HospitalInspections.org

Based on review of records, review of hospital policies and procedures, and interviews with key personnel on April 9 and 12, 2010, it was determined that the hospital failed to ensure that all applicable Federal, State and local law requirements are met.

Findings include:

1. There was no documented evidence that the hospital met all the of the applicable state laws and rules as required by the Rules for the Licensing of Hospitals in the State of Maine, Section 3.5.1.1., which states: "A violation of the Rights of Recipients of Mental Health Services or the Rights of Recipients of Mental Health Services who are Children in Need of Treatment constitutes a violation of the state of Maine Rules for the Licensing of Hospitals. " (See Tag A-0115)

2. The Rights of Recipients of Mental Health Services, Part A. III. Basic Rights, states, " ...F. Recipients have the right to refuse all or some of the services offered. " (See tag A-0115, Tag A-0145, Tag A-0154, Tag A-0164)

3. The Rights of Recipients of Mental Health Services, Part B. II. Privacy and Humane Treatment Environment, states, " ...A. Recipients have the right to a humane psychological and physical environment within the treatment facility. (See Tag A-0115, Tag A-0145, Tag A-0154, Tag A-0164)

4. The Rights of Recipients of Mental Health Services, Part B. II. Privacy and Humane Treatment Environment, states, " ...F. Recipients have the right to be free from abuse, exploitation, or neglect... " (See Tag A-0115, Tag A-0145, Tag A-0154, Tag A-0164)

5. The Rights of Recipients of Mental Health Services, Part B. II. Privacy and Humane Treatment Environment, states, " ...F.2. Recipients shall not be subjected to physical abuse, and corporal punishment is expressly prohibited... " (See Tag A-0115, Tag A-0145, Tag A-0154, Tag A-0164)

6. The Rights of Recipients of Mental Health Services, Part B. III. Individualized Treatment and Discharge Plan in Inpatient Settings, states, " ...B. Treatment and discharge plans shall be based upon consideration of the recipient ' s housing....general health...emotional, and psychiatric and/or psychological strengths and needs as well as his or her potential need for crisis intervention and resolution services following discharge... " (See Tag A-0115, Tag A-0130, Tag A-0131, Tag A-0799)

7. III. Individualized Treatment and Discharge Plan in Inpatient Settings, states, " ...D...A recipient ' s guardian, if any, shall be notified of all treatment and discharge planning meetings and shall be invited to attend...Notices required by this paragraph shall be given by the team coordinator or designee at least two days in advance of the meeting date... " (See Tag A-0115, Tag A-0130, Tag A-0131, Tag A-0799)

8. The Rights of Recipients of Mental Health Services, Part B. III. Individualized Treatment and Discharge Plan in Inpatient Settings, states, " ...K. Discharge or termination 1. Each recipient has the right to be informed of and referred to appropriate resources upon discharge or termination from a facility or program... " (See Tag A-0115, Tag A-o130, Tag A-0131, Tag A-0799)

9. The Rights of Recipients of Mental Health Services, Part B. V. Informed Consent to Treatment, states, " ...A. Right to informed consent. Recipients have the right to informed consent for all treatment... " (See Tag A-0115, Tag A-0117, Tag A-0130, Tag A-0131, Tag A-0799)

10. The Rights of Recipients of Mental Health Services, Part B. V. Informed Consent to Treatment, states, " ...D. Informed consent to treatment. Informed consent to treatment is obtained only where the recipient possesses capacity to make a reasoned decision regarding the treatment, the recipient or the recipient ' s guardian is provided with adequate information concerning the treatment, and the recipient or guardian makes a voluntary choice in favor of the treatment. Informed consent must be documented in each case... " (See Tag A-0115, Tag A-0130, Tag A-0131, Tag A-0799)

11. The Rights of Recipients of Mental Health Services, Part B. V. Informed Consent to Treatment, states, " ...B... 2. Restraint may be employed only when absolutely necessary to protect the recipient from serious physical injury to self or others and shall impose the least possible restriction consistent with its purpose. 3. Restraint may only be used after less restrictive measures have proven to be inappropriate or ineffective...12. A special progress/check sheet record shall be maintained for each use of restraint and shall include the following documentation: a. The indication for the use of the restraint. b. A description of the behaviors that constitute the recipient ' s danger to self or others. c. A description of less restrictive alternatives used or considered, and a description of why these alternatives proved ineffective or why they were deemed inappropriate upon consideration... " (See Tag A-0115, Tag A-0145, Tag A-0154, Tag A-0164, Tag A-0166, Tag A-0175)

The cumulative effect of these findings resulted in this Condition of Participation being out of compliance.

Based on review of records, review of hospital policies and procedures, and interviews with key personnel on April 9 and 12, 2010, it was determined that the hospital failed to protect and promote each patient ' s rights.

Findings include:

1. The hospital failed to provide the " Important Message from Medicare " (IM) to the patient and/or representative or guardian two (2) days prior to discharge. (See Tag A-0117)

2. The hospital failed to include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization in the hospital ' s " IDD#: AD-150 Patient Grievance Procedure " . (See Tag A-0120)

3. The hospital failed to identify in the hospital ' s " IDD#: AD-150 Patient Grievance Procedure " , that the written resolution to the patient and/or the patient ' s representative will contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. (See Tag A-0123)

4. The hospital failed to include the patient and/or the patient ' s representative in the development and implementation of his or her plan of care. (See Tag A-0130)

5. The hospital failed to provide the patient and/or the patient ' s representative with adequate information to make an informed decision regarding his or her care. (See Tag A-0131)

6. The hospital failed to promote the patient ' s right to be free from all forms of abuse or harassment. (See Tag A-0145)

7. The hospital failed to protect the patient ' s right to confidentiality of his or her clinical record. (See Tag A-0146 and A-0147)

