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Based on observations, interviews, record review and document review, the facility failed to provide adequate numbers of nursing and physician staff, and failed to adequately train, supervise and monitor nursing and psychology staff with regard to safety and program management, for 11 of 11 active sample adolescents (L1, L2, L3, L4, L5, L6, L7, L8, L9, L10 and L11) on Unit3 Lower (a dual diagnosis unit for intellectually impaired and psychiatrically ill adolescents).

I. Nursing staff (RNs, LPNs and Mental Health Technicians) assigned to Unit 3 Lower at the time of the survey were not adequate to meet the needs of the patient population, and the staff were not sufficiently trained in the delivery of special programming for the adolescents residing on the unit. Observations and record reviews revealed that nursing staff were barely able to control the milieu, and had to engage untrained security staff to help with manual holds of patients. (Refer to B139)

II. There was inadequate physician staffing on Unit 3 Lower to address the needs of the patients, to train and support nursing staff, and to provide ongoing assessments of patients. The physician staffing dropped from 32 hours per week to under 15 hours per week when the attending psychiatrist was assigned to cover a forensic unit in the facility in January 2011. (Refer to B139)

III. The unit psychologist for Unit 3 Lower was working on the unit without adequate supervision from the Clinical Director. On one occasion observed on the hospital videotape, the psychologist was alone on a locked pod of the unit with a therapy group, when two patients became physically aggressive; the psychologist's call for help led to a delayed response from other staff because the staff were elsewhere at the time and were not readily available to provide assistance. The unit psychologist had asked for supervisory help and training in dealing with this special population and had not received any additional training as of the date of the survey, 4/12/11. (Refer to B151)

IV. The Medical Director failed to assure an adequate physician staff coverage (refer to B144) and the Director of Nursing failed to assure adequate numbers of staff, and adequate training and supervision of nursing staff present on the unit (Refer to B148.)

These failures placed the patients on this unit at risk for harm from inadequate numbers of staff, and inadequate training and supervision of the staff on this locked unit, and was deemed to be a situation of IMMEDIATE JEOPARDY. The facility was notified on 4/12/11 at 1:00 PM. CST.








21993

Based on observation, interview and record review, the facility assigned staff (RNs, LPNs and Mental Health Technicians) to Unit 3 Lower who were not adequately trained in the delivery of special programming for the adolescents with dual diagnosis (intellectually impairment and psychiatrically illness) on the unit . Record review and observation revealed that the patients on the unit were often out of control, and on more than one occasion the staff required the assistance of untrained security staff to restrain patients.

In addition, the physician staffing on Unit 3 Lower were not adequate to address the needs of the patients, to train and support nursing staff, and to provide ongoing assessments. The physician staffing dropped from 32 hours per week to under 15 hours per week when the attending psychiatrist was assigned to cover the forensic unit in the facility in January 2011.

Findings include:

I. Nursing Staffing and Training

A. Record Review

1. Review of the Nursing Needs Assessment dated 04/12/2011 for the 11 patients on Unit 3 Lower revealed the following patient care needs: 11 patients [100%] actively assaultive; 11 patients [100%] on assault precautions; 9 patients [82%] constantly demanding staff time; 6 patients [54.5%] requiring partial assistance when completing self care (includes bathing/hygiene, dressing/grooming, feeding and toileting); 5 [45.5%] requiring total self care assistance; 2 patients [18%] requiring partial assistance with mobility; 2 patients [18%] on seizure precautions; 2 patients [18%] requiring diabetic checks; 1 patient [9%] experiencing hallucinations; 10 patients [91%] taking medications reluctantly; 1 patient [9%] requiring forced medications.

2. Review of the incident reports for Unit 3 Lower during the time frame 01/01/2011-04/07/2011 revealed the following: 32 incidents of peer to peer assaults; 14 incidents of patient to staff assaults; 23 incidents of patient injuries requiring a physician assessment/treatment; 4 incidents of self-injurious behavior; 1 incident of property damage, and 4 incidents of sexually inappropriate behavior.

