HospitalInspections.org

Based on observations, policy reviews, interviews and record reviews the facility:

- failed to ensure patients and visitors were provided full disclosure of monitoring cameras located in the patient seclusion room of the Behavioral Health unit
- failed to ensure patient's rights to privacy is protected in the intensive care unit by allowing a physician to dictate personal patient information in the hallway of the unit
- failed to provide a safe environment on the Behavioral Health unit by allowing non-suicide-resistant shower water control knobs and non-suicide-resistant toilet and sink plumbing in eight of sixteen patient bathrooms. The configuration of these water control knobs, toilets and sinks creates a looping hazard for all patients on the unit
- failed to protect a patient on 1:1 observation from falling by not observing the patient on a 1:1 basis, which resulted in a patient fall and injury
- failed to reassess the risk of suicide for a patient who made an active suicide attempt on the unit
- failed to immediately investigate abuse allegations for two patients
- failed to appropriately assess three patients following abuse allegations
- failed to protect all patients in the facility by not removing three alleged perpetrators from patient care immediately following abuse allegations
- failed to follow the facility abuse investigation policy
- failed to protect patient confidentiality of medical records by maintaining records with patient identifiers inside patient rooms
- failed to obtain physician's orders for physical hold restraints
- failed to provide face to face assessments within one hour of the initiation of a restraint
- failed to ensure all components of a face to face evaluation following a restraint episode are addressed by the physician and
- failed to report a restraint related death to CMS by the end of the next business day following the death.

The cumulative result of these findings resulted in noncompliance with the Condition of Participation: Patient's Rights.

This systematic failure placed patients at continued risk and in immediate jeopardy to their health and safety. The facility submitted an acceptable plan and hospital staff implemented procedures to abate the immediate jeopardy by the time of exit.

The facility had a census of 145.

Findings included:

Based on observation and interview the facility failed to ensure patients and visitors were provided full disclosure of monitoring cameras located in the patient seclusion room of the Behavioral Health unit and the facility failed to ensure patient's rights to privacy is protected in the intensive care unit (ICU) by allowing a physician to dictate personal patient information in the hallway of the unit. The hospital had a census of 145 and the unit had a census of 22.

Findings included:

1. Observation on 05/25/10 at 9:15 a.m. on the behavioral health unit showed a ceiling mounted camera device monitoring the patient seclusion room. Observation of the unit showed no signage informing anyone of possible video monitoring.

During an interview on 05/28/10 at 11:20 a.m. the Director of the unit, Staff GG said the ceiling mounted camera is operational and there is no signage informing any patients of possible camera monitoring. Staff GG said the consent forms the patients sign on admission do not inform the patients or patient's families that they could be monitored on camera if they are in the seclusion room.

2. Observation on 05/27/10 at 1:45 p.m. in the intensive care unit (ICU) showed physician JJ standing in the hallway inside the entry doors dictating notes regarding an ICU patient. Standing approximately six feet away from Physician JJ were three family members of another ICU patient. This surveyor stood at the nurse's station approximately 12 feet away from Physician JJ and heard the physician dictate patient information.

During an interview on 05/27/10 at 1:50 p.m. unit secretary Staff AAA said Physician JJ dictates all his/her notes in the hallways of the unit.

During an interview on 05/27/10 at 1:55 p.m. Physician JJ said he/she dictates patient information in the hallway because there is no private place to dictate the patient visits. Physician JJ said he/she is a hospitalist and routinely dictates in the hallway. Physician JJ said he/she was not aware visitors were standing behind him/her while he/she was dictating patient information.

Based on observation, interview, policy review and record review the facility failed to:
-Provide a safe environment for 22 of 22 patients on the Behavioral Health unit by allowing non-suicide-resistant shower water control knobs and non-suicide-resistant toilet and sink plumbing in eight of sixteen patient bathrooms. The configuration of these water control knobs, toilets and sinks creates a looping hazard for all patients on the unit.
- Protect one of one patient (#52) on 1:1 observation from falling by not observing the patient on a 1:1 basis as ordered by the physician and as indicated by the patient's condition.
- Reassess the risk of suicide for one of one patient (#49) who made an active suicide attempt on the unit.
The facility had a census of 145 and the unit had a census of 22.
Findings included:
1. Observation on 05/25/10 of the Behavioral Health unit showed the following patient safety issues:
Rooms 333; 354; 355; 356: The showers have regular shower water control knobs, which protrude from the wall approximately two inches and the toilets have exposed plumbing.
Rooms 334 and 335: The rooms have regular shower water control knobs, toilets with exposed plumbing and sinks with exposed plumbing.
Rooms 343 and 351: The toilets have exposed plumbing.