8. The hospital failed to promote the patient ' s " right to be free from restraint or seclusion, of any form, imposed as a means...convenience...by staff. Restraint...may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others... " (See Tag A-0154)

9. The hospital failed to determine less restrictive interventions were ineffective prior to the application of restraints. (See Tag A-0164)

10. The hospital failed to modify the patient ' s plan of care with regards to the use of restraints. (See Tag A-0166)

11. The hospital failed to monitor the condition of the restrained patient in accordance with the hospital ' s " IDD#: CL-136 Use of Restraint for all Acadia Hospital/Acadia HealthCare Patients " . (See Tag A-0175)

12. The hospital failed to specify the required timeframe and documentation requirements for reporting restraint deaths to CMS in the hospital ' s " IDD#: CL-136 Use of Restraint for all Acadia Hospital/Acadia HealthCare Patients " . (See Tag A-0214)

The cumulative effect of these findings resulted in this Condition of Participation being out of compliance.

Based on review of patient medical records, hospital policies and procedures and interviews with key hospital personnel on April 9 and 12, 2010, it was determined that the hospital failed to inform the patient and/or his or her representative of the patient ' s rights in advance of discontinuing patient care.

Findings include:

1. A review of the hospital ' s policy, " IDD# AD-123 Patient Rights " , indicated that the hospital " ...will not arbitrarily transfer or discharge patients and will give reasonable advance notice of any transfer or discharge and appropriate discharge plans made. "

2. In a progress note dated April 6, 2010, indicated that " ...clinician had telephone conversation with guardian...regarding discharge plan: [patient] to discharge via taxi...to the Acadia recovery Community emergency shelter (ARC) with psychotropic medication management appointment ... and therapy appointment...; and the Outback program to be started on Friday at the ARC on site programming) ... [Guardian] voiced that [guardian] was not in approval of this plan. [Guardian] voiced that [guardian] had received the fax copy of the medicare Rights form...would not initial the form... (Paper copy of this in paper chart.)... "

3. Review of the medical record revealed that the hospital had provided the " Important Message from Medicare " (IM) to the patient ' s guardian on the day of discharge, April 6, 2010. Therefore, the hospital failed to provide the " Important Message from Medicare " (IM) to the patient and/or representative or guardian two (2) days prior to discharge.

4. During an interview on April 9, 2010, the patient ' s guardian confirmed that she/he did not receive the IM two (2) days prior to discharge. Additionally, the guardian stated, " The hospital was working on placement for [patient] in the morning of April 5, 2010. I was notified by telephone late afternoon on April 5th that [patient] was to be discharged on April 6th to a homeless shelter. I told them that the discharge plan was unacceptable. I understood from the meeting with the hospital on March 25th that [patient] was to stay until suitable placement was found. "

Based on review of patient medical records, hospital policies and procedures and interviews with key hospital personnel on April 9 and 12, 2010, it was determined that the hospital failed to include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization.

Findings include:

1. A review of the hospital ' s " IDD#: AD-150 Patient Grievance Procedure " indicated that there was no mechanism in place for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization.

2. There was documented evidence in the patient ' s medical record that the guardian had refused to initial for receipt of the IM and that [clinician 1] had discussed the refusal with the hospital ' s utilization review department on April 6, 2010.

3. There was no documented evidence in the patient ' s medical record that the guardian ' s disagreement with the discharge plan was referred to the appropriate Utilization and Quality Control Quality Improvement Organization.

Based on review of hospital policies and procedures, it was determined that the hospital ' s " IDD#: AD-150 Patient Grievance Procedure " , failed to identify that the written resolution to the patient and/or the patient ' s representative would include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Based on review of patient medical records, hospital policies and procedures, it was determined that the hospital failed to include the patient and/or the patient ' s representative in the development and implementation of his or her plan of care.

Findings Include:

1. A review of the patient ' s medical record revealed that there was no documented evidence that the patient or the patient ' s guardian was involved in the development and implementation of the patient ' s Treatment Plan dated March 19, 2010.

2. A review of the hospital ' s " IDD#: CL-147 Patient Assessment/Master Treatment Planning " , indicated that the " ...Comprehensive Master Treatment Plan (MTP) - For hospitalized patients, the psychiatrist leads the members of the team with development of the MTP that is to be completed no later than day 5 after admission... "

3. A review of the patient ' s medical record revealed that the patient was admitted March 19, 2010 to an observation bed and then was transferred to inpatient status on March 22, 2010. Additionally, the MTP was not completed until March 29, 2010. The record also revealed that a treatment plan update was completed on March 29, 2010. There was documented evidence that the guardian was involved in the completion of the MTP but not the treatment plan update.

Based on review of patient medical records, hospital policies and procedures and interviews with key hospital personnel on April 9 and 12, 2010, it was determined that the hospital failed to provide the patient and/or the patient ' s representative with adequate information to make an informed decision regarding his or her care.

Findings Include:

1. A review of the patient's medical record revealed that the hospital failed to obtain the guardian's consent to administer routine and as needed medications including: Ben Gay, Vitamin D, Haldol, Cogentin, Ibuprofen, and Benadryl.

2. . A review of the patient's medical record indicated that the patient had been admitted to an observation bed on March 19, 2010 and failed to meet criteria for inpatient care as of March 21, 2010 with plans to discharge the patient back to the group home.

3. In a Progress Note dated March 23, 2010, it stated, "...The assessment up until today was that as [patient] did not meet criteria for voluntary hospitalization or for continuation of observation level of care, but [patient's] group home was not able to take [patient] back...The patient ' s thought process is assessed to be disorganized and delusional as evidenced by the notes that [patient] writes and their content. The patient is assessed to have limited insight and judgment...Global Assessment of Functioning: Currently 25...due to [patient ' s] continued delusional and disorganized thinking, and continued aggression...meets the criteria for voluntary hospitalization at this time..."

