HospitalInspections.org

Based on observation, interview, record review, video review and policy review the facility staff failed to:
- Recognize and respond to escalating behavior which resulted in a physical altercation between patients and injury (A 0144);
- Immediately remove a staff member from patient care, after an allegation of staff to patient abuse was made (A-0144)
- Provide a safe environment when contraband was found, on patient, in room, and left by staff in several areas of the Behavioral Health Units (A 0144);
- Recognize and remove ligature (hanging) risks related to bed rails, phone cords, and the injury potential of phone handsets to be used as a weapon (A 0144);
- Recognize and repair or replace risks of sharp, cracked edges of ceramic tiles, sharp edges on chrome wall fixtures that had come away from the wall and, non safe screws (could easily be removed) throughout the BHU's (A 0144);
- Complete required, timely observation rounding on patients and a failure to document properly in the BHU's (A 0144);
- Ensure that chair alarms functional and safe for patients that were unsafe to stand or walk without assistance (A 0144);
- Prevent abuse and or neglect of patients on the BHU (A 0145); and
- Report patient abuse to hospital leadership in a timely manner (A 0145).
These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition Participation: Patient Rights. The BHU's census was 81. The facility census was 101.

Based on observation, interview, record review, video review and policy review, the facility failed to:
- Recognize escalating behavior which resulted in the delayed activation of Dr.Ryan Security Alerts (notification to the entire facility for assistance to aid in de-escalating a potential danger in a patient's behavior) and physical altercations which resulted with patient injuries for two discharged patients (#47 and #49) of two discharged patients reviewed for physical altercations.
- Remove Staff GG, Registered Nurse (RN), Alleged Perpetrator (AP) from direct patient care after allegations of physical and verbal abuse of two current patients (#3 and #32) of two patients reviewed.
- Provide a safe environment for 22 of 22 patients on the fourth floor Behavioral Health Unit (BHU), and 11 of 11 patients on the Geropsychiatric (Geropsych) BHU, by allowing two patients (#27 and #39) to have access to contraband (harmful material) on the fourth floor BHU and on the Geropsych BHU. This creates potential safety risks and threatens the integrity of the unit.
- Remove ligature (the act of tying or binding) risks from patient rooms for three current patients (#23, #25 and #41) of seven patients observed that were at risk for suicide by using unsafe psychiatric beds with metal railings.
- Remove six telephones with cords (ligature risk) and phone receivers (potentially used as a weapon) of six telephones observed in the hallways (common areas) for three psychiatric units (third floor, fourth floor and third floor Geropsych).
- Ensure patients admitted with diagnoses of suicidal ideation, history of suicidal ideation (thoughts of killing self), physical aggression, or attempts to harm self or others were provided care in a safe setting for three current patients (#35, #36 & #37) of five patients whose restrooms were observed on the fourth floor BHU, which had loose, cracked, sharp edged tiles, and for 22 current patients of 22 current patient's rooms on the fourth floor BHU that had unsecured sharp edged chrome wall fixtures and unsafe wall screws (potentially used for cutting).
- Complete required Patient Observation/Safety Rounds per facility policy for eight current patients (#13, #15, #26, #42, #43, #44, #45 and #46) of eight patients who were reviewed for completion of Daily Observation Flowsheets.
- Chart in real time while doing the Patient Observation/Safety Rounds for eight current patients (#13, #15, #26, #42, #43, #44, #45, and #46) of eight patients who were reviewed for completion of Daily Observation Flowsheets.
- Complete the precaution section and level of observation section on Daily Observation Flowsheet for one current patient (#42) of eight Daily Observation Flowsheets reviewed.
- Ensure chair alarms and bed alarms activated appropriately for three current patients (#13, #14 and #15) of three patients observed who had falls that resulted in injury.
- Follow high fall risk assessment interventions when three current patients (#13, #14 and #15) were not placed on chair alarms and bed alarms as directed.
These failures placed all patients in an unsafe environment and at risk for their safety. The BHU's census was 83 and the facility census was 101.

Findings included:

1. Record review of the facility's policy titled, "Assault Precautions," revised 07/2017, showed directives for staff to perform the following measures to reduce the risk of potentially aggressive behavior:
- Separate hostile parties;
- Maintain a calm and quiet environment;
- Reduce noise, dim bright lights;
- Limit choices and opportunities for frustration;
- Divide large groups into smaller, more manageable groups;
- Place unit on a Timeout, which requires all patients to go to their rooms to de-escalate;
- Ongoing clinical observation of the milieu may further identify patients at risk for aggressive or assaultive behavior and in need of assessment and precautions;
- Assault Level 1 is a patient determined to be at risk of assault, a patient with a history of overt violence and/or aggression;
- Assault Level 2 is a patient determined to be at medium risk of assault, a patient with a history of aggressive and/or assaultive behaviors outside of the facility; and
- Assault Level 3 is a patient determined to be at high risk for assault, patient is/has been threatening, verbally aggressive or has committed an assault this admission.

Record review of the facility's provided undated document showed BHU a (including Geropsych, third floor and fourth floor) total census of 83 patients which 81 patients was assessed as suicide precaution level one (SP1, at risk of harm to self) or higher.

Record review of the facility's provided document, dated 02/08/18, showed BHU (including Geropsych, third floor and fourth floor) had 68 patients that was assessed as assault precaution level one (AP1, at risk of assaulting another) or higher.