Observation showed all sixteen patient rooms are unlocked and patients have access to their rooms and bathrooms without constant monitoring by staff.
During an interview on 05/25/10 at 9:00 a.m. the unit nurse manager Staff FF said that some of the patient rooms have toilets and sinks without suicide prevention plumbing.
During an interview on 05/25/10 at 11:30 a.m. the Program Director, Staff GG said that patients are allowed to go to their rooms if not in groups or working with staff. Staff GG said staff does not monitor patients while in their bathrooms.
Review of the patient census for 05/25/10 showed on admission staff assessed 16 of the current 22 patients as suicide risks ranging from low to moderate risks.
During an interview on 05/26/10 at 3:10 p.m. the chief operational officer (COO) Staff E said the facility has identified not all patient rooms have suicide prevention plumbing. Staff E provided a copy of an e-mail addressed to the Behavioral Health program director and nurse manager dated 03/26/10. The document identifies six patient rooms and informs staff, "It is a list of rooms that we will designate as the suicide precaution rooms along with a list of issues to be addressed in each room. We will be able to tell the Joint [Joint Commission on Accreditation of Healthcare Organizations] that we have identified these rooms for high risk patients and are working toward making all rooms meet those standards as part of our continuous quality improvement plan." The COO said that the facility has no time frame for the additional patient rooms to be outfitted with suicide prevention plumbing. The COO said the facility is opening an adolescent psychiatric unit and will outfit the existing [adult] unit when they prepare the space for the new unit.
2. Review of facility policy "Patient Sitters/Close Observation" dated 05/01/10 showed the purpose of the policy is to promote the safety of patients who present a likelihood of harm to themselves or others, whether intentional or unintentional, patient sitters/close observation (often referred to as 1:1) may be required. This policy provides the guidelines for the use of patient sitters/close observation. The policy defines sitter as personnel assigned to care for an identified patient who is [in] need of bedside visual monitoring to prevent injury to self or others.
Procedure section V.E. (4) shows sitters may not leave the patient unless directed or permitted to do so by the Primary RN (registered nurse) caregiver of Charge Nurse who shall be responsible to provide appropriate coverage during sitter absence. Section V.E. (8) shows sitters shall not leave the patient alone. Sitters must coordinate breaks and meals with the primary caregiver and/or Charge Nurse so as to provide continuous visual monitoring of the patient requiring the sitter.
Review of the history and physical for current Patient #52 showed the patient entered the facility 05/14/10 for medical and psychiatric assessment, monitoring and treatment.
Review of progress notes dated 05/17/10 at 2:25 p.m. showed Patient #52 is unsteady on feet. Progress notes dated 05/18/10 at 10:40 a.m. showed, "Pt. (patient) up by nurses station, very unsteady gait." Staff notified physician and received order to put patient on 1:1 observation. Progress notes dated 05/18/10 at 8:00 p.m. showed patient laying [lying] in bed with 1:1 staff at bedside ...gait unsteady, no falls seen or reported.
Review of a physician's order dated 05/18/10 showed an order for 1:1 nursing.
Progress notes dated 05/19/10 at 9:56 a.m. showed in part, "patient remains on 1:1 because of unsteady gait." A progress note written by the physician on 05/19/10 at 6:40 p.m. showed in part, "requiring 1:1 to prevent falls."
Review of a progress note written by licensed practical nurse (LPN) staff ZZ on 05/19/10 at 8:30 p.m. showed in part, "VERY (Staff ZZ's punctuation) unsteady gait, lethargic and sedated. Cont. (continue) on 1:1 observation. Also continue on safety, seizure and high fall risk. Will continue to monitor." Progress note dated 5/19/10 at 11:20 p.m. written by Staff ZZ showed, "Found pt (patient) in bathroom, bleeding from 3 cm (a unit of length) laceration above R (right) eye by this nurse returning from emergency on unit. Bleeding controlled, steri strips applied. VS (vital signs) stable. Pt denies pain. Gait remains unsteady. Will continue 1:1 monitoring."
During an interview on 05/25/10 at 10:30 a.m. the behavioral health nurse manager Staff FF said he/she has not talked with LPN Staff ZZ to discuss him/her leaving the patient alone when patient was unsteady on his/her feet and the physician ordered staff to be with patient on a 1:1. Nurse manager Staff FF said, "Staff should not leave the room. I haven't met with the nurse regarding this, I just haven't had time."
3. Review of the facility policy, "Suicide Risk Assessment" last reviewed 03/09 showed the purpose is to provide an in-depth Suicide Risk Assessment to all patients admitted to the facility identified as a member of a high risk population and whose primary illness requiring further treatment is Psychiatric. The policy defines high risk population as patients with a reported history of psychiatric illness, patients with a reported history of substance abuse, any patient complaining of depression, verbalizing suicidal ideations or requesting help for mental issues and any patient who has exhibited self-injurious behavior. The policy states all patients admitted to the facility whose primary illness is psychiatric, identified as high risk, will have an in-depth Suicide Risk Assessment upon admission and prior to discharge.
Review of the facility policy, "Assessment/Reassessment" last reviewed 05/01/10 shows in part that the scope of assessment and reassessment is determined by the patient's diagnosis, the treatment setting, the patient's desire for treatment and the patient's response to treatment. Reassessment is based upon but not limited to: 1. Systems status related to the diagnosis, patient care needs or problem identification, response to treatment/interventions. 2. Inpatients are reassessed, every shift or with a change in patient condition, transfer to another unit, transfer to a higher level of care or post-operatively and as needed.
Review of the history and physical dated 05/07/10 for current Patient #49 showed the patient entered the facility on 05/06/10 for treatment of schizoaffective disorder (a combination of schizophrenia symptoms - such as hallucinations or delusions - and of mood disorder symptoms, such as mania or depression) and behavioral problems. Review of the psychiatric admission note dated 05/07/10 showed prior to this admission Patient #49 attempted suicide by trying to hang self with a water hose.
Review of the suicide risk assessment completed on admission showed the patient as a low risk for suicide with a score of 6. The suicide risk assessment lists scores of 7-15 as low.
Review of progress notes dated 05/21/10 show Patient #49 placed in seclusion due to violent behavior toward staff. Notes document staff observed patient in seclusion room take the sheet from the bed and wrap the sheet around his/her neck.
During an interview on 05/27/10 at 10:55 a.m. registered nurse Staff Z said a suicide risk assessment is done only at the time of admission and prior to discharge. Staff Z said if a patient attempts to harm themselves on the unit, no additional suicide risk assessment is completed by the staff. Staff Z said he/she is aware Patient #49 took the sheet from the seclusion room bed and wrapped it around his/her neck. Staff Z said, "Maybe staff should have reassessed the patient after he/she wrapped the sheet around his/her neck." Staff Z said he/she returned Patient #49 to his/her room when the patient calmed down and the patient went to bed and slept. Staff Z said Patient #49 had a sheet on the bed in the patient room.
During an interview on 05/28/10 at 11:05 a.m. registered nurse Staff XX said a suicide risk assessment is completed by the nursing staff on admission and at discharge. Staff XX said a reassessment is not done during the course of the hospital stay.
During an interview on 05/28/10 at 11:30 a.m. Physician II said he/she thinks Patient #49 putting the sheet around his/her neck was attention seeking but because of the patient's low mental functioning he/she puts self at risk and needs more attention/supervision.

