HospitalInspections.org

Based on observation, interview and document review, the hospital failed to ensure patients were provided care in a safe setting for 2 of 10 patients (P2, P4) who were review patient rights. P1 had a history of assaultive behaviors and hit P2 resulting in a left frontal sinus fracture with scalp contusion, and multiple bilateral nasal fractures. In addition, P4 was placed in an unauthorized choke hold when staff reached around and placed their left arm around P4's neck. P4 was thrown to the ground, when P4 attempted to stand up staff placed P4 into a choke hold and pushed him up against the fence.

As a result of these failures, this deficient practices resulted in an immediate jeopardy (IJ) for P2 and P4. The hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.

Findings include:

See A-0145:
The hospital failed to ensure patients was free from abuse for 1 of 10 patients (P2) reviewed when P1 who had a history of assaultive behaviors, assaulted P2 resulting in P2 sustaining a left frontal sinus fracture with overlying scalp contusion, and multiple bilateral nasal fractures.

See A-0167:
During a manual hold, staff placed P4 in an unauthorized choke hold when staff reached around and placed their left arm around P4's neck. P4 was thrown to the ground, and when P4 attempted to get up, staff placed P4 into a choke hold and pushed him up against the fence.

Based on observation, interview, and document review, the hospital failed to ensure patients were free from abuse for 1 of 10 patients (P2) reviewed for patient rights. P1 had a history of assaultive behaviors and hit P2 resulting in P2 sustaining a left frontal sinus fracture with scalp contusion, and multiple bilateral nasal fractures. The facility failure resulted in an immediate jeopardy (IJ) for P2.

The IJ began on 7/28/23 at 1:24 p.m., when P1, who had a history of assaultive behaviors, assaulted P2 resulting in P2 sustaining a left frontal sinus fracture with scalp contusion, and multiple bilateral nasal fractures. On 8/10/23 at 5:45 p.m., nurse executive (NE)-A, the executive director (ED), the administrator, hospital administration (HA)-A, the director of operations (DO), and director of nursing services (DNS) were notified of the IJ. The IJ was removed on 8/11/23, when an acceptable removal plan was verified as being implemented; however, the hospital remained out of compliance with the COP of Patient's Rights at 42 CFR 483.13.

Findings include:

P1's psychiatric assessment dated 7/16/23 indicated diagnoses of schizoaffective bipolar type, schizophrenia paranoid type, post traumatic stress disorder (PTSD), and antisocial personality disorder.

P2's psychiatric progress note dated 2/8/23 indicated diagnoses of unspecified schizophrenia, generalized panic disorder (GAD) with panic attacks, PTSD, stimulant use d/o, antisocial personality disorder, borderline personality disorder.

A facility Incident Report dated 7/14/23 at 3:15 p.m., indicated P1 verbally assaulted and pushed P7 while residing on Unit B. The report indicated the patients were separated by staff. The report indicated P1 was the aggressor.

P1's Violence Risk Assessment (VRA) dated 7/14/23 at 10:42 a.m., indicated P1 was a moderate risk for violence towards others.

A facility Incident Report dated 7/18/23 at 3:49 p.m., indicated P1 verbally and physically assaulted P8 while residing on Unit C. The report indicated an ICS was activated and the patients were separated by staff. The report indicated P1 was placed in a manual hold, and then the restraint chair until his assaultive behavior ceased. The report indicated this assault resulted in minor injuries to P1 and P8.

P1's VRA dated 7/18/23 at 8:43 p.m., indicated P1 was at a high risk of violence towards others.

On 7/18/23 at 10:48 p.m., a nursing note indicated P1 stated he intended to fight another patient. The note indicated multiple unsafe behaviors were identified.

On 7/19/23 at 11:43 a.m., a nursing note indicated P1 was on routine observation.

On 7/19/23 at 12:01 p.m., a psychiatry note indicated P1 had been engaging in aggressive episodes with other patients since his admission. The note indicated P1 was transferred to Unit E and was on routine observation.

