HospitalInspections.org

Based on record review and interviews, the staff failed to ensure all contracted services had an agreement and had services monitored by 1 of 1 governing body to assure compliance. This deficiency has the potential to affect all 77 patients receiving treatment at this facility.

Findings include:

Per review of list of contracted services on 6/13/2016 at 2:30 PM, the list includes 59 Agency names who provide service at this facility.


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An interview was conducted with Medical Records Administrator Y on 6/13/2016 at 8:30 AM. Administrator Y stated this facility has off site storage of medical records contracted through Coakley Company and has not conducted an on site inspection of the medical record storage service to confirm the service is meeting hospital standards.

An interview was conducted with Facility Operations Manager E and Services Manager Z on 6/13/2016 at 12:15 PM. Manager Z stated the facility has a contract with Milwaukee County Department of Corrections Services and this facility does not conduct on site inspection of the laundry service to confirm the service is meeting hospital standards.

Review of an e-mail document from Chief Clinical Officer A on 6/15/2016 at 2:06 PM states "we do not have a laundry contract, however, there are written procedures that address collection, handling and processing."





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An interview with Dietitian G on 6/13/2016 at 10:10 AM stated food service is contracted through Aramark which stores, prepares and distributes food from an offsite location. Dietitian G stated there has not been an onsite inspection to confirm contracted foodservices is meeting hospital standards.

Based on record review and interview, the hospital failed to ensure that all patients/patient representatives were informed about the right to formulate an advanced directive, in 8 of 30 patients reviewed (Patient #'s 16, 17, 18, 19, 20, 23, 24, 25). This has the ability to affect 77 patients.

Findings include:

1) The 6/14/2016 record review of Patient #16 with Nurse manager H revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

2) The 6/14/2016 record review of Patient #17 with Nurse manager H revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

3) The 6/14/2016 record review of Patient #18 with Nurse manager H revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

4) The 6/14/2016 record review of Patient #19 with Nurse manager H revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

5) The 6/14/2016 record review of Patient #20 with Nurse manager H revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

6) The 6/14/2016 record review of Patient #23 with Nurse manager M revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

7) The 6/14/2016 record review of Patient #24 with Nurse manager M revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

8) The 6/14/2016 record review of Patient #25 with Nurse manager M revealed no documented evidence that the patient/patient representative had been informed about the right to formulate a traditional or psychiatric advanced directive. The "Advance Directive Acknowledgement Form" was not completed.

During interview with Nurse manager M on 6/14/2016 at 11:00 AM, M stated "It does not look like anything was recorded (about advanced directives for Patient's #23, 24, or 25)", and confirmed this in writing at 4:00 PM on 6/14/2016.

Per interview with Nurse Manager H on 06/14/2016 at 1:00 PM advance directive information was not documented in the medical records of pt.'s 16 - 20.

Based on observation and staff interview, the hospital failed to ensure a safe environmental setting for patients at risk for suicide, in 1 of 6 patient care areas observed (children's acute in-patient setting). This had the ability to affect all 10 patients on the unit.

Findings include:

During room observations on the children's acute in-patient care unit on 6/15/2016 at 12:13 PM, there were 3 rooms identified (26, 39 and 40) with ceiling fire sprinkler heads that would not break-away at the weight of 50 pounds or more. These traditional fire sprinkler heads were not recessed into the ceiling, and provided a surface that a rope or other material could be tied to for the purpose of suicide by hanging.

During interview with Facility Operations Manager E on 6/15/2016 at 12:13 PM, E stated that these 3 rooms "had been identified earlier today and signage was posted to prevent patient use until they are fixed".

Based on record review and interview, the hospital failed to ensure that a history and physical was obtained and documented as soon as possible after psychiatric admission, in 2 of 30 patients reviewed (Patient #'s 23, 24). This has the ability to affect all 77 patients being treated at this facility.

Findings include:

1) The 6/14/2016 record review of Patient #23 revealed an admission date of 6/9/2016 for treatment of Aggression and Psychosis. The "History and Physical exam report" printed 6/1420/16 at 1:14 PM revealed that no medical physical assessment ("Review of Systems") had been completed. Documentation showed the patient "refused" on 6/9/2016, 6/10/2016 and 6/11/2016. There was no documented evidence that the medical staff made any further attempts to identify medical problems through an physical examination of this patient.

2) The 6/14/2016 record review of Patient #24 revealed an admission date of 3/29/2016 for treatment of Schizophrenia and Psychosis. The "History and Physical exam report" printed 6/14/2016 at 11:50 AM revealed that no medical physical assessment ("Review of Systems") had been completed. Documentation showed the patient "refused" on 3/30/2016 and 3/31/2016. There was no documented evidence that the medical staff made any further attempts to identify medical problems through a physical examination of this patient.

During interview with Nurse manager M on 6/13/2016 at 11:00 AM, M stated "It does not look like anything was recorded".

Based on record review and interview, the hospital failed to ensure that nursing care plans revealed current health status, in 2 of 30 patients reviewed (Patient #'s 23 and 25). This deficiency has the potential to affect all 77 patients receiving treatment at this facility.

Findings include:

1) The 6/14/2016 record review of Patient #23's 6/9/2016 nursing "physical assessment screen" revealed "soreness to right foot...right wrist is wearing splint...limping on right side of foot...client recoiled in pain with right foot near the toes were touch (sic), refused to elaborate on injuries...".

The 6/14/2016 review of the "Recovery Plan face Sheet and Recovery Plan" revealed no informational care planned updates on these symptoms.

During 6/14/2016 at 4:30 PM interview with Chief Nursing Officer B, B stated "we identified issues with the nursing care plans and have been working on them".

2) The 6/14/2016 record review of Patient #25's 5/2/2016 medical history and physical revealed "current Bronchitis...Scabies...and chest pain (of possible cardiac nature)".

The 6/14/2016 review of the "Recovery Plan face Sheet and Recovery Plan" revealed no informational care planned updates on these diagnoses/ symptoms.

During 6/14/2016 at 4:30 PM interview with Chief Nursing Officer B, B stated "we identified issues with the nursing care plans and have been working on them".

Based on record review, observation, and interview, the hospital failed to ensure medications were properly stored and that outdated biologicals were not available for patient use. This could potentially affect all 77 patients receiving treatment at this facility.

Findings include:

Facility policy #1708191; "Expired and other unusable medications", dated 05/01/2015, states: "Expired medications and other unusable medications are stored in a manner that prevents their use and distribution and ensures that they are disposed of safely."

Facility policy #2412802; "Procedure: BHD (Behavioral Health Department) Hospital Snack Delivery and Kitchenette Inventory Management", dated 06/14/2016 states: "Unit staff are responsible for rotating stock and discarding expired stock as part of daily environmental rounds."

Per tour of the observation unit on 06/13/2016 between 10:00 AM and 11:00 AM with Nurse Manager L, observations in the medication room revealed: 2 outdated specimen tubes (Para-Pak C&S) expired on 06/2015.

Per tour of the Intensive Treatment unit on 06/13/2016 between 10:00 AM and 11:00 AM with Nurse Manager L, observations in the medication room revealed: 1 bottle of Abacavir/dolutegravir/lamivudine with no expiration date.

Per tour of the outpatient therapy gym on 06/14/2016 between 11:00 AM and 11:45 AM with OT J, observations in the gym revealed: A box of approximately 20 alcohol prep pads which had expired on 10/2013 outdated specimen tubes (Para-Pak C&S) expired on 06/2015 and a box of approximately 30 Skin Prep Wipes which had expired on 12/2010.

Per tour of the inpatient therapy gym on 06/14/2016 between 11:00 AM and 11:45 AM with PT I, observations in the gym revealed: Glucose Tablets expired 05/2009, Alcare Plus - hand-rub expired 02/2007, Eye wash (a saline solution) expired 10/2003, Bowl Appetit (rice/chicken bowl) expired 10/2006 and (in the fridge) butter with canola oil expired 08/2015. I stated, in an interview, at the time of the observations that "therapy staff are responsible for checking outdates".

