The Police department was notified for request for assistance to contain the situation. Eleven (11) police officers responded to the hospital. Timeline review revealed three patients (#3, #5 and #11) 16 years and older were arrested and incarcerated. Timeline review revealed the hospital started an investigation on 4-19-2010.

Administrative risk management staff interview on 4-27-2010 at 1400 revealed the investigation was still ongoing. The interview revealed no actions yet had been taken regarding the investigation findings. The interview revealed the Risk analyst was reviewing the video as part of the investigation.

Interview with Risk Analyst staff during review of video surveillance on 4-28-2010 (10 days after incident) at 1150 for 4-18-2010 revealed the staff member was not able to identify staff and patients on the video. The interview revealed she had been asked to review the video on 4-23 or 24-2010. The interview revealed she had other priorities and was told to completed those before starting the video review. The interview revealed she started the review on 4-24-2010 and could not identify individuals on the video. The interview revealed the hospital had identified taking control of the incident should have occurred sooner. The interview revealed she had not completed the video review.

Interview with the Chief Executive Officer and Chief Nursing Officer on 4-29-2010 at 1730 revealed the investigation was ongoing. The interview revealed a list of "Action Taken to Date from Incident Occurring on 4-18-2010" documentation. The interview revealed actions that had been taken were taken on 4-29-2010. The interview revealed the screening, admission and exclusion criteria were initiated on 4-29-2010. The interview revealed the hospital would exclude patients with "history of gang violent behavior." The interview revealed most of the actions identified would be completed after 4-29-2010.

Based on hospital job description review, policy and procedure reviews, personnel file reviews, incident report reviews, staff assignment reviews, video surveillance reviews and patient and staff interviews nursing services failed to staff the male adolescent unit (2 E) with an adequate number of staff and adequately trained staff to ensure that the adolescent male unit was safe and free from patient to patient and patient to staff abuse.

The Findings include:

1. The hospital's nursing service failed to provide adequately trained staff for the male adolescent unit 2 E, ensuring and maintaining control of the male adolescent hospital unit (2 East).

~Cross refer to 482.23(a) Nursing Services, Standard Tag A0386.

2. The hospital's nursing services failed to provide an adequate number of staff ensuring and maintaining control of the male adolescent hospital unit (2 East) to prevent patient to patient and patient to staff abuse.

~Cross refer to 482.23(b) Nursing Services, Standard Tag A0392.

3. Nursing services staff failed to ensure adequate nursing staff to provide oversight maintain control ensuring a safe environment in the male adolescent unit (2E) in 9 of 9 pateints reviewed (#1, #3, #4, #5, #9, #10, #11, #12 and #13).

~Cross refer to 482.23(b)(3) Nursing Services, Standard Tag A0395.

4. The hospital's nursing service failed to ensure contract staff were trained and qualified to follow hospital policy for 1 of 1 contract employee files reviewed (#5).

~Cross refer to 482.23(b)(6) Nursing Services, Standard Tag A0398.


10A NCAC 27G .0202, .0203, .0204

Based on the review of job descriptions, policies and procedures, staffing assignment sheets, surveillance camera video, personnel files, and staff interviews the hospital's nursing service failed to ensure staff were trained and responded to a psychiatric emergency according to protocol for 1 of 4 personnel files reviewed (#1).

The findings include:

Review of facility's "JOB DESCRIPTION AND PERFORMANCE EVALUATION FORM" for position title, Registered Nurse (RN), revealed "POSITION SUMMARY: ...Ensure environmental safety and crisis management for the patient population..." Review of job description revealed experience requirement to qualify for registered nurse position is "One year inpatient psychiatric experience with adults, adolescents and/or children preferred." Further review revealed qualifications for RN position included "Knowledge of milieu management" and "Ability to direct subordinates in the performance of their duties."

Review of facility's policy, CODE ONE PSYCHIATRIC EMERGENCY (CLS067, reviewed 9/09), revealed two important roles, Code One Leader and Staff Member Managing the Milieu. The policy revealed the "Code One Leader is the person who will oversee the crisis and give all instructions to the members of the team dealing with the out of control patient." The policy revealed the "Staff Member Managing the Milieu, designated by the charge nurse, is responsible for overseeing all other activities on the Unit, and should be clearly identified at the start of the procedure."

