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Based on observation, interview, policy and record review, the facility failed to ensure patients received care in a safe environment when staff failed to protect two current patients (#1 and #15) and two discharged patients (#2 and #9) of four patients reviewed from physical and or sexual assault by other patients. Staff failed to implement measures in a timely manner to protect patients at risk for assault by others. This had the potential to affect all patients being admitted to the facility. The facility census was 64.

Findings included:

1. Record review of the facility's policy titled, "Abuse and Neglect Definitions, Investigation Procedures and Penalties, State Operated Facilities" dated 08/28/12, showed the following information:
-"Neglect", failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presents either imminent danger to the health, safety or welfare of a consumer, or a substantial probability that death or serious physical injury would result. This would include, but is not limited to, failure to provide adequate supervision during an event in which one consumer causes serious injury to another consumer.
-The department director delegates authority to heads of the facilities to perform duties and take appropriate action to ensure consumers reside in a safe and therapeutic environments, subject to the supervision of the division director or department director.
-After receiving a complaint or report, the head of the facility or designee shall ensure the following requirements are completed:
A. In all cases of physical abuse or neglect resulting in injury, a physical examination of the consumer shall be performed by a qualified medical professional as soon as practicable.

Review of the facility's policy titled, "Safety, Nursing's Responsibility" effective date 08/09 showed the following direction:
-The purpose of the policy was to ensure safe environment and facilitate improvement in the environment;
-The nursing staff shall be responsible for taking immediate action by implementing the appropriate intervention in all conditions that jeopardize the safety of others and the environment;
-Precaution level patients, paragraph 3. Nursing staff is responsible for making ongoing assessment of patients and the environment to identify any risk for harm.

2. Review of the facility's policy titled, "List of Patient's Rights" revised/effective 08/10 showed the following direction:
-Procedure: 1. 3 The following patient rights may not be limited: To safe and sanitary housing.
-1.15 To be free from verbal, physical and sexual abuse.
-Procedure 4.8 As a participant of the Medicaid and Medicare programs, the facility agrees to protect and promote the rights listed below: To receive care in a safe setting.
-4.9 To be free from all forms of abuse and harassment.

3. Review of current Patient #1's re-admission history and physical dated 04/25/12 showed the psychiatrist assessed the patient with the following:
-A recent discharge from the facility on 04/13/12 to a local Skilled Nursing Facility (SNF);
-Diagnoses including paranoid schizophrenia (a mental illness with one or more of the following symptoms: delusions, hallucinations, bizarre behaviors, disorganized speech);
-Mental status examination included irritable mood (shouting and angry responses to questions); statements that everyone in the city was evil and everyone in the medical field was against him; and poor judgment;
-The assessment also reported a violent temper, multiple outbursts with aggression and assaultive behavior towards staff at the SNF.

Review of the patient's nurse's notes dated 04/28/12 through 11/22/12 showed staff assessed Patient #1 with suspiciousness; argumentative verbal interactions with staff and other patients; physical altercations for which restraint had to be used and verbal altercations with other patients that escalated to physical altercations with injury to self and others.

Review of Patient #1's Comprehensive Treatment Plans (CTP) dated 05/11/12 through 11/21/12 showed multiple descriptions of verbal and/or physical altercations with staff and patients but failed to address use of a Recent Predictive Behaviors assessment tool (RPB, an assessment tool used by the treatment team to identify risk factors related to treatment and categorize the patient's current category of risk) and failed to incorporate a Personal Safety Plan (a nursing plan outlining safety risks for each patient) in the CTP. Staff failed to establish measurable objectives and to identify target dates for decreasing aggressive behaviors to protect Patient #1 and for the protection of other patients.

4. Review of Patient #1's incident reports dated 08/07/12 through 12/22/12 showed the following:
-Multiple verbal interactions with staff and other patients that escalated into physical altercations with harm to himself and others. These incidents were sometimes occurring daily;
-Dated 11/12/12 at 9:20 PM the patient sustained facial fractures due to a physical altercation with another patient. Patient #1 was knocked to the floor, struck multiple times with fists and hand and was unconscious for a brief time;
-Dated 11/27/12 at 5:55 PM; 11/29/12 at 10:20 AM; 12/06/12 at 7:35 AM; 12/11/12 at 8:00 AM; 12/19/12 at 8:45 PM multiple verbal altercations with other patients that sometimes escalated into physical assaults and injury;
-Dated 12/22/12 at 10:05 PM Patient #1 was observed to enter a male patient's room. When staff entered the room and asked the occupant of the room for an explanation, that patient responded that Patient #1 wanted to perform a sex act on him.

5. Review of discharged Patient #2's annual medical-psychiatric evaluation dated 04/12/12 showed the physician assessed the patient was admitted on 04/04/11 with diagnoses of schizophrenia, history of closed head injury and gunshot to the groin.

Further review of the patient's annual evaluation showed Patient #2 had a long criminal justice history consisting of assault and auto theft. The patient struck a police officer with a chair at the city jail, was subsequently transferred to a long term psychiatry center then, later to a maximum security forensic (related to court of law) psychiatry center. The patient was currently admitted to the facility for administrative reasons and further management of chronic mental illness. Past diagnoses included polysubstance (multiple drug) abuse and dependence; nicotine dependence; borderline intellectual functioning; antisocial personality disorder; extensive history of trauma, violence and forensic complications.

Review of Patient #2's weekly nursing notes dated 11/10/12 showed the
patient refused medication then, later pushed his way into the medication room demanding medication. When asked to leave the medication room the patient threatened to kill the nurse;

The nurse only noted a plan to continue the current plan of care; failed to address RPB assessment or a Personal Safety Plan for this patient.