4. In a progress note dated March 25, 2010, indicated that a "... community meeting occurred in the Penobscot Room...agree with looking for alternative placement ([patient] not returning to [group home]). Various person presents agree with this; no one voices disagreement...guardian states [he/she] has signed releases allowing communication with PNMI [Private Non-Medical Institution] priortiizer from all three DHHS regions...6. TO DO: Schedule weekly or biweekly follow up community meetings...8. Consider possibility of forensic evaluation. 9. TO DO: Develop detailed crisis plan to address both medical and psychiatric issues to be made available to various community providers and emergency departments. 10. [group home] staff spoke about [patient] not being engaged in treatment decisions in the past...outpatient providers noted [patient] is more easily engaged in during individual or small group settings and becomes very ' anxious " when several person are present...Regarding item #6 above: This clinician recommends having 30 minute meetings with agendas...will need to contact key community and outpatient providers and guardian to set up meeting dates."

5. During an interview with the Attending Psychiatrist on April 9, 2010 at 1400, the Attending Psychiatrist stated, "The detailed crisis plan...the one that was to go to all the hospitals, I don't know anything about it. It wasn't my responsibility."

6. In a Progress Note dated, March 28, 2010, it was stated, "Patient presents with extreme agitation, thought disorganization, and violence...patient did not verbally respond...patient was engaging in self-abusive behaviors...patient had been assaultive towards staff, destructive of property, throwing food...Due to [patient's] level of thought disorganization, self-abusive behaviors, and violence towards staff, I have initiated emergency medications for this patient...At this point, I am adding on the diagnosis of psychotic disorder, not otherwise specified to the patient ' s Axis I..."

7. The Discharge Summary dated April 6, 2010, indicated that "...it was decided that it would be helpful in assessment for potential risk of violence and recommended level of care in community for a forensic evaluation...Communication was made with...psychologist in Bangor who does do forensic evaluations... [Psychologist] ... normally does forensic evaluations when they are court ordered and asked who would pay for the services since it was not paid from Medicare..."

8. In a Progress Note dated March 29, 2010, it was stated, "...contacted Dr. [physician] regarding forensic evaluation as mentioned at treatment team meeting last week...What would be teased out in such an assessment is, 1) risk of future violence; 2) level of care most suitable when discharged; and 3) ...evaluation to determine if [patient] displays psychopathology..."

9. In a physician progress note, dated April 5, 2010 and time dictated at 14:03 that stated, "... Judgment and insight remain impaired...We are looking for a place for [patient] to be discharged to... " Under Diagnoses it was indicated that the patient had an Axis I diagnosis of Schizoaffective disorder and impulse control disorder. Under Axis II: "Personality disorder, not otherwise specified, with borderline and dependent, and antisocial traits..." An addendum added to this progress note was dated April 6, 2010 at 13:01 stated, "Diagnosis was clarified with outpatient treatment team to be Axis I: PTSD [Post Traumatic Stress disorder], Axis II Pers D/O [Personality Disorder] NOS [not otherwise specified] Clusters B and C. Please remove Schizoaffective Disorder because any psychotic symptoms have been fleeting and deemed related to anxiety."

10. In a nursing note, dated April 3, 2010 at 07:08 pm, it was documented under "Shift Assessment Update"; "...Patient had poor boundaries with roommate. Patient urinated on the bathroom floor before roommate was to take a shower...Patient Stated "I refuse my serequel because I don't feel safe..."

11. In a nursing note, dated April 4, 2010 at 11:17 am, it was documented, "Around 0800 [patient] and [peer] were having confrontation...as [peer] was trying to explain something to staff' [patient] grabbed [peer's] wrist and began twisting it, and refused to stop after multiple times being told to do so. At this point [peer] fell backwards into the table and [patient] let go. [Peer] said that [patient] had held a pen up to [peer's] throat and threatened...Private room status re-ordered...Assaulted peer considering contacting police."

12. In a nursing note, dated April 4, 2010 at 04:45 pm, it was documented, "...Other client involved in aggression of this am, has been moved to another unit for [peer's] safety...Assaulted peer plans to meet with the Bangor PD tomorrow to press charges of assault.."

13. In a nursing note, dated April 5, 2010 at 10:56 am, it was documented under "Shift Assessment" , that the patient ' s level of observation was "7.5 minute checks".

14. During an interview with the attending psychiatrist on April 9, 2010 at 1400, it was stated that the patient was on seven and half minute checks because "we wanted to know where [she/he] was."

15. Additionally, during an interview with the attending psychiatrist on April 9, 2010 at 1400, when asked if the patient was safe for discharge, the psychiatrist responded, " [patient] is not safe, the community isn ' t safe. [patient ' s] got a Personality Disorder with antisocial traits. I don ' t think [patient] will ever be safe. I don ' t think the community will be safe. "

16. In a physician progress note, dated April 5, 2010 and time dictated at 14:29, it was stated, "...This patient's outside treating sources are attempting to find a place for the patient to live. The patient appears to be at baseline and is not meeting criteria for continued hospitalization..."

17. In a progress note dated April 6, 2010, indicated that "...At Noon, a meeting was held in medical director, Dr. [medical director]'s office to review discharge plan...inpatient treatment team...confirmed plan of meeting with [patient] to discuss discharge at 1:00 PM...[social worker 2] confirmed...contacted the Bangor police department (BPD) and agreed to follow up with the BPD on their presence...in the event they were needed...Discussion on diagnostic impression occurred with agreement...agreed to discuss diagnostic impression with attending inpatient physician, [name], (not present at this meeting)."

18. In spite of the plan to locate appropriate placement for the patient prior to discharge per the March 25, 2010 meeting, a second meeting had been held, without notifying the guardian, per the documentation in a progress note dated April 6, 2010, to discuss the discharge of the patient to a homeless shelter without the guardian's involvement.