Based on observations, interviews and record reviews, both offsite foodservice department and onsite foodservice department did not meet food safety standards - staff did not have hair appropriately covered and staff continued using dishmachines even though temperatures were not at levels to ensure effective sanitization of utensil surfaces and several times were noted when no temperatures were recorded. At the offsite foodservice department, three industrial pedestal fans had visible layers of thick dust, oven was dirty and utensils were improperly stored, exposing them to cross-contamination. At the onsite foodservice department, staff was not aware of timeframe for returning to work following illness, and several food items were past expiration dates. These issues put all 77 patients at risk for a foodborne illness.

Findings:

MONITORING OF INTERNAL TEMPERATURE OF HOT WATER SANITIZATION DISH MACHINE
According to the 2013 Food and Drug Administration (FDA) Food Code, the nationally recognized professional standard of practice for food safety, a system needs to be in place for monitoring a hot water sanitization dishmachine ' s internal temperature to assure that food contact and utensil surfaces reach a temperature of 160oF as measured by an irreversible registering temperature indicator.

The temperature of hot water delivered must reach at least 160 degrees Fahrenheit on the surface of the utensil as measured by an irreversible registering temperature-measuring device to affect sanitization- enough heat to destroy pathogens that may remain on such surfaces after cleaning. To reach 160 degrees Fahrenheit, the final sanitizing rinse temperature must be at a minimum of 180 degrees Fahrenheit. If the final rinse exceeds 194 degrees Fahrenheit, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces.

OFFSITE FOODSERVICE DEPARTMENT DISHMACHINE
The offsite foodservice department uses a Hobart Model: FT9000 BD dishmachine. According to the manufacturer ' s instructions, the final rinse must be a minimum of 180°Fahrenheit to achieve proper sanitization.

On 6/13/2016, 12:46 PM-1:05 PM, off-site foodservice department dishmachine area, accompanied by Dietitian-G (D-G) and General Manager-S (GM-S), observed temperatures from external gauge of Hobart Model: FT9000 BD dishmachine. The dishmachine ' s final sanitizing rinse recorded at 166 degrees Fahrenheit. According to manufacturer ' s instructions and the 2013 Food and Drug Administration (FDA) Food Code, the final sanitizing rinse should be a minimum of 180 degrees Fahrenheit (external gauge). GM-S validated that the temperature did not meet the minimum temperature of 180 degrees Fahrenheit. Review of " Temperature Log 2, " 5/26/16 - 6/11/16 (current date is 6/13/2016) identified all (45 times) final sanitizing rinse temperatures were less than 168 degrees Fahrenheit. There were 6 blank areas where temperatures were not recorded. On the temperature log, there is a statement in section " Dishmachine Final Temp " - " Run digital waterproof thermometer through dishmachine with hold setting to verify 160o F or thermos-label. Do NOT use gauge outside machine. " Observed Foodservice Worker-X (FSW-X) removing thermometer from dishmachine after it was put through to get internal temperature of final rinse. During observation of this thermometer, FSW-X stated to check temperature quick before it began dropping. FSW-X was using a food thermometer and not a digital waterproof thermometer. Interview with FSW-X revealed using food thermometer to measure internal temperature of hot water sanitizing machine. FSW-X stated there are no thermos-label strips for recording internal dishmachine temperatures available and foodservice department does not have the correct waterproof thermometer. All temperatures recorded on log were from external gauge. Discussion with GM-S reveals no knowledge of this issue - first time heard about it.

On 6/15/2016, 5:00 PM, received dishmachine logs, 2/25/2016 - 6/11/2016, from General Manager-S (GM-S). Review of the logs revealed all temperatures recorded were less than the required minimum of 180 degrees Fahrenheit. The log dated 5/26/2016 - 6/11/2016 had all temperatures recorded. This is the same log a copy was made and provided on 6/13/2016, approximately 1:05 PM when present at the offsite foodservice department. At this time, six areas did not have recorded temperatures. The log ' s column noted as " D " had no recorded temperatures for the 3rd, 4th, 5th, 6th, 16th and 17th line.

ONSITE FOODSERVICE DEPARTMENT DISHMACHINE
The onsite foodservice department uses a Jackson Model: JFT-S dishmachine. According to the manufacturer ' s instructions, the final rinse must be a minimum of 180°Fahrenheit to achieve proper sanitization. Temperatures exceeding 194 degrees Fahrenheit can result in water becoming volatile and vaporizing reducing its ability to convey sufficient heat to sanitize utensil surfaces.

On 6/14/2016, 9:10 AM - 9:45 AM, onsite foodservice department dishmachine area, accompanied by Dietitian-G (D-G) and Foodservice Director-O (FD-O), observed hot water sanitizing rinse of dishmachine exceeding maximum of 194 degrees Fahrenheit. Reviewed onsite foodservice department ' s logs (2/25/2016 - 6/15/2016) of final sanitizing rinse temperatures; taking into account a 2 degree Fahrenheit margin of error, 28 recorded temperatures exceeded the maximum temperature of 194 degrees Fahrenheit. There were 33 areas missing temperatures. D-G and FD-O stated were not aware there was a maximum temperature requirement for the hot water sanitizing dishmachine.

HAIR RESTRAINTS
According to the 2013 Food and Drug Administration (FDA) Food Code, the nationally recognized professional standard of practice for food safety, hair, including facial hair needs to be properly restrained to prevent hair falling into food and onto clean equipment, utensils, linens and unwrapped single-service and single-use articles.
On 6/13/2016, 12:10 PM-1:05 PM, off-site foodservice department, accompanied by Dietitian-G (D-G) and General Manager-S (GM-S), observed the following staff, visitors and inmates without proper hair restraints: Foodservice Worker T (facial hair not covered); Foodservice Worker X (facial hair not covered), Dentist U (stated never was told needed a hair restraint - comes down at least two times a week and no one ever said needed a hair restraint - would have one on had he known); Dental Assistant V; Inmate W mustache not covered; five inmates in dishmachine room with facial hair not covered.

On 6/14/2016, 11:25 AM, onsite foodservice department, tray-line area, accompanied by Dietitian-G (D-G) and Foodservice Director-O (FD-O), observed the following staff without hair properly restrained: Foodservice worker Q (full bang uncovered), Foodservice worker R, (only hair bun was covered) and Foodservice worker P (mustache not covered).

On 6/16/2016, 10:34 AM, received from Foodservice Director-O policy and procedure " Associate Hygiene, " " FS-HY-02, " Rev. 3 - November 2013. In section identified " Hair Restraints, " it states " Associates must wear hair restraints to keep their hair out of food. " It also states facial hair must be restrained if longer than ¼ inch. This statement contradicts current standards of practice for food safety. All facial hair must be covered.

EQUIPMENT AND UTENSILS
According to the 2013 Food and Drug Administration (FDA) Food Code, the nationally recognized professional standard of practice for food safety, equipment and utensils shall be kept free of an accumulation of dust, dirt, food residue and other debris.

On 6/13/2016, 12:08 PM - 12:45 PM, offsite foodservice department kitchen/bakery area, accompanied by Dietitian-G (D-G) and General Manager-S (GM-S), observed:
· Three industrial pedestal fans with visible layers of thick gray dust with one fan blowing directly onto racks of fresh baked bread
· Double oven that had layer of dirt and dust on top and edges
· Two storage pans - one of wire whisks and the other containing serving utensils uncovered
· Five utensils hanging from a rack with food surface areas uncovered
Interview with GM-S validated that the dirty fans is a problem and needs to be corrected. According to cleaning schedule provided on 6/15/2016, 5:00PM from GM-S, " Master Cleaning Schedule, " rev. 3/5/16, identifies fans and ovens are to be cleaned weekly.

Employee Health Policy
According to the 2013 Food and Drug Administration (FDA) Food Code, the nationally recognized professional standard of practice for food safety, the facility must have a system in place that requires food service employees to report information about their health and activities as they relate to diseases that are transmissible through food. There are specific conditions that require the removal, adjusting, excluding or restricting a food employee. Example - If a foodservice employee is symptomatic with vomiting or diarrhea, the employee cannot return to work until asymptomatic for at least 24 hours.

