HospitalInspections.org

This CONDITION was not met as evidenced by:

Based on record review, policy review, observation and interview, it was determined the facility failed to ensure that patients have the right to receive care in a safe setting for potentially all patient's admitted to the facility, failed to ensure each patient had the right to be free from all forms of abuse or harassment for 2 of 2 patient's reviewed, and failed to ensure the use of restraint or seclusion was in accordance with the order of a physician for 2 of 2 records reviewed, and failed to ensure that patient had the right to safe implementation of restraint or seclusion by trained staff for 1 of 1 patients based on video review of having restraints applied.

-Provide a safe environment by failing to monitor 1 housekeeping cart with toxic chemicals (Unit 5-W) and failing to supervise patient access to items on the staff desk at 1 nursing station (Unit 5-K). (A-0144).

-Provide staffing, monitoring and treatment per policies resulting in abuse/neglect and harm to 2 of 2 patients (#1 and #2) and increased risk of harm for all patients and failure to investigate one allegation of patient sexual abuse in a through and timely manner and respond according to policies. (A-0145).

-Obtain complete orders for the use of seclusion for 2 of 2 patients (#2 and #3). (A-0168)

-Apply physical restraints in a safe manner and in accordance with facility policy for 1 of 1 patients (#3) and educated staff in proper technique afterwards. (A-0194)

The cumulative effect of which compromises the safety of all patient's served by the facility.

Based on observation and interview, the facility failed to provide a safe environment by failing to secure one housekeeping cart with toxic substances on it and failing to secure one nursing station, allowing children to reach across the counter and remove items. Findings include:

1. On 3/4/13 at approximately 2:20 pm an unattended housekeeping cart was observed in the hallway of unit 5-W. This finding was verified by Nurse Manager #1 at the time the observation.
2. On 3/5/13 at approximately 2 pm patient #7 was observed entering the Nursing Station on 5-K, then reaching over the counter on to the desk and taking paper. No staff were present in the nursing station when this occurred. Other items on the desk, within reach, included: a stapler, a bottle of hand sanitizer and a pen. This finding was verified by Nurse Manager #1 at the time of the observation.
3. The Census notes that patient #7 had symptoms of "aggression." Nurse Manager #1 was asked if this was safe and responded that she didn't see a problem with it and that there was "usually someone there."

Based on observation, interview and record review, the facility failed to protect all patients on unit 5-K (7 patients) from abuse and neglect on 2/16/13 by failing to provide staff coverage, monitoring and treatment per policies and initiate a prompt, through investigation and response to a sexual abuse allegation resulting in harm to patients #1 and #2 and increased risk of harm for all patients. Findings include:

Policy "Abuse and Neglect," #RR-5, dated 2/11, states:
"Neglect class II means...acts of commission or omission by and employee...with a standard of care or treatment required by law, rules, policies, guidelines, written directive, procedures or, or individual plan of service that cause or contribute to non-serious physical hare or emotional harm to a recipient."

Policy "Patient Observation Sheet/Rounds Board" 8.10, dated 7/10, states:
3. "To mitigate risk...patients are monitored at a minimum of 15 minute increments."
8. "The rounds board is to be maintained during all times, including any crisis."

I. Record review and interview regarding staffing and patient monitoring during the incident on 2/16/17 and patient harm (actual and risk):

