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Based on observation, document review, and interviews with key staff on May 8-10, 2013, it was determined that the hospital failed to be in compliance with the State of Maine Department of Health and Human Services Rights of Recipients of Mental Health Services:

Part A, III Basic Rights, A....Recipients have the right to a humane psychological and physical environment within the facility or program, and

Part B, II. Privacy and Human Treatment Environment, F. 2. Recipients shall not be subjected to physical abuse and corporal punishment is expressly prohibited.

The evidence is as follows:

1. The hospital failed to ensure that all patients received care in a safe setting (see Tag A-0144); and

2. The hospital failed to ensure that patients were free from all forms of abuse or harassment (see Tag A-0145).


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

Based on observation, document review, and interviews with key staff on May 8-10, 2013, it was determined that the hospital failed to have an effective governing body legally responsible for the conduct of the hospital as an institution.

The evidence is as follows:

1. The governing body failed to ensure compliance with the requirements of the 'Rights of Recipients for Mental Health Services' (see Condition of Participation, Compliance with Laws, Tag A-0020);

2. The governing body failed to ensure compliance with the hospital's policies and procedures (see Tag A-0057);

3. The governing body failed to ensure that patient rights were protected and promoted (see Condition of Participation, Patient Rights, Tag A-0115);

4. The governing body failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program focusing on indicators related to improved health outcomes and the prevention and reduction of medical errors (see Condition of Participation, QAPI, Tag A-0263);

5. The governing body failed to hold the medical staff responsible for the quality of care provided to patients (see Condition of Participation, Medical Staff, Tag A-0338); and

6. The governing body failed to ensure that the hospital was constructed, arranged and maintained to ensure the safety of patients (see Condition of Participation, Physical Environment, Tag A-0700).

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

Based on observation, document review, and interviews with key staff on May 8-10, 2013, it was determined that the hospital failed to protect and promote each patient's rights. These findings represented an Immediate Jeopardy to the patients at Riverview Psychiatric Center.

The evidence is as follows:

1. The hospital failed to ensure that patients were free from all forms of abuse or harassment (see Tags A-0145 and A-0154).

2. The potential impact of the facility not ensuring that patients are free of abuse as evidenced by the use of a Taser in a patient who was in a non-threatening position on the floor and use of hard handcuffs by sheriff officers to escort patients to seclusion and restraint would be that patients were placed in danger of physical harm, pain and mental anguish.

3. The failure to prevent abuse represented an immediate jeopardy to patients of Riverview Psychiatric Center.

4. An interim safety plan to prevent abuse was presented to and accepted by the survey team on May 10, 2013. The interim safety plan included immediate education for staff and Kennebec Sheriff Officers (KSO), clarification of protocols, and review of all incidents by the hospital.

5. The hospital failed to be in compliance with the requirements of the 'Rights of Recipients for Mental Health Services' (see Tag A-0020).

6. The hospital failed to provide a patient with a written notice following a grievance (see Tag A-0123).

7. The hospital failed to utilize the least restrictive intervention effective for restraint and seclusion (Tags A-0164 and A-0165).

8. The hospital failed to ensure that all patients received care in a safe setting (see Tag A-0144).


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

Based on document review and interviews with key staff on May 8-10, 2013, it was determined that the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. Additionally the hospital's governing body failed to ensure that the program reflected the complexity of the hospital's organization and services; involved all hospital departments and services (including those services furnished under contract or arrangement); and focused on indicators related to improved health outcomes and the prevention and reduction of medical errors.

The evidence is as follows:

Failure to Have a QAPI Program

1. On May 10, 2013, the hospital Advisory Board meeting minutes of August 20, 2009, were reviewed. and stated, under the issue Performance Improvement, [Director] distributed a packet depicting his vision of quality integrated programs at Riverview and [another facility]. Under Plan it stated, "Informational."

2. A review was made of the [another facility] and Riverview Psychiatric Center Integrated Quality Programs Transition Plan on May 10, 2013. This document stated, "The ultimate goal of this integrated plan is to advance the retention and development of organizational and individual knowledge, improve efficiencies and reduce waste of both time and resources, and improve the value of services for clients, staffs, and the public. This plan is expected to take a period of 3-5 years to complete the transition described."

3. On May 10, 2013, a review was made of the policy titled, 'Organizational Performance Excellence Program.' It stated, "......The performance improvement process is outlined in the Hospital's Organizational Performance Excellence Plan. The plan is reviewed and revised annually, and approved by both the Executive Leadership Committee and the Advisory Board." This policy was approved and implemented February 2012.

4. On May 8, 2013, at approximately noon, when the Superintendent was asked for a copy of the 2012/2013 Hospital's Organizational Performance Excellence Plan, she stated, "You will have to ask the [Director]."

5. During an interview with the Director, Integrated Quality Program, on May 10, 2013, at 8:45 a.m., he stated, "I don't know where or when the transition plan was approved." When asked about the quality assessment and performance improvement data, he stated, "The data would be found in the quarterly reports."

6. The Riverview Psychiatric Center Quarterly Report on Organizational Performance Excellence, Third State Fiscal Quarter 2013, January, February, March 2013, dated April 15, 2013, was reviewed May 8-10, 2013. This report did not contain data that reflected the complexity of the hospital's organization and services; involved all hospital departments and services (including those services furnished under contract or arrangement); and focused on indicators related to improved health outcomes and the prevention and reduction of medical errors.

7. During an interview with the Director, Integrated Quality Program, on May 10, 2013, at 8:50 a.m., he stated, "There were no medical staff projects for the past year until the third quarter and then canceled for the fourth quarter due to a lack of psychology providers."

8. During an interview with the Director, Integrated Quality Program, on May 10, 2013 between 9:15 a.m. and 9:20 a.m., he stated, "The transition plan was not approved by the Board. It was informational only on August 20, 2009. We focused on the Consent Decree since 1980. QAPI didn't come in until the Affordable Care Act of 2009. There is no 2013 PI [Performance Improvement] Plan. Whatever you say, the outcome is predetermined anyway."

9. In spite of the Transition Plan and the Organizational Performance Excellence Program Policy, presented in August 2009, there was no QAPI [Quality Assurance and Performance Improvement] Program for 2012 or 2103.

10. The survey team was presented with the Integrated Plan for Performance Excellence for 2014, to be submitted in the future.

11. The potential outcome of the lack of a current effective, QAPI Program is that prevention and reduction of medical errors, improved health outcomes and identification of areas needing improvement would not be identified.

Failure to Have Performance Improvement for the Medical Staff

12. Please see Tag A-0338 for additional information regarding the Quality Assessment and Performance Improvement Program for Medical Staff

Failure to Complete the Quality Process

13. A Statement of Deficiencies (Form CMS-2567) dated March 29, 2013 was issued to Riverview Psychiatric Center which cited issues with Patient Rights and Nursing Services. Please see this Form CMS-2567.

14. The LOWER SACO PERFORMANCE IMPROVEMENT TEAM FINAL REPORT AND RECOMMENDATIONS was presented to the co-team leaders on May 9, 2013. This document was a result of a Process Improvement Team's approach to the issues identified during the recent complaint investigation in April 2013. It stated the following:

a. This is part of the Mission Statement that was agreed to 2 weeks ago: ".....It is the goal of the Unit to provide high quality care while maintaining privacy, respect and safety for clients and staff."
b. "Physical plant requirements and needed changes: all areas of the unit, but especially the special care unit and seclusion rooms, need to be hardened."
c. "staff changes: All agreed that an ideal complement of nurses on the day shift would be 5 staff nurses plus treatment team coordinator, plus Nurse VI, but concluded that this is probably an unrealistic number."
d. "Potential Job Description for Correctional Officer."
e. "Unit guidelines and practices: the PIT [Process Improvement Team] agreed that a significant change in treatment philosophy and mission is necessary. A greater emphasis on on-unit treatment groups, security, and safety; and a lesser dependence on off unit activities will be needed."
f. "Policies and practices on preventing and dealing with violence on the unit. A. In a effort to prevent violence there needs to be a proactive approach to identify those at high risk of violence or having difficulty at self-control. Early and effective intervention is necessary."
g. "Management of monitored items and client belongs: the Team acknowledged that management of material possessions of the clients on Lower Saco has been a concern over the past few years."
h. "A subgroup of the PIT team met and made some suggestions for enhance on-unit programming."

15. An interview was conducted with the Acting Director of Nursing on May 9, 2013, at approximately 10:30 a.m. He/she stated that the Final Report referenced above was not the final report. That management staff had received the report a few days earlier and had been asked to comment on it soon with what they agreed with and disagreed with. Additionally, nothing discussed in the Final Report had been acted upon.

16. Even though the Quality Council [Integrated Performance Excellence Committee] met seven (7) times between May 24, 2012 and April 25, 2013, there was no discussion about the lack of an approved Integrated Plan for Performance Excellence for 2013.

17. The potential outcome of a quality committee not identifying the need to address action plans for quality issues, is that processes and systems do not get changed and therefore the same quality issues arise again.


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on review of documents and interviews with the Medical Director on May 8 and 9, 2013, it was determined that Riverview Psychiatric Center's Medical Staff was not responsible for the quality of care provided to the patients and was not in compliance with its Bylaws.

Findings Include:

Lack of Peer Review

1. The Medical Staff Quality Improvement Plan 2012-2013 states, " Regularly scheduled internal peer review by full time medical staff occurs on a monthly basis. Our plan is to focus on pharmacological issues as related to client weight and non-response to expected psychiatric treatment and mandated abnormal involuntary movement assessments in this fiscal year. We will peer review all patients judged by the attending physician, or others (including nursing, administration, the risk manager, or the medical director), as not exhibiting a satisfactory response to their medication regimens. In addition we will peer review the medical treatment plan for all patients with seriously elevated BMIs. "

2. In a meeting on May 8, 2013 at approximately 9:30 AM, the Medical Director was asked where minutes of the above described peer reviews and Medical Staff Quality Improvement activities would be found. He said they would be in the minutes of the Medical Staff Peer Review and Quality Assurance Committee or in the minutes of the Medical Executive Committee.

3. The minutes of the Medical Staff Executive Committee from April 2012 through April 2013 were reviewed. There were no minutes documenting discussion of peer review.

4. The minutes of the Medical Staff Peer Review and Quality Assurance Committee from April 2012 through April 2013 were reviewed. There were five (5) meetings during this time period.

5. Of the five (5) meetings from April 2012 through April 2013, only three (3) meetings contained any case discussion. The two (2) meetings held in 2013, (February 26 and April 16), had no case discussion.

6. There were five cases discussed in these minutes. All cases were " Informational " . Only one case in the minutes had documentation of a discussion of therapeutic options. None of the case discussions involved commentary on medical or psychiatric decision-making.

7. There was no evidence of review of " pharmacological issues as related to client weight and ... peer review the medical treatment plan for all patients with seriously elevated BMIs. " Nor review of " mandated abnormal involuntary movement assessments. "

8. There was no evidence of discussion regarding the quality of care provided to the patients in any of the case reviews summarized in the minutes. There was no evidence that the quality of medical or psychiatric decision-making was reviewed for any of the practitioners.