On 6/14/2016, 10:23 AM, onsite foodservice department, accompanied by Dietitian-G (D-G) and Foodservice Director-O (FD-O), interviewed Foodservice Worker P (FW-P) on what to do if wakes up prior to work with vomiting and diarrhea. FW-P stated would call-in. Asked FW-P when return to work would be. FW-P stated when feels better - did not know there were certain guidelines to follow. FD-O showed training on employee health, but time-period when to return to work following illness is not identified.

On 6/16/2016, 10:34 AM, received from Foodservice Director-O, " Form A: Conditional Applicant Health Form " that is filled out when a conditional offer of employment is made. This is not a policy and procedure that is readily available for staff to know what specific protocols should be followed when ill.

EXPIRED FOOD
On 6/14/2016, 9:00 AM, onsite foodservice department, dry food storage, accompanied by Dietitian-G (D-G) and Foodservice Director-O (FD-O), observed the following nutritional supplements: One bottle Nepro with expiration date of March 1, 2016, five cases (two dozen cans of supplements per case) with expiration date of June 1, 2016.

On 6/14/2016, 11:00 AM - 11:20 AM, accompanied by Dietitian G, observed the following items past expiration dates: Kitchenette 4-3A, four (8oz.) cartons 1% milk dated 6/13/2016; Kitchenette 4-3B, no discard date on opened gallon of fruit punch; Kitchenette 4-3C, six (8oz.) cartons 1% milk dated 6/13/2016; Kitchenette on children ' s unit, one (8oz.) carton 1% milk dated 6/13/2106. Dietitian G states nursing is responsible for monitoring expiration dates. Review of policy received from Dietitian G, " Procedure: BHD Hospital Snack Delivery and Kitchenette Inventory Management, " Date Issued: 6/14/2016, Policy #2412802, Section " Unit Kitchenette Floor Stock Inventory, " " Unit staff are responsible for rotating stock and discarding expired stock as part of daily environmental rounds. "

On 6/16/2016, 10:34 AM, received from Foodservice Director-O, received procedure, " How to Label a Food Item, " " FS-FH-07-HG-02, " dated 04/14/15. Procedure states: Associates must Use, freeze if appropriate, or discard all foods by the manufacturer ' s " Use By/Best Before " date or Aramark " Use By " date.

Based on observation, staff interviews and review of maintenance documents, the Milwaukee County Behavioral Health Division hospital failed to construct and maintain the building systems to ensure a safe physical environment. The cumulative effects of these environment deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41- Condition of Participation: Physical Environment IS NOT MET. These deficiencies have the ability to affect 77 in-patients as identified on the first day of surveying and an unknown number of outpatients, staff and visitors who were present during the survey.

FINDINGS INCLUDE:

The facility had the following (14) life safety deficiencies.
K-17: Corridor Doors,
K-27: Smoke Barrier Doors,
K-29: Hazardous Spaces,
K-38: Egress,
K-46: Emergency Lighting,
K-51: Fire Alarm System Installation,
K-52: Fire Alarm System Maintenance,
K-54: Smoke Detection System Maintenance & Testing,
K-56: Sprinkler System Installation,
K-62: Sprinkler System Maintenance & Testing,
K-67: Heating, Ventilating & Air Conditioning Installation,
K-144: Generator Installation and Maintenance,
K-145: Essential Electrical System Branches, and
K-147: Electrical Systems.

Please refer to the full description at the cited K-tags.

Based on observation, staff interviews and review of maintenance documents, the hospital failed to construct and maintain the building systems to ensure Life Safety from Fire. The cumulative effects of these safety from fire deficiencies resulted in the hospital's inability to ensure an environment free of potential life safety from fire for the patients.

42 CFR 482.41(b) - Life Safety from Fire: IS NOT MET. These deficiencies have the ability to affect 77 in-patients as identified on the first day of the survey and an unknown number of outpatients, staff and visitors who were present during the survey.

FINDINGS INCLUDE:

The facility had the following (14) life safety deficiencies.
K-17: Corridor Doors,
K-27: Smoke Barrier Doors,
K-29: Hazardous Spaces,
K-38: Egress,
K-46: Emergency Lighting,
K-51: Fire Alarm System Installation,
K-52: Fire Alarm System Maintenance,
K-54: Smoke Detection System Maintenance & Testing,
K-56: Sprinkler System Installation,
K-62: Sprinkler System Maintenance & Testing,
K-67: Heating, Ventilating & Air Conditioning Installation,
K-144: Generator Installation and Maintenance,
K-145: Essential Electrical System Branches, and
K-147: Electrical Systems.

Please refer to the full description at the cited K-tags.

Based on observations and interview, the hospital failed to maintain a sanitary environment in 2 of 6 patient care units (43B and 43C); and failed to ensure that nursing staff washed hands, in 2 of 3 staff observed (Staff AA and BB); and failed to ensure that nursing staff used aseptic technique when administering medication in 1 of 2 staff observed (Registered Nurse AA). This has the ability to affect all 77 patients being treated at this facility.

Findings include:

Sanitary Environment:
1) Observations on 6/13/2016 at 10:10 AM of the 43B patient unit in Room 10 (laundry room) revealed the inside of the washing machine drum to be dirty and stained with dark brown debris.

During interview with Nurse manager M, at the time and date of the observation, M stated that "the staff should be cleaning the washer and dryer after every patient use".

2) Observations on 6/13/2016 at 11:10 AM of the 43C patient unit in Room 10 (laundry room) revealed the inside of the washing machine drum to be dirty and stained with dark brown debris. The dryer had an irregular lump of black debris stuck to it's drum surface.

Medication Administration:
3) Observations on 6/14/2016 at 11:20 AM in the 43C medication dispensing room revealed that Registered Nurse (RN) AA did not disinfect the injection port of the multidose vial of Humalog insulin before inserting syringe to draw out insulin for Patient #1. RN AA went to Patient #1's chairside and pulled up left (short) sleeve, and disinfected the posterior upper arm with 70% alcohol, RN AA let the sleeve fall back over and touch the disinfected skin surface contaminating it, then pulled it up again to administer the insulin injection.

During interview with Unit 43C's Nurse manager N on 6/15/16 at 10:10 AM, N stated when told of observations, "we just had training over medication preparation".

Hand Washing:

4) Observations on 6/14/2016 at 8:10 AM of medication preparation for Patient #3 by Registered Nurse (RN) BB, while in the 43C medication dispensing room revealed no hand washing before medications were accessed and no disinfection of the medication preparation surface (computer on wheels) that medication was prepared upon. RN BB touched computer scanner and patient's wrist band, contaminating hands, and did not hand wash before removing medications from individual packets to administer to patient.

5) Observations on 6/14/2016 at 8:50 AM of medication preparation for Patient #13 by Registered Nurse (RN) AA, while in the 43C medication dispensing room revealed RN AA did not hand wash between the medication preparation for Patient #31 and Patient #32.

During interview with Unit 43C's Nurse manager N on 6/15/2016 at 10:10 AM, N stated when told of observations, "we continue to do hand washing audits to improve".

Based on interview and document review, the facility failed to ensure that the use of ambulatory restraints (waist to waist and/or ankle restraints) was based on an immediate threat of danger to self/others for two (2) of two (2) active sample patients (A12, B7) and one (1) of one (1) non-sample patients (A3) for whom this procedure was reviewed. These patients were maintained in ambulatory restraints for up to 70 hours without documented justification based on an immediate threat of violence to self or others. One patient (A3) was secluded while in ambulatory restraints for a period of time. In addition, these patients were allowed to walk about in the hallways and dayrooms among other patients that resulted in violation of patients' rights for privacy. These failures resulted in a safety risk and an environment of fear for other patients on the units. These findings resulted in IMMEDIATE JEOPARDY.

I. On 8/30/16 at 3:25 p.m. a conference was held with the Administrator, the Chief Medical Officer and the Director of Nursing in an Executive Meeting Room. At that time they were advised of the findings as stated below and that a state of Immediate Jeopardy related to patients' rights, safety and psychological threat to patients exists.

