HospitalInspections.org

Based on a review of the South Dakota Department of Health (SD DOH) complaint intake information, SD DOH facility reported incidents (FRI), observations, interviews, record review, and policy review, the provider failed to ensure safety mechanisms were in place to support five of five sampled patients (2, 3, 4, 5, and 6) and staff were safe from physical abuse and harassment by one of one sampled patient (1) who frequently displayed verbal, physical, aggressive, and sexually inappropriate behaviors. Findings include:

This failure has the potential to cause harm to other patients who reside in the same unit from serious injury or harm from his unpredictable and inappropriate behaviors.

Notice:
On 5/30/24 at 4:30 p.m. administrator A was informed of an Immediate Jeopardy (IJ) for failure to have had a plan in place to prevent patients from serious injury or harm.

Plan:
The facility provided the following acceptable removal plan on 5/31/24 at 11:03 a.m. for patient rights:
1. "Multi program collaboration review of the treatment plan and daily rounds.
a. Weekly treatment team, consisting of attending psychiatrist or designee, charge nurse (or designee) from both programs
(Psych Rehab and Intensive Treatment Unit), Social Work, Psychologist, and other disciplines as assigned will meet weekly and update the treatment plan. Documenting updates to goals, interventions, and objectives.
b. Meet Friday May 31, 2024 and weekly thereafter until patient is stable and returns to his home program.
c. Psych Rehab treatment team will round each business day with Intensive Treatment Unit team for updates to the active
treatment for patients.
d. Chart reviews completed nightly by assigned night shift staff to monitor completion of the treatment plan documentation
each business day. Night shifts staff will report to Adult Acute Hospital Nurse Manager or designee compliance or lack of compliance. Acute Hospital Nurse Manager or designee will compile audits and report to Quality Council beginning
in June and monthly until patient returns to home program."
2. "Create behavior plan if assessed by the treatment team as appropriate based on patient ability to engage and follow a plan.
a. Complete by end of day 5/31/2024 if treatment team deems clinically appropriate.
b. Will include patient strengths, likes and dislikes and guidance to staff on how to interact safely.
c. Will give outline of positive reinforcement, not negative reinforcement that would be indicative of a punitive response.
d. Behavior plan will be reviewed weekly or sooner as clinically appropriate during the treatment team meeting to review
the treatment plan.
e. Every two weeks chart reviews will be completed by assigned night shift staff to ensure behavior plan is updated. Assigned night shift staff will report to Adult Acute Hospital Nurse Manager or designee compliance or lack of compliance. Adult Acute Hospital Nurse Manager or designee will compile audits and report to Quality Council
beginning in June and monthly until patient returns to home program.
f. C2 Staff will be required to document they have read the behavior plan.
g. Adult Acute Program Nurse Manager or designee will monitor log to ensure all staff working have signed acknowledgement of understanding behavior plan (if behavioral plan is deemed applicable)."
3. "Physical Therapeutic Environment.
a. Patient will remain on C2 Adult side with no other patients for reduced stimulation for patient and safety of other patients
until medication affecting behaviors has cleared and behaviors and aggression has diminished.
b. Other adult patients will be house on the C2 Adolescent side of the unit until patient on adult side is stable once again
free from aggression behaviors.
c. All patients will be given individualized treatment and assessed for appropriateness of level of care on intensive treatment unit based on their individual needs and their ability to handle the stimulus of other patients.
d. This will be audited through regular clinical assessment."
4. "Staff education and support with interacting with patient.
a. SDHSC [South Dakota Human Services Center] will have Employee Assistance Program services available on campus weekly beginning week of June 3, 2024. Staff will be encouraged to utilize these services to process any concerns, fears, and barriers to interacting therapeutically with patients.
b. Staff will be directed that all interactions with patient will be with no less than two staff.
c. SDHSC Nonviolent Crisis Intervention Coordinator created a guide with de-escalation techniques and suggestions on how to safely interact with patient utilizing Nonviolent Crisis Intervention skills. This guide has been developed and will be distributed beginning with PM on 5/30/24.
d. C2 Staff will be required to document they have read the de-escalation guide.
e. Adult Acute Program Nurse Manager or designee will monitor log to ensure all staff working have signed acknowledgement they read the de-escalation guide."
5. "All nursing staff working on C2 will read nursing documentation required reading on day published (May 31). Nursing staff not working on C2 on 5/31/2024 will read the documentation changes prior to working their next shift on C2.
a. Nursing documentation required reading will be distributed via Policy tech reiterating all patients on C2 will have a nursing note documented for each patient each shift on C2.
b. Adult Acute Nurse Manager or Designee will monitor completion of required reading and report to Quality Council in June 2024."

