HospitalInspections.org

Based on observation, interview, record review, and policy review the facility failed to ensure:
- Protection of one of one patient (#48) on the Senior Care Behavioral Health Unit (a unit dedicated to the treatment of elderly psychiatric patients) when two staff members dragged a patient approximately 40 feet to a room used to restrain (to prevent freedom of movement) patients. (Refer to A145)
- Personal privacy for one of one patient (#48) when staff exposed her breasts, during a manual restraint, in the Senior Care Behavioral Health Unit (Refer to A142)
- Protection of patients in the Senior Care Behavioral Health Unit by allowing alleged perpetrators (Staff PP and Staff SS) to continue to work following an incident of alleged physical and emotional abuse. (Refer to A144)
- Staff obtained a physician's order for a manual hold to restrain one of one patient (#48) in the Senior Care Behavioral Health Unit. (Refer to A154)
These failed practices had the potential to put all psychiatric patients in the Senior Care Behavioral Health Unit at risk for inappropriate restraint techniques and lack of patient privacy. The facility census was 172. The unit census was 20.

As a result of this survey, the complaint was substantiated and the Condition of Participation: Patient Rights was found to be out of compliance. Please see the 2567.

Based on observation, interview, record review and policy review the facility failed to ensure personal privacy when two of two staff (PP and SS) exposed the breasts one of one patient (#48) during a manual restraint episode. This failure increased the potential for lack of patient privacy and dignity for all patients in the Senior Care Behavioral Health Unit. The facility census was 172. The Senior Care Behavioral Health Unit census was 20.

Findings included:

1. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48 showed on 02/09/16 at approximately 11:30 PM, the 66 year old female, was admitted to the Senior Care Behavioral Health Unit. Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary).
Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint)Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

2. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above her head and Staff SS, Clinical Partner, pulled on the patient's left hand. Staff pulled Patient #48 backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's shirt had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed as staff dragged her backward to the restraint room with her feet slightly touching the floor.

3. Record review of the facility policy titled, "Restraint Utilization (Violent, Self-
Destructive)," dated 01/2014, showed directives for staff to consider whether the application or initiation of a restraint respects the patient as an individual and the modesty and visibility to others are maintained.

4. Record review of Staff L's, Director of Behavior Health Services, chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II,Vice President Behavioral Health Services; Staff ZZ, Administrator; and Staff AA, Patient Safety, Quality, Risk, and Regulatory Coordinator and copied to Staff H, Team Leader of Senior Health Behavioral Health Unit showed no documentation of the patient's exposed breasts.

During an interview on 04/12/16 at 2:10 PM, Staff SS, stated that she could not remember if Patient #48's shirt came up or not, but she recalled that she and Staff PP stopped part way to the restraint room to get a better grip on Patient #48 before they continued to the restraint room.

The restraint method performed by Staff PP and Staff SS failed to protect the privacy of the patient and take into consideration the patient's modesty and visibility to others.

Based on observation, interview, record review, and policy review, the facility failed to provide a safe environment in the Senior Care Behavioral Health Unit (unit used to treat psychiatric illnesses of the elderly) when they failed to remove two alleged perpetrators (Staff PP and Staff SS) from patient care during an investigation of an incident of alleged physical and emotional abuse of one of one patient (#48). The failure to remove the alleged perpetrators from patient care resulted in an unsafe environment for all patients and had the potential to place all patients admitted for treatment in the Senior Care Behavioral Health Unit at risk for abuse. The facility census was 172. The unit census was 20.


Findings included:

1. Record review of the facility's policy titled, "Assessment, Investigation, and Reporting of Suspected Abuse/Neglect," dated 05/02/14 showed:
- Abuse of an adult (elder or disabled) was defined as the infliction of physical, sexual, or emotional injury or harm.
- Eligible adult was defined as any adult, aged 60 or older or 18-59 with a disability, defined as a mental or physical impairment that substantially limits one or more major life activities, whether the impairment was congenital or acquired by accident, injury or disease, where such impairment was verified by medical findings.
-Staff members were to assess, investigate, and report abuse and neglect to the appropriate State agencies.
-The Clinical Support Nurse (CSN) or department equivalent should immediately notify their Administrative Supervisor after ensuring the safety of the patient, which shall include immediate removal of the involved staff from patient care.

2. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48 showed on 02/09/16 at approximately 11:30 PM, the 66 year old female, was admitted to the Senior Care Behavioral Health Unit (BHU.) Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary.)