Review of facility's policy, ASSAULT PRECAUTIONS (CLS068AAAA, reviewed 9/09), revealed "all patients will be cared for by staff members who have received approved management of assaultive behavior training and are knowledgeable in de-escalation techniques." Policy review revealed that trained staff will be able to "...2. Institute appropriate treatment at the onset of increased patient agitation. 3. Ensure that patient and staff injuries are prevented and kept to a minimum during an assaultive crisis..."

Review of the 1600 to 2400 (second shift) staff assignments for the male adolescent unit for 4-18-2010 revealed one Registered Nurse (RN #1), and two Mental Health Technicians (MHT#1 and 2). Review of the assignment revealed a contract staff (MHT #5) was assigned to patient #14 requiring 1: 1 (one staff to one patient only). The 2 E unit had a census of 22 patients including patient #14.

Review of hospital video surveillance for 4-18-2010 revealed at 1810 on the 2 E unit patients in the hallway in front of the nursing station and patient #9 at the nursing station talking with RN #1. The video revealed the patients pacing in front of the nurses station and grouping together (#s9, 3, 5, and 11) unsupervised in the ante room for the seclusion room for 56 seconds. At 1814 patient #9 was observed attacking patient #4 in front of the nursing station and joined by patient #11 and #10. RN #1 is observed pushing the Code One button and within seconds MHT #1 was observed jumping over the nursing station into the group of patients. MHT #2 came and pulled the patients apart from MHT #1 and Patient #4. Staff from other units were observed coming into camera view at this time (less than 40 seconds after Code One paged). At 1815 Patient #9 and #11 were observed trying to attack MHT #1 and MHT #2 pulling the patients off of MHT #1. At 1815 physician #1 was observed sitting at the nursing station and patient #9 pacing around the nursing station without a shirt. Patient #11 was observed following closely with patient #9. Patient #9 was observed for approximately 4 minutes pacing the hall shirtless, making threatening gestures and appeared to be in an agitated state before the house supervisor arrived. When the supervisor arrived at 1818 she took patient #9 down the "long hall" outside of camera view. Patient #11 was observed to follow the supervisor. Video review revealed from 1814 to 1821 (7 minutes) patients #9, #11, and #10 displayed escalating and assaultive behavior with no effective staff intervention. At 1821 patient #9 was observed running from the long hall into the nursing station tackling MHT #1. Patient #11 shirtless was immediately running behind patient #9 along with patients #3 and 5. Patients #9, 3, 5 and 11 jumped on MHT #1 and went out of camera view. The physician was observed at the nursing station from 1815 through the last attack (1821) on MHT #1. Review of the video did not reveal staff member taking a lead role after the Code One was initiated. Review of the video did not reveal patients #9, 11, 3 and 5 displaying aggressive/violent behaviors being removed from the escalating situation. Video review revealed physician #1 was present from 1815 through 1821(six minutes) and failed to engage or respond to the Code One psychiatric emergency.
.
Personnel file review revealed RN #1 was licensed as an RN on 01/29/2010 and started employment at the facility on 04/05/2010. Personnel record review revealed RN #1 participated in Hospital Orientation on 04/05/2010-04/16/2010 (ten days of orientation). Further review revealed RN #1 completed Patient Safety competency on 04-26-2010, eight days after the psychiatric emergency.

Interview on April 28 at 0915 with RN #1 revealed new nurse orientation included "(one) day learning to deal with agitated patients." Interview revealed RN #1 was given a "five day unit orientation and the House Supervisor (RN #4) was available." Interview revealed RN #1 was charge nurse on 2nd shift (1600-2400) on Unit 2 East on 04/18/2010, the day of the psychiatric emergency. Interview revealed that 04/18/2010 was the second day this nurse had been assigned as charge nurse without a preceptor. Interview revealed during the "out of control situation" on 04/18/2010, the patients did not respond to verbal redirection. Interview revealed that redirection was the only de-escalation technique used during the psychiatric emergency. Interview revealed that other de-escalation techniques including seclusion, restraint, or medication were not used when verbal redirection proved ineffective. Interview revealed the roles of "Code One Leader" or "Staff Member Managing the Milieu" were not taken by staff during the psychiatric emergency. Interview revealed RN #1 did not direct staff responding to the "Code One." Interview with RN #1 revealed "I was frightened. I would not (attempt a therapeutic hold), they were much bigger."

