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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 the patient's right to be free from abuse and assure that 2 (#1 and #3) of 11 (#1 - #11) patients with dual diagnoses (intellectual impairment and psychiatric illness) at Unit 3 Lower, had an environment that was free from physical and psychological abuse. The findings constituted an Immediate Jeopardy situation. Facility staff failed to prevent, identify and report verbal, physical, psychological abuse and neglect, therefore the safety of the patients was not assured and the potential abuse or neglect of patients existed. The failed practices resulted in actual harm to Patient #1 and #3 and had the potential to affect the other 9 patients on Unit 3 Lower. The findings are:

A. On 05/13/11 at 0925, the Risk Management Director stated she had received a call at 0500 that there was an incident with Patient #3 on Unit 3 Lower. Patient #3 alleged that staff had abused him. On 05/13/11 at 1030, facility video and audio recording for 05/12/11 beginning at 1911 were reviewed in the presence of the Risk Management Director, her assistant and State Surveyors.

1) At 1911 on 05/12/11, Patient #3 was observed on the video in the Recreation Day Area playing ball. One male staff member, identified by the Risk Management Director as a "Unit Safety Officer," was present.

2) Patient #3 entered Pod C (an open area surrounded by four semi-private rooms) where Mental Health Worker (MHW) #1, identified by Risk Management Director and assistant, stated to Patient #3 "Boy you need to go somewhere in your room."

3) At 1917, MHW #1 stated to Patient #3, "Give me the ball." Patient #3 began striking out with feet and hands toward MHW #1. MHW #1 called for another employee, then used one hand, palm toward Patient #3 and pushed Patient #3.

4) Patient #3 continued to strike out with hands and feet toward MHW #1. MHW #1 then used both hands, palms toward Patient #3 and pushed Patient #3, at which time Patient #3 fell onto the floor and landed on his buttocks.

5) The Risk Management Director confirmed on 05/13/11 at 1115 that the video recording revealed that Patient #3 was pushed by MHW #1 and stated "this was not reported to me."

B. On 05/12/11 at 1415, the video recording of 05/11/11 was reviewed regarding Patient #1 in the presence of the Risk Management Director, her assistant and the State Surveyors.

1) Patient #1 was observed to be asleep and wearing a red t-shirt and red sweat pants, lying on a blue mat on the floor of the Recreation Day Area on 05/11/11 at 1200.

2) At 1230, the Dietician instructed LPN #1 to "call the kitchen for Patient #1 for a sack lunch so he can have his lunch when he wakes up." LPN #1 verbally indicated she would call the kitchen.

3) The video recording at 1524 on 05/11/11 revealed Patient #1 was awake and asked for crackers.

4) Patient #1 was offered and served milk and cereal instead of a sack lunch or replacement meal by LPN #1 at 1524. Patient #1 knocked the unopened cartons of milk and cereal off the table and onto the floor.

5) At 1525, Public Safety Officer (PSO) #1 walked by Patient #1 in the Recreation Day Area and stated "wouldn't give him nothing."

6) At 1537, Patient #1 stated "I'm wet." Patient#1 was instructed by Unit Safety Officer (USO) #1, "Go ahead and eat your cereal."

7) USO #1 replied, "You want to eat first and then go the bathroom?"

8) At 1538, Patient #1 briefly sat at the table, then stood and stated "I want to change right now." The USO #1 stated, "Your cereal is gonna get soggy."

9) At 1539, "You want to do a shower or do you wanna change?" Patient was escorted by USO #1 and LPN #1 to his room (observed by surveyors during a tour on 5/11/11 at 0853 to not include shower facilities.)

10) At 1547, Patient #1 returned to the Recreational Day Area wearing different color pants.

11) Review of Patient #1's clinical record dated 05/11/11, timed 1550 revealed "Patient up at this time, was showered at 1535 due to enuresis". (Tour of facility on 05/11/11 at 0830 revealed there was no shower in the room that Patient #1 was escorted to.) Signature in clinical record for entry was LPN #1.

D. The findings on the video for Patient #1 were verified through interview with the Risk Management Director at 1537 on 05/12/11.

Based on interview, observation, observation of video with audio recording, facility document review and clinical record review, it was determined the facility failed to protect patient's right to be free from verbal and psychological abuse and assure that 3 patients (Patients #1, #3 and #11) of 11(#1-#11) on Unit 3 Lower, had an environment that was free from verbal and psychological abuse. Facility staff failed to prevent, identify and report verbal and psychological abuse, therefore, there was a potential for further instances of abuse or neglect. The failed practice resulted in actual verbal abuse to Patients #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. Patient #1 was served milk and cereal instead of a sack lunch or replacement meal since the patient was asleep when lunch was served.
1) Patient #1 knocked the unopened cartons of milk and cereal off the table and onto the floor. At 1525 Public Safety Officer #1 walked by Patient #1 in the Recreation Day Area and stated "Wouldn't give him nothing."
2) The video recording on 05/12/11 confirmed the above findings and verified by the Risk Manager Director and her assistant at 1537 on 05/12/11.

B. Patient #3 was playing ball in the Recreational Day Area on 05/12/11 at 1911.
1) At 1916, Patient #3 entered the Pod C (open area surrounded by 4 semi-private rooms) with his ball.
2) Mental Health Worker #1 stated to Patient #3 "Boy you need to go somewhere in your room."

C. 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?" Another unidentifiable patient was heard asking Charge Nurse #3 a question.
1) 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."

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

On 05/16/11 a situation of IMMEDIATE Jeopardy to patient health and safety existed. Subsequently, a plan of correction was submitted by the facility on 05/16/11 at 1700. The plan of correction was not acceptable. On 05/16/11 an alternate plan of correction was submitted for review. Based on review of the second plan of correction on 05/17/11 and consultation with CMS it was determined the second plan of correction was not acceptable because it required full implementation of the plan and an evaluation of the effectiveness once it was implemented.

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 policy and procedure review and interview, it was determined that the facility did not have a policy and procedure in place for reporting to the Centers for Medicare and Medicaid Services (CMS) deaths associated with the use of seclusion or restraints. Failure to have a policy and procedure in place had the potential outcome of prohibiting the monitoring of restraint related deaths by the facility and CMS. The failed practice could affect 11 of 11 patients on census on 05/17/11. Findings follow:

A. The facility was asked for a policy and procedure for reporting deaths associated with the use of seclusion or restraints. The facility produced policy # ASH (Arkansas State Hospital) 05.01.06, titled "Reporting Incidents". Policy # ASH 05.01.06 included the following information related to deaths: ..." B. Deaths (1) Report all deaths to the following agencies within 1 hour: (a) The State Medical Examiner (M.E.): ask the M.E's office for instruction regarding autopsies and/or notification. (b) County Coroner: ask the Coroner for instruction regarding autopsies and/or notification. (c) Disability Rights Center. (2) Document the office called; name of person spoken to; what was said; and time and date of conversation. C. Incidents relating to criminal conduct or death will be reviewed by the Chief Executive Officer (CEO), Quality Assurance Director and Medical Director for further action." ...

B. During an interview with the Performance Improvement Director on 05/17/11 at 1230 and again at 1500, it was confirmed that ASH 05.01.06 is the current policy and procedure in place.