HospitalInspections.org

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Based on record review and interviews the facility failed to ensure the hospital met the Condition of Participation for Patient Rights. The hospital failed to assure patients rights were protected and promoted. Due to the severity of deficient practice at CFR 482.13(c)(3) resulted in an immediate jeopardy under CFR 482.13 Patient Rights.

Findings:

A145 - Patient Right: Free from Abuse/Harassment: The facility failed to ensure: 1) one patient (#8) was free from sexual abuse as a result of negligence; 2) measures were implemented to further protect Patient #8, or other patients residing on the Taku unit, from unsolicited sexual contact by the perpetrating patient; 3) conduct a comprehensive assessment of the allegation of abuse and neglect; and 4) a report of sexual abuse and neglect was reported to the State Agency.

Thes failed practices constituted an immediate jeopardy to Patient #8's health and safety. This situation was brought to the attention of the facility's administration on January 29, 2019 at 3:40 pm, at which time the facility was notified of the deficient practice and risk to patients.

The immediacy was removed by the facility by January 29, 2019 at 4:56 pm.


State of Alaska
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Based on record review, video review, interview, observation and facility policy review the facility failed to ensure:

1) one patient (#8) was free from sexual abuse as a result of negligence;

2) measures were implemented to further protect Patient #8, or other patients residing on the Taku (forensic) unit, from unsolicited sexual contact by the perpetrating patient (based on census of 10 patients);

3) conduct a comprehensive assessment of the allegation of abuse and neglect; and

4) a report of staff neglect that resulted in sexual abuse was reported to the State Agency.

These failed practices constituted an immediate jeopardy to the health and safety of all patients (current census of 10) residing on the forensics (Taku) unit. This situation was brought to the attention of the facility's administration on January 29, 2019 at 3:40 pm, at which time the facility was notified of the deficient practice and risk to patients. The immediacy was removed by the facility by January 29, 2019 at 4:56 pm.

Findings:

Sexual Abuse & Neglect:

Record review of the Taku unit 24 hour nursing report form, dated 1/28/19, revealed Patient #11 reportedly touched Patient #8's genital area while in the TV room on 1/27/19. Further review revealed the Taku unit census was 10 patients (including perpetrator).

Patient #11

Review of Patient #11's medical record on 1/29-30/19 revealed the Patient had a history of schizophrenia, paranoid typed (A serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling). Additional review revealed the Patient had a history of asking individuals about performing oral sex on himself/herself.

Review of "Treatment Plan Review", dated 1/24/19, revealed Patient #11 "Problem #2: Dangerous Behaviors...Patient remains dangerous." Specifically, the treatment plan identified the Patient engaged in repeated assaultive behaviors and had made attempts to hit and bite others without any provocation.

Review of a "Nursing Care Plan", dated 12/3/18, revealed "Risk for other directed violence AEB [as evidenced by] hx [history] of assaultive bxs [behaviors] delusional though process." The "interventions" listed included "2/1 [degree] COSS [Close Observation Status Scale- level of observation and monitoring due to potential harm to that patient or others] protocol for safety ...Long Term Goal ...[Patient #11] will not engage in any unsafe behaviors (biting, hitting, etc.) for a period of 3 weeks."

Review of the medical record revealed Patient #11's had a "COSS Order", dated 12/3/18, for "2nd Milieu [one to one (1:1) level of staffing while outside of his/her room] / 1st Bed Area [level of monitoring that requires staff to observe the patient every 15 minutes while in his/her room] ...Secure Area Observational Level Danger to Others Unpredictable Behavior."

Review of a nurse's "Information Note", dated 1/27/19 at 6:49 pm, in Patient #11's medical record revealed "At approximately [6:15 pm][Patient #8] ran out of the Taku TV room ... [Patient #8] stated that ...[Patient #11] touched [his/her] genital area. Staff shut the tv room doors to separate the patients. [Patient #8] walked back into the tv room while [Patient #11] stood by the nursing desk. [Patient #11] was asked to stay away from ...[Patient #8]...When the [Registered Nurse] asked [Patient #11] what happened the patient replied 'You guys told me to do it...Everyone in the world told me to do it.' RN spoke with [Patient #8] about the incident also. [Patient #8] stated [he/she] just walked up and reached for my [genitalia]. He touched me and I got up and ran out to you guys. RN asked if [Patient #8] wanted to press charges and [he/she] declined."

Further review of the medical record revealed Patient #11's COSS level did not changed after the event and the nursing care plan had not been revised to reflect the need for increased monitoring.