Telephone interview on 4/29/2010 at 1500 with RN #4 (House Supervisor working on 04/18/2010) revealed that she responded to the psychiatric emergency and was not made aware of where staff were located and what immediate events had occurred. Interview revealed staff attempted to direct and redirect patients without successful intervention. Interview revealed redirection without success should lead to redirection with consequences. "If that is not effective, treat the escalating behaviors". Interview revealed that other available Crisis Prevention techniques were not used by staff during this psychiatric emergency to prevent escalation of behaviors.


10A NCAC 27G .0202, .0203, .0204

Based on incident report review, staff interview, staff assignment documentation review, hospital video surveillance review, and patient interview, the hospital failed to provide an adequate number of staff ensuring and maintaining control of the male adolescent hospital unit (2 East) to prevent patient to patient and patient to staff abuse.

The findings included:

Review of an incident report dated 04-18-2010 for patient #3 revealed "pt (patient) as part of the mob attacked staff and damaged property". Further review revealed the patient threatened to punch staff, attacked security guard, attempted to elope and pulled metal ceiling framing for use as a weapon resulting in patient injury. Review revealed the patient was placed in police custody and charged with assault.

Review of an incident report dated 04-18-2010 for patient #5 revealed "pt (patient) as part of the mob attacked staff and damaged property using damaged property to attack and threaten staff". Further review revealed the patient attacked and injured the security guard, attempted to elope and pulled metal ceiling framing for use as a weapon resulting in patient injury. Review revealed the patient was placed in police custody and charged with assault.

Review of an incident report dated 04-18-2010 for patient #9 revealed "pt (patient) attacked (patient #4). When staff intervened, staff was also attacked."

Review of an incident report dated 04-18-2010 for patient #10 revealed "pt (patient) was part of initial attack on staff when two peers went after male MHT. Pt was highly agitated due to peers being spit on by female peer".

Review of an incident report dated 04-18-2010 for patient #11 revealed "pt (patient) as part of the mob attacked staff and damaged property, using damaged property and threatened staff". Further review revealed the patient threatened girls on the female adolescent unit, attacked the security guard and used metal ceiling supports as weapons. Review revealed the patient was placed in police custody and charged with assault.

Interview on 04/28/2010 at 0910 with RN #1 responsible for the unit on 04/18/2010 revealed on 04/18/10 when patient #9 came back to the unit after dinner he was agitated because he had been "spit" at by a female patient in the cafeteria (patient #12). Interview revealed patient #9 was "fixated" on the thought of being spit at and displayed his agitation by yelling and pacing the unit hallway. Interview revealed patient #9 requested to speak with the house supervisor several times. Interview revealed one of the mental health technicians (MHT #1) had told him several times that the house supervisor ( RN #4) was not able to come right then and would come as soon as she was able. Interview revealed patient #4 was coming out of the day room and patient #9 threw patient #4 to the floor and punched him repeatedly in the head and face. Interview revealed that "about the same time" patient #10 was leaving the day room and also started "beating" patient #4 in the face and head. Interview revealed that the RN #1 called a "Code One". Interview revealed staff was trying to redirect the patients. Interview revealed that MHT #1 who had been behind the nursing station jumped over the nursing station counter and broke up the fight. Interview revealed the RN #1 moved patient #4 to a safer area, the supply room (because it had a door that locked), so the patient could be assessed for any injuries. Interview revealed patient #4 had received a cut on his lip from the attack. Interview revealed that the RN left patient #4 in the supply room for his safety and returned to the nursing station to see patients #3, 5, 9, 10, and 11 "milling around the nursing station talking about how the girl (that spit on him) needed to be punished and wanted to go to the other side" (the female adolescent unit which connected to the male adolescent unit by a door each entering to a common shared medical records area). Interview revealed the MHT #1 and MHT #2 directed the patients to go to their rooms a number of times to no avail. Interview revealed that patients #3, 5, 9, 10 and 11 each had threatening postures, and patients #9 and 11 were pacing up and down the hallway. Interview revealed that when the house supervisor (RN #4) arrived on the unit she went down the hallway where patients #9 and 11 were located. Interview revealed the agitation of the patients were escalating. Interview revealed redirection of the patients continued. Interview revealed approximately 2-3 staff had arrived on the unit in response to the "Code One", along with a security guard (which patient #5 threatened physical harm) and a physician was sitting at the nursing station. Interview revealed that patients #3, 5, 9, 10, and 11 attacked MHT #1 and "broke through to the female adolescent unit". Interview revealed patients #3, 5, 9, 10, and 11 were brought back to the male adolescent unit, by MHT #1 and MHT #2. Interview revealed redirection of the patients continued, but patients #3, 5 and 11 were still agitated and "ran down the hall to the exit door, pounding and kicking the door trying to elope and jumping up pulling the ceiling tiles down". Interview revealed patient #5 was 6'3" and had no problem reaching the ceiling. Interview revealed patients #3, 5, 11 ripped down the aluminum tracks that held the ceiling tiles and used them as weapons. Interview revealed "the situation was out of control and needed police back-up". RN #1 stated patients (patient #3) and ( patient #5) approached the nursing station and I saw that the weapon that (patient #3) was holding was bloody. Interview revealed that patients were asked to put down their weapons, and staff was still trying to redirect the patients. Interview revealed that patient #10 had earlier went to the day room followed by (patient #5) because he thought that if he was nice that he would get to leave (be discharged) the next day as planned", patient #3 was put in a therapeutic hold by MHT #2, and patient #11 went to seclusion. Interview revealed RN #1 was scared for his safety during this incident, and he did not try to initiate any therapeutic hold because the patients were "bigger" than him. Interview revealed that approximately 6-7 police arrived on the unit but "by this time, the situation had de-escalated somewhat". Interview revealed the police were present for approximately 40 minutes and arrested patients #3, 5 and 11. Interview revealed patient #9, who continued to be agitated and was not taken into custody because he was only 15 years old.