On 7/20/23 at 9:39 p.m., a nursing note indicated P1 threatened to harm others until his demands were met. The note indicated P1 was on routine observation.

On 7/21/23 at 1:44 p.m., a psychiatry note indicated P1 had been exhibiting dangerous and impulsive aggression, and had been refusing alternative pharmacological treatment options.

On 7/21/23 at 4:55 p.m., a psychiatry note indicated P1 had been exhibiting poor personal boundaries by invading other patients' personal space.

A facility Incident Report dated 7/22/23 at 4:31 p.m., indicated P1 assaulted P3 while residing on Unit E. The report indicated the patients were separated by staff. P1 was placed in a manual hold and the seclusion room until his assaultive behavior ceased. The report indicated this assault resulted in minor injuries to P1 and P3. The report was reviewed by RN supervisor-A on 7/27/23 wherein P1 was identified as having a pattern of assaulting other patients.

P1's VRA dated 7/22/23 at 5:06 p.m., indicated P1 was at high risk for violence towards others.

A facility Incident Report dated 7/24/23 at 11:51 a.m., indicated P1 was assaulted by P9, after P1 made multiple inflammatory comments throughout lunch. The report indicated the patients were separated by staff. The report indicated P1 was placed in a manual hold by staff and escorted from the scene. The report indicated P1 was the victim and sustained minor injuries.

P1's VRA dated 7/24/23 at 3:38 p.m., indicated P1 was at high risk of violence towards others.

P1's Physician Order dated 7/24/23 at 12:29 p.m., directed P1 was to have frequent observation while on the unit, and routine observation in his room. At 9:50 p.m., P1's Physician's Order directed P1 was to have routine observation on the unit and frequent observation in his room. This order expired on 7/27/23 at 9:49 p.m. P1 resumed routine observation at that time.

On 7/27/23 at 4:51 p.m., a nursing note indicated P1 had a verbal altercation with P2 during lunch. P1 began advancing towards P2 with a closed fist. The note indicated staff were able to de-escalate the situation and instructed P1 to stay out of P2's hallway to avoid further conflict. The note indicated P1 and P2 showed no signs of aggression towards each other following this agreement.

P1's VRA on 7/28/23 at 10:56 a.m., indicated P1 was at moderate risk for violence towards others.

A facility Incident Report dated 7/28/23 at 1:24 p.m., indicated P1 assaulted P2 while exiting the sensory room at the end of the hallway. The report indicated the patients were separated by staff. The report indicated P1 was placed in seclusion for patient safety. The report indicated P1 was transferred to Unit G on frequent observation for safety.

On 7/28/23 at 10:57 p.m., a nursing note indicated P2 was sent to the emergency department (ED) at approximately 4:00 p.m. for injuries sustained during the assault. P2's ED discharge paperwork dated 7/28/23 indicated P2 suffered a left frontal sinus fracture with overlying scalp contusion, multiple bilateral nasal fractures, and additional fractures of the nasal spine and septum.

On 8/8/23 at 8:26 a.m., video review of the Unit H hallway and Unit H nursing station with registered nurse (RN) supervisor-D and the Management Analyst revealed the following: On 7/28/23 at 1:24 p.m., P1 exited the sensory room and began walking quickly towards P2. P2 walked backwards towards the nursing station as P1 continued to walk towards him with fists balled. Staff attempted to separate P1 and P2 by placing their arms between them and verbally directing P1. P1 charged at P2 and began throwing punches at P2's head as P2 shielded himself and attempted to disengage. Multiple staff members arrived throughout the assault and continually attempted to intervene. P1 walked away and reentered the sensory room. Safety Support Staff (SSS) then escorted P1 to the seclusion room.

On 8/8/23 at 10:29 a.m., P2 stated he had been threatened by P1 previously. P2 stated because of those threats, staff were not supposed to allow P1 down P2's hallway.

