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Based on record review, interview, and observation, the hospital failed to:

A. Ensure three of 30 patients rooms and one of one isolation rooms, on behavioral health units #1 and 2, were free from environmental hazards, and the timely replacement of the smoke protection doors between units #1 and 2 that were torn off by a patient in July 2017. (See Tags K- 0761 and K-0791)

B. Conduct an investigation of alleged abuse, remove patient #8 from patient areas during an investigation of alleged abuse and ensure a patient who required line-of-site monitoring was provided the monitoring. Additionally, the hospital failed to ensure patient #3 was allowed to file a police report after alleged assault by patient #8. (See Tags A-145 and A-395)

C. Ensure patient #3's order for a mechanical soft diet was properly entered into the computer system, provided patient #3 the wrong diet and resulted in patient #3 choking on his/her food. (See Tag A-630)


These deficient practices were determined to pose an immediate jeopardy to patients health and safety and placed all patients on the behavioral health units #1 and 2 at risk for the likelihood of harm, serious injury and possible subsequent death.

On 04/20/18, at 2:30 pm, the hospital leadership was notified of the immediate jeopardy findings.

On 04/23/18 at 9:30 am, the hospital submitted a plan of removal which contained the following elements:

The facility would:

~ vacate, close and lock the three patient rooms with the missing and modified wicket doors on 04/20/18.

~ order replacement wicket doors on 04/18/18 with an estimated installation date of 06/08/18.

~ order replacement smoke barrier doors on 04/19/18.

~ educate staff on the environmental dangers and safety.

~ initiate a fire watch schedule until the smoke barrier doors could be replaced.

~ revise their Abuse, Neglect and Exploitation policy to include process to follow in the event of patient-on-patient violence.

~ educate all hospital staff, physicians and contract staff on the the revised abuse, neglect and exploitation policy.

~ create a log of patients on line-of-site to include date and time of initiation and discontinuation. Copies would be sent to Quality on a daily basis.

~ educate staff on the line-of-site log and process and to notify physicians of change in status to 1:1 or Line of Site.

~ provide one-on-one education on how to process, to enter, and to modify dietary orders properly.

~ conduct a skills lab starting 04/23/18 for verification, re-validation on knowledge, abilities and accuracy.

~ implement 100% verification audit of diet ordered vs delivered on all three meals per day, and audit logs would be sent to Quality on a daily basis.


On 04/23/18 at 2:30 pm the removal of immediacy was verified. The surveyors:

~ observed the three affected patient rooms with modified wicket doors were vacant, closed and locked.

~ interviewed staff to ensure their knowledge of not using the three patient rooms with the modified wicket doors. The staff stated the three patient rooms were to not be used for any reason until after the repairs were made to the doors.

~ interviewed staff regarding their knowledge of emergencies, such as fire, and were able to express the appropriate steps in the event of a fire.

~ observed a fire watch by hospital staff and reviewed the fire watch log schedule which showed staff conducting a fire-watch up to the date of the fire doors can be installed.

~ interviewed staff to ensure education was completed regarding abuse and to determine if staff knew how to report abuse. The staff stated what steps to take if abuse was suspected and how to report it.

~ interviewed staff to ensure education was completed regarding the line-of-site process including documentation and notification of physicians of a status change.

~ observed the modified computer process by all staff who enter and modify orders.

~ interviewed staff to ensure education was completed regarding the process for ordering diets, modifying diets, and diet verification practices.

Based on record review, interview, and observation, the facility failed to provide a safe environment for patients as evidenced by:

A. Failure to ensure three of 30 patients rooms and one of one isolation rooms, on behavioral health units #1 and 2, were free from environmental hazards and failure to replace the smoke protection doors between units #1 and 2 that were torn off by a patient in July 2017.

B. Failure to conduct an investigation of alleged abuse, remove patient #8 from patient areas during an investigation of alleged abuse and ensure patients who required line-of-site monitoring was provided the monitoring. Additionally, the hospital failed to ensure patient #3 was allowed to file a police report for alleged assault by patient #8.

C. Failure to ensure patient #3's order for a mechanical soft diet was properly entered into the computer system, provided patient #3 the wrong diet and resulted in patient #3 choking on his/her food.

Findings:

A. Wicket Doors and Smoke Barrier Doors

On 04/19/18, at 1:32 pm, the seclusion room doors were observed to be fire rated door assemblies. The ante door was a fire rated door assembly with a 20 minute rated fire resistant rated door observed on the label near the door frame and the patient room door label showed it to be a 20 minute rated fire resistant rated door, too. Both doors had been field modified and both doors had deadbolt locks installed. The fire rated metal door frame assembly was observed to have a hole drilled into it so the deadbolt lock could fit into it. The ante room fire rated door was observed to have a piece of plywood screwed onto it and the seclusion room patient room door was observed to have a piece of Plexiglass screwed onto the egress side of the door.

