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Based on review of facility documents, medical records (MR) and interviews with staff (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to provide and maintain care in a safe setting in three of ten medical records reviewed.(MR4, MR5, and MR6)

Findings:

1) A review of facility "Patient Rights and Responsibilities" review/revise July 2011, revealed "... 6. Patients have the right to safety applied to all aspects of hospital care, ... ."

A review of facility policy "Care of the Patient Suicide/Close Observation Precautions" review/revise April 2011, revealed "... III. Definitions ... Close Observation- 15 Minutes; The patient is observed by the staff at a minimum of 15 minute intervals." The policy did not address whether or not suicidal/close observation patients could have roommates, nor did it include criteria to discontinue the checks.


A Review of MR4 on December 7-8, 2011, revealed "Initial Psychiatric Summary: Identifying Information: ... year old admitted in a 201 commitment. Chief Complaint: 'I don't know why I'm here.' HPI: This ... admitted on 201 from ... . pt presented with poor eye contact, internally preoccupied, responding to internal stimuli, stated awake for 2 days and 2 nights, increased latency to responses, poverty of speech, & thought blocking. ... pt has been living at ... residential since Sept 2011. Pt has been diagnosed with SAD, ADHD, Autistic Spectrum d/o,and Conduct d/o... ."

The patient (MR4) was assessed to have aggressive behaviors and was placed in four point restraints on two separate occasions on November 26, 2011, for "safety to self and others." It was documented that the patient was "assaultive to peers" and on November 28 at 7:30 AM, the patient was placed on every 15 minute checks until November 30, 2011, at 9:30 AM. Further review of the Progress Notes revealed: "November 30, 2011 9:20 AM, Psychiatric; Behaving better no longer 'accidentally bumping into people' - got labs done...speech clearer-still energetic-pacer- mood good- affect- blunt-TP- coherent, concrete...cooperative...D/C q15min checks... ."

A Nursing Note addendum revealed, "11/30/11, 11:10 PM, Nursing (3-11 Addendum) S. I had an altercation with my roommate. I knocked (them) out. O. Came to Nursing Station reporting above. Upon investigation, roommate found unresponsive. Patient (MR4) was placed in 4 pts at 10:40 PM. A. + assaultive behavior. P. 4 pts. for protection of self and others."

A review of MR5 on December 7-8, 2011, revealed the following nursing documentation: "Code 99 called at 10:45 PM because pt (MR4) told staff they knocked their roommate (MR5) out. Patient (MR5) found laying in bed, blood stained sheet near patient's pillow. Unresponsive to verbal stimuli and sternal rub. No breath sounds audible, no palpable pulse. CPR initiated at 10:45 PM, 911 called, CPR continued till arrival of 911 at 11:00 PM. 911 unable to intubate on scene, CPR continued, 0.9% saline administered. Pt taken out at 11:15 PM. Will contact Attending on call. Paged at 11:15 PM. Awaiting call back." MR5 was transported to a local hospital and pronounced dead.

An interview was conducted with EMP1 on December 7, 2011, at 10:00 AM. EMP1 stated, "We interviewed the staff after the event, and staff could not explain why this event occurred. The police/911 were called, and took the patient off the unit and interviewed them without staff present. From our various interviews, we suspect one patient strangled the other patient with their bare hands. We did not observe any visible wound. ... The patient was taken away by the police and charged with homicide. ... Staff did not complete an internal report after this happened."

2) During a tour of Belmont 3 South on December 7, 2011, at 1:30 PM, a staff member was observed sitting at the entrance to a patient's (MR6) room. It was observed that only the lower half of the patient's body was visible to the staff member due to the location of a wall in the patient room.

A review of MR6 conducted on December 8, 2011, revealed a physician order sheet dated December 7 at 9:00 AM, "1:1 eyesight for safety needs."

A review of facility policy "Care of the Patient Suicide/Close Observation Level" reviewed April 2011, revealed "... III. Definitions... Close Observation-1:1: The patient is observed continually by a staff member. A minimum distance of 12 feet is maintained between the staff and patient with no barriers between them. An example of a barrier would be a glass window or partial wall. ... C. Staff actions when caring for patients on suicide/close observations precautions include the following: ... b. The patient must be in direct view of the assigned staff member at all times. No barriers to vision can be between the patient and assigned staff member at any time, including while sleeping or using the bathroom. ..."

An interview was conducted with EMP1 on December 7, 2011, at 1:30 PM. EMP1 confirmed that the staff member who was assigned to a 1:1 with MR6, could only see the patient's legs and did not have a full view of the entire patient. Further interview confirmed that the 1:1 was not being done according to the facility's policy.

Cross Reference:
482.21 QAPI

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to obtain physician orders for the use of restraints for two of ten restraint records reviewed (MR2 and MR4).

Findings include:

A review on December 7-8, 2011, of facility policy "Use of Restraints/Seclusion on Inpatient Units" reviewed February 2010, revealed, "...A. Each restraint/seclusion episode requires a physician's order. ... "

1) A review of MR2 on December 8, 2011, revealed the patient was placed in four point restraints on September 24, 2011, at 1:30 AM. Further review revealed there was no physician order for the use of restraint on September 24, 2011, at 1:30 AM.