Patient #8:

Review of Patient #8's medical record "Admission ASO Assessment", dated 8/23/18, revealed "has long history of sexual abuse ...has history of aggressive behavior."

During an interview on 1/28/19 at 11:50 am Patient #8 was asked about his/her day. The Patient immediately stated he/she was touched inappropriately by Patient #11 yesterday. During the interview Patient #8 became tearful and upset.

Camera Review:

A camera review was conducted on 1/29/19 at 11:30 am, of the Taku unit for 1/27/19 starting at 5:56 pm. The observation consisted of Patient #11 and Psychiatric Nurse Assistant (PNA) #1, who was assigned as the Patient's 1:1 staff. During the 27 minute length of video, the following was observed:

- Starting at 5:56 pm, PNA #1 was observed to be positioned at the Nurse's Desk counter as Patient #11 was standing in the area around the Nurse's Desk with other patients and staff.

- At 6:01 pm, PNA #1 walked away from Patient #11 and down the hall, out of sight of the Patient. PNA #1 returned one minute later, and repositioned himself/herself at the Nurse's Desk counter.

- At 6:04 pm, PNA #1 went into the unit kitchen doorway and then into the kitchen itself (A separate, closed door room with no windows, within the unit), again out of sight of the Patient.

- At 6:05 pm, while PNA #1 was still in the kitchen, Patient #11 walked away from the Nurse's Desk area, into the Dining Room of the unit where other patients were present, and sat in a chair near the door.

- At 6:06 pm, it was observed that PNA #1 returned from the kitchen and repositioned himself/herself near the Nurse's Desk counter without looking in the general direction of Patient #11.

- At 6:09 pm, PNA #1 was observed to be looking for Patient #11, saw he/she was seated in the Dining Room with other patients, then went into the Nurse's Station (A separate, closed door room within the unit).

- PNA #1 came out of the Nurses Station and went into the Dining Room area at approximately 6:10 pm. He/she then returned to the Nurse's Desk counter and was observed to write on a clipboard with his/her back to Patient #11 from 6:10:57 pm to 6:13:35 pm.

- At 6:13:35 pm, as PNA #1's back was still to the Patient, it was observed that Patient #11 left the Dining Room, went into the TV Room, approached Patient #8 (who was seated and watching TV), reached down and groped Patient #8 genital region over his/her clothes. Patient #8 immediately got up from his/her chair, left the TV Room, and reported the incident to PNA #1. There was a witness to the incident, Patient #17, who followed Patient #8 out of the TV Room and reported what he/she saw as well.

- At 6:14 pm, it was observed that Registered Nurse (RN) #1 directed Patient #8 back into the TV Room. Next, RN #1 and PNA #1 processed with Patient #11 in the hall near the Nurse's Desk about the event.

- At 6:17 pm, it was observed that PNA #1 led Patient #11 to the medication distribution window in the hall (which is directly across from the TV Room) and left the Patient unsupervised again as he/she reentered the Nurse's Station. Several patients, including Patient #8, were accessible to Patient #11 at this time.

- Patient #11 remained standing unattended at the medication distribution window until 6:21 pm, then started walking around the unit without 1:1 staff. RN #1 was seated at the Nurse's Desk and did talk to Patient #11, but did not prompt a PNA to continue Patient's 1:1 staff observation.

- At 6:23 pm, while Patient #11 was still unsupervised, it was observed the Patient attempted to follow staff out of the unit entry/exit door. The staff leaving the unit redirected the Patient to stop following him/her, but did not look into why PNA #1 was not with the Patient.

Interviews:

During the camera review on 1/29/19 at 11:30 am Nursing Unit Manager #1, Nursing Unit Manager #2 and Non-Abusive Psychological and Physical Intervention (NAPPI - behavior assessment, de-escalation, and defusing skills for humane and effective response to violent and/or unsafe patient behavior) Instructor #1 were present during the review.

During an interview on 1/29/19 at 11:30 am, Nursing Unit Manager #1 stated PNA #1 should not have left Patient #11 to go down the hall, into the kitchen, or into the Nurse's Station. He/she further stated that PNA #1 should not have positioned himself/herself by the Nurse's Desk counter when Patient #11 moved into the Dining Room, the PNA should have moved into the Dining Room with the Patient.