II. Findings include:

A. Review of seclusion/restraint (including ambulatory restraints) logs provided by administration revealed that between 7/29/16 and 8/29/16 (first day of the survey) Patient A3 had 21 episodes of seclusion and restraint with a total of 97.25 hours, Patient A12 had 7 episodes of seclusion/restraint with a total of 95.12 hours and Patient B7 had 6 episodes of seclusion/restraint with a total of 144.72 hours.

B. Review of the medical records for these three (3) patients (A3, A12 and B7) revealed that justification for use of these restraints was listed in the physician orders as "agitation." The majority of the hourly registered nurse assessments documented "unpredictable behavior," rather than an immediate threat of danger to self of others. Justification for continuing these restraints was usually listed as "unpredictable violence and aggressive (sic)", "high risk for violence" or "disruptive to milieu." These RN assessments, as well as the 15-minute monitoring checks by nursing staff, documented long periods of time when these patients were sleeping, watching television and out in the hallways around other patients and staff.

C. Specific Patient Findings:

1. Patient A3 was admitted to the hospital on 8/6/16.

a. Medical Record Review

1)According to the psychiatric evaluation dated (8/9/16), Patient A3 was admitted to the hospital after "becoming very disorganized in (his/her) mother's home, taking off (his/her) clothes and being generally disinhibited...threatening others and home."

2) Review of RN Progress Record for Seclusion/Restraint revealed
that Patient A3 was placed in "ambulatory restraints: wrist w/waist belt and ankle" at 10:20 p.m. on 8/13/16 for "unpredictable violence and aggression." This patient remained in ambulatory restraints until removal on 8/15/16 at 1:00 p.m. The amount of time listed for this episode in the seclusion/restraint log was a total of 37.92 hours.

3) Review of the physician orders for use of seclusion/restraints during this above documented seclusion/restraint episode failed to include reason/justification for the use of these procedures.

4) During interview, with review of Patient A3's medical record, on 8/30/16 at 10:00 a.m., RN 2 verified acknowledged that the continuation of ambulatory restraints for Patient A3 was not supported by medical record documentation. RN 2 reported that Patient A3 was at times secluded while in ambulatory restraints. Due to unclear documentation, surveyor was unable to verify this information in the seclusion/restraint documentation.

5) The hourly RN assessments completed while Patient A3 was in seclusion/restraints documented may periods of time when the patient was asleep, walking about the hallways or sitting in the dayroom among other patients and staff while in ambulatory restraints.

6) The 1:1 15-minute monitoring checks for Patient 3 documented time periods when the patient was asleep. No specific behaviors shown by this patient were documented in the records by the certified nursing assistants. The terms "verbal agitation" and "physical agitation" were on the form. These options were often not checked which implied that the patient was not presenting threatening behaviors.

7) Review of Patient A3's treatment plan (8/6/16 with last revision date of 8/9/16) revealed no revision of the interventions even though this patient has had 21 episodes of seclusion and restraint with a total of 97.25 hours since admission to the facility. The only intervention to address this patient's aggressive behavior was a nursing intervention listed as "Nursing staff will monitor for symptoms of aggression c/ (with) (Patient) + (and) redirect each occurrence."


2. Patient A12 was admitted to the hospital on 7/1/16 with diagnosis of Schizoaffective Disorder, bipolar type and Substance Abuse Disorder, severe, was brought in by police with manic presentation.

a. Medical Record Review

1) Assessment and Progress Record for seclusion / restraints indicate the patient A12 was place in ambulatory wrist and ankle restraints due to continued threat of violence / aggressive behavior towards others at 1pm on 8 /5/16. He remained in ambulatory restraints until removal on 8/8/16 at 11:00 a.m. for a total of 70 hours.

2) Review of the physician's orders for use of seclusion / restraint during this above mentioned documented seclusion / restraint episodes failed to include reasons/justifications for use of these procedures.

3) Review of the nursing progress notes for this episode of ambulatory restraints for the patient A12 revealed the following. On 8/6/16 at 10:14am the nursing note indicated "Patient up and active on the unit...no unsafe behavior reported." On 8/7/16 at 4:57am, nursing note indicated "Patient slept majority of the night, only coming out to ask for water. No unsafe behaviors noted."

4) Review of Rehab Services on 8/5/16 at 6:04pm indicated patient attended "third group this evening with in/out participation."

b. Staff Interview

During the interview on 8/13/16 around 2:00 p.m., RN2 verified and acknowledged to the physician surveyor that the documentation showed that the patient A12 attended the group and was in common area while in ambulatory restraints. He also acknowledged the documentation that ambulatory restraints were continued even when patient was sleeping.


3. Patient B7was admitted on 8/11/16.

a. Medical Record Review

1) According to the Psychiatric Assessment Report dated (8/12/16), Patient B7 was admitted to the hospital after "being combative at home and attempting to jump out of a window."

2) Review of RN Progress Record for seclusion / restrain revealed that the patient B7 was placed in "ambulatory wrist restraints due to high risk for unpredictable aggressive and self-injurious behaviors" on 8/15/16 at 3:55 p.m. He remained in ambulatory wrist restraints until removal on 8/18/16 at 12:15 p.m. for a total of 68.3 hours.

3) Review of the physician order for use of seclusion/restraints during this above mentioned documented ambulatory restraint episodes failed to include reasons/justification for use of these procedures.

4) Review of the nursing progress notes for this episode of ambulatory restraints for the patient B7 revealed the following. On 8/15/16, "Patient was up on the unit from 1600 to 1930 watching TV...." "Patient's behavior has remained has remained generally calm since his release from 4 point restraints at 1555." On 8/16/16 nursing note reveals "Patient is on ambulatory wrist restraints all night....No violent behavior noted at this time. No unsafe behavior at this time." On 8/16/16 at 10:38pm nursing note reveals "Patient's behavior has been calm and in control with no episodes of aggression or self-injurious behavior." On 8/17/16 nursing note at 5:07 am reveals patient "slept" and "on ambulatory wrist restraints all night." On 8/18/16 at 5:32 a.m. nursing note indicated "patient slept all night. Patient is on ambulatory wrist restraints all night."

b. Staff Interview

During the interview on 8/30/16 around 2:00 p.m., RN2 verified and acknowledged the documentation above.

D. Interview:

1. During interview on 8/30/16 at 9:05 a.m., the Chief Medical Officer related that "close view of the record of patients in ambulatory restraints for long periods of time may prove that the documentation does not support its use." He stated, "There is a disconnect between their (staff) perception of the patient and what they are doing (interventions). He related that use of ambulatory restraints is based on historical use in this hospital. During follow-up interview on 8/30/16 at 11:30 a.m., the Chief Medical Officer stated, "We need to do away with use of ambulatory restraints except for patient transport."

2. During interview on 8/30/16 at 10:15 a.m., RN 2 stated "Our policy and practice (related to use of ambulatory restraints) are not in line with the regulations and standard practice. We are working on past practices that are not based on current standards." RN 2 added, "Patients' behavior is always unpredictable (stated in response to major documented reason for use of ambulatory restraints in this facility)."

III. Removal of IMMEDIATE JEOPARDY

The IMMEDIATE JEOPARDY WAS REMOVED on 8/31/16 at 2:15 p.m. based on the following:

1. Verbal request as well as written letter dated 8/31/16 jointly written by the Administrator, Chief Medical Officer, Chief Nursing Officer requesting for removal of IMMEDIATE JEOPARDY citing revision to seclusion and restraint policy.

2. Highlights of revision in seclusion and restraint policy included:
a. Elimination of Ambulatory Restraints
b. Face to face evaluation of the patient post initiation of seclusion or restraint by only physicians.
c. Limiting the length of initial order and extensions for all seclusion and restraint to one hour.

3. Letter dated 8/30/16 from the operations manager indicating that all ambulatory restraints were removed from all units at Milwaukee County Behavioral Health Division as well as elimination of the same from the central supply.

4. Evidence that the communication, education and training of the staff had begun on August 30th, 2016 regarding revised policy on seclusion and restraints as well as commitment to train all employees till 100 % target was met.