Record review of the facility's policy titled, "Dr. Ryan," revised 06/2017, showed directives for staff when a potentially threatening situation is encountered:
- Communicate with the patient using verbal de-escalation to allow ventilation of feeling in an attempt to calm patient.
- Remove other patients and visitors from the area.
- Assess the environment for precipitating factors and make changes as needed.
- If the above steps do not result in a de-escalation of the threatening situation, call a Dr. Ryan.
- All available psychiatric staff, all available Crisis Prevention Intervention (CPI, specific techniques used to de-escalate aggression in a patient) trained hospital employees, Manager of the department, House Supervisor, and Security will respond to a Dr. Ryan.
- If a Dr. Ryan does not elicit the amount of staff necessary for a safe intervention, staff may call 22222 and request all available CPI trained staff to assist.

Review of the facility's employee education titled, "Violence Prevention/Control the Situation," dated 01/04/18, showed directives for staff to:
- Identify patients displaying warning signs of distress (pacing halls, angry facial expressions, weird or aggressive statements, punching items, hallucinations, talking to self).
- Quickly perform assessment of those showing warning signs and provide quick intervention (medication, time out or allow venting in private area).
- Remain with patients who are displaying warning signs.
- Solicit the help of another staff member to assist you in this crisis.
- If the above fails, call a Dr. Ryan immediately, separate hostile parties and remove all other patients from the area.

Record review of Patient #49's History and Physical (H&P), dated 12/23/17, showed that he was a 26 year old male admitted to the facility on 12/23/17. He was admitted for increased agitation and refusal of medications. He was difficult to understand and had pressured and slurred speech, which was his baseline (normal). He had a history of autism (developmental disorder that impaired the ability to communicate and interact), bipolar affective disorder (mood disorder), and anxiety (feeling of worry or fear).

Record review of Patient #49's Daily Observation Flowsheet dated 01/01/18 showed that he was on fall precautions and assault/homicidal (thoughts of killing others) level three (high risk of assault, has been threatening, verbally aggressive or has committed an assault this admission). Measures in use to reduce risk was to reduce noise, and separate hostile (agitated or aggravated) parties.

Record review of Patient #49's post fall follow up, dated 01/01/18 at 4:05 PM, documented by Staff DD, Registered Nurse (RN), showed:
- Location of fall was in the hallway near the Multi-Purpose Room (MPR);
- Detail of fall was "another peer pushed patient and he fell on his bottom"; and
- Patient statement was "he pushed me".

Review of the facility's video recording, dated 01/01/18, from 4:21 PM to 4:23 PM, showed Patient #49 walking away from the MPR. Staff DDD, Patient Care Technician (PCT) attempted to redirect Patient #49 to return to the MPR. Staff DDD, left the camera's view. Patient #34 exited from the MPR, walked down the hallway and assaulted Patient #49 by forcefully shoving Patient #49, causing him to fall backward on the floor. Camera's view showed Patient #33 (standing in hallway by MPR) observing Patient #49 being assaulted. Patient #34 left the camera's view. At 4:23 PM camera's view showed three staff members walking calmly toward Patient #49, who was lying on the floor, while patients were walking around Patient #49, with some patients in the MPR, and some patients entering their rooms.

Record review of Patient #34's H&P, dated 07/02/17, showed that he was a 26 year-old male admitted to the facility on 06/30/17. He had aggressive behavior and could not be handled in a safe manner. He had been physically aggressive and assaultive towards others. His insight and judgment was impaired. He had history of bipolar affective disorder, and schizoaffective personality disorder (persistent symptoms of psychosis).

Record review of Patient #34's behavior assessment dated 01/01/18 at 2:44 AM showed that he was on an assault/homicidal level three (high risk of assault, has been threatening, verbally aggressive or has committed an assault this admission). Measures in use to reduce risk was to reduce noise, and separate hostile parties.

Record review of Patient #34's Daily Observation Flowsheet on 01/01/18 showed that he was on assault/homicidal level three.

Record review of Patient #34's post altercation follow up, dated 01/01/18 at 4:30 PM, documented by Staff DD, RN, showed:
- Location of altercation was "hallway near MPR";
- Detail of altercation was "patient became agitated and pushed a peer"; and
- Patient statement was "I'm tired of hearing his voice".

Review of the facility's video recording dated 01/01/18 from 4:32 PM to 4:33 PM showed Patient #49 standing at the entrance of the MPR. Staff GGG, RN was standing across the hall from Patient #49. Patient #33 entered the camera's view, walked behind Patient #49, bent down grabbed Patient #49 around the knees and stood up picking Patient #49 off the ground. Patient #33 leaned forward in a forceful manner threw Patient #49 to the floor causing his face to hit the floor. Patient #33 exited the camera's view, and Staff GGG attended to Patient #49.

Record review of Patient #33's H&P, dated 12/22/17, showed that he was a 27 year old male admitted to the facility on 12/21/17. He was admitted for threats to staff. He had history of assaultive and threatening behavior, as well as suicide attempts, and schizoaffective disorder.

Record review of Patient #33's behavior assessment on 01/01/18 at 2:40 AM showed that he was on and assault/homicidal level two. Measures in use to reduce risk was to reduce noise, and separate hostile parties.

Record review of Patient #33's Daily Observation Flowsheet on 01/01/18 showed that he was on assault/homicidal level two.

Record review of Patient #33's post altercation follow up, dated 01/01/18 at 4:37 PM, documented by Staff GGG, RN, showed:
- Location of altercation was "MPR/Hallway";
- Detail of altercation was "patient bent over and picked up male peer around his lower legs, lifted him up and threw him to the floor"; and
- Patient statement was "I couldn't take it anymore, he is too loud".

