HospitalInspections.org

Based on record reviews (medical staff bylaws, physician credentialing files) and staff interviews, the governing body failed to ensure the privileges of the medical staff were clearly delineated by the applicant and approved by the medical staff and governing body for 1 of 3 medical staff files (S19MD, Family Practice). Findings:

Review of Physician S19MD's credentialing file revealed the reappointment date was 2/24/11 and included no documented evidence of a request for and approval of delineation of privileges granted by the Medical Executive Committee (MEC) and Governing Body.

In a face-to-face interview on 4/13/11 at 9:15 a.m., S5RHIA/Medical Record Director indicated she was responsible for the credentialing process for the physicians. S5 indicated she reviewed the credentialing file's applications and then sent the files to MEC and the governing body for approval. S5 could offer no explanation for why the physician's (S19) privileging were not performed according to the bylaws.

Review of the "By-Laws, Rules and Regulations of Medical Staff", with no last reviewed and approved date(s) by the Director of Nursing, Medical Director, and Administrator and no documented evidence of approval by the governing body, revealed, in part, "... Article VI Section 1. Clinical Privileges Restricted A. Each practitioner practicing at this hospital shall be entitled to exercise only those clinical privileges specifically granted to him by the Board ..."

Based on record review and interview the hospital failed to meet the Condition of Participation of Patient Rights as evidenced by:

1) failing to ensure a patient was free from abuse by failing to detect/prevent a male patient (#2), who was assessed upon admission to be "walking down the halls checking doors", from entering the room of a female patient (#15) on 01/15/11 and exposing himself to her and attempting to disrobe her. The hospital staff failed to follow hospital policy and report the allegations of sexual abuse of patient #15 by patient #2. By definition this resulted in neglect by staff indifference of the reported sexual abuse of patient #15. This affected 1 of 15 sampled patient's (#15) and had the potential to affect 7 female patient's (#1, #3, #15, #R1, #R4, #R5, #R8) in a hospital census of 15 on 01/15/11 and 01/16/11. (see findings at A0145)

2) failing to ensure the environment was safe for all patients in the hospital as evidenced by a male patient (#2) verbally threatening staff and patients on the unit causing multiple patient's emotional distress to the point they were asking to be locked in their rooms to protect themselves from patient #2 and requesting/requiring increased medications for two days. This had the potential to affect all of the patient's in the hospital on 01/15/11 and 01/16/11. (#1, #2, #3, #15, #R1, #R2, #R3,#R4, #R5,#R6, #R7, #R8) (see findings at A0144)

3) failing to ensure that seclusion is only used to ensure the immediate physical safety of the patient, staff, or others as evidenced by the patient becoming compliant and walking calmly to the seclusion room when the staffing level was supplemented by the police department for 1 of 1 focused sampled patients with seclusion ordered in a total sample of 15. (#2) (see findings at A0154)

4) failing to ensure seclusion was discontinued at the earliest possible time as evidenced by staff obtaining a renewal order for seclusion of a patient documented to be asleep for 1 of 1 focused sampled patients with seclusion ordered in a total sample of 15. (#2) (see findings at A0154)

5) failing to ensure medications ordered and administered to a patient had an overall effect of improving the patients ability to effectively and/or appropriately interact with staff and peers and the treatment program as evidenced by administering Haldol/Ativan/Benadryl in a combination injection rendering the patient incapable of functioning in the treatment program for 1 of 1 focused sampled patient's with seclusion orders in a total sample of 15. (#2) (see findings at A0160)

6) failing to ensure seclusion was only used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm as evidenced by the patient becoming compliant when police officers (PD1) arrived at the hospital. The hospital was staffed by three people (one RN,one LPN, and one MHT) who were afraid of the patient and failed to take control of the situation for 1 of 1 focused sampled patients in a total sample of 15. (#2) (see findings at A0164)

7) failed to modify the treatment plan when seclusion was ordered for 1 of 1 focused sampled patient's with seclusion orders in a total sample of 15. (#2) (see findings at A0166)

8) failing to ensure that orders for seclusion used for safety of the staff and patient's were only in effect for up to 4 hours for an adult patient as evidenced by the physician ordering a patient into seclusion and staff failed to obtain a new order or release the patient for 4 hours and 15 minutes for 1 of 1 focused sampled patient's with seclusion orders in a total sample of 15. (#2) (see findings at A0171)

9) failing to ensure the patient in seclusion was monitored continuously per hospital policy for 3 of 3 seclusion periods and one renewal order for seclusion as evidenced by no documented evidence of continuous visual observation and statements by staff that the patient was not continuously monitored for 1 of 1 focused sampled patient's with seclusion orders in a total sample of 15. (#2) (see findings at A0175)

10) failing to ensure that upon each new order for seclusion that a face to face evaluation was conducted within one hour per hospital policy by a physician or RN deemed competent to perform the evaluation as evidenced by no documented evidence of a face to face evaluation within one hour of seclusion initiation for 3 of 3 seclusion orders and 1 renewal order written after the original seclusion order had expired for 1 of 1 focused sampled patient's with seclusion orders in a total sample of 15. (#2) (see findings at A0178)

11) failing to ensure that upon each new order for seclusion that a face to face evaluation to evaluate the situation, the patients reaction to the intervention, and the need to continue or terminate the seclusion was conducted within one hour per hospital policy by a physician or RN deemed competent to perform the evaluation as evidenced by no documented evidence of a face to face evaluation within one hour of seclusion initiation for 3 of 3 seclusion orders and 1 renewal order written after the original seclusion order had expired for 1 of 1 focused sampled patient's with seclusion orders in a total sample of 15. (#2) (see findings at A0179)

12) failing to ensure that upon each new order for seclusion that a face to face evaluation was conducted within one hour per hospital policy by a physician or RN deemed competent to perform the evaluation as evidenced by no documented evidence of a face to face evaluation within one hour of seclusion initiation for 3 of 3 seclusion orders and 1 renewal order written after the original seclusion order had expired for 1 of 1 focused sampled patient's with seclusion orders in a total sample of 15. (#2) (see findings at A0184)

Based on record review and interview the hospital failed to ensure the environment was safe for all patients in the hospital as evidenced by a male patient (#2) verbally threatening staff and patients on the unit causing multiple patients emotional distress to the point they were asking to be locked in their rooms to protect themselves from patient #2 and requesting/requiring increased medications for two days. This had the potential to affect all of the patients in the hospital on 01/15/11 and 01/16/11. (#1, #2, #3, #15, #R1, #R2, #R3,#R4, #R5,#R6, #R7, #R8) Findings:

Review of the medical record of patient #2 revealed he was admitted on Friday 01/14/11 at 1830 (6:30 p.m.) to S17MD, Psychiatrist, with a diagnosis of Chronic Paranoid Schizophrenia (CPS). Patient #2 was a 40 year old male. Further review of the medical record revealed patient #2 was sent to an Emergency Room (ER) directly from jail and was placed under a Physician's Emergency Certificate (PEC). Patient #2 was ordered to be on "q (every) 15 minute safety checks."
Review of the Initial Nursing Assessment for patient #2 revealed it was performed by S13RN on 01/14/11 at 1830 (6:30 p.m.). Further review revealed: "Reason for Admission: Pt had been in jail for wandering on streets, talking to things/people not there. Began yelling in jail. Seemed to be responding to internal stimuli. History of Mental Illness: long hx. (history). Presenting Symptoms: (the following were checked as positive) Anxiousness/Restlessness, Confusion, Hallucinations, Impulsivity, Isolative/withdrawn behavior, Lack of Concentration, Paranoia/suspiciousness, Sleep disturbance...Appearance: Disheveled...Thought Content: Paranoid delusions...RN Admission note:..Pt. walks down halls - checking doors."
In an interview on 04/12/11 at 3:30 p.m. with S13RN she stated she notified the LPN and MHT's on duty and the oncoming shift that patient #2 was walking down the halls checking doors.
Review of the Multidisciplinary Treatment Plan revealed the following problems were identified on the care plan: Problem #1 Disturbed Thought Process, date initiated: 01/14/11. Problem #2: Self Care Deficit, date initiated 01/14/11. Problem #3: Date Identified: 01/15/11. Risk for other - directed violence. Related to: Hx of Chronic Paranoid Schizophrenia. As Evidenced by "(patient #2) loudly curses and threatens violence toward staff and peers, (patient #2) pounds on walls of nursing station, (patient #2) resists all attempts to redirect. Clinical Interventions: Educate (patient #2) on anti-psychotic medications - assess effectiveness. Person responsible: (S7RN); offer (patient #2) to reality when he verbalizes auditory/visual hallucinations/paranoid delusional thoughts. Person responsible: (S7RN) and (S16MHT) assist (patient #2) with identifying triggers to agitation and effective alternatives to aggressive behaviors. Persons Responsible: (S7RN) and (S16MHT)."
01/15/11
Review of the nursing note for patient #2 documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note for patient #2 documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR (behavioral control room)."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a", pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet in the medical record of patient #2 revealed: "Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours)...Clinical Justification: safety of others. Describe Specific Behavior: loud, threatening to "f*** us all up", cursing loudly, exposed self to female pt., attempted to disrobe female pt., wandering..."
Further review of the nursing notes in the medical record of patient #2 for 01/15/11 at 1130 (11:30 a.m.) revealed S11RN documented "Locked BCR D/C'd (discontinued)."
Review of the nursing documentation in the medical record of patient #2 for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM". The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, (patient #2) escorted to BCR - Haldol 10 mg, Ativan 2 mg, Benadryl 50mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet on the medical record of patient #2 revealed: Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)...Chemical Adjunctive Support Ordered: No. Clinical Justification: danger to others. Describe Specific Behavior: threatening violence towards staff and peers, loud cursing, throwing objects, hitting windows of nsg (nursing) station..."
Review of S12RN's documentation on the medical record of patient #2 for 01/15/11 at 2200 (10:00 p.m.) read as follows: "Occasional outburst of cursing and threatening staff. When told we would call police if necessary (patient #2) calms down and apologizes."
Documentation by S12RN for patient #2 at 2330 (11:30 p.m.) on 01/15/11 revealed: "Dr. (S17MD) notified of patient escalating, threatening staff with loud cursing. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. (PD1) call to assist. (3rd call) Injections given with pt cursing and threatening but willingly took the injections."
Review of the Physician' s Orders sheet in the medical record of patient #2 revealed an order dated 01/15/11 at 2330 (11:30 p.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
01/16/11
S11RN documented the following in the medical record of patient #2 on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests ...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for patient #2 on 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
S11RN documented in the medical record of patient #2 at 1230 (12:30 p.m.) on 01/16/11 the following: " (PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD). "
Review of the Physician's Orders sheet revealed an order for patient #2 dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the Physician's Order Sheet in the medical record of patient #2 dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet in the medical record of patient #2 revealed: "Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)...Chemical Adjunctive Support Ordered: Yes. Clinical Justification: safety of others. Describe Specific Behavior: cursing loudly and threatening violence toward staff and peers..."
01/17/11
Review of the nursing documentation by S12RN in the medical record of patient #2 on 01/17/11 at 0120 (1:20 a.m.) read: "(S17MD) called for pt yelling, cursing, threatening staff, threw shampoo bottle at nsg station. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM X 1 dose now. (PD1) called to assist. (5th call). Pt took injections willingly ..."
Review of nursing documentation in the medical record of patient #2 on 01/17/11 at 0730 (7:30 a.m.) by S7RN revealed the following: "Pt. up and ambulatory. Episodes of verbal aggression, cursing loudly, able to redirect pt without incident. Pt. yelling at a spot of kool-aid on the floor and accusing the spot of kool-aid of stealing his breakfast ..."
Review of the Psychiatric Evaluation revealed S17MD, Psychiatrist, performed the evaluation on Monday January 17th, 2011 at 12:00 noon. This evaluation was 65 ? hours after admission and was the first face to face assessment of patient #2 by S17MD. Further review of the documentation by S17MD revealed: "Patient's Chief Complaint: "I'm Jesus Christ" . Onset: Chronic. Reason for Admission/Signs/Symptoms/Precipitating Factors: 41 yo admitted for tx (treatment) of acute psychosis. Past History of any Psychiatric Problems/Treatment. Patient is acutely ill related to: Schizophrenia. Patient has had past psychiatric history of: Schizophrenia. Patient has had multiple treatments and hospitalizations at inpatient, PHP (partial hospitalization program). Patient has been consistently ill for period of lifelong, relapsed. Precipitating factors include: homeless. Persistent Symptoms include: Hallucinations, Delusions...Mental Status Exam: Appearance: Disheveled, Attitude/Behavior: Suspicious, Motor Activity: Calm, Affect: Labile, Mood: Calm, Speech: Normal, Thought Process: Flight of Ideas, Loose Assoc. (associations), Thought Content: Hallucinations: Auditory, Delusions: Grandiose, Suicidality: Not Present, Homicidality: Not Present, Sensorium and Cognition...Judgment: Impaired...Capacity for ADL's (activities of daily living). Diagnosis: Axis I: Chronic Paranoid Schizophrenia, Axis II: No Dx. (diagnosis), Axis III: No Dx., Axis IV: Problems related to the social environment. Axis V: Current 10, Past Year? Initial Plan for Treatment: New medication prescribed: Yes, Medication Evaluation, adjustment or trial, Crisis Intervention, Provide a Safe and Structured Environment, Evaluation of Psychiatric Status, Laboratory Tests/Work-up. Discharge Criteria for lower level of care: Resolution of impaired function due to bizarre, psychotic behavior/affect and/or thinking. Preliminary Discharge Plan: Psychiatrist. Hospitalization needed: No. Estimated length of stay: 4 days. Prognosis: Fair. Formulation: Pt's problems are behavioral. He is not suited for inpatient care. He will be referred for outpatient care. "
Review of the Discharge Summary for patient #2 revealed the following: "Admission Diagnosis: Axis I: Chronic Schizophrenia. Axis II: No Diagnosis. Axis III: No Diagnosis. Axis IV: Problems related to social environment. Axis V: GAF On Admission: 10. Past Year: Unknown. Chief Complaint: (I'm Jesus Christ). History of Present Illness: This is a 41 year old black male admitted for treatment of acute psychosis. Mental Status on Admission: Patient appeared disheveled. Attitude and behavior was suspicious and belligerent. Motor activity was calm. Affect was labile. Mood was normal. Speech was normal. Thought process was positive for flight of ideas and disassociation. Thought content was positive for auditory hallucinations and grandiose delusions. Patient denied any suicidal or homicidal ideations. Cognitive Examination on Admission: Patient was oriented X 4 to person, place, time, and situation. Memory function was intact in regards to immediate, recent and remote event. Concentration was intact. Attention was intact. Abstract thinking was impaired. Insight was limited. Judgment was severely impaired. Intelligence was average...At around 11:00 on 1-15-11 the patient was placed on seclusion BCR for threatening violence to staff and increased psychotic behavior. At 11:30 seclusion was discontinued. Around approximately 15:00 (3:00 p.m.) the patient was placed back in BCR for threatening violence to staff and increased agitation of psychosis. He was also given Haldol 10 mg IM, Ativan 2 mg IM and Benadryl 50 mg IM due to the increased psychosis. Order was renewed for seclusion at 19:15 (7:15 p.m.). At 20:30 (8:30 p.m.) the patient was given Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM X 1 for increased agitation related to psychosis. On 1-16-11 at 12:05 (p.m.) the patient was given Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg IM X 1 for increased agitation related to psychosis. At 12:30 (p.m.) on 1-16-11, the patient was placed on locked BCR for threatening staff and peers for increased agitation related to psychosis. At 16:30 (4:30 p.m.) seclusion orders were discontinued. On 1-17-11 at approximately 1:20 a.m., the patient was given Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg IM X 1 dose for increased agitation related to psychosis. On 1-17-11, the patient was seen by Psychiatrist for psychiatric evaluation. (This was 65 hours after admission) It was determined by this exam, that the patient's problems were behavioral and he was not suitable for inpatient care, therefore patient was discharged from this facility. The patient was discharged to Salvation Army in Lafayette. Complications Through Hospital Care: Patient required continuous redirection and IM prn medication throughout stay. Mental Status Examination on Discharge: Patient denied any homicidal or suicidal ideations or passive death wishes. Mood and affect were stable. He denied any auditory or visual hallucinations...Condition Upon Discharge: stable..." Further review of the document revealed it was dictated by S7RN. The Discharge Summary was blank on the signature line for the person who dictated the information, S7RN, and also on the line for the Psychiatrist, S17MD to sign.
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN further confirmed that there was 1 RN, 1 LPN, and 1 MHT, all female, on duty for the Saturday (15th) and Sunday (16th) shifts. S11RN stated that on 01/15/11 patient #2 was roaming the halls checking doors. S11RN stated that some of the other patients in the unit were scared of patient #2 and stayed in their rooms. S11RN further stated that some patients, both male and female, were requesting that their room doors be locked to prevent patient #2 from getting into the room. S11RN stated that she did lock the doors of those patients. S11RN stated that although the doors were locked from the outside, the patients could exit the room from the inside without needing a key. S11RN stated a female patient reported patient #2 entered the room she was in and patient #2 had his penis out and was attempting to disrobe patient #15. S11RN stated that the female patient told patient #2 to leave the room as she exited the room to summon help. The female patient exited the room and reported what was occurring to patient #15. S11RN stated that no staff witnessed the incident and that patient #2 had exited the room prior to staff arrival. S11RN stated that patient #15 reported that patient #2 was in her room with his penis exposed and was "reaching for her clothing" when the other female patient in the room, who was behind a curtain, came into the area and told patient #2 to leave the room. S11RN stated that this is patient to patient abuse. S11RN further stated she could not remember if an incident report was filled out. When asked by this surveyor what she did to protect the patients from patient #2, S11RN replied that she was complying with requests of approximately 5 female patients to lock them in their room. S11RN stated she does not remember if she informed anyone else of patients "being so scared (of patient #2) that they were requesting to be locked in their room." S11RN was asked why the police were called and she stated she was afraid patient #2 would hurt the staff. S11RN stated the entire staff was scared of patient #2. S11RN stated she thinks she called either S7RN on-call or S10, staffing, not to request additional staff but to update them of the problems on the unit. S11RN confirmed that patient #2 became calm when the police arrived, but was still placed in the BCR. S11RN confirmed there was no documented evidenced of a face to face evaluation within 1 hour of initiation of seclusion by an MD or RN deemed competent per hospital policy to perform the evaluation for any of the 3 seclusion initiations. S11RN stated she never initiated or requested 1:1 or continuous visible observation status for patient #2 for the monitoring of patient and/or the safety of the other patients. S11RN stated she never entered the seclusion room to check on patient #2 unless he was asleep because she was scared. S11RN stated that constant visual observation of patient #2 was not in place per hospital policy on any occasion when patient #2 was in seclusion 3 times during the two shifts she worked, 01/15/11 and 01/16/11. S11RN confirmed there was no documentation of less restrictive methods being attempted except on the seclusion flow sheet when seclusion was ordered. S11RN stated that on 01/16/11 patient #2 also threatened visitors. S11RN stated she did not report the incident with patient #2 and patient #15 to the Nursing Director per hospital policy. S11RN stated that every time the police entered the hospital they were carrying their police issued weapons.
In an interview on 04/12/11 at 3:30 p.m. with S14LPN she confirmed she worked the day shift on 01/15/11 and 01/16/11. She further stated that on 01/15/11 patient #2 exposed himself to patient #15 by pulling his pants down and then attempting to disrobe patient #15. S14LPN stated that after that all of the patients were scared of him, both male and female, and were requesting to be locked in their rooms or in the dayroom so patient #2 could not get to them. S14LPN stated that staff complied with the request. S14LPN stated that she did notify S7RN on-call and S10, staffing. S14LPN stated that other patients were requesting/required increased medications due to the events on the unit. S14LPN stated the police were called several times. S14LPN stated she was afraid of patient #2 and she did not feel like staff could take him down.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/14/11, 01/15/11, and 01/16/11. S12RN stated he was aware on 01/14/11 of the initial assessment findings documented by S13RN that patient #2 was "walking down the halls checking doors." S12RN stated that he was not informed during his on-coming shift report on the evening of 01/15/11 that patient #2 had exposed himself to patient #15 and was reportedly attempting to disrobe her in her room while having his penis exposed. S12RN stated that male and female patients were still requesting to be locked in their rooms and in the dayroom because they were afraid of patient #2. S12RN was asked by this surveyor what measures were put in place to protect the patients from patient #2. S12RN stated that locking patients in their room and the dayroom while patient #2 was in the hall was the only thing done. S12RN confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained. S12RN stated there was no face to face evaluation of patient by the MD or LIP deemed competent to perform the evaluation within 1 hour of the seclusion renewal order. Further review of the nursing notes documented by S12RN revealed patient #2 was "allowed out of seclusion" at 2030 (10:30 p.m.) on 01/15/11. S12RN confirmed his documentation dated 01/15/11 at 2200 (10:00 p.m.) that read as follows: "Occasional outbursts of cursing and threatening staff. When told we would call the police if necessary (patient #2) calms down and apologizes." S12RN confirmed the documentation for 01/15/11 at 2330 (11:30 p.m.) that patient #2 was "escalating, threatening staff with loud cursing." S12RN stated he contacted S17MD and was given an order for Haldol 10mg, Ativan 2mg, Benadryl 50mg IM stat X 1 dose. S12RN further confirmed that (PD1) was called to assist. S12RN stated that there was "not enough staff" and that the police were needed to assist with patient #2. S12RN stated that on 01/17/11 the other patients in the hospital were still isolating themselves from patient #2 by requesting to be locked in their rooms so patient #2 "could not get to them." S12RN stated patient #2 was not placed on 1:1 observation or continuous observation while in seclusion or at any other time during the 3 night shifts he worked (14th, 15th, and 16th). S12RN stated that patient #2 was a danger to patients and staff. S12RN stated he "could not remember if the Director of Nursing or Administration were notified" of the events of the weekend of 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:40 p.m. with S15LPN she confirmed she was the LPN on duty on 01/15/11 and 01/16/11 from 6:00 p.m. - 6:00 a.m. S15LPN stated that PD1 was called on 01/15/11 at 2330 (11:30 p.m.) because "(patient #2) was not going to allow staff to give the shot. "S15LPN stated there was inadequate staffing present." S15LPN stated that the information regarding patient #2 exposing himself to patient #15 and reportedly attempting to disrobe her was not passed on in shift report. S15LPN stated she "could not remember" if anyone was called to get additional staff. She further stated that it is routine hospital procedure to call the police for assistance. S15LPN stated that on the night shift of 01/16/11 the other patients in the hospital "were scared." S15LPN stated she did hear S12RN tell patient #2 "we will call the police if necessary." S15LPN stated she also overheard "phone calls to S10LPN, staffing, to get more staff." S15LPN stated she was informed that the staff were told to "do the best that you can."
In an interview on 04/12/11 at 12:45 p.m. with S7RN she confirmed her documentation on 01/17/11 that patient #2 was "yelling at a spot of kool-aid on the floor and accusing the spot of kool-aid of stealing his breakfast." She further confirmed that patient #2 was discharged 5 hours later to the "Salvation Army" and that there was no documentation of any staff member speaking to any person at that facility. S7RN was interviewed again on 04/13/11 at 10:20 a.m... S7RN stated that she was the on-call nurse for the weekend of 01/15/11 and 01/16/11. S7RN stated she received a call and was notified of "patient problems" on the floor, that she was not asked to come in, and that she was not informed that patients were requesting to be locked in their rooms.
In an interview on 04/13/11 at 10:15 a.m. with S10LPN, staffing, she stated she does not recall any request from staff between 01/14/11 - 01/17/11 for additional staff. S10LPN further stated there is no documentation that the staff on duty requested additional staff for 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done " S17MD stated he did not recall if he was advised of the incident between patient #2 and patient #15. S17MD stated that patient #2 "should have been on 1:1 observation." After review of the documentation in the medical record of patient #2 S17MD stated that the events documented in the medical record of patient #2 exposing himself to patient #15 and attempting to disrobe her "are abuse." S17MD stated that staffing was not appropriate and should have been increased. S17MD reviewed the documentation of 01/15/11 at 1915 (7:15 p.m.) by S12RN. The documentation reads: "(S17MD) contacted, he reordered the seclusion order until pt awakens to reassess for violent behavior." S17MD stated that a patient should not be ordered seclusion "until he awakens to assess "
S17MD reviewed the Psychiatric Evaluation dated 01/17/11 at 12:00 noon. S17MD confirmed his documentation that "Formulation: Pt 's problems are behavioral. He is not suited for inpatient care. He will be referred for outpatient care." S17MD stated he assessed patient #2 on 01/17/11 and that patient #2 was cooperative and he felt that if patient #2 "was out of the facility all behavior would stop." S17MD reviewed the Discharge Summary on the medical record of patient #2 and confirmed it was dictated by S7RN. The Discharge Summary was blank on the signature line for the person who dictated the information, S7RN, and also on the line for the Psychiatrist, S17MD, to sign. S17MD stated that patient #2 was not benefiting from inpatient care and "his behavior would continue if he stayed here." S17MD was asked about the content of the Discharge Summary as it had multiple statements that patient #2 was experiencing "increased agitation related to psychosis" during his stay and prior to the multiple injections of Haldol/Ativan/Benadryl and orders to "place pt. in BCR." S17MD confirmed that the Discharge Summary was not signed by him and he would not sign it as written. S17MD further stated that he "probably would not have discharged patient #2 if he were aware of the documentation by S7RN dated 01/17/11 at 7:30 a.m. of patient #2 accusing a spot of kool-aid on the floor of stealing his breakfast." S17MD then stated that patient #2 was "discharged to the street due to his behaviors and aggression." S17MD again stated he believed the patients behaviors were not due to psychosis but were a "behavioral" problem. On 04/12/11 at 1:30 p.m. the medical record of patient #2 was reviewed. The Discharge Summary, without changes, indicating patient #2 was "experiencing agitation related to psychosis" was signed by S17MD dated 04/12/11 at 1:00 p.m.
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated patient #2 was "responding to internal stimuli" upon admission on 01/14/11 and met admission criteria for the hospital. S2DON confirmed the Initial Assessment findings that patient #2 was "walking down the halls checking doors." S2DON stated the documentation for 01/15/11 that patient #2 was exposing himself and attempting to disrobe patient #15 was Abuse according to hospital policy and should have been reported to DHH. S2DON confirmed there was no incident report as required by hospital policy regarding the incident. S2DON stated the incident should have been reported to the police department. S2DON stated the RN should have initiated 1:1 monitoring of patient #2 and notified the physician to obtain the order. S2DON stated Administration and the DON should have been notified of the incident. S2DON stated staffing should have been increased based on the acuity of patient #2. S2DON confirmed there was no documentation of least restrictive methods being attempted prior to the documentation on the seclusion flow sheet and implementation of seclusion. S2DON confirmed there was no documentation of 1:1 continuous visual observation of patient #2 while he was in seclusion. S2DON stated that the failure to complete an incident report and notify management of the 01/15/11 incident between patient #2 and patient #15 was "passive abuse/neglect." S2DON confirmed that hospital policy requires either the psychiatrist or RN deemed competent to perform a face to face interview within 1 hour of initiation of seclusion. S2DON confirmed this evaluation was not done for the 01/15/11 at 11:00 a.m. seclusion, the 01/15/11 at 3:00 p.m. seclusion, the 01/15/11 1915 (7:15 p.m.) renewal order, or the 01/16/11 at 12:30 p.m. seclusion order. S2DON reviewed the documentation for 01/15/11 seclusion renewal order and stated "there is no documented reason to keep a sleeping patient in seclusion " and that this was done for "nursing convenience." S2DON stated the 01/15/11 at 2200 (10:00 p.m.) statement by S12RN that "we will call the police if necessary" is a threat. S2DON stated that on 01/16/11 the staffing level was inadequate. S2DON confirmed there was no documented evidence patient #2 was on 1:1/continuous observation while in seclusion on 01/16/11. S2DON confirmed there was no face to face evaluation done at any time for the seclusion of patient #2 on 01/16/11. S2DON confirmed the Discharge Summary was not signed by S17MD. S2DON confirmed that patient #2 was discharged to the street as the Salvation Army is only open at night. S2DON stated the discharge was "probably not appropriate." S2DON stated that patient #2 was "probably not ready" for discharge.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no face to face assessment of patient #2 done at any time after initiation of seclusion for the entire hospitalization of patient #2. S2DON and S3ADON stated they were not aware that staff was locking patients in their rooms and the dayroom on the weekend of 01/15/11 - 01/16/11 to per patient request due to fear of patient #2. S2DON and S3ADON stated the staff failed to fill out an incident report on the allegation of sexual abuse of patient #15 by patient #2. S2DON and S3ADON confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital. S2DON and S3ADON verified there was no physician countersignature on the seclusion order sheets within 24 hours of initiation as required by hospital policy. S2DON and S3ADON both stated they were not aware of the findings of the survey and the events of the weekend of 01/14/11 through 01/17/11 until the survey on 04/11/11 - 04/13/11. Both confirmed there was no investigation of the events of the weekend of 01/14/11 through 01/17/11.
Review of a hospital policy titled "Staffing patterns/Variances/Acuity" , no date effective, reviewed or revised, reads in part: "The program is staffed in a manner to meet the various needs of the patients served. The staffing pattern for the program is based on aspects of care and services provided, patient census, and acuity to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, Administration is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs ...B. High Census/Acuity Staff Adjustments. In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. The primary goal is to maintain a safe, therapeutic environment. The charge nurse on duty will notify Administration on call if the census increases and additional staffing is required."
Review of a hospital policy titled "Reporting Alleged Child/Adult Neglect and/or Abuse" , effective 01/10, no date of review or revisi