9. The Medical Staff Quality Improvement Plan 2012-13 state, " Internal Peer Review outcomes: Medical Director reports monthly to the Med Staff QA and Peer Review Committee ... "

10. In the thirteen (13) months from April 2012 through April 2013, there were only five (5) meetings of the Med Staff QA and Peer Review Committee.

11. The minutes of the October 16, 2012 Peer Review meeting state, "[Medical Director] noted that the committee's only peer review at this time is the monthly review of progress notes, discharge summaries, history & physicals, and admission psychiatric evaluations. "

12. During a meeting on May 9, 2013, the Medical Director stated that these reviews are related to quality of documentation.

13. During a meeting on May 9, 2013, the Medical Director stated that the minutes were accurate. He confirmed that the Medical Staff had not reviewed the peer review indicators as outlined in the quality plan. He further stated that the medical staff had not selected other peer review indicators.

Lack of Performance Improvement

1. The Medical Staff Bylaws, Article 7.5.2. a. states, " ...supervise the conduct of specific programs and procedures for assessing, maintaining and improving, as required, the quality and efficiency of medical care provided in the hospital. "

2. The document " Medical Staff Quality Improvement Plan 2012-2013 " was reviewed. The Plan states, " ...medical staff members will participate in ongoing and systematic performance improvement efforts...This is accomplished through peer review, clinical outcomes review, variance analysis, performance appraisals, and other appropriate quality improvement techniques. "

3. According to the " Medical Staff/Clinical Services Department, Plan of Operation 2013 " , " The primary functions of the medical staff department include the provision of psychiatric services, general medical services, dental services, psychology services and podiatry services. " This was confirmed by the Medical Director during a meeting on May 8, 2013.

4. The Medical Director stated that Podiatry was a consultative service and was not often performed.

5. The Medical Staff Quality Improvement Plan 2012/2013 lists the following Quality Improvement initiative. " Timeliness of Psychological Testing " .

6. The Plan states, "The Director of Psychology will collect referral and test completion data, prepare a monthly report of compliance with this timeliness measure, and report it to the Medical Executive Committee at its monthly meeting."

7. The minutes of the Medical Staff Executive Committee from April 2012 through April 2013 were reviewed. There were no reports of "compliance with this timeliness measure" from the Director of Psychology.

8. The, " Riverview Psychiatric Center Quarterly Report on Organizational Performance Excellence, Third State Quarter 2013, January, February, March 2013, dated April 15, 2013 " , completed by the Superintendent states, " ...Quarterly Update ...2nd Quarter 2013...Due to a significant loss of Psychology providers during the past few months this study has been delayed until replacements can be recruited. "

9. The Medical Director confirmed that there were no results available for this quality improvement initiative related to psychology. The Medical Director further stated there were no other quality improvement initiatives related to psychology.

10. There was no Quality Improvement Initiative in 2012/2013 related to the care provided by the Psychiatrists. This was confirmed by the Medical Director during a meeting on May 9, 2013.

11. There was no Quality Improvement Initiative in 2012/2013 related to the care provided by the Primary Care providers. This was confirmed by the Medical Director during a meeting on May 9, 2013.

12. There was no Quality Improvement Initiative in 2012/2013 related to the care provided by the Dentist, although the Medical Director provided evidence of outside peer review for the care provided in the dental clinic.

13. The Medical Director confirmed that the psychological testing initiative was the only prospective quality improving initiative for the Medical Staff in 2012/2013.

Patient Abuse

The medical staff failed to ensure that patients were free from all forms of abuse or harassment (see Tags A-0145 and A-347);

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

Based on tours and observations of the facility, document review, and interviews with key staff on May 8-10, 2013, it was determined that the facility failed to be constructed, arranged, and maintained to ensure the safety of the patient. These findings represented an Immediate Jeopardy to the patients on the Lower Saco Unit at Riverview Psychiatric Center.

The evidence is as follows:

1. While surveying the facility with the safety officer the Inspector observed the following violations of NFPA Life Safety Code 101 2000 Edition Section 19.2.2.2.2, and MSRA Title 25 Section 2452:

a. During a tour of the Lower Saco Unit Main Section on May 8, 2013, the Inspector observed that a door leading from the corridor to a seclusion patient room was equipped with ( 2) sliding deadbolt locks and a key operated lock at 2:35 p.m.

b. During a tour of the Lower Saco Unit ( Forensic section) on May 8, 2013, the Inspector observed the door from the corridor to the patient seclusion room was equipped with two (2) sliding deadbolt locks and a key operated lock at 2:50 p.m.

c. At 3:05 p.m. at the verbal order of the Inspector, the deadbolt locks were removed by facility maintenance staff.

d. At approximately 5:34 p.m., this Inspector went back to the Lower Saco Unit (forensic section) and observed the door to the seclusion room that was locked with a key and asked the Law Enforcement Officer that was charged with monitoring the patient in the seclusion room to open the door. Prior to opening the door the officer inserted a steel rod in to the floor outside of the door that restricted the opening of the door to approximately 10 inches in width. This Inspector was told that using this restriction device on the door was the required practice when the door was opened.

2. Potential Life Safety Impact statement: The use of a non approved lock (deadbolt) on a door in a required means of egress could result in a patient or staff person not being able to egress the space in the event of an emergency such as fire,smoke, building collapse. The deadbolt lock does not require a key to lock the door and any one in the corridor could lock the door and not be an approved staff person. The exceptions in NFPA Life Safety code 101 2000 Edition Section 19.2.2.2.2 ( a and b) both require a key to lock a patient room door from the corridor side.

3. These findings represented an Immediate Jeopardy to any patient on this unit (please see Life Safety Code Statement of Deficiencies dated May 10, 2013 for additional information).

4. The facility immediately removed the dead bolts on May 8, 2013, thus removing the Immediate Jeopardy.

5. The hospital failed to meet Life Safety Code requirements (See Life Safety Code Statement of Deficiencies dated May 10, 2013).

6. The hospital failed to be constructed, arranged and maintained to ensure the safety of patients (see Tag A-0701).


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

Based on medical record review, observation, staff and patient interview it was determined that the facility failed to:

1. Revise treatment plans to include a treatment regime based on the current treatment needs for 3 of 8 active sample patients (B11, C2, D18) and 1 of 2 non-sample patients (C17) who were added to the sample for review of active treatment. These patients were scheduled for groups that they were clinically unable to attend (B11 and B18) or refused to attend (C2 and C17). In spite of continued failure to attend, treatment plans were not revised to meet patient needs. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement. (Refer to B118)

2. Assure that modalities selected for the treatment of 2 of 8 active sample patients (Patients B11 and D18) were appropriate to their individual needs. In the case of Patient B11, the interventions were not appropriate based on the patient's current acute clinical status and in the case of Patient D18, the interventions were excessively restrictive, utilized law-enforcement, and were planned to be continued without further alteration for a 90 day period. This failure results in lack of guidance to clinical staff in providing consistent and effective treatment related to patients' identified problems and goals. (Refer to B122)

3. Ensure that active treatment was provided for 3 of 8 active sample patients (Patients A1, C2, and D18) and 1 of 2 non-sample patients (C17) added for review. These patients were scheduled for groups which they were clinically too acutely ill to attend or refused to attend. There were no other alternative treatment modalities selected. This failure may prolong the need for hospitalization. (Refer to B125)

4. Manage potentially violent patients without the help of law-enforcement, who are deployed and armed with Taser weapons and present within the acute care setting 24 hours daily. (Refer to B122 and B125, findings related to Patient B18, for details)

Based on interview and document review, the facility failed to assure that the Medical Director and the Director of Nursing (DON) monitored active treatment and took needed corrective actions. Specifically,

I. The Medical Director failed to provide adequate medical leadership. The Medical Director failed to:

A. Assure that Treatment Plans were revised when the clinical status of the patient changed for 3 of 8 active sample patients (Patients B11, C2 and D18) and 1 of 2 non-sample patients (C17) added for assessment of active treatment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement. (Refer to B144)

B. Assure that modalities for 2 of 8 active sample patients (Patients B11 and D18) were not overly restrictive and prolonged and assure that for D18 the modalities were administered without the assistance of law-enforcement. This failure results in lack of guidance to clinical staff in providing consistent and effective treatment related to patients' identified problems and goals. (Refer to B144)

C. Assure that the Treatment Plans for 2 of 8 active patients (Patients C2 and D18) listed the names of responsible team members for modalities chosen. This failure results in an inability to identify which team member is accountable. (Refer to B144)

D. Assure that active treatment was occurring for 3 of 8 active sample patients (A1, C2 and D18) and 1 of 2 non-sample patients (Patient C17) chosen for review. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement. (Refer to B144)

E. Assure that management of violence-prone patients was conducted by clinical staff and without the use of Taser-armed Sheriff Officers. (Refer to B144)

II. The Director of Nursing failed to:

A. Assure that management of violence-prone patients was conducted by clinical staff and without the use of armed Sheriff Officers. This results in a) conflict between treatment and law enforcement actions, and b) a potential breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment, rather than one that threatens. (Refer to B148)

B. Provide adequate numbers of Registered Nurses (RNs), to monitor and supervise the patient care on 2 of 4 wards (Lower Kennebec and Lower Saco). Each of these 2 units serves acutely ill patients in 2 areas that are physically separated by a locked door. This staffing pattern hinders the provision of quality nursing care due to failure of on-going professional nursing assessments of patients, and professional nursing direction and supervision of non-professional nursing personnel. (Refer to B150)

Based on observation, document review and interviews with key personnel on May 9 and 10, 2013, it was determined that the Chief Executive Officer (CEO) failed to manage the hospital to ensure compliance with the hospital's policies and procedures.
Findings include:

Dental Clinic Staff Infection Control Proceedings Policy

1. During observation of a dental procedure at the Portland Outpatient Clinic at approximately 1120, it was observed that neither the dentist nor the dental hygienist wore protective eyewear.

2. The hospital policy Dental Clinic Staff Infection Control Proceedings stated, "Protective clothing shall be worn by staff at all times during treatment ...this includes safety glasses ...."

3. During an interview with the dentist at approximately 1130, when asked if he ever wears eye protection, he stated, " no, I don't wear any other glasses except these [pointing to his prescription eye glasses]."

4. During an interview with the dental hygienist at approximately 1130, when asked if she ever wears eye protection, she stated, "our policy just says they have to be available..."

5. These findings were immediately confirmed with the Acting Assistant Director of Nursing.

6. These findings were also discussed with the Clinical Director, who was then observed discussing the policy with the dentist.


Provision of Care, Treatment and Services Topic Universal Assessment Policy

7. Riverview Psychiatric Center Policy No: PC.2.20 Provision of Care, Treatment and Services Topic Universal Assessment,stated, a."Complete all relevant pages of the Universal Assessment (Physician/Psychiatrist) within 24 hours; b. Complete all relevant pages of the Universal Assessment (Nursing) within 24 hours after client's admission ; and c. The Universal Assessment is completed for all annual reassessments."