On 8/9/23 at 9:50 a.m., registered nurse supervisor (RNS)-A stated P1 needed to be on frequent observations while out of his room for the safety of other patients. RNS-A stated a patient with consistent aggression towards peers was appropriate for frequent observations. RNS-A stated observational levels were only altered after the patient had been assessed by a psychiatric clinician, or nursing staff must contact the on-call provider. RNS-A stated she was not aware P1 was instructed to stay out of P2's hallway.

On 8/9/23 at 11:23 a.m., RNS-B stated she did not want patients with recent aggressive history towards each other on the same unit without interventions in place. RNS-B stated P1 required frequent monitoring while out of his room due to his assaultive behavior towards other patients. RNS-B stated observational levels were only altered after the patient had been assessed by a psychiatric clinician.

On 8/8/23 at 12:33 p.m., the director of nursing services (DNS) stated the hospital mainly relied on increased observational status and unit transfers to keep patients safe. The DNS stated there were no patient specific interventions implemented for P1 following each of his assaultive episodes. The DNS stated if an observational level was altered, a patient must be evaluated by the interdisciplinary team.

The facility policy Assault and Violence Risk Assessment dated 3/7/23, directed prior to altering any observational status for a patient with a high or moderate risk identified by the VRA, a patient must be assessed in person by a psychiatric clinician. The policy directed if a clinician feels the patient does not require therapeutic observation contrary to the VRA findings, the rationale is to be reviewed and discussed by the Interdisciplinary Team and documented in the medical record.

The IJ was removed on 8/11/23, at 12:40 p.m. when the hospital had submitted and implemented an acceptable removal plan. Violence Risk Assessments were completed, and reviewed of all patients with a history of violence and aggression to ensure specific interventions were identified on their treatment plans.This was verified through document review, observation, and interview.

Based on observation, interview, and document review, the hospital failed to ensure patients were free from unauthorized restraints for 1 of 10 patients (P4) reviewed for patient rights. P4 was placed in an unauthorized choke hold by staff when staff reached around and placed their left arm around P4's neck. This deficient practice resulted in an immediate jeopardy for P4.

The IJ for P4 began on 7/7/23 at approximately 5:34 p.m., when P4 was placed in an unauthorized choke hold by staff. On 8/10/23 at 5:45 p.m., nurse executive (NE)-A, the executive director (ED), the administrator, hospital administration (HA)-A, the director of operations (DO), and director of nursing services (DNS) were notified of the IJ. The IJ was removed on 8/11/23, when an acceptable removal plan was verified as being implemented; however, the hospital remained out of compliance with the COP of Patient's Rights at 42 CFR 483.13

Findings include:

P4's diagnoses list indicated diagnoses of post-traumatic stress disorder (PTSD), reactive disorder, and conduct disorder.

P4's admission Physician's Orders included intensive care area (ICA) low stimulus environment (LSE) due to his PTSD. The LSE consisted of 2:1 staff, and routine observation (which included 15-minute checks of the patient).

P4 was unavailable for interview.

On 8/8/23, at 8:26 a.m. the video from 7/7/23 at approximately 5:28 p.m. was reviewed. While escorting P4 from the courtyard into the facility, P4 struck safety support staff (SSS)-A in the back of the head. Mental health patient assistant (MHPA)-A responded immediately by reaching around and placing his left arm around P4's neck. MPHA-A threw P4 onto the ground, and when P4 attempted to stand, MHPA-A used both hands to push P4 onto the ground again. When P4 got up from the ground, MPHA-A placed P4 into another choke hold, and pushed P4 up against the fence in the courtyard. MHPA-A held P4 against the fence until additional safety support staff and nursing staff arrived.

On 8/8/23, at 2:36 p.m. MHPA-A was interviewed and stated he did not recall if he used a choke hold restraint on 7/7/23 with P4. MHPA-A stated, "I guess the camera will show what happened." MHPA-A stated he would do anything within reason to keep himself and other staff safe. MHPA-A verified placing a patient in a choke hold was not part of restraint technique training, nor was pushing a patient to the ground. MHPA-A stated he had been allowed to work the remainder of his shift on 7/7/23, and his shifts on 7/8/23, and 7/9/23 which included providing direct patient care.