6. Review of Patient #2's incident report dated 11/12/12 at 9:20 PM showed the patient was struck with a bag of clothing by Patient #1. Patient #2 physically attacked Patient #1 by striking Patient #1 with fists and hand to the head and eye. Patient #1 was on the floor and beaten by Patient #2 for an estimated full minute, briefly lost consciousness and consequently sustained facial fractures.

Review of Patient #2's incident reports (all dated after he severely injured Patient #1) showed the following:
-On 11/13/12 at 8:10 AM the patient threw hot coffee on another patient. Patient #2 laughed and walked away;
-On 11/13/12 at 4:45 PM the patient refused restraints for transfer to a maximum security forensic psychiatry center; became combative striking staff in the face and injuring the left wrist of staff. The local city police department had to be called for assistance in securing restraints for transport.

7. Review of Patient's #2's nurse's notes from 11/12/12 evening (just after the patient to patient attack) through 11/13/12 (approximately twenty four hours) when Patient #2 was put in restraints for transport showed the following:
-Staff failed to protect other patients on the unit from physical attacks by Patient #2.
-Staff failed to change interventions on the CTP to implement safety precautions and protect other patients from Patient #2.
-Staff failed to address a RPB assessment or a Personal Safety Plan.

8. During an interview on 01/08/13 at 9:58 AM Staff L, Mental Health Technician (MHT) stated, "Patients do fight each other and us. I would never get between two patients unless there was another staff right there to help me."

9. During an interview on 01/09/13 at 9:15 AM Staff Q, Psychiatrist stated the following:
-Most patients admitted here had long term mental illness and this facility was their home;
-The closeness of living on the unit contributed to the increased number of physical altercations;
-Some patients who were currently admitted to the units were inappropriate admissions here (due to their need for more structured environment).

10. During an interview on 01/09/13 from 9:15 AM through 10:35 AM Staff R, Psychiatrist stated the structure on the units was very loose.

11. Record review of current Patient #15's medical record showed this 5 foot 6 inch tall male was admitted to the facility on 02/07/11 with complaints of molesting children.

12. Record review of discharged Patient #9's medical record showed this 6 foot tall, 345 pound male was admitted to the facility on 06/30/11 with complaints of aggressive behavior.

13. Record review of Patient #9's Customer Information Management Outcomes and Reporting (CIMOR)-Single Event reports showed he was involved in 59 events from 01/17/12 to 08/07/12 that ranged from manipulation, verbal threats, physical and sexual assault against peers and staff. The patient was discharged from the facility on 08/08/12 to a maximum security facility.

Record review of the patient's CIMOR showed staff documented the following verbal threats and physical assaults Patient #9 had towards Patient #15:
-On 02/20/12 at 5:52 PM, Patient #9 physically assaulted Patient #15.
-On 02/20/12 at 6:15 PM, Patient #9 attempted to physically assault Patient #15.
-On 02/28/12 at 7:48 PM, Patient #9 physically assaulted Patient #15.
-On 03/04/12 at 8:20 PM, Patient #9 verbally threatened to physically assault Patient #15.
-On 03/05/12 at 1:00 PM and 1:10 PM, Patient #9 verbally threatened to physically assault Patient #15.
-On 03/05/12 at 1:40 PM, Patient #9 physically assaulted Patient #15 by grabbing him from behind in a choking position.
-On 03/05/12 at 3:20 PM, Patient #9 verbally threatened to physically assault Patient #15.
-On 03/05/12 at 3:30 PM, Patient #9 physically assaulted Patient #15 while in group and attempted to assault the psychiatrist.

14. Record review of Patient #9's CTP dated 02/15/12 showed the following direction for staff:
-Problem #1: Verbally abusive language is used to intimidate or control others.
-Goals: Decrease overall frequency, intensity and duration of angry thoughts, feelings and actions. Target Date: 02/29/12.
-Objectives:
-The patient will verbalize increased awareness of anger expression patterns, their possible origins and their consequences.
-The patient will use learned DBT (Dialectical Behavior Therapy is a cognitive behavior therapy that focuses on the role of cognition (thoughts and beliefs) and behaviors (actions) in the development and treatment of borderline personality) skills for avoiding aggressive behavior.
-The patient will learn and implement problem-solving and/or conflict resolution skills to manage specific interpersonal problems.
-The patient will participate in group and individual social skills therapy and anger management.
-The CTP Review showed under the Summary of Changes, Additions, Deletions and Original CTP Updates the following information:
-On 02/29/12 staff documented as a result of these aggressive events, the patient will remain on level 2 (a level where the patient is safe to be on the unit) at this time.
-On 03/14/12 staff documented patient is now on level 2 because of increase in target behavior.

Due to a lack of staff interventions, Patient #15 did not receive care in a safe environment when Patient #9 verbally threatened to physically assault Patient #15 numerous times and carried out his threats on several occasions. Staff failed to take immediate action to put into place preventive measures to protect Patient #15's safety when it was jeopardized by Patient #9.

15. Record review of Patient #9's Discharge Summary dated 08/14/12 showed the following information:
-Clinical Course: Since admission, the patient has had numerous problems with behavioral issues. There have been multiple incidents of assaultive and aggressive behaviors directed towards staff and his peers. The patient required restraint or seclusion multiple times to prevent potential harm to others. He has been placed on observation in direct line of sight while in the milieu (environment) and outside his bedroom to prevent harm to others all with consideration to his physically aggressive and assaultive behavior. The psychiatrist noted that he physically attacked peers on the unit multiple times in calculated, premeditated manner. His victims were usually weak, vulnerable patients in order to meet his self-gratifying wants. It is also noted that he was manipulative and disregarded rules on the unit. In the past few days, the patient's aggressive and assaultive behavior worsened. A day prior to his discharge, the patient had assaulted a peer unprovoked by punching him several times on the face, which ended up in a nasal bone fracture of the peer.
The patient was discharged to a more secured facility to ensure the safety of other peers at this time.

