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350 FISHER ROAD

BERLIN, VT 05602

PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

Tag No.: A0145

Based on staff and patient interviews and record review, the hospital failed to ensure all patients were free from verbal harassment for 1 of 10 applicable patients. (Patient # 2). Findings include:

Per record review on 2/3/15 & 2/4/15, Patient #2 was admitted to the hospital on 11/19/14 with severe OCD (Obsessive Compulsive Disorder associated with anxiety characterized by recurrent, unwanted thoughts and repetitive behaviors). During Patient #2's hospitalization, certain "triggers" and "fears" have resulted in maladaptive behaviors which have impacted the patient's ability to sustain and maintain compliance with hospital rules, medication administration, activities of daily living and food consumption. Since admission various behavioral plans have been developed by the treatment team (Psychiatrist, psychologist, social worker, nursing and recreational therapy) to include very specific schedules to address personal hygiene, acceptance of meals and prescribed medication. Per physician progress note for 1/02/15, Patient #2's attending psychiatrist states: " We all have difficulties trying to find a consistent and recovery centered approach and everybody wants a magic formula". Record review noted evidence of various approaches to assist both Patient #2 and staff to manage his/her day to day stressors.

However, on the evening of 1/3/15 and 1/4/15 the evening Charge Nurse decided s/he would manage Patient #2's behaviors by directing staff to play a role in "planned ignoring" (behavioral management strategy used to reduce attention seeking behaviors). During the course of both evening shifts, staff were directed to ignore Patient #2's requests, to include special
accommodations previously provided to assist with the patient's significant OCD, forbidding any interaction with the patient unless specifically directed by the charge nurse. Per written statements obtained on 1/5/15 by Administration from staff assigned on 1/3/15 and 1/4/15 noted staff were told to not engage with or answer requests from Patient #2. Staff described Patient #2 as visibly upset, crying and pleading for assistance through out the evening. Witnesses described the charge nurse as "taunting" Patient #2 by repeatedly asking the patient to play a horseshoe game. The patient continuously refused, saying "No", expressing increased agitated and emotional frustrating with each repeated request made by the Charge Nurse over and over again.

A second reported interaction transpired at the nurses station on 2/5/15. Patient #2 approached the nurses station requesting staff to call the nursing supervisor or on call physician regarding the escalating anxiety s/he was experiencing, attempting to seek help from staff outside the unit. At that point the Charge Nurse opened the door to the nurses station and Patient #2 grabbed the door and slammed it shut. Per witness accounts, the Charge Nurse continued to reopen the door to the nurses station approximately 5-7 times , each time smiling and laughing at the patient, inciting and provoking the patient, who then slammed the door. Per interview on the afternoon 2/4/15, a staff member described Patient #2 during the door slamming incident as "...angry, yelling and hysterical...." Per interview on the afternoon of 2/4/15 the evening Charge Nurse confirmed the door slamming incident, identifying it as a physical "distraction", assisting the patient to "deescalate".

Per review of Precaution Monitoring Special Consideration/15 minute observation record for both 1/3/15 and 1/4/15, staff had recorded during the evning shift on 1/3/15 from 3:00 PM to 7:00 PM Patient #2 was observed to be "restless/troubled; afraid & anxious; angry talking or behavior; possible internal stimulation and expresses or appears sad". On 1/4/15 staff again recorded similar observations from 4:00 PM through 11:00 PM. These behaviors were not observed on 1/3/15 or 1/4/15 on the other shifts (7:00 am - 3:00 PM or 11:00 PM - 7:00AM).

Per Psychology Service Progress note for 1/5/15 at 1430 notes: Patient #2 "...reported that her/his anxiety level has been "through the roof" the past several days because s/he feels that most staff don't understand her/him..." to include the diagnosis of OCD. S/he reported that the anxiety level has been so bad that s/he thought about killing herself." S/he further requested a transfer off the unit to get away from staff who were triggering behaviors. Per interview on 2/4/15 at 10:30 AM the Licensed Psychologist confirmed "planned ignoring" was not part of Patient #2's treatment plan nor was it recommend to be used with OCD, especially not with Patient #2. It was further confirmed nursing should not be determining such a technique be used to manage Patient #2's behaviors.

