HospitalInspections.org

Based on observation, document review and staff interview, it was determined the hospital failed to protect patient rights to:

a. participate in the development of his/her treatment plan. The hospital enforced a treatment plan for all patients on the mental health unit that required the patients to be locked out of their rooms for up to 13 hours everyday. See tag A-130;

b. care in a safe environment in a manner to ensure patient physical and psychological well-being. The hospital failed to maintain security for patients and staff, failed to provide an environment free from known hazards and failed to ensure patients were treated with respect and dignity and were provided with basic comfort. See tag A-0144; and

c. the hospital failed to require mental health staff to utilize interventions that were less restrictive before they implemented physical restraints and seclusion. The mental health staff also engaged in behavior that was provocative to patients that resulted in physical holds and restraints. See tag A-0164.

These deficient practices resulted in immediate jeopardy to patient safety and psychological well-being.

Based on observation, hospital document review and staff interview, it was determined the hospital failed to develop and implement (with the patient's participation) a therapeutic treatment plan that considered each patient's physical and psychological needs.

This failure resulted in immediate jeopardy to patients' physical and psychological well-being when the hospital enforced a policy on the psychiatric unit, as a part of the treatment program, to lock all patients out of their rooms for up to thirteen hours everyday, without regard to individual patient needs for rest, privacy, solitude and safety.

As a result of this policy, all 29 patients and staff on the unit were forced into over-crowded conditions around the nurses' station. During the survey, the patients had limited seating in the day room and some patients sat or reclined on the floor. Patients stood around the nurses' station and some patients slept in chairs or on the floor.

The unit corridors to the patient rooms were also locked so that patients could not work off restless energy or anxiety by walking the halls. Adding to the confinement was a unit schedule that only permitted patients to go outside for 30 minutes a day and then, only when the weather permitted and when staff were available.

Many of the patients were admitted to the unit with psychiatric symptoms that included agitation, aggression, paranoia, hallucinations, homicidal and suicidal ideations. These symptoms were aggravated by the unit over-crowding, confinement around the nurses' station and an excessive noise level of the unit. Patients spent up to 13 hours every day in the presence of other psychiatric patients, some of whom were unpredictable and potentially dangerous to themselves or others. Patients were not allowed to go to their rooms when other patients became agitated and threatening. If a patient became violent, the other patients had no retreat.

The hospital documented the following dangerous behaviors of patients towards other patients and staff in incident reports. These events usually occurred in the day area and around the nurses' station in the presence of the other patients:

09/12/2015 - "male patient in altercation with patients and others..."
09/15/2015 - "female patient in altercation with patients and others, violent behavior, patient bit staff..."
09/25/2015 - "male patients in altercation with patients and others..."
01/01/2016 - "patient suddenly ran over to refrigerator in dining room and tried to push refrigerator over; he then attempted to punch a staff member..."
01/07/2016 - "[male patient] placed [another male patient] in a choke hold for no apparent reason, [patient] was CAPED and he released the hold..."
01/08/2016 - "male patient turned refrigerator over and attacked staff..."
01/08/2016 - "male patient attacked peer and punched in the face without provocation..."
01/09/2016 - "patient states to tech he was going to mess up a patient. He then directly goes and punches patient in the face..."
01/10/2016 - "patient turned fridge over, then attempted to attack a tech when he was CAPED..."
01/10/2016 - "patient stated 'I am going to get [mental health tech]', picked up an ink pen and started towards him, pt. was CAPED, staff trying to retrieve the ink pen, during the process a mental health tech was stabbed in the neck..."
01/12/2016 - "female patient jumped on top of the nurses station and tried to escape through the window, pt. was CAPED..."
01/12/2016 - "male patient in the day room when without warning he hit patient in the face breaking his glasses, pt. was CAPED..."
01/13/2016 - "male patient headed toward a pt with his arms raised as if to hit him, pt. was CAPED..."
01/15/2016 - "Patient placed in CAPE hold in dayroom after walking up to another patient and punching him in the face... He then goes into the hallway between the observation room, he then starts punching the plastic glass..."
01/17/2016 - "Patient rushed [mental health tech] hitting him in the head multiple times... sent to the ER..."
01/24/2016 - "[male patient] was kicking doors and throwing chairs... had to be CAPED to receive injections..."
01/26/2016 - "Pt.'s aggressive behavior escalated and he broke through door on the unit again, then assaulted staff when approached..."
02/01/2016 - "Sudden onset of violent attack on staff member..."
02/02/2016 - "Patient went up behind male tech in dayroom and punched him in the back of the head..."
02/04/2016 - "Pt. became agitated and assaulted a male peer for no apparent reason..."