16. During interview on 01/09/13 at 9:05 AM, Staff R, Physician stated that the facility should have admission criteria before patients are admitted to the facility.




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31891

Based on observation, interview and record review facility staff failed to ensure a registered nurse evaluated the care provided to psychiatric patients by assessing care needs; assessing the patient's health status and the patient's response or lack of response to interventions provided (refer to A 0395). The facility also failed to ensure staff established, revised and maintained an effective care plan for each patient addressing problems, setting goals, time frames with specific interventions for each problem identified (refer to A 0396).

The cumulative effect of these systemic problems resulted in the facility's inability to meet the specific requirements under the Condition of Participation: Nursing Services.

Based on observation, interview, policy and record review, the facility failed to provide adequate nursing supervision and oversight for patients when two current patients ( #1 and #15) were physically assaulted by two discharged patients (#2 and #9) of four patients reviewed. This had the potential to affect all patients admitted to the facility. The facility census was 64.

Findings included:

1. Record review of the facility's, "Plan for the Provision of Nursing Care" updated 04/12 showed the following information:
-Psychiatric-Mental Health Nursing's Focus of Concern: Behaviors and mental states that indicate the client is a danger to self or others or has a severe disability.
-Nursing Department Patient Related Goals: Provide a safe, secure, therapeutic unit environment.
-Nursing Department Patient Related Activities: The plan of care will be reviewed and will reflect ongoing assessments.

2. Review of Patient #1's re-admission history and physical dated 04/25/12 showed the psychiatrist assessed the patient with the following:
-A recent discharge from the facility on 04/13/12 to a local Skilled Nursing Facility (SNF);
-Diagnoses including paranoid schizophrenia (a mental illness with one or more of the following symptoms: delusions, hallucinations, bizarre behaviors, disorganized speech);
-Mental status examination included irritable mood (shouting and angry responses to questions); statements that everyone in the city was evil and everyone in the medical field was against him; and poor judgment;
-The assessment also reported a violent temper, multiple outbursts with aggression and assault behavior towards staff at the SNF.

Review of the patient's nurse's notes dated 04/28/12 through 05/01/12 showed the patient was suspicious of male staff, had verbal altercations with other patients, and displayed aggressive behaviors.

Review of Patient #1's Comprehensive Treatment Plans (CPT) dated 05/11/12; 05/25/12; 06/08/12; 07/06/12; 08/03/12; 08/31/12 and 10/26/12 showed multiple verbal and physical altercations with staff and other patients with no interventions to curb the behaviors or address suicidal statements or urinating on himself (10/26/12).

3. Review of Patent #1's incident reports dated 10/02/12; 10/11/12; 10/13/12; 10/14/12; 10/18/12; 10/19/12; 10/29/12, 10/31/12 at 11:00 AM, 10/31/12 at 8:15 PM, 11/02/12, 11/06/12 and 11/07/12, staff continued to describe physical altercations, some with physical injury with other patients and incidents in which the patient had to be physically restrained (manual hold).

Review of the patient's incident reports dated 11/12/12 at 9:20 PM showed Patient #1 and Patient #2 engaged in a physical altercation during which Patient #1 provoked Patient #2 (struck him with a grocery bag of clothing) and Patient #2 struck Patient #1 in the face and head. Patient #1 was knocked to the floor, sustained multiple blows to the face/head and when staff were able to separate the two combatants, staff discovered Patient #1 had lost consciousness for a minute or so. Staff did not call for additional manpower during the fight, however did call a Code Blue. Patient #1 was transported to the local Emergency Room. Patient #1 was diagnosed with facial fractures and eye injury (currently causing permanent double vision).

4. Review of the patient's nurse's notes dated 11/22/12 showed staff noted the patient approached a male Mental Health Technician (MHT) and asked if he (the patient) could perform a sex act on the MHT. The nurses' note concluded with "will continue with current plan of care."

5. Review of Patient #1's incident reports dated 11/27/12 5:55 PM threatening verbal and physical altercations, again some with physical injury. A report dated 12/22/12 at 10:05 PM showed Patient #1 was observed entering a male patient's room. When staff entered the room and asked the occupant of the room for an explanation, that patient responded that Patient #1 wanted to perform a sex act on him.

6. Review of Patient #1's most current medical record dated 11/22/12 through present time showed no revisions to the CTP or entries assessing the Recent Predictive Behaviors (RPB is an assessment tool used by the treatment team to identify risk factors related to treatment and to categorize the patient's current category of risk) for additional sexual advances or Personal Safety Plan (a nursing plan outlining safety risks for each patient) for provocation of altercations with the other patients.

7. Review of Patient #2's annual medical-psychiatric evaluation dated 04/12/12 showed the physician assessed the patient was admitted on 04/04/11 with diagnoses of schizophrenia (a mental illness characterized by delusions, hallucinations, bizarre behaviors, disorganized speech), history of closed head injury and gunshot to the groin.

Further review of the patient's annual evaluation showed Patient #2 had a long criminal justice history consisting of assault and auto theft. The patient struck a police officer at the jail; was subsequently transferred to a long term psychiatry center then, later to a maximum security forensic psychiatry center. The patient was currently admitted to the facility for administrative reasons and further management of chronic mental illness. Past diagnoses included polysubstance (multiple drug) abuse and dependence; nicotine dependence; borderline intellectual functioning; antisocial personality disorder; extensive history of trauma, violence and forensic (law enforcement) complications.