A review of MR4 on December 8, 2011, revealed the patient was placed in four point restraints on November 30, 2011, at 10:45 PM. Further review revealed there was no physician order for the use of restraint on November 30 , 2011, at 10:45 PM.

2) An interview was conducted with EMP1 on December 8, 2011, 11:20 AM. EMP1 confirmed there were no physician orders for the use of restraints for MR2 on September 24, 2011, and MR4 on November 30, 2011.

Based on review of facility documents and interviews with staff (EMP), it was determined that the Governing Body failed to ensure that Belmont Center for Comprehensive Treatment initiated quality improvement activities for problem prone areas, which could affect health outcomes and patient safety (A285), and failed to ensure the timely investigation of adverse patient events for two of two records (MR4, MR5) (A286).

Findings include:

Review of "Albert Einstein Healthcare Network, Belmont Behavioral Health Performance Improvement Plan" "Performance Improvement Plan" revealed, "I. Scope and Organization. The mission and values of the Albert Einstein Healthcare Network provides the basis for the Belmont Behavioral Health Quality Management program. The processes that insure patient safety and quality of care and that address the Einstein Experience are planned, designed and monitored with oversight from the Belmont Center for Comprehensive Treatment Quality Management Committee. The committee determines improvement priorities and allocated resources to address these. ... ."

Belmont Behavioral Health Performance Improvement Plan: "Belmont Behavioral Health Appraisal Of FY 2011 Plan: Projects: Assessment: Restraint and Seclusion Use; Multiple Antipsychotic Medication; Discharge Communication; AWOL; Safety;Treatment Plans; Hand Hygiene; Restraint reduction; Suicide assessment and reassessment; Medication Use -Atypical Antipsychotics; NCR Picker patient satisfaction survey."

1) A Review of MR4 conducted on December 7-8, 2011, revealed that the patient was assessed to have aggressive behaviors and was placed in four point restraints on two separate ocassions on November 26, 2011, for "safety to self and others." It was documented that the patient was "assaultive to peers" and that on November 28 at 7:30 AM, the patient was placed on every 15 minute checks until November 30, 2011, at 9:30 AM.

Further review of the Progress Notes revealed: "November 30, 2011 9:20 AM, Psychiatric; Behaving better no longer 'accidentally bumping into people' - got labs done...speech clearer-still energetic-pacer- mood good- affect- blunt-TP- coherent, concrete...cooperative...D/C q15 min checks... ."

A Nursing Note addendum revealed, "11/30/11, 11:10 PM, Nursing (3-11 Addendum) S. I had an altercation with my roommate. I knocked (them) out. O. Came to Nursing Station reporting above. Upon investigation, roommate found unresponsive. Patient (MR4) was placed in 4 pts at 10:40 PM. A. + assaultive behavior. P. 4 pts. for protection of self and others."

A review of MR5 conducted on December 7-8, 2011, revealed the following Nursing documentation: "Code 99 called at 10:45 PM because pt (MR4) told staff they knocked their roommate (MR5) out. Patient (MR5) found laying in bed, blood stained sheet near patient's pillow. Unresponsive to verbal stimuli and sternal rub. No breath sounds audible, no palpable pulse. CPR initiated at 10:45 PM, 911 called, CPR continued till arrival of 911 at 11:00 PM. 911 unable to intubate on scene, CPR continued, 0.9% saline administered. Pt taken out at 11:15 PM. Will contact Attending on call. Paged at 11:15 PM. Awaiting call back." MR5 was transported to a local hospital and pronounced dead."

A review conducted on December 7-8, 2011, of facility Performance Improvement Plan revealed no evidence of tracking, trending, or monitoring aggressive/assaultive behavior or increased level of observation. (0285)

2) An interview was conducted with EMP1 on December 7-8, 2011, EMP1 confirmed the facility does not track, trend, or monitor aggressive/assaultive behavior or increased level of observation as part of the Performance Improvement Plan. (0285)

An interview was conducted with EMP1 on December 8, 2011, at 11:20 AM. EMP1 confirmed that no internal event report was completed on the assault and death of a patient (MR5). (0286)


Cross Reference:
482.13(c)(2) Care in a Safe Setting
482.21 QAPI

Based on review of facility documents and interviews with staff (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to follow their adopted policy by not completing an internal report of an adverse patient event.


Findings include:

A review on December 7-8, 2011, of facility policy "Event Reporting" reviewed December 2009, revealed, "1. Purpose: This policy provides guidance for the purpose of identifying, reporting, and handling events that occur within the Albert Einstein Healthcare Network and it's affiliates, Albert Einstein Medical Center (AEMC), the Belmont Center for Comprehensive Treatment "Belmont", and their respective divisions, (collectively referred to hereinafter as "AEHN" ), to facilitate the improvement of patient care, and to reduce the risk of injury to patients, volunteers, visitors, and others. The systemic process for evaluating events will assist in the prevention or the reoccurrence of similar events in the future and to satisfy licensure and accreditation requirements. II. Policy: It is the policy of AEHN that all employees and health care providers will report any unanticipated event that has caused or has the potential to cause injury to patient's visitors, volunteers, and others. ..."

1) An interview was conducted with EMP1 on December 8, 2011, at 11:20 AM. EMP1 confirmed that no internal event report was completed on the assault and death of a patient (MR5).

Cross Reference:
482.21 QAPI