8. Record V's last Annual Nursing Assessment documented in the patient medical record was dated August 7, 2011.

9. Record X's last Annual Nursing Assessment documented in the patient medical record was dated March 26, 2012.

10. Record Z 's last Annual Nursing Assessment documented in the patient medical record was dated November 26, 2011.

Based on review of five (5) grievances, and interviews with key personnel on May 10, 2013, it was determined that the facility failed to provide the patient with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. The Grievance Form B, dated January 27, 2013, indicated that the patient voiced a written grievance which was reviewed and a response was written; however, it also indicated that the patient was discharged back to prison before the written response with the resolution of the grievance could be given to the patient.

2. This finding was confirmed by the Program Services Director for Nursing on May 10, 2013, at 11:35 a.m.

Based on observations of forensic units on May 8-10, 2013, review of three (3) inpatient clinical records, document review and interviews with patients and key staff on May 8-10, 2013, it was determined that the hospital failed to provide protection for the emotional health and safety of patients as well as their physical safety.

The evidence is as follows:

1. On May 9, 2013, a document, not titled, was provided for review. This document stated its purpose was to assist in maintaining a safe environment for staff and patients with the use of two (2) Kennebec Sheriff Officers (KSO) to provide twenty-four/seven (24/7) coverage for lower Saco SCU (Special Care Unit).

2. In an interview with KSO Officer 1 on May 10, 2013, he stated that since April 29, 2013, KSO can now take over on all patients on Lower Saco, their purpose being to maintain safety of staff and allow staff to do their job. Their training differs from RPC staff in that they are certified in use of Tasers, and licensed in Corrections. When asked what force is used by KSO, he stated " Restraint/Control." He stated threats from patients are always present on the Lower Saco Unit.

3. In an interview with KSO Officer 1 on May 10, 2013, he stated the Taser is present as a deterrent for behavior from patients. He stated that since KSO presence on the Lower Saco unit there is much less violence from the patients. He stated that one (1) patient who had destroyed a lot of property had stated in a joking manner that he/she would not do that anymore because he/she did not want to get "Tasered."

4. A Psychiatrist note dated April 30, 2013 in Patient A's medical record, noted the following: '[Patient A] was preoccupied with corrections officers who are assigned to our ward and kept turning around to monitor what they were doing and where they were on the ward. [He/She] yelled at the corrections officer "What ' re you looking at? You don ' t have to be looking down here." Clearly, the officer was monitoring the unit, which is his assignment to ensure my safety and the safety of other staff and clients on the ward. Suddenly [patient named] turned and charged towards the officer shouting, "What 're you looking at," along with expletives. [He/She] was also making large muscle movements suggesting that physical aggression was imminent. A psychiatric emergency was declared to allow [him/her] to get some medication as [he/she] had been ultimately aroused for forty (40) minutes."

5. The potential outcome of the above protocols and practice would be a violation of the patient ' s rights to receive care in a humane treatment environment with care being directed by sheriff officers rather than nursing staff.

6. The hospital failed to be in compliance with the requirements of the 'Rights of Recipients for Mental Health Services' (see Tag A-0020); the hospital failed to ensure that patients were free from all forms of abuse or harassment (see Tags A-0145 and Tag A-0154); and the hospital failed to be constructed, arranged and maintained to ensure the safety of patients (see Tags A-0700 and A-0701).

Based on observations, review of three (3) inpatient clinical records, document review, and interviews with patients and key staff on May 8-10, 2013, it was determined that the hospital failed to ensure that all patients are free from all forms of abuse.

The evidence is as follows:

42 Code of Federal Regulation Part 488.301 defines abuse as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish."

Protocol for Tasers and Handcuffs

1. While the utilization of weapons such as Tasers and handcuffs were not considered a healthcare intervention, under " Protocol," the untitled document presented on May 9, 2013 stated: "KSO will observe for any situation that appears to be escalating and may intervene without staff request if there is imminent danger...RPC staff will not interfere and will assist as needed." Specific duties were listed for the KSO which included periodic walk through's on the main units at times when requested by staff or when KSO is able to, participation in unit searches, monitor for contraband and a requirement that KSO will document each shift anything out of the ordinary that happens and report it to the charge nurse. Under the category entitled "Taser," it stated, " if at any time the KSO deploys the Taser, staff do not remove the probes from the client once he/she is down...Once the probes are removed by KSO, RPC will assist the KSO to move/secure the client as needed... An incident report is made if Taser is used."

2. In an interview with KSO Officer 1 on May 10, 2013, he stated that if KSO officers see body language, stance or threatening patient behavior and nursing does not make the call for help they can step in. Their training differs from RPC staff in that they are certified in use of Taser, and licensed in Corrections. They are trained in different type of force than NAPPI (Non Abusive Psychological and Physical Intervention) used by RPC. When asked what force used by KSO he stated " Restraint/Control."

3. The potential outcome of the above protocols and practice may be that patient assessment and intervention are directed by the KSO, rather than by medical and nursing staff.

Use of Taser and Handcuffs on Patient A

4. Patient A's clinical record indicated that Patient A was admitted to Riverview and determined to be not criminally responsible (NCR). The record contained an order for restraint dated May 1, 2013, at 10:55 p.m. The order stated "Taser used by Police here." This order was signed by a physician assistant. The interventions used prior to the use of the Taser included Voluntary time out, Redirection and asked to go back to room. A psychiatric emergency was declared and the documentation included that the patient had pulled a soap dispenser off the wall and thrown it at staff.

a. A physician note dated May 1, 2013, which described the above behavior noted that "Security Officers at that point stepped in and were about to Taser the [lady/gentleman] when [he/she] went to [his/her] room and closed [his/her] door, after which point I arrived on the unit." Patient A came out of his/her room and continued to escalate verbally. Further documentation noted "[He/She] refused to go back to [his/her] room and sat on the ground. Security told [him/her] that they would have to Taser [him/her] if [he/she] would not do it. [He/She] refused to get up, continuing to be verbally hostile and was apparently Tasered by the security officer. [He/She] was already sitting when this happened and apparently [he/she] stopped being as agitated and did not lose consciousness." An assessment was completed by the psychiatrist who noted "Left thoracic-abdominal abrasion secondary to Taser metal prong puncturing skin with no signs of infection or deeper injury. Generalized thoracic discomfort secondary to likely with the time some muscle cramping as to the Taser application but without any significant findings of any cardiac injury or respiratory injury or any significant musculoskeletal injury, just as achy discomfort that [he/she] has in this generalized area when [he/she] moves without any antalgia. I do not see any further workups at this point is warranted."

b. There was documentation dated May 1, 2013, by a physician assistant which noted an electrocardiogram (EKG) and vital signs were ordered. There was documentation that the patient refused to have vitals signs done and ignored staff when called to have the EKG.

c. A nursing note recorded on May 2, 2013, at 5:28 a.m. noted, "Taser was deployed by the KSO officer. Client was then escorted by the KSO officers to the SRC [Seclusion and Restraint Suite] on the main unit. Client was handcuffed. Client walked under [his/her] own power with assisted walk."

5. Nurse 1 (author of above note) was interviewed on May 10, 2013, at 9:30 a.m. She stated she did not witness the Taser being used, but she observed the escort with KSO officers with the patient handcuffed with hands behind his/her back. She stated she was shocked about the use of the Taser as she had never seen this happen before. She stated she was concerned with the patient's well-being. She said the patient screamed at her stating "see what they're doing." She stated that there was some training with staff related to Taser use but she worked nights and had not attended the training. She stated she would ask KSO to assist but not to use the Taser. She stated she had not received education for the nursing assessment of a patient following the use of the Taser.

6. Patient A was interviewed on May 9, 2013, at 1: 25 p.m. He/She stated when Tasered he/she was sitting on the floor. When asked to describe how he/she felt after being Tasered he/she stated " skin hurt, stomach hurt, elbow hurt, heart hurt." He/She was sore to touch when moved. He/She further stated that he/she was handcuffed and escorted to SRC. The next morning, he/she was handcuffed and carried back from the main unit to the SCU unit by four (4) guards.

7. Nurse 3 was interviewed on May 10, 2013, at 11:45 a.m. He was present when the patient was Tasered. He described the scenario which led up to the event. He stated he offered to talk with the patient, and the patient refused and swore at him and was posturing. At that point KSO officers to the right and left of him stepped in and told the patient not to talk to staff that way and to back away. He stated that staff had had a meeting that afternoon prior to this incident and were instructed that the guards have full range of decision to intervene. The guards then told the patient that he/she had to go to his/her room. Then the patient walked to back of unit near the doors to the main unit and slid down against the wall. The patient was sitting on the floor when he/she was Tasered by guards. This nurse stated that he had received quite a bit of instruction regarding the use of Taser by E-mail and KSO staff but never believed that it would be used. When asked if it was necessary to get the patient into his/her room, he stated that the room was the safest place for purpose of close monitoring.

8. There were no orders for use of a Taser or handcuffs in clinical record of Patient A.

9. The potential impact of the facility not ensuring that patients are free of abuse as evidenced by the use of a Taser in a patient who was in a non-threatening position on the floor and the use of hard handcuffs by sheriff officers to escort patients to restraint and seclusion would be that patients were placed in danger of physical harm, pain or mental anguish.

Use of Handcuffs on Patient B

10. Patient B's nursing note dated May 7, 2013, included documentation that this patient had kicked a hole in the bathroom wall and Mental Health Workers (MHW) responded to this incident with hands on. Then the KSO stood at the bathroom door and requested that the patient return to her/his room. She/He initially resisted but ultimately complied. Then the patient escalated and was placed in 5 point restraints. She/He was able to get out of these restraints twice and attempted to assault staff. The documentation included "KSO assisted in maintaining control of [patient name] so RPC staff could place restraints." She/He was taken out of restraints, escalated again and SRC was ordered. It was noted [Psychiatrist named] ordered SRC and a RN requested KSO assistance to walk [patient named] to the main unit. It was noted that the patient was compliant with the instructions and was in the main unit SRC at 1015. The note did not include that the patient was in handcuffs during this assisted walk by KSO. The fact that the patient was handcuffed with hands behind his/her back was confirmed in an interview with KSO Officer 1 on May 10, 2013, at 3:45 p.m.

11. In an interview with KSO Officer 1 on May 10, 2013, he described the use of handcuffs with two (2) patient escorts and demonstrated how they operate the "hard" restraint. Patients are asked to kneel down, cross ankles, and place their hands above head on wall to stabilize them, and then the handcuffs are applied and double locked.

12. In interview with author of above nursing note (Nurse 6) on May 9, 2013, it was verified that this patient was escorted to SRC in handcuffs by the KSO. She stated that she supported the use of handcuffs in this highly assaultive patient.