8. Review of Patient #2's psychiatrist's progress note dated 08/21/12 showed the physician assessed the following:
-At the time of admission, the patient was restless at times due to lack of activity and not being able to work as he had at the maximum security forensic psychiatry center:
-Recently, the patient had shown clinical improvement after he started a meaningful activity during which he had scheduled time for cleaning inside the facility and outside the unit. The activity addressed the patient's long standing desire to work;
-The patient was described as less disorganized, more focused and much happier.

9. Review of Patient #2's weekly nursing notes dated 11/10/12 showed the following:
-The patient refused medication then, later pushed his way into the medication room demanding medication. When asked to leave the medication room the patient threatened to kill the nurse;
-The patient was noted to leave food and trash in the ice machine drain. When redirected the patient told the staff to leave him alone, the staff could not tell him what to do;
-The nurse noted a plan to continue the current plan of care.

Nursing failed to address RPB assessment or a Personal Safety Plan for this patient.

10. Review of Patient's #2's nurse's notes from 11/12/12 evening (just after a patient to patient attack) through 11/13/12 (approximately twenty four hours) when Patient #2 was put in restraints for transport showed staff failed to implement any actions to protect other patients from Patient #2.

11. Observations on 01/07/13 at 2:50 PM on unit 2B showed one Mental Health Technician (MHT) seated at a desk and two or three patients seated in the area or walking around in the area. No organized activities were being conducted and several patients asleep in their rooms.

12. During an interview on 01/08/13 at 9:10 AM Staff E, MHT stated the following:
-Lead Technicians attend Care Plan Meeting and were involved with the Treatment Plan and that's how we know what to do for each patient to take care of them. We tell the other MHTs on the shift.
-Patients usually have to attend group meetings to get to a higher, less restrictive level.
-If a patient was asleep in their rooms and was supposed to be in group, I go and ask them why they didn't go to group.
-Some patients just say they don't want to go to groups.
-We can't make them go. We don't make them go.
-We have a new system now where each MHT was assigned to some patients and we tell the nurses things they did not know about the patient's behaviors.
-Daily activities here usually were patients could sleep in bed or go to group or watch television. Patient's have their choice. We don't make them do anything.

13. Observation on 01/08/13 at 9:56 AM in a 2B unit corridor showed no staff in the area, a female patient pacing back and forth multiple times, glaring and other patients asleep in their beds.

14. During an interview on 01/08/13 at 9:58 AM Staff L, MHT stated the following:
-Patients do fight each other and us.
-I would never get between two patients unless there was another staff right here to help me.
-We have group meetings on the unit. Groups were Monday through Fridays. Saturdays and Sundays were rest days.
-Going to group was an option for patients. We cannot force patients to go to group meetings.

15. During an interview on 01/09/13 at 9:15 AM Staff Q, Psychiatrist stated the following:
-Most patients admitted here had long term mental illness and this facility was their home.
-The closeness of living on the unit contributes to the increased number of physical altercations.
-There are limited activities on the units so the patients have time to brood over things.
-The patients need purpose in their lives.
-Recreation therapy would be ideal but due to decreased staffing recreation programs were not done.
-Some patients who were currently admitted to the units were inappropriate admissions here (due to their need for more structured environment).

16. During an interview on 01/09/13 from 9:15 AM through 10:35 AM Staff R, Psychiatrist stated the following:
-The structure on the units was very loose.
-The patients need groups and activities according to their physical abilities.
-It was difficult to combine patients from so many mixed populations (different diagnoses) into an activity group.
-Some of the patients need work therapy activities and purposeful activities.
-The units need physical activities such as ping-pong or basketball. Physical activity was very important.

17. Review of the Unit 2B Activities schedule revised 01/01/13 showed multiple planned activities called "personal time" and "patient choice" in increments of one hour time blocks. Some time blocks without notations of any planned activities.

Some planned activities called "reflection group"; "community reintegration"; "assertiveness skills" and "friendship and dating skills" may be inappropriate for chronic mentally ill patients.

18. Record review of current Patient #15's medical record showed this 5 foot 6 inch tall male was admitted to the facility on 02/07/11 with complaints of molesting children.

19. Record review of discharged Patient #9's medical chart showed this 6 foot tall, 345 pound male was admitted to the facility on 06/30/11 with complaints of aggressive behavior.

20. Record review of Patient #9's Customer Information Management Outcomes and Reporting (CIMOR)-Single Event showed the following information:
-On 02/20/12 staff documented Patient #9 engaged in two different altercations with Patient #15. At 5:52 PM Patient #9 became angry and grabbed Patient #15 by the neck and swung him around and down into the couch face first. At 6:15 PM when Patient #15 was attempting to go back to his room, Patient #9 lunged toward him with his fist clenched and had an angry affect.
-On 02/28/12 at 7:48 PM staff documented Patient #9 asked Patient #15 if he could play the Wii game. Patient #15 told him no, so Patient #9 hit him on the back of the head with his fists.
-On 03/04/12 at 8:30 PM staff documented Patient #9 and Patient #15 were in the television (TV) room when Patient #9 lunged toward Patient #15. Patient #9 left the room when staff intervened. Patient #9 went to the kitchen area and grabbed a tray and went back to the TV room. Staff blocked the entryway and attempted to redirect Patient #9. Patient #9 slammed the tray against the TV window as he stated "I don't care who I have to go through male or female. I'll still fuck him up!" Patient #9 then charged through the TV room door towards Patient #15.
-On 03/05/12 staff documented Patient #9 engaged in five different altercations with Patient #15:
-At 1:00 PM Patient #9 verbally threatened Patient #15 when he stated "You wait until next shift, surely there is one weak person to watch you, that's when I'm going to fuck you up".
-At 1:10 PM Patient #9 stated "I'm going to get a hold of Patient #15 sometime this evening and do him in. I already have it planned!" Staff informed him that was considered premeditated and he stated "I don't give a fuck! That is the best way to get it done!"
-At 1:40 PM Patient #15 was playing cards with another peer when suddenly Patient #9 walked up to him and physically grabbed him from behind in a choking hold. Patient #9 intended to do that because it was reported he did make a threat and actually carried it out.
-At 3:20 PM Patient #9 became agitated and loudly shouted "I better get moved to 3C tonight or I will kill Patient #15!" Patient #9 stated that he felt his only option at this time was to move units or go to prison to solve the issue. Patient #9 stated that Patient #15 got what he deserved.
-At 3:30 PM Patient #9 was in group sitting next to Patient #15 and began to intimidate and threaten him. Patient #9 was asked to move away from Patient #15. Patient #9 stated that he would just leave. Patient #9 left the group but returned after approximately 10 minutes and began to intimidate and threaten Patient #15 again. The psychologist announced that the group would end early due to Patient #9's behavior/disrupting the group. Patient #9 then walked over and punched Patient #15's face with his closed fist. Patient #9 then attempted to assault the psychiatrist.

