HospitalInspections.org

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Based on record review and interview the facility failed to ensure medical staff followed the medical staff bylaws in the area of peer review. This failed practice denied the facility the ability to identify opportunities for improvement. In addition, this failed practice placed all patients residing in the facility at risk for substandard quality of care (based on a census of 57) . Findings;

Review of the Licensed Independent Practitioner (LIP) files on 7/18-19/18 revealed:

LIP #7 had references for competency completed by registered nurses. There were no references from peers or evidence of peer review activity in the provider binder.

LIP #2 had no references for competency by peers in his/her record. There was no evidence of peer review activity.

LIP #3 had 2 references for competency by peers in his her record. There was no evidence of peer review activity.

The remaining 4 LIP files reviewed did not contain evidence of peer reviews.

During an interview on 7/19/18 at 2:00 pm, Office Assistant (OA) #1, stated he/she was responsible for maintaining the credentialing files as well as other duties. The OA stated he/she had wanted to become credentialed but had never found the time.

When asked about the peer review for LIP #7 AO stated because LIP was an advanced nurse practitioner, nurses had provided the reviews. When asked how a nurse could evaluate the clinical judgement of LIP #7, the AO stated stated they could not. The LIP stated the non-clinician reviews were not a review of LIP clinical performance.

Further review of the providers binder revealed LIP #7 had been provided with an extension for credentialing.

Review of the Medical Staff Bylaws, effective 7/1/14, revealed "Membership Responsibilities...Participate in quality/ performance improvement and peer review activities." Review of "Ongoing Professional Practice Evaluation (OPPE)" revealed "The Medical Staff will engage in OPPE to identify professional practice trends that affect quality of care and patient safety. Information from this evaluation process will be factored into the decision to allow LIPs to maintain existing privileges ...prior to or at the time of reappointment.

Review of the "Medical Staff Meeting", dated 1/9/18, revealed "Peer review feedback...review at future meeting."

There was no information about the peer reviews in the "Med Exec Team" meeting minutes from 5/22/18; 5/29/18;

Review of the facility policy, "Peer Review", dated 11/1/14, revealed "At least quarterly 5% of the cases performed by a medical staff member will be randomly selected for peer review."

During the interview on 7/19/18 the OA stated the facility had completed an independent peer review by an outside agency 9 months ago.

The independent peer review was not provided to the survey team at the time of exit.
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Based on record review and interviews the facility failed to ensure the hospital protected and promoted each patients' rights according to the Condition of Participation: CFR 482.13 Patient's Rights. findings:

The facility failed to:

Ensure patients in 4 of 4 nursing care units were provided care in a safe setting free of ligature risk, inadequate supervision and hazardous items.
Reference at tag A 144

Ensure allegations and/or of potential abuse and/or maltreatment of patients were investigated in a timely manner. Reference at tag A 145

Ensure 1 patient (#22), out of 30 sampled patients, was free from unnecessary restraint and/or seclusion. Reference at tag A 154

Ensure 2 patients (#10 and #24), were free from unnecessary seclusion. Reference at tag A 162

Ensure sufficient opportunities at least restrictive interventions were attempted prior to a restraint and/or seclusion initiated for 1 patient (#22).
Reference at tag A 164

Ensure the type or technique of restraint or seclusion used was the least restrictive intervention for 2 patients (#10 and #24). Reference at A 165

Ensure seclusions were discontinued at the earliest possible time for 2 patients (#10 and #24) Reference at tag A 174

Ensure ongoing assessment and monitoring of 1 patient's (#10) condition while in seclusion. Reference at tag A 175

Ensure the patient's medical record contained a description of warranted conditions or symptoms to place 2 patients (#10 and #24) in seclusion. Reference at tag A 187

The facility was out of compliance with the Condition during the investigation.

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Based on observation, interview and document review the facility failed to ensure patients in 4 of 4 nursing care units were provided care in a safe setting free of ligature risk, inadequate supervision and hazardous items. This failed practiced placed patients, on 4 of 4 unitsbeing utilized, at risk for injury from self harming behaviors. Findings:

Taku Unit:

Coat Closet Hall Ligature Risk:

During an observation on 7/16/18 at 2:35 pm, of the Taku unit, revealed 5 different ligature point opportunities within the coat closet hall leading from the unit corridor to the courtyard:

- 3 office doors with ligature handles;
- 1 entry door from corridor to coat closet hall with ligature handle; and
- 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar.

During the same observation on 7/16/18, the coat closet hall door was observed to be propped open. The design of the door revealed the door swung into the coat closet hall resulting in the ligature risk handle to be out of view of cameras and staff at the central nurse's station. In addition, there were no staff present in or near the area for observation of any patients that may be in the coat closet hallway alone.

During an interview on 7/16/18 at 2:35 pm, Psychiatric Nursing Assistant (PNA) #1, stated the coat closet hall door from the unit hallway always stays open while patients are outside.

Half-Wall Ligature Risk:

Additional observation of Taku unit on 7/16/18 revealed a closed-in alcove, with half-wall and a window at the end of hallway near bedrooms T5 and T6, with no camera monitoring within the visually obstructed space. There was a hand rail system within the alcove that is not anti-ligature designed. The interior of the alcove is not viewable from the front desk of the unit.

During an interview on 7/16/18 at 2:36 pm PNA #2 stated he/she was assigned to sit at the central nursing station and observe the unit's corridors. When asked if he/she could observe the area behind the half-wall, the PNA stated he/she was unable to view the ligature-risk handrails behind the half-wall from the desk and there was no camera to observe the concealed area. PNA #2 further stated that suicidal patients may be housed in rooms T5 and T6.

Medication Room Door Ligature Risk:

Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member.

During an interview on 7/17/18 at 10:10 pm, PNA #3 stated patients do sit within the medication room alcove and cannot be seen from the front desk or subsequent hallway space in between. The PNA further stated the coat closet hall door (from hallway of unit) remained open while patients are outside. When asked where do staff sit while patients are outside, PNA #3 stated the staff would sit anywhere within the courtyard and/or follow patients around. The PNA was then asked if the courtyard entrance door (leading from the unit) could be seen at all times while other staff followed patients outside, he/she stated no.

During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas.

Susitna Unit:

Plastic Bag Risk:

During an observation on 7/16/18 at 10:10 am of the courtyard on Susitna Unit, three plastic garbage bags full of leaves were sitting on the ground amongst the bushes within the courtyard unsecured.

Coat Closet Ligature Risk:

Observation of the Susitna Unit on 7/16/18 at 1:42 pm revealed the two ligature points in the coat closet hall leading from the unit corridor to the courtyard:

- 1 entry door from corridor to coat closet hall with ligature handle; and
- 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar.

Further observation revealed no cameras were located in this area. In addition, the coat closet hall was not viewable from the center nursing desk.

Medication Room Door Ligature Risk:

Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member.

During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas.

During an interview on 7/17/18 at 9:50 pm PNA #4 stated when he/she sits at the central nursing station, during the night time shift, the medication room alcove is hard to see via the half-dome safety mirror due to the dim lighting and skewed reflection.

During an observation on 7/17/18 at 9:50 pm the Surveyor stood in the blind spot of the medication room alcove. The Nursing Supervisor #1 stated it was difficult to see the surveyor due to dim lighting and skewed reflection from the side of the half-dome safety mirror.

Chilkat Unit:

Coat Closet Hall Ligature Risk:

Observation of the Chilkat Unit on 7/16/18 at 10:20 am revealed the two ligature points in the coat closet hall leading from the unit corridor to the courtyard:

- 1 entry door from corridor to coat closet hall with ligature handle; and
- 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar.

During an interview on 7/16/18 PNA #5 stated when patients are in the courtyard. The door leading from the unit corridor to the coat closet hall stays open.

Further observation revealed no cameras were located in this area. In addition, the coat closet hall was not viewable from the center nursing desk.

During an observation on 7/17/18 at 9:10 pm PNA #6 stated when patients are in the courtyard, the door leading from the unit corridor to the coat closet hall stays open.

During an observation on 7/17/18 at 9:11 pm PNA #7 stated when patients are in the courtyard staff will sit facing the courtyard with backs to the courtyard entrance door (coat closet hall) and/or follow patients around.

Propane Gas Tank Risk:

Observation of the Chilkat Unit courtyard on 7/16/18 at 10:28 am revealed a propane grill. Further observation revealed the compartment harboring the propane tank was easily accessible. The tank was in the on position. Fuel lines leading form the tank supply were accessible.

During an interview on 7/16/18 at 10:28 am Protective Services Specialist stated the tank needed to be secured immediately as it may pose a safety risk.

Corridor Handrail Ligature Risk:

Observation, from a seated position where staff sit at the center nursing desk, on 7/16/18 at 1:59 pm revealed the middle hall of Chilkat Unit was partial obstructed from view on the left side of the hallway. Further observation revealed approximately 27 feet of ligature risk hand rails were out of view from the monitoring staff person that sat at the central nursing station.

During an interview on 7/16/18 at 1:59 pm PNA #8 stated, when seated, he/she could view all three hallways and if needed could review the camera monitor at the central nursing desk. When asked if all three hallways on the unit were visible by camera, the PNA stated yes. Observation of the camera monitor during this interview revealed the camera (C21) was not functioning for the middle hallway.

Continuous observation on 7/16/18 from 2:01 pm to 2:07 pm revealed no staff was continuously present at the center nursing station.

During an interview on 7/16/18 at 3:35 pm the Quality Manager stated staff should not use the camera as a primary method for observing patients location and activity.

Review of the facility's policy "Video Surveillance/Closed Circuit Television (CCTV) System," dated 12/22/11, revealed "The CCTV system shall not be used as a primary method for observation and monitoring of patient."

Medication Room Door Ligature Risk:

Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member.

During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas.

Katmai Unit:

Coat Closet Hall Ligature Risk:

Observation of the Katmai Unit on 7/16/18 at 2:24 pm revealed the two ligature points in the coat closet hall leading from the unit corridor to the courtyard:

- 1 entry door from corridor to coat closet hall with ligature handle and
- 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar.

During an interview on 7/16/18 at 2:24 pm PNA #9 stated when patients are in the courtyard, the door leading from the unit corridor to the coat closet hall stays open.

Medication Room Door Ligature Risk:

Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member.

During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas.

Review of the facility's policy "Searches, Contraband & Restricted Items, including Weapons," dated 4/15/18, revealed: "Definitions: Restricted Items ...potential for being hazardous to patient safety ...plastic bags ..."

"Procedure: Section I: Staff Responsibility for contraband & restricted items: A. All staff will continuously observe the environment for contraband, restricted items, and other safety hazards."

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Based on record review and interview the facility failed to ensure allegations and/or of potential abuse and/or maltreatment of patients were investigated in a timely manner for 2 patients (#22 and 25) out of 30 sampled patients. This failed practice created a risk for further abuse and/or harassment for all patients residing in the hospital. Findings:

Record review on 7/17-18/18 of Patient #22's record revealed an event on 6/18/18 of the Patient jumping on the furniture. When the Patient refused to get down the Patient was approached by WEKA (contracted security support staff). After the Patient struck out at the WEKA staff, the Patient was placed in a manual hold, strapped to a gurney, and placed in seclusion.