13. The Mental Health Worker (MHW) named as being threatened with assault in above nursing note was interviewed on May 10, 2013. She stated that she had been asked in an earlier incident when the patient had to go to SRC if the patient needed handcuffs to be escorted. She stated "absolutely not" and the handcuffs were not used. She was not present when the patient was handcuffed for the above incident. She stated there is a different emphasis between law enforcement and staff in the use of seclusion/restraint.

14. There were no orders for use of handcuffs in clinical record of Patient B.

15. The potential impact of the facility not ensuring that patients are free of abuse as evidenced by the use of hard handcuffs by sheriff officers to escort patients to restraint and seclusion would be that patients were placed in danger of physical harm, pain or mental anguish.

Based on observations of forensic units on May 8-10, 2013, review of three (3) inpatient clinical records, document review, and interviews with patients and key staff on May 8-10, 2013, it was determined that the hospital failed to ensure that all patients are free from physical abuse, mental abuse, and corporal punishment.

The evidence is as follows:

1. Patient A's clinical record contained an order for restraint dated May 1, 2013, at 10:55 p.m. The order stated "Taser used by Police here." This order was signed by a physician assistant. A nursing note recorded on May 2, 2013, at 5:28 a.m. noted, "Taser was deployed by the KSO officer. Client was then escorted by the KSO officers to the SRC [Seclusion and Restraint Suite] on the main unit. Client was handcuffed. Client walked under [his/her] own power with assisted walk." (See Tags A-0144 and A-0145 for further information.)

2. Patient B's documentation included "KSO assisted in maintaining control of [patient name] so RPC staff could place restraints." She/He was taken out of restraints, escalated again and SRC was ordered." It was noted "[Psychiatrist named] ordered SRC and RN requested KSO assistance to walk [patient named] to the main unit." It was noted that client was compliant with the instructions and was in main unit SRC at 1015. The note did not include that the patient was in handcuffs during this assisted walk by KSO. The fact that the patient was handcuffed with hands behind his/her back was confirmed in an interview with the KSO officer on May 10, 2013, at 3:45 p.m. (See Tags A-0144 and A-0145 for further information.)

Based on observation of forensic units on May 8-10, 2013, review of three (3) inpatient clinical records, document review, and interviews with patients and key staff on May 8-10, 2013, it was determined that the hospital failed to ensure that the least restrictive interventions were utilized for all patients.

Findings include:

1. While the utilization of weapons such as Tasers and handcuffs were not considered a healthcare intervention, under " Protocol," the untitled document presented on May 9, 2013 stated: " KSO will observe for any situation that appears to be escalating and may intervene without staff request if there is imminent danger...RPC staff will not interfere and will assist as needed."

2. In an interview with KSO Officer 1 on May 10, 2013, he stated that if KSO officers see body language, stance or threatening patient behavior and nursing does not make the call for help they can step in. Their training differs from RPC staff in that they are certified in use of Taser, and licensed in Corrections. They are trained in different type of force than NAPPI (Non Abusive Psychological and Physical Intervention) used by RPC. When asked what force used by KSO he stated " Restraint/Control."

3. The potential outcome of the above protocols and practice may be that least restrictive interventions may not always be utilized prior to implementation of restraint or seclusion. Please see Tag A-0145 for information.

Based on observation of forensic units on May 8-10, 2013, review of three (3) inpatient clinical records, document review, and interviews with patients and key staff on May 8-10, 2013, it was determined that the hospital failed to ensure that the least restrictive interventions were utilized for all patients.

Findings include:

1. While the utilization of weapons such as Tasers and handcuffs were not considered a healthcare intervention, under " Protocol," the untitled document presented on May 9, 2013 stated: " KSO will observe for any situation that appears to be escalating and may intervene without staff request if there is imminent danger...RPC staff will not interfere and will assist as needed."

2. In an interview with KSO Officer 1 on May 10, 2013, he stated that if KSO officers see body language, stance or threatening patient behavior and nursing does not make the call for help they can step in. Their training differs from RPC staff in that they are certified in use of Tasers, and licensed in Corrections. They are trained in different type of force than NAPPI (Non Abusive Psychological and Physical Intervention) used by RPC. When asked what force used by KSO, he stated " Restraint/Control."

3. The potential outcome of the above protocols and practice may be that patient assessment and intervention are directed by the KSO, rather than by medical and nursing staff. Please see Tag A-0145 for information.

Based on review of documents as described below, along with interviews with the Medical Director on May 8, and May 9, 2013, it was determined that the Riverview Psychiatric Center's Medical Staff was not responsible for the quality of care provided to its patients.

Findings include:

1. The medical staff failed to be in compliance with the requirements of the 'Rights of Recipients for Mental Health Services' (see Tag A-0020); and

2. The medical staff failed to ensure that patients were free from all forms of abuse or harassment (see Tags A-0144 and A-0145).

Based on record review and interviews with key personnel on May 8-9, 2013, it was determined that the facility failed to assure that verbal orders were authenticated within 48 hours.

Findings include:

1. Review of Patient Record I indicated telephone verbal orders dated February 27, 2013 and March 5, 2013, taken by nursing from a PAC (Physician Assistant Certified).

2. Neither of these orders taken on the dates indicated had been authenticated as of May 9, 2013.

3. Review of Patient Record L indicated telephone verbal orders dated March 28, 2013, taken by nursing from a physician.

4. The orders taken on March 28, 2013, had not been authenticated as of May 9, 2013.

5. The above findings were confirmed by the Nurse Manager on May 9, 2013, at 10:30 a.m.

Based on record review and interviews with key staff on May 8-9, 2013, it was determined that the facility failed to assure that informed consent for treatments was obtained on admitted patients.

Finding include:

1. The medical record of Patient A indicated that he/she was admitted voluntarily on April 3, 2013. The informed consent for treatment indicated that the patient refused to sign at this time.

2. The informed consent for Patient A was signed, and the date written in was April 3, 2013. There was no indication when this was signed if the patient had refused on admission.

3. The medical record of Patient C indicated that he/she was committed on April 4, 2011. He/she became voluntary in July 2012.

4. The informed consent for Patient C was signed documented on January 11, 2013, "Client refused to sign", also "Client verbalized 'I've been voluntary for months."

5. The medical record of Patient D indicated that he/she was admitted voluntary January 30, 2013. The informed consent for treatment indicated that the patient refused to sign at this time.

6. The informed consent for Patient D was signed, and dated January 30, 2013, and was signed by the patient's guardian, and indicated the form was signed on January 30, 2013, with no indication that this was signed on that date if the patient refused to sign on that date.

7. The above findings were confirmed by the Unit Manager, Nurse IV on May 8, 2013, between 2:00 and 3:00 p.m.

Based on observations, document review and interviews with key personnel on May 8-9, 2013, it was determined that the facility failed to assure that the facility was maintained in a safe and sanitary manner.

Findings include:

1. During a tour of The Portland Outpatient Clinic on May 9, 2013, at approximately 10:00 a.m., an examination table with torn covering was observed in treatment room 3. This table was not able to be easily cleaned and sanitized.

2. This finding was immediately verified with the Acting Assistant Director of Nursing.

3. During the tour of the hospital physical plant on May 8. 2013 - May 10, 2013, a surveyor observed the following:
a. The ceiling light fixtures were soiled with dead flies in Rooms #1416, #1412, #2424, and #2411 on upper and lower Kennebec units.
b. The seam was not sealed by the toilet in Room #2453 on the Upper Kennebec Unit, creating an uncleanable surface.
c. The ceiling tiles were chipped, marred, water stained, and/or lifted in Rooms #1468, #2459, Stairwell #6, Rooms #2539, #2518, #2516, #2513, in the main facility and in Rooms #2, and the Recovery Room in the Preble Street Unit in Portland.
d. The vents were soiled with dust in office #1, the front office, the bathroom, Treatment room #1, #2, #3, the medical exam room, and the staff bathroom in the Preble Street unit in Portland.
e. The paint was chipped on the toilet seats in Rooms #1535, #1547, #and #1521 creating an uncleanable surface.
f. The seam is not sealed by the toilet in Room #2453 creating an uncleanable surface.
g. The tub/floor joint is not sealed in Room #1458 creating an uncleanable surface.
h. The walls are marred, gouged, chipped and/or has holes in Rooms #1462, # 1510, #2437, #2460, #2530, office #1 at Preble Street, and the Recovery Room at Preble Street creating an uncleanable surface.
i. The wall/floor joint and the shower/floor joint in Rooms #2437, and #1458 creating an uncleanable surface.

4. The above findings were confirmed in an interview with the Safety Officer at Preble Street and the Safety Office, The Director of Support Services, the Maintenance Director. and the Ward Charge Nurse between May 8 and May 10, 2013.

5. On May 10, 2013, between 7:30 and 9:30 a surveyor observed two hose laying in a sink in room #2548. These hoses were not equipped with back flow prevention devices as required by the Maine State Plumbing Code.

6. This finding was confirmed in an interview with the Director of Support Services the
Maintenance Supervisor, and the ward charge person.

7. On May 9 and 10, 2013, a surveyor observed that the oxygen tanks on the crash carts were covered with a cloth over the neck, gauges and fittings in room #1455, #2447, #1544 A, and the exam room. The facility is not in compliance with NFPA 99 Section A-4-3.5.2.1(a)(b)(1) which states. "Special precautions of oxygen cylinders and manifolds: oil, grease and readily flammable materials shall never be permitted to come in contact with oxygen cylinders, valves, regulators, gauges and fittings."

8. This finding was confirmed in an interview with the Safety Officer, The Director of Support Operations and the Maintenance Director.

9. On May 9, 2013, a surveyor observed that the emergency eyewash station located in the boiler room was covered with a plastic bag impeding immediate access to the emergency eyewash station as required by 29 CFR 1910.151, which states, "Eyewash stations shall be accessible for immediate emergency use."

10. This finding was confirmed in an interview with the Safety Officer, Director of Support Services, and the Director of Maintenance on May 9, 2013.

11. On May 9, 2013, during the observation of the noon meal preparation a surveyor observed that there was no air gap provided on the drain line of two vegetable sinks. The facility was not in compliance with the State of Maine, Internal Plumbing Code Regulations, 10-144 Chapter 238 Section 11.1 C.3.e. which states "Direct connections between potable water piping and sewer connected wastes shall not exist under any condition with or without backflow protection. Where potable water is discharged to the drainage system, it shall be by means of an approved air gap. The size shall be two pipe diameters of the supply inlet, but in no case shall the gap be less than one inch."

12. This finding was confirmed in an interview on May 9, 2013, with the Safety Officer, The Director of Support Services, The Director of Nutritional Services and the Food Service Supervisor.

Based on observation, document review and interviews with key personnel on May 9 and 10, 2013, it was determined that the infection control officer failed to implement the infection control policy at the dental clinic.
Findings include:

1. During observation of a dental procedure at the Portland Outpatient Clinic at approximately 1120, it was observed that neither the dentist nor the dental hygienist wore protective eyewear.