Record review showed the fire rated seclusion room doors located in the behavioral unit on the second floor were not included on the 2017 Annual Fire/Smoke Door Inspection Report.

On 04/19/18, at 1:33 pm, the surveyor asked Staff D why the fire rated doors and fire rated door assemblies had been modified. He stated he did not know but would look into it. The surveyor stated that since they are fire rated doors and fire rated assemblies they should have been identified on the annual fire rated door inspection report and been repaired by manufacturer's recommendation or replaced.

On 04/19/18, at 2:10 pm, a set of smoke barrier doors were observed to be missing from a metal frame assembly separating the Adult M Behavioral Unit 1 from the Adult M Unit 2 Behavioral Unit. The existing metal smoke door frame assembly had an "L" bracket holding the frame assembly leg in place and was also screwed into the floor to hold it into place. The middle wicket access door was observed to be missing from three (#2248, #2249, and #2250) of four patient rooms and the seclusion room. Rooms #2248, #2249, and #2250 were observed to have a piece of raw plywood screwed with metal wood screws onto the damaged patient room door covering the area where the wicket access door once was. The seclusion room door had a piece of Plexiglass screwed onto the door where the wicket access door once was.

Each of the patient beds in rooms #2248, #2249, and #2250 were observed not bolted down and the behavioral patients could use the beds to barricade themselves in their rooms not allowing egress or staff access in an emergency.

Record review of facility maintenance logs/reports showed the facility did not replace four damaged wicket access doors and a set of smoke barrier doors within the Adult M Unit 1 and Adult M Unit 2 Behavioral Unit on the second floor.

An incident report written by the evening nurse house supervisor dated 07/19/17, at "19:20," documented a "code purple" was called on Adult M Unit 1 and the patient from room #2247b damaged the smoke barrier doors, and pulled down an exit sign.

A security services incident report #130763 dated 07/20/17, at 9:10 am, showed a security officer reported to Adult M Unit 1 to assist on a door watch plan, that a door leading to the other Adult M Unit 1 unit had been damaged that night. The security incident report also documented the plan to have a "tech sit" by the damaged door and "security to frequent patrol" to the area. A facility Interim Life Safety Measures (ILSM) document dated 10/05/17 showed the smoke doors were removed until the frame/new doors could be installed. Review of four facility invoice purchase orders documented the smoke doors and four wicket access doors were ordered on 04/19/18.

On 04/19/18, at 2:30 pm, the surveyor asked Staff D what happened to the behavioral patient doors and smoke doors. Staff D stated a behavioral patient on the unit last year damaged the smoke doors and tore off the wicket access doors in the behavioral unit. The surveyor asked Staff D why the damaged doors were modified beyond manufactures recommendation instead of being replaced at the time the damage was received. Staff D stated it could or may have been a budgeting issue at that time but he would look into it. He also stated, he did not know about these issues and was called to assist only a day ago due to the old director of facility management having left employment with the hospital on 04/13/18. He stated, he ordered the smoke barrier doors and replacement wicket access doors upon being made aware of the problem by the OSDH Health team.

On 04/20/18, at 10:02 am, the surveyor requested manufacturer's documentation from Staff D showing the facility's patient doors in the behavioral unit could have deadbolts installed, holes drilled into the door frames, and raw plywood screwed onto the egress side of the patient room doors. Staff D did not provide the manufacturers documentation showing the behavioral patient room doors could be field modified.


B. Allegations of Abuse

Review of a document titled "Event Report", dated 03/25/18 (no time(s) documented) showed the following:

Patient #8 went from Unit One to Unit Two "throughout the day on several occasions". Patient #8 entered Patient #3's room. Patient #3 stated Patient #8 "grabbed her legs and tried to pull her out of the geri-chair." Patient #8 cursed Patient #3 and was redirected back to his room. (This report did not parallel the 03/25/18 video reviewed by the surveyors, which showed Patient #8 exiting Patient #3's room and attempting to enter another patient's room). Patient #3 was "very upset, crying, and wanted to file a police report". Staff P took Patient #3 to office, allowed patient "to vent and express his/her concerns." Staff P recommended Patient #3 "sleep on it" and speak to the Director in the morning.

Review of "Event Report," dated 03/26/18, showed (no time documented) Staff N spoke with Patient #3 and "he/she is still upset."

On 04/18/18 at 9:30 am, Staff A stated he/she did not know if a Licensed Certified Social Worker had followed up on the alleged assault of Patient #3.

