HospitalInspections.org

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During a revisit the hospital failed to ensure the Condition of Participation: CFR 482.13 Patient's Rights was not met as evidenced by:

A 144 - Failed to ensure: emotionally safe care was provided to 1 patient (#9) and staff had received education on manual holds for 1 patient with an injury (#10).

A 145 - Failed to ensure one patient (#7) injury was reported for investigation

A 162 - Failed to ensure 1 patient (#8) was only placed in seclusion when a danger to self or others.

A 167 - Failed to ensure 2 patients (#s 9 and 10) were restrained using appropriate restraint techniques. This placed patient #9 at risk for psychological harm from further trauma and caused injury to patient #10.

A 174 - Failed to ensure one patient (#8) was released from seclusion in a timely manner in conjunction with the absence of immediate or imminent destructive and/or harmful behavior.
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Based on record review, video review, observation, and interview the facility failed to ensure: emotionally safe care was provided for 1 patient (#9) and to ensure safe standards were developed for manually restraining 1 patient (#10) and out of 9 patients reviewed. This failed practice placed the patients at risk for further physical and psychological harm. findings:

Patient #9

Record review on 7/5-6/18 revealed Patient #9 was 16 years old and had a history of trauma, sexual abuse and exploitation.

Video review on 7/6/18 of a seclusion event that occurred on 6/19/18 revealed RN #3 informed Patient #9 that he/she needed to take diffrent medications by mouth or the Patient would receive an injection of those medications. When the Patient requested to take melatonin (a dietary supplement used to treat insomnia) , the RN began to argue with the Patient indicating that he/she take the other medications or receive an injection. When the Patient again requested to take the melatonin by mouth the RN proceeded to prepare and administer an injection in to the Patient's buttocks. At 7:40 pm eight staff members entered the room, as one staff attempted to process with the Patient #8, the Patient immediately began to tremble and cry as he/she backed into a corner and lowered self to the floor. The Patient because hysterical and the staff locked the Oak Room door, at 7:42 pm, placing the Patient in seclusion.

During an interview on 7/6/18 the Safety Officer stated the large number of staff approaching the Patient was not concurrent with trauma-informed care.

During an interview on 7/6/18 the Clinical Director stated the nurse had engaged into a power struggle (an argument type conversation between two people where neither side agrees) with the Patient and should have attempted to give the melatonin (if available by order) with other ordered medications by mouth.

Patient #10

Record review on 7/5-6/18 revealed Patient #8 had diagnoses that included depression, posttraumatic stress disorder (a mental disorder that can develop after a person is exposed to a traumatic event, such as sexual assault, warfare, traffic collisions, or other threats on a person's life), reactive attachment disorder (a condition found in individuals who may have received grossly negligent care and do not form a healthy emotional attachment with their primary caregiver), and neurocognitive disorder (a general term that describes decreased mental function due to a medical disease other than a psychiatric illness).

Video review on 7/6/18 of a physical hold event that occurred on 7/4/18 at approximately 7:03 pm where the Patient was held prone vertically face first into a door. During this event the patient complained of collar bone pain.

Record review of the post incident face to face assessment on 7/4/18 at 8:25 pm revealed Patient #8 complained of shoulder pain and was noted to be guarding the area.

Record review of the facility's consultation report form, dated 7/5/18 at 11:00 am, revealed the Patient suffered a mid-shift clavicle (collar bone) fracture that was displaced.

Observation of Patient #8 during the survey 7/5-6/18 revealed the Patient was in and out of an arm sling. The area of the left clavicle appeared to be swollen. The patient complaint of pain in the area.

During an interview on 7/9/18 at 11:15 am, when asked how facility staff would safely place the Patient in a manual hold, if the need should arise, Registered Nurse (RN) #2 stated the facility had not developed a manner in which to safely restrain the Patient. The RN further stated the facility did not provide training on how to restrain a patient with an injury. When asked if a standard physical hold could further cause injury to the affected area, the RN stated yes.

Review of "Your Mental Health Rights in Alaska", published 2016, revealed patients have "the right to a clean, safe, humane treatment environment where you will not be harmed..."

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Based on record review and interview the facility failed to ensure 1 patient's (#7) injury was reported and investigated of 8 patients reviewed. In addition, all staff did not receive appropriate training on managing patients with complex behaviors. This failed practice placed all patients residing in the facility at risk for injury and/or harm. Findings:


Patient #7

Record review of Patient #7's record on 7/5-6/18, revealed a nursing note, dated 6/30/18 at 7:11 pm, "Pt. was standing at the nursing desk when a male peer [Patient #1] bit his left shoulder."

