HospitalInspections.org

This CONDITION is not met as evidenced by:

I. Based on document review, observation, and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure the nursing staff did not violate patient rights with the use of restraint and seclusion related to 1 of 27 Behavioral Health Patients reviewed. Please refer to A-0144 for additional information.

2. Ensure the nursing staff identified and investigated an incident of abuse for 1 of 2 patients reviewed for abuse in the inpatient Behavioral Health Units. Please refer to A-0145 for additional information.

3. Ensure the hospital developed policies addressing the transportation of pediatric patients throughout the facility. Please refer to A-0144.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure the safety of patients in the hospital's Behavioral Health unit and the pediatric population.

The hospital's administrative staff identified an initial inpatient census on the three Behavioral Health Units of 54 patients.

II. During the investigation of 72523-C and 73217-C, the on-site survey team identified two Immediate Jeopardy (IJ) situations (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient Rights (42 CFR 482.13). The hospital staff failed to ensure the nursing staff did not violate patient rights with the use of restraint and seclusion or ensure the hospital staff identified and investigated an incident of abuse. The hospital failed to develop policies addressing the transportation of pediatric patients.

1. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 1/31/2018. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the complaint investigation when the administrative staff took the following actions:

2. The administrative staff initiated disciplinary action to the Manager of Behavioral Health of a 3 day administrative suspension and transfer to a position that did not involve direct patient care or supervision of direct patient care staff.

3. The administrative staff terminated RN O and RN P from employment effective 2/7/2018.

4. The administrative staff updated the policies on Patient Rights and Restraint and Seclusion.

5. The administrative staff developed and implemented a policy addressing the transportation of pediatric patients.

6. The administrative staff entered into an agreement with a consulting group for behavioral health staff training and education.

7. The Behavioral Health camera monitor techs received re-education to bookmark any restraint and seclusion incidents they observed, as well as any staff-patient contact that appears unrelated to clinical care, effective 2/6/2018.

8. The Director of Behavioral Health and/or Risk Management will review all restraint and seclusion incidents and bookmarked video footage within 1 business day, effective 2/6/2018.

9. The Director of Behavioral Health, Pharmacy, and Risk Management will review all as needed injectable Haldol orders within 1 business day, effective 2/6/2018.

10. All inpatient Behavioral Health staff, Behavioral Health providers, House Supervisors, and Security will review and sign off on externally prepared Abuse and Harassment and Restraint and Seclusion educational materials prior to the start of their next shift, effective 2/6/2018.

11. All inpatient Behavioral Health staff and providers will review and sign off on the Behavioral Health Restraint and Seclusion Protocol prior to the start of their next shift, effective 2/7/2018.

The following Condition level deficiency remained for the Condition of Participation in Patient Rights (42 CFR 482.13).

I. Based on document review, observations, and staff interviews, the hospital's administrative staff failed to ensure the nursing staff only used restraint and seclusion with 1 of 2 reviewed patients (Patient #1) when the patient's behavior required restraint or seclusion to protect the patient's safety. The hospital's administrative staff identified 54 patients in the Behavioral Health Unit 1W at the time of the investigation.

Failure to ensure the nursing staff only used restraint and seclusion when the patient's behavior required restraint or seclusion to protect the patient's safety resulted in nursing staff awakening the patient, forcefully removing the patient from the recliner and dragging the patient to their room. The nursing staff forced the patient to receive an injection of a medication used as a chemical restraint to keep the patient in their room. When the patient would not stay in their room, the nursing staff placed the patient in seclusion, only releasing the patient from seclusion when the staff members' shift ended.

Findings include:

1. Review of the policy Compliance with Dependent Adult Abuse Act, effective 3/2017, revealed in part, Dependent Adult Abuse means any of the following as a result of the willful, negligent acts ... of a caretaker: ...unreasonable punishment ... of a dependent adult.