5. Plan for ongoing monitoring of use of seclusion and restraints, and case reviews of complex cases of frequent/extended utilization of restraints or seclusion by the multidisciplinary teams and Chief Medical Officer, Chief Nursing Officer or their representatives to support the least restrictive management patient and update recovery plan.

Non-compliance continues at the condition level due to failure in the following areas. Specifically the facility failed to:

I. Revise treatment plans for two (2) of eight (8) active sample patients (A12 and B7) and one (1) of one (1) non-sample patient (A3) who had been secluded/restrained and for one (1) of eight (8) active sample patients (C5) who refused to attend assigned treatment/groups. This failure results in fragmented treatment plans and hinders the treatment and discharge of patients. (Refer to B118)

II. Develop treatment plans that clearly delineated physician, nursing and social work interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): A8, A12, B7, B15, C4, C5, E4 and E9. This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment. (Refer to B122)

III. Provide alternative treatment activities for one (1) of eight (8) active sample patients (C5). Patient C5 refused to attend assigned scheduled programming activities and instead stayed in her room most of the time, sitting in [his/her] wheelchair or lying in bed the majority of the time. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on record review and interview the facility failed to revise treatment plans for two (2) of eight (8) active sample patients (A12 and B7) and one(1) of one (1) non-sample patient (A3) who had been secluded/restrained and for one (1) of eight (8) active sample patients (C5) who refused to attend assigned treatment/groups. This failure results in fragmented treatment plans and hinders the treatment and discharge of patients.

Findings include:

A. Patient Findings:

1. Patient A3

a. Patient A3 was admitted to the hospital on 8/6/16.

b. According to the psychiatric evaluation dated (8/9/16), Patient A3 was admitted to the hospital after "becoming very disorganized in (his/her) mother's home, taking off (his/her) clothes and being generally disinhibited...threatening others and home."

c. Review of Patient A3's treatment plan (8/6/16 with last revision date of 8/9/16) revealed no revision of the interventions even though this patient has had 21 episodes of seclusion and restraint with a total of 97.25 hours since admission to the facility. The only intervention to address this patient's aggressive behavior was a nursing intervention listed as "Nursing staff will monitor for symptoms of aggression c/ (with) (Patient) + (and) redirect each occurrence."

2. Patient A12

a. Patient A12 was admitted to the hospital on 7/1/16 with diagnosis of Schizoaffective Disorder, bipolar type and Substance Abuse Disorder, severe, was brought in by police with manic presentation.

b. Review of Patient A12's treatment plan (7/1/16 with last revision date of 8/29/16) revealed no revision of the interventions even though this patient has had 7 episodes of seclusion and restraint with a total of 95.12 hours since 7/29/16.

3. Patient B7

a. Patient B7 was admitted on 8/11/16 after "being combative at home and attempting to jump out of window".

b. Review of Patient B7's treatment plan dated 8/11/16 and the subsequent revisions revealed no changes in the interventions even though this patient had 6 episodes of restraint/seclusion with total of 144.72 hours since admission to the facility.

4. Patient C5

a. Patient C5 was a 59 year-old patient who was admitted to the facility on 8/11/15. According to the psychological assessment (8/12/15) Patient C5 has a diagnosis of Schizoaffective Disorder with Diabetes.

b. Review of Patient C5 progress notes, this patient refused to attend assigned scheduled programming activities and instead stayed in [his/her] room most of the time, sitting in [his/her] wheelchair or laying in bed the majority of time.

c. Review of the master treatment plan for Patient C5 revealed a plan that was initiated on 8/11/15. Due to the many dates of additions, revisions and extensions of goals and interventions, the current plan for this problem was unclear. Even though this patient refused to attend groups/activities (other than physical therapy), there were no specific interventions to address this issue.

d. During interview on 8/30/16 at 1:25 p.m. RN 1 and SW 3 acknowledged that Patient C5's treatment plan should have been revised based on [his/her] current behaviors.

Based on record review and interview, the facility failed to develop treatment plans that clearly delineated physician, nursing and social work interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): A8 (8/22/16); A12 (7/1/16 with last revision date 8/29/16); B7 (8/11/16); B15 (7/27/16); C4 (8/17/16 with last revision date of 8/25/16); C5 (8/11/15 with last revision date of 8/24/16); E4 (8/22/16 with last revision date of 8/25/16) and E9 (8/22/16 with last revision date of 8/25/16). This resulted in treatment plans that failed to reflect a comprehensive, integrated, and individualized approach to multidisciplinary treatment.

Findings include:

A. The master treatment plans for eight (8) of eight (8) patients (A8, A12, B7, B15, C4, C5, E4 and E8) failed to include any physician interventions, including medications.

B. The master treatment plans for eight (8) of eight (8) patients (A8, A12, B7, B15, C4, C5, E4 and E8) failed to include individualized nursing and social work interventions.

1. Patient A8

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will report an absence of delusional ideas and hallucinations for five (5) consecutive days" and "will interact with others without sexually inappropriate behavior for five (5) consecutive days," the only nursing interventions were listed as "Nursing staff will assess reality orientation each waking shift by conversing with [patient] for at least 5 minutes" and "Nursing staff will monitor and redirect sexually inappropriate bx (behavior) at each occurrence." There were no specific interventions to direct staff in the care of this patient based on specific patient findings.

b. For problem listed as "Domain 2-Violence," and goals stated as "...will interact with others in a safe, non-threatening manner for five (5) consecutive days" and "will exhibit safe and non-harmful behavior toward self for seven (7) days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for sxs (symptoms) of aggression and redirect each occurrence, offer support and encouragement for safe bxs (behaviors) daily." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of aggression to self and others in the clinical area.

c. For problem listed as "Domain 5-Recovery Environment," and goal stated as "verification of ability to return to group home and psychiatric after care" interventions listed where generic social worker function. "Social work designee will meet with (name of patient) at least 1 x weekly to discuss discharge planning...Social worker will verify patients return to the group home and will schedule psychiatric after care and other as appropriate."

2. Patient A12

a. For problem listed as "Domain 1- Psychological" and goal listed as "...will exhibit safe and non-harmful behavior toward self for seven days," a nursing intervention was listed as "1:1 will be provided by nursing staff per shift to ascertain pt (patient) feelings, mood and allow pt (patent) to vent. (ventilate)." Even though this patient had 7 episodes of seclusion restraint for a total of 95.12 hours since admission (7/1/16), there were no interventions to direct nursing staff regarding what behaviors should be monitored while caring for this patient, not what actions to take should aggression occur in the clinical area.

b. For problem listed as "Domain 5-Recovery Environment," and goal stated as "Name of patient) will need a stable group home placement, psychiatric after care" had no social work interventions listed.


3. Patient B7

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will report decrease or absence of delusional ideas/ hallucinations for 7 consecutive days," the only nursing intervention were listed as "Nursing staff to assess reality orientation every shift, refocus to reality issues, give reassurance, suggest interventions and offer medications to help relieve distress every shift for 7 consecutive days." There were no specific interventions to direct staff in the care of this patient based on specific patient findings.

b. For problem listed as "Domain 2-Violence," and goals stated as "will exhibit the ability to interact with others in a safe, non-threatened (sic) manner for 7 consecutive days" and "will exhibit safe and non-harmful behavior toward self for 7 consecutive days," the only nursing interventions were listed as "Nursing staff will monitor [Patient] for symptoms of aggression and redirect each occurrence every shift for 7 consecutive days" and "Nursing staff will monitor [Patient's] SOS (observation level) per MD order per policy every shift for 7 consecutive days." Even though this patient had 21 episodes of seclusion restraint for a total of 97.25 hours since admission (8/11/16), there were no interventions to direct nursing staff regarding what behaviors should be monitored while caring for this patient, not what actions to take should aggression occur in the clinical area.

c. There were no goal or objective for Domain-5 Recovery Environment and no social work interventions listed.

