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Based on staff interview and record review, the hospital's Quality Assurance/Performance Improvement failed to assure that its program activities included a timely and complete review and analysis of all adverse events and their causes, and failed to develop and implement hospital wide preventive actions to assure that adverse events will not recur. Findings include:
Per record review Patient #7 was involuntarily admitted to the hospital on 12/10/14, with a diagnosis of Bipolar Disorder with suicidal ideation and a reported history of suicide attempts, as well as a history of aggressive and assaultive behaviors towards others. Nursing progress notes over the days and weeks following admission revealed the patient exhibited behaviors that included verbal and physical aggressiveness towards other patients and staff. A note on 12/18/14 indicated that Patient #7 was physically restrained and received emergency medications following an assault that included throwing coffee and a radio at staff. The patient was transferred to the ALSA (Adult Low Stimulation Area) where s/he remained until 1/2/15, at which time a note, at 2:57 AM indicated that the patient had been "....extremely agitated at start of shift, swearing at writer and other staff members. At 1:30 AM pt went into bathroom when staff heard crashing sounds and found pt in bathroom with a piece of porcelain in [his/her] hand walking towards staff. Staff immediately closed bathroom door and stood against it for safety. Code Green was called and door to bathroom was opened within 3-5 minutes, and pt was found to be bleeding from [his/her] right hand .... [S/he] was also c/o inability to move fifth digit ....." A subsequent progress note, on 1/2/15 at 11:45 AM, stated; "pt is currently at [hospital] undergoing hand surgery following [his/her] aggressive dismantling of our ALSA program bathroom (toilet and bathtub) destroyed with pt sustaining hand injuries requiring ER visit ...." Subsequent progress notes revealed that Patient #7 returned to the facility on 1/2/15 and was transferred to the Tyler 4 unit.
Per record review, there was no evidence that a debriefing process had occurred in accordance with the facility's Code Green Policy, last reviewed January 2014, which stated; "Debriefing - 1. Once the behavioral emergency is resolved, a debriefing assists the group to review the situation and discuss what worked well, opportunities for improvement and other strategies that might have been used ....2. Debriefing is mandatory and all involved responders participate unless excused by the charge person or incident leader ...." In addition an event report completed at the time of the Code Green (safety emergency) described the event only as an 'environmental issue', in the form of destruction of facility property. And, although written statements provided by staff involved were obtained, information regarding the patient's behavior while in the bathroom with the porcelain object was inconsistent, with at least one staff member reporting that the patient was charging staff with the object. However, per review of the written statement provided by MHW #1, who was reportedly the only eye witness to the patient's behavior in the bathroom, there was no evidence the patient had charged anyone.
During interview, at 10:50 AM on 1/12/15, the Director of Quality stated that although the incident was reviewed, by unit Nurse Managers at morning meeting, on the morning of 1/2/15, the Director of Quality was not present and it wasn't until 3 days later, on 1/5/13, after having reviewed the event report that the Director of Quality identified the event as a 'medical' rather than environmental issue and prioritized it at a severity level 5 (an incident that resulted in hospitalization, temporary harm). However, despite recognition of inaccuracy of the initial event report and acknowledgement of the true significance of the event by the Director of Quality s/he and the VP of Quality and Clinical Services, also present during interview, both confirmed that a critical incident review was not conducted until 1/13/15, eleven days after the event. The Director of Quality stated that key staff members who had been involved in the incident were not present at the critical incident review and that those who were present did not have access to all needed information, including staff statements, which had yet to be provided by staff. The VP of Quality and Clinical Services stated that immediately following the incident the focus was on mitigating the environmental risk by replacing the destroyed porcelain toilet and tub with environmentally safe fixtures, and surveying other bathroom fixtures hospital wide in an effort to identify and mitigate additional environmental risks. S/he stated ' we looked at mitigating the EOC (environment of care) risk rather than the human risk. ' S/he further stated that to reduce the risk of a recurrence of a like incident, the patient was transferred to another unit upon return from the acute care hospital. The Director of Quality stated that issues reviewed at the meeting included; sufficiency of staffing numbers and level of training for night shift staff. S/he stated, as an outcome of the meeting, RN #1 was charged with reviewing the training of staff in an attempt to identify any needs for further training, and a report of his/her findings would occur on 2/20/15.