Based on record review and interview the hospital failed to ensure all patients were free from abuse by failing to to detect/prevent a male patient (#2), who was assessed upon admission to be "walking down the halls checking doors", from entering the room of a female patient (#15) on 01/15/11 and exposing himself to her and attempting to disrobe her. The hospital staff failed to follow hospital policy and report the allegations of sexual abuse of patient #15 by patient #2. By definition this resulted in neglect by staff indifference of the reported sexual abuse of patient #15. This affected 1 of 15 sampled patients (#15) and had the potential to affect 7 female patients (#1, #3, #15,#R1, #R4, #R5, #R8) in a hospital census of 15 on 01/15/11 and 01/16/11.

Findings:

Review of the medical record of patient #2 revealed he was admitted on Friday 01/14/11 at 1830 (6:30 p.m.) to S17MD, Psychiatrist, with a diagnosis of Chronic Paranoid Schizophrenia (CPS). Patient #2 was a 40 year old male. Further review of the medical record revealed patient #2 was sent to an Emergency Room (ER) directly from jail and was placed under a Physician's Emergency Certificate (PEC). Patient #2 was ordered to be on "q (every) 15 minute safety checks."
Review of the PEC dated 01/14/11 at 1410 (2:10 p.m.) revealed the following "History of Present Illness: Pt. (patient brought from jail for admit to Psyc facility. Past hx (history) of Paranoid Schizophrenia ...Mental Condition: Pt. in handcuffs constant talking and rambling. Hx of Paranoid Schizophrenia." The ER physician documented that patient #2 was "Dangerous to self, Unwilling to seek voluntary admission, and Gravely Disabled."
Further review of the medical record revealed patient #2 was placed under Coroner's Emergency Certificate (CEC) at the same ER on 01/14/11 at 1503 (3:03 p.m.). Under "History of Present Illness" the Coroner documented "40 yo (year old) BM (black male) brought by deputies from the jail - yelling, hallucinating, rambling. Mental Condition: Pt. yelling, rambling, aggressive, actively hallucinating. Unable to seek voluntary admission, Gravely Disabled."
Review of the Hospital's "Admission Criteria" sheet dated 01/14/11 revealed that S13RN documented that patient #2 met the following criteria: "...7. Acute onset or acute exacerbation of hallucinations, delusions, illusions, the magnitude and severity of which threats the patients well being...10. Acute onset of inability to cope with stressful situation."
Review of the Initial Nursing Assessment revealed it was performed by S13RN on 01/14/11 at 1830 (6:30 p.m.). Further review revealed: "Reason for Admission: Pt had been in jail for wandering on streets, talking to things/people not there. Began yelling in jail. Seemed to be responding to internal stimuli. History of Mental Illness: long hx. (history). Presenting Symptoms: (the following were checked as positive) Anxiousness/Restlessness, Confusion, Hallucinations, Impulsivity, Isolative/withdrawn behavior, Lack of Concentration, Paranoia/suspiciousness, Sleep disturbance...Appearance: Disheveled...Thought Content: Paranoid delusions...RN Admission note:...Pt. walks down halls - checking doors."
In an interview on 04/12/11 at 3:30 p.m. with S13RN she stated she notified the LPN and MHT's on duty and the oncoming shift that patient #2 was walking down the halls checking doors.
Review of the Multidisciplinary Treatment Plan revealed the following problems were identified on the care plan of patient #2: "Problem #1 Disturbed Thought Process, Problem #2: Self Care Deficit, Problem #3: Date Identified: 01/15/11. Risk for other - directed violence. Related to: Hx of Chronic Paranoid Schizophrenia. As Evidenced by (patient #2) loudly curses and threatens violence toward staff and peers, (patient #2) pounds on walls of nursing station, (patient #2) resists all attempts to redirect. Long Term Goal: (patient #2) will demonstrate mood stability with absence of psychosis and no further displays of aggression. Date expected to achieve: 01/29/11...Clinical Interventions: Educate (patient #2) on anti-psychotic medications - assess effectiveness. Person responsible: (S7RN); offer (patient #2) to reality when he verbalizes auditory/visual hallucinations/paranoid delusional thoughts. Person responsible: (S7RN) and (S16MHT) assist (patient #2) with identifying triggers to agitation and effective alternatives to aggressive behaviors. Persons Responsible: (S7RN) and (S16MHT)."
01/15/11
Review of the nursing note for patient #2 documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note for patient #2 documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN further confirmed that there was 1 RN, 1 LPN, and 1 MHT, all female, on duty for the Saturday (15th) and Sunday (16th) shifts. S11RN stated that on 01/15/11 patient #2 was roaming the halls checking doors. S11RN stated that some of the other patients in the unit were scared of patient #2 and stayed in their rooms. S11RN further stated that some patients, both male and female, were requesting that their room doors be locked to prevent patient #2 from getting into the room. S11RN stated that she did lock the doors of those patients. S11RN stated that although the doors were locked from the outside, the patients could exit the room from the inside without needing a key. S11RN stated a female patient reported patient #2 entered the room she was in and patient #2 had his penis out and was attempting to disrobe patient #15. S11RN stated that the female patient told patient #2 to leave the room as she exited the room to summon help. The female patient exited the room and reported what was occurring to patient #15. S11RN stated that no staff witnessed the incident and that patient #2 had exited the room prior to staff arrival. S11RN stated that patient #15 reported that patient #2 was in her room with his penis exposed and was "reaching for her clothing" when the other female patient in the room, who was behind a curtain, came into the area and told patient #2 to leave the room. S11RN stated that this is patient to patient abuse. S11RN further stated she could not remember if an incident report was filled out. When asked by this surveyor what she did to protect the patients from patient #2, S11RN replied that she was complying with requests of approximately 5 female patients to lock them in their room. S11RN stated she does not remember if she informed anyone else of patients "being so scared (of patient #2) that they were requesting to be locked in their room." S11RN was asked why the police were called and she stated she was afraid patient #2 would hurt the staff. S11RN stated the entire staff was scared of patient #2. S11RN stated she thinks she called either S7RN on-call or S10, staffing, not to request additional staff but to update them of the problems on the unit. S11RN confirmed that patient #2 became calm when the police arrived, but was still placed in the BCR. S11RN stated she never initiated or requested 1:1 or continuous visible observation status for patient #2 for the monitoring of patient and/or the safety of the other patients. S11RN stated she did not report the incident with patient #2 and patient #15 to the Nursing Director per hospital policy.
In an interview on 04/12/11 at 3:30 p.m. with S14LPN she confirmed she worked the day shift on 01/15/11 and 01/16/11. She further stated that on 01/15/11 patient #2 exposed himself to patient #15 by pulling his pants down and then attempting to disrobe patient #15. S14LPN stated that after that all of the patients were scared of him, both male and female, and were requesting to be locked in their rooms or in the dayroom so patient #2 could not get to them. S14LPN stated that staff complied with the request. S14LPN stated that she did notify S7RN on-call and S10, staffing. S14LPN stated that other patients were requesting/required increased medications due to the events on the unit. S14LPN stated the police were called several times. S14LPN stated she was afraid of patient #2 and she did not feel like staff could take him down.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/14/11, 01/15/11, and 01/16/11. S12RN stated he was aware on 01/14/11 of the initial assessment findings documented by S13RN that patient #2 was "walking down the halls checking doors." S12RN stated that he was not informed during his on-coming shift report on the evening of 01/15/11 that patient #2 had exposed himself to patient #15 and was reportedly attempting to disrobe her in her room while having his penis exposed. S12RN stated that male and female patients were still requesting to be locked in their rooms and in the dayroom because they were afraid of patient #2. S12RN was asked by this surveyor what measures were put in place to protect the patients from patient #2. S12RN stated that locking patients in their room and the dayroom while patient #2 was in the hall was the only thing done. S12RN confirmed the documentation for 01/15/11 at 2330 (11:30 p.m.) that patient #2 was "escalating, threatening staff with loud cursing." S12RN stated he contacted S17MD and was given an order for Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. S12RN further confirmed that (PD1) was called to assist. S12RN stated that there was "not enough staff " and that the police were needed to assist with patient #2. S12RN stated that on 01/17/11 the other patients in the hospital were still isolating themselves from patient #2 by requesting to be locked in their rooms so patient #2 "could not get to them." S12RN stated patient #2 was not placed on 1:1 observation or continuous observation at any time during the 3 night shifts he worked (14th, 15th, and 16th). S12RN stated that patient #2 was a danger to patients and staff. S12RN stated he "could not remember if the Director of Nursing or Administration were notified" of the events of the weekend of 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:40 p.m. with S15LPN she confirmed she was the LPN on duty on 01/15/11 and 01/16/11 from 6:00 p.m. - 6:00 a.m. S15LPN stated there was inadequate staffing present. S15LPN stated that the information regarding patient #2 exposing himself to patient #15 and reportedly attempting to disrobe her was not passed on in shift report. S15LPN stated she "could not remember" if anyone was called to get additional staff. She further stated that it is routine hospital procedure to call the police for assistance. S15LPN stated that on the night shift of 01/16/11 the other patients in the hospital "were scared." S15LPN stated she also overheard "phone calls to S10LPN, staffing, to get more staff." S15LPN stated she was informed that the staff were told to "do the best that you can."
In an interview on 04/13/11 at 10:20 a.m. S7RN stated that she was the on-call nurse for the weekend of 01/15/11 and 01/16/11. S7RN stated she received a call and was notified of "patient problems" on the floor, that she was not asked to come in, and that she was not informed that patients were requesting to be locked in their rooms.
In an interview on 04/13/11 at 10:15 a.m. with S10LPN, staffing, she stated she does not recall any request from staff between 01/14/11 - 01/17/11 for additional staff. S10LPN further stated there is no documentation that the staff on duty requested additional staff for 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:05 p.m. with S17MD stated he did not recall if he was advised of the incident between patient #2 and patient #15. S17MD stated that patient #2 "should have been on 1:1 observation." After review of the documentation in the medical record of patient #2 S17MD stated that the events documented in the medical record of patient #2 exposing himself to patient #15 and attempting to disrobe her "are abuse." S17MD stated that staffing was not appropriate and should have been increased.
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated patient #2 was "responding to internal stimuli" upon admission on 01/14/11 and met admission criteria for the hospital. S2DON confirmed the Initial Assessment findings that patient #2 was "walking down the halls checking doors." S2DON stated the documentation for 01/15/11 that patient #2 was exposing himself and attempting to disrobe patient #15 was Abuse according to hospital policy and should have been reported to DHH. S2DON confirmed there was no incident report as required by hospital policy regarding the incident. S2DON stated the incident should have been reported to the police department. S2DON stated the RN should have initiated 1:1 monitoring of patient #2 and notified the physician to obtain the order. S2DON stated Administration and the DON should have been notified of the incident. S2DON stated staffing should have been increased based on the acuity of patient #2. S2DON stated that the failure to complete an incident report and notify management of the 01/15/11 incident between patient #2 and patient #15 was "passive abuse/neglect." S2DON stated that on 01/16/11 the staffing level was inadequate.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both stated they were not aware that staff was locking patients in their rooms and the dayroom on the weekend of 01/15/11 - 01/16/11 per patient request due to fear of patient #2. S2DON and S3ADON stated the staff failed to fill out an incident report on the allegation of sexual abuse of patient #15 by patient #2. S2DON and S3ADON confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital. S2DON and S3ADON both stated they were not aware of the findings of the survey and the events of the weekend of 01/14/11 through 01/17/11 until the survey on 04/11/11 - 04/13/11. Both confirmed there was no investigation of the events of the weekend of 01/14/11 through 01/17/11.
Review of a hospital policy titled "Staffing patterns/Variances/Acuity" , no date effective, reviewed or revised, reads in part: "The program is staffed in a manner to meet the various needs of the patients served. The staffing pattern for the program is based on aspects of care and services provided, patient census, and acuity to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, Administration is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs ...B. High Census/Acuity Staff Adjustments. In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. The primary goal is to maintain a safe, therapeutic environment. The charge nurse on duty will notify Administration on call if the census increases and additional staffing is required."
Review of a hospital policy titled "Reporting Alleged Child/Adult Neglect and/or Abuse" , effective 01/10, no date of review or revision, reads in part: "Policy: In accordance with La. Criminal Code Title XIV, Section 403 , it is the policy of the program to report suspected cases of abuse or neglect of minors or adults to the appropriate authorities. See La. R.S. 14:403. Abuse/Neglect is defined as follows: 1) Abuse...b. Emotional - Threats, ridicule, isolation, intimidation, harassment. c. Sexual - Any unwanted sexual activity, without regard to contact or injury; any sexual activity with a person whose capacity to consent or resist is limited. 2) Neglect. a. Care Giver - Withholding or not assuring provision of basic necessary care, such as...safety...Purpose: To establish guidelines and accountability for reporting allegations of abuse or neglect of a patient, family member or significant other, both minors and adults. Procedure:..2. Observations leading to suspicions of abuse or neglect as well as allegations or reports of abuse or neglect shall be documented in the Progress Notes. 3. Suspicions of abuse or neglect of a minor or adult or allegations made by the patient or a family member will be reported to the Social Worker, attending physician and DON or Administrator immediately, upon discovery by any staff member. 4. If the information is obtained by a staff member other that the social worker, a social worker will meet with the patient to obtain information relative to possible abuse or neglect. If a social worker is not available, the nurse on duty shall obtain this information & advise Program Director immediately. 5. The social worker or Nurse shall notify the Office of Community Services or appropriate law enforcement agency within 24 hours of receiving the data..."
Review of a hospital policy titled "Incident/Occurrence Reporting" , no effective, reviewed or revised date, reads in part: "An incident is an unplanned event or occurrence that interrupts or interferes with the orderly progress or completion of an activity and may or may not include property damage or personal injury. Policy: An important aspect of the safety program is that of incident reporting...Employees will report all incidents, whether it be a patient, visitor, or employee...Complete an "Occurrence Report" for any patient or visitor incident."
Review of a hospital policy titled "Alleged Patient Abuse on the Unit" , no effective, reviewed, or revised date, reads in part: "Purpose: To provide guidelines for procedures to be carried out whenever it is alleged that patient abuse has occurred on the unit. Policy: The staff is responsible for investigating and reporting any alleged incident of patient abuse in a manner that will protect the rights and dignity of the alleged victim. Definition of Terms: A) "Abuse" is defined as the infliction of physical or mental injury to other parties, including but not limited to such means as sexual abuse, physical attack...to such an extent that his health, morals or emotional well being is endangered. B) A detailed explanation from the alleged victim will be documented/recorded...C) Administration will take the following actions: If physical or sexual abuse is alleged: 1) He/She will notify the police..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record review and interview the hospital 1) failed to ensure that seclusion is only used to ensure the immediate physical safety of the patient, staff, or others as evidenced by the patient becoming compliant and walking calmly to the seclusion room when the staffing level was supplemented by the police department for 1 of 1 focused sampled patients with seclusion ordered in a total sample of 15 (#2) and 2) failed to ensure seclusion was discontinued at the earliest possible time as evidenced by staff obtaining a renewal order for seclusion of a patient documented to be asleep for 1 of 1 focused sampled patients with seclusion ordered in a total sample of 15. (#2) Findings:

1)

01/15/11 Seclusion Order #1
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
Review of the Physician' s Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours) ...Clinical Justification: safety of others. Describe Specific Behavior: loud, threatening to "f*** us all up" , cursing loudly, exposed self to female pt., attempted to disrobe female pt., wandering... Discontinue seclusion/restraints when these behaviors are noted: Patient verbalizing self control, Patient demonstrates controlled behavior, Patient no longer is a threat to themselves/others."
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a" , pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
01/15/11 Seclusion Order #2
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician' s Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, escorted to BCR - Haldol 10 mg, Ativan 2mg, Benadryl 50mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours) ...Chemical Adjunctive Support Ordered: No. Clinical Justification: danger to others. Describe Specific Behavior: threatening violence towards staff and peers, loud cursing, throwing objects, hitting windows of nsg (nursing) station...Discontinue seclusion/restraints when these behaviors are noted: Patient no longer is a threat to themselves/others." The flowsheet is signed by S11RN on 01/15/11 at 1500 (3:00 p.m.) S17MD signed the order on 02/4/11 at 1:00 p.m., 10 days after the implementation of seclusion of patient #2.
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
Review of a document titled "Doctor's Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake." The Order is signed by S12RN on 01/15/11 at 1915 (7:15 p.m.). The physician signed the order on 01/17/11 at 12:00 noon, 49 hours after patient #2 was ordered by the physician to remain in seclusion.
S12RN documented on 01/15/11 at 2030 (8:30 p.m.) the following: "(patient #2) is awake and alert. He is calm at this time, allowed out of seclusion ..."
Review of S12RN' s documentation for 01/15/11 at 2200 (10:00 p.m.) read as follows: "Occasional outburst of cursing and threatening staff. When told we would call police if necessary (patient #2) calms down and apologizes."
01/16/11 Seclusion Order #3
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
Review of the Physician's Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of a Doctor ' s Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours) ...Chemical Adjunctive Support Ordered: Yes. Clinical Justification: safety of others. Describe Specific Behavior: cursing loudly and threatening violence toward staff and peers... Discontinue seclusion/restraints when these behaviors are noted: Patient verbalizing self control. Patient no longer is a threat to themselves/others." The flowsheet is signed by S11RN on 01/16/11 at 1230 (12:30 p.m.) S17MD signed the order on 01/17/11 at 11:50 a.m., 48 hours and 50 minutes after the implementation of seclusion of patient #2.
Review of the documentation for 1630 (4:30 p.m.) on 01/16/11 by S11RN read: "Pt awake ...Pt displays calm behavior. Allowed out of BCR ..."
Review of the Physician's Order Sheet for patient #2 dated 01/16/11 at 1630 (4:30 p.m.) revealed a verbal order taken by S11RN from S17MD that read: "OK to D/C (discontinue) Seclusion order."
Review of the staffing for 01/14/11 night shift from 6:30 p.m. when patient #2 was admitted through 01/17/11 at discharge at 12:15 p.m. when patient #2 was discharged revealed the following nursing staff were present:
RN/LPN/MHT
01/15/11- Day Shift - 1 female RN, 1 female LPN, 1 female MHT
S11RN worked 6:00 a.m. - 6:00 p.m. on 01/15/11
S14LPN worked 6:00 a.m. - 6:00 p.m. on 01/15/11
01/15/11 1 MHT on day shift

01/15/11 - Night Shift - 1 male RN, 1 female LPN, 1 female MHT
S12 RN worked 6:00 p.m. - 6:00 a.m. on 01/15/11
S15LPN worked 6:00 p.m. - 6:00 a.m. on 01/15/11
01/15/11 1 MHT on night shift.

01/16/11 - Day Shift - 1 female RN, 1 female LPN, 1 female MHT
S11RN worked 6:00 a.m. - 6:00 p.m. on 01/16/11
S14LPN worked 6:00 a.m. - 6:00 p.m. on 01/16/11
1 MHT on duty for day shift on 01/16/11

01/16/11 - Night Shift - 1 male RN, 1 female LPN, 1 female MHT
S12 RN worked 6:00 p.m. - 6:00 a.m. on 01/16/11
S15LPN worked 6:00 p.m. - 6:00 a.m. on 01/16/11
1 MHT on duty for night shift on 01/16/11
2)
01/15/11 Seclusion Order #2 Renewal
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
Review of a document titled "Doctor's Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake." The Order is signed by S12RN on 01/15/11 at 1915 (7:15 p.m.). The physician signed the order on 01/17/11 at 12:00 noon, 49 hours after patient #2 was ordered by the physician to remain in seclusion.
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN further confirmed that there was 1 RN, 1 LPN, and 1 MHT, all female, on duty for the Saturday (15th) and Sunday (16th) shifts. S11RN was asked why the police were called and she stated she was afraid patient #2 would hurt the staff. S11RN stated the entire staff was scared of patient #2. S11RN stated she thinks she called either S7RN on-call or S10, staffing, not to request additional staff but to update them of the problems on the unit. S11RN confirmed that patient #2 became calm when the police arrived, but was still placed in the BCR. S11RN confirmed there was no documented evidenced of a face to face evaluation within 1 hour of initiation of seclusion by an MD or RN deemed competent per hospital policy to perform the evaluation for any of the 3 seclusion initiations. S11RN stated she never initiated or requested 1:1 or continuous visible observation status for patient #2 for the monitoring of patient and/or the safety of the other patients.S11RN stated she never entered the seclusion room to check on patient #2 unless he was asleep because she was scared. S11RN stated that constant visual observation of patient #2 was not in place per hospital policy on any occasion when patient #2 was in seclusion 3 times during the two shifts she worked, 01/15/11 and 01/16/11. S11RN confirmed there was no documentation of less restrictive methods being attempted except on the seclusion flow sheet when seclusion was ordered. S11RN stated that on 01/16/11 patient #2 also threatened visitors. S11RN stated she did not report the incident with patient #2 and patient #15 to the Nursing Director per hospital policy. S11RN stated that every time the police entered the hospital they were carrying their police issued weapons.
In an interview on 04/12/11 at 3:30 p.m. with S14LPN she confirmed she worked the day shift on 01/15/11 and 01/16/11. S14LPN stated that she did notify S7RN on-call and S10, staffing. S14LPN stated that other patients were requesting/required increased medications due to the events on the unit. S14LPN stated the police were called several times. S14LPN stated she was afraid of patient #2 and she did not feel like staff could take him down.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/14/11, 01/15/11, and 01/16/11. S12RN stated he was aware on 01/14/11 of the initial assessment findings documented by S13RN that patient #2 was "walking down the halls checking doors." S12RN confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained. S12RN stated there was no face to face evaluation of patient by the MD or LIP deemed competent to perform the evaluation within 1 hour of the seclusion renewal order. S12RN confirmed his documentation dated 01/15/11 at 2200 (10:00 p.m.) that read as follows: "Occasional outbursts of cursing and threatening staff. When told we would call the police if necessary (patient #2) calms down and apologizes." S12RN confirmed the documentation for 01/15/11 at 2330 (11:30 p.m.) that patient #2 was "escalating, threatening staff with loud cursing." S12RN stated he contacted S17MD and was given an order for Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. S12RN further confirmed that (PD1) was called to assist. S12RN stated that there was "not enough staff" and that the police were needed to assist with patient #2. S12RN stated patient #2 was not placed on 1:1 observation or continuous observation while in seclusion or at any other time during the 3 night shifts he worked (14th, 15th, and 16th). S12RN stated that patient #2 was a danger to patients and staff. S12RN stated he "could not remember if the Director of Nursing or Administration were notified" of the events of the weekend of 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:40 p.m. with S15LPN she confirmed she was the LPN on duty on 01/15/11 and 01/16/11 from 6:00 p.m. - 6:00 a.m. S15LPN stated that PD1 was called on 01/15/11 at 2330 (11:30 p.m.) because "(patient #2) was not going to allow staff to give the shot." S15LPN stated there was inadequate staffing present. S15LPN stated that she "could not remember" if anyone was called to get additional staff. She further stated that it is routine hospital procedure to call the police for assistance. S15LPN stated she did hear S12RN tell patient #2 "we will call the police if necessary." S15LPN stated she also overheard "phone calls to S10LPN, staffing, to get more staff." S15LPN stated she was informed that the staff were told to "do the best that you can."
In an interview on 04/13/11 at 10:15 a.m. with S10LPN, staffing, she stated she does not recall any request from staff between 01/14/11 - 01/17/11 for additional staff. S10LPN further stated there is no documentation that the staff on duty requested additional staff for 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done." S17MD stated that patient #2 "should have been on 1:1 observation." S17MD stated that staffing was not appropriate and should have been increased. S17MD reviewed the documentation of 01/15/11 at 1915 (7:15 p.m.) by S12RN. The documentation reads: "(S17MD) contacted, he reordered the seclusion order until pt awakens to reassess for violent behavior." S17MD stated that a patient should not be ordered seclusion "until he awakens to assess."
S17MD reviewed the Psychiatric Evaluation dated 01/17/11 at 12:00 noon. S17MD confirmed his documentation that "Formulation: Pt's problems are behavioral. He is not suited for inpatient care. He will be referred for outpatient care." S17MD stated he assessed patient #2 on 01/17/11 and that patient #2 was cooperative and he felt that if patient #2 "was out of the facility all behavior would stop." S17MD reviewed the Discharge Summary on the medical record of patient #2 and confirmed it was dictated by S7RN. The Discharge Summary was blank on the signature line for the person who dictated the information, S7RN, and also on the line for the Psychiatrist, S17MD to sign. S17MD stated that patient #2 was not benefiting from inpatient care and "his behavior would continue if he stayed here." S17MD was asked about the content of the Discharge Summary as it had multiple statements that patient #2 was experiencing "increased agitation related to psychosis" during his stay and prior to the multiple injections of Haldol/Ativan/Benadryl and orders to "place pt. in BCR". S17MD confirmed that the Discharge Summary was not signed by him and he would not sign it as written. S17MD further stated that he "probably would not have discharged patient #2 if he were aware of the documentation by S7RN dated 01/17/11 at 7:30 a.m. of patient #2 accusing a spot of kool-aid on the floor of stealing his breakfast." S17MD then stated that patient #2 was discharged to the street due to his behaviors and aggression. S17MD again stated he believed the patients behaviors were not due to psychosis but were a "behavioral" problem." On 04/12/11 at 1:30 p.m. the medical record of patient #2 was reviewed. The Discharge Summary, without changes, indicating patient #2 was experiencing "agitation related to psychosis" was signed by S17MD dated 04/12/11 at 1:00 p.m.
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated patient #2 was "responding to internal stimuli" upon admission on 01/14/11 and met admission criteria for the hospital. S2DON confirmed the Initial Assessment findings that patient #2 was "walking down the halls checking doors." S2DON stated the RN should have initiated 1:1 monitoring of patient #2 and notified the physician to obtain the order. S2DON stated staffing should have been increased based on the acuity of patient #2. S2DON confirmed there was no documentation of least restrictive methods being attempted prior to the documentation on the seclusion flow sheet and implementation of seclusion. S2DON confirmed there was no documentation of 1:1 continuous visual observation of patient #2 while he was in seclusion. S2DON confirmed that hospital policy requires either the psychiatrist or RN deemed competent to perform a face to face interview within 1 hour of initiation of seclusion. S2DON confirmed this evaluation was not done for the 01/15/11 at 11:00 a.m. seclusion, the 01/15/11 at 3:00 p.m. seclusion, the 01/15/11 1915 (7:15 p.m.) renewal order, or the 01/16/11 at 12:30 p.m. seclusion order. S2DON reviewed the documentation for 01/15/11 seclusion renewal order and stated "there is no documented reason to keep a sleeping patient in seclusion" and that this was done for "nursing convenience." S2DON stated the 01/15/11 at 2200 (10:00 p.m.) statement by S12RN that "we will call the police if necessary" is a threat. S2DON stated that on 01/16/11 the staffing level was inadequate. S2DON confirmed there was no documented evidence patient #2 was on 1:1/continuous observation while in seclusion on 01/16/11. S2DON confirmed there was no face to face evaluation done at any time for the seclusion of patient #2 on 01/16/11. S2DON confirmed the Discharge Summary was not signed by S17MD. S2DON confirmed that patient #2 was discharged to the street as the Salvation Army is only open at night. S2DON stated the discharge was "probably not appropriate." S2DON stated that patient #2 was "probably not ready" for discharge.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no face to face assessment of patient #2 done at any time after initiation of seclusion for the entire hospitalization of patient #2. S2DON and S3ADON confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital. S2DON and S3ADON verified there was no physician countersignature on the seclusion order sheets within 24 hours of initiation as required by hospital policy. S2DON and S3ADON both stated they were not aware of the findings of the survey and the events of the weekend of 01/14/11 through 01/17/11 until the survey on 04/11/11 - 04/13/11. Both confirmed there was no investigation of the events of the weekend of 01/14/11 through 01/17/11.
Review of a hospital policy titled "Staffing patterns/Variances/Acuity" , no date effective, reviewed or revised, reads in part: "The program is staffed in a manner to meet the various needs of the patients served. The staffing pattern for the program is based on aspects of care and services provided, patient census, and acuity to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, Administration is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs ...B. High Census/Acuity Staff Adjustments. In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. The primary goal is to maintain a safe, therapeutic environment. The charge nurse on duty will notify Administration on call if the census increases and additional staffing is required."
Review of a hospital policy titled "Use of Assistance from Law Enforcement Officials/Uniform Weapons" , effective July 2010, no date reviewed or revised, reads: "Purpose: The purpose of this policy is to provide guidance to clinical staff in situations where Law Enforcement Officials enter the psychiatric unit. It is the policy if this hospital to maintain a weapon free environment. A request will be made of all Law Enforcement Officials to leave all uniform weapons outside of the unit. Policy: 1. Upon arrival at the facility, law enforcement officials will be advised of the hospital' s no weapons policy. The Law Enforcement official may choose to leave his/her weapon with staff...3) Law Enforcement Official electing to exercise the right to retain his/her weapon...is acknowledging that he/she understands that this hospital maintains a weapons free environment...in order to assist the staff in keeping a patient from causing harm to him/herself or others...5. Staff will document in nurse's notes the events of assistance given by Law Enforcement Officials along with patient' s tolerance of assistance."
Review of a hospital policy titled "Policy for the use of Restraints/Seclusion" revealed "Our pledge to our patients and their families or significant others is that restraints will only be used as a last resort when alternatives fail, and the use of restraints will be discontinued as soon as safely possible. Purpose: Although it is our goal to provide a restraint free environment there are times when preventative and alternative strategies do not work and the use of restraints becomes clinically justified to prevent a patient from serious injury to themselves or others. When restraints are required, the least restrictive measure will be used. During the use of restraints the frequency of patient monitoring is increased...The use of restraints will be discontinued at the earliest possible time. Restraints will NEVER be used for staff convenience. Policy: It is the practice of the hospital to use restraint/seclusion in clinically appropriate and adequately justified situations. Patients have the right to be free from restraint/seclusion. Whenever possible, restraints/seclusion will be avoided and will only be used when alternative measures have been unsuccessful in maintaining the safety of the patients and/or others...The least restrictive measure of restraints/seclusion that meets the patient's needs will be utilized. Excluded devices: The following are excluded from the restraint policy:..4. Handcuffs or other restrictive devices applied by law enforcement officials. Definitions:..2. Chemical Restraint. A medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment of the patient's medical or psychiatric condition...Medications used as chemical restraints are medications used in addition to or in replacement of the patient's regular medication regime to control extreme behavior during an emergency. Least restrictive interventions must be documented prior to chemical restraint...4. Seclusion: Involuntarily confining an individual alone to a room or an area where he or she is physically prevented from leaving...6. Behavioral emergency: A situation where the patient's behavior is violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff or others..."
Review of the "Behavioral Restraint/Seclusion Procedure Flow Sheet" revealed the following: "Procedure: Initial Assessment: Responsibility - RN. 1. Assess and evaluate the effectiveness of CPI (Crisis Prevention Intervention) strategies utilized. 2. Attempt alternative methods listed above and in Alternatives to Restraints example...4. Evaluate the intervention that is the least restrictive and is most beneficial to the patient...Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...4. The physician or specially trained RN must see the patient face to face and evaluate the need for restraint or seclusion within 1 hour after the initiation...(The RN performing the face to face evaluation may NOT be the RN initiating the intervention.)...6. Responsibility: RN. The order must be in accordance to a written modification to the patient's plan of care. Ongoing Assessment of the need for continuation: Responsibility: RN/MD. 1 ...Additionally, if the order is discontinued and reordered, the initial sequence begins with face to face in 1 hour. 2. If restraint or seclusion is discontinued prior to expiration of the original order, a new order must be obtained prior to reinitiating or reapplying the restraints or seclusion...Documentation requirements: Responsibility: RN/MHT/LPN. 7. Level of Observation 1:1..."
Review of a hospital policy titled "Psychiatric Emergency - Code 13" , no effective, reviewed or revised date, reads in part: "Purpose: To prevent injury to patient and others in the event of behavioral escalation. Policy: It is the function of hospital personnel in the event of a psychiatric emergency, to maintain safety and order in a therapeutic environment. Procedure: 1. Access paging system to announce: Code 13. 2. Staff attempts verbal de-escalation. 3. Team Approach (Use of Non Violent Crisis Prevention Interventions): Team Leader Duties: RN Charge Nurse. 1. Assess the situation. 2. Plan the intervention. 3. Cuing & Directing the staff. 4. Communicate with the acting out person. Auxiliary Team Member Duties - All other staff present. 1. Check the safety of the environment. 2. Address that the control dynamics are being done correctly. 3. Recognize if additional assistance is needed. 4. Engage in verbal de-escalation only if requested by the team leader. 4. Use Control Dynamics of CPI to gain physiological and psychological advantage. 5. Use Non Violent Physical Crisis Intervention. May notify 911 for backup assistance if needed. 6. Follow policy and procedures for restraint and seclusion per physician orders if warranted."