19. The Discharge Summary dated April 6, 2010, indicated that "...The discharge plan was discussed with the guardian, in which [patient] was to be discharged with handicapped accessibility ... to the Acadia Recovery emergency shelter with psychotropic medication management appointments...and therapy appointments...The guardian expressed concern that [she/he] was not in approval of this plan..."

20. Additionally, the Discharge Summary dated April 6, 2010, stated, "...At noon on 4/5/2010, a meeting was held with the medical director...to review the discharge plan. During this meeting, [patient] treatment team was involved and confirmed the plan of being discharged...contacted the Bangor Police department in which they would be in the [hospital] back parking lot in the event they were needed if the patient refused to leave the. Acadia Hospital property. The patient arrived at the Acadia Recovery Community around 1:45 pm...At around 2:40 pm [patient's] clinician...had conversation with...director of the Acadia Recovery Community and provided a case summary regarding [patient's] presentation including the patient's difficulty with tolerating a roommate...[director] stated that if needed, staff could contact the Bangor Police Department..."

21. In spite of the discharge planning meeting dated March 25, 2010, there was documentation in the Discharge Summary, dated April 6, 2010, that indicated, "...It was discussed with his treatment team...that the medical director's decision was to discharge [patient] to the Acadia Recovery Homeless Shelter on Tuesday, April 6, 2010. This plan was discussed with the...guardian...in which [guardian] stated that it was not acceptable and [guardian] was uncomfortable with the risk associated with discharging the patient to a homeless shelter."

22. There was documented evidence in the patient's medical record that the hospital had not informed the guardian until April 5, 2010, that the patient would be discharged on April 6, 2010 in spite of the guardian's objections.

23. There was documented evidence in the patient's medical record that the hospital had not informed the patient of the plan to discharge until April 6, 2010 at 1300. The patient was discharged at 1:20 pm by taxi. Therefore, there was documented evidence that the hospital had not included the guardian or the patient in the decision for discharge.

24. During an interview with the VP Clinical Operations on April 9, 2010 at 1500, the VP Clinical Operations stated, "We had to do a sudden discharge. We told the guardian the night before and the patient the next day. It was well organized. When the patient was here before, [she/he] was quite resistive to discharge."

25. During an interview with the Attending Psychiatrist on April 9, 2010 at 1400, the Attending Psychiatrist stated, "The Medical Director made the administrative decision to discharge the patient. The patient wasn't getting any better or worse. [She/He] was taking up space. [She/He] didn ' t need to be here in an acute hospital at twenty-three hundred dollars a day.

26. In spite of the documented recertification for continued stay on April 5, 2010, it was stated by the President & CEO during an interview on April 12, 2010 at 1630, that, "The patient had to be discharged. The patient was decertified and no one was willing to pick up the expenses."

Based on review of patient medical records, hospital policies and procedures, it was determined that the hospital failed to promote the patient ' s right to be free from all forms of abuse or harassment.

Findings include:

1. On March 20, 2010, the nurse's note stated, "...Pt went into [patient's] room this afternoon at 1615 and sitting on [patient's] bed started banging [patient's] head against the wall repeatedly. Pt's behavior was brought to the attention of [name], PMHNP [Psychiatric Mental Health Nurse Practitioner] and Charge Nurse, [name] and both indicated that pt's behavior should be ignored...Pt did not cease the pounding. Staff attempted to offer pt [patient's] HS [hour of sleep] meds at 2000, but pt refused...2138 Pt began banging wall with elbow instead of head...PMH-NP was consulted and came to speak with patient. Patient was advised that if behavior did not stop [patient] would receive emergency IM [intramuscular] medication. Pt ceased banging but still refused Seroquel..."

2. On March 21, 2010 at 0125, the nurses note stated, "...Nurse asked patient to please remove blanket from over head so that [she/he] could visualize patient was safe. At this point patient punched wall but left blanket over [patient's] head. Charge nurse consulted and entered patient room. Charge RN and PMH-NP in to see patient. PMH-NP offered patient Seroquel 900mg or IM thorazine 100mg. Pt refused several offers and reasoning by both RN (x3) and PMH-NP (x3). Pt punching wall and exhibiting middle finger. Charge RN from 3S entered unit and entered patient room to offer Seroquel. Pt refused Seroquel for [her/him] x4. IM thorazine was then drawn up per PMH-NP [name],order. Pt attacked PMH-NP and Carge RN...when [patient] was informed [patient] would receive IM injection if [patient] did not take Seroquel. Pt restraint called at 0220 and lasted until 0225. Pt received 100 mg thorazine IM. Pt was informed that [patient] would be released as soon as [patient] stopped attempting to hurt staff... "

3. In a physician order dated March 21, 2010 at 3:58:06 AM, it was documented, "Provider notified at 03/21/10 3:58:00, Restrain due to ASSAULT, Physical, patient was held for administration of IM medication at approx 0220, for a period of approx 5 minutes"

4. There was no documented evidence that there had been a psychiatric emergency ordered to give emergency intramuscular medications on March 21, 2010.

5. In spite of the patient's refusal of oral medications, notifying the guardian after the fact and the hospital's failure to declare a psychiatric emergency, the patient was placed in a physical hold to receive IM Thorazine on March 21, 2010 at 0220.

Based on review of patient medical records, hospital policies and procedures and interviews with key hospital personnel on April 9 and 12, 2010, it was determined that the hospital failed to maintain the confidentiality of the patient ' s clinical record. (See Tag A-0147)

Based on review of patient medical records, hospital policies and procedures and interviews with key hospital personnel on April 9 and 12, 2010, it was determined that the hospital failed to protect the patient ' s right to confidentiality of his or her clinical record.