2. Review of The Behavioral Support (Including Restraint & Seclusion) Protocol, issued 2/15 revealed, in part, Purpose: ...Restraints and seclusion are to be used only in an emergency when there is imminent risk of an individual harming himself or herself or others ...Emergency- An emergency is an instance in which there is an imminent risk of an individual harming himself or herself or others, including staff; when non-physical interventions are not viable; and safety issues require an immediate physical response ... Restraint/Seclusion will not be used for any other purpose, such as coercion, discipline, convenience or retaliation. ... Identify and attempt alternative interventions... Attempt the use of recliners if appropriate ...

3. Review of Patient #1's medical record revealed the court involuntarily committed Patient #1 to the inpatient Behavioral Health Unit for psychiatric evaluation on 12/22/2017. The nursing staff documented Patient #1 slept between 0 and 3.75 hours each night in broken intervals.

On 12/30/2017 at 8:57 PM RN (Registered Nurse) O administered one tablet of PRN (as needed) Seroquel (antipsychotic) 50 milligrams (mg). Patient # 1 complained of anxiety.

On 12/31/2017 at approximately 2:30 AM RN O documented she approached Patient #1 to "gently" remind them to go to their room to sleep. Patient #1 began getting angry and arguing with the staff. RN O told Patient #1 they had the option to go to their room independently or RN O would escort Patient # 1 to their room. Patient #1 resisted going to their room. RN O requested help from RN P to help escort Patient #1 to their room. RN O and RN P attempted to assist Patient #1 to their room. Patient #1 became combative and attempted to hit and bite staff. Patient #1 then suddenly dropped to the floor. Patient #1 refused to get off the floor. Staff notified security. Patient #1 got off floor before Security arrived.

On 12/31/2017 at 2:40 RN O documented Patient #1 stomped on a staff member's foot.

On 12/31/2017 at 2:41 AM RN O documented Patient #1 was yelling for Patient #2 to help Patient #1. Patient #2 was sleeping on a couch in the day room. Patient #2 got up from the couch and Patient Care Technician (PCT) F redirected Patient #2.

On 12/31/2017 at 2:43 AM RN O documented RN O returned to Patient #1's room and administered an injection of 2 mg Haldol (antipsychotic medication) after Patient #1 refused to swallow pills.

On 12/31/2017 at 3:29 AM RN O documented Patient #1 came out of their room. Patient #1 complained of being cold. RN O instructed Patient #1 to return to their room and cover up with a blanket.

On 12/31/2017 at 4:37 AM RN O documented Patient #1 came out of their room. RN O gave Patient #1 the option to stay in their room or Patient #1 could go to the seclusion room. RN O charted Patient #1 chose to go to the seclusion room.

On 12/31/2017 at 5:06 AM RN O documented RN O put Patient #1 into seclusion.

On 12/31/2017 at 5:12 AM RN O documented RN O administered Patient #1 an injection of Thorazine (medication used to treat psychotic disorders, this medication promotes sleepiness).

On 12/31/2017 at 6:37 AM RN O documented that RN O released Patient #1 from seclusion.

4. Review of video footage revealed:

On 12/31/2017 at 2:26 AM - showed Patient #1 was sitting in a recliner in the day room.

On 12/31/2017 at 2:37 AM - Patient #1 was sitting in the recliner and Patient #2 laying on the couch in the day room. RN O entered the day room and had a conversation with Patient #1.

On 12/31/2017 at 2:38 AM - RN O and RN P grabbed Patient #1 under Patient #1's arms and pulled Patient #1 out of the recliner.

On 12/31/2017 at 2:40 AM - RN O and RN P dragged Patient #1 part way through the day room before RN O and RN P lowered Patient #1 to the floor. The video failed to clearly reveal if RN O and RN P attempted to hold Patient #1 up from falling to the floor. Patient #2 arose from the couch in the day room and started walking toward RN O, RN P, and Patient #1. PCT F walked over and intervened before Patient #2 reached RN O, RN P, or Patient #1. Patient #1 got off of the floor and attempted to return to the recliner. RN O prevented Patient #1 from returning to the recliner on three separate occasions.

On 12/31/2017 at 2:41 AM - RN O and RN P took Patient #1 by the arms again and walked Patient #1 to their room.