Review of Patient #25's medical record revealed there was an event of the Patient stashing 3 pills and a bobby pin (considered contraband). On 6/24/18 the Patient was placed into a safety vest (a thick garment that doesn't tear) and physically had his/her underwear removed by staff after refusing to completely disrobe. The event was assigned for process review on on 6/28/18.

Review of the investigations revealed the process reviews of both events had not been completed by nursing administration and none of the involved staff had been interviewed and/or educated on possible patient maltreatment.

Review of the "Process Review Update", updated 6/26/18, revealed events were patients had been possibly maltreated or denied their rights from 1/2018 until 6/13/18, totaling 16 cases, had not been reviewed by administrative staff.

During an interview on 7/19/18 at 8:40 am, when asked about the incomplete reviews of incidents involving potential patient abuse and/or harassment, the Quality Manager (QM) stated they had not been getting completed. The QM stated they were reassigned to the current interim Director of Nursing (DON) and the facility was planning on hiring a contractor to help finish them.

During an interview on 7/19/18 at 10:05 am, the Safety Officer stated process reviews assigned to nursing administration for review were not getting completed, in addition, the review done by nursing administration were not completed objectively.

Review of the policy "Conduct Involving Patients" dated 10/13/17, revealed "the Senior Manager Department Head of the identified staff person, their designee or the RSS will: 1. Investigate the allegation of abuse, neglect, or serious misconduct using the Process Review from and 2. Complete the investigation, and 3. Document the findings and recommendations on the Process Review form within (5) business days of the original notice."

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Based on record review and interview, the facility failed to ensure 1 patient (#22), out of 30 sampled patients, was free from unnecessary restraint and/or seclusion. This failed practice violated the patient's right to be free from restraint and seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. This had the potential to effect the patient's response to treatment and increase potential risk for injury. Findings:

Patient #22

Record review on 7/16-19/18 revealed Patient #22 was admitted to the facility on 6/15/18 with a diagnosis of Oppositional Defiant Disorders (a disorder in a child marked by defiant and disobedient behavior to authority figures).

Record review of Patient #22's medical record on 7/17/18 at 11:45 am revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) took place on 6/18/18 at 2:26 pm. Indication for BMR was: "[Patient] on unit refocus program. [Patient] exited room and was not redirectable back to [his/her] room. [Patient] informed staff that [he/she] was afraid of [his/her] room. Staff offered the family room as an alternative refocus area. [Patient] refused. [Patient] asked to walk to the Oak Rook to work on [his/her] refocus. [Patient] refused. [Patient] placed in a BMR to assist [him/her] to Gurney and then to Oak Room. [Patient] became very elevated and fought staff throughout the BMR-Gurney-Oak Room process..."

Further review revealed this BMR incident escalated patient to the point of requiring a seclusion (the act prohibiting a patient from leaving an area) for safety. During this seclusion, Patient #22 attempted to tie a sweatshirt around his/her neck. A second attempt was made with his/her pants. This prompted an increased restriction, the use of mechanical restraints (use of straps to secure patient's wrists, ankles, and chest to a bed), for safety.

Review of the order for BMR, dated 6/18/18 at 2:26 pm, Licensed Individual Practitioner #1 revealed the clinical justification for the BMR was "[Patient] not redirectable from the staff hallway, [Patient] refused to walk to a safe area."

During an interview on 7/19/189 at 10:25 am, Registered Nurse (RN) # #1 stated he would initiate a BMR, retraint, or seclusion if a patient was "a danger to self, danger to others, or disruptive behavior to point of creating an unsafe environment." When asked about Patient #22's BMR and subsequent seclusion and restraint, he stated it may have been "rushed." RN #1 could not state the behavior Patient #22 was exhibiting that justified the start of the restrictive measures taken by staff except to say he/she felt it was "unsafe" having Patient #22 in a unit hallway that contained some staff offices. RN #1 further stated that a patient has the right to refuse refocus.

Review of the facility policy "Management of Patient Behavior", effective date 6/1/2018, revealed: "API will provide least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and well ensure the safety and well-being of all patients, staff and visitors."

The policy further revealed: "Definitions: Management of Patient Behavior: ...These procedures include de-escalation of a patient through the progression of non-verbal, verbal, and physical interventions necessary to safely and therapeutically manage a patient's behavior. As a last resort, the interventions may include seclusion, physical holds/restraint, and mechanical restraint ..."

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Based on record review, video observation, and interview the facility failed to ensure 2 patients (#10 and #24) out of 30 sampled patients, were free from unnecessary seclusion. This failed practice created a non-therapeutic environment and an increased potential for injury. Findings:

Patient #10

Record review on 7/16-19/18 revealed Patient #10 was admitted to the facility on 7/7/18 with a diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal though processes and disturbance in the person's mood) and Mild Intellectual Disabilities (impairment of cognitive skills, adaptive life skills, and social skills).

Episode #1

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) and seclusion (the act prohibiting a patient from leaving an area) occurred on 7/15/18 at 2:34 am. Indication for the BMR was "...disruptive to milieu ...going into other patient's room..." Indication for the seclusion was "Decision made to put [patient] in locked seclusion for the welfare of the other patients on the unit." This seclusion lasted 2 hours and 4 minutes.

Video observation on 7/18/18 at 1:36 pm of the 7/15/18 event revealed the Patient walked around the front desk and raised his/her voice at times. The Patient #10 walked up and down the hallway, but did not enter other patients' rooms. Staff placed Patient #10 into a BMR, and walked him/her down to the Oak Room. On the camera, it was observed that Patient #10 calmly walk into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time.

During an interview on 7/18/18 at 1:36 pm, the Medical Director, who watched the camera review with surveyor, stated the door did not need to be locked.

During an interview on 7/18/18 at 1:36 pm, Chief Operating Officer watched the camera review with surveyor and stated the staff overreacted by closing the door.

Record review of Patient #10's Master Treatment Plan, dated 7/10/18, revealed no indication or history of patient's behavior pattern that would required an instant seclusion when taken to the Oak Room.

Episode #2

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a BMR and seclusion occurred on 7/16/18 at 3:43 am. Indication for the BMR was "[Patient] yelling/screaming, disruptive to milieu...antagonizing a [male/female] peer, tried to follow [male/female] peer in [his/her] room..." Indication for the seclusion was "Due to patient's behavior pattern locked seclusion initiated for the welfare of the other patients on the unit."

Video observation on 7/18/18 at 2:35 pm of the 7/16/18 event revealed the Patient walked around the front desk, raised his/her voice at times, and talked with another patient. When this patient returned to his/her room, Patient #10 followed him/her but did not enter the bedroom. He/she stood by the door and continued to talk to the other patient. Staff placed Patient #10 into a BMR, and walked him/her down to the Oak Room. On the camera, it was observed that the Patient #10 calmly walked into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time. This seclusion last for 41 minutes.

Record review of Patient #10's Master Treatment Plan, dated 7/10/18, revealed no indication or history of patient's behavior pattern that would required an instant seclusion when taken to the Oak Room.

Patient #24

Record review on 7/16-19/18 revealed Patient #24 was admitted to the facility on 7/7/18 with a diagnosis of Autistic Spectrum Disorder (A serious developmental disorder that impairs the ability to communicate and interact).

Record review of Patient #24's chart on 7/17/18 at 12:25 pm revealed a BMR and seclusion occurred on 7/5/18 7:18 pm. Indication for the BMR was "unsafe and slamming door in room repetitively refusing to redirect and so hard it seemed he could break door." Indication for the seclusion was "With encouragement he was escorted to the OAK room. Given [his/her] autism [he/she] was praised for walking to the OAK room and told [he/she] would remain there to cool off. [He/she] sat down quietly and door was locked at [7:19 pm]." This seclusion last for 40 minutes.

Video observation on 7/18/18 at 2:15 pm of the 7/5/18 event revealed the Patient #24 being escorted from his/her bedroom, unassisted, to the Oak room and sat on the bed inside without prompts. A nursing staff could be seen telling Patient #24 he/she needed to remain in the Oak room until calm. The door was then locked and seclusion was started. Throughout the seclusion, the Patient sat down or laid down on the seclusion bed the entire length of time.

During an interview on 7/18/18 at 3:15 pm, Registered Nurse #1 stated the note written about the incident does indicate that Patient #24 was calm when the seclusion was initiated. He/she could not justify the decision for the seclusion.

Review of the facility's policy "Management of Patient Behavior," dated 6/1/18, revealed: "Section III: Seclusion: Section B: Seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time."

Review of the facility's policy "Seclusion and or Restraint, Patient Safety Equipment," dated 6/1/18, revealed: "API is committed to providing the least restrictive environment that supports the safe and therapeutic treatment of patients; and in doing so, API allows the use of seclusion and restraint only in response to a clear and significant risk to the patient or others."

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Based on record review and interview, the facility failed to ensure sufficient opportunities at least restrictive interventions were attempted prior to a restraint and/or seclusion was initiated for 1 patient (#22), out of 30 sampled patients. This failed practice violated the patient's right to be free from restraint and/or seclusion which could affect the patient's response to treatment and increase potential risk for injury. Findings:

Patient #22

Record review on 7/16-19/18 revealed Patient #22 was admitted to the facility on 6/15/18 with a diagnosis of Oppositional Defiant Disorders (a disorder in a child marked by defiant and disobedient behavior to authority figures).

Record review of Patient #22's chart on 7/17/18 at 11:45 am revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) took place on 6/18/18 at 2:26 pm. Indication for BMR was: "[Patient] on unit refocus program. [Patient] exited room and was not redirectable back to [his/her] room. [Patient] informed staff that [he/she] was afraid of [his/her] room. Staff offered the family room as an alternative refocus area. [Patient] refused. [Patient] asked to walk to the Oak Rook to work on [his/her] refocus. [Patient] refused. [Patient] placed in a BMR to assist [him/her] to Gurney and then to Oak Room. [Patient] became very elevated and fought staff throughout the BMR-Gurney-Oak Room process..."

Review of the order for BMR, dated 6/18/18 at 2:26 pm, Licensed Individual Practitioner #1 revealed the clinical justification for the BMR was "[Patient] not redirectable from the staff hallway, [Patient] refused to walk to a safe area."

Review of the "Restraint Assessment," dated 6/18/18 at 2:26 pm, written by Registered Nurse (RN) #1 revealed the only least restrictive interventions that were attempted prior to the BMR were verbal interaction and redirection.

During an interview on 7/19/189 at 10:25 am, RN #1 stated the BMR on 6/18/18 for Patient #22 may have been "rushed." RN #1 could not state the behavior Patient #22 was exhibiting that justified the start of the restrictive measures taken by staff except to say he/she felt it was "unsafe" having Patient #22 in a unit hallway that contained some staff offices..