Record review of Patient #49's post altercation follow up, dated 01/01/18 at 4:37 PM, documented by Staff DD, RN, showed:
- Location of altercation was "MPR";
- Detail of altercation was "patient went behind patient and picked him up from his legs and patient fell on the floor";
- Patient statement was "I don't know what happen"; and
- Description of injury was "patient has a laceration to his chin and his front two teeth are chipped and pushed upperwards".

During an interview on 02/07/18 at 3:00 PM, Staff DD, RN, stated that:
- She remembered the events on 01/01/18;
- She responded to Patient #49 lying in the hallway (after being assaulted by Patient #34);
- She followed Patient #34 to his room and left him unattended;
- She did not place the unit on a "time out" (have the patient go to their rooms for safety);
- There were some patients in the MPR, and some in their rooms;
- She left Patient #34 unattended because another patient was verbally escalating;
- She did not call a Dr. Ryan;
- Patient #33 picked up Patient #49 and threw him to the floor;
- The unit was "short staffed" was why she left Patient #34 unattended; and
- She did not think of the other patient's safety, in their rooms, when Patient #34 escalated to aggressive behavior and left him unattended.

During an interview on 02/07/18 at 1:45 PM, Staff GGG, RN, stated that:
- She remembered the events on 01/01/18;
- She was in the medication room and was called to stand in the hallway because of escalating patients;
- She had been informed that Patient #34 had "pushed" patient #49 in the hallway;
- Patient #49 was "loud, very loud";
- The staff never placed the unit on a "time out";
- There were some patients in the MPR, and some in their rooms;
- The staff never called a Dr. Ryan;
- Patient #33 picked up Patient #49 and threw him to the floor; and
- Patient #49 had blood in his mouth and his teeth were chipped.

During an interview on 02/07/18 at 2:30 PM, Staff FFF, RN, stated that:
- She remembered the events on 01/01/18;
- Staff did not place the unit on a "time out"; and
- Staff never called a Dr. Ryan.

During an interview on 02/07/18 at 2:30 PM, Staff ZZZ, PCT, stated that the nurses should have known that Patient #49 was a risk, because he was "loud".

During an interview on 02/07/18 at 3:15 PM, Staff EEE, House Supervisor, stated that:
- She remembered the events on 01/01/18;
- No staff had notified her that the patients had escalated;
- She, by accident, was making rounds on the BHU when Patient #33 assaulted Patient #49;
- She then was informed of the altercation between Patient #34 and Patient #49;
- With the patients escalating, staff should of had the other patients go to their rooms; and
- Staff should have notified security or called a "Dr. Ryan".

During an interview on 02/07/18 at 3:25 PM, Staff H, Director of BHU, stated that:
- Staff should have called a Dr. Ryan to help de-escalate the situation;
- Staff should have placed the unit on time out, and had all the patients go to their room; and
- Staff DD should have never left Patient #34 alone after he escalated and pushed Patient #49.

The facility failed to recognize warning signs of distress, and take control of the situation. The staff failed to de-escalate the situation and call for assistance/personnel to aid in de-escalation. The staff left an escalated patient unattended which had the potential to cause harm or injury to others. This failure allowed one patient to be assaulted twice within 30 minutes, which resulted in injury that required more than first aid. This failed practice had the potential to affect all patients that were admitted to the BHU.

Record review of Patient #48's H&P showed that he was a 31 year old male admitted to the Third Floor BHU on 01/04/18 following a physical altercation with another resident at the facility he lived in. Patient #48's past medical history included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings).

Record review of Patient #48's medical record showed that on 01/16/18 at 9:29 PM, Patient #48 had a physical altercation with a peer, bear hugged (to wrap your arms tightly around the arms and chest of another person) the peer, and they both fell to the ground. Patient #48 was transferred to the Fourth Floor BHU.

Record review of Patient #48's Daily Observation Flowsheet on 01/18/18 showed that he was on low fall risk precautions and assault/homicidal level two.

Record review of Patient #47's H&P showed that he was a 50 year old male admitted to the Fourth Floor BHU on 01/09/18 for violent and combative behavior. Patient #47 hit staff and another resident at the facility he lived in. Patient #47's past medical history included schizophrenia and bipolar disorder.

Record review of Patient #47's Daily Observation Flowsheet on 01/18/18 showed that he was on low fall risk precautions and assault/homicidal level one.

Review of the facility's video recording of the Fourth Floor BHU MPR, dated 01/18/18 at 1:49 PM, showed the following:
- Patient #47 was sitting in the MPR by the window on the west end of the room;
- Patient #48 walked up to Patient #47 and appeared to yell at him;
- Staff KKK, PCT, was standing close by and listened;
- The verbal confrontation lasted approximately one minute before Patient #48 physically hit Patient #47 in the face.
- Staff PPP, Music Therapist, was sitting at a table in the MPR, listened and watched the event take place and was seen leaving the room when physical altercation occurred.

Record Review of Patient #48's post altercation follow up, dated 01/18/18 showed the following:
- Prior to the physical altercation that occurred in the MPR, Staff Y, LPN, was at the nurse's station talking with Patient #48 when Patient #47 interrupted the conversation;
- Patient #48 informed Patient #47 that he was rude and expressed dissatisfaction to Staff Y, LPN, for talking with Patient #47 in the middle of the conversation;
- Patient #47 walked away and Patient #48 stated to Staff Y, LPN, that he could not let people keep disrespecting him;
- Staff Y, LPN, educated Patient #48 on ways to redirect his behavior; and
- Patient #48 then went to MPR, argued with Patient #47 for approximately one minute and then punched Patient #47 in the face.