On 12/31/2017 at approximately 2:46 AM - RN O came to Patient #1's room with a security guard. Patient #1 did not display violent behaviors on the video. Patient #1 then appeared to willingly walk to the room with the security guard and RN O.

On 12/31/2017 at 4:40 AM - Patient #1 came out of her room. RN O yanked a blanket from Patient #1's hands and threw the blanket on the floor. RN O then grabbed Patient #1's right arm and pulled the patient towards the seclusion room. RN O then let go of Patient #1's arm and pulled the restraint bed (a bed used to tie down a patient's arms and legs to immobilize the patient) out of the seclusion room. RN O placed Patient #1 into seclusion.

On 12/31/2017 at 4:40 AM - Audio recording from the video footage revealed RN O told Patient #1 to let RN O pull the restraint bed out of the seclusion room, unless Patient #1 thought they would need it too. RN O pulled the restraint bed out of the seclusion room. Patient #1 turned to walk away. Patient #1 walked towards the day room. RN O took Patient #1 by the right arm and right wrist. RN O walked Patient #1 to the seclusion room.

5. During an interview with PCT F on 1/31/2018 at 7:30 AM, PCT F revealed she told RN O the nurses who worked earlier in the week allowed Patient #1 to sleep out in the recliner in the day room the night of 12/30/2017. PCT F reported noticing RN O became agitated with Patient #1 when Patient # 1 walked around the unit and would not stay in their room on the night of 12/31/2017.

6. During an interview on 1/31/2018 at 10:30 AM and 2/5/2018 at 1:26 PM, RN O revealed she woke Patient #1 up and forced the patient to go to their room. RN O reported Patient #1 lacked the capacity to remember to stay in their room or if Patient #1 had received any medications earlier in the evening since Patient #1 continued asking for medications throughout the shift. RN O told Patient #1 they could not receive any additional oral medications, as RN O had administered all of the medications Patient #1's physician ordered for Patient #1. (On 12/31/2017 at 2:43 AM, RN O documented returning to Patient #1's room and administering an injection of Haldol 2mg after Patient #1 refused oral medications).

7. During an interview on 1/31/2018 at 11:30 AM and 2/6/2018 at 4:30 PM RN P revealed she was unaware RN O woke Patient #1 up and instructed Patient #1 they could either go to their room or RN O would escort Patient #1 to their room. RN P said if she had known RN O woke up Patient #1 she would have told RN O that waking Patient #1 up was inappropriate. Patient #1 was upset when RN P arrived to the recliner in the day room. RN P stated she received training to calm the patient down by talking with patients, rationalize with the patient, or to attempt to bribe patients to go to their room by offering snacks. RN P acknowledged she and RN O previously engaged in power struggles with patients.

8. During an interview on 1/31/2018 at 7:30 AM PCT F revealed RN O told PCT F and RN P that RN O preferred to give patients injections into the patient's buttocks, as injecting the medication into the patient's buttocks causes the patient more pain. PCT F revealed that RN P agreed with RN O that administering injections into a patient's buttocks causes more pain, but RN P preferred to request a security guard hold the patient down against the patient's will when administering injections into the patient's buttocks. PCT F reported when Patient #1 came out of their room the last time on the morning of 12/31/2017 at approximately 4:35 AM, RN O told Patient #1 they had left the room for the last time and RN O was going to place Patient #1 into seclusion. RN O grabbed Patient #1's right arm and told PCT F to grab Patient #1's other arm, PCT F reports PCT F did not grab Patient #1's other arm, but instead, placed a hand on the back of Patient #1.