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

3. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above the patients head and Staff SS, Clinical Partner, pulled on the patient's left hand. Patient #48 was pulled backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

During an interview on 04/13/16 at 10:35 AM, Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator, and Staff L, Director of Behavioral Health Services, confirmed the distance from the day hall to the restraint room was approximately 40 feet.

During an interview on 04/12/16 at 3:35 PM, Staff L, stated that she reviewed part of the video mid-morning on 02/11/16 and was unsure of Staff PP's actions.

During an interview on 04/13/16 at 3:30 PM, Staff L stated that on 02/11/16:
- She requested Staff H, Team Leader of Senior Care (BHU), to visit with staff on the Senior Care BHU and see if the staff felt Staff PP was abusive.
- Staff L then reviewed the video again.
- She then completed a chart review and a summary that was sent to Staff ZZ, Administrator, Staff II, VP Behavioral Health Services, and Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator.
- The investigation was completed by Staff AA.

4. Record review of Staff L's chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II, Staff ZZ, Staff AA, and copied to Staff H showed:
- Patient #48 requested a hug from Patient #49 and Patient #49 pushed at Patient #48.
- Patient #48 choked Patient #49 and licked and bit her face.
- The event occurred in the day room, but the actual event was obscured by pillars.
- Staff were seen responding.
- Staff had difficulty separating the two patients due to Patient #48's bite.

5. Record review of "Time Detail," (time cards) showed Staff SS and Staff PP continued to provide patient care during the investigation of alleged abuse of Patient #48. The time cards showed:
Staff SS worked:
- On 02/11/16 from 7:05 AM until 7:16 PM;
- On 02/15/16 from 7:00 AM until 7:28 PM;
- On 02/19/16 from 7:02 AM until 7:34 PM.

Staff PP worked:
- On 02/11/16 from 6:49 AM until 7:10 PM;
- On 02/12/16 from 6:52 AM until 7:17 PM;
- On 02/16/16 from 7:00 AM until 7:30 PM.

During an interview on 04/12/16 at 4:05 PM, Staff AA stated that:
- She received an e-mail on 02/11/16 from Staff L, but was at another facility.
- The video was reviewed on the following Monday (02/15/16).
- Interviewed staff on 02/15/16.
- She wrote a summary of her interviews.
- She reviewed the information with Staff II and stated that Staff II agreed with her analysis of the incident.

During an interview on 04/11/16 at 3:55 PM and 04/13/16 at 10:36 AM, Staff PP stated that he had not been told he had done anything wrong during the incident. He stated that the crisis prevention program instruction was just a foundation and not an exact science. Staff PP felt this patient's behaviors were too escalated for him to use the crisis prevention techniques (verbal de-escalation and physical holds to control a patient) he was trained to use. He stated that he continued to work after the incident.

During an interview on 04/11/16 at 9:00 AM, Staff H, Team Leader of Senior Care Behavioral Health Unit (BHU), stated that Staff PP and Staff SS were not removed from patient care (during the investigation of alleged patient abuse.)

The facility failed to remove the alleged perpetrators, Staff PP and Staff SS, from patient care during the investigation of alleged patient abuse, which put all patients in the Senior Care BHU at risk for potential abuse.

6. Record review of the facility's letter to the State Agency, dated 02/24/16, showed no documentation of removal from patient care of Staff PP or Staff SS (alleged perpetrators) during the facility investigation.

Based on observation, interview, record review, and policy review the facility failed to prevent abuse of one of one patient (#48) on the Senior Care Behavioral Health Unit (unit for the treatment of elderly psychiatric patients) when staff members dragged a patient backwards to move her to a room used to restrain (to prevent freedom of movement) patients. The facility failed to recognize this incident as abuse. This failure had the potential to place all patients admitted to the facility at risk for abuse. The facility census was 172. The unit census was 20.

Findings included:

1. Record review of the facility's policy titled, "Assessment, Investigation, and Reporting of Suspected Abuse/Neglect," dated 05/02/14 showed:
- Abuse of an adult (elder or disabled) was defined as the infliction of physical, sexual, or emotional injury or harm.
- Eligible adult was defined as any adult, aged 60 or older or 18-59 with a disability, defined as a mental or physical impairment that substantially limits one or more major life activities, whether the impairment was congenital or acquired by accident, injury or disease, where such impairment was verified by medical findings.
-Staff members were to assess, investigate, and report abuse and neglect to the appropriate State agencies.
-The Clinical Support Nurse (CSN) or department equivalent should immediately notify their Administrative Supervisor after ensuring the safety of the patient, which shall include immediate removal of the involved staff from patient care.

2. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48, showed on 02/09/16 at approximately 11:30 PM, the 66 year old female, was admitted to the Senior Care Behavioral Health Unit (BHU.) Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary.)

