HospitalInspections.org

Based on observation, interview and record review the facility failed to protect the rights of current and discharged, placing all current patients at risk for loss of their rights.
Findings include:

--the facility failed to provide a safe environment for 4 current patients (#3, #10, #11 and #12) and 1 of 1 discharged patients (#1), resulting in increased risk of injury due to lack of supervision for all patients (See A-0144)

--the facility failed to update treatment plans for 2 of 2 current patient (#2 and #3) who were restrained or secluded, increasing the risk of restraint and seclusion for all patients. (See A-0166)

--the facility failed to prevent the use of PRN ("as needed) use of restraints for 1 of 1 current patients (#4). (See A-0169)

--the facility failed to train 1 of 1 staff members in close proximity to a patient in "Time Out" in hospital policies and procedures for Time Out and Seclusion. (See A-0196)

Based on observation, interview and record review, the facility failed to maintain staffing according to policy on 1 of 5 units (Mod K), for 4 current patients (#3, #10, #11 and #12) and failed to adequately supervise 1 of 1 discharged patients (#1), resulting in increased risk of injury due to lack of supervision for all patients. Findings include:

Policy:
On 6/18/14 at approximately 1500 the staffing matrix for all units was reviewed. The staffing matrix does not allow for 1 staff member to supervise all patients without additional staff on any unit, no matter how low the patient census.

Observations & Interviews:
1. On 6/17/14 at 1115, during at tour of Mod K unit, patient #3 was heard threatening to hurt staff.
2. On 6/17/14 at approximately 1115 staff L stated that patient #3; "is always threatening patients and staff."
3. On 6/17/14 at 12 noon staff K was observed entering and exiting a small room located in the hallway across from the nurses's station and outside of the Day Room.
4. On 6/17/14 at 12:05 staff K stated that she was the only staff member on the Unit (Mod K) at that time. Staff K stated that there were 4 patients on the unit (#3, #10, #11 and #12), all eating lunch at the back of the Day Room.
5. Staff K was asked how she would call for help if necessary. Staff K stated: "I would need to come out to the phone and call a Code." Staff K stated that she does not carry a panic call device and would need to get to the phone at the nurse's station to call for help.
6. On 6/17/14 at approximately 1210 staff C stated that it is facility policy to have at least two staff members on all units at all times.

Record Review:
1. On 6/18/14 from 1240-1600 review of patient #1's records revealed a "Recipient Rights Investigative Report," dated 6/9/14, stating that video evidence and staff statements substantiated the allegation that patient #1 was slapped or punched in the head by patient #9 on 5/8/14 "in the evening" (time unspecified) in the Mod K Day Room. The report states that patient #1 was sent to a hospital emergency department for evaluation of a possible seizure shortly after being assaulted.
2. On 6/18/14 at approximately 1300 review of video evidence of the hallway and Day Room at the time of the (above) assault revealed that patients #1, #9 and a third male patient were interacting in the Day Room with no staff present in the Day Room at the time of the incident. Staff N was seated outside of the Day Room, in front of the Day Room window, moving his head between the window and the Nurse's Station, located behind him.

Interviews:
1. On 6/18/14 at 1520 staff M, present at the time of the above incident, stated that patient #1 had complained of being bullied by other boys on the unit prior to the assault on 5/8/14. Staff M stated that patient #1 suffered an apparent seizure "shortly after the incident" and that he was transferred to a hospital Emergency Department for evaluation and did not return to the facility.
2. On 6/18/14 at 1540, staff N confirmed that he was seated outside the Day Room window when the (above) incident occurred. Staff N stated that he first became aware of the assault when he heard yelling. Staff N stated that he then ran into the Day Room and observed patient #9 hitting patient #1 in the face. Staff N stated that patient #1 had complained of being bullied by patient #9 prior to this incident and that staff presence in the Day Room would have been safer for the patients.

Based on record review and interview the use of restraint or seclusion did not result in updates to treatment plans for 2 of 2 current patient (#2 and #3), increasing the risk of restraint and seclusion for all patients. Findings include:

Policy:
On 6/18/14 from 1-3 pm policy RR#12, dated 3/13, titled "Restraints" was reviewed. The policy states:
"The use of restraint must be:
(i) In accordance with a written modification to the patient' plan of care..."