Findings include:

1. There was no documented evidence that the hospital had received signed consent from the patient ' s guardian to disseminate the patient ' s clinical information to the Acadia Recovery Community (ARC).

2. The VP Clinical Operations stated during an interview on April 9, 2010 that the patient had been discharged to the ARC.

3. In a "Progress Note" that was signed April 5, 2010, it was stated, "This clinician contacts DHHS guardian...to discuss discharge plan. [Guardian] states "This is absolutely not acceptable. "[Guardian] states [guardian] is uncomfortable "with the risk" associated with discharge to a homeless shelter...i contact the Acadia recovery Shelter and speak to a woman named...who tells me to contact supervisor of the program, [name] in the AM regarding whether an exception would be allow [patient] to stay there during the day..."

4. In a "Progress Note" that was signed April 6, 2010, it was stated, "At about 2:40 PM, this clinician had telephone conversation with [name],director at the Acadia recovery community (ARC). This clinician provided case summary regarding [patient's] presentation, including [patient's] difficulty with tolerating a roommate. [Director of ARC] stated that if the ARC staff needs to contact Bangor police department tonight or if they need to call to arrange for ambulance transfer secondary to [patient] having any emergency medical needs, ARC staff will also call the Acadia Hospital House Administrator and the Acadia Access Center."

Based on review of patient medical records, hospital policies and procedures, it was determined that the hospital failed to promote the patient's "right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience...by staff. Restraint...may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others..." during the patient's admission of January 12, 2010 and a subsequent admission on March 19, 2010.

Findings include:

Admission of January 12, 2010

1. There was documented evidence in the patient's medical record that the hospital staff had physically restrained the patient in a wheelchair on January 13, 2010, as the patient was uncooperative with discharge.

2. The physician's order for restraint, no date or time identified, stated the "Purpose of Restraint: ...Restrain due to SEVERE MILIEU DISRUPTION...Restrain due to specify: patient refusing to be discharged..."

3. The "Seclusion Restraint Flow Sheet" dated January 13, 2010 indicated that the patient was placed in physical restraints at 1525-1550. Additionally, at 1545, there was documentation that stated, "...Pt being discharged today but pt is refusing to cooperate [with] discharge procedure...trying to work with patient on planned admissions for the future at q [every] 2 wk intervals. Pt put in restraint at 1525 in hallway of unit and assisted into wheelchair where [she/he] continued to struggle against staff and refuse to engage with staff...Pt choosing to have police escort [her/him] off property by default while being held in wheelchair by staff."

4. The "Seclusion Restraint Flow Sheet" dated January 13, 2010 indicated at 1525 "Pt put in physical hold when refusing escort off unit for discharge. Pt put in wheelchair + [and] held in physical restraint in wheelchair by 4-5 staff...1540 However pt stopped struggling + agreed to hold hand of one female staff member at 1550. Pt discharged at 1615 via police. "

5. The "Restraint Note" dated January 13, 2010, indicated at 1540, "Pt refusing to discharge back to group home and needed to be physically restrained to get pt off unit to custody of police. Pt refused to leave when discharged. Offer choices: walk or wheelchair...resisted transfer to W/C [wheelchair] then sat. Offered choice to ride with staff of home or police. [She/He] did not choose despite repeated offers. Police called to remove [patient] from building."

6. In the "Discharge Summar " dated January 13, 2010, it was documented that the patient " ...was discharged via wheelchair from 3 North and escorted by Bangor Police to the staff support car for the safety of self and others."

7. The "PSYCHIATRIC EVALUATION/ADMISSION HISTORY/PSYCHOSOCIAL HISTORY" dated January 13, 2010 stated, "...[patient] presents at ... emergency department today for the third time in 3 days. The patient was admitted to the Acadia Hospital on January 12, 2010 for a period of less than 24 hours due to her/his group home unwilling to take [her/him] back at that time, as [she/he] was aggressive and assaultive with staff there [group home]...subsequently discharged on January 13, 2010...The patient required brief physical restraint to reportedly put [her/him] in a wheelchair, as [she/he] was being noncooperative. [She/He] had to be wheeled downstairs backwards, as [she/he] would not pick up [her/his] feet off the floor for the wheelchair to move correctly...the patient reportedly refused to get into the group home staff member's car...the Bangor Police Department was called and upon their arrival, they were asked to arrest the patient for criminal trespassing, as at this point [she/he] had been discharged from the Acadia Hospital. Bangor Police Department did not feel comfortable arresting the patient...who was uncooperative and nonverbal. It is reported that they [Bangor Police Department] did not become involved at all. The patient was placed in the group home staff member's car by the house administrator and a communication tech from the front lobby...It is reported that this entire process took 2 hours to complete..."

8. The "PSYCHIATRIC EVALUATION/ADMISSION HISTORY/PSYCHOSOCIAL HISTORY" dated January 13, 2010, stated, "...Upon the patient's arrival at the ....Group Home, [patient] reportedly refused to get out of the staff member's car. The staff member in fact turned the car off and went inside the group home and the patient remained sitting in the car, would not accept a jacket or a blanket to keep warm, and would not communicate with any of the staff members from the group home, refusing again to go inside...the only option at that point was to bring the patient to the emergency department for evaluation....upon state police arrival, the patient's lips were reportedly blue, as were [her/his] fingernails, and they [state police] indicate that the patient was making a choice at that time to "freeze to death."... TREATMENT RECOMMENDATIONS AND PLAN: This case was thoroughly reviewed with the on-call psychiatrist at the Acadia Hospital... [psychiatrist] indicates that the patient does not currently meet criteria for inpatient psychiatric hospitalization and recommends that the patient remain in the emergency department tonight..."

9. Documentation in the patient's medical record indicated that the patient was readmitted to The Acadia Hospital on January 14, 2010 and was discharged on February 3, 2010.