4. Patient B15

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will report decrease or absence of delusional ideas/ hallucinations for 7 consecutive days," the only nursing intervention was listed role functions listed as "Nursing staff to assess [Patient's] reality orientation every shift, refocus to reality issues, give reassurance, suggest interventions and offer medications to help relieve distress every shift for 7 consecutive days." There were no specific interventions to direct staff in the care of this patient based on specific patient findings.

b. For problem listed as "Domain 2-Violence," and goal stated as "will exhibit the ability to interact with others in a safe, non-threatening manner for 7 consecutive days," the only nursing intervention was listed as "Nursing staff will monitor [Patient] for symptoms of aggression and redirect each occurrence every shift for 7 consecutive days." There were no specific nursing interventions to address the aggression in the clinical area based on patient findings.

c. For problem listed as "Domain 5-Recovery Environment," and goal stated as "lack of engagement with providers" the social work interventions listed were generic role function. "Social worker or designee will meet with (patient) a minimum of once weekly or prior to discharge to create a community care plan. Social worker will consider referrals back to Horizons targeted case management outreach community help and other referrals as needed."

5. Patient C4

a. For problem listed as "Domain 1- Psychological" and goal listed as "...will report a decrease or absence of delusional ideas and/or hallucinations for 7 days...will engage in reality-based conversation with staff without evidence of delusional ideas/hallucinations for 7 days," the only nursing intervention was listed as "Nursing staff will assess reality orientation each shift, refocus to reality issues, give reassurance, suggest interventions and offer medications to help relieve stress." Even though this patient remained in bed most of the time during the survey (8/29-30/16), there were no specific interventions to guide nursing staff to help the patient to decrease isolation and engage in reality.

Even though the psychologist was working with this patient as reflected in progress notes, there was failure to document this intervention in the treatment plan.

b. For problem listed as "Domain 2-Violence," and goal stated as "...will exhibit the ability to interact with others in a safe, non-threatening manner for 7 days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for symptoms of aggression and redirect each occurrence." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of violence in the clinical area.

c. For problem listed as "Domain 5-Recovery Environment," and goal stated as "Will meet with SW (social worker) to discuss [his/her] preference for discharge and after care several x time (sic) a week until discharged," the only social work intervention was stated as an expected role function: "Will meet c/ (with) [Patient] 1 x (time) week or more often to assess for ongoing needs (remainder of sentence unclear)."

6. Patient C5

a. The plan for Problem listed as "Domain 1- Psychological" was initiated on 8/11/15. Due to the many dates of additions, revisions and extensions of goals and interventions, the current plan for this problem was unclear. The only nursing intervention was listed on 8/11/16 and stated as "Nursing staff will assess reality orientation each shift, refocus to reality issues, give reassurance, suggest interventions and offer medication to help relieve distress."

Based on interview of the patient on 8/29/16 at 11:10 a.m., Patient C5 remains in (his/her) room most of the time. There have been no specific nursing interventions to direct nursing personnel in the care of this patient based on changing behaviors/needs.

b. For problem listed as "Domain 5-Recovery Environment," and goal stated as "Will meet c/(with) social worker 1 x (time) week or more often to discuss [his/her] feelings about placement in a group home (remainder of sentence unclear)," the only social work intervention (dated 8/13/15) was stated as an expected role function: "Social Worker will meet c/ (with) [Patient] 1 time week or more often to discuss (Patient's) feelings re (regarding): placement options. Social Worker will make appropriate referral to housing option for discharge. "

7. Patient E4

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will display a calm and well-modulated mood appropriate to the situation with stable and appropriate behavior for 5 days" and "will identify three (3) consequences of negative behavior of past 30 days within 7 days," the only nursing intervention generic listed as "Nursing staff will assess (Patient's) mood, triggers and effectiveness and refocus the patient to positive and effective coping skills."

b. For problem listed as "Domain 2-Violence," and goal stated as "...will exhibit safe and non-harmful behavior toward herself for five (5) consecutive days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for symptoms of aggression and redirect each occurrence immediately, each shift." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of violence in the clinical area.

c. For problem listed as "Domain 5-Recovery Environment," and goal stated as "Will meet with SW (social worker) to discuss...to discuss appropriate placement...," the social work interventions were stated as an expected role functions: "Will work with pt (patient)...to ensure pt (patient) has safe, appropriate placement upon discharge" and "will encourage pt (patient...in conversations weekly to confirm appts (appointments) (remainder of sentence unclear)."

8. Patient E9

a. For problem listed as "Domain 1- Psychological" and goal listed as "...will engage through interpreter in reality based conversation with staff without evidence of delusions or hallucinations for seven (7) consecutive days," the only nursing intervention was generic and listed as "Nursing staff will assess and document paranoid thinking and engage [Patient] in reality based conversation each shift, while awake." There were no specific nursing interventions to direct staff in how to handle irrational behaviors presented by the patient.

b. For problem listed as "Domain 2-Violence," and goal stated as "will interact with others without evidence of hostility, threats or violence for seven (7) consecutive days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for symptoms of aggression and redirect each occurrence immediately, each shift." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of violence in the clinical area.

c. For problem listed as "Domain 5-Recovery Environment," and goal stated as "Will meet with social worker to discuss treatment needs-concerns and work together to develop after care plans within 1 week," the social work intervention was stated as an expected role function: "...to communicate with (patient) and guardian as indicated and at least one time per week to coordinate aftercare plans. Writer to schedule/confirm appointments prior to discharge. [Patient] will be connected with Cempatico Insurance providers in [his/her] community for treatment needs + (and) community supports."

C. Interviews

1. During interview on 8/30/16 at 1:55 p.m., SW3 acknowledged that the treatment plans for Patients C4 and C5 needed more individualized interventions by social work. RN 1 reported that the nursing interventions for Patient C4 needed to be more specific.

2. During interview on 8/30/16 about 11:00 a.m., RN4 stated that the nursing interventions in the treatment plan for Patient E9 need to be more specific for treatment.

3. During interview on 8/31/16, with review of treatment plans, the DON verified the absence of individualized nursing interventions based on patients' needs.

4. During interview on 8/31/16 at 11:15am the Chief Clinical Officer verified the absence of individualized social worker interventions based on patient's needs. She acknowledged and agreed with the surveyor that there were no social workers interventions for the Domain - 1 Psychological problem in all sample patients.

5. During interview on 8/31/16 at 2:45pm the Chief Medical Officer verified that there were no psychiatric interventions including interventions for medication in any of the sample patients' Master Treatment Plans.

Based on observation, interview and record review the facility failed to provide alternative treatment activities for one (1) of eight (8) active sample patients (C5) in one (1) of four (4) patient units (Unit C). Patient C5 refused to attend assigned scheduled programming activities and instead stayed in her room most of the time, sitting in [his/her] wheelchair or laying in bed the majority of time. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement.

Findings include:

A. Patient C5 was a 59 year-old patient who was admitted to the facility on 8/11/15. According to the psychological assessment (8/12/15) Patient C5 has a diagnosis of Schizoaffective Disorder with Diabetes. This assessment documented that Patient C5 is "safer in a wheelchair, [s/he] is able to transfer out of the wheelchair onto a chair or bed with supervision."

B. Observation and Interview

1. On 8/29/16 at 11:10 a.m. Patient C5 was observed sitting alone in [his/her] wheelchair in assigned bedroom. During interview Patient C5 reported that other than attending physical therapy 3 times weekly, [s/he] only attends a music and OT (Occupational Therapy] group at intervals.

2. During interview on 8/30/16 at 1:25 p.m., RN 1 and SW 3 reported that Patient C5 seldom attends groups/activities, but stays in [his/her] room.

C. Progress Note Review of Activities:

1. A Rehabilitation staff progress note (8/18/16) documented "Of the 10 Occupational therapy groups offered 8/15-8/17/16, patient actively engaged in 1 10 minutes 1:1 discussion with writer and was unexcused from the remainder of the groups offered." Nursing note (8/20/16) documented "Patient isolative to room and self. Pt (Patient) up for meal only."

2. Nursing note (8/21/16) documented "Patient isolative to room and self. Pt (Patient) up for meal and snack."

3. A Rehabilitation staff progress note (8/22/16) stated "For the dates 8/18-22, [Patient] attends (sic) 1 OT discussion group on 8/19/ and is otherwise absent from 9 other offered rehab groups in that time period."