On 04/18/18 at 3:10 pm, Staff B stated "there was no substantiation of the complaint" and no changes in processes or policies had occurred as a result of this incident.

On 04/18/18 at 3:30 pm, during a phone interview, Staff N stated on 03/26/18, Patient #3 "was very upset and angry" after the incident on 03/25/18 and expressed that staff hadn't listened to him/her.

Surveyors requested documentation of an investigation of Patient #3's complaint and it was not provided.


Review of Patient #8 medical record showed:

On 03/21/18, patient was admitted with a chief complaint of Psychosis, Major Depressive Disorder and Schizophrenia.

On 03/24/18 at 7:57 pm, Staff Q documented "client is up disrupting unit being aggressive and making vulgar and aggressive statements to staff and peers."

On 03/25/18 at 7:12 pm, Staff S documented "patient was put into the seclusion room due to the fact that patient can not keep hands to self and keeps going into patient rooms and making racial slurs while also getting into altercations with other patients. Patient called staff obscene names. Patient was kicking and punching the door, while also trying to destroy anything [he/she] could."

On 04/19/18 at 11:30 am, Staff O stated Patient #8 did go into patient #3's room and touched his/her leg. He/She was so upset. I put patient #8 into the seclusion room. I talked to him/her. Patient #3 wanted to call the police to file a report. I told patient #3 that I don't know what the police could do. I told patient #3 that the director would come see him/her the next day. Then we could determine if we could call police.

On 04/23/18 at 1:20 pm, Staff O stated I put patient #8 on line of sight, because of Patient #8's behavior. It all happened at visitation. I do not know if I charted line of sight because I was off the next day. I did chart the seclusion.

Review of a document titled "Behavioral Health Patient Observation" showed patient was not placed on line of sight or 1:1 observation.


C. Dietary

A review of patient #3 medical record showed:

A document titled "Nutrition Assessment" showed Staff U documented "patient reports chewing difficulty; patient agreeable to mechanical soft diet; patient missing top teeth and poor dentition on lower."

On 03/23/18 a regular mechanical soft diet was ordered.

On 03/25/18 patient #3's mechanical soft diet was changed to a regular diet with double portions. The only change to the order should have been adding double portions.

A document titled "Progress Note" for 03/26/18, showed Staff V documented patient reported that he/she choked on his/her food over the weekend and that made his/her anxiety worse.

On 04/18/18, Staff E stated patient was ordered a regular mechanical soft diet on 03/23/18. The diet was changed on 03/25/18 to a regular diet with double portions. Staff E stated regular mechanical soft diet would have to be typed into the comments.

Based on record review and interview, the hospital failed to protect patient #3 from being allegedly assaulted by patient #8, who was documented to be an aggressive patient and failed to implement safety measures during an abuse investigation to protect all patients on the Behavioral Health Units when the hospital received allegations of abuse/assault.

This failed practice resulted in patient #3 being allegedly assaulted and had the potential for all patients admitted to the Behavioral Health Unit to be at risk for abuse by failing to implement safety measures during an abuse investigation.

Findings:

Review of a document titled "Event Report", dated 03/25/18 (no time(s) documented) showed the following:

Patient #8 went from Unit One to Unit Two "throughout the day on several occasions". Patient #8 entered Patient #3's room. Patient #3 stated Patient #8 "grabbed her legs and tried to pull her out of the geri-chair." Patient #8 cursed Patient #3 and was redirected back to his room. (This report did not parallel the 03/25/18 video reviewed by the surveyors, which showed Patient #8 exiting Patient #3's room and attempting to enter another patient's room). Patient #3 was "very upset, crying, and wanted to file a police report". Staff P took Patient #3 to office, allowed patient "to vent and express his/her concerns." Staff P recommended Patient #3 "sleep on it" and speak to the Director in the morning.

Review of "Event Report," dated 03/26/18, showed (no time documented), Staff N spoke with Patient #3 and "he/she is still upset."

On 04/18/18 at 9:30 am, Staff A stated he/she did not know if a Licensed Certified Social Worker had followed up on the alleged assault of Patient #3.

On 04/18/18 at 3:10 pm, Staff B stated "there was no substantiation of the complaint" and no changes in processes or policies had occurred as a result of this incident.

On 04/18/18 at 3:30 pm, during a phone interview, Staff N stated on 03/26/18, Patient #3 "was very upset and angry" after the incident on 03/25/18 and expressed that staff hadn't listened to him/her.

Surveyors requested documentation of an investigation of Patient #3 complaint and it was not provided.