2. The hospital policy Dental Clinic Staff Infection Control Proceedings stated, "Protective clothing shall be worn by staff at all times during treatment ...this includes safety glasses ...."

3. During an interview with the dentist at approximately 1130, when asked if he ever wears eye protection, he stated, " no, I don ' t wear any other glasses except these [pointing to his prescription eye glasses]."

4. During an interview with the dental hygienist at approximately 1130, when asked if she ever wears eye protection, she stated, "our policy just says they have to be available..."

5. These findings were immediately confirmed with the Acting Assistant Director of Nursing.

6. These findings were also discussed with the Clinical Director, who was then observed discussing the policy with the dentist.

Based on record review and documentation review on May 8, 2013, it was determined that the facility failed to assure that all rehabilitation orders were documented in the patient ' s medical record.

Findings include:

1. A review of three (3) medical records of clients receiving Occupational Therapy (OT) was conducted.
2. Three (3) of three (3) medical records failed to contain physician orders for occupational therapy (see Records XX,YY, and ZZ).

3. These findings were confirmed on May 8, 2013, at 1 p.m. with the Rehabilitation Services Director. She stated, " There are no physician orders for OT in any of these records. "

Based on medical record review and staff interview it was determined that for 8 of 8 active sample patients selected (Patients A1, A20, B7, B11, C1, C2, D12 and D18), the Psychosocial Assessments failed to include either a summarization of the data contained within the assessment and/or a description of the anticipated Social Service staff's role in the treatment of the patient. This failure results in the multi-disciplinary treatment team not having conclusions about the psychosocial functioning of the patient and not having information about what the social service member will be attempting to provide for the patient during and after hospitalization.

Findings include:

I. Medical Record Review:

A. Patient A1. The Psychosocial Assessment dated 4/17/2013 failed to include a summarization of the data obtained or the role of the social service staff in treatment, except the statement "Social Worker will assist (patientA1) in maintaining contact with [his/her] attorney."

B. Patient A20. The Psychosocial Assessment dated 10/9/2012 failed to include a summarization of the data obtained or the role of the social service staff in treatment.

C. Patient B7. The Psychosocial Assessment dated 6/11/2012 failed to include a summarization of the data obtained or the role of the social service staff in treatment.

D. Patient B11. The Psychosocial Assessment dated 10/16/2012 failed to include a summarization of the data obtained or the role of the social service staff in treatment.

E. Patient C1. The Psychosocial Assessment dated 7/23/2012 failed to include a summarization of the data obtained or the role of the social service staff in treatment.

F. Patient C2. The Psychosocial Assessment dated 6/2/2012 failed to include a summarization of the data obtained.

G. Patient D12. The psychosocial Assessment dated 3/13/2013 failed to include a summarization of the data obtained or the role of social work staff in treatment, except the statement "Writer will meet with client once weekly to assist in treatment."

H. Patient D18. The Psychosocial Assessment dated 5/8/2013 failed to include a summarization of the data obtained or the role of the social service staff in treatment, except the statement "Writer will meet with client weekly to assist in treatment, pending safety."

II. Staff Interview:

On 5/9/2013 at 2:05 PM the Director of the Department of Social Services was interviewed. She was presented the Psychosocial Assessments of Patients A1, A20, D12 and D18. She concurred with the findings described above.

Based on record review and interview, the facility failed to revise treatment plans to include a treatment regime based on the current treatment needs for 3 of 8 active sample patients (B11, C2, D18) and 1 of 2 non-sample patients (C17) who were added to the sample for review of active treatment. These patients were scheduled for groups that they were unable to attend (B11 and B18) or refused to attend (C2 and C17). In spite of continued failure to attend, treatment plans were not revised to meet patient needs. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement.

Findings include:

A. Patient B11 (admitted on 9/6/12)

1. Patient B11's Master Treatment Plan, updated 4/8/13, identified the following interventions:

"Encourage participation in on unit groups and activities."

"Will approach [Patient B11] to help in developing and maintaining a daily schedule, reminding [him/her] when available activities/groups and encouraging participation."

"Will offer [Patient B11] daily enrichment activities such as fitness, computer lab, social games and 1:1 leisure games."

"Will offer and encourage [Patient B11] to participate in unit activities daily 15 minutes before each activity is offered."

"Will encourage [Patient B11] to attend: Creative Journaling Through Art, Let's Practice our Social Skills, Managing Anxiety, Mindful Based Stress Reduction, Managing Depression, Self-Esteem, Women's Group, So Your [sic] Think You're Angry and Healing Expressions."

"Will invite and encourage [Patient B11] to attend community meetings 2xweek and encourage [him/her] to share [his/her] thoughts and opinions and assist with self-expression statements."

2. A physician progress note (4/30/13) documented, "Will work with psychology services to develop a continued plan and work on lessening [his/her] behavior of swallowing objects."

3. There was a behavioral plan developed and in the treatment plan section of Patient B11's medical record, but the date for this safety plan was not present, and parts of it were not applicable to current needs.

4. According to interview with Physician B8 on 5/8/13 at 1:45 p.m., this patient had been in almost continuous seclusion for severe repetitive self-mutilation with an immediate threat to life since 5/6/13. S/he had been swallowing objects (forks, pens, plastic objects, etc.) with the most recent event resulting in a perforated esophagus. Less restrictive supervision for safety (2:1 or 1:1 staffing) had not been adequate as s/he had forced his/her way into the nursing station and grabbed an object.

5. During interview on 5/8/13 at 1:45 p.m., Physician B8 reported that he had been told by the physician at the general hospital that one more incident such as the recent swallowing of the fork could result in death for Patient B11. Physician B8 reported that he saw and talked with Patient B11 frequently (5 times/week) and that the patient continued to work with a psychologist. In a follow-up interview on 5/9/13 at 11:30 a.m., Physician B8 stated that the treatment plan should have been revised to reflect the current treatment for Patient B11.

Although Patient B11 was too acutely ill to participate in [his/her] treatment as identified in the treatment plan, as of 5/9/13 the plan had not been revised to reflect current treatment needs. The use of continuous seclusion was not added as a modality to the treatment plan, nor was the plan adapted as to how s/he would receive treatment while in seclusion and unable to attend all of the previously listed modalities, nor the change in focus of the modalities s/he was receiving from the physician and the psychologist.

B. Patient C2 was admitted on 6/10/70 after s/he was deemed NCR(Not Criminally Responsible) in 1968 for murder.

1. The psychiatric evaluation (6/22/12) stated, "[S/he] meets with [chaplain] weekly to talk but has decline [sic] all other treatment including individual and group." The summary note in this evaluation stated, "[Patient] is not amendable [sic] to treatment at this time. [S/he] considers [himself/herself] retired. We will continue to offer treatment."

2. During observations made on Upper Saco Unit on 5/9/13 at 9:15 a.m., Patient C2 was found in his/her assigned room with the door closed. When asked if s/he attends treatment groups, Patient C2 replied, "I don't go to anything. I went to all those groups in the past. I have a personality disorder and they've (staff) told me that I'm untreatable."

3. Review of a Nurse Practitioner treatment note on 5/2/13 states, "It is concerning that [s/he] is still inflexible about any attempts at treatment, still saying that [s/he] is retired."

4. Review of Patient Notes regarding treatment from 4/29/13 through 5/8/13 revealed that Patient C2 failed to attend all treatment groups/activities other than one 1-hour "News Group" and one 1:1 meeting with the chaplain.

5. Staff interviews:

a. During unit rounds on 5/9/13 at 3:00 p.m., when Mental Health Technician (MHT) C10 was asked where Patient C2 was, she stated, "[Patient C2] is probably in [his/her] room. [S/he] says that [s/he] is retired from the treatment mall."

b. During interview on 5/10/13 at 10:10 a.m., Treatment Team Nurse C16 reported that Patient C2 does not attend any treatment groups/activities.

6. Review of the master treatment plan dated 4/8/13 revealed many assigned meetings 1:1 with staff and groups/activities:

a. "Dr/RN/ MHW (Mental Health Worker) will encourage [Patient C2] to become familiar with antisocial and narcissistic personality traits and attempt to engage [him/her] in discussion of them and how they pertain to [his/her] risk for violence in the community."

b. "Will meet with assigned MHW x3 a week...for 1:1 supportive engagement."

c. "Will attend a minimum of 4-5 treatment mall groups per week." Groups assigned were Anger Management, Upper Saco Process Group, So You Think You're Angry? and Destinations Group.

d. "Will attend and participate, as appropriate, in weekly unit community meetings."

e. "Staff will encourage [Patient C2] to attend weekly enrichment groups, including but not limited to: Hospital wide gym, News Group (Daily), Coffee Social (Sat/Sun), Social Hour (Sunday), Game of the week (Sunday), US (Upper Saco) computer lab (Saturday), US Unit Activities (Varied)."

f. "Will offer and encourage [Patient C2] to participate in unit based enrichment activities, such as, crafts and games and off unit activities such as: fitness, computer lab, outside walks, cardio workout and community resource trips."

7. Review of Patient C2's master treatment plan dated 4/8/13, revealed no change in treatment schedule (groups and 1:1) as of 5/9/13, even though s/he was non-compliant with treatment attendance. Patient C2's treatment team failed to develop a treatment regimen based on his/her current behaviors.

C. Patient C17 was admitted on 3/7/08. According to a Nurse Practitioner progress note (5/9/13), his/her current diagnoses were Bipolar Disorder, Mixed Type; Intermittent Explosive Disorder; Attention Deficit Hyperactivity Disorder; Polysubstance Abuse; and Personality Disorder NOS (Not otherwise specified) with Antisocial and Narcissistic Traits.

1. During observations made on Upper Saco Unit on 5/9/13 at 9:15 a.m., Patient C17 was walking around the ward talking to staff and other patients. When asked if s/he attended treatment groups, Patient C17 replied, "I only go to one group a week, anger management. There's no need for me to go to groups."

2. Review of Patient Notes regarding treatment from 4/29/13 through 5/8/13 revealed that Patient C17 only attended one group, plus a 35 minute session with a psychologist on 5/2/13 regarding anger management.

3. Staff interviews:

a. During interview on 5/9/13 at 3:00 p.m., MHT C10 stated, "[S/he] only attends one group a week."

b. During interview on 5/10/13 at 10:10 a.m., Treatment Team Nurse C16 verified that Patient C17 only attended one treatment group weekly.

4. Review of the master treatment plan dated 5/2/13 revealed many assigned meetings 1:1 with staff and groups/activities:

a. "RN/MHW will meet with [Patient C17] daily to discuss positive coping skills and encourage [him/her] to attend Coping Skills Group at the treatment mall."

b. "Staff will help [Patient C17] recognize signs of increased anxiety and agitation...will encourage [Patient] to identify/utilize coping skills to help decrease [his/her] anxiety and agitation."

c. "Staff will help [Patient C17] to choose appropriate TX (treatment) groups, and encourage participation in these groups."

d. "Staff will encourage [Patient C17] to attend weekly enrichment groups, including but not limited to: Hospital wide gym, News Group (Daily), Coffee Social (Sat/Sun), Social Hour (Sunday), Game of the week (Sunday), US (Upper Saco) computer lab (Saturday), US Unit Activities (Varied)."

e. "TRS (Therapeutic Recreation Staff) will offer and encourage full participation in the following groups weekly: open rec. (recreation) room, games, open gym, exercise, walks, computer lab, fitness unit activities, fitness."

f. "Will encourage [Patient C17] to attend [his/her] prescribed treatment mall groups so you think your angry [sic]."