During the camera review 1/29/19 at 11:30 am, the Non-Abusive Psychological and Physical Intervention (NAPPI - behavior assessment, de-escalation, and defusing skills for humane and effective response to violent and/or unsafe patient behavior) Instructor #1 stated a 1:1 staff should be in the same room as the Patient they are assigned to. He/she further stated PNA #1 should not have left Patient #11's sight at any time.

During an interview at 1/29/19 at 11:40 am Nursing Unit Manager #2 stated Patient #11 was very dangerous with violent tendencies and requires a 1:1 supervision. Nursing Unit Manager #2 further stated the 1:1 staff was to be close to the Patient at all times. The Nursing Unit Manger stated PNA #1 was not conducting the appropriate 1:1 supervision by leaving the Patient alone multiple times.

During an interview on 1/29/19 at 12:54 pm, the Chief Nursing Officer (CNO) and the Assistant Director of Nursing (ADON) stated they became aware of the 1/27/19 incident, between Patient #11 and Patient #8, when State Surveyors brought it to their attention on 1/29/19. In addition, the CNO stated the facility had not implemented any safety measures to prevent further victimization.

The ADON further stated that Patient #11 had a near miss incident on 1/28/19 where his/her 1:1 staff prevented the Patient from inappropriately touching Patient #8 again.

During an interview on 1/29/19 at 1:15 pm, PNA #2 stated Patient #11 was admitted on 1:1 due to disorganized thinking, assaultive behavior, and trying to touch both staff and patients almost as soon as he/she entered the unit. PNA #2 identified Patient #11 as a threat to anyone near him/her and needed prevention intervention at all times. The 1:1 staff was supposed to provide this prevention by being between the Patient and everyone else at all times. PNA #2 also stated he/she has had to prompt 1:1 staff to remain close enough to intervene should it be needed multiple times.

Record review on 1/28/19 of Patient #8's medical record revealed the patient had an extensive history of physical, sexual and emotion abuse dating from childhood to adulthood. Further review revealed a Nursing Note, dated 1/28/19 at 6:22 am, stated "Patient was in an anxious mood due to another patient touching [him/her] inappropriately."

During an interview on 1/30/19 at 9:35 am the Chief of Psychiatry stated that Patient #8 did not receive any trauma informed care after the event that occurred on 1/27/19 and further stated the facility could have done better at provided follow up to the victims of such events. When asked about PNA #1's actions that led up to the sexual touching by Patient #11, the Chief of Psychiatry stated "The event was obvious negligence of [PNA #1]."

Review of the facility provided policy "Conduct Involving Patients," dated 10/13/17, revealed neglecting or endangering a patients is the failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any patient when that failure presents either imminent danger to the health, safety or welfare of a patient. The policy provided the following example "failure to provide adequate supervision to patients...or not providing the ordered supervision level of a patient.

Review of the facility provided policy "Response to Assaults," dated 6/1/15, revealed the NSS must immediately arrange for the continued monitoring and safety of the alleged assailant, victim, and milieu. When a patient to patient assault occurs the staff were to comfort and attend to any immediate physical and emotional needs of the victim who will be asked if he/she would like to have his/her support systems notified. Specifically, in the event of a sexual assault, staff must interact with the victim in a supportive way.

During an interview on 1/30/19 at 9:44 am Psychiatrist #1 stated Patient #8 was anxious about talking to the police about the event. Psychiatrist #1 further stated Patient #8 stated he/she was upset and didn't understand why someone he/she doesn't know should not have touched him/her inappropriately. In addition, the Psychiatrist stated that Patient #11 was unpredictable and has had past occurrences where he/she attempted to reach out and touch others. Specifically, the Psychiatrist stated Patient #11 attempted to again touch Patient #8 the day after the event that occurred on 1/27/19. When asked about Patient #8's abuse history, Psychiatrist #1 stated Patient #8 had "profound sexual abuse since childhood."

Incident Investigation

Review of the "Alaska Psychiatric Institute (API) - Unusual Occurrence Report (UOR)", dated 1/27/19 at 6:30 pm, revealed a sexual encounter occurred between Patient #8 (victim) and Patient #11 (perpetrator). The UOR did not indicate Patient #17 as a witness. The UOR further revealed no injury assessment or treatment type was conducted or identified. Review of the Immediate Supervisor/Nursing Shift Supervisor (NSS) Review, dated 1/27/19 at 7:25 pm revealed Nursing Unit Manger #1 stated that Patient #8 did not want to press charges, no other patients were on the unit at the time of the event, no witnesses of the event and no staff were located in the TV room. The document had no indications that administration was notified of the event or what interventions were put in place to protect Patient #8 and/or other patients residing on the unit.