Record review of Patient #47's medical record post altercation showed that on 01/18/18 at 3:14 PM, Computerized Tomography (CT, detailed x-ray) of the head, revealed a fractured left nasal bone. On 01/18/18 at 4:15 PM, Patient #47 received laceration/wound repair to two areas of the left forehead.

During an interview on 02/07/18 at 1:30 PM, Staff KKK, PCT, stated that:
- She remembered the events on 01/18/18;
- Patient #48 had been responding to voices most of the day (warning sign of distress);
- She did not call for a Dr. Ryan immediately when Patient #48 was yelling at Patient #47;
- Staff Y, LPN, did not communicate with her that Patient #48 and Patient #47 had a verbal altercation at the nurse's station prior to the event.

During an interview on 02/07/18 at 1:50 PM, Staff Y, LPN, stated that:
- She remembered the events on 01/18/18;
- She did not separate Patient #47 and Patient #48 after verbal altercation at the nurse's station;
- She did not remain with Patient #48 and did not follow him into the MPR; and
- She did not communicate with staff in the MPR that a verbal altercation occurred between Patient #48 and Patient #47 at the nurse's station.

During an interview on 02/08/18 at 10:30 AM, Staff PPP, Music Therapist stated that:
- She remembered the events on 01/18/18;
- She did not call for a Dr. Ryan immediately when she heard Patient #48 yelling at Patient #47; and
- Staff did not communicate to her that Patient #48 and Patient #47 had a verbal altercation at the nurse's station prior to the event.

During an interview on 02/08/18 at 9:45 AM, Staff H, Director of BHU, stated that:
- Staff waited too long before calling a Dr. Ryan;
- Staff should have separated Patient #48 and Patient #47 after verbal altercation at the nurse's station; and
- Staff should have stayed and walked into the MPR with Patient #48 to make sure all issues were resolved.

Staff failed to recognize warning signs of distress and escalating behavior, which resulted in a physical altercation with patient injury and delayed activation of Dr. Ryan security alert. This failed practice had the potential to affect the safety of all patients admitted to the BHU.

Record review of the facility's provided document, dated 02/08/18, showed BHU (including Geropsych, third floor and fourth floor) had 33 patient-to-patient altercations for January 2018, a ratio of greater than one patient-to-patient altercation per day.

Record review of the facility's policy titled, "Abuse and Neglect," revised 12/2016, showed that:
- When there is reasonable cause to suspect that a patient may have been subjected by abuse/neglect, the identifier will immediately report his/her findings to the Department Manager/House Supervisor;
- The Manager/House Supervisor will notify the Director of Risk Management, the Manager of Social Services, the Attending Physician, and Administration;
- The investigation will start immediately; and
- The Department Manager/House Supervisor will immediately remove the staff member from patient care and put them on leave until investigation is complete.

Record review of a facility's investigation timeline showed that:
- The alleged abuse occurred on 12/21/17 at approximately 11:30 PM.
- Staff M, Licensed Practical Nurse, (LPN), witnessed verbal and physical abuse of Patient #3 and verbal abuse of Patient #32 by Staff GG, Registered Nurse (RN), Alleged Perpetrator (AP).
- Staff JJ, Behavioral Health Technician (BHT), witnessed verbal abuse of Patient #32 by Staff GG, RN (AP).
- Staff NNN, BHT, witnessed verbal and physical abuse of Patient #3 by Staff GG, RN (AP).
- Five days after the alleged abuse, Staff L, Nurse Manager, Third Floor Behavioral Health Unit (BHU), located staff statements on the morning of 12/26/17 and at 9:18 AM notified Staff H, Director of Behavioral Health.
- On 12/26/17 at 9:35 AM, Staff H called and left a voice message for Staff GG, RN (AP), and attempted to notify her of her suspension pending investigation; and
- On 12/26/17 at 9:40 AM, there was a conference call with Staff H, Director of Behavioral health, Staff L, Nurse Manager, Third Floor BHU and the Human Resource department, that initiated the investigation.

During an interview on 02/05/18 at 4:00 PM, Staff L, Nurse Manager, Third Floor BHU, stated that:
- Video of the incident that occurred on 12/21/17 at 11:30 PM observed the common areas, hallways and dayrooms. There were no videos in the patient rooms.
- The video was very limited and had no sound.
- When the allegation statements were found, it was reported to Staff H, Director of Behavioral Health, immediately.
- Staff GG, RN, (AP) continued to work the remainder of her shift after the incident.

Record review of the nursing shift assignment sheet for 12/21/17 showed that Staff GG, RN (AP), worked her full shift after the incident occurred.

2. Review of the facility policy, "Contraband," revised 07/2017, showed the purpose was to define items considered as contraband and to establish controls for maintaining the safety and security of the milieu (person's social environment). Contraband:
- Included sharp objects: razor blades, knives, scissor, nail clippers, nail files, keys, coat hangers, metal cutlery (knives, forks, spoons);
- Included glass objects: cosmetic and cologne bottles, mirrors, glass inserts for picture frames, vases, flower pots, drinking glasses;
- Included medications and Drugs: prescribed, over-the-counter and illicit medications and/or drugs;
- Included plastic bags;
- Was not permitted in the therapeutic milieu of Psychiatric Services and would be secured in the patient belongings closet or in the security office, and not to be returned until discharge; and
In the event weapons, illegal substances or paraphernalia was found on a patient or in their belongings the following action will be taken:
- A staff member will inform the patient of our policy concerning contraband.
- The nurse, Nurse Manager and Security personnel would be notified that contraband was found.
- The personnel will take control of the contraband and place it in a secured area.
- If the item was deemed a weapon, the Security department would contact the St. Louis Police Department for direction.
- If there was a suspicion of drugs or other unsafe articles being present on the unit, staff would conduct a room search in the patient's presence as well as a metal detector scan of the patient's belongings and person.