5. Review of Patient C17's master treatment plan dated 5/2/13, revealed no change in treatment schedule (groups and 1:1) as of 5/9/13, even though s/he was non-compliant with treatment attendance. Patient C17's treatment team failed to develop a treatment regimen based on his/her current behaviors.

D. Patient D18

Medical Record Review:

1. This patient had an extensive history of assaultive behaviors and his/her Problem#1, as identified by Treatment Team at the Updated review dated 1/30/2013 and unchanged at the review dated 3/16/2013, was "Assaultive"; Problem #2 (also unchanged) was "Medical-History of closed head injury and Imbalanced Nutrition." The short term goals for these problems were "For the next 90 days [Patient D18] will refrain from harming self or others or destroying property" and "During hospitalization [Patient D18] will follow directions from staff and respond to verbal cues about maintaining safety" and "[Patient D18] will maintain/decrease weight while hospitalized." The principal modality listed was seclusion for most of every 24 hour period.

2. The Treatment Plan of Patient D18, dated 3/16/2013 as the most recently modified Plan, stated "Plan continued for another 90 days from 3/16 to 6/16/2013." The Plan stated "[Patient D18] has daily structured schedule that [s/he] and staff are to follow."

3. Patient D18's "[Patient D18] Daily Schedule" updated 5/03/2013 stated that s/he might come out of the Seclusion Room, where s/he remained continuously confined, at 3 separate times (1000-1200, 1400-1600, and 1800-1900) daily, at the discretion of law-enforcement who managed his/her behavior. For the period 1000-1200 the patient was to have "snack, phone calls, newspaper, prn meds if needed/available, time in bedroom on unit, unit treatment groups. Games with staff. Hygiene supplies. [S/he] is to brush teeth and shave while shackled." For the period 1400-1600: "phone calls, games, snack, prn meds if needed/available, tv channel approved". For the period 1800-1900: "News on TV, relaxation music in SRC (cards, collage, tv, or phone calls)."

The Daily Schedule also stated "Restraints: are at discretion of KSO (Kennebec Sheriff's Office). Provided behavior is safe, [s/he] is to use wrist to waist device and KSO to apply. [S/he] is currently being handcuffed. Unit staff are not to be involved in application of restraint." (His/her meals and medications were provided within the Seclusion room by the Nursing staff, as reported to the surveyor by RN#D1 on 5/08/2013 at 2:15 PM.)

These restrictions of engagement prevented him/her attending any groups provided on the Unit.

4. On 5/09/2013 at approx. 9:40 AM the Unit Treatment Team Co-coordinator confirmed that the Daily Schedule of Patient D18 was designed by the Treatment Team as an integral part of the patient's treatment plan.

On 5/10/2013 at 9:20 AM the Clinical Director was interviewed by the survey team. When asked about the statement on the plan that Patient D18 would require Seclusion "for the next 90 days," he replied "That may be an arbitrary number, but probably, yes."

Patient D18's treatment team failed to develop a treatment regimen based on his/her current behaviors. No alternative treatment was provided, and there was no plan to reevaluate the need for continuous seclusion before the next 90 day cycle, in June.

Based on medical record review, observation and staff interview it was determined that the modalities selected for the treatment of 2 of 8 active sample patients (Patients B11 and D18) were not appropriate. In the case of Patient B11, the interventions were not appropriate based on the patient's current high level of acuity; in the case of Patient D18, the interventions were excessively restrictive, confining the patient to a seclusion room most of every day, included law enforcement rather than clinical staff in determining how the patient's behavior should be controlled, and were planned to be used without reassessment for a 90 day period (noted on the Treatment Plan review dated 3/16/13). For two of 8 active sample patients (D12 and D18) there were no interventions for the psychiatrist listed on the treatment plans. These failures result in lack of guidance to clinical staff in providing effective psychiatric treatment related to patients' identified problems and goals.

Findings include:

A. Patient B11.

Patient B11 was admitted on 9/6/12. Master Treatment Plan dated 4/8/13. According to a physician progress note (5/6/13) the current diagnoses were Mood Disorder NOS, Posttraumatic Stress Disorder, Factitious Disorder and Borderline Disorder with Extreme Self-Injurious Behavior. Patient B11 had been in almost continuous seclusion for severe repetitive self-mutilation with an immediate threat to life since 5/6/13. S/he had been swallowing objects (forks, pens, plastic objects, etc.) with the most recent event resulting in a perforated esophagus. Less restrictive supervision for safety (2:1 or 1:1 staffing) had not been adequate, as s/he had forced his/her way into the nursing station and grabbed an object.

Patient B11's Master Treatment Plan, dated 4/8/13 identified the following interventions:

"Encourage participation in on unit groups and activities."

"Will approach [Patient B11] to help in developing and maintaining a daily schedule, reminding [him/her] when available activities/groups and encouraging participation."

"Will offer [Patient B11] daily enrichment activities such as fitness, computer lab, social games and 1:1 leisure games."

"Will offer and encourage [Patient B11] to participate in unit activities daily 15 minutes before each activity is offered."

"Will encourage [Patient B11] to attend: Creative Journaling Through Art, Let's Practice our Social Skills, Managing Anxiety, Mindful Based Stress Reduction, Managing Depression, Self-Esteem, Women's Group, So Your [sic] Think You're Angry and Healing Expressions."

"Will invite and encourage [Patient B11] to attend community meetings 2xweek and encourage [him/her] to share [his/her] thoughts and opinions and assist with self-expression statements."

Because the patient was in continuous seclusion since 5/6/13 for safety, and the plan had not been updated since 4/8/13, the interventions listed were not applicable at the time of the survey.

B. Patient D18:

This patient had an extensive history of assaultive behaviors and his/her Problems as identified by Treatment Team at the Updated review dated 1/30/2013 and which remained unchanged on 3/16/13 review date were "Assaultive"; and "Medical-History of closed head injury and Imbalanced Nutrition." The short term goals for these problems were "For the next 90 days [Patient D18] will refrain from harming self or others or destroying property" and "During hospitalization [Patient D18] will follow directions from staff and respond to verbal cues about maintaining safety" and "[Patient D18] will maintain/decrease weight while hospitalized."

The Treatment Plan of Patient D18, dated 3/16/2013 as the most recently modified Plan, stated "Plan continued for another 90 days from 3/16 to 6/16/2013." The Plan stated "[Patient D18] has daily structured schedule that [s/he] and staff are to follow." Patient D18's "[Patient D18] Daily Schedule" updated 5/03/2013 stated that s/he could come out of the Seclusion Room, where s/he remained continuously confined, if deemed appropriate by law-enforcement who continuously monitored the patient, at 3 separate times (1000-1200, 1400-1600, and 1800-1900) daily. For the period 1000-1200 the patient was to have "snack, phone calls, newspaper, prn meds if needed/available, time in bedroom on unit, unit treatment groups. Games with staff. Hygiene supplies. [S/he] is to brush teeth and shave while shackled." For the period 1400-1600: "phone calls, games, snack, prn meds if needed/available, tv channel approved". For the period 1800-1900: "News on TV, relaxation music in SRC (cards, collage, tv, or phone calls)." The Daily Schedule also stated "Restraints: are at discretion of KSO (Kennebec Sheriff's Office). Provided behavior is safe, [s/he] is to use wrist to waist device and KSO to apply. [S/he] is currently being handcuffed. Unit staff are not to be involved in application of restraint." (His/her meals and medications were provided within the Seclusion room by the Nursing staff as reported to the surveyor by RN#D1 on 5/08/2013 at 2:15 PM.) This restriction of engagement prevented him/her attending any groups provided on the Unit.

4. The Treatment Plan dated 1/30/13 and the update on 3/16/13 had no interventions by a psychiatrist for the identified problems of this patient.

Staff Interview:

On 5/09/2013 at approx. 9:40 AM the Unit Treatment Team Co-coordinator confirmed that the Daily Schedule of Patient D18 was designed by the Treatment Team as an integral part of the patient's treatment plan.

On 5/10/2013 at 9:20 AM the Clinical Director was interviewed. When asked about the statement that Patient D18 would require Seclusion "for the next 90 days," he replied "That may be an arbitrary number, but probably, yes."

C. Patient D12.

The Treatment Plan dated 4/03/2013 had only one intervention identified for the psychiatrist. The sole intervention was that the psychiatrist was to monitor, by report from the MHW (Mental Health Worker) staff, Patient D12's behavior in the cafe and if it were appropriate for Patient D12 to eat there.

Staff Interview:

On 5/10/2013 at 9:20 AM the Clinical Director was interviewed by the survey team. He was shown the Treatment Plans for Patients C2, D12 and D18. He replied that for Patient D12 the attending psychiatrist "Won't be monitoring the MHWs work in the cafeteria" (an inappropriate modality for the psychiatrist.)

Based on Medical Record Review and staff interview it was determined that for 2 of 8 active sample records (Patients C2 and D18) the designation of responsible treatment team member was inappropriate or not present on the Master Treatment Plan. This failure results in an inability to identify which team member is accountable for the treatment modality identified on the Plan.

Findings include:

A. Medical Record Review:

1. Patient C2. Treatment Plan dated 4/8/13: There was no physician listed as being responsible for intervention listed as "DR/RN/MHW will encourage [Patient C2] to become familiar with antisocial and narcissistic personality traits and attempt to engage [him/her] in discussion of them and how they pertain to [his/her] risk for violence in the community."

2. Patient D18. The Treatment Plan dated 3/07/2013 listed the Unit Treatment Team "Co-ordinator" or "designee" as the sole provider for the 4 interventions addressing Patient D18's "Problem #1-Assaultive." The "designee" was not identified. No other treatment team member was identified as addressing this issue or the interventions they might have selected.

B. Interview:

On 5/10/2013 at 9:20 AM the Clinical Director was interviewed by the survey team. He was shown the Treatment Plans for Patients C2 and D18; he agreed that there was no role described for the attending psychiatrist for Patients C2 and D18.

Based on observation, interview and document review, the facility failed to ensure that active psychiatric care was provided for 3 of 8 active sample patients (A1, C2 and D18), and 1 of 2 non-sample patients (C17) who were added to the sample for review of active treatment. These patients were scheduled for groups which they were unable (D18) or refused (A1, C2, C17) to attend. No alternative treatment was implemented for these patients. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, delaying their improvement.