Review of the facility provided policy "Sentinel and Unanticipated Adverse Events," dated 10/8/13, revealed types of events to be considered sentinel events under this policy included event/occurrences that meet "Sexual Contact/Abuse/Assault occurs when there is sexual contact involving a patient and another patient ...while a patient is treated by, or on the premises of, API ...Sexual contact includes ...fondling of a patient's sex organ(s) by another individual's hand ..." The policy further stated all staff shall immediately report possible sentinel event to the NNS and a UOR will be completed. The NSS will first take any immediate actions necessary to prevent further harm to patients and then immediately notify the Medical Director, Chief Executive Officer, Chief Nursing Officer, Hospital Administrator, Clinical Director, Risk Manager, Safety Officer, Quality Improvement Coordinator or their designees.

Reporting of Event:

Review of the State Agency's reporting system on 1/29/18 at 8:00 am (37 hours and 47 minutes post incident) revealed the facility had not submitted a report of the incident.

During an interview on 1/29/19 at 12:54 pm, the Chief Nursing Officer (CNO) and the Assistant Director of Nursing (ADON) stated they became aware of the 1/27/19 incident, between Patient #11 and Patient #8, when State Surveyors brought it to their attention on 1/29/19. They also stated the incident had not been reported to the State Agency at the time of this interview.

During an interview on 1/29/19 at 1:00 pm Administrative Assistant (AA) #1 stated once a UOR has been created by floor staff and reviewed by a nursing supervisor the form comes to him/her. Once received AA #1 would review and log the incident and forward to a member of administration. In reference to the sexual event on 1/27/19 the AA stated he/she was not at work on 1/28/19 and wasn't sure what happened to the UOR because he/she was unaware of who reviews the UORs when he/she was out of the office.

During an interview on 1/29/19 at 1:01 pm the Quality Assurance and Performance Improvement (QAPI) Director stated he/she picked up the UORs on 1/28/19 but the UOR pertaining to the 1/27/19 event that occurred between Patient #8 and #11 was not in the UORs. He/she further stated he/she received the UOR the morning of 1/29/19.

Review of the facility policy, Abuse and Neglect Prevention Policy, dated 10/31/18, revealed "If the employee making the report to the CEO, Safety Officer (SO), Nursing Shift Supervisor (NSS) or designee is a mandatory reported per Reporting requirements for Vulnerable Adults-A.S. 47.24.010 ...the staff member will comply with the applicable statutes."

AS 47.24.010 states:

(a) Except as provided in (e) and (f) of this section, the following persons who, in the performance of their professional duties, have reasonable cause to believe that a vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect shall, not later than 24 hours after first having cause for the belief, report the belief to the department's central information and referral service for vulnerable adults:

(1) a physician or other licensed health care provider;
(2) a mental health professional as defined in AS 47.30.915 (11) and including a marital and family therapist licensed under AS 08.63;
(3) a pharmacist;
(4) an administrator of a nursing home, residential care or health care facility;
(5) a guardian or conservator;
(6) a police officer;
(7) a village public safety officer;
(8) a village health aide;
(9) a social worker;
(10) a member of the clergy;
(11) a staff employee of a project funded by the Department of Administration for the provision of services to older Alaskans, the Department of Health and Social Services, or the Council on Domestic Violence and Sexual Assault;
(12) an employee of a personal care or home health aide program;
(13) an emergency medical technician or a mobile intensive care paramedic;
(14) a caregiver of the vulnerable adult;
(15) a certified nurse aide.

(b) A report made under this section may include the name and address of the reporting person and must include
(1) the name and address of the vulnerable adult;
(2) information relating to the nature and extent of the abandonment, exploitation, abuse, neglect, or self-neglect;
(3) other information that the reporting person believes might be helpful in an investigation of the case or in providing protection for the vulnerable adult.


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Based on record review, camera review and interview the facility failed to ensure an effective process was in place to receive and analyze adverse patient events and implement corrective actions and safety measures to protect patients. Specifically, the facility failed to ensure a process for accurate and timely review of Unusual Occurrence Reports (UORs) was effectively practiced by facility staff. This failed practice placed all patients (based on a current census of 38) at risk for prolonged exposure to an unsafe environment due to a lack of review and implementation of safety measures by the facility. Findings:

Record review of the Taku (Forensic Ward) unit 24 hour nursing report form, dated 1/28/19, revealed Patient #11 reportedly touched Patient #8's genital area while in the TV room on 1/27/19. Further review revealed the Taku unit census was 10 patients (including perpetrator).