Based on record review and interview the hospital failed to ensure medications ordered and administered to a patient had an overall effect of improving the patients ability to effectively and/or appropriately interact with staff and peers and the treatment program as evidenced by administering Haldol/Ativan/Benadryl in a combination injection rendering the patient incapable of functioning in the treatment program for 1 of 1 focused sampled patients with seclusion orders in a total sample of 15 (#2) Findings:

Administration #1
Review of the Physician' s Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, escorted to BCR - Haldol 10 mg, Ativan 2mg, Benadryl 50mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
Review of the Medication Administration Record (MAR) for patient #2 revealed he was administered Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM at 1515 (3:15 p.m.).
Review of the "Behavioral Restraint/Seclusion Flow Sheet" record revealed S11RN documented patient #2 was asleep at 1600 (4:00 p.m.), 1615 (4:15 p.m.), and 1645 (4:45 p.m.) through 1745 (5:45 p.m.). S12RN documented that patient #2 was asleep from 1800(6:00 p.m. through 2015 (8:15 p.m.).
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
S12RN documented on 01/15/11 at 2030 (8:30 p.m.) the following: "(patient #2) is awake and alert. He is calm at this time, allowed out of seclusion ..."
Review of S12RN's documentation for 01/15/11 at 2200 (10:00 p.m.) read as follows: "Occasional outburst of cursing and threatening staff. When told we would call police if necessary (patient #2) calms down and apologizes."
Administration #2
Documentation by S12RN for 2330 (11:30 p.m.) on 01/15/11 revealed: "Dr. (S17MD) notified of patient escalating, threatening staff with loud cursing. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. (PD1) call to assist. (3rd call) Injections given with pt cursing and threatening but willingly took the injections."
Review of the Physician's Orders sheet revealed an order dated 01/15/11 at 2330 (11:30 p.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the MAR revealed documentation that patient #2 was administered Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg IM at 2330 (11:30 p.m.).
Review of the medical record revealed there was no Behavioral Restraint/Seclusion flow sheet for this administration of chemical restraint.
01/16/11
Administration #3
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests ...argues with image in windows and strikes self in window, + (positive) hallucinations ..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
Review of the Physician's Orders sheet revealed an order dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of the Physician's Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
Review of the Behavioral Restraint/Seclusion Flow sheet revealed S11RN documented patient #2 was asleep in the BCR from 1300 (1:00 p.m.) through 1615 (4:15 p.m.).
Review of the Physician's Order Sheet for patient #2 dated 01/16/11 at 1630 (4:30 p.m.) revealed a verbal order taken by S11RN from S17MD that read: "OK to D/C (discontinue) Seclusion order."
01/17/11
Administration #4
Review of the nursing documentation by S12RN on 01/17/11 at 0120 (1:20 a.m.) read: "(S17MD) called for pt yelling, cursing, threatening staff, threw shampoo bottle at nsg station. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM X 1 dose now. (PD1) called to assist. (5th call). Pt took injections willingly ..."
Review of the Physician' s Orders sheet revealed an order dated 01/17/11 at 0120 (1:20 a.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the nursing documentation by S12RN for 0230 (2:30 a.m.) on 01/17/11 revealed patient #2 was asleep. Review of the nursing documentation for 0400 (4:00 a.m.) on 01/17/11 revealed patient #2 was "resting quietly in bed."
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN further confirmed that there was 1 RN, 1 LPN, and 1 MHT, all female, on duty for the Saturday (15th) and Sunday (16th) shifts. S11RN was asked why the police were called and she stated she was afraid patient #2 would hurt the staff. S11RN stated the entire staff was scared of patient #2. S11RN stated she thinks she called either S7RN on-call or S10, staffing, not to request additional staff but to update them of the problems on the unit. S11RN confirmed that patient #2 became calm when the police arrived, but was still placed in the BCR. S11RN stated she never entered the seclusion room to check on patient #2 unless he was asleep because she was scared.
In an interview on 04/12/11 at 3:30 p.m. with S14LPN she confirmed she worked the day shift on 01/15/11 and 01/16/11. S14LPN stated that she did notify S7RN on-call and S10, staffing. S14LPN stated the police were called several times. S14LPN stated she was afraid of patient #2 and she did not feel like staff could take him down.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/14/11, 01/15/11, and 01/16/11. S12RN confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained. S12RN confirmed his documentation dated 01/15/11 at 2200 (10:00 p.m.) that read as follows: "Occasional outbursts of cursing and threatening staff. When told we would call the police if necessary (patient #2) calms down and apologizes." S12RN confirmed the documentation for 01/15/11 at 2330 (11:30 p.m.) that patient #2 was "escalating, threatening staff with loud cursing." S12RN stated he contacted S17MD and was given an order for Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. S12RN further confirmed that (PD1) was called to assist. S12RN stated that there was "not enough staff" and that the police were needed to assist with patient #2.
In an interview on 04/12/11 at 1:40 p.m. with S15LPN she confirmed she was the LPN on duty on 01/15/11 and 01/16/11 from 6:00 p.m. - 6:00 a.m. S15LPN stated that PD1 was called on 01/15/11 at 2330 (11:30 p.m.) because "(patient #2) was not going to allow staff to give the shot." S15LPN stated there was inadequate staffing present. She further stated that it is routine hospital procedure to call the police for assistance. S15LPN stated she did hear S12RN tell patient #2 "we will call the police if necessary." S15LPN stated she also overheard "phone calls to S10LPN, staffing, to get more staff." S15LPN stated she was informed that the staff were told to "do the best that you can."
S7RN was interviewed on 04/13/11 at 10:20 a.m. S7RN stated that she was the on-call nurse for the weekend of 01/15/11 and 01/16/11. S7RN stated she received a call and was notified of "patient problems" on the floor,and that she was not asked to come in.
In an interview on 04/13/11 at 10:15 a.m. with S10LPN, staffing, she stated she does not recall any request from staff between 01/14/11 - 01/17/11 for additional staff. S10LPN further stated there is no documentation that the staff on duty requested additional staff for 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done." S17MD stated that patient #2 "should have been on 1:1 observation." S17MD stated that staffing was not appropriate and should have been increased.
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated staffing should have been increased based on the acuity of patient #2. S2DON stated that on 01/16/11 the staffing level was inadequate.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital.
Review of a hospital policy titled "Staffing patterns/Variances/Acuity " , no date effective, reviewed or revised, reads in part: "The program is staffed in a manner to meet the various needs of the patients served. The staffing pattern for the program is based on aspects of care and services provided, patient census, and acuity to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, Administration is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs...B. High Census/Acuity Staff Adjustments. In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. The primary goal is to maintain a safe, therapeutic environment. The charge nurse on duty will notify Administration on call if the census increases and additional staffing is required."
Review of a hospital policy titled "Policy for the use of Restraints/Seclusion." read in part: "...Restraints will NEVER be used for staff convenience. Policy: It is the practice of the hospital to use restraint/seclusion in clinically appropriate and adequately justified situations. Patients have the right to be free from restraint/seclusion. Whenever possible, restraints/seclusion will be avoided and will only be used when alternative measures have been unsuccessful in maintaining the safety of the patients and/or others...The least restrictive measure of restraints/seclusion that meets the patient's needs will be utilized. Excluded devices: The following are excluded from the restraint policy:..4. Handcuffs or other restrictive devices applied by law enforcement officials. Definitions:..2. Chemical Restraint. A medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment of the patient's medical or psychiatric condition...Medications used as chemical restraints are medications used in addition to or in replacement of the patient's regular medication regime to control extreme behavior during an emergency. Least restrictive interventions must be documented prior to chemical restraint...4. Seclusion: Involuntarily confining an individual alone to a room or an area where he or she is physically prevented from leaving...6. Behavioral emergency: A situation where the patient's behavior is violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff or others..."
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "Procedure: Initial Assessment: Responsibility - RN. 1. Assess and evaluate the effectiveness of CPI (Crisis Prevention Intervention) strategies utilized. 2. Attempt alternative methods listed above and in Alternatives to Restraints example...4. Evaluate the intervention that is the least restrictive and is most beneficial to the patient...Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...Documentation requirements: Responsibility: RN/MHT/LPN. 7. Level of Observation 1:1 ..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record review and interview the hospital failed to ensure seclusion was only used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm as evidenced by the patient becoming compliant when police officers (PD1), arrived at the hospital. The hospital was staffed by three people (one RN, one LPN and one MHT) who were afraid of the patient and failed to take control of the situation for 1 of 1 focused sampled patients in a total sample of 15 (#2) Findings:

01/15/11 PD1 call #1
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a" , pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
PD1 call #2
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, escorted to BCR - Haldol 10 mg, Ativan 2mg, Benadryl 50mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
Review of the Medication Administration Record (MAR) for patient #2 revealed he was administered Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM at 1515 (3:15 p.m.).
PD1 call #3
Documentation by S12RN for 2330 (11:30 p.m.) on 01/15/11 revealed: "Dr. (S17MD) notified of patient escalating, threatening staff with loud cursing. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. (PD1) call to assist. (3rd call) Injections given with pt cursing and threatening but willingly took the injections."
Review of the Physician's Orders sheet revealed an order dated 01/15/11 at 2330 (11:30 p.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the MAR revealed documentation that patient #2 was administered Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg IM at 2330 (11:30 p.m.).
01/16/11
PD1 call #4
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
Review of the Physician's Orders sheet revealed an order dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of the Physician's Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
01/17/11
PD1 call #5
Review of the nursing documentation by S12RN on 01/17/11 at 0120 (1:20 a.m.) read: "(S17MD) called for pt yelling, cursing, threatening staff, threw shampoo bottle at nsg station. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM X 1 dose now. (PD1) called to assist. (5th call). Pt took injections willingly..."
Review of the Physician ' s Orders sheet revealed an order dated 01/17/11 at 0120 (1:20 a.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the nursing documentation by S12RN for 0230 (2:30 a.m.) on 01/17/11 revealed patient #2 was asleep. Review of the nursing documentation for 0400 (4:00 a.m.) on 01/17/11 revealed patient #2 was "resting quietly in bed."
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN further confirmed that there was 1 RN, 1 LPN, and 1 MHT, all female, on duty for the Saturday (15th) and Sunday (16th) shifts. S11RN was asked why the police were called and she stated she was afraid patient #2 would hurt the staff. S11RN stated the entire staff was scared of patient #2. S11RN stated she thinks she called either S7RN on-call or S10, staffing, not to request additional staff but to update them of the problems on the unit. S11RN confirmed that patient #2 became calm when the police arrived, but was still placed in the BCR. S11RN stated she never entered the seclusion room to check on patient #2 unless he was asleep because she was scared.
In an interview on 04/12/11 at 3:30 p.m. with S14LPN she confirmed she worked the day shift on 01/15/11 and 01/16/11. S14LPN stated that she did notify S7RN on-call and S10, staffing. S14LPN stated the police were called several times. S14LPN stated she was afraid of patient #2 and she did not feel like staff could take him down.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/14/11, 01/15/11, and 01/16/11. S12RN confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained. S12RN confirmed his documentation dated 01/15/11 at 2200 (10:00 p.m.) that read as follows: "Occasional outbursts of cursing and threatening staff. When told we would call the police if necessary (patient #2) calms down and apologizes." S12RN confirmed the documentation for 01/15/11 at 2330 (11:30 p.m.) that patient #2 was "escalating, threatening staff with loud cursing." S12RN stated he contacted S17MD and was given an order for Haldol 10mg, Ativan 2mg, Benadryl 50mg IM stat X 1 dose. S12RN further confirmed that (PD1) was called to assist. S12RN stated that there was "not enough staff" and that the police were needed to assist with patient #2.
In an interview on 04/12/11 at 1:40 p.m. with S15LPN she confirmed she was the LPN on duty on 01/15/11 and 01/16/11 from 6:00 p.m. - 6:00 a.m. S15LPN stated that PD1 was called on 01/15/11 at 2330 (11:30 p.m.) because "(patient #2) was not going to allow staff to give the shot." S15LPN stated there was inadequate staffing present. She further stated that it is routine hospital procedure to call the police for assistance. S15LPN stated she did hear S12RN tell patient #2 "we will call the police if necessary." S15LPN stated she also overheard "phone calls to S10LPN, staffing, to get more staff." S15LPN stated she was informed that the staff were told to "do the best that you can."
S7RN was interviewed on 04/13/11 at 10:20 a.m. S7RN stated that she was the on-call nurse for the weekend of 01/15/11 and 01/16/11. S7RN stated she received a call and was notified of "patient problems" on the floor and that she was not asked to come in.
In an interview on 04/13/11 at 10:15 a.m. with S10LPN, staffing, she stated she does not recall any request from staff between 01/14/11 - 01/17/11 for additional staff. S10LPN further stated there is no documentation that the staff on duty requested additional staff for 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done." S17MD stated that patient #2 "should have been on 1:1 observation." S17MD stated that staffing was not appropriate and should have been increased.
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated staffing should have been increased based on the acuity of patient #2. S2DON stated that on 01/16/11 the staffing level was inadequate.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital.
Review of a hospital policy titled "Staffing patterns/Variances/Acuity " , no date effective, reviewed or revised, reads in part: "The program is staffed in a manner to meet the various needs of the patients served. The staffing pattern for the program is based on aspects of care and services provided, patient census, and acuity to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, Administration is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs...B. High Census/Acuity Staff Adjustments. In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. The primary goal is to maintain a safe, therapeutic environment. The charge nurse on duty will notify Administration on call if the census increases and additional staffing is required."
Review of a hospital policy titled "Policy for the use of Restraints/Seclusion."read in part: "...Restraints will NEVER be used for staff convenience. Policy: It is the practice of the hospital to use restraint/seclusion in clinically appropriate and adequately justified situations. Patients have the right to be free from restraint/seclusion. Whenever possible, restraints/seclusion will be avoided and will only be used when alternative measures have been unsuccessful in maintaining the safety of the patients and/or others...The least restrictive measure of restraints/seclusion that meets the patient ' s needs will be utilized. Excluded devices: The following are excluded from the restraint policy:..4. Handcuffs or other restrictive devices applied by law enforcement officials. Definitions:..2. Chemical Restraint. A medication used to control behavior or to restrict the patient ' s freedom of movement and is not a standard treatment of the patient's medical or psychiatric condition...Medications used as chemical restraints are medications used in addition to or in replacement of the patient's regular medication regime to control extreme behavior during an emergency. Least restrictive interventions must be documented prior to chemical restraint...4. Seclusion: Involuntarily confining an individual alone to a room or an area where he or she is physically prevented from leaving...6. Behavioral emergency: A situation where the patient's behavior is violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff or others..."
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "Procedure: Initial Assessment: Responsibility - RN. 1. Assess and evaluate the effectiveness of CPI (Crisis Prevention Intervention) strategies utilized. 2. Attempt alternative methods listed above and in Alternatives to Restraints example..4. Evaluate the intervention that is the least restrictive and is most beneficial to the patient...Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...Documentation requirements: Responsibility: RN/MHT/LPN. 7. Level of Observation 1:1..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record review and interview the hospital failed to modify the treatment plan when seclusion was ordered for 1 of 1 focused sampled patients with seclusion orders in a total sample of 15 (#2) Findings:

Review of the treatment plan in the medical record of patient #2 revealed there was no documentation regarding the 3 seclusion periods ordered by the physician responsible for the care of the patient.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no modification of the care plan of patient #2 regarding the seclusion of patient #2.
Review of a hospital policy titled "Policy for the use of Restraints/Seclusion" revealed in part: "...6. Responsibility: RN. The order must be in accordance to a written modification to the patient's plan of care..."