4. Nursing note (8/22/16) documented "Patient remain (sic). Stayed most of the shift in [his/her] room."

5. Nursing note (8/23/16) documented "Patient isolative to room and self. Pt (Patient) up for meal and snack. Pt (Patient) sits quietly and self-talks."

6. Nursing notes (8/24/16) documented "Patient did not attend groups;" "Pt (Patient) isolative to room and self. Pt (Patient) up for meal only."

7. Nursing notes (8/25/16) documented "The patient has been in and out of [his/her] room throughout the shift. [S/he] did nap after breakfast for about 2 hours and after lunch for about 1.5 hours" and "Pt (Patient) isolative to room and self."

8. A Rehabilitation staff progress note (8/26/16) documented "Of the nine (9) Occupational therapy groups offered 8/23-8/25/16, patient was unexcused from all groups offered...[S/he] did decline the offers to attend group. Will continue to invite [him/her] to groups to encourage socialization with others."

9. Even though there is a social work intervention in the treatment plans that states, "Social Worker will meet c/ (with) [Patient] one time a week or more often to discuss [Patient's] feeling re: (regarding) placement options," a review of the progress notes revealed only one social worker note documented from 8/10-26/16. This note (8/26/16) stated, "Writer met with patient to assess for any needs not met with [his/her] hospital stay. Patient stated that [s/he] was doing well but that [s/he] wanted to be discharge (sic)."

D. Review of the master treatment plan for Patient C5 revealed a plan that was initiated on 8/11/15. Due to the many dates of additions, revisions and extensions of goals and interventions, the current plan for this problem was unclear. Even though this patient refused to attend groups/activities (other than physical therapy), there are no specific interventions to address this issue.

Based on observations, record reviews and interviews:

I. The Chief Medical Officer failed to ensure that the active treatment reflected current standard of practice for interventions, which restrict patients' freedom of movement. The facility used restrictive interventions of ambulatory restraints without immediate threat of danger to self or others and continued these ambulatory restraints for prolonged period of time, even when patients were sleeping. Furthermore the facility failed to ensure their privacy, dignity and safety by taking them to the hallways and day room. (Refer to B144 II)

II. The Chief Medical Officer failed to ensure that the Master Treatment Plans were revised for two (2) of eight (8) active sample patients (A12 and B7) and 1 of 1 non-sample patient (A3) who had been secluded/restrained and for one (1) of eight (8) active sample patients (C5) who refused to attend assigned treatment/groups. This failure results in fragmented treatment plans and hinders the treatment and discharge of patients. (Refer to B144 IV)

III. The Chief Medical Officer failed to ensure that the Master Treatment Plans identified patient specific and individualized treatment interventions by the psychiatry, nursing and social work staff for eight (8) of eight (8) active sample patients (A8, A12, B7, B15, C4, C5, E4 and E9). The Master Treatment Plans included generic functions of the staff disciplines in nursing and social work instead of patient specific individualized interventions based on patients' needs. Furthermore there were no psychiatric interventions at all in these treatment plans. Such failure results in lack of guidance for the staff in providing individualized patient treatment that is purposeful and goal directed (Refer to B144 I)


IV. The Chief Medical Officer failed to ensure that the alternative treatment activities were provided for one (1) of eight (8) active sample patients (C5). Patient C5 refused to attend assigned scheduled programming activities and instead stayed in her room most of the time, sitting in [his/her] wheelchair or lying in bed the majority of the time. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement. (Refer to B144 III)

V. The Director of Nursing failed to ensure that nursing interventions were included in treatment plans based on the individual needs of interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): A8 (8/22/16); A12 (7/1/16 with last revision date 8/29/16); B7 (8/11/16); B15 (7/27/16); C4 (8/17/16 with last revision date of 8/25/16); C5 (8/11/15 with last revision date of 8/24/16); E4 (8/22/16 with last revision date of 8/25/16) and E9 (8/22/16 with last revision date of 8/25/16). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B148 I)

VI. The Director of Nursing failed to ensure that facility policy direct that defensive gear be worn by staff (face shield/mask) with patients who demonstrated a propensity for spitting on staff or others, rather than allowing an unnecessary restraint method (spitting hoods). This failure resulted in policy allowing restraint method that is an unnecessary safety risk for patients. (Refer to B148 II)

Based on observation, record review and staff interviews the Chief Medical Officer failed to ensure that:

I. The Master Treatment Plans identified patient specific and individualized treatment interventions by the psychiatry, nursing and social work staff for eight (8) of eight (8) active sample patients (A8, A12, B7, B15, C4, C5, E4 and E9). The Master Treatment Plans included generic functions of the staff disciplines in nursing and social work instead of patient specific individualized interventions based on patients' needs. Furthermore there were no psychiatric interventions at all in these treatment plans. Such failure results in lack of guidance for the staff in providing individualized patient treatment that is purposeful and goal directed. (Refer to B122)

II. The use of ambulatory restraints (waist to waist and/or ankle restraints) was based on an immediate threat of danger to self/others for two (2) of two (2) active sample patients (A12, B7) and one (1) of one (1) non-sample patient (A3) for whom this procedure was reviewed. These patients were maintained in ambulatory restraints for up to 70 hours without documented justification based on an immediate threat of violence to self or others. One patient (A3) was secluded while in ambulatory restraints for a period of time. In addition, these patients were allowed to walk about in the hallways and dayrooms among other patients that resulted in violation of patients' rights for privacy. These failures resulted in a safety risk and an environment of fear for other patients on the units. These findings resulted in IMMEDIATE JEOPARDY (Refer to B103).

III. Alternative treatment activities were provided for one (1) of eight (8) active sample patients (C5). Patient C5 refused to attend assigned scheduled programming activities and instead stayed in her room most of the time, sitting in [his/her] wheelchair or lying in bed the majority of the time. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement. (Refer to B125)

IV. Master Treatment Plans were revised for two (2) of eight (8) active sample patients (A12 and B7) and one (1) of one (1) non-sample patient (A3) who had been secluded/restrained and for one (1) of eight (8) active sample patients (C5) who refused to attend assigned treatment/groups. This failure results in fragmented treatment plans and hinders the treatment and discharge of patients. (Refer to B118)

V. The facility policy direct that defensive gear to be worn by staff (face shield/mask) with patients who demonstrated a propensity for spitting on staff or others, rather than allowing an unnecessary restraint method (spitting hoods). This failure resulted in policy allowing restraint method that is an unnecessary safety risk for patients.

Findings include:

A. Review of the facility form for documentation of seclusion/restraint revealed a section to be checked if a "spitting hood" was used.

B. During interview on 8/31/16 at 1:00 p.m. the DON stated that even though a "spitting hood" had not been used at the facility in at least 14 months, its use remains in the facility seclusion/restraint policy.

C. Review of facility policy, "Seclusion, Physical Restraint and/or Involuntary Medication: Emergent Use (dated 9/1/12)," stated:

1. "When the transmission of saliva, mucous and blood places others at risk an immediate response is required...In the event of the risk of or occurrence of a patient spitting, an approved, temporary protective head covering may be utilized as clinically appropriate. The spit protection device will be utilized only if used of universal precautions and personal protective equipment is inadequate to keep people safe."

2. "The purpose of this temporary protective head covering is to prevent the wearer from transmitting saliva and mucous to others."

Based on document review and interview, the Director of Nursing failed to:

I. Ensure that nursing interventions were included in treatment plans based on the individual needs of interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): A8 (8/22/16); A12 (7/1/16 with last revision date 8/29/16); B7 (8/11/16); B15 (7/27/16); C4 (8/17/16 with last revision date of 8/25/16); C5 (8/11/15 with last revision date of 8/24/16); E4 (8/22/16 with last revision date of 8/25/16) and E9 (8/22/16 with last revision date of 8/25/16). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care based on individual patient findings.