Review of the medical record revealed Patient #11's had a "COSS [Close Observation Status Scale- level of observation and monitoring due to potential harm to that patient or others] Order", dated 12/3/18, for "2nd Milieu [one to one (1:1) level of staffing while outside of his/her room] / 1st Bed Area [level of monitoring that requires staff to observe the patient every 15 minutes while in his/her room] ...Secure Area Observational Level Danger to Others Unpredictable Behavior."

A camera review was conducted on 1/29/19 at 11:30 am, of the Taku unit for 1/27/19 starting at 5:56 pm. The observation consisted of Patient #11 and Psychiatric Nurse Assistant (PNA) #1, who was assigned as the Patient's 1:1 staff. During the camera review it was observed that Patient #11 was unattended and out of line of sight by his/her 1:1 multiple times. As a result, Patient #11 inappropriately touched Patient #8's genital area.

Review of the "Alaska Psychiatric Institute (API) - Unusual Occurrence Report (UOR)", dated 1/27/19 at 6:30 pm, revealed a sexual encounter occurred between Patient #8 (victim) and Patient #11 (perpetrator). The UOR did not indicate Patient #17 as a witness. The UOR further revealed no injury assessment or treatment type was conducted or identified. Review of the Immediate Supervisor/Nursing Shift Supervisor (NSS) Review, dated 1/27/19 at 7:25 pm revealed Nursing Unit Manger #1 stated that Patient #8 did not want to press charges, no other patients were on the unit at the time of the event, no witnesses of the event and no staff were located in the TV room. The document had no indications that administration was notified of the event or what interventions were put in place to protect Patient #8 and/or other patients residing on the unit.

During an interview on 1/29/19 at 12:54 pm, the Chief Nursing Officer (CNO) and the Assistant Director of Nursing (ADON) stated they became aware of the 1/27/19 incident, between Patient #11 and Patient #8, when State Surveyors brought it to their attention on 1/29/19.

During an interview on 1/29/19 at 1:00 pm Administrative Assistant (AA) #1 stated once a UOR has been created by floor staff and reviewed by a nursing supervisor the form comes to him/her. Once received AA #1 would review and log the incident and forward to a member of administration. In reference to the sexual event on 1/27/19 the AA stated he/she was not at work on 1/28/19 and wasn't sure what happened to the UOR because he/she was unaware of who reviews the UORs when he/she was out of the office.

During an interview on 1/29/19 at 1:01 pm the Quality Assurance and Performance Improvement (QAPI) Director stated he/she picked up the UORs on 1/28/19 but the UOR pertaining to the 1/27/19 event that occurred between Patient #8 and #11 was not in the UORs. He/she further stated he/she received the UOR the morning of 1/29/19.

Review of the facility provided policy "Sentinel and Unanticipated Adverse Events," dated 10/8/13, revealed types of events to be considered sentinel events under this policy included event/occurrences that meet "Sexual Contact/Abuse/Assault occurs when there is sexual contact involving a patient and another patient ...while a patient is treated by, or on the premises of, API ...Sexual contact includes ...fondling of a patient's sex organ(s) by another individual's hand ..." The policy further stated all staff shall immediately report possible sentinel event to the NNS and a UOR will be completed. The NSS will first take any immediate actions necessary to prevent further harm to patients and then immediately notify the Medical Director, Chief Executive Officer, Chief Nursing Officer, Hospital Administrator, Clinical Director, Risk Manager, Safety Officer, Quality Improvement Coordinator or their designees.

Review of the facility's policy "Quality Assurance and Performance Improvement (QAPI) Program," dated 10/31/18, revealed an objective for the QAPI program was to "encourage an environment that promotes safety, encourages reporting of issues related to errors and safety related events ..." Further review revealed "QAPI program specifics include ...API utilized an Unusual Occurrence Reporting System (UOR) System to report identified safety events and near misses. Data from the UOR System is aggregate, analyzed and reported ...where safety risk mitigation plans will be developed, corrective action implemented, and tracked ...Patient safety events, including adverse events and sentinel events, are reported in accordance with all state and federal regulations ..."