Admission of March 19, 2010

1. On March 20, 2010, the nurse's note stated, "...Pt went into [her/his] room this afternoon at 1615 and sitting on [her/his] bed started banging [her/his] head against the wall repeatedly. Pt's behavior was brought to the attention of [name], PMHNP and Charge Nurse, [name] and both indicated that pt's behavior should be ignored...Pt did not cease the pounding. Staff attempted to offer pt [her/his] HS meds at 2000, but pt refused...2138 Pt began banging wall with elbow instead of head...PMH-NP was consulted and came to speak with patient. Patient was advised that if behavior did not stop she/he would receive emergency IM medication. Pt ceased banging but still refused Seroquel..."

2. On March 21, 2010 at 0125, the nurses note stated, "...Nurse asked patient to please remove blanket from over head so that [she/he] could visualize patient was safe. At this point patient punched wall but left blanket over [her/his] head. Charge nurse consulted and entered patient room. Charge RN and PMH-NP in to see patient. PMH-NP offered patient Seroquel 900mg or IM thorazine 100mg. Pt refused several offers and reasoning by both RN (x3) and PMH-NP (x3). Pt punching wall and exhibiting middle finger. Charge RN from 3S entered unit and entered patient room to offer Seroquel. Pt refused Seroquel for [her/him] x4. IM thorazine was then drawn up per PMH-NP [name] order. Pt attacked PMH-NP and Charge RN...when [she/he] was informed [she/he] would receive IM injection if [she/he] did not take Seroquel. Pt restraint called at 0220 and lasted until 0225. Pt received 100 mg thorazine IM. Pt was informed that [she/he] would be released as soon as [she/he] stopped attempting to hurt staff... "

3. In a physician order dated March 21, 2010 at 3:58:06 AM, it was documented, "Provider notified at 03/21/10 3:58:00, Restrain due to ASSAULT, Physical, patient was held for administration of IM medication at approx 0220, for a period of approx 5 minutes"

4. There was no documented evidence that there had been a psychiatric emergency ordered to give emergency intramuscular medications on March 21, 2010.

5. In spite of the patient's refusal of oral medications, notifying the guardian after the fact and the hospital's failure to declare a psychiatric emergency, the patient was placed in a physical hold to receive IM Thorazine on March 21, 2010 at 0220.

6. A review of the hospital's policy, "IDD#: CL-136 Use of Restraint for all Acadia Hospital/Acadia HealthCare Patients" stated, "...IV. Procedure:...D. Obtain an order within 30 minutes..."

Based on review of records, review of hospital policies and procedures, it was determined that the hospital failed to determine less restrictive interventions were ineffective prior to the application of restraints during the patient's admission of January 12, 2010 and a subsequent admission on March 19, 2010.
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Findings include:

Admission of January 12, 2010

1. The "Seclusion Restraint Flow Shee " dated January 13, 2010 indicated at 1525 Pt put in physical hold when refusing escort off unit for discharge. Pt put in wheelchair + held in physical restraint in wheelchair by 4-5 staff...1540 However pt stopped struggling + agreed to hold hand of one female staff member at 1550. Pt discharged at 1615 via police."

2. The "Restraint Note" date January 13, 2010 indicated at 1540, "Pt refusing to discharge back to group home and needed to be physically restrained to get pt off unit to custody of police. Pt refused to leave when discharged. Offer choices: walk or wheelchair...resisted transfer to W/C [wheelchair] then sat. Offered choice to ride with staff of home or police. [She/He] did not choose despite repeated offers. Police called to remove from building."

Admission of March 19, 2010

1. On March 20, 2010, the nurse's note stated, "...Pt went into [her/his] room this afternoon at 1615 and sitting on [her/his] bed started banging [her/his] head against the wall repeatedly. Pt's behavior was brought to the attention of [name], PMHNP and Charge Nurse, [name] and both indicated that pt's behavior should be ignored...Pt did not cease the pounding. Staff attempted to offer pt [her/his] HS meds at 2000, but pt refused...2138 Pt began banging wall with elbow instead of head...PMH-NP was consulted and came to speak with patient. Patient was advised that if behavior did not stop [she/he] would receive emergency IM medication. Pt ceased banging but still refused Seroquel..."

2. On March 21, 2010 at 0125, the nurses note stated, "...Nurse asked patient to please remove blanket from over head so that [she/he] could visualize patient was safe. At this point patient punched wall but left blanket over [her/his] head. Charge nurse consulted and entered patient room. Charge RN and PMH-NP in to see patient. PMH-NP offered patient Seroquel 900mg or IM thorazine 100mg. Pt refused several offers and reasoning by both RN (x3) and PMH-NP (x3). Pt punching wall and exhibiting middle finger. Charge RN from 3S entered unit and entered patient room to offer Seroquel. Pt refused Seroquel for [her/him] x4. IM thorazine was then drawn up per PMH-NP....order. Pt attacked PMH-NP and Charge RN...when [she/he] was informed [she/he] would receive IM injection if [she/he] did not take Seroquel. Pt restraint called at 0220 and lasted until 0225. Pt received 100 mg thorazine IM. Pt was informed that [she/he] would be released as soon as [she/he] stopped attempting to hurt staff..."

3. During a telephone interview with the patient's guardian on April 22, 2010 at 1410, it was confirmed that the hospital had telephoned the guardian at 0331 on March 21, 2010 that the patient had received IM Thorazine on March 21, 2010 at 0220.

4. In spite of the patient's refusal of oral medications, notifying the guardian after the fact and the hospital's failure to declare a psychiatric emergency, the patient was placed in a physical hold to receive IM Thorazine on March 21, 2010 at 0220.

Based on review of patient medical records, hospital policies and procedures, it was determined that the hospital failed to modify the patient ' s plan of care with regards to the use of restraints.