1 On the morning of this incident, at 7:30 am on 2/16/13, RN #2 described patient #1, the alleged perpetrator, as: "paranoid. and sexualized" with "paranoid delusions," and "auditory" and "visual" hallucinations.
2. On 2/16/13 at 11 am, patient rounds were documented for patients #1 and #2.
3. At 11:04 am, video evidence, verified by the Recipient Rights Officer, reveals that patients #1 and #2 were found in patient #2's room. MHA (Mental Health Assistant) #1 directed patient #2 to leave the room.
4. At 11:10 am patient #1 returned to patient #2's room, walking past staff engaged in physical restraint of patient #3.
5. At 11:15 am, staff documented that patient #1 was resting and patient #2 was calm. Video evidence shows that neither patient was observed by staff at that time. Both patients were in #2's room, unobserved by staff, from 11:10-11:22 am, according to the Rights Officer's video timeline.
6. On 2/16/13 at 12 pm, Nurse #3 documented that another 5-K patient (#3) was restrained and secluded. This patient was physically restrained repeatedly throughout the day and evening on 2/16/13 but was not placed on 1:1 supervision, per staffing documentation.
7. On 2/16/13 at 12 pm Nurse #3 completed a "Staff Analysis" of patient #3's Restraint/Seclusion episode and recommended: "more staff for higher acuity patients" and using "1:1 observation."
8. During an interview on 3/5/13 at approximately 4 pm, the Nursing Administrator (NA) for Behavioral Health reviewed the facility's staffing grid and explained the unwritten protocol for adjusting staffing for acuity. The actual staffing documentation for 2/16/13 at the date of the incident was reviewed. There were 7 patients and 3 staff assigned to the unit at the time of the incident.
9. On 3/5/13 at approximately 4 pm, the NA stated that staffing was below protocol at the time of the incident on 2/16/13 because of patient acuity.
10. Following this incident, a facility report notes: "On 2/17/13 at 12:30 am the Oakland County Sheriff's Department came to Kingswood Hospital requesting to take the male patient involved in the incident (#1) into custody, stating the results of (patient #2's) medical examination found semen in the vaginal orifice, as well as signs of forced entry i.e.. tearing, redness." Patient #1 was jailed on 2/17/13.

II. Record review and interview regarding patient #1 lack of a treatment plan for sexual aggression and preoccupation despite documented history:

Facility policy: "Interdisciplinary Treatment Plan/Conference" 8.27, dated 7/09, states:

1. 7. "The Clinical Team will continue to identify problems and develop short term (and long term as indicated) goals with measurable objective, interventions, and time win which patient will attain completion."

From 3/4/13-3/5/13 review of patient #1's clinical record revealed the following:

1. Progress Notes documenting sexual preoccupation and aggression:
-1/27/13- "intrusive/stalking-like behavior"
-1/28/13- "patient found standing over female peer's bed"
-1/29/13- "needed occasional staff redirections for coming too close to female peer"
-2/1/13- "Patient has been closely monitored due to (unreadable) sexual preoccupation"
-2/2/13- "exposing self to others with erection"
-2/6/13- "he (patient #1) remains sexually preoccupied /unpredictable toward female peers and female staff"
-2/9/13- "Patient displayed verbal sexual inappropriateness towards female peers. Increased aggressive behavior ..."
-2/14/13- "(patient #1) "grabbed staff in the buttocks ...saying sexually inappropriate things. He also attempted to hide in female peer ' s room x 2."
-2/15/13- "pt (patient) became very sexually preoccupied."
2. No entry in patient #1's "Master Treatment Plan" related to sexual aggression or preoccupation was noted despite repeated notes documenting these behaviors.
3. The above findings were verified by Nurse Manager #1 during record review.

III. Record review and interview regarding the facility's failure to follow policies and protocols for patient assault/rape allegations:

Policy 1.72 B, "Patient-to-Patient Alleged Sexual Assault/Rape," dated 2/28/07 states:
"Any employee who receives notice of or witnesses an incident of sexual assault of a patient in the hospital must report the incident immediately."
"NOTE: There is no distinction between unconsented and consensual sexual contact with persons under the age of 18, or with incompetent persons."

The Charge Nurse/Nurse Manager:

1. "Assesses the alleged victim" and is assigned to:
(c) "Explain need for patient to not shower or wash away evidence..."
(d) "Obtain as much detailed information as possible regarding incident before patient is transported to the emergency room."
(e) "Document all information and actions in the patient's progress note."

2. Assesses the alleged perpetrator and is assigned to:
(c) "Document patient's account of events in patient's Progress notes."
(d) "Place patient on 1:1 staffing until evaluated by physician."
(g) "Document all actions taken in the Progress notes."

From 3/4/13-3/5/13 review of the alleged victim's (patient #2's) clinical record revealed the following:
1. On 2/16/13 at 11:22 am, per the facility's video timeline, MHA #1 found patients #1 and #2 in patient #2's bathroom, with "his (patient #1's) erect penis visible above the top of his boxers."
2. Nursing notes on 2/16/13 did not contain documentation of a post-incident nursing assessment or of instructing the patient not to shower or detailed information regarding the incident.
3. Nursing notes did not document detailed information regarding this incident.