On 8/9/23, at 2:36 p.m. SSS-A stated he did not recall if MHPA-A placed P4 in a choke hold type of restraint on 7/7/23. SSS-A stated a choke hold was not part of Effective and Safe Engagement (EASE training; training on appropriate restraints). SSA-A stated he did see MHPA-A push P4 onto the ground, which was also not part of EASE training.

On 8/9/23, at 11:01 a.m. safety operations supervisor (SOS)-A stated she had reviewed the video which revealed MHPA-A had not used an approved method taught through EASE training to physically restrain P4 on 7/7/23. SOS-A stated upon review of the video, it appeared MHPA-A had placed P4 in a choke hold, threw P4 to the ground, and shoved/pushed P4 away when he attempted to get up. SOS-A stated MHPA-A's arm then went behind P4's back, and his arm went across the P4's neck, which could have resulted in the patient being injured.

On 8/9/23, at 11:41 a.m. registered nurse (RN)-A stated upon review of the video it appeared MHPA-A placed P4 in a choke hold, threw P4 to the ground, shoved/pushed P4 away, and had P4's arm behind his back and his arm across P4's neck, which could have resulted in the P4 being injured. RN-A stated MHPA-A had not used an approved method taught through EASE training.

On 8/9/23, at 12:47 p.m. nursing services director (NSD) stated through review of the video, it appeared MHPA-A placed P4 in a choke hold, threw P4 to the ground, shoved/pushed P4 away, and had P4's arm behind his back and his arm across P4's neck, which could have resulted in the patient being injured. NSD stated MHPA-A had not used an approved method taught through EASE training. NSD verified MHPA-A had been allowed to work the remaining part of his shift on 7/7/23, as well as shifts on 7/8/23 and 7/9/23 which included providing direct patient care.

The facility EASE Foundations Physical Safety Strategies training dated 4/9/21, directed staff to avoid placing a hand on patients' ear, temple, neck or face. The training further directed when securing a patient's body, ensure there is no pressure on the torso or neck. Reiterate the importance of not blocking a person's ability to breathe.

The facility Program Abuse Prevention Plan dated 4/23, directed all staff will adhere to Anoka Metro Regional Treatment Center's policies, procedures, and rules.

The IJ was removed on 8/11/23, at 12:40 p.m. when the hospital had submitted and implemented an acceptable removal plan. This included reviewing policies, removing MHPA-A from direct patient care, providing scenario-based training to all staff on unapproved physical interventions and approved wrap and standing hold techniques for moderate/high risk patients. Violence Risk Assessments were completed, review of all patients with a history of violence and aggression to ensure specific interventions were identified on their treatment plans, and This was verified through document review, observation, and interview.

Based on observation, interview, and document review, the hospital failed to ensure 3:1 therapeutic observation for P6 was completed with these enhanced levels to prevent P6 from self injurious behavior. As a result of not implementing these theraputic observations, P6 had instances of potential ligature, insertion of foreign object, and flooded her room to divert attention.

As a result of this failures, the hospital was found out of compliance with the Condition of Participation Nursing Services CFR 482.23.

See A-0392 for additional information.

Based on observation, interview, and document review, the hospital failed to ensure 3:1 therapeutic observation for P6 was completed with these enhanced levels to prevent P6 from self injurious behavior. As a result of not implementing these theraputic observations, P6 had instances of potential ligature, insertion of foreign object, and flooded her room to divert attention.

Findings Include:

P6's History and Physical Audit dated 7/5/23 at 3:50 p.m., indicated P6 was admitted to Unit C directly to the unit Intensive Care Area (ICA) for her safety. P6's diagnoses included schizoaffective disorder bipolar type, posttraumatic stress disorder, borderline personality with antisocial features, and a history of inserting foreign objects into her body.

P6's Vulnerability Risk Reduction Plan (VRRP) dated 7/5/23 at 2:38 p.m., indicated P6 was at risk for self-harm or suicide, with a suicide attempt within the last six months. The VRRP identified P6 was at risk for ingesting foreign objects, self-injurious behavior, experienced active and passive suicidal thoughts, and had an identified suicide plan.