Per a Physician Progress Note dated 1/5/05 at 15:30, Patient #2's Psychiatrist states: "S/he also had complaints about the staff not been available to work with (Patient #2) or talk to her/him over the weekend mainly during second shift. I got the report that many people thought that this approach was not productive." Per interview on 2/4/15 at 11:35 AM, the attending psychiatrist reconfirmed "planned ignoring" was "...never part of the plan..." and the evening Charge Nurse should not have instituted this behavioral technique. The Psychiatrist stated decisions such as this are only determined through discussions with the treatment team. Further noting "planned ignoring" was inappropriate and not used in psychiatry for patients with OCD.

Per interview on 2/4/15 at 1:40 PM, Patient #2 confirmed the events which occurred during the 2 evening shifts on 1/3/15 and 1/4/15. S/he expressed how emotionally difficult it was to have staff ignore her/him. Patient #2's account of the events concurred with staff statements and specifically acknowledged the evening Nurse Manager had "harassed" her/him during both evening shifts. The patient also noted s/he should not have been subjected to "planned ignoring" and all staff involved should have refused to be compliant with direction of the evening Charge Nurse.

USE OF RESTRAINT OR SECLUSION

Tag No.: A0154

Based on staff interview and record review, the hospital failed to assure that 1 of 6 applicable patients in the targeted sample was released from seclusion at the earliest possible time. (Patient #1). Findings include:

Per review of the medical record for Patient #1 on 2/3/15, the patient was secluded and administered emergency involuntary medication on 11/5/14 after attempting to physically assault and then threatening to kill the psychiatrist. Although the seclusion and subsequent administration of involuntary medication was determined to be necessary, there was a lack of documentation to show evidence of the continued need for seclusion after 2250 hours.
Per the psychiatrist notes of 11/5/14 at 2245 hours, "he/she became enraged ,....threatened to kill me and rapidly approached down the hallway. When a staff member tried to intervene, patient came within a few inches of staff", (hands raised per the Registered Nurse) "and threatened to kill him/her." (The patient was offered PRN medication and had refused this.) The patient was restrained at 2155 hours and brought to the seclusion room. In the seclusion room, "the patient remained severely agitated... When I attempted to speak with him, .....he began to slam...head repeatedly on the seclusion room door". The psychiatrist ordered emergency medication to be given, including Haldol, 5 mg. (milligrams), Ativan 2 mg., and Benadryl, 50 mg. I.M. (intramuscularly) and this was administered by the nurse at 2205 hours, per the CON (Certificate of Need) documentation flow sheet.
Per review of the "Emergency Seclusion/Restraint Record" log of recorded patient behaviors at designated times, at 2250 hours, the patient was coded to be 'restless and confused'; at 2305 hours the patient was coded as 'confused'; at 2320, the patient was coded as 'resting/RN notified'. At 2330 hours, the seclusion ended. Per review of the RN assessment of need to continue seclusion beyond 1 hour, Section 2 of the CON, Pg. 2 of 4, the RN wrote "calming but still incessantly talking at 2250 hours". 'The patient drank offered water.'
During interview on 2/4/15 at 2:25 PM, the ADON (Assistant Director of Nursing Services) confirmed that the RN documentation regarding the need for continued seclusion lacked evidence that the need continued until 2330 hours. The descriptors used to describe the behaviors did not indicate a risk of serious harm continued after 2250 hours.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on staff and patient interview and record review, the RN (Registered Nurse) failed to follow the current care and treatment plan established by the treatment team to manage the behaviors of 1 of 10 patients in the total sample. (Patient #2)

Regarding a targeted sample of 6 patients who were restrained, RNs failed to consistently perform an assessment of one patient who had undergone a restraint procedure, to assure that there were no possible injuries sustained, in accordance with accepted standards of nursing practice and hospital nursing documentation policy. The Patient was affected on 2 occasions. (Patient #1).

Findings for Patient #2 include:

1. Per record review on 2/3/15 & 2/4/15, Patient #2 was admitted to the hospital on 11/19/14 with severe OCD (Obsessive Compulsive Disorder associated with anxiety characterized by recurrent, unwanted thoughts and repetitive behaviors). During Patient #2's hospitalization, certain "triggers" and "fears" have resulted in maladaptive behaviors which have impacted the patient's ability to sustain and maintain compliance with hospital rules, medication administration, activities of daily living and food consumption. Since admission various behavioral plans have been developed by the treatment team (Psychiatrist, psychologist, social worker, nursing and recreational therapy) to include very specific schedules to address personal hygiene, acceptance of meals and prescribed medication. Per physician progress note for 1/02/15, Patient #2's attending psychiatrist states: " We all have difficulties trying to find a consistent and recovery centered approach and everybody wants a magic formula". Record review noted evidence of various approaches to assist both Patient #2 and staff to manage his/her day to day stressors.