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

3. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above her head and Staff SS, Clinical Partner, pulled on the patient's left hand. Staff pulled Patient #48 backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

During an interview on 04/13/16 at 10:35 AM, Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator, and Staff L, Director of Behavioral Health Services, confirmed the distance from the day room to the restraint room was approximately 40 feet.

During an interview on 04/12/16 at 3:35 PM, Staff L, stated that she reviewed part of the video mid-morning on 02/11/16 and was unsure of Staff PP's actions.

During an interview on 04/13/16 at 3:30 PM, with Staff L and Staff H, Team Leader of Senior Behavioral Health, Staff L stated that on 02/11/16 she requested Staff H to visit with staff on the Senior Care BHU and see if the staff felt Staff PP was abusive. Staff L then reviewed the video again. Staff H stated that an incident like this would not happen again.

Staff L failed to recognize patient abuse after reviewing a video of two staff members dragging a patient backward for approximately 40 feet.

4. Record review of Staff L's chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II, Staff ZZ, Staff AA, and copied to Staff H showed:
- Patient #48 requested a hug from Patient #49 and Patient #49 pushed at peer.
- Patient #48 licked and bit Patient #49 and choked her.
- The event occurred in the day room, but the actual event was obscured by pillars.
- Staff were seen responding.
- Staff had difficulty separating the two patients due to Patient #48's bite.
- Patient #48 continued to hit, kick, and spit at staff and was restrained.
- The physician was on the unit and assessed the patient and ordered observation of within arm's reach.
- Patient #49 was taken to the Emergency Department (ED) with abrasions, tenderness, and bruising to the left cheek at site of the bite. No sutures needed.

During an interview 04/13/16 at 10:07 AM, and 10:15 AM Staff EE, RN, and Staff FF, RN both stated that staff should not drag (pull the patient along the floor) a patient.

During an interview on 04/13/16 at 10:20 AM, Staff GG, Clinical Support Nurse (CSN), stated that dragging a patient would not be an appropriate crisis prevention technique.

Staff PP, Staff SS and the facility failed to recognize Staff PP and Staff SS physically abused the patient by dragging her backward.

5. Record review of the facility's policy titled, "Just Culture," dated 12/01/15, showed directive for a manager's roles and responsibilities included knowing the potential risks, investigating the source of errors, designing safe systems, helping employees understand safety risks within their environment, and helping the employee make safe choices. The process will guide managers to identify opportunities for system/structure improvements and assess an employee's choices that may have contributed to the event.

During an interview on 04/11/16 at 3:55 PM and 04/13/16 at 10:36 AM, Staff PP stated that he had not been told he had done anything wrong during the incident on 02/11/16. He stated that the crisis prevention program (a training program on how to deescalate a patient and use appropriate holds to control a patient) instruction was just a foundation and not an exact science. Staff PP felt this patient's behaviors were too escalated for him to use the crisis prevention techniques he was trained to use.

The facility's staff, failed to follow their, "Just Culture," policy by not helping employees make safe choices when caring for psychiatric patients and not identifying abuse when it occurred in their facility.

6. Record review of a self report letter dated 02/24/16, that the facility sent to the State Agency, showed no discussion of abuse of Patient #48 by Staff PP or Staff SS.

During an interview on 04/13/16 at 10:06 AM, Staff II, Vice President of Behavioral Services and Staff TT, Human Resource Partner, both stated that Staff PP acted correctly during the 02/11/16 incident.

Staff II and Staff TT failed to recognize that restricting the patient's movement was a form of restraint and failed to recognize that dragging a patient was patient abuse.

Based on observation, interview, record review, and policy review the facility failed to ensure staff obtained a physician's order for a manual hold restraint for one of one patient (#48) on the Senior Care Behavioral Health Unit (unit for the treatment of elderly psychiatric patients.) This failure increased the risk for patients to be restrained inappropriately and prior to the use of least restrictive alternatives. The facility census was 172. The Senior Care Behavioral Health Unit census was 20.

Findings included:

1. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48 showed on 02/09/16 at approximately 11:30 PM, the 66 year old female, was admitted to the Senior Care Behavioral Health Unit. Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary).

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face, and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the facility intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

2. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above her head and Staff SS, Clinical Partner, pulled on the patient's left hand. Patient #48 was pulled backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

During an interview on 04/13/16 at 10:35 AM, Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator, and Staff L, Director of Behavioral Health Services, confirmed the distance from the day room to the restraint room was approximately 40 feet.