Staff did not provide adequate supervision and oversight for Patient #9 to prevent him from verbally harassing and physically assaulting Patient #15. Patient #9 made several verbal threats to assault Patient #15 numerous times throughout a 24 hour period and often carried out his threats on Patient #15.

21. Record review of Patient #9's Discharge Summary dated 08/14/12 showed the following information:
-Clinical Course: Since admission, the patient has had numerous problems with behavioral issues. There have been multiple incidents of assaultive and aggressive behaviors directed towards staff and his peers. The patient required restraint or seclusion multiple times to prevent potential harm to others.
The psychiatrist noted that the patient physically attacked peers on the unit multiple times in a calculated, premeditated manner. His victims were usually weak, vulnerable patients in order to meet his self-gratifying wants. It was also noted that he was manipulated and disregarded rules of the unit, which appeared to be consistent with antisocial personality behavior.
The patient was discharged from the facility on 08/08/12 to a maximum security facility.

22. During an interview on 01/09/13 at 9:05 AM, Staff R, Psychiatrist stated that the facility should have admission criteria before patients are admitted to the facility. Staff R stated that there needs to be consistency with care of patients and treatment plans. Staff R stated that there is a lack of activities and groups that are meaningful to patients and patients needed activities and groups that would benefit them.




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31891

Based on observation, interview and record review the facility failed to develop, revise and maintain an individualized care plan as directed by facility policy for four of four patients (#1, #2, #9 and #15) that addressed interventions (such as activity programs) that would protect the patient from physical altercations, targeting by other patients and provide specific safety measures to prevent multiple repetitive verbal and physical interactions. Staff also failed to develop, revise and maintain an individualized care plan that meaningfully met the needs of two of two patients (#14 and #15) who complained of boredom. The facility census was 64.

Findings included:

1. Review of the facility's policy titled, "Comprehensive Treatment Plan - Development and Documentation" #140.119 revised 09/12, showed the following direction:
-Purpose: Treatment planning is a dynamic process that provides the foundation for the active treatment of all admitted patients;
-Planning is based on assessment of the patient's needs and strengths and identifies the patient's behavioral and psychiatric issues, establishes specific goals for inpatient treatment, and outlines the interventions selected to address identified issues;
-Definitions: Comprehensive Treatment Plan (CPT) is the outline of what the patient and staff will work together on to achieve stabilization and acquisition of new skills;
-Recent Predictive Behaviors (RPB) is an assessment tool used by the treatment team to identify risk factors related to treatment and categorize that patient's current category of risk;
-Goal: Each problem category expressed in terms of replacing problem behavior with more effective alternatives, each goal will have a specific timeline;
-Objectives: Objectives are written to address and shape skill acquisition which is necessary to achieve a goal;
-The treatment planning process begins with the development of the Nursing Plan of Care on admission;
-The CPT will be developed by the treatment team members who assess and add problems, goals, objectives and interventions throughout the course of treatment;
-The Nurse completes the Personal Safety Plan (a nursing plan outlining safety risks for each patient) for the patient;
-CPT is completely weekly for the first four weeks, bimonthly for the next two months, every thirty days for the third month through one year. After one year, every ninety days;
-Reviews (of the CPT) will address progress towards restoration of competency and discharge as well as identify continued barriers;
-When any unexpected or exceptional event (such as restraint/seclusion, self harm, precaution status, and/or significant change in medical status) occurs, the treatment team will meet and discuss the plan, goals, objectives and interventions as written. The meeting should happen within 24 hours of the event and prompt a Treatment Plan Review or revisions to the plan;
-(For the CPT), the problems will be identified from psychiatric and medical conditions;
-Objectives must be measurable and must identify target dates.

2. Review of Patient #1's re-admission history and physical dated 04/25/12 showed the psychiatrist assessed the patient with the following:
-A recent discharge from the facility on 04/13/12 to a local Skilled Nursing Facility (SNF);
-Diagnoses including paranoid schizophrenia:
-Mental status examination included irritable mood (shouting and angry responses to questions); statements that everyone in the city was evil and everyone in the medical field was against him; and poor judgment;
-The assessment also reported a violent temper, multiple outbursts with aggression and assaultive behavior towards staff at the SNF.

Review of the patient's nurse's notes dated 04/28/12 through 05/01/12 showed the patient was suspicious of male staff , had verbal altercations with other patients, and displayed aggressive behaviors.