Review of the facility policy, "Search & Wanding," revised 06/2017, showed the purpose was to ensure the safety of patients, staff, physicians and visitors by implementing the following procedures:
- Security Officers will search all patients presenting at the Emergency Department or intake area who requires the services of an intake coordinator or who have expressed suicidal or homicidal thought or gestures.
- The search will consist of clothing removal and the gowning of the patient (this segment of the search will be conducted by nursing personnel). The responding Security Officer will then search clothing and property and conduct an initial wanding of the patient.
- After all articles have been searched and secured, nursing staff will then contact security again for a second and final wanding, prior to admission.

Observation and concurrent interview on 02/06/18 at 11:15 AM, in the fourth floor BHU hallway, showed Patient #27 walked up to a surveyor and handed the surveyor a piece of Plexiglas (thick plastic, with sharp corners, that can be used for self-harm, or the harm of others). The Plexiglas was approximately one-eighth inch thick, one inch wide, and eight inches long. The patient stated "you can get Plexiglas anywhere in here." Staff H, Director of BHU, stated that the patient should not have the Plexiglas. Staff H directed the staff to search the BHU for other contraband.

Record review of Patient #27's H&P, dated 01/10/18, showed that he was a 36 year old male who was admitted to the facility on 01/08/18. He had a court-appointed legal guardian (someone assigned to make care decisions when a person cannot make appropriate decisions on their own), due to his poor insight and judgment, which would place him in danger. He had a history of paranoid (extremely nervous) and delusional ideation (thoughts that are not reality based).

During an interview on 02/06/18 at 2:00 PM, Staff WW, Unit Clerk, stated that:
- Staff handed him the Plexiglas with instruction to find where it was obtained;
- He had neither maintenance experience nor knowledge where it was obtained;
- He compared the Plexiglas to the light covers, and thought the Plexiglas was from the light covers;
- He search all light covers and could not see any damaged or missing pieces, so he stopped searching;
- He did not interview patient #27 as where the Plexiglas was obtained;
- The Plexiglas could be used as a weapon; and
- There could be other contraband where the patient obtained the Plexiglas.

During an interview on 02/06/18 at 2:10 PM, Patient #27 stated that:
- The Plexiglas was removed from the exit sign;
- The Plexiglas could be broken leaving sharp edges, and "could be used to kill someone"; and
- There were "fights" all the time on the unit, you can find items anywhere.

Observation on 02/06/18 at 2:25 PM, in the fourth floor BHU hallway, showed three exit signs with removable Plexiglas, with one of the exit signs missing Plexiglas.

During an interview on 02/06/18 at 2:35 PM, Staff XX, RN, stated that if the staff found contraband, the staff would have to get a doctor's order to search the BHU rooms. To search for contraband without a doctor's order would be violation of the patient's rights.

During an interview on 02/06/18 at 2:05 PM, Staff CC, Clinical Leader, stated that staff could not search a patient's rooms unless the staff had a doctor's order.

During an interview on 02/07/18 at 4:15 PM, Staff YY, Security Officer, stated that:
- The Plexiglas could have been used as a weapon;
- For security to search the patient's room, there must be a doctor's order; and
- Searching for contraband was not a security responsibility, it was a nursing responsibility.

During an interview on 02/08/18 at 12:05 PM, Staff OOO, Chief Medical Officer, stated that the staff did not have to have a doctor's order to check for contraband. It was the staff's responsibility to keep the patients safe.

Record review of work order for behavior health fourth floor, submitted on 02/01/18, showed exit sign needs replaced. The work order had not been completed.

Record review of an Email (message distributed by electronic means), dated 02/07/08, showed that:
- A contraband check was performed on the entire floor;
- "The only thing we found was a zip lock bag of pink pills under [the] mattress of 403-1"; and
- Pharmacy was notified and confirmed the pills.

Record review of Patient #39's H&P, dated 02/08/18, showed that he was a 51 year old male, admitted to the facility on 02/02/18. He had worsening depression (extreme sadness) as well as having auditory hallucinations (hearing voices) telling him to hurt himself. He had history schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), with poor insight, judgment, and impulse (to react quickly) control.

During an interview on 02/08/18 at 8:45 AM, Staff LLL, Interim Director of Pharmacy, stated that:
- Evening shift confirmed the zip lock bag of pills found on the BHU as an antihistamine;
- The medication could make a patient very drowsy; and
- The major concern was how the patient got the zip lock bag of medication to the BHU floor.

During an interview on 02/08/18 at 9:05 AM, Staff CC, Clinical Leader, stated that the "pills" came from room 403-1. Patient #39 had 48.5 pills in a "sandwich bag" under his mattress.

During an interview on 02/08/18 at 9:10 AM, Patient #39 stated that:
- He had brought the "pills" in through his paper scrub's front pocket;
- When you are admitted here, the staff just wand you, they don't search you; and
- He had been taking the "pills" as he needed.