The removal plan for the IJ was received and accepted on 5/31/24 at 11:03 a.m.
The implementation of their plan was verified and their IJ status was removed on 6/3/24 at 11:00 a.m.

Review of the provider's SD DOH FRIs on 5/2/24, 5/7/24, 5/12/24, and 5/22/24 reports, observation, interview, record review, and policy review, the provider failed to ensure the safety of:
*Five of five sampled patients (2, 3, 4, 5, and 6) from physical and verbal abuse by one of one sampled patient (1).
*One of one mental health associate (I) from verbal and sexual abuse by one of one sampled patient (1).
Refer to A145.

Based on the provider's submitted South Dakota Department of Health (SD DOH) facility reported incidents (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety of:
*Five of five sampled patients (2, 3, 4, 5, and 6) from physical and verbal abuse by one of one sampled patient (1).
*One of one mental health associate (MHS) (I) had been safe from verbal and sexual abuse by one of one sampled patient (1).
Findings include:

1. Review of the provider's SD DOH FRIs regarding patient 1 revealed:
*FRI 1 on 5/2/24 at 6:00 p.m. revealed:
-Patients 1 and 2 had been seated at the dining table watching television in the intensive treatment unit (ITU).
-Patient 1 left where he was seated and went to his room for several minutes. After patient 1 had left, patient 2 got up, moved to where patient 1 had been seated and sat in that spot. Patient 1 came back and stated to patient 2 "I was sitting [in] that spot, you need to move." Patient 1 slapped patient 2 across his head with an open hand. The interventions put in place after the altercation were "increased staffing was added to the adult side of the intensive treatment unit in order to keep the patients physically separated or intervene when they get within arm's reach of each other."

*FRI 2 on 5/7/24 at 4:20 p.m. revealed:
-Patient 3 was seated at the table with his head down listening to music on his headphones. Patient 1 had been seated in the day hall watching television. He stood up and approached patient 3 in a threatening manner. He yelled at patient 3 and then knocked his headphones off and slapped patient 3's head at that time.
-Patient 1 continued to be very agitated and was making threatening statements to patient 3 and the staff. Patient 3 was transferred from the ITU to the adult acute unit. The provider initiated new interventions to keep other patients safe by keeping patient 1 and other patients separated as much as possible. Every attempt was being made to not have other adult patients with him when possible.

*FRI 3 on 5/12/24 at 2:15 p.m. revealed:
-Patient 1 was in the ITU and was watching other patients from the adult acute unit through the windows of the shared courtyard. He and patient 4 had been observed as making hand signs at each other which the staff interpreted as "gang" signs.
-Patient 1 suddenly and forcefully pushed a door open to the courtyard. He and patient 4 ran towards each other and started to have a fist fight. They went to the ground and rolled around and continued to strike each other. MHA Q yelled for them to separate. Patients 1 and 4 stood up and briefly separated. MHA Q was able to get patient 1 to go back to the ITU. Patient 4 continued to attempt to hit patient 1 as he was going into the ITU. MHA Q secured the door between patient 1 and 4. Patient 1 was assessed for injuries and had several cuts and scratches on his hands. He was given an as needed anti-anxiety medication and then went to his room. There were no other interventions implemented.

*FRI 4 on 5/22/24 patient 5 was walking up and down the hallway past patient 1's room. Patient 5 was talking and laughing out loud, which was his typical behavior. Patient 5 entered his bedroom and was standing just inside his doorway when patient 1 opened his bedroom door. Patient 5 then entered his room and shut the door. Patient 1 started to swear and asked patient 5 what he had said. Patient stopped outside patient 5's bedroom door, opened it, and then pushed patient 5 down onto a mat.
-On 5/24/24 a difficult case conference was held with department head staff. Interventions put in place related to patient 1's continued aggression towards other patients from that meeting included:
--"Make medication adjustments based on recommendations from a couple of the more seasoned psychiatrists."
--"Remove the adolescents from one side of the ITU and put all the other adults on that side so that patient 1 would be by himself."

Review of four MHA incident reports revealed patient 1 had aggression towards MHA H, registered nurse (RN) M, and maintenance staff S.