Based on policy review, record review, interview and document review the facility failed to immediately investigate an abuse allegation for two patients (#49 and #4), failed to appropriately assess three patients (#49, #46 and #4) following abuse allegations, failed to protect all patients by not removing two alleged perpetrators (Staff DD, Staff HH and Staff BB) from patient care immediately following an abuse allegation, and failed to follow the facility abuse investigation policy. The facility had a census of 145.
Findings included:
Review of facility policy, "Neglect and Abuse of Patients/Grievance Procedure" last reviewed 9/09 showed the facility will work to provide a safe and secure environment for its patients. It is the policy of the facility to provide a system to support and respond to allegations should there be a breach in that safe environment.
The following criteria will constitute neglect and abuse of patients by staff:
-Physical, verbal or psychological abuse or retaliation
-Ignoring patient needs, wants and desires
-Sexual and/or seductive behavior and/or exploitation
-Failure to provide scheduled treatment
-Infringement on patient's rights and responsibilities
-Unauthorized release of information about the patient

Further review of the policy shows in part, the procedure for patient grievances is:
-Should a patient feel that he/she or any family member or friend visiting the facility has been neglected or abused during the stay, he/she shall report this to a staff member who will in turn report the incident to the Patient Advocate and immediate supervisor.
-The immediate supervisor shall be responsible for reporting the incident to the appropriate hospital personnel (i.e., Risk Management, Administration, etc)
-The patient initiating the complaint will be informed of the disposition within two (2) days.
-In all cases, staff will follow all state laws regarding the appropriate reporting of abuse or neglect.
-While investigation is being conducted, patient care giver involved will not be allowed to give patient care until issue is resolved.

Review of the facility policy, "Assessment/Reassessment" last reviewed 5/01/10 shows in part that the scope of assessment and reassessment is determined by the patient's diagnosis, the treatment setting, the patient's desire for treatment and the patient's response to treatment. Reassessment is based upon but not limited to: 1. Systems status related to the diagnosis, patient care needs or problem identification, response to treatment/interventions. 2. Inpatients are reassessed, every shift or with a change in patient condition, transfer to another unit, transfer to a higher level of care or post-operatively and as needed.
1. Review of the history and physical dated 5/07/10 for current Patient #49 showed the patient entered the facility on 05/06/10 for treatment of schizoaffective disorder (a combination of schizophrenia symptoms - such as hallucinations or delusions - and of mood disorder symptoms, such as mania or depression) and behavioral problems.
Review of the progress notes dated 05/22/10 at 2:25 p.m. showed Patient #49 informed registered nurse (RN) Staff CC a security guard choked him/her the previous evening. The patient demonstrated for the RN how the security guard choked him/her. The patient described how the security guard looked and said he/she wanted a police report filed. Staff CC documented he/she called the nurse manager and reported the allegation of choking.
Progress notes dated 05/22/10 at 3:30 p.m. showed Patient #49 informed Staff CC a nurse on the night shift slapped him/her in the face. There is no documentation that Staff CC reported this allegation of abuse to anyone. There is no documentation in the record of staff assessing Patient #49 for any injury to the face.
During a telephone interview on 05/26/10 at 12:20 p.m. security guard staff HH said he/she assisted staff on the behavioral health unit to hold Patient #49 on 05/21/10. Staff HH said the patient was spitting on staff and out of control. Staff HH said he/she and other staff walked the patient to the seclusion room. Staff HH said he/she took a hold of the patient's face so the patient couldn't turn his/her head to spit at anyone. Staff HH denied holding the patient around the neck. Staff HH said someone, could not remember who, told him/her there had been a problem with Patient #49 saying someone had choked the patient. Staff HH said the facility never suspended him/her and he/she continued to work.