Observation on 02/06/18 at 10:10 AM, in the BHU Geropsych hallway floor, showed an unattended cleaning cart, and a linen cart that contained eight plastic bags. There were no staff in the hallway around the linen cart. A BHU patient was observed walking by the unattended linen cart, which contained the plastic bags, which were within arm's length of the patient. Staff CCC, housekeeper, was in a room and left the carts unattended and unsupervised.

During an interview on 02/06/18 at 10:10 AM, Staff CCC, Housekeeper, stated that:
-The linen cart was stocked with plastic bags so that when housekeeping entered an area, they have the plastic bags they need for linens, trash, and to line trash bins;
- She normally does not work on the BHU;
- She was called in to help;
- She had been trained not to use plastic bags in the BHU;
- She acknowledged that she had left the plastic bags unattended; and
- She should not have brought the plastic bags to the BHU.

During an interview on 02/06/18 at 10:10 AM, Staff H, Director of BHU, stated that staff CCC should not have plastic bags on the BHU. Staff H instructed Staff CCC to remove the plastic bags from the unit.

Record review of the facility's education provided to housekeepers, dated 07/13/17, showed that housekeepers were committed to provide a safe, clean, and sanitized environment to protect every patient. The staff understood that:
- The cart was to be locked at all times;
- The cart was to be attended at all times (particularly on all BHU);
- Paper bags must be used on all BHUs; and
- Failure to adhere to the above on any level will result in corrective action.
Staff CCC signed attesting that she would adhere to the education.

During an interview on 02/06/18 at 3:00 PM, Staff VV, Director of Environmental Services, stated that Staff CCC should not have plastic bags on the BHU and that it was his expectation that all staff adhere to the facility's policies.

Record review of the facility's policy titled, "Safety Management," dated 02/2015, showed the facility was to:
- Provide a physical environment free of hazards.
- Manages staff activities to reduce risk of injuries.
- Identify, assess and evaluate hazards and risks involved with direct patient care.
- Provide a proactive, hospital-wide, hazard surveillance program to detect and report environmental hazards and evaluate the impact of buildings, equipment, occupants and internal physical systems.

Record review of the facility's policy titled, "Room Checks and Environmental Surveillance for Psychiatric Services," dated 07/2017 showed that all occupied areas including patient rooms, group/activity area, common areas and hallways should be surveyed for safety and for anything that could be used as a weapon to harm oneself or others.

Record review of the facility's policy titled, "Suicide Precautions," dated 12/2017, showed that staff should maintain a safe environment to protect the patient from self-destructive tendencies.

3.

Based on record review, policy review, and interview, the facility failed to:
- Prevent abuse and/or neglect of two current patients (#3 and #32) of two patients reviewed;
- Investigate allegations of staff to patient abuse in a timely manner for two current patients (#3 and #32) of two patients reviewed;
- Remove Staff GG, Registered Nurse (RN), Alleged Perpetrator (AP) from direct patient care; and
- Follow the facility's policy for reporting allegations of abuse/neglect.
These failures had the potential to place all patients admitted to the facility at risk for their safety from abuse and neglect by staff. The behavioral health census was 83 and the facility census was 101.

Findings included:

1. Record review of the facility's policy titled, "Abuse and Neglect," revised 12/2016, showed that:
- When there is reasonable cause to suspect that a patient may have been subjected by abuse/neglect, the identifier will immediately report his/her findings to the Department Manager/House Supervisor;
- The Manager/House Supervisor will notify the Director of Risk Management, the Manager of Social Services, the Attending Physician, and Administration;
- The investigation will start immediately;
- The Department Manager/House Supervisor will immediately remove the staff member from patient care and put them on leave until investigation is complete;
- The Department Manager/House Supervisor notifies Risk Manager and secures statements form all staff working the shift in question;
- The Department Manager/House Supervisor will obtain fact based report from the patient or other witnesses;
- Documentation is completed and the determination is made to self- report to the hotline; and
- DHSS (Department of Health and Senior Services) will be notified within 48 hours of the initial report.

Record review of a facility's investigation timeline showed that:
- The alleged abuse occurred on 12/21/17 at approximately 11:30 PM.
- Staff M, Licensed Practical Nurse, (LPN), witnessed verbal and physical abuse of Patient #3 and verbal abuse of Patient #32 by Staff GG, Registered Nurse (RN), Alleged Perpetrator (AP).
- Staff JJ, Behavioral Health Technician (BHT), witnessed verbal abuse of Patient #32 by Staff GG, RN (AP).
- Staff NNN, BHT, witnessed verbal and physical abuse of Patient #3 by Staff GG, RN (AP).
- Five days after the alleged abuse, Staff L, Nurse Manager, Third Floor Behavioral Health Unit (BHU), located staff statements on the morning of 12/26/17 and at 9:18 AM notified Staff H, Director of Behavioral Health.
- On 12/26/17 at 9:35 AM, Staff H called and left a voice message for Staff GG, RN (AP), and attempted to notify her of her suspension pending investigation; and
- On 12/26/17 at 9:40 AM, there was a conference call with Staff H, Director of Behavioral health, Staff L, Nurse Manager, Third Floor BHU and the Human Resource department, that initiated the investigation.