Interview on 04/28/10 at 1515 with RN #2 during the survey revealed that recently additional staff had been requested for 2 East, the male adolescent unit, on numerous occasions and was always told "we have to stay within the (staffing) matrix " such that RN #2 "just stopped asking. I knew there was going to be a riot".

Interview with staffing coordinator on 04/29/10 at 0930 revealed the staffing matrix for 2 East, the male adolescent unit, with a census of 22 patients should be a minimum of at least 1 RN and 3 MHT. Interview revealed additional staff may be requested if specific justification for needing the additional staff is provided.

Review of the 1600 to 2400 (second shift) staff assignments for the male adolescent unit for 4-18-2010 revealed one Registered Nurse (RN #1), and two Mental Health Technicians (MHT#1 and 2). Review of the assignment revealed a contract staff (MHT #5) was assigned to patient #14 requiring 1: 1 (one staff to one patient only). The 2 E unit had a census of 22 patients including patient #14.

Telephone interview on 04/29/10 at 1455 with the 04/18/10 RN #4 (house supervisor) revealed 2 East, the male adolescent unit, did not have adequate staff on 04/18/10 at 1800 when the "riot" occurred because they had 1 RN and only 2 MHTs. The interview revealed according to the staffing matrix the unit should have been staffed with at least 1 RN and 3 MHTs and this is before any changes in any patient need in acuity level is factored in.

Review of the hospital video surveillance for 04/18/10 revealed patients #9 and 10 attacked patient #4 in front of the nursing station at 1814. Video review revealed patients #3, 10, 9, 11, 4 and 1 moved to the area in front of the nursing station just after the altercation initiated. Video review revealed MHT #1 jumped over the nursing station, and tried to break up the fight. Video revealed patients dispersed with patients #9 and 11 pacing up and down corridor, patient #9 removed shirt, continued to pace with patient #11 at his side. Video review revealed as both patients were pacing back up the hall to the nursing station, patient #11 had removed his shirt as well. Video review revealed arms were thrashing around, patients appeared to be yelling and posturing in a threatening manner. Video review revealed patient #9 pushed MHT #2. Video review revealed patients #9 and 11 were behind the nursing station with shirts off, agitated as if yelling, and moving arms with posturing gestures (pulling pants up with insides of lower arms and moving forward with guarded position and shoulder forward). Video review revealed staff also behind the nursing station included a physician, MHT #1 and MHT #2. Video review revealed the house supervisor arrived on the unit and patient #9 who was pacing approached the house supervisor. Video review revealed the house supervisor, patient #9, patient #11 walked down the hall and numerous other patients followed until they were out of the camera view. Video review revealed RN #3 (staff from female adolescent unit) arrived on unit and was located behind the nursing station along with MHT #1, MHT #2, MHT #3, and physician #1. Video review revealed patients #9 and 11 returned back to the nursing station and pushed by the physician and RN #3, attacked MHT #1 and patients #3, 5, and 10 joined in the attacked. Video review revealed the house supervisor arrived back at the nursing station, picked up the telephone and made a call.