Review of a provider note, dated 7/1/18, revealed "Staff reports that peer bit the patient's left shoulder through clothing ...On exam-left shoulder reddened teeth marks noted on patient's left shoulder. No skin penetration."

Review of incident reports provided by the facility revealed the incident between the patients was not listed.

Record review of Patient #1's record on 7/5-6/18 revealed the Patient had a history of Autism spectrum disorder and has a history of unpredictable behavior and physical aggression.

Review of the incident log provided by the facility, revealed the incident between Patent #s 1 and 7 had not been reported for investigation.

During an interview with the Shift Supervisor Registered Nurse (SSRN) #1 on 7/6/18 at 11:22 am, when asked what education facility staff had on dealing with patients with autism, brain injuries, or other developmental disorders the SSRN stated there was no special program he was aware of. The RN stated the incident should had been reported.

During an interview on 7/6/18 at 12:00 pm, when asked what education was provided to the staff in regards to handing patients with complex developmental disorders, Psychiatric Nursing Assistant (PNA) #2 stated they had education on developmental stages but no education on patients with brain trauma and developmental disorders.

Review of the "Management of Behavior and Seclusion Restraint Policy Updates" for enrollment and completion revealed 12 staff had not completed the education.

During an interview on 7/9/18 at 11:28 when asked about the training for the staff, the Quality Manager stated the facility had help in training for the teenagers unit and 1:1 training for one of their autistic patients on the unit.

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Based on record review, video review and interview the facility failed to ensure an appropriate reason occurred for the use of a seclusion for 1 patient (#8) out of 8 patients reviewed. This failed practice resulted in the patients to potentially be unnecessarily secluded and created a risk for psychological harm. Findings

Record review on 3/27-29/18 revealed Patient #8 was admitted to the facility with a diagnosis of developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Video Review on 7/6/18 of the seclusion occurrence on 7/4/18 revealed PAtient #8 was in the central common room after breaking a spoon and placing it on the table with staff prompting. At 9:00 am staff escorted the Patient to the Oak Room (room used for time-outs, seclusions and 5-point restraints) for a time out. Once seated in the Oak Room Registered Nurse (RN) #2 informed the patient that if he/she does not talk with him/her the door would have to be locked and the time out would become a seclusion. Patient #8 remained queit while sitting on the Oak Room bed and did not respond. The RN left the room and locked the door resulting in a seclusion of the Patient.

Record review of the seclusion documentation for Patient #8, dated 7/4/18 at 9:53 am, revealed "[Patient] was unwilling to discuss safe behaviors. [Patient] placed in seclusion." Further review of the document revealed the release criteria was for the patient to stop spitting and display safe behaviors.

Further video review from the same event revealed RN #2 entered the Oak Room at 9:33 am and discussed release criteria. The patient remained calm during the interaction. The patient remained calm until 9:53 am when he/she was released.

During an interview on 7/6/18 the Clinical Director stated the staff could have had a better interaction and communication exchange with the patient. He/she further stated Patient #8 did not have a concept of time and the release criteria was vague and not objective. During the interview the Safety Officer stated he/she could not see an imminent threat resulting in the need for seclusion.

During an interview on 7/9/18 at 11:15 am RN #2 stated he/she recalled the event and stated the Patient not talking wasn't a valid reason for seclusion.

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Based on record review, video review, interview, and observation the facility failed to ensure that acceptable restraint techniques were utilized for 2 patients (#s 9 and 10), out of 4 patients reviewed for seclusion. The facility's failure to ensure NAPPI (Non-
abusive Psychological and Physical Interventions) was used during manual holds placed patients at rick for further psychological trauma and caused an injury to 1 patient. findings:

Patient #9

Record review of Patient #9's medical record from 7/5-6/18 revealed the patient had a history of trauma, sexual abuse and exploitation.

Video review on 7/6/18 of a physical hold and seclusion event that occurred on 6/19/18 revealed at 5:36 pm Psychiatric Nursing Assistant (PNA) #3 was attempting to restraint the patient in the Oak Room as other staff were exiting. During this occurrence PNA laid the patient face down on the Oak Room table and laid on top of the Patient. The PNA then released the Patient's limbs and backed out of the room.

During an interview on 7/6/18 the Safety Officer stated this is was not an approved restraint technique.