2. Review of patient 1's medical record revealed:
*He had been admitted on 8/17/23 and was discharged to be transferred on 10/26/23 to the psych rehab program.
*His medications had been changed in the psych rehab (PR) and was re-admitted to the ITU at the hospital on 5/2/24.
*His diagnoses included schizophrenia and anti-social personality disorder.
*Review of patient 1's physician/psychiatrist progress notes revealed:
*A note on 5/6/24 at 10:45 a.m. by medical director/psychologist stated due to the medication changes.
-His medication had been changed from Risperdal to Abilify (mood stabilizing medications) and after approximately one week he had become agitated and irritable.
*Review of patient 1's behavioral event documentation from 5/2/24 through 5/29/24 indicated he had:
-Three episodes of hitting other patients.
-Two episodes of destruction of property.
-Forty-three episodes of intimidation, physical aggression, refusals, and questioning.
-Eleven episodes of sexual harassment.
-One episode of making physical threats.

Review of patient 1's treatment plan report for 5/2/24 revealed:*Multidisciplinary summary: "[Patient 1] was transferred to C2 on 5/2/24 due to increase paranoia, "
*He had two new problems with short-term goals and interventions. Those included:
-Long term goal was "Within 7 days [patient 1's name] will be able to transfer back to his home after a decrease of paranoia is observed."
-Short Term Goal: "Patient will have 2 instances of paranoia within 7 days."
-Interventions-Mental health staff will offer low-stimulus activities to [patient 1] to monitor for paranoia and offer coping skills when he appears upset."
*Patient 1's multidisciplinary summary 5/23/24 revealed his long and short-term goals included:
-"get money and save money.'
-"Discharge to sisters home in [name of town]."
-"Patient's treatment plan was updated due to a recent seclusion event. Treatment plan content wording was adjusted to reflect verbal and physical aggression. Seclusion event details were documented under the treatment plan objective. An intervention was added for staff to offer supportive 1:1 conversation to the patient. Treatment plan will continue to be reviewed and updated as needed."

3. Observation and interview on 5/29/24 at 9:37 a.m. with RN/nurse manager N revealed:
*RN/nurse manager N was the adolescent nurse manager.
*RN/nurse manager E was adult nurse manager.
*One staff person was assigned to watch the cameras. The cameras were in each patient room, the seclusion rooms, the day room, and the dining area for each side of Cedar 2.
*The staff would rotate to be responsible for two-to-three hours of monitoring the cameras.
*During the tour of the Cedar 2 unit it was revealed the unit was divided in half by a wall. One side was the ITU for adults and the other side was the ITU for adolescents.
*Patient 1 was the only patient in the adult ITU.
*There were three adult patients in the adolescent ITU.
*The adolescent patients had been moved to another unit due to the need for patient 1 to be alone in a unit.
*If an adolescent patient required the adolescent ITU they would have grouped the adults back together.
*Increased staffing would have been needed if the adults on the adolescent side would have to moved back to the adult side.

4 .Video review on 5/29/24 at 11:06 a.m. with assistant administrator D revealed:
*On 5/2/24 patient 1 and 2 were in the adult ITU on Cedar 2.
-At 5:53 p.m. patient 1 was seated in a chair watching television, got up, and went to the nurses' window, then sat down at a picnic-type table.
-At 5:54 p.m. patient 2 stood up and sat at the other end of the table away from patient 1.
-At 5:56 p.m. patient 1 went up to the nurses' window and then went down the hall to his room.
-At 5:57 p.m. patient 2 moved to where patient 1 had been seated. Patient 1 then came immediately back and started to yell at patient 2. Three staff came to the area to intervene and he reached out and hit patient 2 on the left side of his head. Staff assisted patient 1 in walking down the hall to his room. He was cooperative with the staff.
-At 5:59 p.m. patient 1 was out walking in the hallway.
*On 5/7/24 patient 1 and 3 were in the adult ITU on Cedar 2.
-At 4:20 p.m. patient 1 was sitting in the day area.
-At 4:23 p.m. patient 3 was sitting at the table with headphones on, then patient 1 walked over to patient 3 and pulled his headphones off.
-At 4:25 p.m. patient 1 walked down the hall to his room.
-At 4:26 p.m. multiple staff arrived on to the adult ITU.
-At 4:27 p.m. RN R was in patient 1's room with him. A code green [all available staff to report to the unit] was initiated.
-At 4:30 p.m. RN R was in the hall by patient 1's door looking into his room. She then entered his room. RN M then came down the hall and also entered his room. She was holding a syringe and stated she was giving him Ativan (a sedating medication) intramuscularly.
-At 4:37 p.m. RN M left his room and told staff who had reported for the code green they could return to their assigned areas.
*On 5/22/24 patient 1 and patient 5 were in the adult ITU in Cedar 2.
-At 3:58 p.m. patient 5 was walking around the cedar 2 unit with headphones on and talking to himself, then patient 5 was standing in the doorway of his room, when patient 1 went to the doorway of patient 5's room and pushed patient 5 down onto a mat on the floor.
-At 4:01 patient 5 went to his room.
-At 4:02 p.m. patient 5 came out of his room, took his headphones off, and returned them to the nurses' desk.
-At 4:03 p.m. patient 1 went back to his room. Staff had to redirect other patients out of the hallway.