Review of the patient's CTPs dated 05/11/12; 05/25/12; 06/08/12; 07/06/12; 08/03/12 and 08/31/12 showed the following:
-Staff erroneously assessed the patient had no aggressive behaviors (on 05/11/12);
-Staff promoted Patient #1 to a less restricted level (on 05/11/12);
-Staff failed to address use of the RPB (Recent Predictive Behaviors assessment tool) in any of the CTPs;
-Staff failed to incorporate a Personal Safety Plan in the CTP as directed by facility policy for any of the CTPs;
-Staff failed to set goals to address rude and demanding behaviors and attend group meetings;
-Staff again summarized that there were "no changes to the CTP at this time".

Staff failed to establish measurable objectives and to identify target dates for completion of any goals regarding rude, demanding behaviors, verbal and physical altercations (some with resultant injury) with staff and other patients or to attend groups.

3. Review of Patient #1's incident reports showed the following:
-Dated 10/02/12 while "hanging around" at the nurse's desk had verbal altercations with another patient;
-Dated 10/11/12, 10/13/12, 10/14/12, 10/18/12 and 10/19/12 had physical altercations with other patients, some with injury.

4. Review of Patient #1's CTP dated 10/26/12 showed the same problems were identified with a suicidal statement after one incident, plus the patient was then urinating on himself. Staff again summarized that there were "no changes to the CTP at this time:"

Staff continued to fail to include findings of an RPB assessment and failed to incorporate a Personal Safety Plan for the patient.

5. Review of the patent's incident reports dated 10/29/12, 10/31/12 at 11:00 AM, 10/31/12 at 8:15 PM, 11/02/12, 11/06/12 and 11/07/12 showed staff continued to describe physical altercations, some with physical injury, with other patients and incidents in which the patient had to be physically restrained (manual held).

Review of the patient's incident reports dated 11/12/12 at 9:20 PM showed Patient #1 and Patient #2 engaged in a physical altercation during which Patient #1 provoked Patient #2 (struck him with a grocery paper bag of clothing) and Patient #2 struck Patient #1 in the face and head. Patient #1 was knocked to the floor; sustained multiple blows to the face/head and when staff were able to separate the two combatants, staff discovered Patient #1 had lost consciousness for a minute or so. Staff did not call for additional manpower during the fight, however they did call a Code Blue. Patient #1 was transported to the local Emergency Room and diagnosed with facial fractures and eye injury (currently causing permanent double vision).

6. Review of Patient #1's CTP dated 11/21/12 showed the following:
-Staff again described threats, provocative behaviors, physical altercations with staff and other patients (especially the one during which the patient sustained facial fractures);
-Staff failed to include in the CTP review any mention of manual holds and seclusion, which according to the facility policy would trigger an immediate (within twenty-four hours) treatment team meeting to discuss revisions to the plans, goals, objectives and interventions;
-Staff again failed to include findings of an RPB assessment and failed to incorporate a Personal Safety Plan for the patient as outlined in the facility policy;
-Staff again just repeated "no changes at this time;"
-The psychiatrist again reinforced the patient needed active daily inpatient care to improve his condition with no physical aggression, provocation of other patients and safety.

7. Review of the patient's nurse's notes dated 11/22/12 showed staff noted the patient approached a male Mental Health Technician (MHT) and asked if he (the patient) could perform a sex act on the MHT. The nurses' note concluded with "will continue with current plan of care."

8. Review of Patient #1's incident reports dated 11/27/12 at 5:55 PM showed the patient had verbal and physical altercations, some with physical injury. A report dated 12/22/12 at 10:05 PM showed Patient #1 was observed entering a male patient's room. When staff entered the room and asked the occupant of the room for an explanation, that patient responded that Patient #1 wanted to perform a sex act on him.

9. Review of Patient #1's most current medical record dated 11/22/12 through present time showed no revisions to the CTP or entries assessing the RPB for additional sexual advances or Personal Safety Plan for provocation of altercations with the other patients.

10. Review of Patient #2's annual medical-psychiatric evaluation dated 04/12/12 showed the physician assessed the patient was admitted on 04/04/11 with diagnoses of schizophrenia (a mental illness characterized by delusions, hallucinations, bizarre behaviors, disorganized speech), history of closed head injury and gunshot to the groin.

Further review of the patient's annual evaluation showed Patient #2 had a long criminal justice history consisting of assault and auto theft. The patient struck a police officer with a chair at the city jail, was subsequently transferred to a long term psychiatry center then, later to a maximum security forensic psychiatry center. The patient was currently admitted to the facility for administrative reasons and further management of chronic mental illness. Past diagnoses included polysubstance abuse (multiple drug) and dependence; nicotine dependence; borderline intellectual functioning; antisocial personality disorder; extensive history of trauma, violence and forensic (law enforcement) complications.

11. Review of Patient #2's psychiatrist's progress note dated 08/21/12 showed the physician assessed the following:
-At the time of admission, the patient was restless at times due to lack of activity and not being able to work as he had at the maximum security forensic psychiatry center:
-Recently, the patient had shown clinical improvement after he started a meaningful activity during which he had scheduled time for cleaning inside the facility and outside the unit. The activity addressed the patient's long standing desire to work;
-The patient was described as less disorganized, more focused and much happier.

12. Review of Patient #2's weekly nursing notes dated 11/10/12 showed the following:
-The patient refused medication then, later pushed his way into the medication room demanding medication. When asked to leave the medication room the patient threatened to kill the nurse;
-The patient was noted to leave food and trash in the ice machine drain. When redirected the patient told the staff to leave him alone, the staff could not tell him what to do;
-The nurse noted a plan to continue the current plan of care and failed to address RPB assessment or a Personal Safety Plan for this patient.

13. Review of Patient #2's incident reports showed the patient was allowed to remain unrestricted on the unit after a physical altercation with Patient #1. The report showed:
-On 11/13/12 at 8:10 AM the patient threw hot coffee on another patient. Patient #2 laughed and walked away;
-At 4:45 PM on 11/13/12, the patient refused restraints for transfer to a maximum security forensic psychiatry center; became combative striking staff in the face and injuring the left wrist of staff. The local city police department had to be called for assistance in securing restraints for transport.