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Based on record review and interview, the facility failed to ensure the nursing care plan met the needs for appropriate pacemaker care for 1 patient (#3), out of 7 nursing care plans reviewed. Without appropriate and current care plans patients are at risk for not receiving the necessary and/or appropriate care and services. This failed practice placed the patient at risk for potential cardiac complications which could impact the patient's health and overall well-being. Findings:

Record review on 1/28-30/19 revealed Patient #3 was admitted with diagnoses that included sick sinus syndrome (an uncommon heart rhythm disorder where the heart's sinus node, the heart's pacemaker, does not function properly) and Schizophrenia (A serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling).

Review of the most recent "Nursing Care Plan Form," dated 1/26/19, revealed identified problem #3 as "Risk for decreased cardiac output [related to] mitral valve regurgitation and sick sinus syndrome with pacemaker." The long term goal for this problem was "[Patient] will report no symptoms related to cardiac output decreasing throughout the next 6 months." This goal was added on 1/26/19.

During an interview on 1/28/19 at 11:42 am, Registered Nurse (RN) #2 stated Patient #3 is not able to verbalize rational and clear statements due to his/her schizophrenia. RN #2 further stated the Patient would not be able to process signs and symptoms of cardia issues. After review of the nursing care plan long term goal, RN #2 stated the long term goal was not attainable by the Patient at this time.

When the State Surveyor inquired about pacemaker care and if a download of the pacemaker (an electronic transmittal of data to the cardiologist for review of the patient's cardiac status inbetween assessments/visits) had occurred recently, RN #2 stated he/she was not aware pacemaker downloading was something that needed to be done. RN #2 could not identify Patient #3's last cardiac appointment and did not know the recommended routine follow ups for Patient #3's cardiac care.

Review of the medical record on 1/28/19 revealed a "Consult Request & Emergency Treatment Form," dated 7/29/16 for a "pacemaker check." An appointment at Alaska Heart & Vascular Institute was scheduled for 8/5/16 at 2:00 pm. Additional review of the medical record revealed a copy of the original consult request form with a post-it note attached, dated 8/10/16, that read: "I'm guessing the Client refused appt. [appointment] or it was [checked] telephonic ..." The nursing staff could not confirm or deny Patient #3 attended this appointment.

On 1/29/19, the Physician's Assistant Certified (PA-C) #1 requested records from the Alaska Heart & Vascular Institute after RN #2 contacted PA-C #1 to inquire about Patient #3's pacemaker care. The records revealed the last pacemaker download occurred on 8/9/16 with a recommended follow-up in 3 months.

During an interview on 1/30/19 at 10:30 am, PA-C #1 stated he/she could not locate any paperwork in Patient #3's medical record about any pacemaker care after 8/9/16. He/she stated the Health & Physicals (H&Ps) do document the presence of the pacemaker, but no documentation associated with routine follow ups. PA-C #1 stated he/she placed an order for a cardiac consult based on the length of time it has gone unassessed.

Review of the H&Ps for Patient #3 revealed the "History & Physical (Dictated) Date of Admission," dated 4/20/16, which documents "presence of cardiac pacemaker." The "History & Physical (Dragon) Annuall H&P," dated 5/22/17, and the "History & Physical Annual H&P," dated 5/22/18, documented "Sick Sinus Syndrome patient has been asymptomatic since pacemaker implanted, will continue to monitor and treat as indicated." Further review of all H&Ps revealed no documentation associated with routine follow ups for cardiac monitoring or pacemaker downloads.

Review of the facility's policy "Nursing Care Plan," dated 10/15/18, revealed: "A registered nurse will develop and keep current a nursing care plan for each patient, based on nursing assessments, re-assessments, and input from the patient/guardian and other relevant sources. A registered nurse will document patient progress toward nursing goals ...The nursing care plan will include planning for ...physiological ...factors ...The nursing care plan is based on the patient's needs and includes relevant nursing interventions."

Review of the facility's "Nursing Department Procedure - Nurse Responsibilities," dated 4/6/2015, revealed: "Monitor each patient for signs and/or symptoms that suggest their physical status is deteriorating or at risk of evolving into a medical emergency.".

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Based on record review and interview the facility failed to identify an adequate discharge plan for 1 patient (#7), who was admitted to the facility under an Ex Parte order (Court order for temporary custody for emergency psychiatric examination/treatment for up to 72 hours from the time the Ex Parte order is signed), out of 1 Ex Parte discharge reviewed. Specifically, the facility failed to evaluate and identify a patient for whom the lack of an adequate discharge plan is likely to result in an adverse impact on the patient's health. This failed practice placed this vulnerable patient at risk to harm self or others and affected the patient's health and overall wellbeing. Findings:

Record review on 1/28-30/19 revealed that Patient #7 was admitted to the facility under an Ex Parte order due to grave disability (when a person's mental disorder prevents him/her from providing for his/her own basic life-sustaining needs, such as food, clothing, and shelter).