During an interview on 05/27/10 at 9:00 a.m. Certified Nursing Aide (CNA) Staff BB said he/she has worked in the behavioral health unit on the night shift for six years. Staff BB said when he/she came on duty at 7:00 p.m. on 05/21/10 several staff members were standing in the doorway to Patient #49's room talking with the patient. Staff then walked the patient to the seclusion room where the patient continued to be out of control and spit on staff. Staff BB went to the nurses' station and saw on the monitor that Patient #49 had taken the sheet from the bed in the seclusion room and wrapped it around his/her neck and was pulling on both ends of the sheet, choking him/herself. Staff BB said security and other staff members entered the seclusion room and removed the sheet from the patient's neck and from the room. During this episode Staff BB said Patient #49 spit on CNA staff DD, who then slapped the patient on the left side of the face. Staff BB said he/she did not tell Staff DD to leave the room and no one in the room redirected Staff DD. Staff BB said RN Staff CCC was pouring medication and he/she told staff CCC about the slap but staff CCC did not respond.

Staff BB said he/she did not report the incident to anyone else and the next day called the CNA Staff DD and told him/her the incident needed to be reported.

During an interview on 05/27/10 at 9:30 a.m. registered nurse Staff CC said he/she has worked on the behavioral health unit for ten years and was the nurse manager on the unit for over five years until 12/09. Staff CC said on 05/21/10 around change of shift, approximately 7:00 p.m., Patient #49 was spitting on staff and staff had to physically restrain the patient. Staff CC said he/she gave the patient an injection to calm the patient down. Staff CC said he/she told the staff to take the patient to the seclusion room. Staff CC said the night shift nurse Staff CCC told the staff not to take the patient to the seclusion room. Staff CC said the next day Patient #49 said a security guard choked him/her the previous night shift (05/21/10). Staff CC said he/she asked the RN who had the patient the night before (Staff Z) if a security guard had choked the patient and the nurse told Staff CC who the security guard was and that, "He/she wouldn't do that." Staff CC said he/she spoke with (CNA) Staff DD who cared for Patient #49 on the night of 05/21/10 and the CNA said he/she did slap Patient #49 and would inform the nurse manager.
Staff CC said he/she did not follow up with the nurse manager to see if the CNA Staff DD reported the patient abuse. Staff CC said ,"I don't know what the policy is when there is an allegation of abuse." Staff CC said he/she is a mandated reporter but never thought about reporting the conversation with the CNA, Staff DD to anyone. Staff CC said, "I was too busy."
During an interview on 05/27/10 at 10:55 a.m. registered nurse Staff Z said he/she was the nurse assigned to Patient #49 on the night of 5/21/10. Staff Z said he/she heard report on the patient and at approximately 7:35 p.m. went to the seclusion room, unlocked the door and took the patient to his/her room. Staff Z said no staff informed him/her that anyone slapped or choked Patient #49 until the next day when he/she received a call from registered nurse Staff CC. Staff Z said the patient never reported any abuse to him/her.

During an interview on 05/27/10 at 1:05 p.m. CNA Staff AA said he/she has worked on the behavioral health unit for eight years. Staff AA said on the late afternoon of 5/21/10 Patient #49 spit on him/her and the patient's behavior was out of control. Staff AA said he/she and other staff members held the patient down so the nurse could give the patient a shot. Then he/she and other staff walked the patient to the seclusion room where the patient continued to fight with the staff. Staff AA said staff monitored Patient #49 while in the seclusion room by watching the camera monitor at the nurse's station. Staff AA said they saw the patient take the sheet from the bed and wrap it around his/her neck and tie the sheet. Staff AA said he/she and other staff members unlocked the seclusion room and removed the sheet from the patient's neck and from the seclusion room. Staff AA said while in the seclusion room removing the sheet from the patient's neck, Patient #49 spit on CNA Staff DD and Staff DD slapped the patient in the face. Staff AA said Staff DD, CNA told the patient he/she was sorry but stayed in the seclusion room. Staff AA said none of the staff members in the seclusion room who saw the slap intervened and removed Staff DD from the room or said anything to Staff DD about the slap. Staff AA said, "We are supposed to report abuse. It didn't register until after the fact that I should report it."

During a telephone interview on 05/27/10 at 2:10 p.m. CNA Staff DD said he/she has worked on the behavioral health unit for five years and worked the day shift on 05/21/10. Staff DD said Patient #49 went to his/her room, was angry and physically violent with staff. Registered nurse Staff CC gave the patient a shot while other staff physically restrained the patient. Staff DD along with several other staff members walked the patient to the seclusion room. The staff left the patient in the seclusion room, locked the door and Staff DD returned to the nurse's station. Staff DD saw on the camera monitor that Patient #49 took the bed sheet and wrapped it around his/her neck and was pulling on each end of the sheet to tighten it around his/her neck. Staff DD, along with other staff members returned to the seclusion room and in the course of removing the sheet from the patient's neck, the patient spit on Staff DD. Staff DD said, "He/she spit on me and I popped him/her in the mouth." Staff DD said the staff held the patient for approximately five to eight minutes, then left the seclusion room, locking the door behind them. Staff DD said he/she remained on the unit for ten minutes and then left for the day. Staff DD said he/she worked the next day and worked with Patient #49 and other patients.