Review of the facility policy "Management of Patient Behavior", effective date 6/1/2018, revealed: "API will provide least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and well ensure the safety and well-being of all patients, staff and visitors."

The policy further revealed: "Definitions: Management of Patient Behavior: ...These procedures include de-escalation of a patient through the progression of non-verbal, verbal, and physical interventions necessary to safely and therapeutically manage a patient's behavior. As a last resort, the interventions may include seclusion, physical holds/restraint, and mechanical restraint ..."


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Based on record review, video observation, and interview the facility failed to ensure the type or technique of restraint or seclusion used was the least restrictive intervention for 2 patients (#10 and #24) out of 30 sampled patients. This failed practice created a non-therapeutic environment and an increased potential for injury. Findings:

Patient #10

Record review on 7/16-19/18 revealed Patient #10 was admitted to the facility on 7/7/18 with a diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal though processes and disturbance in the person's mood) and Mild Intellectual Disabilities (impairment of cognitive skills, adaptive life skills, and social skills).

Episode #1

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) and seclusion (the act prohibiting a patient from leaving an area) occurred on 7/15/18 at 2:34 am. Indication for the BMR was " ...disruptive to milieu ...going into other patient's room ..." Indication for the seclusion was "Decision made to put [patient] in locked seclusion for the welfare of the other patients on the unit." This seclusion lasted 2 hours and 4 minutes.

Video observation on 7/18/18 at 1:36 pm of the 7/15/18 event revealed the Patient walked around the front desk and raised his/her voice at times. The Patient #10 walked up and down the hallway, but did not enter other patients' rooms. Staff placed the Patient #10 into a BMR, and walked him/her down to the Oak Room. On the camera, it was observed that Patient #10 calmly walk into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time.

Record review of Patient #10's Master Treatment Plan, dated 7/10/18, revealed no indication or history of patient's behavior pattern that would required an instant seclusion when taken to the Oak Room.

During an interview on 7/18/18 at 1:36 pm, the Medical Director, who watched the camera review with surveyor, stated the door did not need to be locked.

During an interview on 7/18/18 at 1:36 pm, Chief Operating Officer watched the camera review with surveyor and stated the staff overreacted by closing the door.

Episode #2

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a BMR and seclusion occurred on 7/16/18 at 3:43 am. Indication for the BMR was "[Patient] yelling/screaming, disruptive to milieu ...antagonizing a [male/female] peer, tried to follow [male/female] peer in [his/her] room ..." Indication for the seclusion was "Due to patient's behavior pattern locked seclusion initiated for the welfare of the other patients on the unit."

Video observation on 7/18/18 at 2:35 pm of the 7/16/18 event revealed the Patient walked around the front desk, raised his/her voice at times, and talked with another patient. When this patient returned to his/her room, Patient #10 followed him/her but did not enter the bedroom. He/she stood by the door and continued to talk to the other patient. Staff placed Patient #10 into a BMR, and walked him/her down to the Oak Room. On the camera, it was observed that the Patient #10 calmly walked into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time. This seclusion last for 41 minutes.

Record review of Patient #10's Master Treatment Plan, dated 7/10/18, revealed no indication or history of patient's behavior pattern that would required an instant seclusion when taken to the Oak Room.

Patient #24

Record review on 7/16-19/18 revealed Patient #24 was admitted to the facility on 7/7/18 with a diagnosis of Autistic Spectrum Disorder (A serious developmental disorder that impairs the ability to communicate and interact).

Record review of Patient #24's chart on 7/17/18 at 12:25 pm revealed a BMR and seclusion occurred on 7/5/18 7:18 pm. Indication for the BMR was "unsafe and slamming door in room repetitively refusing to redirect and so hard it seemed he could break door." Indication for the seclusion was "With encouragement he was escorted to the OAK room. Given [his/her] autism [he/she] was praised for walking to the OAK room and told [he/she] would remain there to cool off. [He/she] sat down quietly and door was locked at [7:19 pm]." This seclusion last for 40 minutes.

Video observation on 7/18/18 at 2:15 pm of the 7/5/18 event revealed the Patient #24 being escorted from his/her bedroom, unassisted, to the Oak room and sat on the bed inside without prompts. RN can be seen telling Patient #24 he/she needed to remain in the Oak room until calm. The door was then locked and seclusion was started. Throughout the seclusion, Patient #24 sat down or laid down on the seclusion bed the entire length of time.

During an interview on 7/18/18 at 3:15 pm, Registered Nurse #1 stated the note written about the incident indicated that Patient #24 was calm when the seclusion was initiated. He/she could not justify the decision for the seclusion.

Review of the facility's policy "Management of Patient Behavior," dated 6/1/18, revealed: "API will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients, staff, and visitors."

Further review of the policy revealed: " ...staff will intervene in the least restrictive manner effective to assist the patient to regain emotional control and to mitigate the danger of the situation."

Review of the facility's policy "Seclusion and or Restraint, Patient Safety Equipment," dated 6/1/18, reveals: "API is committed to providing the least restrictive environment that supports the safe and therapeutic treatment of patients; and in doing so, API allows the use of seclusion and restraint only in response to a clear and significant risk to the patient or others."

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Based on record review, video observation, and interview the facility failed to ensure seclusions were discontinued at the earliest possible time for 2 patients (#10 and #24) out of 30 sampled patients. This failed practice created a non-therapeutic environment, an increased potential for injury, and/or psychological harm. Findings:

Patient #10

Record review on 7/16-19/18 revealed Patient #10 was admitted to the facility on 7/7/18 with a diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal though processes and disturbance in the person's mood) and Mild Intellectual Disabilities (impairment of cognitive skills, adaptive life skills, and social skills).

Episode #1

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) and seclusion (the act prohibiting a patient from leaving an area) occurred on 7/15/18 at 2:34 am. Indication for the BMR was " ...disruptive to milieu ...going into other patient's room ..." Indication for the seclusion was "Decision made to put [patient] in locked seclusion for the welfare of the other patients on the unit." This seclusion lasted 2 hours and 4 minutes.

Video observation on 7/18/18 at 1:36 pm of the 7/15/18 event revealed that Patient #10 calmly walk into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time.

Review of the "Seclusion Face to Face Flow Sheet" for 7/15/18 revealed the Patient #10's behavior for the last 23 minutes of seclusion included "lying/sitting" and it was documented he/she was "quiet" for the last 8 minutes of the seclusion.

During an interview on 7/18/18 at 1:36 pm, the Medical Director, who watched the camera review with surveyor, stated the door did not need to be locked.

Episode #2

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a BMR and seclusion occurred on 7/16/18 at 3:43 am. Indication for the BMR was "[Patient] yelling/screaming, disruptive to milieu ...antagonizing a [male/female] peer, tried to follow [male/female] peer in [his/her] room ..." Indication for the seclusion was "Due to patient's behavior pattern locked seclusion initiated for the welfare of the other patients on the unit."

Video observation on 7/18/18 at 2:35 pm of the 7/16/18 event revealed that the Patient #10 calmly walk into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time. This seclusion last for 41 minutes.

Review of the "Seclusion Face to Face Flow Sheet" for 7/16/18 revealed the Patient #10's behavior was documented as "sleeping" the last 10 minutes of the seclusion.


Patient #24

Record review on 7/16-19/18 revealed Patient #24 was admitted to the facility on 7/7/18 with a diagnosis of Autistic Spectrum Disorder (A serious developmental disorder that impairs the ability to communicate and interact).

Record review of Patient #24's chart on 7/17/18 at 12:25 pm revealed a BMR and seclusion occurred on 7/5/18 7:18 pm. Indication for the BMR was "unsafe and slamming door in room repetitively refusing to redirect and so hard it seemed he could break door." Indication for the seclusion was "With encouragement he was escorted to the OAK room. Given [his/her] autism [he/she] was praised for walking to the OAK room and told [he/she] would remain there to cool off. [He/she] sat down quietly and door was locked at [7:19 pm]." This seclusion last for 40 minutes.

Video observation on 7/18/18 at 2:15 pm of the 7/5/18 event revealed Patient #24 being escorted from his/her bedroom, unassisted, to the Oak room and sat on the bed inside without prompts. RN can be seen telling Patient #24 he/she needed to remain in the Oak room until calm. The door was then locked and seclusion was started. Throughout the seclusion, the Patient #24 sat down or laid down on the seclusion bed the entire length of time.

Review of the "Seclusion Face to Face Flow Sheet" for 7/5/18 revealed the Patient #24's behavior was documented as "quiet" and "lying/sitting" for the entire length of the seclusion.

During an interview on 7/18/18 at 3:15 pm, Registered Nurse #1 stated the note written about the incident indicated that Patient #24 was calm when the seclusion was initiated. He/she could not justify the decision for the seclusion.

Review of the facility's policy "Management of Patient Behavior," dated 6/1/18, revealed: " ...staff will intervene in the least restrictive manner effective to assist the patient to regain emotional control and to mitigate the danger of the situation."

Review of the facility's policy "Seclusion and or Restraint, Patient Safety Equipment," dated 6/1/18, revealed: "API is committed to providing the least restrictive environment that supports the safe and therapeutic treatment of patients; and in doing so, API allows the use of seclusion and restraint only in response to a clear and significant risk to the patient or others."

Further review of the policy revealed: "Psychiatric Nursing Assistant (PNA) responsibilities: 10(i): Determine readiness for discontinuation for [Seclusion/Restraint] based on meeting behavior criteria for discontinuation ...F. Release from seclusion/restraint: 1. The patient will be released when the RN or LIP determines the need for restraint is no longer present or the patient's needs can be addressed using less restrictive methods. 2. Patients who are sleeping may be deemed to be no danger to themselves or others. In such situations, the removal of restraints or discontinuation of seclusion should be considered."


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Based on record review, video observation, and unit observation the facility failed to ensure ongoing assessment and monitoring of 1 patient's (#10) condition while in seclusion. This failed practice placed the patient at risk for injury and falsified medical records as to the monitoring of patient's behavior while in seclusion. Findings:

Record review on 7/16-19/18 revealed Patient #10 was admitted to the facility on 7/7/18 with a diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal though processes and disturbance in the person's mood) and Mild Intellectual Disabilities (impairment of cognitive skills, adaptive life skills, and social skills).

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) and seclusion (the act prohibiting a patient from leaving an area) occurred on 7/15/18 at 2:34 am. This seclusion lasted 2 hours and 4 minutes.

Video observation on 7/18/18 at 1:36 pm of the 7/15/18 incident revealed the Patient #10 was left unattended in seclusion from 2:51 am to 3:33 am (a total of 42 minutes) and again from 4:02 am to 4:17 am (a total of 15 minutes). The staff can be seen standing in the hall by the Oak room entrance door frame leaning on the wall during these times of non-supervision.

