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Based on document review, interview, video observation, clinical record review and observation on 06/13/11-06/15/11, it was determined the Condition of Patient Rights is not met. On 06/15/11 a situation of IMMEDIATE JEOPARDY to patient health and safety existed. This decision was based on the following:

A. Based on document review, interview, clinical record review and observation it was determined the facility failed to provide care in a safe setting for 1 (#2) of 1 (#2) patients on Unit D. This failed practice resulted in actual harm to Patient #2 and had the potential to affect the other 17 patients on Unit D. See A 144

B. Based on document review, interview and observation it was determined the facility failed to protect one (#1) of one (#1) patients from neglect on Unit D. The facility staff failed to identify, prevent and report neglect. This failed practice resulted in neglect of Patient #1 and had the potential to affect the other 17 patients on Unit D. See A 145

C. Based on interview, document review and video observation on 06/15/11 at 0940 it was determined the facility failed to provide care in a safe setting for one (#3) of one (#3) patients on Unit D. This failed practice had the potential for harm for all patients placed in seclusion. See A 144

D. Based on interview, policy and procedure review, and clinical record review, it was determined Unit D did not consider the Intensive Treatment Protocol to be seclusion. The failed practice had the potential of placing patients in seclusion who did not exhibit violent or self destructive behaviors that immediately jeopardized the physical safety of patients, staff or others. The failed practice affected one (#3) of one (#3) sampled patients and had the potential to affect all patients in which the Intensive Treatment Protocol was initiated. See A162

E. A continuing deficiency based on review of the Plan of Correction for the deficiency cited on the complaint investigation dated 05-18-2011. There has not been enough time for the facility to monitor and evaluate the effectiveness of the Plans of Correction put in place to assure facility staff would be able to prevent, identify and report verbal abuse and psychological abuse, and ensure continued compliance. See A 145

Based on document review, interview, clinical record review and observation, it was determined that the facility failed to provide care in a safe setting for 1 (#2) of 1 (#2) patient on Unit D. This failed practice resulted in actual harm to Patient #2 and had the potential to affect the other 17 patients on Unit D. The findings follow:

A. On 06/13/11 the Arkansas State Hospital Patient Complaint Response Form dated 06/01/11 was reviewed. Attached to the form were complaints written by Patient #2 dated 05/27/11,(Patient #2 wrote "wanted off sleeping medication"); 05/28/11,(Patient #2 wrote "(Named) said going to kill everyone I do not feel safe"); 05/30/11,(Patient #2 wrote "I do not feel safe when I sleep"); 05/31/11, (Patient #2 wrote "I do not feel safe"). Under the heading "RESPONSE," the following was documented by the Patient Advocate:

"06/01 Complaints emailed to Dr (Named), Social Worker #1 and Unit D Director." The complaint dated 05-28-11 from Patient #2 stated Patient #1 said going to kill everyone and I do not feel safe. The complaint from Patient #2 dated 05/30/11 was I do not feel safe when I sleep. The complaint from Patient #2 dated 05/31/11 was I do not feel safe here.

B. On 06/14/11 review of the Seclusion and Restraint Report dated 06/08/11 at 2023 revealed Patient #1 and Patient #3 teamed up in room and was hitting Patient #2.

C. On 06/14/11 the Surveyor saw Patient #2 in a line of patients waiting to go outside and observed the left eye of Patient #2 was still bruised.

D. On 06/15/11 review of the medical record for Patient #2 revealed an entry on 06/08/11 at 1045 by the MD which stated -"Pt (patient) was attacked by two peers. On examination patient has swollen left eye intraorbitally, tender and bruised on right side of neck."

E. On 06/15/11 at 0910 an interview was conducted with the Unit D Director and Social Worker #1. The Unit D Director and Social Worker #1 were asked if anyone did a follow-up on the complaints submitted by Patient #2 to the Patient Advocate. Both staff informed the surveyors that they were aware of Patient #2's complaints but no investigations were conducted and staff did not initiate any action to have prevented the assault..




Based on interview, document review and video observation on 06/15/11 at 0940 it was determined the facility failed to provide care in a safe setting for one (#3) of one (#3) patients on Unit D. This failed practice had the potential for harm for all patients placed in seclusion. Findings follow:

A. Video observation at 0940 on 06/15/11 revealed Patient #3 in seclusion. Staff could be seen watching Patient #3 through the glass window in the door. At 0924 the patient removed his white under shirt, tore it into strips that stretched out the length of his arms, then proceeded to wrap it around his neck. The strips of shirt remained around the patient's neck while standing in front of the glass window in the door of the seclusion room. Staff could be seen viewing the patient through the glass window of the door. Patient #3 eventually removed the shirt from his neck at 0927. Staff did not intervene to remove the strips of shirt from the patient's neck.

B. The Unit D Director was interviewed on 06/15/11 at the time of the video observation and confirmed the name of the patient.

Based on document review, interview and observation it was determined the facility failed to protect one (#1) of one (#1) patients from neglect on Unit D. The facility staff failed to identify, prevent and report neglect. This failed practice resulted in neglect of Patient #1 and had the potential to affect the other 17 patients on Unit D. The findings follow:

A. 04/22/11- Complaint from Patient #1 was sent to the Patient Advocate- Date received by Patient Advocate was 04/28/11. Patient complained "Dr. (Named) will not get my glasses." Under the heading "RESPONSE" it was stated "The complaint you submitted was sent to Dr. (Named) requesting an appointment for your glasses-----. There was no date in the area titled RESPONSE given to patient. There was a signature from Patient #1 and the Patient Advocate and the date of 05/09/11 at the bottom of the page.