During interview, at 7:33 AM on 1/13/15, MHW #1 provided the following information: At approximately 12:30 AM on 1/2/15 Patient #7, who was sitting on the couch of the ALSA unit, was making " growling and grunting noises. " MHW #1 described the patient ' s behavior, at that time, as " different " from his/her normal behavior stating the patient seemed to be " seething " with anger. The MHW stated that Patient #1 ' s behavior began to escalate, after a nurse provided the patient with a band aid, but did not provide the bacitracin the patient had previously requested. The patient became more aggressive physically, throwing a potato and slamming a bedroom door, almost hitting another MHW with the door in the process. MHW #1 stated s/he was familiar with Patient #7, having worked with the patient on previous occasions and was aware the patient had refused PRN medications during prior episodes of agitated, aggressive and assaultive behavior, so the MHW asked the patient if s/he would like to shower and the patient agreed. MHW #1 stated that shortly after the patient entered the bathroom s/he heard the toilet lid slam down once and heard porcelain hit the floor. The MHW went to the door and observed Patient #7 in the bathroom, pick up a large chunk of porcelain from the floor and begin slamming the porcelain piece into the (shatterproof) mirror, holding it over his/her head with two hands and smashing it into the mirror 3-4 times, while yelling. MHW #1 stated the patient then turned around and, although the patient was not charging the MHW or specifically threatening, MHW #1 did not know what the patient ' s intention was and s/he closed the door and held it closed to assure the safety of the other patients and staff. A Code Green was called and, while waiting for other staff to arrive MHW #1 stated s/he could hear Patient #1 smashing things. The patient then got quiet and was noted to whimper some. MHW #1 stated it was a period of approximately 3-5 minutes after the door was closed before enough staff arrived to assure safety, the door to the bathroom was opened and Patient #1 was observed sitting on the floor with an injury to his/her right hand. MHW #1 stated that although s/he had received CPI (Crisis Prevention Intervention) training, prior to this incident, s/he had received no training in how to respond to patients exhibiting violent behaviors. S/he further stated that although s/he had spoken with the Nursing Supervisor the night of the incident, who expressed that staff had responded appropriately to the situation, and to the Unit Charge Nurse to provide information for the nurse ' s written report s/he had not spoken with anyone from the Quality department and did not attend the critical incident review.
Per interview, at 9:19 AM on 1/13/15, RN #1 stated that, although discussions had occurred between CPI trainers, and key staff involved with the Code Green, beginning the week following the incident and concluding 2 weeks post incident, MHW #1, was not involved in the discussions. RN #1 stated following discussions with staff the following needs were identified: ' night staff need more advanced training .....they need to be consistent and have the same level of training as all staff and staff need more knowledge in identifying imminent threat of harm. '
The Director of Quality acknowledged, during interview at 2:40 PM on 2/13/15, that the response, by Quality, to the incident had not been timely, that it is difficult to conduct a comprehensive critical incident review without the presence of key players and pertinent information related to the incident and difficult to accurately analyze the incident to determine appropriate action. S/he stated that although all key staff are " invited " to critical incident reviews they don ' t always attend. The Quality Director further confirmed that, although some immediate action had been taken to mitigate the potential for a reoccurrence of a like incident, no further action had been taken, to date, to provide what had been identified as needs, including consistent training for all staff.
Based on the information obtained, and although some actions had been taken to mitigate the potential for recurrence of a like incident, the facility failed to conduct a timely, complete and accurate assessment, failed to discuss all identified needs and implement all recommended actions in a timely manner. Although a key element identified reflected a need to provide staff more advanced training in knowledge to identify signs indicative of imminent threat of harm and techniques to de-escalate behaviors, no training had yet been provided to assure staff had all available tools to reduce the risk of a like incident from occurring.

Based on staff interview and record review, nurses failed to develop and keep current a Nursing Plan, as part of the Multidisciplinary Treatment Plan, that addressed all identified nursing needs, for 1 of 10 patients in the total sample. (Patient #2). Findings include:
Per review of initial Multidisciplinary Treatment Plan for Patient #2 dated 12/23/14, medical problems identified included weight loss, poor compliance with treatment of Vitamin D deficiency, hypothyroidism and Crohn ' s Disease. A Quality Review Synopsis dated 12/31/14, written by the Asst. Nurse Manager of Tyler 4 Unit regarding another issue, stated that the patient was noted to have a red rash on the throat and chest upon admission, received from pepper spraying done by police during arrest and prior to transport to the Retreat. The LIP (licensed independent practitioner) admission H & P also noted the rash. The Nursing Care Plan stated to provide disease and treatment education, including signs and symptoms for Hypothyroidism, Crohn ' s and Vitamin D deficiency as patient tolerates. The admitting physician ordered a nutrition consult for the patient, based on the history of recent weight loss prior to admission. The initial nursing plan did not include any interventions to address monitoring intake and weight loss and did not address the presence of the rash and any treatments provided.
The Multidisciplinary Treatment Plan from 2/6/15 was reviewed during survey on 2/11/15 and it did not address either of these issues. The nursing issues addressed on this care plan included monitoring of adverse side effects of Thorazine and stated medical issues including Hyperthyroidism, Vitamin D and B12 deficiencies and Crohn ' s Disease. The persons responsible for monitoring the medical issues were listed as the medical physician and the Social Worker. There was no nursing plan to address the weight loss, which included an additional 3 pounds lost since the admission weight on 12/14/14 of 163 pounds, down to 160 pounds on 1/15/15. On admission, the patient ' s weight in October 2014 was noted to be 174 pounds, thus there had been a total weight loss of 14 pounds, as of 1/15/15.
During interview on 2/11/15 at 4:50 PM, the RN Unit Assistant Nurse Manager confirmed that the nursing plan section of the Multidisciplinary Treatment Plan did not address Patient #2 ' s weight loss and impaired skin integrity.