1. There was no documented evidence in the patient ' s medical record that the patient ' s treatment plan had been modified after the patient was physically restrained by the hospital staff on January 13, 2010. In spite of being physically restrained, the hospital discharged the patient.

2. There was documented evidence in the patient ' s medical record that the patient was readmitted on January 14, 2010 after attempting to " freeze to death " and returning to the emergency department for evaluation on January 13, 2010.

3. During the patient ' s admission to the hospital on March 19, 2010, there was no documented evidence that the patient ' s treatment plan had been modified after the use of restraints on March 21, 2010.

Based on review of the hospital policies and procedures on April 9 and 12, 2010, it was determined that the hospital failed to specify the required timeframe and documentation requirements for reporting restraint deaths to CMS in the hospital ' s policies and procedures.

Findings include:

1. The hospital ' s " IDD#: CL-136 Use of Restraint for all Acadia Hospital/Acadia HealthCare Patients " stated, " ...G. Restraint Deaths: 1. The hospital must report to CMS any death that: a. occurs while a patient is in restraint for behavioral management reasons or where it is reasonable to assume that a patient ' s death is a result of restraint to CMS; b. occurs within the 24 hours after the patient has been removed from restrain; c. is known to the hospital that occurs within one week after the restraint where it is reasonable to assume that the use of restraint contributed directly or indirectly to the patient ' s death. "

Based on review of records, review of hospital policies and procedures, and interviews with key personnel on April 9 and 12, 2010, it was determined that the hospital failed to have in effect a discharge planning process that applies to all patients.

Findings include:

1. A review of the patient ' s medical record indicated that the patient had been admitted to an observation bed on March 19, 2010 and failed to meet criteria for in patient care as of March 21, 2010 with plans to discharge the patient back to the group home.

2. In a Progress Note dated March 23, 2010, it stated, " ...The assessment up until today was that as [patient] did not meet criteria for voluntary hospitalization or for continuation of observation level of care, but [patient ' s] group home was not able to take [patient] back...The patient ' s thought process is assessed to be disorganized and delusional as evidenced by the notes that [patient] writes and their content. The patient is assessed to have limited insight and judgment...Global Assessment of Functioning: Currently 25...due to [patient ' s] continued delusional and disorganized thinking, and continued aggression...meets the criteria for voluntary hospitalization at this time... "

3. In a Progress Note dated, March 28, 2010, it was stated, " Patient presents with extreme agitation, thought disorganization, and violence...patient did not verbally respond...patient was engaging in self-abusive behaviors...patient had been assaultive towards staff, destructive of property, throwing food...Due to [patient ' s] level of thought disorganization, self-abusive behaviors, and violence towards staff, I have initiated emergency medications for this patient...At this point, I am adding on the diagnosis of psychotic disorder, not otherwise specified to the patient ' s Axis I... " 2. In a progress note dated March 25, 2010, indicated that a " ... community meeting occurred in the Penobscot Room...agree with looking for alternative placement ([patient] not returning to [group home]). Various person presents agree with this; no one voices disagreement...guardian states he has signed releases allowing communication with PNMI [Private Non-Medical Institution] priortiizer from all three DHHS regions...6. TO DO: Schedule weekly or biweekly follow up community meetings...8. Consider possibility of forensic evaluation. 9. TO DO: Develop detailed crisis plan to address both medical and psychiatric issues to be made available to various community providers and emergency departments. 10. [group home] staff spoke about [patient] not being engaged in treatment decisions in the past...outpatient providers noted [patient] is more easily engaged in during individual or small group settings and becomes very "anxious " when several person are present...Regarding item #6 above: This clinician recommends having 30 minute meetings with agendas...will need to contact key community and outpatient providers and guardian to set up meeting dates. "

4. During an interview with the Attending Psychiatrist on April 9, 2010 at 1400, the Attending Psychiatrist stated, " The detailed crisis plan...the one that was to go to all the hospitals, I don ' t know anything about it. It wasn ' t my responsibility. "

5. In a Progress Note dated March 29, 2010, it was stated, " ...contacted Dr. [physician] regarding forensic evaluation as mentioned at treatment team meeting last week...What would be teased out in such an assessment is, 1) risk of future violence; 2) level of care most suitable when discharged; and 3) ...evaluation to determine if [patient] displays psychopathology... "

6. In a progress note dated April 2, 2010 at 14:29, it was documented, " ...This patient ' s outside treating sources are attempting to find a place for the patient to live. The patient appears to be at baseline and is not meeting criteria for continued hospitalization... "

7. In a progress note dated April 2, 2010 at 3:58 pm, it was documented, " ...It is necessary for patient to be in hospital setting at this time as [patient] lacks a supportive, stable disposition at discharge... "

8. In a physician progress note, dated April 5, 2010 and time dictated at 14:03 that stated, " ... Judgment and insight remain impaired...We are looking for a place for [patient] to be discharged to... " Under Diagnoses it was indicated that the patient had for Axis I diagnosis: Schizoaffective disorder and impulse control disorder. Under Axis II: " Personality disorder, not otherwise specified, with borderline and dependent, and antisocial traits... " An addendum added to this progress note was dated April 6, 2010 at 13:01 stated, " Diagnosis was clarified with outpatient treatment team to be Axis I: PTSD [Post Traumatic Stress disorder], Axis II Pers D/O [Personality Disorder] NOS [not otherwise specified] Clusters B and C. Please remove Schizoaffective Disorder because any psychotic symptoms have been fleeting and deemed related to anxiety. "

9. Additionally, during an interview with the attending psychiatrist on April 9, 2010 at 1400, when asked if the patient was safe for discharge, the psychiatrist responded, " [patient] is not safe, the community isn ' t safe. {patient ' s] got a Personality Disorder with antisocial traits. I don ' t think [patient] will ever be safe. I don ' t think the community will be safe. "

10. In a progress note dated April 6, 2010, indicated that " ...At Noon, a meeting was held in medical director, Dr. [medical director] ' s office to review discharge plan...inpatient treatment team...confirmed plan of meeting with [patient] to discuss discharge at 1:00 PM...[social worker 2] confirmed...contacted the Bangor police department (BPD) and agreed to follow up with the BPD on their presence...in the event they were needed...Discussion on diagnostic impression occurred with agreement...agreed to discuss diagnostic impression with attending inpatient physician, [name](not present at this meeting)."