From 3/4/13-3/5/13 review of the alleged perpetrator's (patient #1's) clinical record revealed the following:

1. The only note by the Nurse Manager (NM) #1 on the date of the incident (2/16/13) did not contain the patient's account of the incident.
2. The NM's 2/16/13 note, at 3 pm, states: "Patient hypersexualized and patient continues to think he is God...Patient sexually assaulted another peer...Staff member found (patient #1) in bathroom with another peer...with pants to ground....visible erection."
3. There was no nursing assessment of patient #1 following the incident until 3 pm.
4. Actions taken by the Charge/Nurse Manager in regard to this incident were not documented in the patient's record.
5. No order or documentation of 1:1 supervision of the patient #1 being provided, per policy requirements, following the incident. All 7 patients on the unit were children.

Interview:

During an interview on 3/4/13 at approximately 1 pm, Nurse Manager (NM) #1, on-site at the time of the incident, stated that she was not informed of the incident until 1.5-2 hours afterwards. NM #1 stated that she should have been informed immediately. NM #1 was unable to explain or provide documentation to explain why patient #1 did not get 1:1 supervision, per policy, following the incident. The NM verified above finding regarding gaps between facility actions and policies and procedures.

Based on record and policy review and interview, 2 of 2 patients had missing or incomplete orders for seclusion resulting in documentation of seclusion without an order (patient #3) and the potential for seclusion without an order due to incomplete documentation (patient #2). Findings include:

Policy: "Seclusion" #RR-22, February 2011
There must be a physician's order for each use of seclusion. The order must be time limited, dated and signed."
Patient #3:

1. On 2/16/13 at 11 am RN #3 got a telephone order to restraint, but not seclude, patient #3.
2. On 2/16/13 at 12 am RN #3 documented on the "Staff Analysis" form that patient #3 was both restrained and secluded.
2. The physician's order for the above event was for restraint only and was not dated and timed when signed by Dr. #2.
3. Documentation of this event was reviewed with Dr. #1 on 3/5/13 at approximately 5 pm.

Patient #2:

1. On 3/4/5 and 3/5/13 all physician orders and progress notes for patient #2 were requested.
2. Patient #2's record contained an incomplete telephone order for seclusion, dated 2/17/13, but untimed and unsigned by the ordering physician (Dr. #1).
2. The facility did not provide progress notes for 2/17/13-2/18/13 for patient #2 so it was not possible to determine whether the patient was secluded.
2. On 3/5/13 at approximately 5 pm Dr. #1 was interviewed and could not explain why this order was incomplete and unsigned.

Based on observation, interview and policy review, the facility failed to provide 1 of 1 physically restrained patients (#3) with safe implementation in accordance with facility policies. Findings include:

Policy: "Restraint" #RR-12, April 2005, states:

"The recipient has the right to safe implementation of restraint by trained, qualified staff." "Annual CPI" (Nonviolent Crisis Intervention) training is required.

1. On 3/5/13 at approximately 11:12 am review of video evidence of patient #3's physical restraint on 2/16/13 from approximately 11 am-11:30 am was reviewed. The following observations were verified by Nurse Manager #1.
-From approximately 11:08-11:17, patient #3 was restrained in prone position on the floor in from of the nurses station.
-At 11:17 am- patient #3 was carried down the hall, facing skyward, by 5 staff.
-Staff lost control of patient #3 was lowered the patient to the floor.
-The 5 staff picked the patient back up and resumed the carry to the Restraint/Seclusion room at the end of the hallway.
2. Review of staff training revealed that staff involved in the 2/17/13 restraint of patient #3 had received CPI training within the last year, per policy.
3. During record review the Nurse Manager was asked if the restraint techniques observed on the video complied with CPI training protocols. Nurse Manager #1 stated that they were not.
4. Review of "Nonviolent Crisis Intervention" manuals (2011) provided by the facility confirmed this finding.
5. On 3/5/13 at approximately 4 pm the Nursing Administrator for Behavioral Health stated that there had been no follow-up or re-training of staff involved in this restraint episode.