During an interview on 04/12/16 at 2:10 PM, Staff SS stated that she remembered griping Patient #48's left upper arm or shoulder area. Staff SS stated that she and Staff PP stopped to get a better grip on the patient to get her down the hall safely.

3. Record review of the facility policy titled, "Restraint Utilization (Violent, Self-
Destructive)," dated 01/2014, showed directives for facility staff:
- In an emergency situation, a trained staff member under the supervision of a
Registered Nurse (RN) trained in the use of restraints can initiate the restraint. - An order must be immediately secured from a physician.
- A mechanical restraint is any manual method, physical method, mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body.

Staff held the patient in a manner that restricted her movement which constituted a restraint.

During an interview on 04/13/16 at approximately 3:30 PM, Staff H, Staff Team Leader, Senior Care Behavioral Health Unit and Staff L, Director of Behavioral Services, stated that Staff PP utilized a restraint in an emergent situation.

4. Record review of Patient #48's physician's orders showed no order for a manual restraint.

5. Record review of Staff L's chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II, Vice President of Behavioral Health Services; Staff ZZ, Administrator; Staff AA, Patient Safety, Quality, Risk, and Regulatory Coordinator; and copied to Staff H showed the patient continued to hit, kick, and spit at staff and was restrained.

During an interview on 04/13/16 at 10:53 AM, Staff II, Vice President of Behavioral Health, stated that the facility policy directive for staff was that an order for a therapeutic hold was not needed and Staff PP used no therapeutic hold, but he transferred the patient. This was less restrictive than seclusion or restraint.

Staff II failed to recognize that restricting the patient's movement was a form of restraint.

Patient #48 could not easily remove the staff's hands and she was restricted from freedom of movement. This constituted a manual restraint by Staff PP and Staff SS.

Based on observation, interview and record review the facility failed to ensure all staff who cared for patients that were at increased risk for combative/agitated behaviors and sexual acting out behaviors were educated in five patient care units (two adult Behavioral Health Units, BHU; one adolescent BHU; and two Emergency Departments, ED) of six units after an incident which involved the care of a combative patient, and three patient care units (two ED and one Senior Care Behavioral Health Unit) of three units after an incident which involved care of patients that had increased risk of sexual acting out behaviors. These failures had the potential for similar incidents to re-occur due to uneducated staff. The facility census was 172.

Findings included:

1. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48, showed on 02/09/16 at approximately 11:30 PM, the 66 year old female, was admitted to the Senior Care Behavioral Health Unit (BHU.) Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary.)

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

2. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above the patients head and Staff SS, Clinical Partner, pulled on the patient's left hand. Patient #48 was pulled backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

3. Record review of the undated facility's education titled, "Care of the Agitated Patient, Crisis Intervention," showed directives to staff on how to recognize behavioral changes that could indicate a person becoming more agitated, to report changes to nursing staff, awareness of the need for a plan to provide for everyone's safety, identify coping skills that may be used to de-escalate situations/individuals, how to physically control a patient with two people, and how staff position themselves with a patient to transport (escort a walking patient) patient.

During an interview on 04/14/16 at 9:02 AM, Staff L, Director of Behavioral Health Services, stated that only the staff in the Senior Care Behavioral Health Unit were retrained on the "Care of the Agitated Patient, Crisis Intervention," because that was where the 02/11/16 incident occurred.

During an interview on 04/14/15 at 8:57 AM, Staff YY, Registered Nurse BHU, reported that she was not educated after the event on 02/11/16 on the Senior Care Behavioral Health Unit, but was aware of the event since she floated to that unit and it was discussed by staff.

The facility's lack of education for all staff that cared for this patient population on a regular basis (Behavioral Health and Emergency Department Staff), had the potential to lead to similar incidents of unidentified behavioral changes, inability to de-escalate situations appropriately, and improper physical control of a patient on other units.

4. Record review of the documented titled, "Regulatory Compliance and Risk Management Investigation," dated 04/08/16 showed the following:
-Patient #50 and #51 were both on Sexual Abuse Management (SAM) precautions at level two (patients placed on SAM level two precautions have a risk for major sexual acting out behaviors such as fondling, excessive talk with sexual content, inappropriate touching and also may have been a perpetrator of sexual assault, a registered sex offender, or are currently in treatment for sexual misconduct).
-On 03/28/16 at approximately 3:22 PM, Patient #50 and #51 were alone in Patient #51's shower in his room for approximately three minutes before being discovered by staff.
-Patient #51 was fully clothed and denied any intercourse. He reported he had only, "touched her (#50) between the legs."
-Patient #50 was found with her pants off, but denied any sexual interaction between herself and Patient #51.