Staff DD said he/she informed registered nurse Staff CC the next day he/she had slapped Patient #49. Staff CC directed Staff DD to call the nurse manager and the nurse manager suspended staff DD. Staff DD said, "I should have called my supervisor and reported the incident when it happened. I don't think I hurt him/her."

Review of the facility time sheet for 05/21/10 showed security officer Staff HH worked from 5:45 p.m. until 5:15 a.m. on 05/22/10. Staff HH worked 05/23/10 from 5:45 p.m. until 10:15 p.m. Staff HH worked 05/24/10 from 10:00 p.m. until 6:00 a.m. on 05/25/10. Review of the personnel record showed facility did not suspend Staff HH during the investigation of the alleged choking incident.

During an interview on 05/27/10 the chief nursing officer, Staff C said the facility did not suspend security officer, Staff HH during the investigation.

Review of the facility investigation dated 05/27/10 showed the following actions:
-Immediate (05/27/10) termination of CNA Staff DD.
-24 hour suspension without pay for registered nurse Staff CC.
-24 hours suspension without pay for registered nurse Staff CCC.
-Suspension of Staffs AA and Z.
-No disciplinary taken for Staff BB. Facility did coaching and education with employee.

2. Record review for discharged Patient #46 showed the patient entered the facility on 04/07/10 with depression, suicidal thoughts, stress and history of colon cancer in remission. Review of the progress notes dated 04/07/10 at 3:15 a.m. showed the patient is a 96 hour hold (ordered involuntarily by court to hospital for treatment). Progress notes show, "Pt (patient) has bruises on neck and R (right) elbow arm area, he/she states were made by the security guard at North campus."
Review of photographs in the record show bruising on neck. The photograph does not document which side of the neck the bruising is on. An additional photograph shows a large purple colored bruise approximately 2-3 cm (length of measurement) in length on the right elbow.
Review of the physician's progress note dated 04/09/10 show the patient's mother called the physician and reported that the patient had been assaulted by a security officer on the unit (behavioral health). The physician spoke with the patient, who clarified the alleged assault took place in the emergency room on admission. The patient said he/she had to be subdued by staff and security, restrained on the ground and had hands around his/her neck. Patient #46 told the physician he/she felt uncomfortable with the Port-A-Cath (a small medical appliance surgically inserted under the skin usually in the right upper chest wall to permit repeated access to the venous system for the delivery of medications, fluids, and nutritional solutions and for the sampling of venous blood), from which he/she had prior chemotherapy for colon cancer. The physician documented no swelling at the Port-A-Cath site and some superficial redness along the left side of the neck and right upper chest wall.
The physician discharged the patient on 04/09/10. No documentation is found in the record of any daily assessment of the patients' neck and elbow bruises or reassessment of the Port-A-Cath area on the chest.
No documentation is found in the record of an investigation regarding the allegations by the patient on admission.
During an interview on 05/26/10 at 11:45 a.m. the nursing director of the emergency department (ED), Staff EE said, "I don't know if he/she had the marks on the neck when he/she came in." Staff EE said the patient had been in a physical altercation with family members prior to coming to the hospital.
During an interview on 05/26/10 at 4:05 p.m. security officer Staff DDD said he/she was called to the ED on 04/07/10 to help with a physically aggressive patient. Staff DDD said the staff informed him/her the patient had been in a fight with family members prior to his/her arrival at the hospital. Staff DDD said the patient refused to give the staff a cell phone. Staff DDD said he/she assisted ED staff in physically restraining the patient but did not place his/her hands on the patient's neck. Staff DDD said the patient dropped the cell phone to the floor. Staff DDD said he/she later transported the patient to the other hospital campus. Staff DDD said the facility patient advocate contacted him/her and said the patient had filed a complaint. Staff DDD said he/she was told to go to the police department and make a statement, which he/she did.
Staff DDD said the facility did not suspend him/her.
Review of the security work schedule shows Staff DDD worked on 04/08/10 from 10:00 p.m. until 6:30 a.m. on 04/09/10.
During an interview on 05/27/10 at 1:40 p.m. the chief nursing officer Staff C said the emergency department nurse manager handled this incident but it was his/her understanding the patient had the bruises from a family argument prior to coming into the hospital.

