Interview on 04/28/10 at 1140 with MHT #4, the CPI (crisis prevention & intervention training) instructor, revealed any time patients remove their shirts and display any type of posturing gestures, staff should intervene because this is normally a display of impending assault.

Video review revealed there was an approximate 7 minute time span from the time patient #9 removed his shirt to the time he assaulted MHT #1 without appropriate intervention.

Interview with patient #4 on 04/28/10 at 1445 revealed he was attacked on 04/18/10 by patient #9 because patient #9 was angry that he had been spit on by a girl. Patient #4 stated that he overheard patient #9 say that he was going to hit someone because he was so mad, and about that time "he knocked me to the ground. Seconds later (patient #10) joined in. One was hitting me with his fist on one side of my head and the other was hitting me with his fist on the other side. I didn't want to fight back. I just yelled HELP, HELP, HELP, then 2 staff helped me. I heard a Code 1 called, and the nurse locked me in the supply room for my safety". Interview revealed the patient later went to the emergency department to have his injuries checked. Interview revealed patient #4 was afraid for his safety until patient #9 was discharged on 4/23/10.

In summary, the male adolescent unit failed to have adequate staff available to provide and maintain an abuse free environment. Therefore, facility staff failed to ensure a safe environment for patients and staff by failing to assess, supervise and implement measures to decrease escalation exhibited by patients with a known history of aggressive, assaultive and or violent behaviors. Consequently, patient demonstrations of agitative and aggressive behavior progressed to patient to patient abuse and patient to staff abuse resulting in injury.




10A NCAC 27G .0202, .0204

Based on policy and procedure reviews, medical record review, staff interviews and review of video surveillance, nursing services staff failed to ensure adequate nursing staff to provide oversight and maintain control ensuring a safe environment in the male adolescent unit (2E) in 9 of 9 pateints reviewed (#1, #3, #4, #5, #9, #10, #11, #12 and #13).

.

The Findings include:

Review of the hospital policy "Code One Psychiatric Emergency date reviewed 9/09" revealed "In the event that the number of personnel at the site is not adequate to handle a psychiatric emergency without risk to the patient or staff, a Code One will be paged...In the event that the situation is so out of control that staff is unable to contain it and there is risk of injury, the police may be called...The Code One Leader is the person who will oversee the crisis and give all instructions to the members of the team dealing with the out of control patient. The Code One Leader is usually the person who has already been involved in the situation...It is essential that the person who is assuming this role clearly identifies him/herself as the leader to avoid confusion...When the team arrives, designate those you will need to participate in providing physical assistance with the patient. Ask others to check with the staff members managing the milieu for directions, such as providing assistance with other patients...The Code One Leader is the only one person to communicate with the patient...Staff member managing the Milieu. This person, designated by the nurse in charge is responsible for overseeing all other activities on the unit...Assign someone to be with the other patients away from the Code One activity...Lesser restrictive Interventions: removal from the stimulating situation, the offering of PRN medications, verbal intervention and taking the patient to his/her room with a staff member...When the code leader determines the patient will no respond to lesser interventions and has been given ample opportunity to do so, he/she will explain to the patient the need to escort him/her to the seclusion area. If the patient continues to resist and excalates his/her behaviors, the code leader will direct staff to physically intervene."

Open record review of patient #1 revealed an 11 year-old male admitted to the male adolescent unit on 02-11-2010 with "cyclothymia" (bipolar disorder). Record review revealed the patient had a history of violent behavior.

Closed record review of patient #3 revealed a 17 year-old male admitted to the male adolescent unit on 04-13-2010 with "oppositional defiant disorder, mood disorder and attention deficit hyperactive disorder." Record review revealed the patient had a history of "cutting and assaultive behavior".

Open record review of patient #4 revealed a 15 year-old male admitted to the male adolescent unit on 04-05-2010 with "cyclothymia, oppositional defiant disorder and borderline mental retardation". Record review revealed the patient had a history of aggressive behavior.