The Ex Parte was petitioned by the Anchorage Jail Complex after Patient #7 was detained for assaulting a police officer outside of the Brother Francis Shelter when he/she was not allowed access to the shelter. While at the jail, Patient #7 expressed thoughts of wanting to harm himself/herself and stated he/she would wrap a sheet around his/her neck. The Patient was placed on full suicide precautions during his/her stay in the jail.

Record review revealed Patient #7 was admitted into the Alaska Psychiatric Institute (API) Admissions & Screening Office (ASO) on 12/20/18 and an assessment was completed at 1:20 pm. The "ASO Assessment" indicates: " ...Concerns exists today that [he/she] is incapable of knowing how to care for [his/her] basic needs. [His/her] inability to verbalize reality-based answers is lacking ...[His/her] lack of insight regarding [his/her] mental illness, ability to care for [himself/herself], demonstration of impulsive thoughts, actions and behavior places [him/her] at a level of grave disability at this time ...[He/she] is unable to say how [he/she] would meet basic needs upon release ..."

Review of Patient #7's medical record revealed a "LIP [Licensed Individual Practitioner] Discharge Summary," dated 12/20/18 (signed 1 hour and 3 minutes after the ASO Assessment) at 2:23pm, which documented: "[He/she] clearly is able to state how [he/she] will care for [himself/herself] in the shelter setting. States [he/she] will stay at Brother Francis shelter if [he/she] is allowed to return there. Otherwise, [he/she] is aware of the HOPE ...shelter. States [he/she] can obtain food at Beans Café...[he/she] is able to state how to get [his/her] needs met while living homeless. [He/she] clearly is not gravely disabled ...[He/she] states multiple times that [he/she] is not suicidal and has recently not been suicidal."

Additional review of the "LIP Discharge Summary," dated 12/20/18, documents Patient #7 blamed the LIP for the assault on the police officer, "You made me do it!" Also there is documentation that the Patient believed he/she was pregnant and when reminded of a negative pregnancy test, he/she cursed out the LIP. Prognosis for Patient #7 was documented as "Prognosis continues to be extremely poor due to [his/her] lack of medication compliance, history of violence, acting out when [he/she] does not get [his/her] way."

Further review revealed a final diagnoses of "Malingering [falsely or grossly exaggerated physical or psychological complaints with the goal of receiving a reward] for Housing" and "Schizophrenia ...[A serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling]."

Review of the "SW [Social Worker] Discharge Planning Note," dated 12/20/18 at 2:03 pm, revealed: " ...LIP has ordered [patient] to be discharged from [Alaska Psychiatric Institute] and provided a cab voucher to the Brother Francis Shelter as [patient] is not currently a danger to [himself/herself] or others and does not meet criteria for admission at this time ...It is recommended that [patient] continue to follow up with [BURT - Behavioral Emergency Response Team] team."

Review of the "SW Discharge Summary," dated 12/20/18 at 4:13 pm, revealed: "DISCHARGE PLAN: Patient will be discharged on December 20, 2018 to the Brother Francis Shelter and will take a taxi there ...[He/she] had an appointment with the BURT team on the day of [his/her] last discharge, [12/13/18], but did not make it to [his/her] appointment, despite [his/her] taxi going directly there at the time of discharge ..."

Continued review of Patient #7's medical record revealed an "ASO Assessment," dated 1/10/19 at 3:35 pm, which documented that the Patient was taken to the Alaska Native Medical Center (ANMC) via police 11 days after the 12/20/18 discharge, on 12/31/18, after attempting to assault someone at an assisted living home with a pair of scissors. The Patient had cut off all of his/her hair, was actively psychotic (with the belief he/she had leukemia), and hallucinating. He/she talked to imaginary people and continued to have delusions he/she was pregnant. He/she also stated he/she needed to get his/her seven children back from the gypsies. The Patient was unable to say when he/she ate last and he/she also believed it to be Thanksgiving Day. ANMC requested an Ex Parte, which was granted on 1/1/19 at 9:37 pm, due to the likeliness that the Patient may cause serious harm to others and due to being gravely disabled. Patient #7 was readmitted to API on 1/10/19.