During an interview on 04/14/15 at 8:57 AM, Staff YY, Registered Nurse (RN) BHU, stated the following:
-She was the primary RN for Patient #51.
-All staff that worked the unit on 03/28/16 was aware that Patient #50 and #51 were on SAM level two precautions.
-Observations by staff were made that concerned them that there was potential for inappropriate interactions between the two patients.
-A Safety Huddle (group meeting of staff on the unit that includes leadership) was conducted immediately after the observations occurred and the decision was made to move Patient #51 to another unit as a precaution.
-Due to the paranoid and aggressive behavior of Patient #50, staff had to wait for an opportunity to distract Patient #50 in order to make the transfer of Patient #51 a safer transition for staff and patients.
-An admission came to the floor prior to the transfer being completed, and during that time the patients were found in the bathroom.
-Patient #50 and #51 were on every 15 minute observation checks.

5. Record review of the facility's education sign-in sheets titled, "Observation Levels and Reporting of High Risk Incidents," dated 04/08/16, showed that documentation of re-education was begun for all staff that worked on the adolescent BHU, and two Adult Care BHU's. This was a direct result of the event that occurred on 03/28/16. The sign-in sheets showed no re-education was done by the facility for staff on the Senior Care Behavioral Health Unit or the ED.

During an interview on 04/14/16 at 8:32 AM, Staff W, Team Leader Behavioral Health, stated that education specific to the 03/28/16 event was only administered to the staff of the adolescent BHU and the two Adult Care BHU's. Staff W confirmed that no education was done regarding this event to the Senior Care Behavioral Health Unit or any other departments.

The lack of post-event education for all units that cared for this population placed all patients at risk for further harm due to insufficient knowledge of staff.





36474

Based on interview, record review and policy review, the facility failed to individualize interventions and/or goals for five of five patients (#8, #10, #11, #14 and #34) care plans reviewed. These failures had the potential to affect all patients by having unidentified patient needs which could lead to poor patient outcomes. The facility census was 172.

Findings Included:

1. Record review of the facility policy titled, "Care Planning Policy" revised 06/2014 showed the following:
- The care plan outlines the interdisciplinary care to be provided to a patient. It is a set of actions to be implemented to resolve problems identified by initial and ongoing assessments.
- The Registered Nurse (RN) is responsible for development/revision of the nursing aspects of care.
- The care plan will include individualized measurable goals with interventions identified to help the patient reach the established goals/outcome.
- Planning for care, treatment and services is individualized to meet the patient's unique needs.
- To continue to meet the patients unique needs, the plan is maintained and revised based on the patient's response.

2. Record review of Patient #8's History and Physical (H&P) showed the patient had a diagnosis of cardiomyopathy (disease of the heart muscle) and uncontrolled hypertension (high blood pressure which is not controlled by medication) and had undergone a Coronary Artery Bypass Grafting (CABG, a surgery to improve blood flow to the heart) in this admission.

Record review of the patient's Care Plan showed no problem, goal or interventions related to the CABG or the hypertension.

3. Record review of Patient #10's H&P showed he had a diagnosis of compartment syndrome (pressure within the muscles that can decrease blood flow which can damage muscles and nerves) and resulting left arm surgery. He had an indwelling urinary catheter (a tube that drains urine from the bladder to a bag outside the body) and a Central Venous Catheter (a long, thin flexible tube which is inserted into a large vein to administer fluids, medication or nutrition).

Record review of Patient #10's Care Plan showed no individualized interventions to address the potential for infection of the patient's arm incision, indwelling urinary catheter or the Central Venous Catheter incision.

4. Record review of Patient #11's H&P showed she had a diagnosis of an abdominal mass and a colon mass.

Record review of Patient #11's Care Plan showed no individualized goals or interventions to address her pain, elimination, mobility or nutrition (which can be compromised by the masses.)

5. Record review of Patient #14's H&P showed he had a diagnosis of confusion, senile dementia (mental deterioration or loss of intellectual ability) associated with old age and Parkinson's (a progressive disorder of the nervous system which affects movement). The patient was in a bed, which was completely enclosed with netting and confined the patient in the bed (a restraint) due to his confusion and frequent falls.

Record review of Patient #14's Care Plan showed no individualized interventions to address the bed restraint. The Care Plan included a plan
for maintaining or improving his skin integrity. Patient #14 had no skin integrity issues.

6. Record review of Patient #34's H&P showed she had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, chronic lung disease which makes it hard to breathe) with bronchitis (inflammation of the lining of the bronchial tubes which carry air to and from the lungs).

Record review of Patient #34's Care Plan showed no individualized interventions to address her COPD and bronchitis.