Patient #10

Record review of Patient #10's medical record from 7/5-6/18 revealed the patient had diagnoses that included depression, posttraumatic stress disorder (a mental disorder that can develop after a person is exposed to a traumatic event, such as sexual assault, warfare, traffic collisions, or other threats on a person's life), reactive attachment disorder (a condition found in individuals who may have received grossly negligent care and do not form a healthy emotional attachment with their primary caregiver), and neurocognitive disorder (a general term that describes decreased mental function due to a medical disease other than a psychiatric illness).

Video review on 7/6/18 of a physical hold event that occurred on 7/4/18 at approximately 7:03 pm revealed PNA #4 was attempting to redirect the Patient from the common area to Oak Room. When Patient #10 began walking in the opposite direction of the Oak Room the PNA grabbed the Patient's arm and abruptly placed Patient #10 face-first into a door. While still being held against the door, PNA #5 held the Patient's head against the door by placing his/her hand on one side of the Patient's face and applying pressure. During this occurrence WEKA (contracted security staff) Staff #1 proceeded to lean backwards against PNA #4 and used his/her legs to apply pressure resulting in pushing PNA #4 , which further pushed Patient #10 against the door. During this event the Patient kept yelling complaints about his/her collar bone hurting.

During an interview on 7/6/18 the Safety Officer stated the physical hold was not an approved hold established through the facility. The Safety Officer further stated there was other approved methods that could have been useful.

Record review of the post incident face to face assessment on 7/4/18 at 8:25 pm revealed Patient #10 complained of shoulder pain and was noted to be guarding the area.

Record review of the facility's consultation report form, dated 7/5/18 at 11:00 am, revealed Patient #10 had suffered a mid-shift clavicle (collar bone) fracture that was displaced.

Random observations during the survey on 7/5-6/18 revealed the Patient was in and out of an arm sling. The area over the left clavicle appeared to be swollen. The Patient stated there was pain in that area.

During an interview on 7/9/18 at 11:15 am Registered Nurse #2 stated pushing a patients head against the door was not best practice.

Review of the education provided to facility staff revealed staff had completed "Seclusions and Time-Out Procedures Review" education and had participated in 1 practice restraint/ seclusion drill with the Assistant Director of Nursing on 5/31/18, that 5 staff attended.

During an interview on 7/9/18 at 11:20 am, when asked about further drills, the Director of Nursing confirmed they had only participated in 1 drill.

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Based on record review, video review and interview the facility failed to ensure seclusion was discontinued at the earliest possible time for 1 patient (#8). This failed practice resulted in the patients to potentially be unnecessarily secluded for longer than necessary and created a risk for psychological harm. Findings

Record review on 3/27-29/18 revealed Patient #8 was admitted to the facility with diagnoses that included developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Video Review on 7/6/18 of the seclusion occurrence on 7/4/18 revealed Patient #8 was in the central common room after breaking a spoon and placing it on the table with staff prompting. At 9:00 am staff escorted the patient to the Oak Room (room used for time-outs, seclusions and 5-point restraints) for a time out. Once the Patient was seated on the bed in the Oak Room, Registered Nurse (RN) #2 informed the Patient that if he/she does not talk with him/her the door would have to be locked and the time out would become a seclusion. The Patient remained quiet while sitting on Oak Room table, the RN left the room and locked the door resulting in a seclusion of the patient.

Record review of the seclusion documentation for Patient #8 dated 7/4/18 at 9:53 am revealed "[Patient] was unwilling to discuss safe behaviors. [Patient] placed in seclusion." Further review of the document revealed the release criteria was for the Patient to stop spitting and display safe behaviors.

Review of the "Seclusion Face to Face Flow Sheet", dated 7/14/18, revealed Patient #8 exhibited the following "Patient Behaviors" codes: 9:15 am, "K" for "K. Lying/Sitting" and "AA" for "AA. Other Sign gestures (inappropriate)", 9:30 am "K." and "O" for "O. Quiet"; 9:30 am "K" and "O"; and 9:53 am "K" for "Lying/ Sitting"

Further video review from the same event revealed RN #2 entered the Oak Room at 9:33 am and discussed released criteria with the Patient. The patient remained calm during interaction. The patient remained calm until 9:53 am when he/she was released, 23 minutes after the seclusion was initiated.

During an interview on 7/9/18 at 11:15 am, when asked about the release criteria, RN #2, replied the Patient decides when to release from seclusion.