This CONDITION was not met as evidenced by:

Based on record review, policy review, observation and interview, it was determined the facility failed to ensure that patients have the right to receive care in a safe setting for potentially all patient's admitted to the facility, failed to ensure each patient had the right to be free from all forms of abuse or harassment for 2 of 2 patient's reviewed, and failed to ensure the use of restraint or seclusion was in accordance with the order of a physician for 2 of 2 records reviewed, and failed to ensure that patient had the right to safe implementation of restraint or seclusion by trained staff for 1 of 1 patients based on video review of having restraints applied.

-Provide a safe environment by failing to monitor 1 housekeeping cart with toxic chemicals (Unit 5-W) and failing to supervise patient access to items on the staff desk at 1 nursing station (Unit 5-K). (A-0144).

-Provide staffing, monitoring and treatment per policies resulting in abuse/neglect and harm to 2 of 2 patients (#1 and #2) and increased risk of harm for all patients and failure to investigate one allegation of patient sexual abuse in a through and timely manner and respond according to policies. (A-0145).

-Obtain complete orders for the use of seclusion for 2 of 2 patients (#2 and #3). (A-0168)

-Apply physical restraints in a safe manner and in accordance with facility policy for 1 of 1 patients (#3) and educated staff in proper technique afterwards. (A-0194)

The cumulative effect of which compromises the safety of all patient's served by the facility.

Based on observation and interview, the facility failed to provide a safe environment by failing to secure one housekeeping cart with toxic substances on it and failing to secure one nursing station, allowing children to reach across the counter and remove items. Findings include:

1. On 3/4/13 at approximately 2:20 pm an unattended housekeeping cart was observed in the hallway of unit 5-W. This finding was verified by Nurse Manager #1 at the time the observation.
2. On 3/5/13 at approximately 2 pm patient #7 was observed entering the Nursing Station on 5-K, then reaching over the counter on to the desk and taking paper. No staff were present in the nursing station when this occurred. Other items on the desk, within reach, included: a stapler, a bottle of hand sanitizer and a pen. This finding was verified by Nurse Manager #1 at the time of the observation.
3. The Census notes that patient #7 had symptoms of "aggression." Nurse Manager #1 was asked if this was safe and responded that she didn't see a problem with it and that there was "usually someone there."

Based on observation, interview and record review, the facility failed to protect all patients on unit 5-K (7 patients) from abuse and neglect on 2/16/13 by failing to provide staff coverage, monitoring and treatment per policies and initiate a prompt, through investigation and response to a sexual abuse allegation resulting in harm to patients #1 and #2 and increased risk of harm for all patients. Findings include:

Policy "Abuse and Neglect," #RR-5, dated 2/11, states:
"Neglect class II means...acts of commission or omission by and employee...with a standard of care or treatment required by law, rules, policies, guidelines, written directive, procedures or, or individual plan of service that cause or contribute to non-serious physical hare or emotional harm to a recipient."

Policy "Patient Observation Sheet/Rounds Board" 8.10, dated 7/10, states:
3. "To mitigate risk...patients are monitored at a minimum of 15 minute increments."
8. "The rounds board is to be maintained during all times, including any crisis."

I. Record review and interview regarding staffing and patient monitoring during the incident on 2/16/17 and patient harm (actual and risk):