3. Review of the Seclusion/Restraint Log for 3/26/2011- 04/06/2011 revealed that Unit 3 Lower had 19 occurrences of seclusions, 12 occurrences of physical holds, and 9 occurrences of chemical restraints during this time period.

4. In response to allegations of patient abuse and neglect on Unit 3 Lower, the facility prepared a Plan of Correction which included RN monitoring of the milieu and care given to patients on Unit 3 Lower from 7 AM to 11 PM daily starting 3/18/2011. The RN monitors were rotated from other units of the facility and did not provide direct patient care. Their areas of monitoring included Staff/Patient Interactions, Leisure Activities Offered, Fresh Air Breaks, Training Needs, Equipment Needs and Recommendations. Review of the 3 Lower Monitoring Sheets from 3/20/2011-04/09/2011 revealed the following comments: [dates of observations in parentheses]

a. (03/21/2011) "Entered unit to find staff struggling to gain control over milieu."

b. (03/21/2011) "Need more staff (at least one until bedtime)."

c. (03/22/2011) Written under the Training Needs section, "How to respond to the individual needs of the kids" and "Staff needs training on how to respond to other staff."

d. (03/22/2011) "New staff appears afraid to touch pts [patients], even in appropriate manner."

e. (03/22/2011) "...RN Charge Nurse asked the PSO (Public Safety Officer) to assist in getting the unit under control. The PSO raised his hand and stated he 'could not get involved'."

f. (03/22/2011) "Unit stayed separated this evening due to chaos."

g. (03/23/2011) "Staff spent time monitoring pts but not talking to them much except for giving requests & redirection."

h. (03/23/2011) "Safety needs to be considered for staff & patients;" "Increase staff " and "Charge nurse needs to be in charge of unit ..."

i. (03/25/2011) "More staff for evening (PM) shift...seemed like the staff present couldn't control situations as well as AM shift."

j. (week of 03/21/2011-03/25/2011) "Very confused-staff brought in to help are not being given the opportunity to work with the patients. No staff to pt. interactions other than giving consequences." "Very chaotic and a lot of conflicts between staff." "Program retraining is badly needed." "It appears respect for the Charge Nurse has been demoralized."

k. (03/26/2011) "There were 2-3 pts that were extremely challenging and acting inappropriately. It appeared the staff spent most of their time dealing c/[with] these 2 pts & were unable to interact in any sort of therapeutic manner c/anyone."

l. (03/26/2011) "More licensed staff members [needed]. The RN could not be in all of the places he needed to be. It was exhausting just watching him."

m. (03/27/2011) "Unit D's staff [pulled to work Unit 3 Lower] primary excuse was that they were not familiar with the procedures on this unit. They were not receptive at all to providing any activities or working together with the patients." "PM staff seems to need training in de-escalating disruptive behavior." "It was obvious to me that primary USO [Unit Safety Officer] lacked the necessary training to patiently handle this population."

n. (04/04/2011) "Unit appears disorganized and staff confused." "RN-little interaction unless called by other staff-appeared lost on unit."

o. (04/06/2011) "RN-limited interaction/appears hesitant." "Re-education of staff regarding policy & procedures [needed]. I frequently get response, 'I'm not sure, things change so fast around here'."

p. (04/07/2011) "Real need for continuity of staff all doing & telling the patients the same thing." "RN-scant interaction; indecisive."

5. Review of the document sent to Risk Management on 04/09/2011 by the DON following three days of "rounds" on Unit 3 Lower revealed that staff felt the need for additional training. The DON wrote, "Staff voiced that they were doing their best to maintain a calm and orderly environment. One LPN did voice it was difficult having had little training with working with these particular types of patients. The unit manager and psychologist have provided some training, but more will be needed."

B. Observations

1. Live-feed videos of Unit 3 Lower were viewed on 04/11/2011 and 4/12/2011 in the Risk Manager's conference room. The following incidences were observed:

a. 04/11/2011 at 3:06 PM-Patient L8 reached over the nurses' station counter, opened a drawer and put his hand in it before being stopped by staff.

b. 04/11/2011 at 3:08 PM-Patient L2 reached over the half door of the nurses' station, unlocked it and went into the treatment room behind the station. He was removed from the room and station by Unit Safety Officer 1 [USO].

c. 04/11/2011 at 3:10 PM-The Milieu Coordinator was seen holding Patient L8's wrist as the patient attempted to pull away.

d. 04/11/2011 at 3:36 PM-Patient L2 entered the nurses' station again and went into the conference room. He was led back out by staff.

e. 04/12/2011 at 12:53 PM-Patient L2 entered the nurses' station again and left when re-directed by staff.