During an interview on 1/30/19 at 10:45 am, the Director of Psychiatry (DOP) stated Patient #7's discharge on 12/20/18 from the ASO office, was not good practice. The DOP identified Patient #7 as "very vulnerable" and the DOP stated he/she was not included in the decision to discharge the Patient from the ASO to the shelter. Upon the 1/10/19 admission, the DOP stated he/she assigned a different LIP to the Patient to ensure "better care" was provided.

Review of the facility's policy, "Screening Court-Ordered Admissions," dated 6/15/2015, revealed: "III. All persons seeking or referred for admission who are mentally ill, as defined in [Alaska Statute - AS] 47.30.915 (12), and are likely to cause serious harm to themselves or others, as defined in AS 47.30.915 (10), and/or are gravely disabled, as defined in AS 47.30.915 (7), shall be admitted to API when no less restrictive treatment alternative is available in the community consistent with the person's treatment needs. IV. Persons sent to API on an emergency detention request [i.e., on a legally correct Ex Parte order or a screening order of a Superior Court Judge (see 47.30.700)] shall be admitted for further evaluation. The screening order may be signed by a magistrate pending Superior Court Review ..."

Additional review revealed: "COURT-ORDERED REFERRALS-COMMUNITY ACQUIRED: B. All patients with community acquired Ex Parte orders that present to API are to be admitted without exception."

Review of AS 47.30.915 - Definitions, dated 2008, revealed: "(12) "mental illness" means an organic, mental, or emotional impairment that has substantial adverse effects on an individual's ability or exercise conscious control of the individual's actions or ability to perceive reality or to reason or understand; mental retardation, epilepsy, drug addiction, and alcoholism do not per se constitute mental illness, although persons suffering from these conditions may also suffer from mental illness; (10) "likely to cause serious harm" means a person who (A) poses a substantial risk of bodily harm to that person's self, as manifested by recent behavior causing, attempting, or threatening that harm; (B) poses a substantial risk of harm to others as manifested by recent behavior causing, attempting, or threatening harm, and is likely in the near future to cause physical injury, physical abuse, or substantial property damage to another person; or (C) manifests a current intent to carry out plans of serious harm to that person's self or another; (7) "gravely disabled" means a condition in which a person as a result of mental illness (A) is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, or personal safety as to render serious accident, illness, or death highly probable of care by another is not taken; or (B) will, if not treated, suffer or continue to suffer severe and abnormal mental, emotional, or physical distress, and this distress is associated with significant impairment of judgement, reason, or behavior causing a substantial deterioration of the person's previous ability to function independently."

Review of AS 47.30.700 - Initiation of Involuntary Commitment Procedures, dated 2008, revealed: "(a) Upon petition of any adult, a judge shall immediately conduct a screening investigation or direct a local mental health professional employed by the department or by a local mental health program that receives money from the department under AS 47.30.520- 47.30.620 or another mental health professional designated by the judge, to conduct a screening investigation of the person alleged to be mentally ill and, as a result of that condition, alleged to be gravely disabled or to present a likelihood of serious harm to self or others. Within 48 hours after the completion of the screening investigation, a judge may issue an ex parte order orally or in writing, stating that there is probable cause to believe the respondent is mentally ill and that condition causes the respondent to be gravely disabled or to present a likelihood of serious harm to self or others. The court shall provide findings on which the conclusion is based, appoint an attorney to represent the respondent, and may direct that a peace officer take the respondent into custody and deliver the respondent to the nearest appropriate facility for emergency examination or treatment. The ex parte order shall be provided to the respondent and made a part of the respondent's clinical record. The court shall confirm an oral order in writing within 24 hours after it is issued. (b) The petition required in (a) of this section must allege that the respondent is reasonably believed to present a likelihood of serious harm to self or others or is gravely disabled as a result of mental illness and must specify the factual information on which that belief is based including the names and addresses of all persons known to the petitioner who have knowledge of those facts through personal observation."

Additionally, upon review of the facility's policy "Screening Court-Ordered Admissions," dated 6/15/2015, it was noted the policy referred the 2008 versions of AS 47.30.915 - Definitions. Review of the updated AS 47.30.915, dated 11/15/2016, revealed "mental illness" is now located at AS 47.30.915(14), "likely to cause serious harm" is now located at AS 47.30.915(12), and "gravely disabled" is now located at AS 47.30.915(9). The terminology of all three definitions remains the same with the exception of "mental illness" which removed the term "mental retardation ..." and replaced it with "intellectual disability, developmental disability, or both ..." AS 47.30.700 - Initiation of Involuntary Commitment Procedures also had an updated version, dated 2016. The terminology remained the same.
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