Record review of the "Seclusion Face to Face Sheet," dated 7/15/18 at 2:34 am, revealed documentation during these non-supervised times as to the Patient #10's behavior:

- 3:00 am - Yell/Scream/Cry, Walking/Pacing, Singing, and Beating Door
- 3:15 am - Yell/Scream/Cry, Walking/Pacing, Singing, and Beating Door
- 3:30 am - Yell/Scream/Cry, Walking/Pacing, Singing
- 4:15 am - Lying/Sitting, Yell/Scream/Cry

Additional camera review of these time frames revealed Patient #10 sat or laid quietly on the bed, sang, or walked to the seclusion door and attempted to peer out of the window at an angle to locate staff. He/she occasionally knocked on the seclusion door window.

During an observation on 7/18/18 at 2:14 pm, a surveyor stood in the Oak room seclusion room with the door closed. Another surveyor stood in the hall by the Oak room entrance door frame leaning on the wall in the same position the staff was during the 7/15/18 seclusion. The Surveyor could not visualize the other surveyor in the Oak room from the entrance door frame.

Review of the facility's policy "Seclusion and or Restraint, Patient Safety Equipment," dated 6/1/18 revealed: "When a patient is in the Oak Room, they require one to one staffing at all times; no patient will be permitted in the Oak Room by himself or herself (voluntary, for behavioral emergency, or as an alternate bed area)."

Further review of the policy revealed: "Section D: Psychiatric Nursing Assistant (PNA) responsibilities:
3. Provide [one to one] monitoring of patient as follows: a. If the patient is in seclusion, the PNA staff will observe the patient continuously from outside the room with no obstructions blocking the view of the patient through the window."


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Based on record review, video observation, and interview the facility failed to ensure the patient's medical record contained a description of warranted conditions or symptoms to place 2 patients (#10 and #24), out of 30 sampled patients, in seclusion. This failed practice created a non-therapeutic environment and an increased potential for injury. Findings:

Patient #10

Record review on 7/16-19/18 revealed Patient #10 was admitted to the facility on 7/7/18 with a diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal though processes and disturbance in the person's mood) and Mild Intellectual Disabilities (impairment of cognitive skills, adaptive life skills, and social skills).

Episode #1

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) and seclusion (the act prohibiting a patient from leaving an area) occurred on 7/15/18 at 2:34 am. Indication for the BMR was " ...disruptive to milieu ...going into other patient's room ..." Indication for the seclusion was "Decision made to put [patient] in locked seclusion for the welfare of the other patients on the unit." This seclusion lasted 2 hours and 4 minutes.

Video observation on 7/18/18 at 1:36 pm of the 7/15/18 event revealed the Patient walked around the front desk and raised his/her voice at times. Patient #10 walked up and down the hallway, but did not enter other patients' rooms. Staff placed Patient #10 into a BMR, and walked him/her down to the Oak Room. On the camera, it was observed that Patient #10 calmly walk into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time.

During an interview on 7/18/18 at 1:36 pm, the Medical Director, who watched the camera review with surveyor, stated the door did not need to be locked.

During an interview on 7/18/18 at 1:36 pm, Chief Operating Officer watched the camera review with surveyor and stated the staff overreacted by closing the door.

Episode #2

Record review of Patient #10's chart on 7/16/18 at 1:20 pm revealed a BMR and seclusion occurred on 7/16/18 at 3:43 am. Indication for the BMR was "[Patient] yelling/screaming, disruptive to milieu ...antagonizing a [male/female] peer, tried to follow [male/female] peer in [his/her] room ..." Indication for the seclusion was "Due to patient's behavior pattern locked seclusion initiated for the welfare of the other patients on the unit."

Video observation on 7/18/18 at 2:35 pm of the 7/16/18 event revealed the Patient walked around the front desk, raised his/her voice at times, and talked with another patient. When this patient returned to his/her room, Patient #10 followed him/her but did not enter the bedroom. He/she stood by the door and continued to talk to the other patient. Staff placed Patient #10 into a BMR, and walked him/her down to the Oak Room. On the camera, it was observed that the Patient #10 calmly walked into the seclusion room and sat down on the bed unassisted. Staff locked the door and initiated a seclusion at that time. This seclusion last for 41 minutes.

Patient #24

Record review on 7/16-19/18 revealed Patient #24 was admitted to the facility on 7/7/18 with a diagnosis of Autistic Spectrum Disorder (A serious developmental disorder that impairs the ability to communicate and interact).

Record review of Patient #24's chart on 7/17/18 at 12:25 pm revealed a BMR and seclusion occurred on 7/5/18 7:18 pm. Indication for the BMR was "unsafe and slamming door in room repetitively refusing to redirect and so hard it seemed he could break door." Indication for the seclusion was "With encouragement he was escorted to the OAK room. Given [his/her] autism [he/she] was praised for walking to the OAK room and told [he/she] would remain there to cool off. [He/she] sat down quietly and door was locked at [7:19 pm]." This seclusion last for 40 minutes.

Video observation on 7/18/18 at 2:15 pm of the 7/5/18 event revealed Patient #24 being escorted from his/her bedroom, unassisted, to the Oak room and sat on the bed inside without prompts. An Registerd Nurse can be seen telling Patient #24 he/she needed to remain in the Oak room until calm. The door was then locked and seclusion was started. Throughout the seclusion, Patient #24 sat down or laid down on the seclusion bed the entire length of time.

During an interview on 7/18/18 at 3:15 pm, Registered Nurse #1 stated the note written about the incident indicated that Patient #24 was calm when the seclusion was initiated. He/she could not justify the decision for the seclusion.

Review of the facility's policy "Management of Patient Behavior," dated 6/1/18, revealed: "API will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients, staff, and visitors."

Further review of the policy revealed: " ...staff will intervene in the least restrictive manner effective to assist the patient to regain emotional control and to mitigate the danger of the situation."

Review of the facility's policy "Seclusion and or Restraint, Patient Safety Equipment," dated 6/1/18, revealed: "API is committed to providing the least restrictive environment that supports the safe and therapeutic treatment of patients; and in doing so, API allows the use of seclusion and restraint only in response to a clear and significant risk to the patient or others."


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Based on document review and interview, the hospital failed to utilize their Quality Assessment and Performance Improvement (QAPI) activities to identify the need for patient safety and enhanced health outcomes when providing treatment for behavioral symptoms. This had the potential to affect all patients who were residing in the hospital (Based on a census of 57). Findings:

During the entrance interview on 7/16/18 the Survey Team asked requested the last 4 quarters of quality data reported to the Alaska Psychiatric Institute (API) Leadership and API Governance Committee and the meeting minutes to reflect review of the data reported to those committees.

Review of the "API Senior Leader Management Team" policy, dated 6/15/15, revealed "Meetings are held at least twice monthly, and more frequently as needed."

Record review of the Senior Leadership Management Team meeting minutes for April 2017; December 2017; January 18, 2018; and May 17, 2018, revealed the quarterly "API Performance Indicator Data" had been attached to the minutes.

Further review of the Senior Leadership Management Team meeting notes provided from 4/17 - 5/24/18, revealed no documented discussion of the performance data provided. In addition, the minutes did not reflect how the data was to be used to improve performance and care concerns. i.e., action plans.

Record review of the "API Governance Committee" meeting minutes from 4/17 - 3/17 revealed no documented discussion of the performance data provided. In addition, the minutes did not reflect how the Joint Commission ORXY data provided quarterly to the governance committee was to be used to improve performance and care concerns. i.e., action plans.

Review of the 3 quarterly ORXY (Joint Commission Performance Measure Data) dated:

- 4th Quarter 2016 - 3rd Quarter 2017;
- 3rd Quarter 2016 - 2nd Quarter 2017; and
- 1st Quarter 2017 - 4th Quarter 2017.

Revealed no change in performance for 5 the same "undesirable" in each quarter reported and included:

-Admission Screening - Adult (18-64 years);
-Multiple Antipsychotic Medications at Discharge
With -Appropriate Justification - (18-64 years);
-Multiple Antipsychotic Medications at Discharge
With Appropriate Justification (Overall rate);
-Seclusion - Adult (18-64 years); and
-Seclusion - overall rate.

The ORXY reports defined an undesirable report as "Statistically Significant Performance Issues Identified - Detailed Internal Measure Review Recommended."

During an interview on 7/19/18 at 8:35 am, the Quality Manager (QM) stated he/she was pulling all the quality data. The QM stated the departments had not directly reported any data or measures for improvement.

During an interview on 7/19/18 at 2:45 pm, when asked about the lack of change in the quality data, the Behavioral Health Director (BHD) and the Director, stated part of the problem was no support from the nursing department. Any other departments involvement depended on the reporting data. The BHD stated the data was off because they were a smaller hospital.

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Based on document review and interview, the hospital failed to ensure a Quality Assessment and Performance Improvement (QAPI) program used analyzed allegations of maltreatment for 2 patients (#s 22 and 35) and failed discharges for 2 patients (#s 1 and 2) out of 30 patients reviewed. Although the facility audited allegations of maltreatment or possible/abuse and/or neglect and readmission the audits were not completed to ensure the facility policy and protocols were being implemented. The facility did not differentiate between the different types of discharges and the reasons for readmissions or have a process for following up with patients after discharge. Findings:

Review on 7/19/18 of the API Governance Committee Meeting, dated 3/2/18, "Status/Performance Report" included the "Discharge Barriers"; "Assault and Injury Data"; "Patient Grievances"; and "ORYX Data Review" Review of the "Action Item" was "Ongoing...Topics included obtaining General Relief in a timely bases (sp), lack or appropriate Assisted Living Facilities (ALFs) and document between various state offices.

Allegations of Maltreatment

Record review on 7/17-18/18 of Patient #22's record revealed an event on 6/18/18 of the Patient jumping on the furniture. When the Patient refused to get down the Patient was approached by WEKA (contracted security support staff). After the Patient struck out at the WEKA staff, the Patient was placed in a manual hold, strapped to a gurney, and placed in seclusion.

Review of Patient #25's medical record revealed there was an event of the Patient stashing 3 pills and a bobby pin (considered contraband). On 6/24/18 the Patient was placed into a safety vest (a thick garment that doesn't tear) and physically had his/her underwear removed by staff after refusing to completely disrobe. The event was assigned for process review on on 6/28/18.

Review of the investigations revealed the process reviews of both events had not been completed by nursing administration and none of the involved staff had been interviewed and/or educated on possible patient maltreatment.

Review of the "Process Review Update", updated 6/26/18, revealed events were patients were possibly maltreated or denied their rights from 1/2018 until 6/13/18, totaling 16 cases, had not been reviewed by administrative staff.

During an interview on 7/19/18 at 8:40 am, when asked about the incomplete reviews of incidents involving potential patient abuse and/or harassment, the Quality Manager (QM) stated they had not been getting completed. The QM stated they were reassigned to the current interim Director of Nursing and the facility was planning on hiring a contractor to help finish them.

During an interview on 7/19/18 at 10:05 am, the Safety Officer stated process reviews assigned to nursing administration for review were not getting completed, in addition, the review done by nursing administration were not completed objectively.

Readmission after Discharge

Record review on 7/16/18 revealed Patient # 1 was discharged from the facility on 6/26/18, the Patient was readmitted after a suicide attempt 10 days later.