Based on record review and interview the hospital failed to ensure that orders for seclusion used for safety of the staff and patients were only in effect for up to 4 hours for an adult patient as evidenced by the physician ordering a patient into seclusion and staff failed to obtain a new order or release the patient for 4 hours and 15 minutes for 1 of 1 focused sampled patients with seclusion orders in a total sample of 15 (#2) Findings:


Review of the Physician' s Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, escorted to BCR - Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours) ..."
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
S12RN documented on 01/15/11 at 2030 (8:30 p.m.) the following: "(patient #2) is awake and alert. He is calm at this time, allowed out of seclusion ..."
Review of a document titled "Doctors Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake..."
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/15/11. S12RN confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained.
In an interview on 04/12/11 at 1:05 p.m. with S17MD reviewed the documentation of 01/15/11 at 1915 (7:15 p.m.) by S12RN. The documentation reads: "(S17MD) contacted, he reordered the seclusion order until pt awakens to reassess for violent behavior." S17MD stated that a patient should not be ordered seclusion "until he awakens to assess."
In an interview on 04/12/11 at 11:00 a.m. with S2DON she reviewed the documentation for 01/15/11 seclusion renewal order and stated "there is no documented reason to keep a sleeping patient in seclusion" and that this was done for "nursing convenience."
Review of a hospital policy titled "Policy for the use of Restraints/Seclusion" revealed in part: "...The use of restraints will be discontinued at the earliest possible time. Restraints will NEVER be used for staff convenience. Policy: It is the practice of the hospital to use restraint/seclusion in clinically appropriate and adequately justified situations. Patients have the right to be free from restraint/seclusion. Whenever possible, restraints/seclusion will be avoided and will only be used when alternative measures have been unsuccessful in maintaining the safety of the patients and/or others..."
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "Procedure:..Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...2. If restraint or seclusion is discontinued prior to expiration of the original order, a new order must be obtained prior to reinitiating or reapplying the restraints or seclusion ..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment..."

Based on record review the hospital failed to ensure the patient in seclusion was monitored continuously per hospital policy for 3 of 3 seclusion periods and one renewal order for seclusion as evidenced by no documented evidence of continuous visual observation and statements by staff that the patient was not continuously monitored for 1 of 1 focused sampled patients with seclusion orders in a total sample of 15 (#2) Findings:

01/15/11
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt' s rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up" Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a" , pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours) ...Other interventions while in seclusion/restraints: Assign staff member to provide continuous patient observation while intervention in effect..."
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, escorted to BCR - Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours) ...Other interventions while in seclusion/restraints: Assign staff member to provide continuous patient observation while intervention in effect..."
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
Review of a document titled "Doctor's Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake." The Order is signed by S12RN on 01/15/11 at 1915 (7:15 p.m.).
01/16/11
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of the Physician' s Orders sheet revealed an order dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the Physician' s Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)"...The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints " is not checked. "Other interventions while in seclusion/restraints: Assign staff member to provide continuous patient observation while intervention in effect..."
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN confirmed there was no documented evidence of a face to face evaluation within 1 hour of initiation of seclusion by an MD or RN deemed competent per hospital policy to perform the evaluation for any of the 3 seclusion initiations. S11RN stated she never initiated or requested 1:1 or continuous visible observation status for patient #2 for the monitoring of patient and/or the safety of the other patients. S11RN stated she never entered the seclusion room to check on patient #2 unless he was asleep because she was scared. S11RN stated that constant visual observation of patient #2 was not in place per hospital policy on any occasion when patient #2 was in seclusion 3 times during the two shifts she worked, 01/15/11 and 01/16/11.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained. S12RN stated there was no face to face evaluation of patient by the MD or LIP deemed competent to perform the evaluation within 1 hour of the seclusion renewal order. S12RN stated patient #2 was not placed on 1:1 observation or continuous observation while in seclusion or at any other time during the 3 night shifts he worked (14th, 15th, and 16th).
In an interview on 04/12/11 at 1:05 p.m. with S17MD he stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done." S17MD stated that patient #2 "should have been on 1:1 observation."
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated the RN should have initiated 1:1 monitoring of patient #2 and notified the physician to obtain the order. S2DON confirmed there was no documentation of least restrictive methods being attempted prior to the documentation on the seclusion flow sheet and implementation of seclusion. S2DON confirmed there was no documentation of 1:1 or continuous visual observation of patient #2 while he was in seclusion. S2DON confirmed that hospital policy requires either the psychiatrist or RN deemed competent to perform a face to face interview within 1 hour of initiation of seclusion. S2DON confirmed this evaluation was not done for the 01/15/11 at 11:00 a.m. seclusion, the 01/15/11 at 3:00 p.m. seclusion, the 01/15/11 1915 (7:15 p.m.) renewal order, or the 01/16/11 at 12:30 p.m. seclusion order. S2DON reviewed the documentation for 01/15/11 seclusion renewal order and stated "there is no documented reason to keep a sleeping patient in seclusion" and that this was done for "nursing convenience."
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no face to face assessment of patient #2 done at any time after initiation of seclusion for the entire hospitalization of patient #2. S2DON and S3ADON confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital. S2DON and S3ADON verified there was no physician countersignature on the seclusion order sheets within 24 hours of initiation as required by hospital policy.
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "... 4. The physician or specially trained RN must see the patient face to face and evaluate the need for restraint or seclusion within 1 hour after the initiation...(The RN performing the face to face evaluation may NOT be the RN initiating the intervention.)...6. Responsibility: RN. The order must be in accordance to a written modification to the patient ' s plan of care. Ongoing Assessment of the need for continuation: Responsibility: RN/MD. 1...Additionally, if the order is discontinued and reordered, the initial sequence begins with face to face in 1 hour. 2. If restraint or seclusion is discontinued prior to expiration of the original order, a new order must be obtained prior to reinitiating or reapplying the restraints or seclusion...Documentation requirements: Responsibility: RN/MHT/LPN. 7. Level of Observation 1:1..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record review and interview the hospital failed to ensure that upon each new order for seclusion that a face to face evaluation was conducted within one hour per hospital policy by a physician or RN deemed competent to perform the evaluation as evidenced by no documented evidence of a face to face evaluation within one hour of seclusion initiation for 3 of 3 seclusion orders and 1 renewal order written after the original seclusion order had expired for 1 of 1 focused sampled patients with seclusion orders in a total sample of 15 (#2) Findings:

01/15/11
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
Review of the Physician' s Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a" , pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
Review of a Doctor' s Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours) ...Clinical Justification: safety of others. Describe Specific Behavior: loud, threatening to "f*** us all up" , cursing loudly, exposed self to female pt., attempted to disrobe female pt., wandering..." The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints " is not checked.
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis..." The order is a verbal order taken by S14LPN from S17MD.
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)" The box for " Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints" is not checked.
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
Review of a document titled "Doctor's Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake." The Order is signed by S12RN on 01/15/11 at 1915 (7:15 p.m.).
01/16/11
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)" ... The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints" is not checked... The flowsheet is signed by S11RN on 01/16/11 at 1230 (12:30 p.m.)
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done."
In an interview on 04/12/11 at 11:00 a.m. with S2DON she confirmed that hospital policy requires either the psychiatrist or RN deemed competent to perform a face to face interview within 1 hour of initiation of seclusion. S2DON confirmed this evaluation was not done for the 01/15/11 at 11:00 a.m. seclusion, the 01/15/11 at 3:00 p.m. seclusion, the 01/15/11 1915 (7:15 p.m.) renewal order, or the 01/16/11 at 12:30 p.m. seclusion order.
Review of the "Behavioral Restraint/Seclusion Procedure Flow Sheet" revealed the following: "Procedure:.. Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...4. The physician or specially trained RN must see the patient face to face and evaluate the need for restraint or seclusion within 1 hour after the initiation ...(The RN performing the face to face evaluation may NOT be the RN initiating the intervention.)...Additionally, if the order is discontinued and reordered, the initial sequence begins with face to face in 1 hour. 2. If restraint or seclusion is discontinued prior to expiration of the original order, a new order must be obtained prior to reinitiating or reapplying the restraints or seclusion ..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record review and interview the hospital failed to ensure that upon each new order for seclusion that a face to face evaluation to evaluate the situation, the patients reaction to the intervention, and the need to continue or terminate the seclusion was conducted within one hour per hospital policy by a physician or RN deemed competent to perform the evaluation as evidenced by no documented evidence of a face to face evaluation within one hour of seclusion initiation for 3 of 3 seclusion orders and 1 renewal order written after the original seclusion order had expired for 1 of 1 focused sampled patients with seclusion orders in a total sample of 15 (#2) Findings:

01/15/11
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a" , pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours) ...Clinical Justification: safety of others. Describe Specific Behavior: loud, threatening to "f*** us all up" , cursing loudly, exposed self to female pt., attempted to disrobe female pt., wandering"...The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints" is not checked.
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis..." The order is a verbal order taken by S14LPN from S17MD.
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)"...The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints" is not checked.
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
Review of a document titled "Doctor' s Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake." The Order is signed by S12RN on 01/15/11 at 1915 (7:15 p.m.).
01/16/11
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
Review of the Physician's Orders sheet revealed an order dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the Physician's Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: " Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis. "
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)." The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints" is not checked. The flowsheet is signed by S11RN on 01/16/11 at 1230 (12:30 p.m.).
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done."
In an interview on 04/12/11 at 11:00 a.m. with S2DON she confirmed that hospital policy requires either the psychiatrist or RN deemed competent to perform a face to face interview within 1 hour of initiation of seclusion. S2DON confirmed this evaluation was not done for the 01/15/11 at 11:00 a.m. seclusion, the 01/15/11 at 3:00 p.m. seclusion, the 01/15/11 1915 (7:15 p.m.) renewal order, or the 01/16/11 at 12:30 p.m. seclusion order.
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "Procedure:..Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...4. The physician or specially trained RN must see the patient face to face and evaluate the need for restraint or seclusion within 1 hour after the initiation...(The RN performing the face to face evaluation may NOT be the RN initiating the intervention.)...Additionally, if the order is discontinued and reordered, the initial sequence begins with face to face in 1 hour. 2. If restraint or seclusion is discontinued prior to expiration of the original order, a new order must be obtained prior to reinitiating or reapplying the restraints or seclusion ..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment..."

Based on record review and interview the hospital failed tofollow their policy and procedure for seclusion as evidenced by failing to ensure a face to face evaluation was performed for each new seclusion order within one hour by a physician or RN deemed competent to perform the evaluation resulting in no documented evidence of a face to face evaluation within one hour of seclusion initiation for 3 of 3 seclusion orders and 1 renewal order written after the original seclusion order had expired for 1 of 1 focused sampled patient (#2) with seclusion orders in a total sample of 15. Findings:

01/15/11
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR".
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a", pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety".
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours) ...Clinical Justification: safety of others. Describe Specific Behavior: loud, threatening to "f*** us all up" , cursing loudly, exposed self to female pt., attempted to disrobe female pt., wandering".The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints " is not checked.
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: " Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained. "
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis..." The order is a verbal order taken by S14LPN from S17MD.
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)". The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints" is not checked.
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
Review of a document titled "Doctor's Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake." The Order is signed by S12RN on 01/15/11 at 1915 (7:15 p.m.).
01/16/11
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
Review of the Physician' s Orders sheet revealed an order dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the Physician's Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)". The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints " is not checked... The flowsheet is signed by S11RN on 01/16/11 at 1230 (12:30 p.m.)
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done."
In an interview on 04/12/11 at 11:00 a.m. with S2DON she confirmed that hospital policy requires either the psychiatrist or RN deemed competent to perform a face to face interview within 1 hour of initiation of seclusion. S2DON confirmed this evaluation was not done for the 01/15/11 at 11:00 a.m. seclusion, the 01/15/11 at 3:00 p.m. seclusion, the 01/15/11 1915 (7:15 p.m.) renewal order, or the 01/16/11 at 12:30 p.m. seclusion order."
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "Procedure:..Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...4. The physician or specially trained RN must see the patient face to face and evaluate the need for restraint or seclusion within 1 hour after the initiation...(The RN performing the face to face evaluation may NOT be the RN initiating the intervention.)...Additionally, if the order is discontinued and reordered, the initial sequence begins with face to face in 1 hour. 2. If restraint or seclusion is discontinued prior to expiration of the original order, a new order must be obtained prior to reinitiating or reapplying the restraints or seclusion ..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record review and interview the hospital failed to ensure the History and Physical Examination was performed and in the medical record within 24 hours for 1 of 15 sampled patients as evidenced by the History and Physical being documented 48 hours and 25 minutes after admission (#2) Findings:

Review of the medical record for patient #2 revealed an admission date of 01/14/11 at 1830 (6:30 p.m.). Review of the H&P,documented by S19MD, revealed it was completed on 01/16/11 at 1855 (6:55 p.m.). (48 hours and 25 minutes after admission)

Review of a hospital policy titled "Assessments of Patients", no date effective,reviewed or revised, reads in part: "Purpose: To define scope and time frames for patient assessments for each discipline involved in an individual patient's treatment...Procedure: The department specific time frames for assessments are as follows:...History and Physical...within 24 hours of admission..."

In an interview on 04/12/11 at 11:00 a.m. with S2DON she confirmed the H&P was not complete until 01/16/1 and therefore could not be on the medical of patient #2 within 24 hours as required by hospital policy.

Based on record review and interview the hospital failed to 1) ensure the Director of Nursing (DON) determined and provided sufficient numbers and types of staff on duty to maintain control of the mileau as evidenced by failing to ensure patients received care in a safe setting as evidenced by a male patient (#2), who was assessed upon admission to be "walking down the halls checking doors", to enter the room of a female patient on 01/15/11 and expose himself to her and attempt to disrobe her for 1of 15 sampled patients (#15) and 2) ensure the environment was safe for all patients in the hospital as evidenced by a male patient (#2) verbally threatening staff and patients on the unit causing multiple patients emotional distress to the point they were asking to be locked in their rooms to protect themselves from patient #2 and requesting/requiring increased medications for two days. This had the potetial to affect all of the patients in the hospital on 01/15/11 and 01/16/11. (#1, #2, #3, #15, #R1, #R2, #R3,#R4, #R5,#R6, #R7, #R8) Findings:

1)
Review of the Initial Nursing Assessment of patient #2 revealed it was performed by S13RN on 01/14/11 at 1830 (6:30 p.m.). Further review revealed: "Reason for Admission: Pt had been in jail for wandering on streets, talking to things/people not there. Began yelling in jail. Seemed to be responding to internal stimuli. History of Mental Illness: long hx. (history). Presenting Symptoms: (the following were checked as positive) Anxiousness/Restlessness, Confusion, Hallucinations, Impulsivity, Isolative/withdrawn behavior, Lack of Concentration, Paranoia/suspiciousness, Sleep disturbance...Appearance: Disheveled...Thought Content: Paranoid delusions...RN Admission note:...Pt. walks down halls - checking doors."
In an interview on 04/12/11 at 3:30 p.m. with S13RN she stated she notified the LPN and MHT's on duty and the oncoming shift that patient #2 was walking down the halls checking doors.
Review of the Multidisciplinary Treatment Plan revealed the following problems were identified on the care plan of patient #2: "Problem #1 Disturbed Thought Process, Problem #2: Self Care Deficit, Problem #3: Date Identified: 01/15/11. Risk for other - directed violence. Related to: Hx of Chronic Paranoid Schizophrenia. As Evidenced by "(patient #2) loudly curses and threatens violence toward staff and peers, (patient #2) pounds on walls of nursing station, (patient #2) resists all attempts to redirect. Long Term Goal: (patient #2) will demonstrate mood stability with absence of psychosis and no further displays of aggression. Date expected to achieve: 01/29/11...Clinical Interventions: Educate (patient #2) on anti-psychotic medications - assess effectiveness. Person responsible: (S7RN); offer (patient #2) to reality when he verbalizes auditory/visual hallucinations/paranoid delusional thoughts. Person responsible: (S7RN) and (S16MHT) assist (patient #2) with identifying triggers to agitation and effective alternatives to aggressive behaviors. Persons Responsible: (S7RN) and (S16MHT)."
01/15/11
Review of the nursing note for patient #2 documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note for patient #2 documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN further confirmed that there was 1 RN, 1 LPN, and 1 MHT, all female, on duty for the Saturday (15th) and Sunday (16th) shifts. S11RN stated that on 01/15/11 patient #2 was roaming the halls checking doors. S11RN stated that some of the other patients in the unit were scared of patient #2 and stayed in their rooms. S11RN further stated that some patients, both male and female, were requesting that their room doors be locked to prevent patient #2 from getting into the room. S11RN stated that she did lock the doors of those patients. S11RN stated that although the doors were locked from the outside, the patients could exit the room from the inside without needing a key. S11RN stated a female patient reported patient #2 entered the room she was in and patient #2 had his penis out and was attempting to disrobe patient #15. S11RN stated that the female patient told patient #2 to leave the room as she exited the room to summon help. The female patient exited the room and reported what was occurring to patient #15. S11RN stated that no staff witnessed the incident and that patient #2 had exited the room prior to staff arrival. S11RN stated that patient #15 reported that patient #2 was in her room with his penis exposed and was " reaching for her clothing " when the other female patient in the room, who was behind a curtain, came into the area and told patient #2 to leave the room. S11RN stated that this is patient to patient abuse. S11RN further stated she could not remember if an incident report was filled out. When asked by this surveyor what she did to protect the patients from patient #2, S11RN replied that she was complying with requests of approximately 5 female patients to lock them in their room. S11RN stated she does not remember if she informed anyone else of patients "being so scared (of patient #2) that they were requesting to be locked in their room." S11RN was asked why the police were called and she stated she was afraid patient #2 would hurt the staff. S11RN stated the entire staff was scared of patient #2. S11RN stated she thinks she called either S7RN on-call or S10, staffing, not to request additional staff but to update them of the problems on the unit. S11RN confirmed that patient #2 became calm when the police arrived, but was still placed in the BCR. S11RN stated she never initiated or requested 1:1 or continuous visible observation status for patient #2 for the monitoring of patient and/or the safety of the other patients. S11RN stated she did not report the incident with patient #2 and patient #15 to the Nursing Director per hospital policy.
In an interview on 04/12/11 at 3:30 p.m. with S14LPN she confirmed she worked the day shift on 01/15/11 and 01/16/11. She further stated that on 01/15/11 patient #2 exposed himself to patient #15 by pulling his pants down and then attempting to disrobe patient #15. S14LPN stated that after that all of the patients were scared of him, both male and female, and were requesting to be locked in their rooms or in the dayroom so patient #2 could not get to them. S14LPN stated that staff complied with the request. S14LPN stated that she did notify S7RN on-call and S10, staffing. S14LPN stated that other patients were requesting/required increased medications due to the events on the unit. S14LPN stated the police were called several times. S14LPN stated she was afraid of patient #2 and she did not feel like staff could take him down.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/14/11, 01/15/11, and 01/16/11. S12RN stated he was aware on 01/14/11 of the initial assessment findings documented by S13RN that patient #2 was "walking down the halls checking doors." S12RN stated that he was not informed during his on-coming shift report on the evening of 01/15/11 that patient #2 had exposed himself to patient #15 and was reportedly attempting to disrobe her in her room while having his penis exposed. S12RN stated that male and female patients were still requesting to be locked in their rooms and in the dayroom because they were afraid of patient #2. S12RN was asked by this surveyor what measures were put in place to protect the patients from patient #2. S12RN stated that locking patients in their room and the dayroom while patient #2 was in the hall was the only thing done. S12RN confirmed the documentation for 01/15/11 at 2330 (11:30 p.m.) that patient #2 was "escalating, threatening staff with loud cursing." S12RN stated he contacted S17MD and was given an order for Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. S12RN further confirmed that (PD1) was called to assist. S12RN stated that there was "not enough staff " and that the police were needed to assist with patient #2. S12RN stated that on 01/17/11 the other patients in the hospital were still isolating themselves from patient #2 by requesting to be locked in their rooms so patient #2 "could not get to them." S12RN stated patient #2 was not placed on 1:1 observation or continuous observation at any time during the 3 night shifts he worked (14th, 15th, and 16th). S12RN stated that patient #2 was a danger to patients and staff. S12RN stated he "could not remember if the Director of Nursing or Administration were notified" of the events of the weekend of 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:40 p.m. with S15LPN she confirmed she was the LPN on duty on 01/15/11 and 01/16/11 from 6:00 p.m. - 6:00 a.m. S15LPN stated there was inadequate staffing present. S15LPN stated that the information regarding patient #2 exposing himself to patient #15 and reportedly attempting to disrobe her was not passed on in shift report. S15LPN stated she "could not remember" if anyone was called to get additional staff. She further stated that it is routine hospital procedure to call the police for assistance. S15LPN stated that on the night shift of 01/16/11 the other patients in the hospital "were scared." S15LPN stated she also overheard "phone calls to S10LPN, staffing, to get more staff." S15LPN stated she was informed that the staff were told to "do the best that you can."
In an interview on 04/13/11 at 10:20 a.m. S7RN stated that she was the on-call nurse for the weekend of 01/15/11 and 01/16/11. S7RN stated she received a call and was notified of "patient problems" on the floor, that she was not asked to come in, and that she was not informed that patients were requesting to be locked in their rooms.
In an interview on 04/13/11 at 10:15 a.m. with S10LPN, staffing, she stated she does not recall any request from staff between 01/14/11 - 01/17/11 for additional staff. S10LPN further stated there is no documentation that the staff on duty requested additional staff for 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:05 p.m. with S17MD stated he did not recall if he was advised of the incident between patient #2 and patient #15. S17MD stated that patient #2 "should have been on 1:1 observation." After review of the documentation in the medical record of patient #2 S17MD stated that the events documented in the medical record of patient #2 exposing himself to patient #15 and attempting to disrobe her "are abuse." S17MD stated that staffing was not appropriate and should have been increased.
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated patient #2 was "responding to internal stimuli" upon admission on 01/14/11 and met admission criteria for the hospital. S2DON confirmed the Initial Assessment findings that patient #2 was "walking down the halls checking doors." S2DON stated the documentation for 01/15/11 that patient #2 was exposing himself and attempting to disrobe patient #15 was Abuse according to hospital policy and should have been reported to DHH. S2DON confirmed there was no incident report as required by hospital policy regarding the incident. S2DON stated the incident should have been reported to the police department. S2DON stated the RN should have initiated 1:1 monitoring of patient #2 and notified the physician to obtain the order. S2DON stated Administration and the DON should have been notified of the incident. S2DON stated staffing should have been increased based on the acuity of patient #2. S2DON stated that the failure to complete an incident report and notify management of the 01/15/11 incident between patient #2 and patient #15 was "passive abuse/neglect." S2DON stated that on 01/16/11 the staffing level was inadequate.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both stated they were not aware that staff was locking patients in their rooms and the dayroom on the weekend of 01/15/11 - 01/16/11 per patient request due to fear of patient #2. S2DON and S3ADON stated the staff failed to fill out an incident report on the allegation of sexual abuse of patient #15 by patient #2. S2DON and S3ADON confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital. S2DON and S3ADON both stated they were not aware of the findings of the survey and the events of the weekend of 01/14/11 through 01/17/11 until the survey on 04/11/11 - 04/13/11. Both confirmed there was no investigation of the events of the weekend of 01/14/11 through 01/17/11.
Review of a hospital policy titled "Staffing patterns/Variances/Acuity" , no date effective, reviewed or revised, reads in part: "The program is staffed in a manner to meet the various needs of the patients served. The staffing pattern for the program is based on aspects of care and services provided, patient census, and acuity to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, Administration is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs ...B. High Census/Acuity Staff Adjustments. In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. The primary goal is to maintain a safe, therapeutic environment. The charge nurse on duty will notify Administration on call if the census increases and additional staffing is required."
Review of a hospital policy titled "Reporting Alleged Child/Adult Neglect and/or Abuse" , effective 01/10, no date of review or revision, reads in part: "Policy: In accordance with La. Criminal Code Title XIV, Section 403 , it is the policy of the program to report suspected cases of abuse or neglect of minors or adults to the appropriate authorities. See La. R.S. 14:403. Abuse/Neglect is defined as follows: 1) Abuse ...b. Emotional - Threats, ridicule, isolation, intimidation, harassment. c. Sexual - Any unwanted sexual activity, without regard to contact or injury; any sexual activity with a person whose capacity to consent or resist is limited. 2) Neglect. a. Care Giver - Withholding or not assuring provision of basic necessary care, such as...safety...Purpose: To establish guidelines and accountability for reporting allegations of abuse or neglect of a patient, family member or significant other, both minors and adults. Procedure:..2. Observations leading to suspicions of abuse or neglect as well as allegations or reports of abuse or neglect shall be documented in the Progress Notes. 3. Suspicions of abuse or neglect of a minor or adult or allegations made by the patient or a family member will be reported to the Social Worker, attending physician and DON or Administrator immediately, upon discovery by any staff member. 4. If the information is obtained by a staff member other that the social worker, a social worker will meet with the patient to obtain information relative to possible abuse or neglect. If a social worker is not available, the nurse on duty shall obtain this information & advise Program Director immediately. 5. The social worker or Nurse shall notify the Office of Community Services or appropriate law enforcement agency within 24 hours of receiving the data ..."
Review of a hospital policy titled "Incident/Occurrence Reporting" , no effective, reviewed or revised date, reads in part: "An incident is an unplanned event or occurrence that interrupts or interferes with the orderly progress or completion of an activity and may or may not include property damage or personal injury. Policy: An important aspect of the safety program is that of incident reporting...Employees will report all incidents, whether it be a patient, visitor, or employee...Complete an "Occurrence Report" for any patient or visitor incident."
Review of a hospital policy titled "Alleged Patient Abuse on the Unit" , no effective, reviewed, or revised date, reads in part: "Purpose: To provide guidelines for procedures to be carried out whenever it is alleged that patient abuse has occurred on the unit. Policy: The staff is responsible for investigating and reporting any alleged incident of patient abuse in a manner that will protect the rights and dignity of the alleged victim. Definition of Terms: A) "Abuse" is defined as the infliction of physical or mental injury to other parties, including but not limited to such means as sexual abuse, physical attack ...to such an extent that his health, morals or emotional well being is endangered. B) A detailed explanation from the alleged victim will be documented/recorded...C) Administration will take the following actions: If physical or sexual abuse is alleged: 1) He/She will notify the police ..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment..."
2)
Review of the medical record of patient #2 revealed he was admitted on Friday 01/14/11 at 1830 (6:30 p.m.) to S17MD, Psychiatrist, with a diagnosis of Chronic Paranoid Schizophrenia (CPS). Patient #2 was a 40 year old male. Further review of the medical record revealed patient #2 was sent to an Emergency Room (ER) directly from jail and was placed under a Physician's Emergency Certificate (PEC). Patient #2 was ordered to be on "q (every) 15 minute safety checks."
Review of the Initial Nursing Assessment for patient #2 revealed it was performed by S13RN on 01/14/11 at 1830 (6:30 p.m.). Further review revealed: "Reason for Admission: Pt had been in jail for wandering on streets, talking to things/people not there. Began yelling in jail. Seemed to be responding to internal stimuli. History of Mental Illness: long hx. (history). Presenting Symptoms: (the following were checked as positive) Anxiousness/Restlessness, Confusion, Hallucinations, Impulsivity, Isolative/withdrawn behavior, Lack of Concentration, Paranoia/suspiciousness, Sleep disturbance...Appearance: Disheveled...Thought Content: Paranoid delusions...RN Admission note:..Pt. walks down halls - checking doors."
In an interview on 04/12/11 at 3:30 p.m. with S13RN she stated she notified the LPN and MHT's on duty and the oncoming shift that patient #2 was walking down the halls checking doors.
Review of the Multidisciplinary Treatment Plan revealed the following problems were identified on the care plan: "Problem #1 Disturbed Thought Process, date initiated: 01/14/11. Problem #2: Self Care Deficit, date initiated 01/14/11. Problem #3: Date Identified: 01/15/11. Risk for other - directed violence. Related to: Hx of Chronic Paranoid Schizophrenia. As Evidenced by (patient #2) loudly curses and threatens violence toward staff and peers, (patient #2) pounds on walls of nursing station, (patient #2) resists all attempts to redirect. Clinical Interventions: Educate (patient #2) on anti-psychotic medications - assess effectiveness. Person responsible: (S7RN); offer (patient #2) to reality when he verbalizes auditory/visual hallucinations/paranoid delusional thoughts. Person responsible: (S7RN) and (S16MHT) assist (patient #2) with identifying triggers to agitation and effective alternatives to aggressive behaviors. Persons Responsible: (S7RN) and (S16MHT)."
01/15/11
Review of the nursing note for patient #2 documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt ' s rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note for patient #2 documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt' s behavior escalating, pt loudly cursing and threatening staff, yelling " I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a" , pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
Review of a Doctor ' s Order Sheet Behavioral Restraint/Seclusion Order flowsheet in the medical record of patient #2 revealed: "Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours)...Clinical Justification: safety of others. Describe Specific Behavior: loud, threatening to "f*** us all up" , cursing loudly, exposed self to female pt., attempted to disrobe female pt., wandering..."
Further review of the nursing notes in the medical record of patient #2 for 01/15/11 at 1130 (11:30 a.m.) revealed S11RN documented "Locked BCR D/C' d (discontinued)."
Review of the nursing documentation in the medical record of patient #2 for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician' s Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, (patient #2) escorted to BCR - Haldol 10 mg, Ativan 2 mg, Benadryl 50mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet on the medical record of patient #2 revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)...Chemical Adjunctive Support Ordered: No. Clinical Justification: danger to others. Describe Specific Behavior: threatening violence towards staff and peers, loud cursing, throwing objects, hitting windows of nsg (nursing) station..."
Review of S12RN's documentation on the medical record of patient #2 for 01/15/11 at 2200 (10:00 p.m.) read as follows: "Occasional outburst of cursing and threatening staff. When told we would call police if necessary (patient #2) calms down and apologizes."
Documentation by S12RN for patient #2 at 2330 (11:30 p.m.) on 01/15/11 revealed: "Dr. (S17MD) notified of patient escalating, threatening staff with loud cursing. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. (PD1) call to assist. (3rd call) Injections given with pt cursing and threatening but willingly took the injections."
Review of the Physician's Orders sheet in the medical record of patient #2 revealed an order dated 01/15/11 at 2330 (11:30 p.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
01/16/11
S11RN documented the following in the medical record of patient #2 on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for patient #2 on 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
S11RN documented in the medical record of patient #2 at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of the Physician's Orders sheet revealed an order for patient #2 dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the Physician's Order Sheet in the medical record of patient #2 dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet in the medical record of patient #2 revealed: Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)...Chemical Adjunctive Support Ordered: Yes. Clinical Justification: safety of others. Describe Specific Behavior: cursing loudly and threatening violence toward staff and peers..."
01/17/11
Review of the nursing documentation by S12RN in the medical record of patient #2 on 01/17/11 at 0120 (1:20 a.m.) read: "(S17MD) called for pt yelling, cursing, threatening staff, threw shampoo bottle at nsg station. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM X 1 dose now. (PD1) called to assist. (5th call). Pt took injections willingly ..."
Review of nursing documentation in the medical record of patient #2 on 01/17/11 at 0730 (7:30 a.m.) by S7RN revealed the following: "Pt. up and ambulatory. Episodes of verbal aggression, cursing loudly, able to redirect pt without incident. Pt. yelling at a spot of kool-aid on the floor and accusing the spot of kool-aid of stealing his breakfast ..."
Review of the Psychiatric Evaluation revealed S17MD, Psychiatrist, performed the evaluation on Monday January 17th, 2011 at 12:00 noon. This evaluation was 65 ? hours after admission and was the first face to face assessment of patient #2 by S17MD. Further review of the documentation by S17MD revealed: "Patient's Chief Complaint: "I'm Jesus Christ" . Onset: Chronic. Reason for Admission/Signs/Symptoms/Precipitating Factors: 41 yo admitted for tx (treatment) of acute psychosis. Past History of any Psychiatric Problems/Treatment. Patient is acutely ill related to: Schizophrenia. Patient has had past psychiatric history of: Schizophrenia. Patient has had multiple treatments and hospitalizations at inpatient, PHP (partial hospitalization program. Patient has been consistently ill for period of lifelong, relapsed. Precipitating factors include: homeless. Persistent Symptoms include: Hallucinations, Delusions...Mental Status Exam: Appearance: Disheveled, Attitude/Behavior: Suspicious, Motor Activity: Calm, Affect: Labile, Mood: Calm, Speech: Normal, Thought Process: Flight of Ideas, Loose Assoc. (associations), Thought Content: Hallucinations: Auditory, Delusions: Grandiose, Suicidality: Not Present, Homicidality: Not Present, Sensorium and Cognition...Judgment: Impaired...Capacity for ADL's (activities of daily living). Diagnosis: Axis I: Chronic Paranoid Schizophrenia, Axis II: No Dx. (diagnosis), Axis III: No Dx., Axis IV: Problems related to the social environment. Axis V: Current 10, Past Year? Initial Plan for Treatment: New medication prescribed: Yes, Medication Evaluation, adjustment or trial, Crisis Intervention, Provide a Safe and Structured Environment, Evaluation of Psychiatric Status, Laboratory Tests/Work-up. Discharge Criteria for lower level of care: Resolution of impaired function due to bizarre, psychotic behavior/affect and/or thinking. Preliminary Discharge Plan: Psychiatrist. Hospitalization needed: No. Estimated length of stay: 4 days. Prognosis: Fair. Formulation: Pt's problems are behavioral. He is not suited for inpatient care. He will be referred for outpatient care."
Review of the Discharge Summary for patient #2 revealed the following: "Admission Diagnosis: Axis I: Chronic Schizophrenia. Axis II: No Diagnosis. Axis III: No Diagnosis. Axis IV: Problems related to social environment. Axis V: GAF On Admission: 10. Past Year: Unknown. Chief Complaint: (I'm Jesus Christ). History of Present Illness: This is a 41 year old black male admitted for treatment of acute psychosis. Mental Status on Admission: Patient appeared disheveled. Attitude and behavior was suspicious and belligerent. Motor activity was calm. Affect was labile. Mood was normal. Speech was normal. Thought process was positive for flight of ideas and disassociation. Thought content was positive for auditory hallucinations and grandiose delusions. Patient denied any suicidal or homicidal ideations. Cognitive Examination on Admission: Patient was oriented X 4 to person, place, time, and situation. Memory function was intact in regards to immediate, recent and remote event. Concentration was intact. Attention was intact. Abstract thinking was impaired. Insight was limited. Judgment was severely impaired. Intelligence was average...At around 11:00 on 1-15-11 the patient was placed on seclusion BCR for threatening violence to staff and increased psychotic behavior. At 11:30 seclusion was discontinued. Around approximately 15:00 (3:00 p.m.) the patient was placed back in BCR for threatening violence to staff and increased agitation of psychosis. He was also given Haldol 10 mg IM, Ativan 2 mg IM and Benadryl 50 mg IM due to the increased psychosis. Order was renewed for seclusion at 19:15 (7:15 p.m.). At 20:30 (8:30 p.m.) the patient was given Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM X 1 for increased agitation related to psychosis. On 1-16-11 at 12:05 (p.m.) the patient was given Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg IM X 1 for increased agitation related to psychosis. At 12:30 (p.m.) on 1-16-11, the patient was placed on locked BCR for threatening staff and peers for increased agitation related to psychosis. At 16:30 (4:30 p.m.) seclusion orders were discontinued. On 1-17-11 at approximately 1:20 a.m., the patient was given Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg IM X 1 dose for increased agitation related to psychosis. On 1-17-11, the patient was seen by Psychiatrist for psychiatric evaluation. (This was 65 hours after admission) It was determined by this exam, that the patient's problems were behavioral and he was not suitable for inpatient care, therefore patient was discharged from this facility. The patient was discharged to Salvation Army in Lafayette. Complications Through Hospital Care: Patient required continuous redirection and IM prn medication throughout stay. Mental Status Examination on Discharge: Patient denied any homicidal or suicidal ideations or passive death wishes. Mood and affect were stable. He denied any auditory or visual hallucinations ...Condition Upon Discharge: stable ..." Further review of the document revealed it was dictated by S7RN. The Discharge Summary was blank on the signature line for the person who dictated the information, S7RN, and al

Based on record review and interview the hospital failed to ensure there was adequate numbers of types of nursing personnel on duty based upon patient population and acuity on 01/15/11 and 01/16/11 as evidenced by staff having to call for police assistance 5 times and patients requesting to be locked in their rooms to protect themselves from a patient threatening violence to staff and peers. This had the potential to affect all of the patients in the hospital on 01/15/11 and 01/16/11. (#1, #2, #3, #15, #R1, #R2, #R3,#R4, #R5,#R6, #R7, #R8) Findings:

01/15/11 PD1 call #1
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt's rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained".
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt's rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR".
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)." The order is a verbal order taken by S11RN from S17MD.
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a", pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
PD1 call #2
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained."
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, escorted to BCR - Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
Review of the Medication Administration Record (MAR) for patient #2 revealed he was administered Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM at 1515 (3:15 p.m.).
PD1 call #3
Documentation by S12RN for 2330 (11:30 p.m.) on 01/15/11 revealed: "Dr. (S17MD) notified of patient escalating, threatening staff with loud cursing. (S17MD) ordered Haldol 10mg, Ativan 2mg, Benadryl 50mg IM stat X 1 dose. (PD1) call to assist. (3rd call) Injections given with pt cursing and threatening but willingly took the injections."
Review of the Physician's Orders sheet revealed an order dated 01/15/11 at 2330 (11:30 p.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the MAR revealed documentation that patient #2 was administered Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg IM at 2330 (11:30 p.m.).
01/16/11
PD1 call #4
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests...argues with image in windows and strikes self in window, + (positive) hallucinations..."
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2) is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
Review of the Physician's Orders sheet revealed an order dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)."
Review of the Physician's Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis."
Review of the nursing notes revealed no documented evidence S17MD was informed that patient #2 walked to the BCR upon arrival of PD1.
01/17/11
PD1 call #5
Review of the nursing documentation by S12RN on 01/17/11 at 0120 (1:20 a.m.) read: "(S17MD) called for pt yelling, cursing, threatening staff, threw shampoo bottle at nsg station. (S17MD) ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM X 1 dose now. (PD1) called to assist. (5th call). Pt took injections willingly ..."
Review of the Physician's Orders sheet revealed an order dated 01/17/11 at 0120 (1:20 a.m.) taken by S12RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis."
Review of the nursing documentation by S12RN for 0230 (2:30 a.m.) on 01/17/11 revealed patient #2 was asleep. Review of the nursing documentation for 0400 (4:00 a.m.) on 01/17/11 revealed patient #2 was "resting quietly in bed."
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN further confirmed that there was 1 RN, 1 LPN, and 1 MHT, all female, on duty for the Saturday (15th) and Sunday (16th) shifts. S11RN was asked why the police were called and she stated she was afraid patient #2 would hurt the staff. S11RN stated the entire staff was scared of patient #2. S11RN stated she thinks she called either S7RN on-call or S10, staffing, not to request additional staff but to update them of the problems on the unit. S11RN confirmed that patient #2 became calm when the police arrived, but was still placed in the BCR. S11RN stated she never entered the seclusion room to check on patient #2 unless he was asleep because she was scared.
In an interview on 04/12/11 at 3:30 p.m. with S14LPN she confirmed she worked the day shift on 01/15/11 and 01/16/11. S14LPN stated that she did notify S7RN on-call and S10, staffing. S14LPN stated the police were called several times. S14LPN stated she was afraid of patient #2 and she did not feel like staff could take him down.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed he was the RN Charge Nurse on the 6:00 p.m. - 6:00 a.m. shifts on 01/14/11, 01/15/11, and 01/16/11. S12RN confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained. S12RN confirmed his documentation dated 01/15/11 at 2200 (10:00 p.m.) that read as follows: "Occasional outbursts of cursing and threatening staff. When told we would call the police if necessary (patient #2) calms down and apologizes." S12RN confirmed the documentation for 01/15/11 at 2330 (11:30 p.m.) that patient #2 was "escalating, threatening staff with loud cursing." S12RN stated he contacted S17MD and was given an order for Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM stat X 1 dose. S12RN further confirmed that (PD1) was called to assist. S12RN stated that there was "not enough staff" and that the police were needed to assist with patient #2.
In an interview on 04/12/11 at 1:40 p.m. with S15LPN she confirmed she was the LPN on duty on 01/15/11 and 01/16/11 from 6:00 p.m. - 6:00 a.m. S15LPN stated that PD1 was called on 01/15/11 at 2330 (11:30 p.m.) because "(patient #2) was not going to allow staff to give the shot." S15LPN stated there was inadequate staffing present. She further stated that it is routine hospital procedure to call the police for assistance. S15LPN stated she did hear S12RN tell patient #2 "we will call the police if necessary." S15LPN stated she also overheard "phone calls to S10LPN, staffing, to get more staff." S15LPN stated she was informed that the staff were told to "do the best that you can."
S7RN was interviewed on 04/13/11 at 10:20 a.m... S7RN stated that she was the on-call nurse for the weekend of 01/15/11 and 01/16/11. S7RN stated she received a call and was notified of "patient problems" on the floor,and that she was not asked to come in.
In an interview on 04/13/11 at 10:15 a.m. with S10LPN, staffing, she stated she does not recall any request from staff between 01/14/11 - 01/17/11 for additional staff. S10LPN further stated there is no documentation that the staff on duty requested additional staff for 01/14/11 - 01/17/11.
In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation of patient #2 was not done until 01/17/11 at 12:00 noon, which was 65 ? hours after admission of the patient. S17MD stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done." S17MD stated that patient #2 "should have been on 1:1 observation." S17MD stated that staffing was not appropriate and should have been increased.
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated staffing should have been increased based on the acuity of patient #2. S2DON stated that on 01/16/11 the staffing level was inadequate.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital.
Review of a hospital policy titled "Staffing patterns/Variances/Acuity " , no date effective, reviewed or revised, reads in part: "The program is staffed in a manner to meet the various needs of the patients served. The staffing pattern for the program is based on aspects of care and services provided, patient census, and acuity to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, Administration is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs ...B. High Census/Acuity Staff Adjustments. In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. The primary goal is to maintain a safe, therapeutic environment. The charge nurse on duty will notify Administration on call if the census increases and additional staffing is required."
Review of a hospital policy titled "Policy for the use of Restraints/Seclusion." read in part: "...Restraints will NEVER be used for staff convenience. Policy: It is the practice of the hospital to use restraint/seclusion in clinically appropriate and adequately justified situations. Patients have the right to be free from restraint/seclusion. Whenever possible, restraints/seclusion will be avoided and will only be used when alternative measures have been unsuccessful in maintaining the safety of the patients and/or others...The least restrictive measure of restraints/seclusion that meets the patient's needs will be utilized. Excluded devices: The following are excluded from the restraint policy:..4. Handcuffs or other restrictive devices applied by law enforcement officials. Definitions:..2. Chemical Restraint. A medication used to control behavior or to restrict the patient' s freedom of movement and is not a standard treatment of the patient's medical or psychiatric condition...Medications used as chemical restraints are medications used in addition to or in replacement of the patient's regular medication regime to control extreme behavior during an emergency. Least restrictive interventions must be documented prior to chemical restraint...4. Seclusion: Involuntarily confining an individual alone to a room or an area where he or she is physically prevented from leaving...6. Behavioral emergency: A situation where the patient's behavior is violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff or others..."
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "Procedure: Initial Assessment: Responsibility - RN. 1. Assess and evaluate the effectiveness of CPI (Crisis Prevention Intervention) strategies utilized. 2. Attempt alternative methods listed above and in Alternatives to Restraints example..4. Evaluate the intervention that is the least restrictive and is most beneficial to the patient...Orders for the use of Restraint or Seclusion: Responsibility: RN/MD. The order must include type of restraint, the start and stop time (not to exceed 4 hours), the behavior exhibited and the behavior required for release...Documentation requirements: Responsibility: RN/MHT/LPN. 7. Level of Observation 1:1 ..."
Review of a hospital policy titled "Philosophy of Nursing" , no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record reviews and staff interviews, the hospital failed to ensure the Nursing Care Plan was revised and kept current as evidenced by failing to update and revise a patient 's plan for discharge to home was care planned by having no care planning documented after a patient reported being sexually abused at home during the Treatment Team Meetings conducted on 4/5/11, 4/6/11, 4/11/11 and to S18APRN on 4/7/11 and 4/8/11 for 1 of 1 focused sampled patients, (#14) with discharge planning out of a total of 15 sampled patients. Findings:

Patient #14:
Review of the "Multidisciplinary Treatment Plan" , date initiated of 3/30/11, date resolved of 4/12/11 revealed there was no documentation regarding the patient's discharge plan was revised on an ongoing basis on the care plan from 4/5/11 through 4/12/11.
Review of the "Treatment Team" Meetings dated/timed 4/5/11 (4:55 p.m.), 4/6/11 (1:00 p.m.), and "Physician Progress Note" dated/timed 4/7/11 (4:10 p.m.) and 4/8/11 (3:55 p.m.), revealed the patient reported being sexually abused at home to the treatment team and S18.

In an interview on 04//12/11 at 2:30 p.m., S3 Assistant Director of Nursing (ADON) confirmed there was no modification of the care plan regarding the patient' s (#14 ' s) discharge to home from 4/5/11 to 4/12/11.
During interview on 4/13/11 at 10:45 a.m. and at 12:36 p.m., S2, Director of Nursing (DON) verified there was no modification of the care plan regarding the patient's (#14 ' s) discharge to home from 4/5/11 to 4/12/11.
Review of the policy titled, "Treatment Plans" , with no policy number, effective, revised and/or reviewed date(s), presented as current "Treatment Plan" policy indicated the each patient will have an individualized inter-disciplinary treatment plan developed. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual' s clinical needs, condition, functional strengths, and limitations. The treatment plan will coordinate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. The plan will be revised throughout the patient' s hospitalization to reflect progress towards the treatment goals. The treatment team is led by the attending psychiatrist and is a collaborative effort to ensure effective treatment planning. A multi disciplinary Treatment Team Meeting is held to develop a comprehensive individualized Master Treatment Plan. The Master Treatment Plan is based on the findings of each contributing discipline, which describe the patient' s problems, strengths, clinical needs, and the patient's goals for treatment. The Master Treatment Plan contains, the patient' s diagnosis; estimated length of stay; the problems to be addressed; the strengths to be utilized; long-term goal of treatment for each problem; short-term goals (objectives) of treatment for each problem, written in objective, and measurable terms with expected dates of achievement stated; staff interventions; and discharge criteria. The type and frequency of interventions used to obtain the objectives are specified and the staff member(s) are identified. The treatment plans include referrals for services not directly provided by the hospital. Master Treatment Plan includes patient's family/significant others in the therapeutic process if applicable. The Plan includes planning specifically aimed at achieving the patient's goal(s) of treatment. Each problem of the treatment plan is addressed, updated, revised or resolved, and documented weekly during treatment team. All newly identified patient problems or diagnoses will be incorporated into the plan of care and the treatment plan will be modified to reflect these changes.




26458


Based on record reviews and interviews the hospital failed to ensure the Nursing Care Plan was revised to include patient seclusion and kept current as evidenced by no documented evidence of care planning for the patient while in seclusion for 1 of 1 focused sampled patients with seclusion orders in a total sample of 15 patients (#2). Findings:

Review of the treatment plan in the medical record of patient #2 revealed there was no documentation regarding the 3 seclusion periods ordered by the physician responsible for the care of the patient.
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no modification of the care plan of patient #2 regarding the seclusion of patient #2.
Review of a hospital policy titled "Policy for the use of Restraints/Seclusion" revealed in part: "...6. Responsibility: RN. The order must be in accordance to a written modification to the patient's plan of care..."

Based on record review and interview the hospital failed to ensure the Registered Nurse made patient care assignments based upon the needs of the patient as evidenced by failure to assign staff to 1:1/continuous visual observation of a patient in seclusion per hospital policy (#2) Findings:

01/15/11
Review of the nursing note documented on 01/15/11 at 1000 (10:00 a.m.) by S11RN read as follows: "Pt. manic, laughing loudly, roaming into pt' s rooms, cursing staff, exposing self to female pt. - Dr. (S17MD) notified, new orders obtained."
Review of the nursing note documented on 01/15/11 at 1045 (10:45 a.m.) by S11RN read as follows: "Pt's behavior escalating, pt loudly cursing and threatening staff, yelling "I will f*** you all up." Pt exposed self to female, pt attempted to disrobe female pt, wandering into pt' s rooms. (PD1) phoned for assistance. (1st call) Dr. (S17MD) notified. Orders obtained to place pt in locked BCR".
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1100 (11:00 a.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased psychotic bx (behavior)". The order was a verbal order taken by S11RN from S17MD.
Review of the nursing note for 01/15/11 at 1100 (11:00 a.m.) documented by S11RN reads as follows: "(PD1) arrived on unit, approached pt in room "a", pt had taken off clothes. Agreed to dress and calmly walked to BCR, apologizing to staff - Pt placed in locked BCR per orders. Will monitor continuously for safety".
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: Date: 01/15/11. Time: 1100 (11:00 a.m.). Place patient in: seclusion. Time Limit: 2 (hours)." Other interventions while in seclusion/restraints: "Assign staff member to provide continuous patient observation while intervention in effect... "
Review of the nursing documentation for 01/15/11 at 1500 (3:00 p.m.) by S11RN revealed: "Pt awake, up on unit. Pt resumes to threaten, verbally abuse staff. Pounding on windows of nursing station, throwing objects, cursing loudly, all attempts to redirect fail. (PD1) (2nd call) and Dr. (S17MD) notified. New orders obtained".
Review of the Physician's Orders for patient #2 dated 01/15/11 at 1500 (3:00 p.m.) revealed: "Place patient in locked BCR (behavioral control room) for threatening violence to staff and increased agitation and psychosis. Administer: Haldol 10 mg (milligrams) IM (intramuscular), Ativan 2 mg IM, Benadryl 50 mg IM." The order is a verbal order taken by S14LPN from S17MD.
Review of the nursing documentation by S11RN for 1515 (3:15 p.m.) on 01/15/11 reads: "(PD1) arrived on unit, escorted to BCR - Haldol 10 mg, Ativan 2mg, Benadryl 50mg admin (administered) IM. Pt placed in locked BCR per Dr. (S17MD) order. Will monitor continuously".
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/15/11. Time: 1500 (3:00 p.m.). Place patient in: seclusion. Time Limit: 4 (hours) ...Other interventions while in seclusion/restraints: Assign staff member to provide continuous patient observation while intervention in effect...".
Review of the nursing documentation by S11RN on 01/15/11 from 1645 (4:45 p.m.) through 1730 (5:30 p.m.) and documentation by S12RN from 1815 (6:15 p.m.) through 1915 (7:15 p.m.) revealed the patient was asleep. Further review of the documentation by S12RN for 7:15 p.m. revealed: "Dr. (S17MD) contacted, he reordered (which had expired at 1900 (7:00 p.m.)) the seclusion until pt awakens to reassess for violent behavior."
Review of a document titled "Doctor's Order Sheet Behavioral Restraints/Seclusion Renewal Orders" revealed a Renewal Order for seclusion of patient #2 on 01/15/11 at 1915 (7:15 p.m.), 15 minutes after the 4 hour seclusion order given by S17MD at 3:00 p.m. had expired. The documentation by S12RN read as follows: "Date: 01/15/11. Time from 1915 (7:15 p.m.) to 2315 (11:15 p.m.). Specific Behavior Requiring Order: Continuing to monitor, asleep at this X (time). Will assess when awake." The Order is signed by S12RN on 01/15/11 at 1915 (7:15 p.m.)."
01/16/11
S11RN documented the following on 01/16/11 at 1000 (10:00 p.m.): "Pt awake, up on unit. Loud outbursts, cursing, threatening behavior, unable to redirect. Demanding, becomes angry and aggressive if no given requests ...argues with image in windows and strikes self in window, + (positive) hallucinations ... ".
Review of the documentation by S11RN for 01/16/11 at 1205 (12:05 p.m.) revealed: "(Patient #2 is becoming increasingly agitated and aggressive. Pt is threatening violence toward staff and peers. Loudly cursing at staff and peers. Pounding fists on windows of nsg station and dayroom. All attempts to redirect fail. (S17MD) notified, new orders obtained. (PD1) called for assistance." (4th call)
S11RN documented at 1230 (12:30 p.m.) on 01/16/11 the following: "(PD1) arrived on the unit, escorted pt to BCR, assisted with administration of Haldol/Ativan/Benadryl injection IM. Pt placed in locked BCR per orders of (S17MD)".
Review of the Physician's Orders sheet revealed an order dated 01/16/11 at 1205 (12:05 p.m.) taken by S11RN from S17MD that read: "Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg, IM now x 1 dose for increased agitation R/T psychosis".
Review of the Physician's Order Sheet dated 01/16/11 at 12:30 p.m. revealed a verbal order taken by S11RN from S17MD that read: "Place pt. in locked BCR for threatening violence to staff and peers; increased agitation R/T psychosis".
Review of a Doctor's Order Sheet Behavioral Restraint/Seclusion Order flowsheet revealed: "Date: 01/16/11. Time: 1230 (12:30 p.m.). Place patient in: seclusion. Time Limit: 4 (hours)" The box for "Obtain face-to-face MD/LIP evaluation within one hour of implementation of seclusion/restraints " is not checked. "Other interventions while in seclusion/restraints: Assign staff member to provide continuous patient observation while intervention in effect..."
In an interview on 04/12/11 at 2:20 p.m. with S11RN she confirmed she was the RN on duty for 01/15/11 and 01/16/11 for the 6:00 a.m. to 6:00 p.m. shift. S11RN confirmed there was no documented evidence of a face to face evaluation within 1 hour of initiation of seclusion by an MD or RN deemed competent per hospital policy to perform the evaluation for any of the 3 seclusion initiations. S11RN stated she never initiated or requested 1:1 or continuous visible observation status for patient #2 for the monitoring of patient and/or the safety of the other patients. S11RN stated she never entered the seclusion room to check on patient #2 unless he was asleep because she was scared. S11RN stated that constant visual observation of patient #2 was not in place per hospital policy on any occasion when patient #2 was in seclusion 3 times during the two shifts she worked, 01/15/11 and 01/16/11.
In an interview on 04/12/11 at 3:10 p.m. with S12RN he confirmed that he contacted S17MD at 1915 (7:15 p.m.) and the seclusion order written at 1500 (3:00 p.m.) was renewed. S12RN confirmed his documentation on 01/15/11 at 1915 (7:15 p.m.) that patient #2 was asleep when the order was obtained. S12RN stated there was no face to face evaluation of patient by the MD or LIP deemed competent to perform the evaluation within 1 hour of the seclusion renewal order. S12RN stated patient #2 was not placed on 1:1 observation or continuous observation while in seclusion or at any other time during the 3 night shifts he worked (14th, 15th, and 16th).
In an interview on 04/12/11 at 1:05 p.m. with S17MD he stated he did not perform the face to face evaluation of patient #2 within 1 hour for any of the seclusion orders issued on 01/15/11 - 01/17/11. S17MD further stated he "did not know if they were done." S17MD stated that patient #2 "should have been on 1:1 observation."
In an interview on 04/12/11 at 11:00 a.m. with S2DON she stated the RN should have initiated 1:1 monitoring of patient #2 and notified the physician to obtain the order. S2DON confirmed there was no documentation of least restrictive methods being attempted prior to the documentation on the seclusion flow sheet and implementation of seclusion. S2DON confirmed there was no documentation of 1:1 or continuous visual observation of patient #2 while he was in seclusion. S2DON confirmed that hospital policy requires either the psychiatrist or RN deemed competent to perform a face to face interview within 1 hour of initiation of seclusion. S2DON confirmed this evaluation was not done for the 01/15/11 at 11:00 a.m. seclusion, the 01/15/11 at 3:00 p.m. seclusion, the 01/15/11 1915 (7:15 p.m.) renewal order, or the 01/16/11 at 12:30 p.m. seclusion order. S2DON reviewed the documentation for 01/15/11 seclusion renewal order and stated "there is no documented reason to keep a sleeping patient in seclusion" and that this was done for "nursing convenience."
In an interview on 04/13/11 at 1:00 p.m. with S2DON and S3ADON both confirmed there was no face to face assessment of patient #2 done at any time after initiation of seclusion for the entire hospitalization of patient #2. S2DON and S3ADON confirmed there was no documented evidence patient #2 was placed on an increased observation level for the entire stay in the hospital. S2DON and S3ADON verified there was no physician countersignature on the seclusion order sheets within 24 hours of initiation as required by hospital policy.
Review of the Behavioral Restraint/Seclusion Procedure flow sheet revealed the following: "... 4. The physician or specially trained RN must see the patient face to face and evaluate the need for restraint or seclusion within 1 hour after the initiation...(The RN performing the face to face evaluation may NOT be the RN initiating the intervention.)...6. Responsibility: RN. The order must be in accordance to a written modification to the patient's plan of care. Ongoing Assessment of the need for continuation: Responsibility: RN/MD. 1...Additionally, if the order is discontinued and reordered, the initial sequence begins with face to face in 1 hour. 2. If restraint or seclusion is discontinued prior to expiration of the original order, a new order must be obtained prior to reinitiating or reapplying the restraints or seclusion...Documentation requirements: Responsibility: RN/MHT/LPN. 7. Level of Observation 1:1 ..."
Review of a hospital policy titled "Philosophy of Nursing", no effective date, date reviewed or revised, reads in Part: "...Nursing Standards...Standard of Practice...3. Prevention of Injury. The nurse will provide an environment conducive to safety for patients, visitors and employees. The nurse will assess risks to patient's safety and implement appropriate precautions according to hospital policies and procedures. Standard of Care. The patient will be provided a safe physical environment ..."

Based on record review and interview the hospital failed to ensure medical records were complete within 30 days following discharge by failing to ensure the discharge summary was signed by the physician for 5 of 5 medical records reviewed (#1, #2, #3, #4 and #11). Findings:

Review of the hospital's policy and procedure for Discharge Summaries revealed the attending physician was responsible for developing a discharge summary to be included in the patient's record within 30 days of discharge. Further review of the policy reflected the chart would be considered complete when the discharge summary was filed in the chart and signed by the physician. . . .