Closed record review of patient #5 revealed a 16 year-old male admitted to the male adolescent unit on 04-16-2010 with "bipolar schizophrenia". Record review revealed the patient had a history of aggressive/violent behavior.

Closed record review of patient #9 revealed a 15 year-old male admitted 03-25-2010 with
"adjustment disorder with disturbance in conduct". Record review revealed the patient had a history of oppositional behavior and assaultive behavior.

Closed record review of patient #10 revealed a 14 year-old male admitted to the male adolescent unit on 04-13-2010 with a "cyclothymia and attention deficit disorder with hyperactive conduct". Record review revealed the patient had a history of assaultive and criminal behavior.

Closed record review of patient #11 revealed a 16 year-old male admitted to the male adolescent unit on 04-14-2010 with a "mood conduct disorder, polysubstance abuse and major depression". Record review revealed the patient had a history of gang activity with assaultive and criminal behavior.

Closed record review of patient #12 revealed a 13 year-old female admitted to the female adolescent unit on 04-07-2010 with a "cyclothymia". Record review revealed the patient had a history of self injurious behavior, violence and aggression.

Closed record review of patient #13 revealed a 16 year-old male admitted to the male adolescent unit on 04-16-2010. Record review revealed the patient had a history of assaultive behavior.

Interview with administrative staff on 4-27-2010 at 1400 revealed the hospital had identified an incident on 4-18-2010 as "Grave" and started an investigating of the incident on 4-19-2010. The interview revealed on the 2 E unit (male adolescent unit) on 4-18-2010 at approximately 1800 a patient became agitated and assaulted another patient. The interview revealed a Code One (overhead page requesting assistance for phychiatric emergency) was "called". The interview revealed the agitated and violent behavior continued to escalate with 5 patients (patients #3, 5, 9, 10, and 11) becoming aggressive and violent. The interview revealed the incident required the assistance of the Police Department. The interview revealed this was the first time that they remembered the Police being involved an incident at the hospital. The interview revealed one patient sustained injuries, three staff members had injuries 1 MHT (Mental Health Technician sustained injuries, 1 security officer sustained injuries and third unknown). The interview revealed three patients were arrested and taken to jail. The interview revealed there had been"gang like behavior "with "1-2 ring leaders". The interview revealed the investigation was ongoing. The interview revealed the staff had identified areas of concern. The interview revealed the hospital had not taken any actions at this time since the investigation was still ongoing.

Review of hospital video surveillance for 4-18-2010 revealed at 1810 on the 2 E unit patients in the hallway in front of the nursing station and patient #9 at the nursing station talking with RN #1. The video revealed the patients pacing in front of the nurses station and grouping together (#s9, 3, 5, and 11) unsupervised in the ante room for the seclusion room for 56 seconds. At 1814 patient #9 was observed attacking patient #4 in front of the nursing station and joined by patient #11 and #10. RN #1 is observed pushing the Code One button and within seconds MHT #1 was observed jumping over the nursing station into the group of patients. MHT #2 came and pulled the patients apart from MHT #1 and Patient #4. Staff from other units were observed coming into camera view at this time (less than 40 seconds after Code One paged). At 1815 Patient #9 and #11 were observed trying to attack MHT #1 and MHT #2 pulling the patients off of MHT #1. At 1815 physician #1 was observed sitting at the nursing station and patient #9 pacing around the nursing station without a shirt. Patient # 11 was observed following closely with patient #9. Patient #9 was observed for approximately 4 minutes pacing the hall shirtless, making threatening gestures and appeared to be in an agitated state before the house supervisor arrived. When the supervisor arrived at 1818 she took patient #9 down the "long hall" outside of camera view. Patient #11 was observed to follow the supervisor. Video review revealed from 1814 to 1821 (7 minutes) patients #9, #11, and #10 displayed escalating and assaultive behavior with no effective staff intervention. At 1821 patient #9 was observed running from the long hall into the nursing station tackling MHT #1. Patient #11 shirtless was immediately running behind patient #9 along with patients #3 and 5. Patients #9, 3, 5 and 11 jumped on MHT #1 and went out of camera view. The physician was observed at the nursing station from 1815 through the last attack (1821) on MHT #1. Review of the video did not reveal staff member taking a lead role after the Code One was initiated. Review of the video did not reveal patients #9, 11, 3 and 5 displaying aggressive/violent behaviors being removed from the escalating situation. Video review revealed physician #1 was present from 1815 through 1821(six minutes) and failed to engage or respond to the Code One psychiatric emergency.