Record review on 7/16-19/18 revealed Patient #2 was discharged to home on 7/3/18. The Patient was readmitted to the facility 1 week later after being found in a manic phase at a gas station.

During an interview on 7/18/18 when asked about the discharge planning process and tracking the different types, Social Worker #1 stated the facility does not differentiate between a normal discharge, court discharge, or the patient leaving against medical advice.

During an interview on 7/18/18 Mental Health Clinician Manager (MHCM) #1 stated the hospital tracks the readmission rates. The MHCM stated the facility did not follow up with the Patients after discharge and relied on the out patient providers to contact the patients.

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Based on record review and interview the facility failed to analyze causes of adverse patient events and implement corrective actions and provide feedback and learning to improve facility performance. The failed practice created a risk for abuse and neglect of a vulnerable population in the care of the facility (based on census of 57). Findings;

Review on 7/18-19/18 of the "Pending Assigned Process Reviews, updated 6/26/18 revealed 15 events with allegations of maltreatment and/or allegations of violations of patients rights from 11/27/18 to 6/7/18.

During an interview on 7/19/18 at 8:40 am, when asked about the incomplete reviews of incidents involving potential patient abuse and/or harassment, the Quality Manager (QM) stated they had not been getting completed. The QM stated they were reassigned to the current interim Director of Nursing (DON) and the facility was planning on hiring a contractor to help finish them.

During an interview on 7/19/18 at 10:05 am, the Safety Officer stated process reviews assigned to nursing administration for review were not getting completed, in addition, the review done by nursing administration were not completed objectively.

Review of the API [Alaska Psychiatric Hospital] and P&P Management Meeting, dated 5/24/18 revealed a process review, assigned back in January, was send back to nursing administration for further review. Review of "Allegations of Abuse and Neglect" were blank.

Review of the "Quality Improvement/ Performance Improvement Program", dated 6/13/13, revealed "IV. Senior Management Team Responsibilities...d Identify trends, patterns of performance and potential problems affecting more that one department or patient care unit."
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Based on interview and observation the facility failed to ensure licensed nurses monitored delegated tasks. The failure to ensure licensed nurses (LN) oversaw the tasks preformed by non licensed nursing personal placed patients in the facility at risk for harm and/or substandard quality of care. Findings:

During an interview on 7/16/18 at 11:00 am, Psychiatric Nursing Assistant (PNA) #9 stated if a code is called for a violent patients, the staff in the vicinity will call overhead but will not always respond themselves. The PNA stated he/she will respond to a code and the unit staff will just be standing around. The PNA stated the same core staff will always end up responding to an event. In addition, the PNA stated staff do not encourge the patients to bathe or change their linens.

Observation on 7/17/18 at 7:30-8:00, PNA #10, walked back and forth in the nurses station, the PNA then went out to do the every 15 minute checks (locater checks), the PNA then returned to the nurses station. Both nurses were seated at computers inside the nurses station.

During an observation on 7/17/17 at 9:00 pm , PNA #7 was observed watching videos inside the locked nurses station. At 9:10 pm, the PNA went out to do locater checks on the unit.

During an observation on the locked Susitna unit, on 7/17/18 at 9:42 pm, PNA #4 was observed doing the locater checks (every 15 minute checks) on the unit.

During an interview on 7/17/18 at 9:45 pm, PNA #11 stated the LN never perform the locater checks like they are supposed to, they only initial what the PNAs do.

During an interview on 7/17/18 at 9:52 pm, LN #2 stated the nurses only initial the locater checks, they do not have to do visuals on the patients.

Observation during the survey on 7/13-16/18 revealed each of the locked units had a round nurses desk located in front of the nursing station. The desk was centrally located so the staff sitting at it could visualize the hallways and the common area rooms. The only fire pull station on the unit was located behind the desk .

During an interview on 7/16/18 at 11:00 am, PNA #9 stated staff was always seated at the desk. the PNA stated staff are usually shopping or searching the Internet when seated at the desk.

Observation during the survey:

Observation on 7/16/18 at 9:45 am, PNA #12 knocked on Patient #32's door and entered the room. when the Patient asked what was going on, the PNA stated they are having a class right now but "you don't have to go." The Patient then went back to bed.

On 7/16/18 at 11:41 am, no staff were seated at the desk.

On 7/17/18 at 7:22 am no staff were seated at the desk;

During an interview on 7/17/18 at 6:50 am. PNA #13 stated staff were always supposed to be seated at the desk.

During an interview on 7/19/18 ay 10:05 am, when asked about the patients refusing treatment and not alternative being offered or effort to encourage them to engage, the Mental Health Clinician stated the unit was PNA oriented.

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Based on record review and interview the facility failed to develop accurate and up-to-date nursing care plans by ensuring: 1) the initial treatment plan was completely filled out for 1 patient (#14) out of 30 sampled patients; 2) the master treatment plan was completely filled out for 1 patient (#11) out of 30 sampled patients; and 3) medical interventions were incorporated into the care plan to ensure adequate standards of practice are maintained for 3 patients (#30, #27, and #31) out of 30 sampled patients. These failed practices placed the patients are at risk for not receiving the necessary and/or appropriate care and services. Findings:

1) Initial Treatment Plan Completion

Record Review on 7/16-19/18 revealed Patient #14 was admitted to the facility on 7/15/18 with a diagnosis of Major Depression, Moderate, Recurrent (a severely depressed mood that persists for at least two weeks and can reoccur or relapse. It can have a marked impact on social or occupational functioning).

Review of Patient #14's Initial Treatment Plan (plan completed within 24 hours; includes physician orders written to address problems identified as a result of initial assessment and treatment orders), dated 7/15/18, revealed multiple sections left blank: 1) Admitting Diagnosis; 2) Problem(s): Check the applicable problems(s) at time of admission; 3) Risk/Safety Concerns/Precautions; 4) As manifested by: Check all that apply; and 5) De-escalation Plan: Use quotes throughout this section when possible.

Further review revealed that the Registered Nurse (RN) writing the plan, as well as, the on-coming RN, Licensed Individual Practitioner (LIP), Social Worker, and Clinical Services all signed this incomplete Initial Treatment Plan.

During an interview 7/16/18 at 1:00 pm, RN #3 reviewed Patient #14's Initial Treatment Plan and stated it was not complete.

Review of the facility policy "Treatment Planning," with an effective date of 8/30/2017, revealed: "Section II: Initial Treatment Plan. Section A: This Initial Treatment Plan (ITP) must be completed by the RN within 24 hours of admission. The ITP includes physician orders written to address problems identified as a result of initial assessments and treatment orders. Section B: ...the primary known psychiatric and physical problems requiring initial treatment will be noted on the ITP. Section C: The RN will complete the Risk/Safety Concerns and De-escalation Plan."

2) Master Treatment Plan Completion

Record review on 7/16-19/18 revealed Patient #11 was admitted to the facility on 7/12/18 with a diagnosis of Schizoaffective Disorder, Unspecified (a mental disorder characterized by abnormal though processes and disturbance in the person's mood).

Review of Patient #11's Master Treatment Plan (MTP) (identifies the patient's diagnosis, specific problems, specific goals, and specific interventions to be addressed during hospitalization), dated 7/13/18, revealed multiple sections left blank: 1) Current Active Diagnoses; 2) Other Conditions/Situations for Consideration in Treatment; 3) Strengths/Assets; and 4) Discharge Resources.

Further review revealed that the RN, LIP, and Social Worker all signed this incomplete Master Treatment Plan. The treatment team had Patient #11 sign this incomplete document as well.

During an interview on 7/18/18 at 3:00 pm, RN #4 reviewed Patient #11's Master Treatment Plan and stated it was not complete.

Review of the facility policy "Treatment Planning", effective date of 8/30/17, revealed: "Section III: Master Treatment Plan (MTP). Section B: The MTP addresses significant clinical issues identified in the initial RN Assessment, the LIP Assessments, the Social Worker Discharge Planning Assessment ... Section D: All Clinical disciplines involved in the care of the patient will participate in the development or identification of the following within the Treatment Plan: 2. Diagnoses. 3. Patient's strengths and assets: The strengths/assets are aspects of the patient that help/aid in meeting his/her needs. They are considered by the team when writing goals. 4. Discharge Resources: The assets available to the patient such as income, insurance, and involvement with care providers. Section J: The patient will be asked to indicate agreement, disagreement, and any recommended changes to the plan."

3) Medical interventions within the care plan

Patient #30

Record review on 7/16-19/18 revealed Patient #30 was admitted to the facility on 6/11/18 with a medication regimen that included Semaglutide (a drug for the treatment of type 2 diabetes) 0.25mg subcutaneous (SQ) (an injection in the layer of skin below the dermis and epidermis, but not in the muscle) weekly.

Record review of the Patient #30's "History & Physical" (H & P), dated 6/12/18, revealed an active problem list that included: "elevated blood glucose, no listed [diagnosis] of [diabetes mellitus 2]." Additional review reveals "Impression/Plan: Elevated blood sugar: fasting glucose x3, hemoglobin A1C ..."

Review of the Patient #30's "RN Assessment," dated 6/11/18, revealed documentation that reads: "[History] miscellaneous medical problems: No" and "Current and/or recent medical/health problem(s) description: none."

Further review revealed "Detailed summary of RN Admission Assessment/additional comments & info ...Takes semaglutide weekly last given 6/11."

Review of the Patient #30's "Admit Psychiatric Evaluation," dated 6/12/18, revealed documentation under "Medical History" which reads: "Semaglutide 0.25mg SQ [every week]." Additional review reveals under "Medical Diagnoses" which reads: "Please see medical H & P."

Review of the Patient #30's laboratory blood work since admission, the following fasting glucose (blood sugar before meals, normal range is less than 100 milligrams per deciliter (mg/dL)) and hemoglobin A1C (measured to identify a three-month average plasma glucose concentration within the blood stream, normal range is below 5.7%) labs were drawn:

- 6/12/18: Fasting Glucose - 107 mg/dL (high); Hemoglobin A1C - 5.9% (high)
- 6/14/18: Fasting Glucose - 96 mg/dL
- 6/15/18: Fasting Glucose - 100 mg/dL (high)

Review of the Patient #30's Master Treatment Plan, dated 6/14/18, revealed no mention of Semaglutide treatment or elevated blood sugars or Hemoglobin A1C.

Reviews of the Patient #30's Initial Treatment Plans, dated 6/21/18, 6/28/18, 7/5/18, and 7/12/18, revealed no mention of Semaglutide treatment or elevated blood sugars or Hemoglobin A1C.

Review of the facility's form "Alaska Psychiatric Institute Problem Sheet: Multiple Medical Problems," dated 3/2016, revealed two short term goals and five interventions available to be use in the treatment of hypoglycemia/hyperglycemia, one of which was "RN/[Licensed Practical Nurse] will monitor blood sugar ...as ordered by LIP."