14. Review of Patient #2's nurse's notes from 11/12/12 evening shift (just after the patient to patient attack) through 11/13/12 (approximately twenty four hours) when Patient #2 was put in restraints for transport showed the following:
-Staff failed to implement any actions to protect other patients from Patient #2;
-Staff failed to change the CTP to implement safety precautions to protect other patients from physical attacks by Patient #2.
-Staff failed to address a RPB assessment or a Personal Safety Plan;
-Staff failed to convene a treatment team meeting to address safety measures to institute for Patient #2 and other patients on the unit.

15. Observations on 01/07/13 at 2:50 PM on Unit 2B showed the following:
-One MHT seated at a desk and two to three patients seated in the area or walking around in the area. No organized activities were being conducted.
-Several patients asleep in their rooms (doors opened).

16. During an interview on 01/08/13 at 9:10 AM Staff E, Mental Health Technician (MHT) stated the following:
-Some of the MHTs were called Lead Technicians.
-Lead Technicians attend Care Plan Meeting and were involved with the Treatment Plan and that's how we know what to do for each patient to take care of them. We tell the other MHTs on the shift.
-Patients usually have to attend group meetings to get to a higher, less restrictive level.
-If a patient was asleep in their rooms and was supposed to be in group, I go and ask them why they didn't go to group.
-Some patients just say they don't want to go to groups.
-We can't make them go. We don't make them go.
-We have had patients who swallow things.
-I can remember one man who swallowed coins because he wanted candy and he couldn't get it (was not allowed) so he swallowed the money. Staff was with him. He just did it to get back at staff.
-We have a new system now where each MHT was assigned to some patients and we tell the nurses things they did not know about the patient's behaviors.
-Daily activities here usually were patients could sleep in bed or go to group or watch television. Patient's have their choice. We don't make them do anything.

17. Observation on 01/08/13 at 9:56 AM in a 2B unit corridor showed no staff in the area, a female patient pacing back and forth multiple times, glaring and other patients asleep in their beds.

18. During an interview on 01/08/13 at 9:58 AM Staff L, MHT stated the following:
-Patients fight each other and us.
-I would never get between two patients unless there was another staff right here to help me.
-I remember a patient who swallowed a couple of those Susan B Anthony coins. He had to go to the hospital and get them out.
-The family gave him a five dollar bill and he got change from the coin machine. Staff was with him. Patients were allowed to keep up to five dollars for themselves.
-I saw him just after he swallowed the coins. He was sitting by the telephones and he couldn't talk really well. He was kind of gurgling. He told me he swallowed the coins so, I got the nurse. I guess he just felt like the coins were no use to him so he just swallowed them.
-We have group meetings on the unit. Groups were Monday through Fridays. Saturdays and Sundays were rest days.
-Going to group was an option for patients. We cannot force patients to go to group meetings.

19. During an interview on 01/08/13 at 11:00 AM Staff M, Social Worker stated the following:
-Each of the disciplines were responsible for development, planning and revision of up to four patient CTPs.
-The disciplines were psychology, rehabilitation, nurses and social work. The dietitian volunteered to develop the CTP for Patient #1.
-When the initial plan was developed, that plan was taken to a treatment team meeting (held Wednesday and Friday).
-During the treatment team meeting each of the disciplines can offer changes as needed.
-If no improvement was seen then, the goal was revised and the original plan developer was responsible for recording those revisions on the revised plan.

20. During an interview on 01/09/13 at 9:15 AM Staff Q, Psychiatrist stated the following:
-Most patients admitted here had long term mental illness and this facility was their home.
-The closeness of living on the unit contributes to the increased number of physical altercations.
-There are limited activities on the units so the patients have time to brood over things.
-The patients need purpose in their lives.
-Recreation therapy would be ideal but due to decreased staffing recreation programs were not done.
-Some patients who were currently admitted to the units were inappropriate admissions here (due to their need for more structured environment).

21. During an interview on 01/09/13 from 9:15 AM through 10:35 AM Staff R, Psychiatrist stated the following:
-The structure on the units was very loose.
-The patients need groups and activities according to their physical abilities.
-It was difficult to combine patients from so many mixed populations (different diagnoses) into an activity group.
-Some of the patients need work therapy activities and purposeful activities.
-The units need physical activities such as ping-pong or basketball. Physical activity was very important.

22. Review of Unit 2B Activities schedule revised 01/01/13 showed multiple planned activities call "personal time" and "patient choice" in increments of one hour time blocks. Some time blocks without notations of any planned activities.

Some planned activities called "reflection group"; "community reintegration"; "assertiveness skills" and "friendship and dating skills" may be inappropriate for chronic mentally ill patients.

23. Record review of discharged Patient #9's medical record showed the male was admitted to the facility on 06/30/11 with complaints of aggressive behavior.

Record review of the patient's Medical-Psychiatric Evaluation dated 05/03/12 showed the following information:
-History of Present Illness and Hospital Course Over the Past Two Months: In the past three years, the patient has been discharged from eight different facilities for assaulting staff and other patients.
Over the past two months, he has been acting out several times. During the day of March 15, 2012, he threw a food tray in the dining area hitting a peer. During the evening shift, he hit a male peer several times on the face and head with his fist. The patient has been involved in a number of incidents in the past resulting in one-on-one observation with line of sight since March 31, 2012, when he had inappropriate sexual behavior with male peers.