However, on the evening of 1/3/15 and 1/4/15 the evening Charge Nurse decided s/he would introduce a new plan of treatment to manage Patient #2's behaviors by directing staff to play a role in "planned ignoring" (behavioral management strategy used to reduce attention seeking behaviors). During the course of both evening shifts, staff were directed to ignore Patient #2's requests, to include special accommodations previously provided to assist with the patient's significant OCD. Within the new "plan" staff were forbidden any interaction with the patient unless specifically directed by the charge nurse. Per written statements from staff dated 1/5/15, who witness events on 1/3/15 and 1/4/15 noted staff were told to not engage with or answer requests from Patient #2. Staff described Patient #2 as visibly upset, crying and pleading for assistance through out the evening. Witnesses described the charge nurse as "taunting" Patient #2 by repeatedly asking the patient to play a horseshoe game. The patient continuously refused, saying "No", expressing increased agitated and emotional frustrating with each repeated request made by the Charge Nurse.

A second reported interaction transpired at the nurses station on 2/5/15. Patient #2 approached the nurses station requesting staff to call the nursing supervisor or on call physician regarding the escalating anxiety s/he was experiencing, attempting to seek help from staff outside the unit. At that point the Charge Nurse opened the door to the nurses station and Patient #2 grabbed the door and slammed it shut. Per witness accounts, the Charge Nurse continued to reopen the door to the nurses station approximately 5-7 times , each time smiling and laughing at the patient, inciting and provoking the patient, who then slammed the door. Per interview on the afternoon 2/4/15, a staff member described Patient #2 during the door slamming incident as "...angry, yelling and hysterical...." Per interview on the afternoon of 2/4/15 the evening Charge Nurse confirmed the door slamming incident, identifying it as a physical "distraction", assisting the patient to "deescalate". This mode of "deescalating" for Patient #2's behaviors was not part of of the treatment/nursing plan.

Per Psychology Service Progress note for 1/5/15 at 1430 notes: Patient #2 "...reported that her/his anxiety level has been "through the roof" the past several days because s/he feels that most staff don't understand her/him..." to include the diagnosis of OCD. S/he reported that the anxiety level has been so bad that s/he thought about killing herself." S/he further requested a transfer off the unit to get away from staff who were triggering behaviors. Per interview on 2/4/15 at 10:30 AM the Licensed Psychologist confirmed "planned ignoring" was not part of Patient #2's treatment plan nor was it recommend to be used with OCD, especially not with Patient #2. It was further confirmed nursing should not be determining such a technique be used to manage Patient #2's behaviors. The Licensed Psychologist stated "..not a nursing function".

Per a Physician Progress Note dated 1/5/05 at 15:30, Patient #2's Psychiatrist states: "S/he also had complaints about the staff not been available to work with (Patient #2) or talk to her/him over the weekend mainly during second shift. I got the report that many people thought that this approach was not productive." Per interview on 2/4/15 at 11:35 AM, the attending psychiatrist reconfirmed "planned ignoring" was "...never part of the plan..." and the evening Charge Nurse should not have instituted this behavioral technique. The Psychiatrist stated decisions such as this are only determined through discussions with the treatment team. Further noting "planned ignoring" was inappropriate and not used in psychiatry for patients with OCD.

Per interview on 2/4/15 at 1:40 PM, Patient #2 confirmed the events which occurred during the 2 evening shifts on 1/3/15 and 1/4/15. S/he expressed how emotionally difficult it was to have staff ignore her/him and being subjected to "planned ignoring" plan of treatment instituted by the evening Charge Nurse without the approval of the Treatment Team.

Findings for Patient #1 include:

2. Per review of the CON (Certificate of Need) and Treatment Plan Addendum for Seclusion dated 11/5/14 and 11/15/14 for Patient #1, RNs failed to document assessment of possible injury after the patient required hands on manual restraint for transport to the seclusion room. Section 1 includes a check box which should be completed if the patient required manual restraint during the seclusion process. For each of the CONs completed for 11/5/14 and 11/15/14, the check box stating "Was patient checked for injuries?" was blank.
Per review of the hospital's Nursing Procedure - Restraint/Seclusion Care Tasks, .2, #8, Addressing Injuries: any indication of possible injury should be reported. No evidence of assessment for injury was documented on the CON. The failure of nurses to document assessment for possible injury after manual restraint was confirmed during interview with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) on 2/4/15 at 2:20 PM.