1 On the morning of this incident, at 7:30 am on 2/16/13, RN #2 described patient #1, the alleged perpetrator, as: "paranoid. and sexualized" with "paranoid delusions," and "auditory" and "visual" hallucinations.
2. On 2/16/13 at 11 am, patient rounds were documented for patients #1 and #2.
3. At 11:04 am, video evidence, verified by the Recipient Rights Officer, reveals that patients #1 and #2 were found in patient #2's room. MHA (Mental Health Assistant) #1 directed patient #2 to leave the room.
4. At 11:10 am patient #1 returned to patient #2's room, walking past staff engaged in physical restraint of patient #3.
5. At 11:15 am, staff documented that patient #1 was resting and patient #2 was calm. Video evidence shows that neither patient was observed by staff at that time. Both patients were in #2's room, unobserved by staff, from 11:10-11:22 am, according to the Rights Officer's video timeline.
6. On 2/16/13 at 12 pm, Nurse #3 documented that another 5-K patient (#3) was restrained and secluded. This patient was physically restrained repeatedly throughout the day and evening on 2/16/13 but was not placed on 1:1 supervision, per staffing documentation.
7. On 2/16/13 at 12 pm Nurse #3 completed a "Staff Analysis" of patient #3's Restraint/Seclusion episode and recommended: "more staff for higher acuity patients" and using "1:1 observation."
8. During an interview on 3/5/13 at approximately 4 pm, the Nursing Administrator (NA) for Behavioral Health reviewed the facility's staffing grid and explained the unwritten protocol for adjusting staffing for acuity. The actual staffing documentation for 2/16/13 at the date of the incident was reviewed. There were 7 patients and 3 staff assigned to the unit at the time of the incident.
9. On 3/5/13 at approximately 4 pm, the NA stated that staffing was below protocol at the time of the incident on 2/16/13 because of patient acuity.
10. Following this incident, a facility report notes: "On 2/17/13 at 12:30 am the Oakland County Sheriff's Department came to Kingswood Hospital requesting to take the male patient involved in the incident (#1) into custody, stating the results of (patient #2's) medical examination found semen in the vaginal orifice, as well as signs of forced entry i.e.. tearing, redness." Patient #1 was jailed on 2/17/13.

II. Record review and interview regarding patient #1 lack of a treatment plan for sexual aggression and preoccupation despite documented history:

Facility policy: "Interdisciplinary Treatment Plan/Conference" 8.27, dated 7/09, states:

1. 7. "The Clinical Team will continue to identify problems and develop short term (and long term as indicated) goals with measurable objective, interventions, and time win which patient will attain completion."

From 3/4/13-3/5/13 review of patient #1's clinical record revealed the following:

1. Progress Notes documenting sexual preoccupation and aggression:
-1/27/13- "intrusive/stalking-like behavior"
-1/28/13- "patient found standing over female peer's bed"
-1/29/13- "needed occasional staff redirections for coming too close to female peer"
-2/1/13- "Patient has been closely monitored due to (unreadable) sexual preoccupation"
-2/2/13- "exposing self to others with erection"
-2/6/13- "he (patient #1) remains sexually preoccupied /unpredictable toward female peers and female staff"
-2/9/13- "Patient displayed verbal sexual inappropriateness towards female peers. Increased aggressive behavior ..."
-2/14/13- "(patient #1) "grabbed staff in the buttocks ...saying sexually inappropriate things. He also attempted to hide in female peer ' s room x 2."
-2/15/13- "pt (patient) became very sexually preoccupied."
2. No entry in patient #1's "Master Treatment Plan" related to sexual aggression or preoccupation was noted despite repeated notes documenting these behaviors.
3. The above findings were verified by Nurse Manager #1 during record review.

III. Record review and interview regarding the facility's failure to follow policies and protocols for patient assault/rape allegations:

Policy 1.72 B, "Patient-to-Patient Alleged Sexual Assault/Rape," dated 2/28/07 states:
"Any employee who receives notice of or witnesses an incident of sexual assault of a patient in the hospital must report the incident immediately."
"NOTE: There is no distinction between unconsented and consensual sexual contact with persons under the age of 18, or with incompetent persons."

The Charge Nurse/Nurse Manager:

1. "Assesses the alleged victim" and is assigned to:
(c) "Explain need for patient to not shower or wash away evidence..."
(d) "Obtain as much detailed information as possible regarding incident before patient is transported to the emergency room."
(e) "Document all information and actions in the patient's progress note."

2. Assesses the alleged perpetrator and is assigned to:
(c) "Document patient's account of events in patient's Progress notes."
(d) "Place patient on 1:1 staffing until evaluated by physician."
(g) "Document all actions taken in the Progress notes."

From 3/4/13-3/5/13 review of the alleged victim's (patient #2's) clinical record revealed the following:
1. On 2/16/13 at 11:22 am, per the facility's video timeline, MHA #1 found patients #1 and #2 in patient #2's bathroom, with "his (patient #1's) erect penis visible above the top of his boxers."
2. Nursing notes on 2/16/13 did not contain documentation of a post-incident nursing assessment or of instructing the patient not to shower or detailed information regarding the incident.
3. Nursing notes did not document detailed information regarding this incident.