Record Review:
On 6/17/14 at approximately 1005 review of the Mod W "Restraint Log" for June 2014 revealed that patient was physically restrained on 6/8/14, 6/9/14 and 6/10/14. On 6/18/14 at approximately 1415 review of patient #2's treatment plan revealed that it was not updated in response to these episodes of restraint.

On 6/17/14 at approximately 1120 review of the Mod K "Seclusion Log" for June 2014 for patient #3 revealed that patient #3 was secluded on 6/9/14, 6/10/14, 6/11/14 and 6/14/14. On 6/17/14 at approximately 1125 review of patient #2's treatment plan revealed no updates to the treatment plan following these episodes of seclusion.

Interview:
The above findings were verified with Staff A on 6/18/14 at approximately 1430. Staff A stated that the electronic medical record links daily patient progress notes to treatment plans and that each patient's treatment team meets several times each week. Staff A was unable to provide documentation of treatment plan updates in response to the above episodes of restraint and seclusion for either patient.

Based on record review and interview 1 of 1 current patients (patient #4) was held for administration of an intramuscular medication injection, administered on a PRN basis, without a physician's order for restraint, increasing the risk of restraints without physician's orders for all patients. Findings include:

Policy Review:
On 6/18/14 at approximately 1100 the facility's policy on Restraints was reviewed. The policy states: "holding a recipient in a manner that restricts the recipient's movement against the recipient's will is considered restraint."
"Chemical restraint...a medication used in addition to or in place of the recipient's regular drug regimen to control behavior in an emergency..."

Record Review:
1. On 6/18/14 at approximately 1245, review of Mod W's Restraint Log for June 2014 revealed no documentation that patient #4, a 12 year old child, was physically restrained for administration of intramuscular medication on the evening of 6/13/14.
2. On 6/18/14 at approximately 1300 review of patient #4's Medication Administration Record revealed a note by Nurse P from 1800 on 6/13/14 stating: (Patient #4) "began to be extremely aggressive, not responding to any redirection, kicking and hitting. Decision made to give haldol 5 mg. and benadryl 50 mg IM and placed in seclusion."
3. On 6/18/14 at approximately 1300 review of patient #2's clinical record revealed a nursing note by staff Q dated 6/13/14 at 1755 stating: "Patient kicked RN in the face during hold for PRN..."
4. On 6/18/14 at approximately 1330 review of patient #2's clinical record revealed no order for physical or chemical restraint on 6/13/14.

Interview:
On 6/18/14 at approximately 1400 the above findings were confirmed by Staff C.

Based on observation and interview, the hospital failed to train 1 of 1 staff members present in the hallway where a patient was in "Time Out" in hospital policies and procedures for Time Out and Seclusion, increasing the risk of all patients being secluded in a manner inconsistent with hospital policy. Findings include:

Observation & Interviews:
On 6/17/14 at 0950 staff O, the only staff member present in the hallway where patient #2's bedroom was in "Time Out" was interviewed. Staff O was seated in the doorway to another patient's room, approximately 10-15 feet from patient #2's closed door. Staff O stated that patient #2 was in "Time Out." Staff O stated that staff P informed her of this a few minutes ago. Staff O was asked if patient #2 was free to leave the bedroom during Time Out. Staff O stated that patient #2 had to remain in the bedroom during Time Out. Staff O stated that she was not sure about details of the facility's policy on Time Out.

On 6/17/14 at approximately 0953 patient #2, who had been alone in the bedroom, was asked if he was told that he must stay in his room during Time Out. The patient did not respond. At approximately 0955 staff P entered the hallway where patient #2 had been in Time Out. Staff P stated that patient #2 was not required to stay in his room during Time Out.

On 6/17/14 at approximately 1015 an attempt was made to locate current versions of the hospital's policies on Seclusion and Time Out on the unit. An old (not current) Seclusion policy was found in the "Restraint and Seclusion" Log Book. This observation was confirmed by Staff C.