Patient #1
Review of the medical record for patient #1 reflected the patient was admitted to the hospital on 1/3/11 and discharged on 1/19/11. Review of the discharge summary revealed the attending physician (#S17) had not signed the Discharge Summary as of 4/11/11.

Patient #2
Review of the medical record for patient #2 reflected the patient was admitted to the hospital on 1/14/11 and was discharged on 1/17/11. Review of the discharge summary for the patient revealed physician #S17 had not signed the discharge summary and the record remained incomplete as of 4/11/11.

Patient #3
Review of the medical record for patient #3 revealed the patient was admitted to the hospital on 1/25/11 and was discharged on 2/7/11. Further review of the medical record reflected the discharge summary had not been signed by the physician (#S17) and the record remained incomplete as of 4/11/11.

Patient #4
Review of the medical record for patient #4 reflected the patient was admitted to the hospital on 1/28/11 and was discharged on 2/11/11. Further review of the record reflected the discharge summary had not been signed by the physician (#S17) as of 4/11/11.

Patient #11
Review of the medical record for patient #11 reflected the patient was admitted to the hospital on 1/18/11 and was discharged on 1/28/11. Review of the discharge summary reflected physician #S17 had not signed the discharge summary as of 4/11/11.


Interview on 4/11/11 at 2:00 p.m. with the Medical Records Director, #S5, confirmed the discharge summaries for the above patients remained incomplete past 30 days. #S5 revealed physician #S17 was the physician responsible for signing the discharge summaries for the patients.

Interview on 4/11/11 at 3:00 p.m. with the Administrator, #S1 confirmed the hospital had a problem with discharge summaries being dictated and signed timely. #S1 further revealed that physician #S17 was the full-time physician for the hospital during the above time frame, and the discharge summaries should have been signed by physician #S17.

Based on observation, interview, and record review, the designated Director of Food and Dietetic Services failed to ensure safety practices for handling of food was implemented as evidenced by (1) yogurt dated 4/7/11 still in the patient refrigerator on 4/12/11; opened cereal boxes that were opened longer than 30 days; and (2) failing to measure the food and milk temperatures before being served to patients, having the potential to affect all patients in the facility. Findings:

(1) An observation on 4/12/11 at 11:00 a.m. of the patient's refrigerator revealed 2 containers of yogurt with an expiration date of 4/07/11. S16MHT confirmed the expiration date of the 2 containers of yogurt at the time of the observation.

An observation on 4/12/11 at 11:20 a.m. of the pantry items revealed 1 of 4 cereal boxes had been labeled with the date of 3/10/11 and still available for patient use.

In an interview on 4/12/11 at 11:20 a.m., S10 LPN, Director of Dietary Services stated that all items in the pantry are labeled with a date of when the item was opened. Then after 30 days, S10 stated it was discarded 30 days later. S10 confirmed a box of opened corn flakes had the label date of 3/10/11 and today's date was 4/12/11. S10 confirmed the opened box should have been discarded.

(2) An observation of the food being delivered for lunch on 4/12/11 at 11:00 a.m. revealed S16MHT did not check the temperature of the food. At this time, in an interview with S16MHT, she stated she only checks the breakfast tray.

In an interview on 4/12/11 at 11:00 a.m. with S7RN, she stated the food was delivered from a local nursing home whom the facility had a contract to provide dietary services. The nursing home delivers the food by van. The MHTs check the temperature of the food. The food is served on Styrofoam containers with plastic utensils.

Record review of the Dietary Manager QA form for the dates of 4/1/11 through 4/12/11 revealed no temperature readings for the cold drinks. On 4/1/11, under Findings on the Dietary Manager QA, was documentation that "Milk and juice was cold" out of 11 trays that were tested. On 4/2/11, under Food Temperatures: Drink, was documentation that the "milk was cold and the juice was cold" out of 12 trays tested. On 4/3/11, under Food Temperatures: Drink, was documentation that the "milk was cold and juice was cold" out of 13 trays tested. On 4/4/11, under Findings, documentation revealed "milk and juice was cold" out of 14 trays tested. On 4/5/11, under Findings, documentation revealed "Milk and juice was cold" out of 12 trays tested. On 4/7/11, under Findings, documentation revealed "Milk and juice was cold" out of 10 trays tested. On 4/8/11, under Findings, documentation revealed "Milk and juice was cold" out of 9 trays tested. On 4/9/11, under Food Temperatures: Drink, documentation revealed "Milk cold and juice cold" out of 9 trays tested. On 4/10/11, under Food Temperatures: Drink, documentation revealed "Milk cold and juice cold" on 8 trays tested. On 4/11/11, no documentation that the milk, juice, oranges was cold out of 9 trays tested. On 4/12/11, under Findings, documentation revealed "Milk and juice was cold" out of 9 trays tested.

In an interview on 4/12/11 at 12:14 p.m., with S10,LPN, Director of Dietary Services, stated she monitors the dietary sheets for the temperature. She added that the drinks are only checked for temperatures if the nursing home sends them in a container. S10, LPN confirmed that milk would be considered a perishable food item and should be monitored for temperature. S10 also stated that the nursing home sends a gallon of milk for breakfast and the MHTs monitor the temperature of the milk by the temperature readings of the thermometer in the refrigerator where the milk was stored "if the refrigerator is working like it should" S10 added. S10 confirmed that not all the daily temperature readings of the refrigerator where the milk was stored was 41 degrees and below.

A test tray was ordered for lunch and S16MHT measured the temperature. The rice was 140 degrees F. and the cold potato salad was 80 degrees F.

Record review of the facility's policy titled "Dietary Manager Scope of Service" pg 1 of 1 revealed that "Food shall be transported to the patients' in a manner that protects it from contamination, while maintaining required temperatures" and "All food shall be stored, distributed, and served under sanitary conditions to prevent food borne illness."

Based on record reviews and staff interviews, the hospital personnel failed to ensure the discharge planning evaluations were completed relative to the patient's clinical condition as evidenced by failing to reassess and update the discharge plan periodically after a patient reported being sexually abused at home during the Treatment Team Meetings conducted on 4/5/11, 4/6/11, and 4/11/11 and the "Physician Progress Note" by S18APRN on 4/7/11 and 4/8/11 for 1 of 15 sampled patient record reviews, (Patient #14).
Findings:

Review of the medical record revealed patient #14 was admitted on 3/30/11 at 1930 (7:30 p.m.) to the hospital with diagnosis of Schizoaffective disorder, Bipolar Type.

Review of the "Treatment Team" Meetings documented on the "Physician Progress Note" dated/timed 4/5/11 at 455 pm (4:55 p.m.) read, "patient seen - "don't know if want to go back (home). admits to "sexual" abuse from her mother. I'm tired of it, I cant accept it anymore." I don't know how to protect myself from her, I cant afford nothing" so can't move away from her." I just want to breathe again." "I want somebody to know what I been going thru my whole life...want somebody to know this woman's sick." "she lays in bed next to me masturbating. she's always touching herself (but used another vulgar word) she was always touching me (used another vulgar word). "she tells me she's a good damn mother." "Impression": "I feel helpless, feel like a kid with no one to turn to" "I had to write that letter", in chart "shows I'm ready to open up when I write it down".

The "Treatment Team Physician Progress Note" dated/timed 4/6/11 at 1300 (1:00 p.m.) read, "The pt (patient) had decided she needs to confide a secret she has carried for years. When seen individually she spoke of being sexually abused by her adoptive mother. She then spoke of how she thinks her adoptive mother is able to influence the people around her (the pt) so that other people begin to think and act, and sound like her adoptive mother. she believes her adoptive mother tries to poison her with something that smells like alcohol. Impression: "Pt has had a persistent persecutory complex about her adoptive mother for years". Plan: "Consider residential treatment...".

Review of the "Physician Progress Note" dated/timed 4/7/11 at 410 pm (4:10 p.m.) by S18, Nurse Practitioner (NP) read, "...she is a hateful, cruel woman, ...I need guidance, don't know what to do". "she's treating me like her lover, can't take it anymore...".

The "Physician Progress Note" dated/timed 4/8/11 at 355 pm (3:55 p.m.) by S18NP read,
"...uses vulgar words to describe her mother. "a lot of times I feel like I'm choking"...disorganized in "what [she wants] to tell [us] next" in regard to mother. "have been thinking all day." "she's the one I got the sickness from." started when around 5 yo." "The drug use when I was 19-20, just made it a thousand times worse. I get to be around a nurturing family; "used, abused, misused, & confused feels good to get it out...".

Review of the "Treatment Team Physician Progress Note" dated/timed 4/11/11 at 1420 (2:20 p.m.) read, "...Pt is ambivalent about discharge. "I don't wanta go back there [home] The pt wants to go to Wellness/St Landry Compass-will refer /c (with) d/c (discharge) tomorrow...Impression: Pt will need referral to {no documentation recorded where the patient was to be referred to}. Plan: d/c tomorrow /c f/u at St Landry / Wellness...".

The "Physician Progress Note" dated/timed 4/12/11 at 1150 AM (11:50 a.m.) documented by S18NP read, "patient seen- sleeping better...1st (first) time reported looking forward to move to Wellness...Impression: appropriate for discharge. Plan: discharge as planned followup /c Opelousas Wellness (formerly St Landry Psych/network residential)..."

Review of the "Psychosocial Assessment" dated 4/1/11 read, "Discharge to home".

The "Social Services Contact Log" dated 4/11/11 read, "Other assessments made to not discharge patient to home".

In a face-to-face interview held on 4/12/11 at 2:30 p.m., S3 Assistant Director of Nursing (ADON) indicated there was no documentation that the patient's (#14's) discharge plan was updated and evaluated after the patient reported being sexually abused during the Treatment Team Meetings conducted on 4/5/11 and 4/6/11. S3 stated there was no documented evidence that the patient's (#14's) discharge plan was updated and evaluated after the patient reported being sexually abused to S18APRN on 4/711 and 4/8/11. The ADON indicated the "Discharge Planning" protocol begins at the time of admission into the hospital. S3 reported the Social Worker and/or Treatment Team did not reevaluate, reassess and update the patient's discharge plan on 4/5/11, 4/6/11, 4/7/11, 4/8/11 or 4/11/11 as per policy. S3 from 4/5/11 to 4/11/11 the patients anticipated discharge plan was to home. The ADON reported there was no documented evidence the patient's discharge plan was assessed, evaluated, revised, reviewed and updated by the Treatment Team and Social Worker from 4/5/11 through 4/11/11 as per policy. S3, ADON indicated the patient was stressed due to the thought of being discharged back to the sexual abuse area from 4/5/11 through 4/11/11.

During interviews on 4/13/11 at 10:45 a.m. and at 12:36 p.m., S2, Director of Nursing (DON) indicated there was no documented evidence the patient's (#14's) discharge plan was reassessed and updated after the patient indicated sexual abuse during the Treatment Team Meeting conducted on 4/5/11, 4/6/11 and 4/11/11. S2 reported there was no documentation the patient's discharge plan was reassessed and updated by the Treatment Team and/or Social Worker after the patient reported sexual abuse to S18 APRN on 4/7/11 or 4/8/11.

Review of the policy titled, "Discharge Planning", with no policy number, effective, revised or reviewed date(s) read, the social worker will be responsible in conjunction with other members of the multidisciplinary team for establishing discharge criteria and for formulating aftercare plans for each patient from the time of admission. The social worker will evaluate potential discharge problems and will make recommendations for discharge planning in the psychosocial assessment within 72 hours of admission, The social worker, along with the treatment team, will facilitate discharge planning for each patient. The discharge planning will focus on reviewing the course of treatment, reviewing the precipitating events and stressors which led to the current hospitalization, helping patients recognize individualized "danger signals" which indicate emotional distress, and helping patients finalize living arrangements and aftercare before discharge. The social worker, along with other members of the treatment team, will discuss and document discharge plans with the patient and family prior to discharge. The purpose of the contact is to finalize living arrangements and aftercare plans, review patient's progress in treatment, and educate patient and family on the disease process and what steps to take in the event of a crisis.

Based on observation, record review, and interview, the hospital failed to meet the Condition of Participation of Special Provisions Applying to Psychiatric Hospitals by:

1. The hospital failed to be in compliance with the Conditions of Parcticipation specified in 482.13 by failing to meet the CoP of Patient Rights. (cross reference findings at A0115)

Based on observation, record review, and interview, the Psychiatric hospital failed to be in compliance with the hospital Conditions of Participation specified in ?482.13 by failing to meet the CoP of Patient Rights.

Based on record review and interview the hospital failed to ensure the psychiatric evaluation was performed within 60 hours of admission as evidenced by the psychiatric evaluation of patient #2 being done 65 1/2 hours after admission. Findings:

Review of the medical record of patient #2 revealed he was admitted on 01/14/11 at 1830 (6:30 p.m.).

Review of the Psychiatric Evaluation revealed S17MD, Psychiatrist, performed the evaluation on Monday January 17th, 2011 at 12:00 noon. This evaluation was 65 ? hours after admission.

In an interview on 04/12/11 at 1:05 p.m. with S17MD he confirmed the psychiatric evaluation was not done within 60 hours per hospital policy.

Review of a hospital policy titled "Assessments of Patients" , no date effective, reviewed or revised, reads in part: "To define the scope and time frames for patient assessments for each discipline involved in an individual patient's treatment...Procedure: The department specific time frames for assessments are as follows:..Psychiatric Evaluation - Psychiatrist - within 60 hours of admission ..."

Based on record reviews and staff interviews, the hospital failed to ensure the written plan short-term and long range goals included the patient's discharge criteria as evidenced by failing to modify, change, discontinue and/or update the plan after the patient reported being sexually abused at home during the Treatment Team Meetings held on 4/5/11, 4/6/11, and 4/11/11 and to S18APRN on 4/7/11 and 4/8/11 for 1 of 1 sampled patient records reviewed for discharge planning out of a total of 15 sampled medical records. (Patient #14) Findings:

Patient #14:

Review of the "Treatment Team" Meetings dated/timed 4/5/11 (4:55 p.m.), 4/6/11 (1:00 p.m.), and "Physician Progress Note" dated/timed 4/7/11 (4:10 p.m.) and 4/8/11 (3:55 p.m.), revealed the patient reported being sexually abused at home to the treatment team and S18APRN.

Review of the "Multidisciplinary Treatment Plan" , date initiated of 3/30/11, date resolved of 4/12/11 revealed there was no documentation regarding the patient' s discharge plan was modified, changed, discontinued, and/or updated in the written plan in the patient's medical record from 4/5/11 through 4/12/11.
In an interview on 04//12/11 at 2:30 p.m., S3 Assistant Director of Nursing (ADON) confirmed there was no documentation regarding the patient's (#14's) discharge plan was modified, changed, discontinued, and/or updated in the written plan in the patient's medical record from 4/5/11 through 4/12/11 as per policy.
During interview on 4/13/11 at 10:45 a.m. and at 12:36 p.m., S2, Director of Nursing (DON) verified there was no documentation regarding the patient's (#14's) discharge plan was modified, changed, discontinued, and/or updated in the written plan in the patient's medical record from 4/5/11 through 4/12/11 as per policy.
Review of the policy titled, "Treatment Plans" , with no policy number, effective, revised and/or reviewed date(s), presented as current "Treatment Plan" policy indicated the each patient will have an individualized inter-disciplinary treatment plan developed. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual's clinical needs, condition, functional strengths, and limitations. The treatment plan will coordinate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. The plan will be revised throughout the patient's hospitalization to reflect progress towards the treatment goals. The treatment team is led by the attending psychiatrist and is a collaborative effort to ensure effective treatment planning. A multi disciplinary Treatment Team Meeting is held to develop a comprehensive individualized Master Treatment Plan. The Master Treatment Plan is based on the findings of each contributing discipline, which describe the patient's problems, strengths, clinical needs, and the patient's goals for treatment. The Master Treatment Plan contains, the patient's diagnosis; estimated length of stay; the problems to be addressed; the strengths to be utilized; long-term goal of treatment for each problem; short-term goals (objectives) of treatment for each problem, written in objective, and measurable terms with expected dates of achievement stated; staff interventions; and discharge criteria. The type and frequency of interventions used to obtain the objectives are specified and the staff member(s) are identified. The treatment plans include referrals for services not directly provided by the hospital. Master Treatment Plan includes patient's family/significant others in the therapeutic process if applicable. The Plan includes planning specifically aimed at achieving the patient's goal(s) of treatment. Each problem of the treatment plan is addressed, updated, revised or resolved, and documented weekly during treatment team. All newly identified patient problems or diagnoses will be incorporated into the plan of care and the treatment plan will be modified to reflect these changes.

Based on record reviews and staff interviews, the hospital failed to ensure the treatment received by the patient was documented in the Treatment Plan to assure all active therapeutic efforts were included for the inpatient's discharge and aftercare as evidenced by failing to have an ongoing clinical process in place to assess and reevaluate the care and treatment for the patient's planning for discharge and aftercare after the patient reported an incident of sexual abuse at home during the Treatment Team Meetings held on 4/5/11, 4/6/11, and 4/11/11 and to S18APRN on 4/7/11 and 4/8/11 for 1 of 1 sampled patient records reviewed for discharge planning out of a total of 15 sampled medical records, (Patient #14). Findings:

Patient #14:

Review of the "Multidisciplinary Treatment Plan" , date initiated of 3/30/11, date resolved of 4/12/11 revealed there was no documentation regarding the patient's discharge plan was revised on an ongoing basis on the care plan from 4/5/11 through 4/12/11.
Review of the "Treatment Team" Meetings dated/timed 4/5/11 (4:55 p.m.), 4/6/11 (1:00 p.m.), and "Physician Progress Note" dated/timed 4/7/11 (4:10 p.m.) and 4/8/11 (3:55 p.m.), revealed the patient reported being sexually abused at home to the treatment team and S18.

In an interview on 04//12/11 at 2:30 p.m., S3 Assistant Director of Nursing (ADON) confirmed there was no modification of the care plan regarding the patient's (#14's) discharge to home from 4/5/11 to 4/12/11.
During interview on 4/13/11 at 10:45 a.m. and at 12:36 p.m., S2, Director of Nursing (DON) verified there was no modification of the care plan regarding the patient's (#14 ' s) discharge to home from 4/5/11 to 4/12/11.
Review of the policy titled, "Treatment Plans" , with no policy number, effective, revised and/or reviewed date(s), presented as current "Treatment Plan" policy indicated the each patient will have an individualized inter-disciplinary treatment plan developed. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual's clinical needs, condition, functional strengths, and limitations. The treatment plan will coordinate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. The plan will be revised throughout the patient's hospitalization to reflect progress towards the treatment goals. The treatment team is led by the attending psychiatrist and is a collaborative effort to ensure effective treatment planning. A multi disciplinary Treatment Team Meeting is held to develop a comprehensive individualized Master Treatment Plan. The Master Treatment Plan is based on the findings of each contributing discipline, which describe the patient's problems, strengths, clinical needs, and the patient's goals for treatment. The Master Treatment Plan contains, the patient's diagnosis; estimated length of stay; the problems to be addressed; the strengths to be utilized; long-term goal of treatment for each problem; short-term goals (objectives) of treatment for each problem, written in objective, and measurable terms with expected dates of achievement stated; staff interventions; and discharge criteria. The type and frequency of interventions used to obtain the objectives are specified and the staff member(s) are identified. The treatment plans include referrals for services not directly provided by the hospital. Master Treatment Plan includes patient's family/significant others in the therapeutic process if applicable. The Plan includes planning specifically aimed at achieving the patient's goal(s) of treatment. Each problem of the treatment plan is addressed, updated, revised or resolved, and documented weekly during treatment team. All newly identified patient problems or diagnoses will be incorporated into the plan of care and the treatment plan will be modified to reflect these changes.