Findings include:

1. Patient A8

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will report an absence of delusional ideas and hallucinations for five (5) consecutive days" and "will interact with others without sexually inappropriate behavior for five (5) consecutive days," the only nursing interventions were listed as "Nursing staff will assess reality orientation each waking shift by conversing with [patient] for at least 5 minutes" and "Nursing staff will monitor and redirect sexually inappropriate bx (behavior) at each occurrence." There were no specific interventions to direct staff in the care of this patient based on specific patient findings.

b. For problem listed as "Domain 2-Violence," and goals stated as "...will interact with others in a safe, non-threatening manner for five (5) consecutive days" and "will exhibit safe and non-harmful behavior toward self for seven (7) days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for sxs (symptoms) of aggression and redirect each occurrence, offer support and encouragement for safe bxs (behaviors) daily." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of aggression to self and others in the clinical area.

2. Patient A12

For problem listed as "Domain 1- Psychological" and goal listed as "...will exhibit safe and non-harmful behavior toward self for seven days," a nursing intervention was listed as "1:1 will be provided by nursing staff per shift to ascertain pt (patient) feelings, mood and allow pt (patent) to vent. (ventilate)." Even though this patient had 7 episodes of seclusion restraint for a total of 95.12 hours since admission (7/1/16), there were no interventions to direct nursing staff regarding what behaviors should be monitored while caring for this patient, not what actions to take should aggression occur in the clinical area.

3. Patient B7

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will report decrease or absence of delusional ideas/ hallucinations for seven (7) consecutive days," the only nursing intervention were listed as "Nursing staff to assess reality orientation every shift, refocus to reality issues, give reassurance, suggest interventions and offer medications to help relieve distress every shift for seven (7) consecutive days." There were no specific interventions to direct staff in the care of this patient based on specific patient findings.

b. For problem listed as "Domain 2-Violence," and goals stated as "will exhibit the ability to interact with others in a safe, non-threatened (sic) manner for seven (7) consecutive days" and "will exhibit safe and non-harmful behavior toward self for seven (7) consecutive days," the only nursing interventions were listed as "Nursing staff will monitor [Patient] for symptoms of aggression and redirect each occurrence every shift for seven (7) consecutive days" and "Nursing staff will monitor [Patient's] SOS (observation level) per MD order per policy every shift for seven (7) consecutive days." Even though this patient had 21 episodes of seclusion restraint for a total of 97.25 hours since admission (8/11/16), there were no interventions to direct nursing staff regarding what behaviors should be monitored while caring for this patient, not what actions to take should aggression occur in the clinical area.

4. Patient B15

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will report decrease or absence of delusional ideas/ hallucinations for seven (7) consecutive days," the only nursing intervention was listed role functions listed as "Nursing staff to assess [Patient's] reality orientation every shift, refocus to reality issues, give reassurance, suggest interventions and offer medications to help relieve distress every shift for 7 consecutive days." There were no specific interventions to direct staff in the care of this patient based on specific patient findings.

b. For problem listed as "Domain 2-Violence," and goal stated as "will exhibit the ability to interact with others in a safe, non-threatening manner for seven (7) consecutive days," the only nursing intervention was listed as "Nursing staff will monitor [Patient] for symptoms of aggression and redirect each occurrence every shift for seven (7) consecutive days." There were no specific nursing interventions to address the aggression in the clinical area based on patient findings.


5. Patient C4

a. For problem listed as "Domain 1- Psychological" and goal listed as "...will report a decrease or absence of delusional ideas and/or hallucinations for seven (7) days...will engage in reality-based conversation with staff without evidence of delusional ideas/hallucinations for seven (7) days," the only nursing intervention was listed as "Nursing staff will assess reality orientation each shift, refocus to reality issues, give reassurance, suggest interventions and offer medications to help relieve stress." Even though this patient remained in bed most of the time during the survey (8/29-30/16), there were no specific interventions to guide nursing staff to help the patient to decrease isolation and engage in reality. Even though the psychologist was working with this patient as reflected in progress notes, there was failure to document this intervention in the treatment plan.

b. For problem listed as "Domain 2-Violence," and goal stated as "...will exhibit the ability to interact with others in a safe, non-threatening manner for 7 days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for symptoms of aggression and redirect each occurrence." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of violence in the clinical area.

6. Patient C5

The plan for Problem listed as "Domain 1- Psychological" was initiated on 8/11/15. Due to the many dates of additions, revisions and extensions of goals and interventions, the current plan for this problem was unclear. The only nursing intervention was listed on 8/11/16 and stated as "Nursing staff will assess reality orientation each shift, refocus to reality issues, give reassurance, suggest interventions and offer medication to help relieve distress."

Based on interview of the patient on 8/29/16 at 11:10 a.m., Patient C5 remains in (his/her) room most of the time. There have been no specific nursing interventions to direct nursing personnel in the care of this patient based on changing behaviors/needs.

7. Patient E4

a. For problem listed as "Domain 1- Psychological" and goals listed as "...will display a calm and well-modulated mood appropriate to the situation with stable and appropriate behavior for five (5) days" and "will identify 3 consequences of negative behavior of past 30 days within seven (7) days," the only nursing intervention generic listed as "Nursing staff will assess (Patient's) mood, triggers and effectiveness and refocus the patient to positive and effective coping skills."

b. For problem listed as "Domain 2-Violence," and goal stated as "...will exhibit safe and non-harmful behavior toward herself for five (5) consecutive days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for symptoms of aggression and redirect each occurrence immediately, each shift." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of violence in the clinical area.

8. Patient E9

a. For problem listed as "Domain 1- Psychological" and goal listed as "...will engage through interpreter in reality based conversation with staff without evidence of delusions or hallucinations for seven (7) consecutive days," the only nursing intervention was generic and listed as "Nursing staff will assess and document paranoid thinking and engage [Patient] in reality based conversation each shift, while awake." There were no specific nursing interventions to direct staff in how to handle irrational behaviors presented by the patient.

b. For problem listed as "Domain 2-Violence," and goal stated as "will interact with others without evidence of hostility, threats or violence for seven (7) consecutive days," the only nursing intervention was listed an expected role function: "Nursing staff will monitor for symptoms of aggression and redirect each occurrence immediately, each shift." There were no specific nursing interventions to direct nursing personnel in responding to and prevention of violence in the clinical area.

C. Interviews

1. During interview on 8/30/16 at 1:55 p.m., RN 1 reported that the nursing interventions for Patient C4 needed to be more specific.

2. During interview on 8/30/16 about 11:00 a.m., RN4 stated that the nursing interventions in the treatment plan for Patient E9 needed to be more specific for treatment.

3. During interview on 8/31/16, with review of treatment plans, the DON verified the absence of individualized nursing interventions based on patients' needs.

II. Ensure that facility policy direct that defensive gear to be worn by staff (face shield/mask) with patients who demonstrated a propensity for spitting on staff or others, rather than allowing an unnecessary restraint method (spitting hoods). This failure resulted in policy allowing restraint method that is an unnecessary safety risk for patients.

Findings include:

A. Review of the facility form for documentation of seclusion/restraint revealed a section to be checked if a "spitting hood" was used.

B. During interview on 8/31/16 at 1:00 p.m. the DON stated that even though a "spitting hood" had not been used at the facility in at least 14 months, its use remains in the facility seclusion/restraint policy.

C. Review of facility policy, "Seclusion, Physical Restraint and/or Involuntary Medication: Emergent Use (dated 9/1/12)," stated:

1. "When the transmission of saliva, mucous and blood places others at risk an immediate response is required...In the event of the risk of or occurrence of a patient spitting, an approved, temporary protective head covering may be utilized as clinically appropriate. The spit protection device will be utilized only if used of universal precautions and personal protective equipment is inadequate to keep people safe."

2. "The purpose of this temporary protective head covering is to prevent the wearer from transmitting saliva and mucous to others."

Based on record review and staff interview, Chief Clinical Officer failed to ensure that social work staff included social work interventions that were specific, individualized and based on patient's assessments in the Master Treatment Plans of eight (8) of eight (8) active sample patients (A8, A12, B7, B15, C4, C5, E4 and E9). The Master Treatment Plans included generic functions of the staff disciplines in social work instead of patient specific individualized interventions based on patients' needs. Such failure results in lack of guidance for the staff in providing individualized patient treatment that is purposeful and goal directed. (Refer to B122)