Interview on 5/29/24 at 2:42 p.m. with HA G revealed she:
*Provided direct care of the patients, and helped with everyday activities.
*Watched the adult and adolescent ITUs through the cameras. The task of watching the cameras was rotated between staff to avoid fatigue.
*Had other duties while watching the cameras that included: assisting patients with making phone calls, and observing the day hall and the courtyard. Agreed there were distractions while staff watched the cameras so there were times the cameras were not monitored.
*Had worked with patient 1 since his admission and during his previous admissions.
*Felt he used his size as intimidation to get what he wanted.
*Observed he was less aggressive with women, but did touch them in an unwanted way.
*Charted his behaviors in his electronic medical record.
*Knew he had been in PR prior to his admission to the ITU and that he had a medication change and increased behaviors due to the medication change.
*Explained patient 1 had been doing "pretty good", and was not aware of any need for seclusion. He was very paranoid, he had heard PR did not want him back, and started to be more aggressive.
*Stated he had become more fidgety and watched her because she was assigned to monitor the cameras. He had asked to go outside on 5/12/24 and was told no because there were patients outside from another unit. He had watched and waited until the area was clear and then broke the door open to the courtyard and "went after" patient 4.
*Explained how patients were monitored in seclusion as:
-The cameras were watched by staff, in addition to other duties.
-All of the corners of the rooms were not able to be seen with the current camera system.
-If the person had been placed on suicide precautions staff would go to the patient's room if the patient was unable to be seen on the cameras. The staff could look through the patient's door and see all areas of the room.

Interview on 5/29/24 at 3:19 p.m. with HA HO regarding patient 1 revealed:.
*He felt patient 1 was paranoid, used intimidation, and used aggression against staff.
*Patient 1 had been there for over a month and he had not seen any changes. He was aware patient 1's medications had been changed while in PR when he was at PR he was doing well and working towards discharge.
*He felt if patient 1 did not get what he wanted he would become more aggressive.
*He stated people are scared of patient 1, some staff "walk on eggshells" around him and he is inappropriate with the female staff.
*He felt patient 1 manipulated situations and understood what he was doing.
*He stated there needed to be more interventions for patient's behaviors. He did not feel any changes had been made regarding patient 1 to keep patient 6 safe.

Interview on 5/29/24 at 3:47 p.m. with HA IP regarding patient 1 revealed:
*He primarily worked in PR and would frequently pick up shifts in the SITU in Cedar 2.
*When patient 1 was in PR he had done very well. He would use his headphones and walk around outside, had a job in the unit, and all interactions he observed of him were good.
*After patient 1 moved to the adult SITU in Cedar 2 and his mood would "Go from 0 to 100 very quickly."

Interview on 5/29/24 at 4:11 p.m. with RN AM regarding patient 1 revealed:*Patient 1 had been in the adult SITU in Cedar 2 for about a month.
*Staff were scared of him. They feared what he would do when the redirected him or tried to do any of the interventions for his behaviors.
*There had been multiple incidents of him being threatening and aggressive. She felt there were no consequences for his actions.

Telephone interview on 5/30/24 at 9:00 a.m. with HA I regarding patient 1 revealed:*Patient 1 was hypersexual (compulsive sexual behavior), paranoid, and had threatening behaviors.
*He had inappropriately touched multiple female staff.
*She felt he knew what he was doing.
*He would slap her butt, rub her back up and down, and squeeze her buttocks.
*She would tell him to stop but he was not redirected unless someone else had witnessed and stepped in.
*She felt violated and targeted by his sexual behaviors.
*She would try to not put herself in a position to allow him to be close to her.
*She stated he appeared to run the unit.

Interview on 5/30/24 at 10:38 a.m. with RN/Nurse Manager E regarding patient 1 revealed:*He is the nurse manager for the adult SITU.
*The SITU team had not been involved in patient 1's treatment. The PR team still provided all the interventions regarding patient 1 for staff.
*The teams were aware of his behaviors. The PR team decided on 5/23/24 to have patient 1 in the adult SITU by himself for the safety of others.
*A lot of the staff were scared of patient 1.
*Agreed patient 1 "ran the SITU because he was very scary."

Review of the provider's 1/30/23 Patient Abuse, Neglect, or Exploitation policy revealed the provider was:
*"To ensure that the patients at SDHSC are protected from abuse, neglect or exploitation."
*"To identify a process that shall address allegations of abuse, neglect or exploitation."