From 3/4/13-3/5/13 review of the alleged perpetrator's (patient #1's) clinical record revealed the following:

1. The only note by the Nurse Manager (NM) #1 on the date of the incident (2/16/13) did not contain the patient's account of the incident.
2. The NM's 2/16/13 note, at 3 pm, states: "Patient hypersexualized and patient continues to think he is God...Patient sexually assaulted another peer...Staff member found (patient #1) in bathroom with another peer...with pants to ground....visible erection."
3. There was no nursing assessment of patient #1 following the incident until 3 pm.
4. Actions taken by the Charge/Nurse Manager in regard to this incident were not documented in the patient's record.
5. No order or documentation of 1:1 supervision of the patient #1 being provided, per policy requirements, following the incident. All 7 patients on the unit were children.

Interview:

During an interview on 3/4/13 at approximately 1 pm, Nurse Manager (NM) #1, on-site at the time of the incident, stated that she was not informed of the incident until 1.5-2 hours afterwards. NM #1 stated that she should have been informed immediately. NM #1 was unable to explain or provide documentation to explain why patient #1 did not get 1:1 supervision, per policy, following the incident. The NM verified above finding regarding gaps between facility actions and policies

Based on record and policy review and interview, 2 of 2 patients had missing or incomplete orders for seclusion resulting in documentation of seclusion without an order (patient #3) and the potential for seclusion without an order due to incomplete documentation (patient #2). Findings include:

Policy: "Seclusion" #RR-22, February 2011
There must be a physician's order for each use of seclusion. The order must be time limited, dated and signed."
Patient #3:

1. On 2/16/13 at 11 am RN #3 got a telephone order to restraint, but not seclude, patient #3.
2. On 2/16/13 at 12 am RN #3 documented on the "Staff Analysis" form that patient #3 was both restrained and secluded.
2. The physician's order for the above event was for restraint only and was not dated and timed when signed by Dr. #2.
3. Documentation of this event was reviewed with Dr. #1 on 3/5/13 at approximately 5 pm.

Patient #2:

1. On 3/4/5 and 3/5/13 all physician orders and progress notes for patient #2 were requested.
2. Patient #2's record contained an incomplete telephone order for seclusion, dated 2/17/13, but untimed and unsigned by the ordering physician (Dr. #1).
2. The facility did not provide progress notes for 2/17/13-2/18/13 for patient #2 so it was not possible to determine whether the patient was secluded.
2. On 3/5/13 at approximately 5 pm Dr. #1 was interviewed and could not explain why this order was incomplete and unsigned.

Based on observation, interview and policy review, the facility failed to provide 1 of 1 physically restrained patients (#3) with safe implementation in accordance with facility policies. Findings include:

Policy: "Restraint" #RR-12, April 2005, states:

"The recipient has the right to safe implementation of restraint by trained, qualified staff." "Annual CPI" (Nonviolent Crisis Intervention) training is required.

1. On 3/5/13 at approximately 11:12 am review of video evidence of patient #3's physical restraint on 2/16/13 from approximately 11 am-11:30 am was reviewed. The following observations were verified by Nurse Manager #1.
-From approximately 11:08-11:17, patient #3 was restrained in prone position on the floor in from of the nurses station.
-At 11:17 am- patient #3 was carried down the hall, facing skyward, by 5 staff.
-Staff lost control of patient #3 was lowered the patient to the floor.
-The 5 staff picked the patient back up and resumed the carry to the Restraint/Seclusion room at the end of the hallway.
2. Review of staff training revealed that staff involved in the 2/17/13 restraint of patient #3 had received CPI training within the last year, per policy.
3. During record review the Nurse Manager was asked if the restraint techniques observed on the video complied with CPI training protocols. Nurse Manager #1 stated that they were not.
4. Review of "Nonviolent Crisis Intervention" manuals (2011) provided by the facility confirmed this finding.
5. On 3/5/13 at approximately 4 pm the Nursing Administrator for Behavioral Health stated that there had been no follow-up or re-training of staff involved in this restraint episode.