Review of Patient #8 medical record showed:

On 03/21/18, patient was admitted with a chief complaint of Psychosis, Major Depressive Disorder and Schizophrenia.

On 03/24/18 at 7:57 pm, Staff Q documented "client is up disrupting unit being aggressive and making vulgar and aggressive statements to staff and peers."

On 03/25/18 at 7:12 pm, Staff S documented "patient was put into the seclusion room due to the fact that patient can not keep hands to self and keeps going into patient rooms and making racial slurs while also getting into altercations with other patients. Patient called staff obscene names. Patient was kicking and punching the door, while also trying to destroy anything [he/she] could."

On 04/19/18 at 11:30 am, Staff O stated Patient #8 did go into patient #3's room and touched his/her leg. He/She was so upset. I put patient #8 into the seclusion room. I talked to him/her. Patient #3 wanted to call the police to file a report. I told patient #3 that I don't know what the police could do. I told patient #3 that the director would come see him/her the next day. Then we could determine if we could call police.

On 04/23/18 at 1:20 pm, Staff O stated he/she put Patient #8 on line of sight, because of Patient #8's behavior. It all happened at visitation. He/she did not know if he/she charted line of sight because he/she was off the next day. Staff O stated he/she did chart the seclusion.

Review of a document titled "Behavioral Health Patient Observation" showed patient was not placed on line of sight or 1:1 observation.

Based on record review and interview, the hospital failed to ensure patient #8's level of care was changed to 1:1 or line of sight observation after allegedly abusing patient #3. (See Tag A-395)

This failed practice posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possible subsequent death.

On 04/20/18, at 2:30 pm, the hospital leadership was notified of the immediate jeopardy findings.

On 04/23/18 at 9:30 am, the hospital submitted a plan of removal.

The plan of removal contained the following elements:

The facility created a log of all patients on 1:1 or line of sight observation that included date, time of patient status change, reason of status change and date/time the status was discontinued.

On 04/23/18 at 2:30 surveyors observed the removal of the immediacy by:

Review of the policy revision for 1:1 and line of sight.

Interviews with nursing staff to ensure knowledge of education of 1:1 or line of sight observation for patients with status change. The nursing staff stated patients with status changes should be documented on the observation logs and 15 minute rounding checklist.

Based on record review and interview, the hospital failed to ensure patient #8 level of care was changed to 1:1 or line of sight before entering patient #3 room and allegedly assaulted patient #3.

This failed practice resulted in the alleged assault of patient #3 when patient #8 was allowed to enter patient #3's room after staff had documented Patient #8 had entered other patients' rooms, and was aggressive.

Findings:

Review of Patient #8 medical record showed:

On 03/21/18, patient was admitted with a chief complaint of Psychosis, Major Depressive Disorder and Schizophrenia.

On 03/24/28 at 5:42 pm, Staff O documented patient #8 "having difficulty with directions, agitated, physically aggressive and poor impulse control. Patient continues to be disorganized and have pressured speech. Patient did have one aggressive outburst and was put in seclusion."

On 03/24/18 at 7:57 pm, Staff W documented "client is up disrupting unit being aggressive and making vulgar and aggressive statements to staff and peers."

On 03/25/18 at 1:02 pm, Staff O documented patient # 8 was agitated, argumentative, difficult to redirect, inappropriate touching and intrusive.

On 03/25/18 at 3:09 pm, Staff Q documented patient # 8 was absent from Psy-Theraputic Group "due to being confined to his room."


(Surveyor watched the video recording for alleged abuse which showed:

On 03/25/18 at 4:05 pm, patient #3 is observed going into his/her room via wheelchair.

On 03/25/18 at 4:07 pm, patient #8 is observed walking into patient # 3's room for approximately 15 seconds.

On 03/25/18 at 4:08 pm, patient #3 is observed leaving his/her room via wheelchair.)


On 03/25/18 at 7:12 pm, Staff S documented "patient was put into the seclusion room due to the fact that patient can not keep hands to self and keeps going into patient rooms and making racial slurs while also getting into altercations with other patients. Patient called staff obscene names. Patient was kicking and punching the door, while also trying to destroy anything he/she could."


On 04/19/18 at 11:30 am, Staff O stated Patient #8 did go into patient #3's room and touched his/her leg. He/She was so upset. I put patient #8 into the seclusion room. I talked to him/her. Patient #3 wanted to call the police to file a report. I told patient #3 that I don't know what the police could do. I told patient #3 that the director would come see him/her the next day. Then we could determine if we could call police.


On 04/19/18 at 11:30 am, Staff O stated when patient # 8 went into the other rooms him/her was on the phone, the tech was busy and another tech was busy with visitation. There is not someone to watch the unit all of the time. Staff O tries to get another nurse out on the floor so we can monitor. If you are on the floor, there isn't a place that you can see everyone.