2. Observations on 04/11/2011 at 4:10 PM revealed that Patient L10 climbed to the top of the television set in Pod C and refused to get down. The Milieu Coordinator and USO1 attempted to talk him down but were unsuccessful. Public Safety was called and 3 officers responded. RN2 convinced Patient L10 to come down. When Patient L10 walked into the dayroom, he attempted to attack another patient and was physically held by the Public Safety Officer.

C. Interviews

1. In an interview on 04/11/2011 at 2:30 PM, the Risk Manager stated that the facility had recently become aware that the care of patients on Unit 3 Lower was problematic, that 10 staff had been placed on administrative leave due to abuse allegations and that replacement staff had been pulled from other units of the facility. The Risk Manager acknowledged that the facility was attempting to address on-going safety and clinical issues on that unit.

2. In an interview on 4/11/2011 at 3:50 PM, RN3 was asked how she made patient assignments. She replied, "I just tell them [Mental Health Workers and USO] which group they are responsible for. One gets one Pod [sleeping area] and one gets the other Pod. I just tell them, I don't write it down." Review of the assignment sheet revealed that staff was assigned to functions (such as putting out meal trays) and not to specific patients.

3. In an interview on 4/11/2011 at 4:10 PM, USO1 who had used manual restraint on Patient L2 one hour earlier, reported that he had not received any training in intervening with patients on 3 Lower and stated "I didn't think what I did would be considered a manual hold." He acknowledged that he did not report the manual hold as a restraint incident.

4. In an interview on 4/11/2011 at 5:10 PM, when asked about the issues on Unit 3 Lower, the Medical Director stated that the problems "really snuck up on us. We were surprised that all that was going on." The Medical Director stated that he thought the problems stemmed from the patient population changing over time from patients with borderline intellectual functioning to patients with moderate mental retardation without modification of the program or education of the staff. When asked about training of the staff currently working on Unit 3 Lower, the Medical Director stated, "We've done some but need more."

5. In an interview on 4/12/2011 at 1:30 PM, the DON stated, "With most of the regular staff being out on Administrative Leave, it is hard for those being pulled from other units. They know they are being watched and they are scared and don't want to be here."

6. In an interview on 4/12/2011 at 1:45 PM, RN1 stated that she did not assign staff the same way as RN3 [ who assigned them to Pods] but instead assigned them to groups based on location - with one having the group in school and one having the group on the unit. Review of the assignment sheet revealed that staff was assigned to functions (such as putting out meal trays) and not to specific patients. When asked if she had received any training specific to the patient population on Unit 3 Lower, RN1 stated, "Not yet/" RN1 also stated that she had been working on Unit 3 Lower "about a month."

7. In an interview on 4/12/2011 at 2:05 PM, the Unit 3 Lower Milieu Coordinator initially stated that he had not applied a manual hold on the patient the previous day. He then said, "I may have yanked his arm to get him to the bathroom to wash his hands." The Milieu Coordinator acknowledged that he did not report his actions as a manual hold.

8. In an interview on 4/13/2011 at 9:30 AM, RN1 stated, "I have 3 MHWs and a LPN. I'd like another RN. I can't get anything done. They're [staff] always calling 'nurse' because I have to be there when they [patients] start acting up and I must make decisions about giving them medications. It's go, go, go-I'm always documenting something." Observation of the unit at this time revealed that Patient L5 was screaming in seclusion and RN1 was attempting to get an order for medication and seclusion.

II. Physician Staffing

A. Interviews

1. In an interview on 4/11/11 at 5:20 PM, the Medical Director stated, "I think part of the problem with (Unit) 3 Lower started when we decreased the time [doctor's name] spent on the unit earlier this year. [Doctor's name] splits his time with the forensic unit upstairs." When the Medical Director was asked how the unit psychiatrist impacts the milieu of Unit 3 Lower, he responded "The doctor is crucial to that unit (3 Lower) running well; he's the glue that holds the program together."