Patient #27

Record review on 7/16-19/18 revealed Patient #27 was admitted with a diagnosis of Borderline Personality Disorder (long-term pattern of abnormal behavior characterized by unstable relationships, unstable sense of self, and unstable emotions).

Record review of the Patient #27's H & P, dated 7/17/18, revealed an active problem list that includes: "self mutilative behavior."

Record review of a medical note labeled "MOS Progress Note," dated 7/17/18, revealed: "Patient admitted today with a self-inflicted 1.5 inch laceration on left calf, without signs or [symptoms] of infection. Interventions: Daily wound care with triple [antibiotic ointment] and bandage."

Review of the Patient #27's Initial Treatment Plan," dated 7/17/18, revealed no mention of daily wound care.

Review of the "Alaska Psychiatric Institute Problem Sheet: Multiple Medical Problems," dated 3/2016, revealed a section under short term goals titled "Other Medical Conditions" and nine interventions available to be use in the treatment of other medical conditions, one of which was "Nursing staff will encourage/assist the patient with the following in order to attain or maintain the optimal level of wellness ...maintenance of skin integrity."

Patient #31

Record review on 7/16-19/18 revealed Patient #31 was admitted with a diagnosis of Autistic Disorder (A serious developmental disorder that impairs the ability to communicate and interact).

Review of a medical note labeled "MOS Progress Note," dated 7/5/18, revealed a diagnosis of "Acne, face and neck" with the following note: "Staff reports that patient has facial acne. Acne noted on facial, mainly forehead but also no neck ...Minocycline 50 mg [twice a day] [by mouth] [for] 12 weeks ordered ..."

Review of the Patient #31's Master Treatment Plan, dated 6/14/18, revealed no mention of antibiotic use for acne.

Review of the Patient #31's Initial Treatment Plan, dated 7/10/18, revealed no mention of antibiotic use for acne.

Review of the "Alaska Psychiatric Institute Problem Sheet: Multiple Medical Problems," dated 3/2016, revealws a section under short term goals titled "Other Medical Conditions" and nine interventions available to be use in the treatment of other medical conditions, one of which was "RN/LPN will administer prescribed medications/treatments, monitor patient's compliance with treatment, monitor effectiveness of treatment, and observe for potential side effect of medications providing education about the prescribed medication ..."

During an interview on 7/18/18 at 10:05 am, RN #3 stated he/she would only do a medical problem page if he/she were providing wound care or for patients who are diabetic with injectable insulin, but only if it is new and required education.

During an interview on 7/18/18 at 10:18 am, RN #4 stated he/she would do a problem page for patients if he/she was actively treating a problem. RN #4 further stated he/she would not address "chronic" diabetes, one who has been on insulin for years.

During an interview on 7/18/18 at 3:15 pm, RN #1 stated he/she had never seen the "Alaska Psychiatric Institute Problem Sheet: Multiple Medical Problems" form before. RN #1 stated he has made a medical problem page before for "acute" medical conditions, but not "chronic" medical conditions.

Review of the facility's policy "Treatment Planning," dated 8/30/17, revealed: "Section II: Initial Treatment Plan: Section A: The Initial Treatment Plan (ITP) must be completed by the [Registered Nurse] within 24 hours of admission. The ITP includes physician orders written to address problems identified as a result of initial assessments and treatment orders."

Addition review revealed: "Section III: Master Treatment Plan: Section B: The [Master Treatment Plan] addresses significant clinical issues identified in the initial [Registered Nurse] Assessment, the [Licensed Individual Practitioner] Assessments ...and at any time during the course of treatment subsequent to re-assessments or changes in the patient's presentation."
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Based on interview and record review, the hospital failed to conduct Utilization Review (UR) tasks to determine medical necessity for Medicare and Medicaid patients as evidenced by:

Based on interview and record reviews the facility failed to have a utilization review plan (UP) that defined the effective utilization of health care resources and made recommendations for the optimum use of hospital resources and facilities (see A-0653).

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Based on interview and record reviews the facility failed to have a utilization review plan (URP) that defined the effective utilization of health care resources and made recommendations for the optimum use of hospital resources and facilities. This failed practice placed all patients in the hospital at risk for not receiving necessary services (based on census of 57). Findings:

During an interview on 7/19/18, when asked for the URP, the Quality Manager, stated the facility didn't have one.

During an interview on 7/19/18, at 2:45 pm, when asked for the URP, the Chief Operation Officer stated the facility did not have one.

Review of the quality meeting minutes, medical executive board meeting minutes, and governing body body minutes revealed no information about a URP.

Review of the "Medical staff Review", dated 6/18, revealed a "Calendar Year Snap Shot of API [Alaskia Psychiatric Institute] Utilization". The information contained: average daily census; number of admissions and discharges; readmission rates; seclusion rates; injury rates; grievance results; and average length of stay. In addition, the report contained information about the staff vacancy rates and recent survey reports.

The review contained no information about precertification and the standard criteria for payment; formal review of patients length of stay; discharge planning concerns and readmissions; and case management concerns that identified patients with protracted stays and investigations to ensure appropriate and cost effective care.
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Based on interview, observation, and record review the facility failed to ensure patients were involved in the discharge process prior to discharge for 2 patients (#s 1 and 17) of 5 discharges reviewed. This failed practice denied patients to be a part of the discharge planning process. Findings:

Patient #1

Record review on 7/17-18/18 revealed Patient #1 was admitted to the facility for depression and suicidal ideation.

Review of an individual therapy note, dated 6/25/18, reveled "Pt suspected [he/she] may discharge this week and possibly as soon as tomorrow. [The Patent] expressed frustration and disbelief that [Alaska Psychiatric Institute (API)] would move towards discharge because [he/she] is ramping up [his/her] self harm behaviors (swallowing batteries and pen caps) instead of keeping [him/her] longer because of them.

Further review of the medical record revealed the Patient was on 2nd degree COSS check (Close Observation Status Scale 1 person monitoring) during the hospitalization. On 6/25/18, the COSS check was changed to 1st degree (every 15 minute checks) "Behavior related to COSS status...Pts 2nd degree had been discontinued. Pt expressed no will to change and no desire to participate in treatment..." Under "Has patient been exhibiting self injurious behavior" the entry was "No", under "COSS reason(s) Unpredictable Behavior and Danger to Self."

Review of the "Discharge Summary" written by a social worker (SW), dated 6/26/18, revealed "This was the 1st admission for this 22 year old female admitted for danger to self, during admission patient displayed self injurious behaviors in the form of cutting arms and swallowing various objects. Pt had multiple medication changes with some benefit. Pt has been working with psychology to develop coping skills. Pt anxious to discharge however is able to complete safety planning with social worker and psychology. Pt continues to verbalize self-harm scratching and cutting but denies suicidal thoughts..."

Review of a note about a phone call, dated 6/27/18, the day after discharge, revealed "...[Patient #1] called [the caller] saying that [Patient #1] had taken 35,000 mg of Aleve to commit suicide..." After calling administration the facility staff contacted the Medical Director who was able to access the medical record and the facility staff called 911.

Review of a note, dated 6/28/18, 2 days after discharge. revealed "...stated [he/she] was a Providence Hospital's Intensive Care unit after attempted to overdose on aspirin."


Patient #17

During an interview on 7/17/18 at 7:00 am, Licensed Nurse (LN) #5 stated Patient #17 was going to be discharged today. the LN stated the Patient was not aware of the impending discharge.

Observation on 7/17/18 at 8:30 am, the LN sat with Patient #17 and informed him/her he would be discharged in an hour. During the discharge Patient #17 stated are you telling me I'm being discharged?

Record review on 7/17/18 revealed Patient #17 had diagnoses that included Schizoaffective Disorder (mental disorder characterized by delusions and hallucinations). This was the Patient's 51st admission.

Review of a Discharge Plan, dated 1/5/18, revealed "The Patient has a history of blowing out [Assisted Living Facilities] per file review, during the pt's last admission over 100 ALFs denied the pt due to [Patient #17]'s behavior."

During an interview on 7/18/18 from 2:45-3:38 pm, when asked about patients involvement in the discharge planning process, Social Worker #1 stated they don't tell some patients about their impending discharge because some patients might sabotage their discharges.

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Based on record review and interview the facility failed to ensure 1 patient (#1)'s discharge plan, out of 5 discharges reviewed, reflected the patients refusal of treatment. Without identifying the causative factor and identifying interventions the patient was placed at further risk for an unsuccessful discharge. Findings:

Record review on 7/17-19/18 revealed Patient #1 was admitted to the facility on 4/19/18 with depression and suicidal ideation after a suicide attempt.

Review of a note, dated 6/25/18, revealed "Progressed to 1st degree [observation status was changed to every 15 minute checks]. Pt disclosed no intention to modify bx [behavior] and participate in treatment. medication complaint."

Review of the discharge plan and the Patient's treatment plan, dated 6/26/18, revealed no information about Patient #1's refusal to participate in treatment and why. Review of the Discharge Summary, dated 6/26/18, revealed "Pt anxious to discharge however is able to complete safety planning with social worker and psychology. Pt continues to verbalize thoughts to self harm and cutting, but denies suicidal thoughts."

Further review of the medical record revealed after discharge the Patient was readmitted on 7/6/18 after being hospitalized for a second suicide attempt.

During an interview with Social Worker (SW) #1, when asked about the discharge plan for Patient #1, since he/she was resistant to therapy and discharge, the SW stated that particular social worker no longer worked here. The SW stated the facility identifies a patient's strengths and weaknesses for the discharge.
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Based on interview and review of hospital documents, it was determined that the hospital failed to develop and implement a plan to reassess the discharge planning process on an on-going basis. The hospital's failure to do so potentially contributed to the lack of a complete and accurately implemented discharge plan for Patient #1 and may have contributed to the same for other patients. Findings:

During an interview on 7/18/18 at 1:10 pm, Social Worker (SW) #1 was asked to describe how the facility reassess failed discharges and evaluate the discharge planning process. The SW stated if the discharge process was unsuccessful the discharge planners try to introduce something new to the discharge plan.

When asked about the facility tracking different types of discharges, such as court ordered discharge versus leaving against medical advice, the SW stated the facility did not differentiate between the different types of discharges.

During an interview on 7/18/18 the Mental Health Clinician Manager (MHCM) #1 was asked what measures the facility implements to prevent readmission after discharge. The MHCM stated the discharge planners will try to do something different from the last discharge. When asked how the facility reassessed the discharge process, the MHCM stated the facility focuses on the rates and some of the patients are flagged.

When asked if there was a process for following up with the patients after discharge the MHCM stated the facility relied on the outreach providers to follow up with the patients after discharge.

Review of Alaska Psychiatric Hospital Program Improvement Plan, revealed no information about reassessing the facility's discharge processes.