P6's Psychiatric Assessment dated 7/7/23 at 3:32 p.m., indicated P6 was admitted directly to the hospital from jail when she was found mentally incompetent to stand trail. The assessment indicated P6 was observed by staff to exhibit multiple self-injurious behaviors, and required R6 to be dressed in a Kevlar (strong, synthetic fiber material) suicide gown and Kevlar mitts to prevent further self-harm.

P6's Physician Order effective from 7/19/23 at 3:07 p.m. until 7/20/23 at 3:06 p.m., indicated P6 was to have 3:1 staffing with two sets of eyes on her at all times.

A facility Incident report dated 7/20/23 at 3:00 p.m., indicated P6 clogged her toilet and her shower drain, causing her room to flood. The Incident Report indicated P6 was able to achieve this despite 3:1 staffing with two sets of eyes on her at all times.

P6's Physician Order effective from 7/21/23 at 9:59 a.m. until 7/22/23 at 6:57 a.m., indicated P6 was to have 3:1 staffing with two sets of eyes on her at all times.

A facility Incident Report dated 7/21/23 at 3:04 p.m., indicated P6 manually removed one of her molars, and inserted the tooth and a paper spoon into her rectum. P6 was able to achieve this despite 3:1 staffing with two sets of eyes on her at all times.

P6's treatment plan dated 7/21/23, with an update on 7/24/23 at 11:20 a.m., indicated P6 required 3:1 staff observation while in the ICA, and one of these staff members during therapeutic observation must be a licensed staff, such as a registered nurse (RN).

P6's Physician Order effective from 8/1/23 at 10:39 a.m. until 8/1/23 at 10:34 p.m., indicated P6 was to have 3:1 staffing with frequent observations every five minutes while in the ICA.

A facility Incident Report dated 8/1/23 at 8:50 p.m., indicated P6 wrapped a strip of mattress around her neck and inserted a portion of wall trim into her vagina. The Report indicated P6 required manual holds, the restraint chair, and staff assistance to remove the ligature and inserted foreign body.

R6's Physician Order effective from 8/1/23 at 10:56 p.m. until 8/2/23 at 12:45 p.m., indicated P6 required 3:1 staffing, with distant observation of 2:1 staff and two sets of eyes on her at all times while in the ICA.

On 8/8/23 at 8:26 a.m., video review of the Unit C hallway with registered nurse supervisor (RNS)-D and the Management Analyst (MA) revealed the following: On 8/2/23 at 3:55 a.m., mental health program assistant (MHPA)-C, registered nurse (RN)-A, and human services technician (HST)-A were seen sitting in chairs in the hallway, appearing to observe P6 in her room. HST-A left the observational area multiple times while RN-A's head was tilted back with a slow, regular breathing pattern. RN-A appeared asleep. MHPA-A left the doorway when HST-A returned to the observational area. HST-A was observed to lean forward, and cupped her face in her hands while RN-A continued to be asleep. Prior to MHPA-A returning to his chair, HST-A repositioned her chair and leaned her head and body against the back of her chair, raised her shirt hood over her head, and appeared to fall asleep. RNS-D stated these staff were not following P6's therapeutic observation orders, appeared asleep, and stated it appeared there were rarely two sets of eyes on P6 during these observations.

A facility Critical Event Review and Action form dated 8/2/23, indicated hospital administration discovered discrepancies with P6's therapeutic observations. The form indicated HST-A admitted to falling asleep. The form also indicated administration had completed reeducation with MHPA-A, RN-A, and HST-A.

An email titled Observations sent by hospital administration on 8/2/23 at 4:27 p.m. to all RN supervisors, indicated the following changes to therapeutic observation orders: hourly rotations for therapeutic observation staff, chairs were removed from therapeutic observation areas, and hallway lights were to remain on at all times.

An email titled Important Memo - Action Required sent by hospital administration on 8/2/23 at 4:33 p.m., indicated staff were not allowed to sleep during therapeutic observation duties, and any time this behavior was observed staff must intervene and report the action to their supervisor.