2. In an interview on 4/12/11 at 1:15 PM, RN3 was asked about a psychiatrist presence on Unit 3 Lower. RN3 stated "We don't see [Doctor's name] much anymore; he's mostly on the forensic unit."

3. In an interview on 4/12/11 at 2:30 PM, MD3 confirmed that he had reduced his hours on Unit 3 Lower from 32 hours per week to fewer than 10 hours per week. MD3 stated, "I don't get to see my patients much anymore; I don't like seeing my unit go downhill." He agreed with the Medical Director's assessment of the relationship between the reduction in physician hours and the decline in focused treatment on Unit 3 Lower.

B. Observation

During observations on 4/11/11 at 11:00 AM and 4/12/11 at 4:00 PM, MD3 was present on Unit 3 Lower only once - 4/12/11 at 2:15 PM. MD3 had come to the unit to perform a one hour face-to-face evaluation and talk with two patients in the day area. During the observation, MD3 stated, "I've been focused on court issues and the forensic unit lately and haven't been here (Unit 3 Lower) much."













21993

Based on observation and interviews the facility failed to provide psychology services to meet the patient needs on Unit 3 Lower, failed to provide adequate supervision for a unit psychologist, and failed to intervene when the unit psychologist asked for additional training and supervision in the care of intellectually challenged/psychiatrically ill adolescents. On at least one occasion observed on the hospital videotape, the facility allowed the psychologist to work in an isolated setting potentially dangerous to the safety of the psychologist and the patient population. The unit psychologist had asked for supervisory help and training in dealing with this special population and had not received any additional training as of the date of the survey, 4/12/11.

Findings include:

A. Observation

On 4/11/11 at 11:00 AM, the surveyors reviewed an archived digital video of PhD1 leading an insight oriented group therapy session with 5 patients on unit 3 Lower on 4/5/11. During the group session, PhD1 was unable to deescalate two of the patients, This led to one child throwing a notebook at another child. The psychologist called for help over the surveillance system (no other staff were present in the pod area where the session was occurring). There was a delay in staff responding to the situation because the psychologist had locked the pod area door that leads to the day area where other staff were present.

B. Interviews

1. In an interview on 4/11/11 at 5:20 PM, the Medical Director informed the surveyors that PhD1 had asked for additional clinical supervision from her director in March 2011 because of the staffing changes on Unit 3 Lower, the line staff's (nursing and program) inconsistent application of the unit behavioral program, and PhD1's difficulty with getting staff trained and implementing the program.

2. In an interview on 4/12/11 at 9:25 AM, the Clinical Director acknowledged that PhD1 had asked for additional clinical supervision in March 2011 and stated, "I've haven't done any supervision with [PhD1]." The Clinical Director was asked if it was his responsibility to assure that PhD1 received additional supervision and/or training. He stated "I guess so." When the Clinical Director was asked if he was responsible for the implementation and monitoring of the behavioral treatment program on Unit 3 Lower, he stated "Yes." He was then asked whether he had actively monitored the behavioral program over the last two months; he stated "No."

3. In an interview on 4/12/11 at 10:15 AM, PhD1 was asked about her role on Unit 3 Lower. PhD1 acknowledged that she had asked for increased supervision from her supervisors in March 2011. She stated that the additional supervision had not occurred as of the time of the survey (4/13/11). PhD1 reported that the current unit-wide treatment needed to be reviewed and revised because of inconsistent staff execution of the plan. She stated "With all the new staff on the unit, there hasn't been enough training to make sure people know what to do for the kids."

4. In an interview on 4/12/11 at 1:30 PM, PhD2 (PhD1's direct supervisor) was asked if she was aware that PhD1 had requested additional training and supervision because of problems on Unit 3 Lower. PhD2 responded that she was aware of PhD1's request. She then added, "But I haven't done anything about it yet."