11. The Discharge Summary dated April 6, 2010, indicated that " ...The discharge plan was discussed with the guardian, in which [patient] was to be discharged with handicapped accessibility ... to the Acadia Recovery emergency shelter with psychotropic medication management appointments...and therapy appointments...The guardian expressed concern that [she/he] was not in approval of this plan... "

12. Additionally, the Discharge Summary dated April 6, 2010, stated, " ...At noon on 4/5/2010, a meeting was held with the medical director, [name], to review the discharge plan. During this meeting, [patient] treatment team was involved and confirmed the plan of being discharged...contacted the Bangor Police department in which they would be in the the Acadia Hospital back parking lot in the event they were needed if the patient refused to leave the Acadia Hospital property. The patient arrived at the Acadia Recovery Community around 1:45 pm...At around 2:40 pm [patient ' s] clinician...had conversation with [name] director of the Acadia Recovery Community and provided a case summary regarding [patient ' s] presentation including the patient ' s difficulty with tolerating a roommate...[director] stated that if needed, staff could contact the Bangor Police Department... "

13. In spite of the discharge planning meeting dated March 25, 2010, there was documentation in the Discharge Summary, dated April 6, 2010, that indicated, " ...It was discussed with his treatment team...that the medical director ' s decision was to discharge [patient] to the Acadia Recovery Homeless Shelter on Tuesday, April 6, 2010. This plan was discussed with the...guardian...in which [she/he] [guardian] stated that it was not acceptable and [she/he] was uncomfortable with the risk associated with discharging the patient to a homeless shelter. "

14. There was documented evidence in the patient ' s medical that the hospital had not informed the guardian until April 5, 2010 that the patient would be discharged on April 6, 2010 in spite of the guardian ' s objections.

15. There was documented evidence in the patient ' s medical that the hospital had not informed the patient of the plan to discharge until April 6, 2010 at 1300. The patient was discharged at 1:20 pm by taxi. Therefore, there was documented evidence that the hospital had not included the guardian or the patient in the decision for discharge.

16. A review of the hospital ' s policy, " IDD# AD-123 Patient Rights " , indicated that the hospital " ...will not arbitrarily transfer or discharge patients and will give reasonable advance notice of any transfer or discharge and appropriate discharge plans made. "

17. In a progress note dated April 6, 2010, indicated that " ...clinician had telephone conversation with guardian...regarding discharge plan: [patient] to discharge via taxi...to the Acadia recovery Community emergency shelter (ARC) with psychotropic medication management appointment ... and therapy appointment...; and the Outback program to be started on Friday at the ARC on site programming) ... [Guardian] voiced that [guardian] was not in approval of this plan. [Guardian] voiced that [guardian] had received the fax copy of the medicare Rights form...would not initial the form... (Paper copy of this in paper chart.)... "

18. Review of the medical record revealed that the hospital had provided the " Important Message from Medicare " (IM) to the patient ' s guardian on the day of discharge, April 6, 2010. Therefore, the hospital failed to provide the " Important Message from Medicare " (IM) to the patient and/or representative or guardian two (2) days prior to discharge.

19. During an interview on April 9, 2010, the patient ' s guardian confirmed that she/he did not receive the IM two (2) days prior to discharge. Additionally, the guardian stated, " The hospital was working on placement for [patient] in the morning of April 5, 2010. I was notified by telephone late afternoon on April 5th that [patient] was to be discharged on April 6th to a homeless shelter. I told them that the discharge plan was unacceptable. I understood from the meeting with the hospital on March 25th that [patient] was to stay until suitable placement was found. "

20. The Discharge Summary dated April 6, 2010, indicated that " ...it was decided that it would be helpful in assessment for potential risk of violence and recommended level of care in community for a forensic evaluation...Communication was made with ... psychologist in Bangor who does do forensic evaluations... [Psychologist] ... normally does forensic evaluations when they are court ordered and asked who would pay for the services since it was not paid from Medicare... "

21. During an interview with the VP Clinical Operations on April 9, 2010 at 1500, the VP Clinical Operations stated, " We had to do a sudden discharge. We told the guardian the night before and the patient the next day. It was well organized. When the patient was here before, [she/he] was quite resistive to discharge. "

22. During an interview with the Chief Medical Officer on April 12, 2010 at 1425, the Chief Medical Officer stated, " I decertified the patient. We are an acute care hospital and the patient did not meet criteria. I did not write the order for discharge. I did not make the decision to discharge. "

23. During an interview with the Chief Medical Officer on April 12, 2010 at 1425, the Chief Medical Officer clarified and verified that the attending psychiatrist had documented on the " Admission and Weekly Continued Stay Certification by Physician " on April 5, 2010, " I certify that the patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel. "

24. During an interview with the Attending Psychiatrist on April 9, 2010 at 1400, the Attending Psychiatrist stated, " The Medical Director made the administrative decision to discharge the patient. The patient wasn ' t getting any better or worse. [She/He] was taking up space. [She/He] didn ' t need to be here in an acute hospital at twenty-three hundred dollars a day. "

25. During an interview with the President & CEO on April 12, 2010 at 1630, the President & CEO stated, " The patient had to be discharged. The patient was decertified and no one was willing to pick up the expenses. "

The cumulative effect of these findings resulted in this Condition of Participation being out of compliance.