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Based on record review, observation, and interviews, the facility failed to ensure that active treatment measures, such as group and/or individual treatment were provided for two (2) of nine (9) active sample patients (Patients A8 and A9) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (See B125)

Based on medical record review, document review, and interview, the facility failed to provide Psychiatric Evaluations that included an assessment of patient assets in descriptive fashion for four (4) of nine (9) sample patients (Patients A1, A2, A3, and A9). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings Include:

A. Medical Records

Patient A1 (Psychiatric Evaluation dated 06/28/18), Patient A2 (Psychiatric Evaluation dated 06/28/18), Patient A3 (Psychiatric Evaluation dated 06/12/18), and Patient A9 (Psychiatric Evaluation dated 03/26/18), failed to list patient assets in the Psychiatric Evaluations.

B. Document Review

Medical Staff Bylaws dated 07/1/14, "Section H. Admission Psychiatric Evaluation (APES)," lists the following requirement for psychiatric evaluations:

"The admission workup will include at least the following:" "7. Patients assets: Assets and strengths that might be brought to bear on the patient's treatment or discharge planning should be descriptive and must be documented."

C. Interview

In an interview on 07/17/18 at 9:55 a.m., the Medical Director concurred with the lack of an assessment of patient assets within the Psychiatric Evaluations described in Section A, above,

Based on medical record review, document review, and interview, the facility failed to provide Treatment Plans that identified patient-related short-term and long-term goals stated in observable, measurable, behavioral terms for eight (8) of nine (9) sampled patients (Patients A1, A2, A3, A4, A5, A7, A8 and A9). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs.

Findings Include:

A. Medical Records

1. Patient A1's Master Treatment Plan (MTP), dated 06/28/18, documented for the Problem, "DAMAGE TO OTHERS;UNPREDICTABLE BEHAVIOR," the following non-measurable short-term goals (STGs), "Respond politely to staff requests each shift" and "Will demonstrate the ability to tolerate corrective feedback without becoming threatening."

2. Patient A2 's MTP, dated 06/28/18, documented for the Problem, "DISTURBANCE OF THOUGHT," the following non-measurable STGs, "Demonstrate trust of staff members and become relaxed in their presence" and "Will rationally discuss plans and future activities."

3. Patient A3's MTP, dated 06/14/18, documented for the Problem, "DANGER TO OTHERS," the following non-measurable STGs, "Will respond politely to staff requests" and "Have no instances, attempts, or threats of harm to others."

4. Patient A4's MTP, dated 06/29/18, documented for the Problem, "DANGER TO SELF AND DANGER TO OTHERS," the following non-measurable STGs, "Respond politely to staff requests each shift" and "Demonstrate the ability to recognize and effectively express thoughts that may previously have led to self-harm or harm to others."

5. Patient A5's MTP, dated 06/11/18, documented for the Problem, "DANGER TO SELF AND DANGER TO OTHERS," the following non-measurable STGs, "Discuss the circumstances of recent self-harm event(s) or threats that led to hospitalization or continued stay" and "Have no instances, attempts or threats of self-harm or harm to others X 3 days."

6. Patient A7's MTP, dated 07/10/18, documented for the Problem, "BORDERLINE PERSONALITY TRAITS," the following non-measurable STGs, "Demonstrate improved ability to think, concentrate and make decisions" and 'Make positive future plans verbalizing feeling of hope."

7. Patient A8's MTP, dated 2/27/18, documented for the Problem, "DANGER TO SELF," the following non-measurable STGs, "Attend at least ____{sic} groups per day to interact with others and gain skills" and "Will be visible and active in the unit milieu."

8. Patient A9's MTP, dated 3/29/18, documented for the Problem, "DANGER TO SELF," had the following non-measurable STGs, "Interact with others outside of the patient's room" and "Will be visible and active in the unit milieu."

B. Policy Review

Review of Policy, "Master Treatment Plan," [PC-050-05-05 Effective Date 08/30/17], revealed that although short-term goals were not addressed, long-term goals were identified as, "general statements of specific behaviors or conditions desired at discharge (i.e. 'Patient will be free from aggressive /threats and self-injury/ a sustained time period')"

C. Interview

In an interview on 7/18/18 at 2:30 p.m., the Interim Director of Nursing and the Director of Quality Improvement concurred with the findings regarding short-term goals.

Based on medical record review, document review, and interview, the facility failed to document specific nursing treatment interventions that were based on the individual needs of eight (8) of nine (9) sample patients (A1, A2, A3, A4, A5, A7, A8 and A9). Specifically, the nursing interventions were generic nursing functions that would be provided for every patient. This failure to document specific nursing treatment approaches on the Treatment Plans interferes with the assurance of consistency of approach to each patient's problem(s).

Findings Include:

A. Medical Records

1. Patient A1's Master Treatment Plan (MTP), dated 06/28/18, listed for the Problem, "DAMAGE TO OTHERS;UNPREDICTABLE BEHAVIOR," the generic nursing interventions, "Nursing staff will assure that ordered safety measures are in place and assess their effectiveness" and "Nursing staff will encourage the patient to request PRN medications or a time out when needed."

2. Patient A2 's MTP, dated 06/28/18, listed for the Problem, "DISTURBANCE OF THOUGHT," the generic nursing intervention, "RN/LPN will administer medications as ordered to assist in the management of the patient's symptoms and provide education about the prescribed medication."

3. Patient A3's MTP, dated 06/14/18, listed for the Problem, "DANGER TO OTHERS," the generic nursing intervention, "Nursing will regularly observe and interact with patient to provide a positive reinforcement of behaviors that help to increase self-control."

4. Patient A4's MTP, dated 06/29/18, listed for the Problem, "DANGER TO SELF AND DANGER TO OTHERS," the generic nursing interventions, " Nursing staff will regularly observe and interact with patient to provide positive reinforcement of behaviors that help to increase self-control" and "Nursing staff will assure ordered safety measures are in place and assess their effectiveness."

5. Patient A5's MTP, dated 06/11/18, listed for the Problem, "DANGER TO SELF AND DANGER TO OTHERS," the generic nursing interventions, "Nursing staff will assure ordered safety measures are in place and assess their effectiveness" and "Nursing staff will regularly observe and interact with patient to provide positive reinforcement on behaviors that help to increase self-control."

6. Patient A7's MTP, dated 07/10/18, listed for the Problem, "BORERLINE PERSONALITY TRAITS," the generic nursing intervention, "Nursing will monitor this patient's attendance at activities and encourage involvement and interest in treatment recovery and leisure activities."

7. Patient A8's MTP, dated 2/27/18, listed for the Problem, "DANGER TO SELF," the generic nursing intervention, "Nursing staff will assure ordered safety measures are in place and assess their effectiveness."

8. Patient A9's MTP, dated 3/29/18, listed for the Problem "DANGER TO SELF," the generic nursing interventions, "Nursing staff will regularly observe and interact with patient to provide positive reinforcement of behaviors that help to increase self-control" and "Nursing staff will assure ordered safety measures are in place and assess their effectiveness."

B. Policy Review

Review of the policy, "Treatment Planning," [PC-050-05-05 Effective date 8/30/17], revealed the following requirements for treatment interventions:

1. "Be specific as to what is to be done."
2. "Be written in behavioral terms."
3. "Include the frequency of the intervention."

C. Interview

In an interview on 7/18/18 at 2:30 p.m., the Interim Director of Nursing and the Director of Quality Improvement concurred with the findings regarding short-term goals.

Based on medical record review, policy review, and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTPs) for eight (8) of nine (9) sample patients (A1, A2, A3, A4, A5, A7, A8, and A9). This practice resulted in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings Include:

A. Medical Records:

Patient A1's MTP dated 06/28/18, Patient A2's MTP dated 06/28/18, Patient A3's MTP dated 06/14/18, Patient A4's MTP dated 06/29/18, Patient A5's MTP dated 06/11/18, Patient A7's MTP dated 07/10/18, Patient A8's MTP dated 02/27/18, and Patient A9's MTP dated 03/29/18 failed to indicate the name and discipline of staff persons responsible for specific aspect of care provided to the patient.

B. Policy Review

Review of the facility policy titled, "Treatment Planning," [PC-050-05.05 Effective Date 8/30/17] stated the following about "interventions"; "Treatment interventions will include the discipline or person responsible for the interventions."

C. Interviews

1. In an interview on 7/17/18 at 9:55 a.m., the Medical Director concurred with the finding of the lack of staff names and disciplines responsible for implementing the treatment interventions on the Master Treatment Plans.

2. In an interview on 7/17/18 at 2:30 p.m., the Acting Director of Nursing and the Quality Improvement Director concurred with the findings of a lack of documentation of staff name and discipline who were responsible for the implementation of the treatment interventions.

Based on record review, observation, and interviews, the facility failed to ensure that active treatment measures, such as group and/or individual treatment were provided for two (2) of nine (9) active sample patients (Patients A8 and A9) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Specific Patient Findings

1. Patient A8 was admitted on 2/21/18. The Psychiatric Evaluation dated 2/22/18 revealed that admission was necessary due to the patient assaulting and injuring staff at the adult living home. In addition, Patient A was hearing "scary" voices and was "crawling on the floor, yelling at ceiling, walking in circles, or hiding under furniture." Review of the Group Treatment Notes from 6/30/18-7/13/18 revealed that Patient A8 attended the following groups:

6/30/18-attended no groups
7/1/18-attended Walking Group
7/2/18-attended Healing Concepts Group
7/3/18-attended Walking Group
7/4/18-attended Milieu Group
7/5/18-attended no groups
7/6/18-attended no groups
7/7/18-attended Walking Group
7/8/18-attended no groups
7/9/18-attended Horticulture Group
7/10/18-attended no groups
7/11/18-attended no groups
7/12/18-attended no groups
7/13/18-attended Making Changes Group (arrived late, left early)

Review of the Master Treatment Plan revisions from the initial plan dated 3/27/18 to the latest Treatment Plan Review dated 7/12/18 failed to reveal that Patient A8's non-attendance at groups was addressed on the Treatment Plan nor and that alternative treatment options were listed on the Treatment Plan.

During observation on the Katmai Unit on 7/16/18 from 1:30-2:30 p.m., Patient A8 was seen pacing in the hallway and standing at the nursing station. During this time, there was a Walking Group and a Club House Group. Patient A8 did not attend either group.

During observation on the Katmai Unit on 7/17/18 from 10:00-11:00 a.m., Patient A8 was in bed. During this time, there was a Gym Group and a Healing Arts Group. Patient A8 did not attend either group.

In interview on 7/16/18 at 2:00 p.m., PNA8 stated that Patient A8 didn't go to many groups because "s/he gets too stimulated and doesn't really understand." PNA8 further stated that Patient A8 did go to the Club House sometimes but had to be there by herself, and not with other patients, because s/he was so disruptive. When asked for the patient's schedule for going to the Club House, PNA8 stated that there wasn't a schedule that the Rehab staff called when they had time to see the patient.