Interview with risk analyst staff during the review of the video on 4-27-2010 at 1150 revealed the hospital had identified that the staff did not follow the Code One policy by staff not taking a leadership/control role sooner.

Interview with MHT #4 on 4-29-2010 at 1110 revealed he had been called in on 4-18-2010 by the Assistant Director of Nursing to come and assist with a situation that was "out of control" on the 2 E unit. The interview revealed the lead MHT was also a hospital CPI (Crisis Prevention) instructor. The interview revealed when there is a potential aggressive patient the staff are to verbally redirect the patient 1-2 times. If this does not de-escalate the patient the staff are then to redirect with setting limits such as removal of privileges. The interview if redirection does not de- escalate the patient then the patient should be removed from stimulating circumstances. The interview revealed when he arrived the police were present on the unit. Two officers were standing one each at entrances into the day room. The interview revealed two patients in the day room were still agitated/excited and another patient was in hand cuffs. The interview revealed the nursing station was considered a secured area and patients are not allowed in the station area. The interview revealed the staff member was asked on Tuesday 4-27-2010 to review the surveillance video of the incident on 4-18-2010. The interview revealed areas of concern were identified and staff needed to have education reinforcing the Code One policy and the CPI protocol.

Telephone interview with RN #4 (house supervisor) on 4-29-2010 at 1455 revealed the supervisor was making rounds in the north area of the hospital when a Code One was called on 4-18-2010. The interview revealed the supervisor had worked on Friday 4-16-2010 and there had been a "fight" that day on the 2 E unit. The interview revealed the Code One may be connected to the Friday event. The interview revealed when she arrived on the unit there was no identified Code leader, she was told what had occurred and that patient #9 had wanted to talk to her. The interview revealed patient # 10 was "egging" patient #9 on about a spitting incident. The interview revealed she talked patient #9 to come down the hall with her so they could talk. The interview revealed within "few minutes" patient #11 came down towards her and patient #9. The interview revealed 5 to 6 other patients came down the hall. The interview revealed patient #11 was yelling. The interview revealed MHT #1 came into view in the nursing station and patient #11 while taking his shirt off said " there he is". The interview revealed patient #9 and #11 ran down the hall followed by two other patients. The interview revealed the patients jumped "on top of " MHT #1. The interview revealed she heard a Code One paged overhead about 4-5-6 times during the this time. The interview revealed the patients pushed through the door behind the nursing station and three patients ended up on the 2 W girls unit. The interview revealed patient #11 and #3 got onto the 2 W unit and patient #10 was on 2 W yelling at female patients in the day room. The interview revealed the staff got the three patients back to the 2 E unit. The interview revealed she called the "Respond" unit and requested male counselors to respond to 2 E and the Police needed to be called for assistance. The interview revealed the supervisor knew the staff assigned to the 2 E unit on second shift was "short".

In summary, staff failed to ensure a safe environment for patients and staff by failing to adequately supervise the care delivery and rimplement measures to decrease escalation exhibited by patients with a known history of aggressive, assaultive and or violent behaviors. Consequently, patient demonstrations of agitative and aggressive behavior progressed to patient to patient abuse and patient to staff abuse resulting in injury.


10A NCAC 27D .0202, .0204

Based on the review policies and procedures, personnel file, job description and staff interviews the hospital's nursing service failed to ensure contract staff were trained and qualified to follow hospital policy for 1 of 1 contract employee files reviewed (#5).

The findings include:

Review of facility's policy, BEHAVIOR MANAGEMENT PROGRAM (CLS068AAA, reviewed 9/09), revealed "...3. Mandatory training in Crisis Prevention Intervention procedures for all clinical staff and any other employees who participate in such situations."

Review of the facility "Job Description and Performance Evaluation Form" revealed qualification requirements for the MHT position included "licensure/certification: current North Carolina driver's license, current CPR certification and CPI certification". Further review revealed the following mandatory requirements: "... 1. fire/safety/disaster/MSDS/MOST, 2. infection control, 3. confidentiality/HIPPA, 4. CPR (maintains current licensure & certification), 5. CPI (maintains current certification ), 6. equipment competency, 7. documentation, 8. corporate compliance, 9. therapeutic boundaries, 10. patient neglect and abuse..."