9. During an interview on 1/20/18 at 8:15 AM, the Manager of Behavioral Health for 1W and 3E, revealed on the morning of 12/31/2017, RN O informed the Manager of Behavioral Health of the incident with Patient #1. The Manager of Behavioral Health reported she placed a non-disciplinary note in the personnel file for RN O and RN P, documenting the events that occurred on 12/31/17. The Manager of Behavioral Health reported she informed RN O and RN P it was not acceptable behavior to use physical force with patients, force patients to go to their rooms, and put patients into seclusion for any reason other than patient safety. The Manager of Behavioral Health wrote in the non-disciplinary note that staff can not use seclusion for punishment. Instead, the patient must pose a danger to themselves or others before staff can use seclusion. The Manager of Behavioral Health reinforced with RN O and RN P that the nursing staff can not engage in power struggles with patients. The Manager of Behavioral Health discussed with RN O and RN P the challenges of working with mentally ill patients. Mentally ill patients can not always reason or meet expectations set by the staff members. The Manager of Behavioral Health asked RN O and RN P if Patient #1 was in danger of hurting themselves, or was not doing what the nurses requested from Patient #1. The Manager of Behavioral Health reinforced with RN O and RN P that the patient must present a clear danger to themselves or others before the nursing staff can make physical contact with a patient or place the patient in restraints or seclusion.

10. During an interview on 1/30/2018 at 3:30 PM and 1/31/2018 at 4:20 PM, the Director of Behavioral Health revealed she did not believe did the situation involving RN O, RN P and Patient #1 rose to the level of abuse. The Director of Behavioral Health reported if a situation was abuse and therefore failed to report it to the appropriate state agency (the Iowa Department of Inspections & Appeals (DIA)). The Director of Behavioral Health lacked knowledge regarding the information provided to the nursing staff to assist them in handling situations where the patients fail to behave as the staff wished, and to prevent the situations from escalating into a power struggle. The Director of Behavioral Health divulged that neither RN O nor RN P received education after the incident on 12/31/2017 to prevent RN O or RN P from engaging in power struggles with patients, or to prevent RN O or RN P from using restraints or seclusion to punish patients if the patient failed to behave.

11. Review of the Behavioral Health Unit staffing schedule revealed RN O worked an additional 13 shifts and RN P worked an additional 12 shifts on the Behavioral Health Unit 1W from 12/31/2017 to 2/2/2018, after RN O and RN P placed Patient #1 into seclusion.

II. Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff developed and implemented policies regarding the safe transport of pediatric patients. The lack of a policy impacted 1 of 9 pediatric patients identified by the hospital administrative staff (#3).

Failure to develop and implement policies regarding the safe transport of pediatric patients resulted in a staff member transporting a patient recovering from anesthesia, which attempted to get to get up and fell, striking their cheek against a bare metal rail sustaining an injury to the left cheek.

Findings include:

1. Review of Patient #3's medical record revealed Patient #3 was 3 years old, and presented for same day dental surgery on 12/7/2017 at 9:15 AM. The hospital staff administered general anesthesia (medication used to render patients unconscious for surgery) to perform the dental procedures. Registered Nurse (RN) U documented in a nurse's note dated 12/7/2017 at 2:04 PM, which revealed in part, While transferring to surgery via crib, patient attempted to sit up in the crib .... Child then fell to the side and hit the upper left cheek on bed rail. When we arrived to surgery, the child's upper left cheek appeared bruised.

2. During an interview on 1/30/18 at 12:55 PM, RN U revealed the nursing staff usually carried infants and small children from the recovery room back to surgery area. RN U did not carry Patient #3 because Patient #3 was asleep. RN U transported Patient #3 in a wheeled crib with metal bars. Patient #3 rested with their knees pulled up to their chest, lying face down. As RN U turned a corner while transporting Patient #3, Patient #3 rose up on their knees and started to cry. RN U stopped moving the crib and told the child to lie back down. Patient #3 toppled to the side, hitting their left cheek on the metal bars on the side of the crib. RN U reported she failed to know of a policy instructing hospital staff on the safe transportation of infants and children.

3. During an interview on 1/30/2018 at 2:30 PM, Administration Patient Advocate (APA) revealed the Manager of Peri-Anesthesia and Interventional Services contacted her and requested she come down to the surgery department on 12/7/2017 to speak with Patient #3's mother. Patient #3's mother was upset about a bump on Patient #3's cheek. The APA then requested permission to take a photo of Patient #3's cheek. Patient #3's mother gave permission to take the photo of Patient #3's cheek.