Record review of Patient #9's CIMOR showed staff documented the following verbal threats and physical assaults he had towards Patient #15:
-On 02/20/12 at 5:52 PM, Patient #9 physically assaulted Patient #15.
-On 02/20/12 at 6:15 PM, Patient #9 attempted to physically assault Patient #15.
-On 02/28/12 at 7:48 PM, Patient #9 physically assaulted Patient #15.
-On 03/04/12 at 8:20 PM, Patient #9 verbally threatened to physically assault Patient #15.
-On 03/05/12 at 1:00 PM and 1:10 PM, Patient #9 verbally threatened to physically assault Patient #15.
-On 03/05/12 at 1:40 PM, Patient #9 physically assaulted Patient #15 by grabbing him from behind in a choking position.
-On 03/05/12 at 3:20 PM, Patient #9 verbally threatened to physically assault Patient #15.
-On 03/05/12 at 3:30 PM, Patient #9 physically assaulted Patient #15 while in group and attempted to assault the psychiatrist.

Record review of the patient's CTP dated 02/15/12 showed the following information:
-Problem #1: Verbally abusive language is used to intimidate or control
others.
-Goals: Decrease overall frequency, intensity, and duration of angry thoughts, feelings and actions-Target date 02/29/12.
-Objectives:
-The patient will verbalize increased awareness of anger expression patterns, their possible origins and their consequences.
-The patient will use learned DBT (Dialectical Behavior Therapy, a behavioral therapy that focuses on the role of thoughts and beliefs and behavior skills for avoiding aggressive behavior.)
-The patient will learn and implement problem-solving and/or conflict resolution skills to manage specific interpersonal problems.
-The patient will participate in group and individual social skills
therapy and anger management.

Record review of the patient's CTP Review showed under the section Summary of Changes, Additions, Deletions and Original CTP Updates the following information:
-On 02/29/12 staff documented as a result of recent aggressive events, the patient will remain on level 2 (patient is safe to be on the unit).
-On 03/14/12 staff documented patient is now on level 2 because of increase in target behavior.

Staff did not update the patient's CTP to reflect interventions to prevent him from physically assaulting Patient #15. Due to a lack of staff interventions, Patient #15 did not receive care in a safe environment when he received physical assaults by Patient #9, sometimes several times throughout a 24 hour time period.

24. Record review of current Patient #14's medical record showed she was admitted to the facility on 07/11/12 with complaints of auditory hallucinations (a perception where patients hear sounds that aren't real), suicidal tendencies, bipolar disorder (mood disorder where people experience disruptive mood swings) and schizoaffective disorder (false perceptions and disordered thought processes).

Record review of the patient's Medical-Psychiatric Evaluation dated 07/16/12 showed the following information:
-History of Present Illness: The patient has a history of schizoaffective disorder, bipolar disorder and polysubstance abuse (multiple drug.) The patient was admitted for self-injurious behavior from self-inflicted stab wound to the abdomen as commanded to her by auditory hallucinatory voices.

Record review of the patient's CTP dated 01/04/13 showed the following information:
-Problem #1: Self harming behavior as evident by stabbing self in abdomen with scissors.
-Goal: Patient will utilize skills developed to manage her emotions, anger and grief to assist her in being free of self harm.
-Objectives: (no target date is listed):
-Patient will develop a plan for handling delays in her discharge and how she will/can handle stressors of the new placement when she is discharged to remain free of self harming behaviors.
-Patient will continue to participate in community outings to help with her transition back into the community and prepare for her discharge.
-Patient will work with staff to identify causes of boredom and develop a list of activities that she can do individually and with others when she is feeling bored.

25. During an interview on 01/08/13 at 9:15 AM, the patient stated that her stay could be better if the facility offered more activities because she gets bored. The patient stated that the one area the facility could improve on would be to offer more group activities.

Staff did not include in the patient's CTP activities or groups the patient could participate in that would benefit and be meaningful for her.

26. Record review of current Patient #15's medical record showed he admitted to the facility on 02/07/11 with complaints of molesting children.

Record review of the patient's Medical-Psychiatric Evaluation dated 02/17/12 showed the following information:
-History of Present Illness and Hospital Course: During the past year, the patient continues to have difficulty with limiting inappropriate sexual behavior and violating boundary and the patient continues to have one on one for inappropriate sexual activity and significant risk for fall. The patient also reported that he gets bored in the unit and he does that for fun and he likes to see peoples' response.
-Mental Status Examination: The patient describes his mood, "I get bored" and reported it makes him excited to see other peoples' responses after his inappropriate behavior and funny faces. The patient's insight appears to be fair as he could not maintain his boundaries and continued to have an inappropriate sexual behavior. The patient's judgment appears to be poor. The patient has poor impulse control.

Record review of the patient's CTP dated 09/28/12 showed the following information:
-Problem #1: Poor impulse control and decision-making skills resulting in unsafe behaviors involving self and others.
-Substantiated Diagnosis: Asperger's Disorder, Pedophilia.
-Goals: Patient will exhibit appropriate delay and think about consequences before acting.
-Objectives (what patient will achieve as a result of the intervention) date: 09/28/12, target date: 12/28/12:
-Patient will learn how to self-assess appropriateness of behaviors in certain situations and locations.
-Patient will learn and express understanding of how his behaviors affect his safety.
-Patient will learn to monitor his interpersonal needs and express them appropriately without provoking others.

Staff did not address or include interventions/measures to prevent the patient from being physically assaulted by Patient #9 or becoming bored on the unit and acting out inappropriately.

27. During an interview on 01/09/13 at 9:05 AM, Staff R, physician stated that the facility should have admission criteria before patients are admitted to the facility. Staff R stated that there needs to be consistency with care of patients and their treatment plans. Staff R stated that there is a lack of activities and groups that are meaningful to patients and patients needed activities and groups that would benefit them.




















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