During a telephone interview on 02/06/18 at 6:10 AM, Staff M, LPN, stated that:
- At 11:30 PM she witnessed Patient #3 and Patient #32 being verbally and physically abused by Staff GG, RN (AP);
- Staff GG requested Staff M's assistance in Patient #3's room (room 326);
- Staff GG asked Patient #3's roommate and her sitter to leave the room;
- Staff GG and Patient #3 were cursing back and forth, verbally abusive and when Patient #3 tried to remove herself from the room, Staff GG, physically blocked her from exiting by using her body. Staff GG stepped in front of her, and stated, "move this 280 lbs.";
-Patient #3 requested to walk herself to the seclusion room for a time out (when a patient who was acting out or escalating, went to a quiet room for up to 30 minutes and calmed down on their own), and was directed by Staff GG to "sit your ass down on the bed";
- While this was occurring, in room 318, Patient #32, whom had a history of PTSD (Post traumatic stress disorder), heard all of the yelling and cursing, left her room, went to the day room (to remove herself from the commotion), and was yelled at by Staff GG to, "Go back to her room";
- When Patient #32 reentered her room, she slammed the door and Staff GG opened it, pointed her finger at the patient, and yelled at her "Do not slam doors, you don't own anything here";
- Staff M attempted to speak with Staff HH, RN, but ended up getting distracted; and
- She wrote up her concerns and slipped them under the door for Staff L, Third Floor Nurse Manager.

During a telephone interview on 02/07/18 at 6:45 AM, Staff JJ, BHT, stated that:
- She witnessed Staff GG, RN (AP), curse out Patient #32 on the women's hall because the patient wouldn't go back to her room;
- Staff M, LPN, went to Patient #32's room to help Staff GG;
- She didn't hear anything else, because she was halfway down the hall, and Staff GG had closed the door to room 318; and
- Staff M, LPN, was with Staff GG and would have heard more.

Record review of a written statement obtained by the facility dated 12/29/17 at 8:05 PM, Staff NNN, BHT, stated that:
- At approximately 11:00 PM on 12/21/17, Patient #3 was upset and Staff GG, Staff M, and Staff NNN, all tried to talk Patient #3 down;
- Staff GG then yelled at Staff NNN, "Get back" and "Step Off", and that she, Staff GG, would handle it;
- She followed the direction of Staff GG, and went down the hall, but could still hear Staff GG yelling; and
- Staff GG yelled at Patient #3, "try to move 250 lbs." and "you're not going anywhere".

During a telephone interview on 02/07/18 at 6:35 PM, Staff HH, RN, stated that:
- The hall was a "mess", and Staff GG went into the women's hall to send patients to their rooms;
- Patient #32 had approached her and told her that one of the nurses had yelled at her and what should she do about it;
- At Staff HH's direction Patient #32 wrote down what happened, dated and timed it, and she placed it under the Manager's door;

During a telephone interview on 02/07/18 at 6:52 PM, Staff MMM, Charge nurse, Third Floor BHU stated that:
- Patient #32 handed her a note, and asked her to give it to the clinical leader.
- She did not remember the time of day that this occurred.
- Patient #32 had not appeared to be upset, and had not indicated any urgency.
- When she read the note, it indicated that Staff GG, RN, had yelled at Patient #32 and pointed her finger at her.
- Staff MMM folded the note and placed it in Staff L, Nurse Manager, Third Floor BHU's box.
- She did not see the need to notify the supervisor, since she had placed it in her box.
- She was later informed that it was an allegation of verbal abuse, and she should have notified the supervisor.
- She had not reported it since she didn't know what happened, and patients complain all the time and staff and management yelled at them.

During an interview on 02/05/18 at 4:00 PM, Staff L, Nurse Manager, Third Floor BHU, stated that:
- Video of the incident that occurred on 12/21/17 at 11:30 PM observed the common areas, hallways and dayrooms. There were no videos in the patient rooms.
- The video was very limited and had no sound.
- When the allegation statements were found, it was reported to Staff H, Director of Behavioral Health, immediately.
- Staff GG, RN, (AP) continued to work the remainder of her shift after the incident.

Record review of the nursing shift assignment sheet for 12/21/17 showed that Staff GG, RN (AP), worked her full shift after the incident occurred.

Record review of a written statement obtained by the facility dated 12/27/17 by Staff EEE, House Supervisor, showed that:
- She had received a call from the Third Floor to let her know that the patient in room 318 (Patient #32) wanted to talk to her on 12/22/17;
- She could not recall which staff member called her about the request;
- When she arrived on the Third Floor, Patient #3, approached her to speak with her and she informed Patient #3 that she was there to speak to someone in room 318;
- At that time, she was paged overhead and left the unit before she spoke to either patient; and
- She never had time on her shift to get back to that unit.

Record review of Patient #32's handwritten statements dated 12/22/17 and 12/23/17 showed that:
- She reported to Staff L, Nursing Manager, Third Floor BHU, that Staff GG had yelled at Patient #3 and triggered her PTSD symptoms;
- She removed herself from her room to the dayroom down the hall to avoid the yelling;
- Staff GG then entered the dayroom, and told her that, "You could have just closed the door to your room".
- She tried to explain to Staff GG that her actions caused her to have flashbacks, and asked that she not follow her back to her room (Room 318);
- Patient #32 admitted to having slammed the door to her room, and when Staff GG entered, she asked her to "leave her alone";
- Staff GG proceeded to get into the patient's face, pointed her finger in her face, and told her "you don't own anything here";
- She stated that by the time Staff GG left the room, she was back into her past, and had locked herself into the bathroom, bawling in tears.

During an interview on 02/05/18 at 3:35 PM, Patient #3 stated that she did not remember the specific incident but felt that staff were not receptive to the patients, when they needed to discuss their feelings and constantly told the patients to get away from the nurses desk.