Review of personnel file for MHT #5 revealed the staff member was a contract staff. File review revealed MHT #5 had a signed, non dated job description for "Mental Health Technician". Review of the job description revealed key responsibilities included "...Must successfully complete competencies for this position...Provides hands-on physical care, supervision, crisis intervention, behavior management..." Review of personnel file revealed no documentation of Crisis Prevention Institute (CPI) training, a policy requirement for all clinical staff. Personnel file review revealed no required documentation, respectively.

Telephone interview on 04/29/2010 at 1455 with RN #4 (House Supervisor assigned 04/18/2010 on second shift) revealed MHT #5 was assigned 1:1 with patient #14. Interview revealed MHT #5 did not have training in CPI therefore could not provide assistance during the Code One psychiatric emergency on 04/18/2010.


10A NCAC 27D .0202, .0204

Based on observations, tours and staff interviews as referenced in the Life Safety survey completed 4-28-2010 the hospital failed to ensure the safety and well-being of patients.

The findings include:

1. The hospital failed to develop and maintain a safe physical plant and overall safe environment assuring the safety and well being of patients.

~Cross refer to 482.41(a) Physical Environment, Standard Tag A0701.

2. The hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association assuring the safety and well being of patients.

~Cross refer to 482.41(b)(1)(2)(3) Physical Environment, Standard Tag A0710.

Based on observations, tours and staff interviews as referenced in the Life Safety survey completed 4-28-2010 the hospital failed to develop and maintain a safe physical plant and overall safe environment assuring the safety and well being of patients.

The findings include:

1. Observation of Building One on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
There was storage (plastic bin with cloths) throughout in the corridor on 2-west. During the fire drill conducted at the facility at the time of the survey the halls on 2-west were not cleared of item stored in the hall.

~Cross refer to Life Safety Code 2000 Health Existing K01.03, Standard NFPA 101, Tag 0072.

2. Observation of Building One on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) Full and empty oxygen cylinders were stored together. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (Room 44 and exam room 36).

~Cross refer to Life Safety Code 2000 Health Existing K01.03, Standard NFPA 101, Tag 0076.

3. Observation of Building Two on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) Facility was equipped with 5 master override switches in the facility and the staff was not provided with keys to operate the switches.

~Cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag 0038.

4. Observation of Building Two on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) On Hall 1, A & B North Corridor exit and directional signs are not presently displayed upon leaving 1-West and 1-East entering into A & B North corridor, 1st floor.

~Cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag 0047.

5. Observation of Building Two on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) When the facility conducted a fire drill at the time of the survey, staff did not close all resident room doors on 2nd floor.

~Cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag 0050.

6. Observation of Building Two on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) The shower curtain in all the patient showers are not provided with a mesh netting within 18 inched of the ceiling.

~Cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag 0074.

Based on observations, tours and staff interviews as referenced in the Life Safety survey completed 4-28-2010 the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association assuring the safety and well being of patients.

The Findings include:

1. Observation of Building One on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) Throughout the facility there are holes in the ceiling tile that were not sealed and maintained in good repair.
2) The facility could not verify the fire resistance rating of the ceiling tile in exit corridors in the facility.

~Cross refer to Life Safety Code 2000 Health Existing K01.03, Standard NFPA 101, Tag 0012.

2. Observation of Building One on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) On 1-west and 1-east there are a number of patient bedroom doors that did not close smoke tight in there frames.

~Cross refer to Life Safety Code 2000 Health Existing K01.03, Standard NFPA 101, Tag 0018.

3. Observation of Building Two on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) On the ground floor in the large storage rooms, records room and mechanical rooms there are PVC pipe penetrations in the 1-hr fire resistance rated walls and ceiling that are not properly protected with an approved UL or equivalent fire stop assembly.

~Cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag 0029.

4. Observation of Building Two on Tuesday 4/27/2010 between 1100 and 1700 the following was noted:
1) The key operated Fire Alarm Pull Station on 2nd floor, 2 North B at at stairwell did not operate on all keys provided for to staff.

~Cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag 0052.