Findings include:

A. Patient A1 was admitted 9/02/1977. S/he was interviewed on the Unit on 5/09/2013 at 12 noon. When asked how s/he would be spending the rest of the afternoon, s/he replied "I have the day off." A review of his/her attendance at the 16 groups selected for him/her from 5/02/2013 to 5/09/2013 disclosed attendance at 1. His/her repeated refusals to attend groups were noted.

B. Patient C2 was admitted on 6/10/70 after being deemed NCR (Not Criminally Responsible) in 1968 for murder.

1. The psychiatric evaluation (6/22/12) stated, "[His/her] judgment is poor as evidence [sic] by [his/her] verbalizing want [sic] to be released from RCP (Riverview Psychiatric Center) but not participating in treatment or treatment plan." "[S/he] meets with [chaplin] weekly to talk but has decline [sic] all other treatment including individual and group." The summary note in this evaluation stated, "[Patient] is not amendable [sic] to treatment at this times. [S/he] considers [himself/herself] retired. We will continue to offer treatment."

2. Review of the master treatment plan dated 4/8/13 revealed many assigned meetings 1:1 with staff and groups/activities:

a. "Dr/RN/ MHW (Mental Health Worker) will encourage [Patient C2] to become familiar with antisocial and narcissistic personality traits and attempt to engage [him/her] in discussion of them and how they pertain to [his/her] risk for violence in the community."

b. "Will meet with assigned MHW x3 a week...for 1:1 supportive engagement."

c. "Will attend a minimum of 4-5 treatment mall groups per week." Groups assigned were Anger Management, Upper Saco Process Group, So You Think You're Angry? and Destinations Group.

d. "Will attend and participate, as appropriate, in weekly unit community meetings."

e. "Staff will encourage [Patient C2] to attend weekly enrichment groups, including but not limited to: Hospital wide gym, News Group (Daily), Coffee Social (Sat/Sun), Social Hour (Sunday), Game of the week (Sunday), US (Upper Saco) computer lab (Saturday), US Unit Activities (Varied)."

f. "Will offer and encourage [Patient C2] to participate in unit based enrichment activities, such as, crafts and games and off unit activities such as: fitness, computer lab, outside walks, cardio workout and community resource trips."

g. Review of Patient C2's master treatment plan dated 4/8/13, revealed no change in treatment schedule (groups and 1:1) as of 5/9/13, even though s/he was non-compliant with treatment attendance.

3. During observations made on Upper Saco Unit on 5/9/13 at 9:15 a.m., Patient C2 was found in his/her assigned room with the door closed. When asked if s/he attends treatment groups, Patient C2 replied, "I don't go to anything. I went to all those groups in the past. I have a personality disorder and they've (staff) told me that I'm untreatable." When Patient C2 was asked about his/her private television on the wall in the bedroom, the patient responded, "I am allowed the t.v. as long as I keep it off during group times." When asked why he would be allowed a television even though s/he does not attend assigned treatment, Patient C2 replied, "I don't have to go, I went to all those groups for several years."

4. Review of a Nurse Practitioner treatment note on 5/2/13 states, "It is concerning that [s/he] is still inflexible about any attempts at treatment, still saying that [s/he] is retired."

5. Review of Patient Notes regarding treatment from 4/29/13 through 5/8/13 revealed that Patient C2 failed to attend all treatment groups/activities other than one 1-hour "News Group" and one 1:1 meeting with the chaplin.

6. Staff interviews:

a. On 5/8/13 at 3:00 p.m., when Mental Health Technician (MHT) C10 was asked where Patient C2 was, she stated, "[Patient C2] is probably in [his/her] room. [S/he] says that [s/he] is retired from the treatment mall." MHT C10 added that this patient participated in the past, but would not attend any functions.

b. During interview on 5/10/13 at 10:10 a.m., Treatment Team Nurse C16 reported that Patient C2 did not attend any treatment groups/activities.

C. Patient C17 was admitted on 3/7/08. According to a Nurse Practitioner progress note (5/9/13), his/her current diagnoses were Bipolar Disorder, Mixed Type; Intermittent Explosive Disorder; Attention Deficit Hyperactivity Disorder; Polysubstance Abuse; and Personality Disorder NOS (Not otherwise specified) with Antisocial and Narcissistic Traits.

2. During observations made on Upper Saco Unit on 5/9/13 at 9:15 a.m., Patient C17 was walking around the ward talking to staff and other patients. When asked if s/he attended treatment groups, Patient C17 replied, "I only go to one group a week, anger management. They (staff) want me to pick up more groups, but they have given me until next Monday to get a job in the community. There's no need for me to go to groups."

3. Review of Patient Notes regarding treatment from 4/29/13 through 5/8/13 revealed that Patient C17 only attended one group, plus a 35 minute session with a psychologist on 5/2/13 regarding anger management.

4. Staff interviews:

a. During interview on 5/8/13 at 3:00 p.m., when MHT C10 was asked where Patient C17 was, she stated, "[Patient C17] is probably in [his/her] room." When asked why s/he was not in the treatment mall, MHT C10 replied, "[S/he] only attends one group a week. [Patient C17] did attend treatment, but now wants to work in the community. [S/he] goes to Planet Fitness."

b. During interview on 5/10/13 at 10:10 a.m., Treatment Team Nurse C16 verified that Patient C17 only attends one treatment group weekly.

6. Review of the master treatment plan dated 5/2/13 revealed many assigned meetings 1:1 with staff and groups/activities:

a. "RN/MHW will meet with [Patient C17] daily to discuss positive coping skills and encourage [him/her] to attend Coping Skills Group at the treatment mall."

b. "Staff will help [Patient C17] recognize signs of increased anxiety and agitation ...will encourage [Patient] to identify/utilize coping skills to help decrease [his/her] anxiety and agitation."

c. "Staff will help [Patient C17] to choose appropriate TX (treatment) groups, and encourage participation in these groups."

d. "Staff will encourage [Patient C17] to attend weekly enrichment groups, including but not limited to: Hospital wide gym, News Group (Daily), Coffee Social (Sat/Sun), Social Hour (Sunday), Game of the week (Sunday), US (Upper Saco) computer lab (Saturday), US Unit Activities (Varied)."

e. "TRS (Therapeutic Recreation Staff) will offer and encourage full participation] in the following groups weekly: open rec. (recreation) room, games open gym, exercise, walks, computer lab, fitness unit activities, fitness."

g. "Will encourage [Patient C17] to attend [his/her] prescribed treatment mall groups so you think your angry [sic]."

7. Review of Patient C17's master treatment plan dated 5/2/13, revealed no change in treatment schedule (groups and 1:1) as of 5/9/13, even though s/he was non-compliant with treatment attendance.

D. Patient D18 was admitted 10/26/2012 with an extensive history of violent behaviors. The Treatment Plan 3/16/2013 documented that s/he was to be in the Unit Seclusion room 24 hours daily with 3 breaks to enter the milieu for up to 2 hours each time while handcuffed and monitored by 2 non-clinical law-enforcement members. This restriction of engagement prevented him/her attending any groups or meals provided on the Unit. (Refer to B122 for details of Treatment Plan contents)

The Treatment Plan of Patient D18, dated 3/16/2013 as the most recently modified Plan, stated "Plan continued for another 90 days from 3/16 to 6/16/2013." The Plan stated "[Patient D18] has daily structured schedule that [s/he] and staff are to follow".

Patient D18's "[Patient D18] Daily Schedule," an integral part of the treatment plan, updated 5/03/2013, stated that s/he might come out of the Seclusion Room (where s/he remained continuously confined, since at least the time the plan was last updated 3/16/13), at 3 separate times (1000-1200, 1400-1600, and 1800-1900) daily. (His/her meals and medications were provided within the Seclusion room by the Nursing staff as reported to the surveyor by RN#D1 on 5/08/2013 at 2:15PM .)

The Daily Schedule also stated "Restraints: are at discretion of KSO (Kennebec Sheriff's Office). Provided behavior is safe, [s/he] is to use wrist to waist device and KSO to apply. [S/he] is currently being handcuffed. Unit staff are not to be involved in application of restraint."

Observations:

1. On 5/08/2013 at 11:00 AM surveyor observed via television camera the monitoring of Patient D18 who was sleeping in the Seclusion area. There were 2 Kennebec Sheriff's Office (KSO) officers wearing Taser weapons standing outside the Seclusion Room door. This was one of the periods per day when the patient was permitted out of seclusion, if deemed appropriate (Staff believed however that seclusion was the primary intervention for this patient, and they were safer thereby.)

2. On 5/08/2013 at 2:20 PM Patient D18 was at the Nurses' Station and was in handcuffs. The 2 armed KSO officers were at the side of the patient. He was observed playing cards while handcuffed for approximately 10 minutes, after which time he stopped and laid down on a bed on the unit still in handcuffs awaiting his return to the Seclusion room.

3. On 5/08/2013 at approximately 5:15 PM Patient D18 was observed in the Seclusion Room, the modality listed on the treatment plan for that time frame daily. The 2 armed KSO officers were stationed outside the locked Seclusion room door.

4. On 5/09/2013 at 8:55 AM Patient D18 was observed lying on a mattress in the Seclusion Room, the modality listed on his treatment plan for that time frame daily. The 2 KSO officers were outside the Seclusion room door wearing their law enforcement equipment.

5. On 5/9/2013 at 9:05 AM Patient D18 attended the Treatment Team meeting in handcuffs. Patient D18 was accompanied by 2 KSO officers throughout the meeting. At the Treatment Team meeting, the discussion was if Pt. D18 could go into an outside area with the Officers during his 3 times out of Seclusion daily. No other interventions were discussed.

Staff interviews:

On 5/08/2013 at 2:15 PM RN# D1was interviewed regarding the clinical management of Patient D18. If the patient required medication and refused, the KSO officers would assist the nurse, she reported.

On 5/09/2013 at approx. 9:40 AM the Unit Treatment Team Co-coordinator confirmed that the Daily Schedule of Patient D18 (with primarily the use of seclusion as the main modality) was an integral part of the Treatment Team's selection of interventions.

On 5/10/2013 at 9:20AM the Clinical Director was interviewed by the survey team. He was shown the Treatment Plan for Patient D18. When asked about the statement that Patient D18 would require Seclusion "for the next 90 days," he replied "That may be an arbitrary number, but probably, yes."

Based on medical record review, observation, and patient and staff interview it was determined that the Clinical Director failed to:

1. Assure that Treatment Plans were revised when the clinical status of the patient changes for 3 of 8 active sample patients (Patients B11, C2 and D18) and 1 of 2 non-sample patients (C17) added for assessment of active treatment. (Refer to B118 for details)

2. Assure that modalities for 2 of 8 active sample patients (Patients B11 and D18) were not overly restrictive and prolonged and were administered without the assistance of non-clinical law-enforcement staff. (Refer to B122 for details)

3. Assure that the Treatment Plans for 2 of 8 active patients (Patients C2 and D12) had assignment of responsible team members for modalities chosen. (Refer to B123 for details)

4. Assure that active treatment was occurring for 3 of 8 active sample patients (A1, C2 and D18) and 1 of 2 non-sample patients (Patient C17) chosen for review. (See B125 for details)

5. Assure that management of violence-prone patients was conducted by clinical staff and without the use of Taser- armed Sheriff Officers.