When patients showed signs of increasing agitation or aggressiveness, the staff did not allow them to de-escalate quietly to their rooms. Instead, the unit staff intervened immediately with physical restraint of the patient in front of other patients.

On 04/27/2016 at 8:00 p.m., the surveyors witnessed the beginning of an altercation between two male patients. In response, the mental health tech placed himself physically between the patients to stop the behavior. The other patients who were in the immediate area had nowhere to go for safety in the event the altercation became violent.

In addition to the negative psychological effects of this policy, the hospital did not consider the negative physical effects the policy had on those patients with chronic medical problems or those patients who experienced the sedative effects of psychotropic medications. Even these patients were not allowed to rest in their rooms. Instead, they slept in chairs or on the floor in the day area.

At various times during the survey, patients were observed sleeping in the day area. Patient round sheets had documentation many patients slept in the day area when they were not allowed to go to their rooms.

On 04/27/2016 at 12:00 p.m., the unit nursing staff stated all patients had no choice but to remain in the lobby until the specified afternoon nap time or bedtime.

The unit manager stated the psychiatrist insisted on the unit policy restricting the patients from free access to their rooms. She stated this policy applied to all patients as part of their treatment plan. The manager stated the intent of the practice was to keep the patients from sleeping all day, but the staff could not prevent the patients from sleeping in the day area anyway. The manager stated the restrictions from the rooms was not a formally written policy. She stated there were no physician orders directing this restriction as a prescribed therapeutic intervention for each patient.

On 04/29/2016 at 2:15 p.m., the psychiatrist confirmed the practice of restricting patient access to their rooms was a part of the unit requirements.

The hospital had no documentation it had developed and implemented a specific therapeutic plan of care to meet each patient's needs. Instead, the hospital implemented the same universal plan for every patient.

The patient records had no documentation each patient understood and agreed to a restriction from their rooms for so many hours every day as a part of their therapeutic treatment plan.

The hospital's "Mental Health Unit Bill of Rights" documented the right to "participate in patient's own treatment planning... rights may be limited by the treatment team for therapeutic reasons, including safety of the consumer or other consumers and staff in the facility. These limitation must be documented in the clinical record, reviewed frequently, and shall not be limited for purposes of punishment, staff convenience, or in retaliation for a consumer exercising any of his/her rights..."

A hospital document titled, "Wagoner Community Hospital Mental Health Unit Orientation Patient/Family Information Handbook," documented, "... Your health care providers will describe your proposed treatment to you. You can expect them to explain your condition and proposed treatments using clear and understandable terms... the alternatives of treatment... the benefits and risks of each alternative, including the recommended course of therapy... We respect your right:... to refuse a... treatment..."

Based on observation, hospital document review and staff interview, it was determined the hospital failed to:

a. protect patients and staff from physical and psychological harm;
b. maintain security for patients and staff;
c. provide a safe environment that was free from known hazards; and
d. the hospital failed to ensure patients were treated with respect and dignity and were provided with basic comfort.

These failures resulted in immediate jeopardy when the hospital did not provide a therapeutic environment for patients with serious psychiatric illness who were admitted to the mental health unit.

Although hospital leadership was aware of these conditions, effective actions were not taken.