Record review of Staff GG, RN (AP)'s written statement dated 12/26/17, showed that:
- On 12/21/17 she had observed two patients in a verbal altercation and she tried to diffuse it as quickly as possible (Patient #3 and her roommate).
- Patient #3 walked to her room (room 326) and slammed the door;
- She asked Staff M, LPN, to accompany her to the room;
- She spoke with Patient #3 for a little bit, then she left the room go talk to the roommate, whom was now in the dayroom with her assigned sitter;
- There was another patient in the dayroom, Patient #32, and she directed her to return to her room, room 318;
- That Patient #32 attempted to talk to Staff GG about the loud noises, door slamming, and that it had scared her, at that point Staff GG told her she would be in to speak with her after the first situation was handled;
- Patient #32 went into her room and slammed her door, Staff GG followed her into room 318 and asked her not to slam the door, that it was late, and patients were trying to sleep;
- Staff GG told Patient #32 that she knew she was upset, and that she would be back, the door to the room closed behind her as she exited, and that she had been alone in the room with Patient #32;
- Staff GG then went back to room 326 to talk to Patient #3 and her roommate to discuss the situation and both patients were asleep, and no further aggression was displayed throughout the night.

During an interview on 02/06/18 at 10:00 AM, Staff Q, RN, stated that:
- Her interaction with Staff GG, RN (AP) was at change of shift reports, and her demeanor was that she "told the patient's how it was going to be and what they were going to do";
- She received advice from Staff GG to "tell them to sit their ass down", and "I just close the door so no one can witness it";
- Staff M, LPN, was in tears over the situation, and felt badly that she didn't report it immediately to the supervisor; and
- When a staff member had to be pulled for a 1:1 (when a staff member is required to remain within arm's length of a patient that is at risk for harming self or others) the floor staff ended up working short.

During an interview on 02/06/18 at 2:45 PM, Staff S, RN, stated that the units are short staffed most days and they definitely work short anytime a 1:1 was required.

During an interview on 02/05/18 at 3:20 PM, Staff G, Patient Care Technician (PCT), BHU, stated that when patients go into seclusion (required staff for one on one), they were left short-staffed for the rest of the unit and that made it dangerous.

During an interview on 02/07/18 at 4:05 PM, Staff FFF, RN, Charge Nurse, BHU, stated that they were not staffed for unpredictable psychiatric patients.

During an interview on 02/06/18 at 10:50 AM, Staff Z, RN, BHU, stated staffing was horrible and that when they pulled staff from one unit to help on another, it left their unit short-staffed and unsafe.

During an interview on 02/06/18 at 3:10 PM, Staff H, Director of the fourth floor BHU, stated that they only used agency, when they had an emergency and that they did not have any at that time.

During an interview on 02/08/18 at approximately 1:30 PM, Staff N, Chief Nursing Officer, stated that there were processes and policies in place for best care and safety of the patients. It was her expectation that staff adheres to those processes and policies, and "short staff" was not a good answer.

Interviews and record reviews showed that Patient #3 was physically prevented from leaving her room, and that both patients #3 and #32 were verbally abused by Staff GG, RN (AP). The facility failed to prevent abuse, remove the AP from patient care, investigate and had a significant delay in the reporting of the incident by all staff involved.










36473

Based on interview, record review and policy review, the facility failed to ensure that patient care plans (process to identify that are goals and interventions, individualized to direct nursing care for every patient) were modified when patients were placed in restraints (devices that limit the ability of patients to move hands and/or legs) for two current patients (#7, #18), and one discharged patient (#16), of four patient records reviewed, that had been placed in restraints in the Intensive Care Unit (ICU- area of the hospital where the sickest patients are usually sent). This had the potential to affect all patients that were placed in restraints by failing to ensure the patients' physical and psychological (mental health) needs were met. The facility census was 101.

Findings included:

1. Review of the facility's policy titled, "Restraint or Seclusion," revised 10/2017 showed that when restraints are placed, the patient's Care Plan must be modified to reflect the change and any additional needs the patient may have related to the restraints.

Review of the facility's, "Restraint Log," for the ICU in 01/2018 showed a total of four patients were restrained in the ICU in January.

2. Review of Patient #7's Physician's Orders and Restraint Flowsheets showed he was restrained from 01/28/18 through 01/31/18.

Review of Patient #7's Care Plan showed no modifications to reflect individualized goals or interventions while he was restrained from 01/28/18 through 01/31/18.

3. During an interview on 02/06/18 at 2:15 PM, Staff X, Registered Nurse (RN) stated that there were no modifications to Patient #7's Care Plan to reflect individualized goals or interventions while he was restrained from 01/28/18 through 01/31/18.

Review of Patient #18's Physician's Orders and Restraint Flowsheets showed he was restrained from 01/29/18 through 01/30/18.

Review of Patient #18's Care Plan showed no modifications to reflect individualized goals or interventions while he was restrained from 01/29/18 through 01/30/18.

Review of discharged Patient #16's Physician's Orders and Restraint Flowsheet showed he was restrained on 01/04/18.

Review of Patient #16's Care Plan showed no modifications to reflect individualized goals or interventions while he was restrained on 01/04/18.

During an interview on 02/06/18 at 4:30 PM, Staff N, Chief Nursing Officer (CNO) stated that she had reviewed these patient records and there were no modifications to the Care Plans to ensure individualized, safe and consistent care while patients were restrained. Staff N stated that Care Plans should always reflect appropriate goals and interventions so that restrained patients were provided the best possible care.