R6's Physician Order effective 8/5/23 at 4:13 p.m. until 8/6/23 at 4:12 p.m., indicated P6 required 2:1 staffing, with distant observation of 2:1 staff and two sets of eyes on her at all times while in the ICA.

R6's Physician Order effective 8/6/23 at 4:13 p.m. until 8/7/23 at 4:12 p.m., indicated P6 required 2:1 staffing, with distant observation of 2:1 staff and two sets of eyes on her at all times while in the ICA.

On 8/8/23 at 8:26 a.m., video review of the Unit C hallway with RNS-D and MA revealed the following: On 8/6/23 at 2:33 a.m., two unidentified staff members were standing in the hallway outside P6's room. The two staff members did not maintain eye contact with P6 during their therapeutic observations, and were turned towards each other in conversation until 2:55 a.m. At 4:03 a.m., two different unidentified staff were observed standing in the hallway outside P6's room. One staff member had his eyes closed, and the other staff member's head was down. Both appeared asleep. Neither staff appeared to have eyes on P6.

On 8/8/23 at 8:26 a.m., video review of the Unit C hallway with RNS-D and MA revealed the following: On 8/7/23 at 2:53 a.m., two unidentified staff members were seen outside P6's doorway. One of the staff members was sitting on a towel spread out on the ground, with his head tilted forward. The staff member appeared to be asleep. The other staff member stood in the doorway and continued to monitor P6.

On 8/8/23 at 8:26 a.m., video review of the Unit C hallway with RNS-D and MA revealed the following: On 8/8/23 from 1:40 a.m. until 2:29 a.m., no movement could be seen in the hallway as all therapeutic observation was being completed inside of P6's room. P6's room was not equipped with cameras.

On 8/8/23 at 1:15 p.m., P6 stated she disliked her current observational status. P6 stated when she has so many staff surrounding her, she wants to lash out and assault staff.

On 8/9/23 7:20 a.m., the director of nursing services (DNS) and the administrator were interviewed. The DNS stated they identified staff were not performing therapeutic observation with P6 within ordered parameters. The DNS stated no staff should be inside P6's room while she was sleeping, and staff should have their eyes on her at all times.

On 8/9/23 at 7:29 a.m., MHPA-A stated he had been one of the staff who fell asleep during P6's therapeutic observations. MHPA-A stated distant observations were conducted outside the patient's room, while maintaining a direct line of sight with the patient. MHPA-A stated staff should not be entering P6's room during the night to maintain her privacy during therapeutic observations.

On 8/9/23 at 7:42 a.m., licensed practical nurse (LPN)-A stated it was very common to see staff sleeping during P6's therapeutic observations. LPN-A stated staff were purposefully entering P6's room to sleep during overnight therapeutic observations, as they knew cameras in the hallway could not see them.

On 8/9/23 at 8:18 a.m., HST-B stated staff were sleeping during P6's overnight therapeutic observations. HST-B stated they were instructed to stay out of P6's room to maintain patient privacy during overnight observations.

On 8/9/23 at 8:34 a.m., RN-A stated she had seen other staff members fall asleep during P6's therapeutic observations. RN-A stated staff were instructed they could no longer complete observations inside of P6's room and eyes needed to remain on P6 for all of her observations.

On 8/9/23 at 12:33 p.m., the DNS was interveiwed again. The DNS stated staff should never sleep during therapeutic observations. The DNS stated all breaks should be taken before or after their rotation into therapeutic observation, and if staff need to leave the observational area, they need to use their personal radio devices to request a temporary replacement to maintain therapeutic observation. The DNS stated patients have a right to privacy during therapeutic observations and staff monitoring should be completed in the least intrusive manner possible.

A facility policy titled Therapeutic Observation dated 1/3/23, directed staff assigned to distant 1:1 or higher observation must maintain continuous observation with the patient. The policy directed these observations must be conducted in the least invasive manner possible, while maintaining the dignity and privacy of the patient.