21993

Based on observation, document review and interviews, the facility failed to plan and implement an adequate structured program of therapeutic activities to address the special needs of 11 of 11 active sample patients on the Unit 3 Lower (L1, L2, L3, L4, L5, L6, L7, L8, L9, L10 and L11). These patients were adolescents who had dual diagnoses (intellectual impairment/psychiatric illness) who needed a high level of structure for therapeutic programming. The lack of structured therapeutic activities contributed to a chaotic milieu. Failure to provide adequate structure for this special population of patients results in inadequate treatment, that can lead to prolonged hospitalization.

Findings include:

A. Observations

1. During the survey, various observations were made by the surveyors between 1:00 PM and 5:00 PM on 4/11/11 and on 4/12/11 from 9:00 AM to 10:30 AM and 1:00 PM to 4:30 PM. During these times the surveyors observed the recreation therapist on Unit 3 Lower only once - at 3:30 PM on 4/11/11, playing basketball with the patients.

2. Live-feed videos of Unit 3 Lower were viewed on 04/11/2011 and 4/12/2011 in the Risk Manager's conference room. The following incidences were observed:

a. 04/11/2011 at 3:06 PM-Patient L8 reached over the nurses' station counter, opened a drawer and put his hand in it before being stopped by staff.

b. 04/11/2011 at 3:08 PM-Patient L2 reached over the half door of the nurses' station, unlocked it and went into the treatment room behind the station. He was removed from the room and station by Unit Safety Officer 1 [USO].

c. 04/11/2011 at 3:10 PM-The Milieu Coordinator was seen holding Patient L8's wrist as the patient attempted to pull away.

d. 04/11/2011 at 3:36 PM-Patient L2 entered the nurses' station again and went into the conference room. He was led back out by staff.

e. 04/12/2011 at 12:53 PM-Patient L2 entered the nurses' station again and left when re-directed by staff.

3. Observations on 04/11/2011 at 4:10 PM revealed that Patient L10 climbed to the top of the television set in Pod C and refused to get down. The Milieu Coordinator and USO1 attempted to talk him down but were unsuccessful. The Public Safety office was called and 3 officers responded. RN2 convinced Patient L10 to come down. When Patient L10 walked into the dayroom he attempted to attack another patient and had to be physically restrained by the Public Safety Officer.

B. Document Review

In a summary document submitted by Nursing Staff Monitors assigned to observe and report findings about the milieu on Unit 3 Lower between 3/19/11 and 3/31/11, the following notes were recorded under the section titled "Equipment/Activities":

1. "Need more activities for the patients-games, quiet games."
2. "Incorporate more fresh air breaks."
3. "Kids need something constructive to do when school is not in session."
4. "Need more visual aids-something that helps kids transition from one activity to another."
5. "These boys need more physical activities. They need more room to move around."
6. "Offer arts and crafts. All the boys seem to love to color and draw."
7. "Need more individualized activities. This group does not interact well with each other."
8. "Patients state they are bored. Need more organized activities."

In the same document noted above, the nurse monitors noted the chaos of the unit with the following observations:

1. "Charge nurse asked PSO (Public Safety Officer) to assist in getting the unit under control. The PSO stated he could not get involved.
2. "Unit needs a secluded area or more walls around nursing station. Noticed patients constantly reaching over the counter and continuously unlocking the gate to the nursing station."
3. "Poor control of unit."
4. "Entered unit to find staff struggling to gain control over milieu."
5. "Unit appears disorganized and staff confused."

C. Interview

1. In an interview on 4/12/11 at 10:15 AM, PhD1 stated that there were not enough structured activities for the special population of patients on the Unit 3 Lower.

2. In an interview on 4/12/11 at 1:30 PM, PhD2 stated, "The recreation therapist might spend about 5 hours a week on (Unit) 3 Lower." When asked if she thought this was an adequate number of hours given this patient population, she stated "No."

3. In an interview on 4/12/11 at 2:30 PM, MD3 stated that the recreation therapist was shared with two other adolescent units of the facility and spent very little time on the Unit 3 Lower. He noted that patients on the dual diagnosis unit (Unit 3 Lower) needed more structured activities than other types of patients in the facility.