Findings include:

Observations:

1. On 5/08/2013 at 11:00 AM surveyor observed via television camera the monitoring of Patient D18 who was sleeping in the Seclusion area. There were 2 Kennebec Sheriff's Office (KSO) officers wearing Taser weapons standing outside the Seclusion Room door.

2. On 5/08/2013 at 2:20 PM Patient D18 was at the Nurses' Station and was in handcuffs. The 2 armed KSO officers were at the side of the patient.

3. On 5/08/2013 at approximately 5:15 PM Patient D18 was observed in the Seclusion Room. The 2 armed KSO officers were stationed outside the locked Seclusion room door.

4. On 5/09/2013 Patient D18 was observed lying on a mattress in the Seclusion Room. The 2 KSO officers were outside the Seclusion room door wearing their law enforcement equipment.

Record Review:

Patient D18's Daily Schedule stated "Restraints: are at discretion of KSO (Kennebec Sheriff's Office). Provided behavior is safe, [s/he] is to use wrist to waist device and KSO to apply. [S/he] is currently being handcuffed. Unit staff are not to be involved in application of restraint."

Interview:

On 5/08/2013 at 2:15 PM RN# D1was interviewed regarding the clinical management of Patient D18. If the patient required medication and refused, the KSO officers would assist the nurse, she reported. It was remarked by RN#D1 that the KSO officers had helped the day before when they told a different patient that the patient might get Tased if s/he continued to be uncooperative.

These failures result in use of non-clinical staff for patient management, inappropriate selection of treatment modalities, and lack of active psychiatric care.

I. Based on observation, interview and record review, the DON failed to assure that management of violence-prone patients, or patients resistive to treatment, was conducted by clinical staff and without the use of Taser-armed Sheriff Officers. This results in a) conflict between treatment and law enforcement actions, and b) a potential breach in the patient's right that care and interventions be delivered by health care professionals in a therapeutic treatment environment, rather than one that threatens.

Findings include:

Observations:

1. On 5/08/2013 at 11:00 AM surveyor observed via television camera the monitoring of Patient D18 who was sleeping in the Seclusion area. There were 2 Kennebec Sheriff's Office (KSO) officers wearing Taser weapons standing outside the Seclusion Room door.

2. On 5/08/2013 at 2:20 PM Patient D18 was at the Nurses' Station and was in handcuffs. The 2 armed KSO officers were at the side of the patient.

3. On 5/08/2013 at approximately 5:15 PM Patient D18 was observed in the Seclusion Room. The 2 armed KSO officers were stationed outside the locked Seclusion room door.

4. On 5/09/2013 Patient D18 was observed lying on a mattress in the Seclusion Room. The 2 KSO officers were outside the Seclusion room door wearing their law enforcement equipment.

Record Review:

Patient D18's Daily Schedule stated "Restraints: are at discretion of KSO (Kennebec Sheriff's Office). Provided behavior is safe, [s/he] is to use wrist to waist device and KSO to apply. [S/he] is currently being handcuffed. Unit staff are not to be involved in application of restraint."

Interview:

On 5/08/2013 at 2:15 PM RN# D1was interviewed regarding the clinical management of Patient D18. If the patient required medication and refused, the KSO officers would assist the nurse, she reported. It was remarked by RN#D1 that the KSO officers had helped the day before when they told a different patient that the patient might get Tased if s/he continued to be uncooperative.

During interview on 5/9/13 at 10:30 a.m., RN B12 reported that the presence of the sheriffs on the unit (referring to Lower Saco) "impacts the milieu." She added, "Everyone is expecting violence."

II. Based on interview and document review, the Director of Nursing (DON) failed to provide adequate numbers of Registered Nurses (RNs), to direct and supervise the patient care 2 of 4 wards (Lower Kennebec and Lower Saco). Each of these 2 units serves acutely ill patients in 2 areas that are physically separated by a locked door. This staffing pattern hindered the provision of quality nursing care due to failure of on-going professional assessments of patients and direction and supervision of non-professional nursing personnel. (Refer to B150)

Based on interview and document review, the Director of Nursing failed to provide adequate numbers of Registered Nurses (RNs), to monitor and supervise the patient care 2 of 4 wards (Lower Kennebec and Lower Saco). Each of these 2 units serves acutely ill patients, with high acuity levels requiring close nursing supervision in 2 areas that are physically separated by a locked door. This staffing pattern hindered the provision of quality nursing care due to failure of on-going professional nurse assessments of patients and professional nursing direction and supervision of non-professional nursing personnel.

Findings include:

A. Document Review:

1. The Lower Kennebec and Lower Saco Units serve acutely ill patients. Both units serve both male and female patients. Each of these 2 units serves acutely ill patients in 2 areas that are physically separated by a locked door. These 20-24 bed units have a "Main" section of the ward and a "Special Care" section (2-4 beds) that serve patients who present such behaviors as highly assaultive behavior or severe self-harm behaviors. This Unit configuration with acutely ill patients in both areas prohibits the single RN covering this large census of acutely ill patients from being immediately available to patients and staff on both sections of these wards.

2. Review of the a) nursing need patient assessments completed by the ward RNs on 5/8/13 (first day of survey) and b) nursing personnel staffing for 5/2/13 through 5/8/13 (first day of survey) provided by the Director of Nursing revealed that the level of RN nursing staffing was insufficient to provide adequate RN monitoring of patient care.

a. Lower Kennebec had a census of 18 patients on 5/8/13. Of these 18 patients, 6 were assessed as potentially assaultive, 4 patients were actively assaultive, 2 patients were listed as low risk for suicide and 1 patient listed as intermediate risk for suicide. Ten patients were listed as having hallucinations/delusions and 4 patients required forced (non-voluntary) medications or parenteral medications. Three patients had been placed in seclusion and/or restraints within the previous 48 hours, 2 patients were on assault precautions, 1 patient was on elopement precautions, 2 were on special monitoring due to eating disorders and three patients were on 1:1 supervision.

The staffing schedule reflected that only 1 RN was on duty on this Unit on the night shift on 5/2/13, 5/3/13, 5/4/13 and 5/5/13 even though the patients (17-18) on this ward were located on 2 separate areas that were physically divided by a locked door.

The staffing schedule reflected that only 2 RNs were on duty on this Unit on 1) the evening shift on 5/2/13, 5/4/13, 5/6/13 and 5/8/13; and 2) the day shift on 5/4/3, even though the patients on this ward were located on 2 separate areas that were physically divided by a locked door and the census on the "Main" side of this Unit served 17 patients who were acutely ill and required frequent assessments and interventions by a Registered Nurse, and direction and supervision of the unlicensed nursing personnel.

b. Lower Saco had a census of 18 patients on 5/8/13. Of these 18 patients, 7 were assessed as potentially assaultive, 2 patients were actively assaultive, 1 patient was listed as low risk for suicide and 1 patient listed as intermediate risk for suicide. Four patients were listed as having hallucinations/delusions and 1 patient required forced non-voluntary medications or parenteral medications. Two patients had been placed in seclusion and/or restraints within the previous 48 hours, 5 patients were on assault precautions and 1 patient was on elopement precautions and 2 patients were on 1:1 supervision.

The staffing schedule reflected that only 1 RN was on duty on this Unit on the night shift on 5/3/13, 5/4/13, 5/5/13 and 5/6/13 even though the patients (19) on this ward were located on 2 separate areas that were physically divided by a locked door.

The staffing schedule reflected that only 2 RNs were on duty on this Unit on 1) the evening shift on 5/5/13; and 2) the day shift on 5/4/3 and 5/5/13, even though the patients on this ward were located on 2 separate areas that were physically divided by a locked door and the census on the "Main" side of this Unit served 13-14 patients and the "Special Care" side of this Unit served 4 patients. These patients were acutely ill and required frequent assessments and interventions by a Registered Nurse and direction and supervision of the unlicensed nursing personnel.

B. Interviews:

1. During interview on 5/9/13 at 10:30 a.m., RN B12 stated that she is assigned to work on all three shifts and floats to Lower Kennebec and Lower Saco. She reported that there was a patient incident recently on the evening shift on Saco, Main section; she was the RN in charge back on the Special Unit on Lower Saco. She stated, "I called the other end of the hall (main section) to see if the RN needed my assistance. I did not have to go, but I sometimes go help when something happens." When asked what she does about the patient supervision on the section of the hall where she is assigned, she replied, "The mental health worker calls me if I'm needed." She reported that she sometimes works on nights when she is the only RN on duty on Lower Kennebec and Lower Saco even though there are 2 sections of each of these wards, all separated by locked doors. She stated, "I would like to see at least 2 RNs on nights." She stated "I came in for half of a shift on the evening shift on 5/6/13. The other RN left early and I was the only RN on duty for both sections for the remainder of the shift." When asked about relief for meals, etc., she replied, "Many times I do not get a dinner break, I eat on the ward. It's a good thing there is a bathroom on the unit."

2. During interview on 5/9/13 at 11:35 a.m., RN B13 reported that she works on Lower Kennebec Unit. She stated, "We need at least 2 RNs on the main section of the ward on day shift so we can attend treatment team meetings, give medications, do patient admissions. I have had to help the RN working on the Special Care end of the ward when I was the only RN working on the Main side of the Unit." She reported that the RN had to decide whether the patients could be left with only technicians present when she was the only RN working on the main section.

3. During interview on 5/9/13 at 2:10 p.m. with RN C14 and RN C15, who stated that they work on Lower Saco Unit, RN15 reported that the Main section was very busy with "medications, notes and overall care. When there is only one RN on duty on the Main section, it impacts on time to meet with patients. We work in A and B teams (on the main side) and need at least 2 RNs on the day and evening shift."

RN C14 stated, "I often have to go over to the main section (while working the special care end of unit) to make photo copies, assist with a patient event." RN C14 reported that the mental health worker calls if s/he is needed on the other end of the unit. RN C15 reported, "I have to go (from the main section) to the special care to help the RN about 1-2 times every week."

4. During interview with the Acting Director of Nursing on 5/9/13 at about 2:00 p.m., the staffing data (patient needs and staffing schedule) was discussed. She replied, "I don't understand why this is a problem now."

Based on record review and interview the Director of Social Services failed to assure that Psychosocial Assessments for 8 of 8 active sample patients (Patients A1, A20, B7, B11, C1, C2, D12 and D18) contained a summarization of material collected and that the role of the Social Work staff was described in patient care. This failure results in the multi-disciplinary treatment team not having conclusions about the psychosocial functioning of the patient and information about the social service role in treatment during and after hospitalization.

Findings include:

A. Medical Record Findings

Refer to B108 for details of the record findings.

B. Interview


On 5/9/2013 at 2:05 PM the Director of the Department of Social Services was interviewed. She was presented the Psychosocial Assessments of Patients A1, A20, D12 and D18. She concurred with the findings.