On 04/23/18 at 1:20 pm, Staff O stated I put patient #8 on line of sight, because of Patient #8's behavior. It all happened at visitation. I do not know if I charted line of sight because I was off the next day. I did chart the seclusion.


Review of a document titled "Behavioral Health Patient Observation" showed patient was not placed on line of sight or 1:1 observation. On 03/24/18, before the alleged abuse incident patient # 8 was exhibiting aggressive behavior but was not put on line of sight or1:1 observation.

Based on record review and interview, the hospital failed to ensure the correct diet was entered into the computer system for one patient (#3) of 21 patient medical records reviewed. Patient #3 required a mechanical soft diet but received a regular texture diet and choked while eating.

See Tag - O630

This failed practice posed an immediate jeopardy to the health and safety for all patients with special diet orders.

On 04/20/18, at 2:30 pm, the hospital leadership was notified of the immediate jeopardy findings.

On 04/23/18 at 9:30 am, the hospital submitted a plan of removal.

The plan of removal contained the following elements:

The hospital would:

~ educate clinical staff and those who receive diet orders on the process to enter and modify dietary orders.

~ provide one-on-one education and will be added to daily safety huddles.

~ provide a skills lab starting on 04/23/18 for verification, re-validation and knowledge, abilities and accuracy.

~ implement 100% verification audit of diet ordered versus delivered on behavioral health 3 meals/day. Started on 04/22/18 prior to delivery of meals to the patient.

~ audit logs would be sent to Quality daily.


On 04/23/18 at 2:30 the removal of immediacy was verified. The surveyors:

~ observed lunch on both behavioral health units. The mental health technician verified patients' meal tickets with order entry for diet before deliver.

~ reviewed education materials for topics covered.

~ interviewed nursing staff and mental health technicians to confirm knowledge of proper verification of orders and revised processes.

~ interviewed staff on the proper method of modifying dietary orders in the computer system.

Based on record review and interview, the hospital failed to ensure patient #3's order for a mechanical soft diet was properly entered into the computer system and failed to provide the appropriately ordered diet.

This failed practice resulted in patient #3 choking on his/her food.

Findings:

A review of patient #3's medical record showed:

A document titled "Nutrition Assessment" showed Staff U documented "patient reports chewing difficulty; patient agreeable to mechanical soft diet; patient missing top teeth and poor dentition on lower."

On 03/23/18 a regular mechanical soft diet was ordered.

On 03/25/18 patient #3's mechanical soft diet was changed to a regular diet with double portions. The only change to the order should of been adding double portions.

A document titled "Progress Note" for 03/26/18, showed Staff V documented patient reported that he/she choked on his/her food over the weekend and that made his/her anxiety worse.

On 04/18/18, Staff E stated patient was ordered a regular mechanical soft diet on 03/23/18. The diet was changed on 03/25/18 to a regular diet with double portions. Staff E stated regular mechanical soft diet would have to be typed into the comments.

Based on record review, interview and observation, the hospital failed to ensure patient safety by replacing damaged patient room wicket doors with plywood or plexi-glass that were screwed in from the inside of three out of 30 (# 2248, # 2249, and # 2250) patients rooms and one seclusion room on behavioral health unit 2. This alteration of wicket doors had the potential for patients occupying those rooms, to barricade themselves in the rooms and not be able to be extracted by staff in the event of an emergency Additionally, the facility failed to replace the smoke doors located between units 1 and 2 which would have been a potential for smoke exposure if a fire were to occur. (See Tag K- 0761 and K-0791)

These deficient practices were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possible subsequent death.

On 04/20/18, at 2:30 pm, the hospital leadership was notified of the immediate jeopardy findings.

On 04/23/18 at 9:30 am, the hospital submitted a plan of removal.

The plan of removal contained the following elements:

The facility would:

~ order smoke doors on 04/18/18.

~ implement a fire watch with hourly rounding. The rounding logs would be sent to Quality daily.

~ vacate, close and locke the patient rooms with the modified wicket doors on 04/20/18.

~ educate staff on the Interim LIfe Safety Policy.

~ discuss the Interim Life Safety Measures during daily safety huddles.


On 04/23/18 at 2:30 the removal of immediacy was verified. The surveyors:

~ observed the hourly roundings

~ reviewed the documentation for hourly rounding logs and schedule.

~ observed the affected patient rooms were vacant, closed and locked.

~ interviewed clinical staff to ensure what actions they would take in case of a fire and their knowledge of not using the affected patient rooms.