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3. During interview on 05/28/10 at 8: 20 a.m., CNA BB reported the incident of Patient #4, who had accused CNA BB of patient sexual molestation on 12/16/09. CNA BB always worked the night shift. CNA BB stated that he/she had reported the allegation to the Social Worker (Staff NN), as soon as possible. CNA BB stated he/she had expected the nursing staff to document reports because, "They heard it all." CNA BB also stated that he/she continued to work three more nights before being put on Administrative Leave (off work with pay). CNA BB stated that he/she did not remember any abuse/ neglect training by the facility within the past year.
During phone interview on 05/26/10 at 2:00 p.m., the Social Worker, Staff NN stated that the report had been relayed to the Director of the Behavior Health Unit. Staff NN also stated that it is not a responsibility of the staff Social Worker to report any further outside of the facility. Staff NN also knew that the alleged perpetrator had worked additional shifts after the report(s) had been filed.
Staff NN stated that he/she had been employed at this facility for more than four years; and he/she did not remember any formal training from the facility regarding abuse and neglect.
Review of the staff schedule for the Behavior Health Unit showed that Staff BB worked 12/17, 12/21, 12/22, 12/25, 12/28, 12/29, 12/30, 12/31/09 and 01/04, 01/05, 01/06, 01/07/10.
Review of Staff NN and CNA BB ' s employee files both showed signatures that they had attended and experienced the Annual Skills Fair held in April of 2010, which included a segment on abuse and neglect.
During interview on 05/28/10 at 1:00 p.m., the Chief Nursing Officer, Staff C, stated that the Director of Behavior Health had been terminated because of this event his/ her lack of reporting this case; and that CNA BB had been put on Administrative Leave as soon as upper management got the report by 12/23/09.
Record review for Patient #4, admitted 12/14/09 for bipolar disease and manic behavior, showed that the allegation was documented and the staff had called the Emergency Department to inquire about a rape kit. The physician on call replied to them that the results would not be accurate because the patient was on menstrual cycle at the time and that the patient's need was "not an Emergency Department need". The patient was not examined or assessed by a physician at that time.
During interview on 5/27/10, at 1:00 p.m., the Emergency Room physician, Dr X, stated "I don't know why they didn't just bring {him/her} over here. They usually do. We never saw the patient that time."
During interview on 5/26/10 at 11:35 a.m., the gynecologist who had been consulted for examination and assessment of the patient, stated that Patient #4's appointment was conducted on 12/28/10, more than 10 days after the alleged incident. On 12/28/09, the results of the examination were inconclusive. Dr. X stated that the patient had two small skin tears, but that the tears did not look ten days old; nor could a conclusive determination be made because the alleged event had happened so long before. The physician office conducted a pregnancy test, which returned with negative results.
During interview on 5/28/10 at 1:00 p.m., the CNO (Chief Nursing Officer) stated "no one took her seriously".

Based on observation, interview and record review facility staff failed to protect the confidentiality of patient medical records by maintaining paper I&O (Intake and Output) vital signs and flow sheets in folders on an open shelf inside the patient's room by the entry door, making the folders readily assessable to visitors and/or anyone entering the patients' room on the Pediatric, the 4th floor wing, and the 200 hall. The facility census was 145 patients.

Findings included:

1. Facility policy titled "Confidentiality of Information", effective 05/14/10 states on page 1 of 2, "Information known or contained in the patient's medical record shall be treated as confidential and will be released in appropriate curcumstances only with the written consent of the patient or legal guardian".

2. Observation on 05/26/10 at 11:00 a.m. in the 100 hall (Pediatric) unit revealed staff stored plastic colored folders (large enough to hold eight and a half by eleven sheets of paper) inside each patient door on an open shelf.

3. Record review of one patient's folder revealed several documents with information including I&O sheets, with patient name, date of birth and other identifying information.

4. During an interview on 05/26/10 at 11:05 a.m. Staff U, registered nurse (RN) stated the following:
-always kept folders in room
-guess never thought about information kept in them
-use to keep track of patient's I&O

5. Observation on 05/26/10 at 11:30 A.M. in the 400 hall (Progressive Care) unit revealed staff stored plastic colored folders (large enough to hold eight and a half by eleven sheets of paper) inside each patient door on an open shelf.

6. Record review of one patient's folder revealed several documents with information including I&O sheets, charge slips and 24 hour flow sheet with patient name, date of birth and other identifying information.

7. During an interview on 05/26/10 at 11:45 A.M. Staff T, RN verified the contents in the folders in the patient rooms.




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Observations on 05/25/10 between 10:20 a.m. and 11:30 a.m. on the 200 hall (Medical) unit showed staff stored colored plastic folders inside patient doors on a built-in wooden shelf.
8. Patient # 11 had a folder on the shelf inside the patient's room containing an Intake and Output record, and a Certified Nurse's Aide (CNA) Flow sheet. Both documents had the patient's name and date of birth, and were accessible to anyone on the nursing unit.
9. Patient #13 had a folder on the shelf inside the patient's room containing an Intake and Output record, and a CNA Flow sheet. Both documents included the patient's name and date of birth, and were accessible to anyone on the nursing unit.
10. Patient #9 had a folder on the shelf inside the patient's room containing a 24 Hour Nursing Flow Sheet. The document included the patient's name and date of birth, and was accessible to anyone on the nursing unit.
11. Patient #14 had a folder on the shelf inside the patient's room containing a 24 Hour Nursing Flow Sheet. The document included the patient's name and date of birth, and was accessible to anyone on the nursing unit.
12. Patient #10 had a folder on the shelf inside the patient's room containing a 24 Hour Nursing Flow Sheet. The document included the patient's name and date of birth, and was accessible to anyone on the nursing unit.
13. Patient #15 had a folder on the shelf inside the patient's room containing a 24 Hour Nursing Flow Sheet. The document included the patient's name and date of birth, and was accessible to anyone on the nursing unit.
Staff O, Registered Nurse Manager of 200 Hall said during an interview on 05/25/10 at 11:30 a.m. that Intake and Output Records are kept in the patient rooms. The CNA's are supposed to keep the CNA Daily Flow Sheet with them. The 24 Hour Nursing Flow Sheets are not to be kept in the patient rooms.