Based on observation, interview and record review the facility failed to protect the rights of current and discharged, placing all current patients at risk for loss of their rights.
Findings include:

--the facility failed to provide a safe environment for 4 current patients (#3, #10, #11 and #12) and 1 of 1 discharged patients (#1), resulting in increased risk of injury due to lack of supervision for all patients (See A-0144)

--the facility failed to update treatment plans for 2 of 2 current patient (#2 and #3) who were restrained or secluded, increasing the risk of restraint and seclusion for all patients. (See A-0166)

--the facility failed to prevent the use of PRN ("as needed) use of restraints for 1 of 1 current patients (#4). (See A-0169)

--the facility failed to train 1 of 1 staff members in close proximity to a patient in "Time Out" in hospital policies and procedures for Time Out and Seclusion. (See A-0196)

Based on observation, interview and record review, the facility failed to maintain staffing according to policy on 1 of 5 units (Mod K), for 4 current patients (#3, #10, #11 and #12) and failed to adequately supervise 1 of 1 discharged patients (#1), resulting in increased risk of injury due to lack of supervision for all patients. Findings include:

Policy:
On 6/18/14 at approximately 1500 the staffing matrix for all units was reviewed. The staffing matrix does not allow for 1 staff member to supervise all patients without additional staff on any unit, no matter how low the patient census.

Observations & Interviews:
1. On 6/17/14 at 1115, during at tour of Mod K unit, patient #3 was heard threatening to hurt staff.
2. On 6/17/14 at approximately 1115 staff L stated that patient #3; "is always threatening patients and staff."
3. On 6/17/14 at 12 noon staff K was observed entering and exiting a small room located in the hallway across from the nurses's station and outside of the Day Room.
4. On 6/17/14 at 12:05 staff K stated that she was the only staff member on the Unit (Mod K) at that time. Staff K stated that there were 4 patients on the unit (#3, #10, #11 and #12), all eating lunch at the back of the Day Room.
5. Staff K was asked how she would call for help if necessary. Staff K stated: "I would need to come out to the phone and call a Code." Staff K stated that she does not carry a panic call device and would need to get to the phone at the nurse's station to call for help.
6. On 6/17/14 at approximately 1210 staff C stated that it is facility policy to have at least two staff members on all units at all times.

Record Review:
1. On 6/18/14 from 1240-1600 review of patient #1's records revealed a "Recipient Rights Investigative Report," dated 6/9/14, stating that video evidence and staff statements substantiated the allegation that patient #1 was slapped or punched in the head by patient #9 on 5/8/14 "in the evening" (time unspecified) in the Mod K Day Room. The report states that patient #1 was sent to a hospital emergency department for evaluation of a possible seizure shortly after being assaulted.
2. On 6/18/14 at approximately 1300 review of video evidence of the hallway and Day Room at the time of the (above) assault revealed that patients #1, #9 and a third male patient were interacting in the Day Room with no staff present in the Day Room at the time of the incident. Staff N was seated outside of the Day Room, in front of the Day Room window, moving his head between the window and the Nurse's Station, located behind him.

Interviews:
1. On 6/18/14 at 1520 staff M, present at the time of the above incident, stated that patient #1 had complained of being bullied by other boys on the unit prior to the assault on 5/8/14. Staff M stated that patient #1 suffered an apparent seizure "shortly after the incident" and that he was transferred to a hospital Emergency Department for evaluation and did not return to the facility.
2. On 6/18/14 at 1540, staff N confirmed that he was seated outside the Day Room window when the (above) incident occurred. Staff N stated that he first became aware of the assault when he heard yelling. Staff N stated that he then ran into the Day Room and observed patient #9 hitting patient #1 in the face. Staff N stated that patient #1 had complained of being bullied by patient #9 prior to this incident and that staff presence in the Day Room would have been safer for the patients.

Based on record review and interview the use of restraint or seclusion did not result in updates to treatment plans for 2 of 2 current patient (#2 and #3), increasing the risk of restraint and seclusion for all patients. Findings include:

Policy:
On 6/18/14 from 1-3 pm policy RR#12, dated 3/13, titled "Restraints" was reviewed. The policy states:
"The use of restraint must be:
(i) In accordance with a written modification to the patient' plan of care..."