2. Patient A9 was admitted on 3/26/18. The Psychiatric Evaluation dated 3/26/18 revealed that admission was necessary due to bizarre behavior (naked in a parking lot), ingesting foreign objects, inability to sleep and thinking that laser beams were coming out of his/her eyes. Review of the Group Treatment Notes from 6/30/18-7/13/18 revealed that Patient A9 attended the following groups:

6/30/18-attended no groups
7/1/18-attended Team Solutions Group (PNA group)
7/2/18-attended Team Solutions Group and Healing Concepts Group
7/3/18-attended Team Solutions Group
7/4/18-attended no groups
7/5/18-attended Team Solutions Group
7/6/18-attended Team Solutions Group
7/7/18-attended no groups
7/8/18-attended no groups
7/9/18-attended Team Solutions Group
7/10/18-attended Team Solutions Group
7/11/18-attended no groups
7/12/18-attended Team Solutions Group
7/13/18-attended Team Solutions Group

Review of the Master Treatment Plan revisions from the initial plan dated 3/29/18 to the latest Treatment Plan Review dated 6/26/18 revealed only one notation on the 4/5/18 review that stated, " ...has not been attending groups regularly." Alternative treatment options were not addressed.

During observation on the Katmai Unit on 7/16/18 from 1:30-2:30 p.m., Patient A9 was seen sleeping in the television room. During this time, there was a Walking Group and a Club House Group. Patient A9 did not attend either group.

During observation on the Katmai Unit on 7/17/18 from 10:00-11:00 a.m., Patient A9 was pacing the halls and sleeping in the television room. During this time, there was a Gym Group and a Healing Arts Group. Patient A9 did not attend either group.

In interview on 7/16/18 at 2:00 p.m., PNA8 stated that Patient A9, "rarely goes to group."

B. General Observations

1. While rounding on Taku Unit on 7/16/18 at 12:15 p.m., a Team Solutions Group was in progress. The unit census was nine (9) patients. Four (4) patients were in the group. PNA5 confirmed with the surveyor that five (5) patients were not in group. Four (4) patients were in their rooms and one (1) patient was walking the hall.

2. On 7/16/18 at 2:15 p.m., the Clubhouse Activity was occurring with 10 patients in the room. The activity was designed for both Adult units (Susitna and Katmai) which had a combined census of 49 patients. The room was small and could not have contained all the patients scheduled to attend the activity. The Clinical Services Director confirmed on 7/16/18 at 3:00 p.m., that the room was too small to accommodate the patients from both units.

3. On 7/17/18 at 11:00 a.m. on the Susitna Unit, a Skills to Thrive Group was scheduled from 10:45 a.m. to 11:00 a.m. The unit census was 24. Eight (8) patients were observed in the group. PNA4 reported that four (4) patients were in their rooms. Eleven patients were either roaming the halls or moving in and out of their rooms. One (1) patient was observed sitting on the floor in the middle of the unit hall.

4. On 7/17/18 at 11:00 a.m., PNA4 noted that Patient A3 had been in bed all morning after attending community meeting. PNA 4 noted that upon asking the patient to attend groups, Patient A4 indicated that whether or not s/he attended was his/her choice.

C. General Interviews

1. In an interview on 7/16/18 at 12:20 p.m., PNA5 indicated that there were no direct instructions given to deal with patients who refused groups. He/she was unaware of the need to attempt patient engagement in alternate activities if there was group refusal by a patient.

2. In an interview on 7/16/18 at 3:00 p.m., the Clinical Services Director indicated that the difficulties with the provision of active treatment revolved around the lack of coordination between disciplines regarding how to provide treatment.

3. In an interview on 7/17/18 at 11:00 a.m., PNA7 indicated that the Dual Diagnosis Group scheduled for 12:00 noon on the Taku Unit had been cancelled. He/she indicated that there were only "leisure" groups scheduled for the rest of the day.

Based on record review, observations and interviews, the hospital failed to:

I. Ensure that the provision of active treatment measures, such as group and/or individual treatment were provided for two (2) of nine (9) active sample patients (Patients A8 and A9) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B144)

II. Ensure that nursing staff encouraged patients to attend active treatment interventions, such as group and/or individual treatment for two (2) of nine (9) active sample patients (Patients A8 and A9) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. Specifically, nursing staff asked the patients to attend, but did not continue to encourage attendance, if the patients refused. In addition, the nursing staff were not involved in the provision of alternate treatment when patients refused group. (Refer to B148)

III. Ensure the availability of a Registered Nurse (RN) on the patient care units 24 hours a day. Specifically, the RN and the Nurse Manager on the Chilkat Unit (Adolescent Unit) were both off the unit for approximately 20 minutes, leaving only the unlicensed PNAs in charge of the patients. In addition, one patient (Patient A6), left the Chilkat Unit several times a day in order to receive special programming on an empty unit that was closed to admissions (Denali Unit). There was no RN on this unit to supervise the PNA who was carrying out the special programming. This failure resulted in patients not receiving adequate assessments and care from a professional RN and could result in medical and individual psychiatric patient issues being undetected and not addressed. This failure also places PNAs alone on the unit with patients and no supervision or guidance from the RN on how to care for and provide for the safety of patients. (Refer to B 149)

IV. Ensure the provision of sufficient therapeutic programming to meet the needs of restoring and managing optional levels of psychosocial functioning for five (5) of nine (9) sample patients (Patients A3, A4, A7, A8 and A9). Specifically, there were limited numbers of therapeutic activities for significant periods of time on evenings and week-ends. This lack of active therapies results in the patients being hospitalized without interventions for patient recovery provided to them, potentially delaying their discharge. (Refer to B 157)

Based on record review, document review, observation, and interview, the medical director failed to:

1. Ensure the provision of Psychiatric Evaluations that included an assessment of patient assets in descriptive fashion for four (4) of nine (9) sample patients (Patients A1, A2, A3, and A9). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy. (Refer to B117)

2. Ensure that the provision of active treatment measures, such as group and/or individual treatment were provided for two (2) of nine (9) active sample patients (Patients A8 and A9) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Interviews

In an interview on 07/17/18 at 9:55 a.m., the Medical Director concurred with the lack of assets on Psychiatric Evaluations and the need for the provision of additional active treatment for patients when selected modalities were not utilized by the patient.

Based on record review and interview the Director of Nursing failed to:

l. Develop nursing interventions based on the individual needs for nine (9) of nine (9) patients in the sample (Patients A1, A2, A3, A4, A5, A6, A7, A8, and A9). This failure resulted in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122)

ll. Ensure that nursing staff encouraged patients to attend active treatment interventions, such as group and/or individual treatment for two (2) of nine (9) active sample patients (Patients A8 and A9) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. Specifically, nursing staff asked the patients to attend, but did not continue to encourage attendance if the patients refused. In addition, nursing staff were not involved in the provision of alternate treatment when patients refused groups. (Refer to B125)

Based on observation and interview, the facility failed to ensure the availability of a Registered Nurse (RN) on the patient care units 24 hours a day. Specifically, the RN and the Nurse Manager on the Chilkat Unit (Adolescent Unit) were both off the unit for approximately 20 minutes, leaving only the unlicensed Psychiatric Nursing Assistants (PNAs) in charge of the patients. In addition, one patient (Patient A6), left the Chilkat Unit several times a day in order to receive special programming on an empty unit that was closed to admissions (Denali Unit). There was no RN on this unit to supervise the PNA who was carrying out the special programming. This failure results in patients not receiving adequate assessments and care from a professional RN and could result in medical and individual psychiatric patient issues being undetected and not addressed. This failure also places PNAs alone on the unit with patients and no supervision or guidance from the RN on how to care for and provide for the safety of patients.

Findings Include:

A. Observations:

1. On 7/17/18 at 10:00 a.m., PNA8 was observed on the Denali Unit with Patient A6, who was completing a written work assignment. The Denali Unit had been closed to admissions due to staffing issues and there were no other hospital patients or staff on the unit. There were two (2) WEKA (security agency hired by the state) (Wisdom, Experience, Knowledge, Abilities) agents present on the unit for the safety of PNA8 and Patient A6. The WEKA agents were not to intervene in patient care unless instructed by staff. There was no RN available on the unit to supervise the PNA, ensure the appropriate clinical care of the patient or instruct the agents to intervene if necessary. Although the PNA and the security agents had radios, the RN would have to go through two (2) locked doors, down a long hall and through another locked door to supervise the PNA or respond to a request for help.

2. On 7/17/18 at 10:10 a.m. on the Chilkat Unit, the nurse surveyor asked to speak to the charge nurse. PNA9 stated that the charge nurse and unit manager were off the unit. There were two patients on one-to-one observation and five other patients on the unit. Because of the acuity on the unit, there was also a WEKA agent present. There was no assigned RN present to supervise the care being given to the seven patients or to instruct the security agent if help was needed. When the surveyor left the unit at 10:30 a.m., neither RN had returned to the unit.

B. Interviews

1. In interview on 7/16/18 at 1:20 p.m., PNA3 stated that he/she had taken Patient A6 to the Denali unit on several occasions. When asked if he/she was by him/herself with Patient A6, PNA3 answered "yes." PNA3 further stated that he/she would call a code on his/her radio if he/she needed help with Patient A6.

2. In interview on 7/17/18 at 9:15 a.m., PNA8 acknowledged that although they tried to have two PNAs with Patient A6 on the Denali Unit, it was not always possible because of staffing. PNA8 stated that Patient A6 went to the Denali Unit three or four times a day and a RN was not present on the locked unit during those times. He/she stated they could call for help on the radio if needed and it would take the RN two or three minutes to reach the unit.

3. In interview on 7/ 17/18 at 2:30 p.m., the Director of Quality Improvement and the Interim Director of Nursing agreed that a RN was to be on each patient care unit at all times.

Based on document review and interview, the facility failed to provide sufficient therapeutic programming to meet the needs of restoring and managing optional levels of psychosocial functioning for five (5) of nine (9) sample patients (Patients A3, A4, A7, A8 and A9). Specifically, there were limited numbers of therapeutic activities for significant periods of time on evenings and week-ends. This lack of active therapies results in the patients being hospitalized without interventions for patient recovery provided to them, potentially delaying their discharge.

Findings include:

A. Document Review

Review of the "Treatment and Activity Schedule" for two of the four units revealed the following:

1. Katmai (Adult) Unit-There was no scheduled therapeutic programming after 3:30 p.m. (seven days a week.) On the week-end (prior to 3:30 p.m.) there was one PNA led group on Saturday and Sunday and one Psychology led group on Saturday and Sunday.

2. Susitna (Adult) Unit-There was no scheduled therapeutic programming after 3:30 p.m. (seven days a week.) On the week-end (prior to 3:30 p.m.) there was one PNA led group on Saturday and Sunday and one Psychology led group on Saturday and Sunday.

B. Interviews

1. In interview on 7/16/18 at 2:00 p.m., PNA1 stated that the evening Rehab Group, listed on the Katmai Unit Treatment and Activity Schedule, was no longer being held because there was a "cut back" of rehab staff.

2. In interview on 7/17/18 at 9:00 a.m., the Director of Clinical Services acknowledged that there was little in the way of active programming after 3:30 p.m. and on the week-ends, primarily on the Katmai and Susitna Units. She further stated that they had "lost" a couple of recreation therapy positions in the past and this was impacting on their ability to offer groups.