4. During an interview on 1/30/18 at 2:08 PM, the Manager of Peri-Anesthesia and Interventional Pain Services reported the hospital lacked a policy instructing staff on how to transport pediatric patients. If a child was awake and calm, the nursing staff carried the patient in the staff member's arms to surgery/recovery. If the child was not awake or alert, the nursing staff transports the patient in a bed or crib to surgery/recovery.

5. Review of a photograph of Patient #3's injury taken on 12/7/2017 depicts a linear bruise under Patient #3's left eye, along the upper cheek.


39445

Based on document review and interviews administrative staff failed to identify and investigate an allegation of abuse for 1 of 2 patient records reviewed (Patient #1). The hospital's administrative staff identified 54 patients in combination of all behavioral health units at the time of the investigation.

Failure to identify and investigate an allegation of abuse resulted in the hospital's administrative staff allowing 2 nurses who committed an act of alleged abuse against a patient to continue working multiple shifts after the incident, potentially exposing other patients to abuse.

Findings include:

1. Review of the policy Compliance with Dependent Adult Abuse Act, effective 3/2017, revealed in part, Dependent Adult Abuse means any of the following as a result of the willful, negligent acts ... of a caretaker: ...unreasonable punishment ... of a dependent adult. Upon an allegation of dependent adult abuse in this facility ... we will separate the victim and alleged abuser immediately and will maintain the separation until the State agency (Department of Inspections & Appeals (DIA)) investigation is completed and the abuse determination is made.

2. Video footage recorded the morning of 12/31/2017 revealed at approximately 2:30 AM, Patient #1 was resting in a recliner in the day room when Registered Nurse (RN) O approached Patient #1. RN O, with help from RN P, grasped Patient #1 by the arms and removed Patient #1 from the recliner and made Patient # 1 go to their room. Patient #1 came out of their room 2 more times throughout the morning. Patient #1 failed to exhibit any aggressive behaviors or attempt to harm themselves. Patient #1 returned to their room the first time at 2:40 AM. Patient #1 came out of their room at approximately 4:35 AM and RN O yanked a blanket from Patient #1's hands and put Patient #1 into the seclusion room. RN O released Patient # 1 from seclusion just before the end of her shift on 12/31/18 at 7:00 AM.

3. During an interview on 1/31/2018 at 7:30 AM, Patient Care Technician (PCT) F revealed she informed RN O the nurses who worked earlier in the week allowed Patient #1 to sleep out in the recliner in the day room. PCT F reported noticing RN O became agitated with Patient #1 when Patient # 1 walked around the unit and would not stay in their room on 12/31/2017.

4. During interviews with RN O on 1/31/2018 at 10:30 AM and 2/5/2018 at 1:26 PM revealed Patient #1 was sleep deprived. RN O acknowledged she woke Patient #1 up, forced the patient to their room, and administered a Haldol injection. According to RN O she put Patient #1 into seclusion until the end of her shift, the morning of 12/31/17. RN O acknowledged the decisions she made during the morning of 12/31/2017 failed to create a healing atmosphere in the Behavioral Health Unit. RN O acknowledged if she could change the events on 12/31/2017 she would have let Patient #1 keep sleeping in the recliner.

5. Review of the Behavioral Health Unit 1W staffing schedule revealed RN O worked an additional 13 shifts and RN P worked an additional 12 shifts with mental health patients on the Behavioral Health Unit 1W from 12/31/2017 to 2/2/2018, after RN O and RN P placed Patient #1 into the seclusion room.

6. Review of the Patient Rights and Responsibilities, effective 10/2015, revealed in part, Patients have the right: to be treated kindly and respectfully by hospital personnel.... in a safe environment free from abuse.

7. Review of The Behavioral Support (Including Restraint & Seclusion) Protocol, issued 2/15 revealed, in part, Purpose: To outline the nursing responsibilities in management of maintaining a safe environment for patients and staff and that no corporal punishment is used in the Behavioral Health Services.

8. During an interview on 1/30/17 at 3:30 PM and 1/31/18 at 4:20 PM, the Director of Behavioral Health revealed she did not consider the actions of RN O and RN P's as abuse, and therefore failed to report the incident to the appropriate State Agency (Department of Inspections & Appeals (DIA)).