Record Review:
On 6/17/14 at approximately 1005 review of the Mod W "Restraint Log" for June 2014 revealed that patient was physically restrained on 6/8/14, 6/9/14 and 6/10/14. On 6/18/14 at approximately 1415 review of patient #2's treatment plan revealed that it was not updated in response to these episodes of restraint.

On 6/17/14 at approximately 1120 review of the Mod K "Seclusion Log" for June 2014 for patient #3 revealed that patient #3 was secluded on 6/9/14, 6/10/14, 6/11/14 and 6/14/14. On 6/17/14 at approximately 1125 review of patient #2's treatment plan revealed no updates to the treatment plan following these episodes of seclusion.

Interview:
The above findings were verified with Staff A on 6/18/14 at approximately 1430. Staff A stated that the electronic medical record links daily patient progress notes to treatment plans and that each patient's treatment team meets several times each week. Staff A was unable to provide documentation of treatment plan updates in response to the above episodes of restraint and seclusion for either patient.

Based on record review and interview 1 of 1 current patients (patient #4) was held for administration of an intramuscular medication injection, administered on a PRN basis, without a physician's order for restraint, increasing the risk of restraints without physician's orders for all patients. Findings include:

Policy Review:
On 6/18/14 at approximately 1100 the facility's policy on Restraints was reviewed. The policy states: "holding a recipient in a manner that restricts the recipient's movement against the recipient's will is considered restraint."
"Chemical restraint...a medication used in addition to or in place of the recipient's regular drug regimen to control behavior in an emergency..."

Record Review:
1. On 6/18/14 at approximately 1245, review of Mod W's Restraint Log for June 2014 revealed no documentation that patient #4, a 12 year old child, was physically restrained for administration of intramuscular medication on the evening of 6/13/14.
2. On 6/18/14 at approximately 1300 review of patient #4's Medication Administration Record revealed a note by Nurse P from 1800 on 6/13/14 stating: (Patient #4) "began to be extremely aggressive, not responding to any redirection, kicking and hitting. Decision made to give haldol 5 mg. and benadryl 50 mg IM and placed in seclusion."
3. On 6/18/14 at approximately 1300 review of patient #2's clinical record revealed a nursing note by staff Q dated 6/13/14 at 1755 stating: "Patient kicked RN in the face during hold for PRN..."
4. On 6/18/14 at approximately 1330 review of patient #2's clinical record revealed no order for physical or chemical restraint on 6/13/14.

Interview:
On 6/18/14 at approximately 1400 the above findings were confirmed by Staff C.

Based on observation and interview, the hospital failed to train 1 of 1 staff members present in the hallway where a patient was in "Time Out" in hospital policies and procedures for Time Out and Seclusion, increasing the risk of all patients being secluded in a manner inconsistent with hospital policy. Findings include:

Observation & Interviews:
On 6/17/14 at 0950 staff O, the only staff member present in the hallway where patient #2's bedroom was in "Time Out" was interviewed. Staff O was seated in the doorway to another patient's room, approximately 10-15 feet from patient #2's closed door. Staff O stated that patient #2 was in "Time Out." Staff O stated that staff P informed her of this a few minutes ago. Staff O was asked if patient #2 was free to leave the bedroom during Time Out. Staff O stated that patient #2 had to remain in the bedroom during Time Out. Staff O stated that she was not sure about details of the facility's policy on Time Out.

On 6/17/14 at approximately 0953 patient #2, who had been alone in the bedroom, was asked if he was told that he must stay in his room during Time Out. The patient did not respond. At approximately 0955 staff P entered the hallway where patient #2 had been in Time Out. Staff P stated that patient #2 was not required to stay in his room during Time Out.

On 6/17/14 at approximately 1015 an attempt was made to locate current versions of the hospital's policies on Seclusion and Time Out on the unit. An old (not current) Seclusion policy was found in the "Restraint and Seclusion" Log Book. This observation was confirmed by Staff C.