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Based on a follow-up verification visit on 08/11/2016 through 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 58 patients as identified on the day of the verification visit and an unknown number of staff and visitors who were present during the survey.

FINDINGS INCLUDE:

The facility had the following (5) life safety deficiencies.
K-29: Hazardous Spaces,
K-56: Sprinkler System Installation,
K-62: Sprinkler System Maintenance & Testing,
K-145: Essential Electrical System Branches, and
K-147: Electrical Systems.

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

Based on a follow-up verification visit on 08/11/2016 through 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 the following safety from fire deficiencies below 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 58 patients as identified on the day of the verification visit, and an unknown number of staff and visitors who were present during the survey.

FINDINGS INCLUDE:

The facility had the following (5) life safety deficiencies still outstanding.
K-29: Hazardous Spaces,
K-56: Sprinkler System Installation,
K-62: Sprinkler System Maintenance & Testing,
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, interview, and record review, the facility failed to:


I. Ensure that comprehensive Master Treatment Plan (MTP) revisions occurred for the care and treatment of two (2) of eight (8) active sample patients (C, H). Specifically, the treatment plans for these patients were not revised when a change in treatment was warranted based on the patient's change in clinical status. This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)


II. Ensure that patient's restraints were discontinued when patients (A, H) no longer demonstrated behaviors that necessitated the use of physical restraints. This practice violates the patients' rights to be treated in the least restrictive manner and is a potential for patient harm. (Refer to B125)

Based on record review, policy review and interview the facility failed to revise treatment plans for one (1) of eight (8) active sample patients (Patients H) who had been restrained multiple times and for one (1) of eight (8) active sample patients (Patient C) who was placed on 2:1 observation due to inappropriate sexual issues and accusations. This failure resulted in plans that did not address relevant behaviors; and hindered treatment and the timely discharge of patients.


Specific findings include:


I. Record Review

A. Patient C (Master Treatment Plan dated 10/21/16) was placed on 2:1 staffing status on 11/9/16 and remained on this status until 11/29/16. When reviewed by surveyor on 11/28/16, the master treatment plan had not been revised to indicate that the patient had been placed on 2:1 staffing status.


B. Patient H (Master Treatment Plan dated 11/24/16) was restrained on 11/25/16 at 4:15 P.M., on 11/26/16 at 2:20 A.M. and on 11/27/16 at 6:35 P.M. The master treatment plan had no revisions of interventions after the restraint episodes. The only nursing intervention (dated 11/24/16) to address this patient's aggressive behavior was: "Nursing staff will monitor for symptoms of aggression and redirect each occurrence."


II. Document Review

The Facility Policy 2039356 entitled, "Recovery Planning and Recovery Conference Guidelines: Treatment Team Assessments and Procedures" and last reviewed on 6/14/16 stated on page 4, "IV. Change of Condition-Revisions to the Recovery Plan: The Recovery Plan will also be reviewed and updated, as needed, after the occurrence of any event that would be reportable per the Incident/Risk Management Reporting Policy, or if there is a noteworthy change in the condition of the patient. The Recovery Plan will be updated during the shift in which the event occurred by adding a problem to the appropriate domain and a corresponding objective and method, with their signature, to address the issue."



III. Interviews

A. RN1 stated in an interview on 11/28/16 at noon that she would not expect the master treatment plan to reflect that the patient had been placed on 2:1 staffing status.

B. RN2 stated in an interview on 11/29/16 at 10:00 A.M. that she would not expect the master treatment plan to reflect that the patient had been placed on 2:1 staffing status, "because it is already in the doctor's orders."

C. RN3 stated in an interview on 11/28/16 at 1:51 P.M., "I would expect that a 2:1 intervention would be on the treatment plan."

D. RN5 stated in an interview on 11/28/16 at 1:45 P.M., "No, the plan was not revised after the restraints."

Based on record review, document review, and interview, the facility failed to discontinue physical restraints for two (2) of eight (8) sample patients (Patients A and H), even though the patients no longer demonstrated behaviors that necessitated the use of physical restraints. This practice violated the patients' rights to be treated in the least restrictive manner and is a potential for patient harm.

Specific findings include:

I. Record Review

A. Patient A (admitted 11/22/16) was restrained in 4-point restraints on 11/25/16 at 2:00 P.M. for "threatening behaviors, posturing towards staff and security." The nursing progress note timed 4:18 P.M. reads, "Pt. [patient] asleep while in restraints."

B. Patient H (admitted 11/24/16)

1. Patient H was restrained in 4-point restraints on 11/25/16 at 4:15 P.M. for, "yelling at staff, physically threatening, fighting." The monitoring document noted no verbal or physical agitation after 4:30 P.M. The physician charted, "Pt [Patient] sleeping, appears comfortable" at 4:50 P.M. The patient was not released from restraints until 5:10 P.M. when the R.N. charted, "Patient asleep, released from 4-pt. restraints."

2. Patient H was restrained in 4-point restraints on 11/27/16 at 6:35 P.M. because, "[Patient] became agitated during meeting with mother. Patient began hitting walls, yelling." The monitoring document noted no verbal or physical agitation after 6:35 P.M. The patient was not released from the restraints until 7:35 P.M.

II. Document Review

The Facility Policy entitled, "Seclusion, Physical Restraint, and/or Involuntary Medication: Emergent Use" (ID 2161481; updated 8/31/16) states:

A. "Restraint or seclusion must be discontinued at the earliest possible time." (p. 3)

B. "When the dangerous behavior which led to the seclusion or restraint episode has resolved, (i.e., kicking, verbalization of threats to self or others) and the patient is able to manage in a less restrictive environment, the restraint or seclusion episode is discontinued." (p.8)

III. Interview

A. On 11/29/16 at 1:00 P.M., RN2 stated, "I agree that the patient could have been released sooner."

B. On 11/29/16 at 1:20 P.M., the Director of Nursing stated, "Yes, it is inappropriate for the patient to remain in restraints after they are settled," and "Having a patient sleep in restraints is not appropriate."

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

I. The master treatment plans for one (1) of eight (8) active sample patients (Patient H) who had been restrained multiple times and for one (1) of eight (8) active sample patients (Patient C) who had been placed on 2:1 observation due to sexual issues were revised. This failure resulted in plans that did not address relevant behaviors, hindered treatment and the timely discharge of patients. Refer to B118.

II. Two (2) of eight (8) sample patients (Patients A and H) were released from 4 point restraints when they no longer demonstrated the behaviors that necessitated the use of such restraints. This practice violated the patients' rights to be treated in the least restrictive manner and is a potential for patient harm. Refer to B125.

Based on record review, policy review and interviews, the Director of Nursing failed to ensure that:

I. The master treatment plans for one (1) of eight (8) sample patients (Patient H) who had been restrained multiple times and for one (1) of eight (8) sample patients (Patient C) who had been placed on 2:1 observation for sexual issues had been revised. This failure resulted in plans that did not address relevant behaviors, hindered treatment and the timely discharge of patients. Refer to B118.

II. Two (2) of eight (8) sample patients (Patients A and H) were released from 4 point restraints when they no longer demonstrated the behaviors that necessitated the use of such restraints. This practice violated the patients' rights to be treated in the least restrictive manner and is a potential for patient harm. Refer to B125.