Based on policy review, record review and interview the facility failed to obtain physician's orders for physical hold restraints for two patients (#49 and #46) of six restraint records reviewed. The facility had a census of 145.

Findings included:

Review of facility policy "Restraint and Seclusion" last revised 07/09 shows the definition of restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient of move his or her arms, legs, body, or head freely.

Further review of the policy shows for behavioral health restraint and seclusion if the safety of the patient, staff or others is at jeopardy, a registered nurse may initiate restraint or seclusion in advance of the physician's order. Immediately after the initiation of restraint or seclusion, the registered nurse shall consult with a responsible physician about the patient's physical and psychological status and obtain an order.

1. Review of the history and physical dated 05/07/10 for current Patient #49 showed the patient entered the facility on 05/06/10 for treatment of schizoaffective disorder (a combination of schizophrenia symptoms - such as hallucinations or delusions - and of mood disorder symptoms, such as mania or depression) and behavioral problems.

During a telephone interview on 05/26/10 at 12:20 p.m. security guard Staff HH said he/she assisted staff on the behavioral health unit to physically hold Patient #49 on 05/21/10. Staff HH said the patient was spitting on staff and out of control. Staff HH said after holding the patient in his/her room he/she and other staff walked the patient to the seclusion room. Staff HH said he/she took a hold of the patient's face so the patient couldn't turn his/her head to spit at anyone.

During an interview on 05/27/10 at 9:00 a.m. CNA staff BB said he/she has worked in the behavioral health unit on the night shift for six years. Staff BB said when he/she came on duty at 7:00 p.m. on 05/21/10 several staff members were standing in the doorway to Patient #49's room talking with the patient. Staff then walked the patient to the seclusion room where the patient continued to be out of control and spit on staff. Staff BB said on 05/21/10 at approximately 7:30 p.m. registered nurse (RN) Staff Z asked for the paperwork for the seclusion restraint. Staff BB told RN Staff Z the nurse did not start any paperwork for seclusion.

During an interview on 05/27/10 at 9:30 a.m. Staff CC said on 05/21/10 around change of shift, at approximately 7:00 p.m., Patient #49 was spitting on staff and staff had to physically restrain the patient. Staff CC said he/she gave the patient an injection to calm the patient down. Staff CC said it is routine in a physical hold not to get a restraint order; that until this morning (05/27/10) he/she did not consider a physical hold a restraint. Staff CC said he/she has worked on the behavioral health unit for ten years and until 12/09 was the nurse manager for five years.

During an interview on 05/27/10 at 10:55 a.m. registered nurse Staff Z said he/she was the nurse assigned to Patient #49 on the night of 05/21/10. Staff Z said he/she went to the seclusion room and woke up the patient at approximately 7:35 p.m. and walked the patient back to his/her room. Staff Z said he asked a CNA where the paperwork was for seclusion and the CNA told him/her there was no paperwork. Staff Z said, "There was no documentation as to why the staff put the patient in seclusion." Staff Z said since there was no paperwork for the seclusion, he/she could not chart the patient was in the seclusion room. Staff Z said he/she did not know if staff had been monitoring Patient #49 in the seclusion room because there was no paperwork and he/she did not ask the staff.

Review of progress notes entered by Staff CC dated 05/21/10 at 6:25 p.m. showed patient agitated and Staff CC gave the patient an injection of medication for the agitation and the patient remained argumentative. A progress note entered by Staff Z dated 05/21/10 is timed at 7:45 p.m. and states patient is asleep in bed. There is no documentation in the record by Staff CC that staff did a physical hold on Patient #49 and there is no documentation by Staff Z that staff placed Patient #49 in seclusion.

Review of the physician's orders dated 05/21/10 showed no order for a physical hold and no order for seclusion.

2. Record review for discharged Patient #46 showed the patient entered the facility through the emergency department on 04/07/10 with depression, suicidal thoughts, stress and history of colon cancer in remission.

During an interview on 05/26/10 at 4:05 p.m. security officer staff DDD said he/she was called to the ED on 4/07/10 to assist with Patient #46 who was being physically aggressive. Staff DDD said the patient refused to give the staff a cell phone. Staff DDD said he/she assisted ED staff in physically restraining Patient #46.

Review of the emergency room physician's orders show an order for seclusion dated 04/07/10 at 8:10 p.m. due to the patient being combative and physically threatening. There is no physician's order for a physical hold for Patient #46.

Based on policy review, interview and record review the facility failed to provide within one hour of the initiation of a restraint, a face to face assessment for four patients (#49, #52, #53 and #46) of six restraint records reviewed. The facility census was 145.

Findings included:

Review of facility policy "Restraint and Seclusion" last revised 7/09 shows the definition of restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient of move his or her arms, legs, body, or head freely.
The licensed independent practitioner or an appropriately trained registered nurse or physician's assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint whether or not the restraint/seclusion has been discontinued within the hour.