B. 05/02/11-Complaint from Patient #1 sent to Patient Advocate-Date received by Patient Advocate was 05/02/11. Patient complained "need to go to Wal-Mart to get glasses." Under the heading "RESPONSE" it was written-

"The complaint concerning your need to go to Wal-Mart to get glasses was submitted to the Unit Charge Nurse. She stated there is no indication of an appointment set up for you at this time. However, it was explained to me that you are only allowed one pair of glasses yearly which makes it very important that you take responsibility of caring for your glasses at all times. Keep them in a safe place and do your best to prevent anything from happening to them. If you feel your peers are going to break your glasses let the staff know right away. I understand you are upset because you can't see well and I will ask for another pair or get your old pair repaired."

C. 06/13/11-Surveyor interviewed the Patient Advocate and requested information as to where Patient #1's glasses were. The Patient Advocate stated she did not have any information regarding the patient's glasses.

D. 06/14/11-Surveyor interviewed the Unit Director for Unit D. The Unit Director did not know where the patient's glasses were. The Unit Director stated they were probably sent to the Clinic.

E. 06/15/11-Surveyor interviewed the Unit Director for Unit D and Social Worker #1 and Social Worker #2 that worked on Unit D and the Social Worker Director at 0910. The Surveyor asked where Patient #1's glasses were. The Unit Director stated she would call the Clinic and see if the glasses were there. Social Worker #1 and #2 did not know.

F. During review of medical records on Unit D, at 1415 on 06-15-11, the Unit Director approached the Surveyor and was holding a pair of glasses that were found in the medication room. The glasses had a side missing and were not wearable. The Unit Director stated the patient had identified the glasses as belonging to the patient.


This is a continuing deficiency based on review of the Plan of Correction for the deficiency cited on the complaint investigation dated 05-18-2011. There has not been enough time for the facility to monitor and evaluate the effectiveness of the actions put in place based on the Plan of Correction to assure facility staff will be able to prevent, identify and report verbal abuse and psychological abuse, and to ensure compliance. The deficiency cited on 05-18-11 follows:

Based on interview, observation, observation of video with audio recording, facility document review, and clinical record review, it was determined that the facility failed to protect patient's right to be free from verbal and psychological abuse. Three ( #1, #3 and #11) of 11 (#1- #11) patients with dual diagnosis on Unit 3 Lower, did not have an environment that was free from verbal and psychological abuse. The facility staff failed to prevent, identify and report verbal and psychological abuse, therefore the potential existed for further instances of abuse. The failed practice resulted in actual verbal abuse to Patient's #1, #3 and #11 and had the potential to affect the other 8 patients on the 3 Lower Unit. The findings are:

A. Patient #1 was in the Recreational Day Area on 05/11/11 at 1524 asking for crackers.
1) Patient #1 was served milk and cereal. Patient #1 knocked the unopened cartons of milk and cereal off the table and onto the floor.
2) At 1525, Public Safety Officer #1 walked by Patient #1 in the Recreation Day Area and stated "Wouldn't give him nothing."

B. The video recording confirmed the above findings and were verified by the Risk Manager Director and her assistant at 1537 on 05/12/11.

C. Patient #3 was playing ball in the Recreational Day Area on 05/12/11 at 1911.
1)At 1916, Patient #3 entered Pod C (open area surrounded by four semi-private rooms) with his ball.
2) Mental Health Worker #1 stated to Patient #3 "Boy, you need to go somewhere in your room."

D. Patient #11 was standing in the Recreational Day Area on 05/12/11 at 1951 asking Charge Nurse #3 "Why can't we come out?"
1)Another unidentifiable patient was heard asking Charge Nurse #3 a question. Before Charge Nurse #3 could respond, Patient #11 answered the question.
2) As Charge Nurse #3 was walking across the Recreational Day Area he responded to Patient #11 "Thank you staff member."

E. The above findings were confirmed by the Risk Management Director and her assistant at 05/13/11 at 1115.

Based on interview, policy and procedure review, and clinical record review, it was determined Unit D did not consider the Intensive Treatment Protocol to be seclusion. The failed practice had the potential of placing patients in seclusion who did not exhibit violent or self destructive behaviors that immediately jeopardized the physical safety of patients, staff or others. The failed practice affected one (#3) of one (#3) sampled patients and had the potential to affect all patients in which the Intensive Treatment Protocol was initiated. The findings were:

Review of Policy #223-Intensive Treatment Protocol (ITP)-revealed the following:
A doctor's order specifying the level of staff supervision is required to initiate.
ITP status will be reviewed every 24 hours and if continued a new order is required.
Patients assigned to ITP will be separated from the general milieu and one staff member from each shift will be assigned to provide supervision.

Assignments based on identified problem behaviors as well as a routine format for daily work will be set. If more than one individual is on ITP status at the same time, there will be limited interactions between such patients. The level of compliance and participation will be scored on the ITP Flow Sheet every 15 minutes as a " O " or a " + " . Meals will be served at regular meal times and will be eaten on the Unit with staff observing. Patients will be Unit restricted while on ITP but may be allowed some RT, i.e. exercise, stretching activities.
Patients may be allowed to go outside (at staff discretion) once per shift on 7-3 and 3-11 shifts if 12 " + " are earned during the preceding 4 ? hour time period. Fluid intake and bathroom privileges will be offered as needed and requested by the patient.

Medical record review on 06/15/11 revealed a Physician order on 06/08/11 for " .....pt (patient on ITP x 24 hours to be done on Unit E.

Surveyor asked in an interview on 06/14/11 at 1530 with the Unit D Director what a ITP (Intensive Treatment Protocol) was. The Unit D Director stated " It was a program ordered by the Physician. The patient was separated from others. It was a written assignment for the patient to complete and the patient must complete it before they could attend regular activities. For example it there was a Unit activity like a barbeque the patient could not attend but would be brought a plate of the food fixed."