During an interview on 05/25/10 at 9:20 a.m. the behavioral health nurse manager, Staff FF said only physicians do a face to face evaluation following a restraint episode.
1. Review of the history and physical dated 05/07/10 for current Patient #49 showed the patient entered the facility on 05/06/10 for treatment of schizoaffective disorder (a combination of schizophrenia symptoms - such as hallucinations or delusions - and of mood disorder symptoms, such as mania or depression) and behavioral problems.
Review of the physician's orders dated 05/20/10 at 9:37 a.m. shows an order for the patient to be in seclusion due to physically aggressive behavior. There is no face to face evaluation completed by the physician.
Review of the physician's orders dated 05/20/10 at 2:05 p.m. shows an order for a physical hold due to physically aggressive behavior and being dangerous/threatening to other patients/staff. There is no face to face evaluation completed by the physician.
2. Review of the Psychiatric Admission note dated 05/19/10 for current Patient #53 shows the patient entered the facility on 05/18/10 for treatment of bipolar disorder (periods of manic behavior then periods of depression).
Review of the physician's orders dated 05/20/10 at 11:13 a.m. shows an order for four point restraints (both wrists and ankles) due to physically aggressive behavior. There is no face to face evaluation completed by the physician.
3. Review of the History and Physical for current Patient #52 dated 05/15/10 shows the patient entered the facility on 05/14/10 for treatment of psychosis (loss of contact with reality, usually related to intense or distressing experiences).
Review of the physician's orders dated 05/19/10 at 10:00 a.m. shows an order for the patient to be in seclusion for dangerous/threatening danger to other patients or staff. There is no face to face evaluation completed by the physician.
Review of the physician ' s orders dated 05/20/10 at 12:00 p.m. shows an order for four point restraints due to physically aggressive behavior toward others. There is no face to face evaluation completed by the physician.
4. Review of the Psychiatric Discharge Summary dated 04/09/10 for discharged Patient #46 shows the patient entered the facility on 04/07/10 due to depression, suicidal thoughts, stress and history of colon cancer in remission.
Review of the emergency department physician's orders dated 04/09/10 at 12:35 a.m. shows an order for seclusion due to being combative and physically threatening to staff. There is no face to face evaluation completed by the physician.

Based on policy review and record review the facility failed to ensure all components of a face to face evaluation following a restraint episode are addressed by the physician for two patients (#52 and #53) of six restraint records reviewed. The facility had a census of 145.
Findings included:
Review of facility policy "Restraint and Seclusion" last revised 07/09 shows the definition of restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient of move his or her arms, legs, body, or head freely.
The licensed independent practitioner or an appropriately trained registered nurse or physician's assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint whether or not the restraint/seclusion has been discontinued within the hour.

The facility policy does not address the four elements to be evaluated during the course of the face to face assessment.

1. Review of the History and Physical for current Patient #52 dated 05/15/10 shows the patient entered the facility on 05/14/10 for treatment of psychosis (loss of contact with reality, usually related to intense or distressing experiences).
Review of the physician's orders dated 05/22/10 at 11:30 a.m. show an order for the patient to be in seclusion for being physically aggressive toward others. The physician documented the patient's immediate situation but failed to document the patient's reaction to the seclusion, the patient's medical condition and the need to continue or terminate the seclusion.
2. Review of the Psychiatric Admission note dated 05/19/10 for current Patient #53 shows the patient entered the facility on 05/28/10 for treatment of bipolar disorder (periods of manic behavior then periods of depression).
Review of the physician's orders dated 05/19/10 at 12:12 p.m. show an order for four point restraints (both wrists and ankles) due to physical aggressive behavior and being dangerous/threatening danger to other patients or staff. The physician documented the patient's immediate situation but failed to document the patient's reaction to the four point restraints, the patient's medical condition and the need to continue or terminate the seclusion.
Review of the physician's orders dated 05/23/10 at 8:45 a.m. shows an order for seclusion due to physical aggressive behavior and being dangerous/threatening danger to other patients or staff. The physician documented the patient's immediate situation but failed to document the patient's reaction to the four point restraints, the patient's medical condition and the need to continue or terminate the seclusion.

Based on record review and interview the facility failed to report one (Patient #45) restraint related death to CMS by the end of the next business day following the death. Two deaths that occurred while the patients were in the Intensive Care Unit were reviewed for the month of April 2010. The facility census was 145.

Closed record review on 05/27/10 at 2:30 p.m. showed Patient #45 was admitted to the facility on 04/15/10 for treatment of pneumonia. Physician orders and nursing documentation showed the patient had been placed in bilateral soft wrist restraints from 04/22/10 at 10:00 p.m. until 04/28/10 at 11:00 a.m. The patient expired on 04/28/10 at 11:40 a.m. The medical record had no documentation of the CMS death requirement to report.
Staff A, Director of Clinical Affairs said on 05/25/10 at 3:00 p.m. that there had been no patient deaths while in or following the use of restraints in the facility in the past six months.
Staff C, Chief Nursing Officer said during an interview on 05/27/10 at 2:00 p.m. that nursing is responsible for reporting deaths in restraints to the risk manager. Staff C confirmed that the facility did not have a formal/written policy regarding reporting deaths in restraints to CMS at that time.