Findings:

1. The hospital admitted adult patients to the mental health unit for the following symptoms: suicidal ideation, homicidal ideation, aggressiveness, hallucinations and delusions. On 04/27/2016, the unit staff stated many patients were involuntarily admitted, having been brought to the hospital by the police.

The unit had a bed capacity of 32 patients. At the time of the survey, there were 29 patients and 8 staff members occupying the unit. It was the unit's policy to require the patients to be locked out of their rooms during the daytime hours. The hospital also locked the corridors leading to the patient rooms.

Because patients were restricted from their rooms and had no access to the unit corridors, all patients and staff were confined to a space of approximately 1400 square feet that also included a nurses' station, nourishment station, and a TV dayroom with multiple tables and chairs. The space was over-crowded and there was excessive noise. The TV in the day area was on every time the surveyors were on the unit and at times the conversation noise was very loud.

All patient activities were provided on the unit. The patients were never allowed to leave the dayroom area except when they asked permission to use the toilets. The patients spent up to 13 hours a day in the presence of other psychiatric patients who were sometimes unpredictable and violent.

The hospital provided documentation of multiple incident reports of patient assaults on other patients and assaults on staff. Some of these events resulted in patient and staff injuries that required treatment in the hospital's emergency department. The incident reports documented the following:

09/12/2015 - "male patient in altercation with patients and others..."
09/15/2015 - "female patient in altercation with patients and others, violent behavior, patient bit staff..."
09/25/2015 - "male patients in altercation with patients and others..."

In 2015, the hospital documented 29 patient to-patient physical altercations and 43 patient to staff physical altercations. Staff sustained back and hip injuries as a result from some of these altercations. The hospital had no documentation of tracking patient injuries.

Also in 2015, patient satisfaction surveys documented that 49 mental health patients indicated they did not feel safe and their privacy was not respected while in the hospital.

A hospital quality committee meeting in January 2016, documented the following report for the mental health unit, "... There were 47 staff assaults, 4 resulting in injury. 6 elopement attempts... [Fourth quarter] total of 33 incidents of seclusion and restraint..."

In January and February of 2016, the hospital documented 8 patient to patient altercations and 21 patient to staff altercations. The hospital documented three patient injuries and two staff injuries. Some examples of these events included:

01/01/2016 - "patient suddenly ran over to refrigerator in dining room and tried to push refrigerator over; he then attempted to punch a staff member..."
01/07/2016 - "[male patient] placed [another male patient] in a choke hold for no apparent reason, [patient] was CAPED and he released the hold..."
01/08/2016 - "male patient turned refrigerator over and attacked staff..."
01/08/2016 - "male patient punched in the face by peer, sent to ER for evaluation and treatment..."
01/08/2016 - "male patient attacked peer and punched in the face without provocation..."
01/09/2016 - "patient states to tech he was going to mess up a patient. He then directly goes and punches patient in the face..."
01/10/2016 - "patient turned fridge over then attempted to attack a tech when he was CAPED..."
01/10/2016 - "patient stated 'I am going to get [mental health tech], picked up an ink pen and started towards him, pt. was CAPED, staff trying to retrieve the ink pen, during the process a mental health tech was stabbed in the neck..."
01/12/2016 - "female patient jumped on top of the nurses station and tried to escape through the window, pt. was CAPED..."
01/12/2016 - "male patient in the day room when without warning he hit patient in the face breaking his glasses, pt. was CAPED..."
01/13/2016 - "male patient headed toward a pt with his arms raised as if to hit him, pt. was CAPED..."
01/15/2016 - "Patient placed in CAPE hold in dayroom after walking up to another patient and punching him in the face... He then goes into the hallway between the observation room, he then starts punching the plastic glass..."
01/17/2016 - "Patient rushed [mental health tech] hitting him in the head multiple times... sent to the ER..."
01/24/2016 - "[male patient] was kicking doors and throwing chairs... had to be CAPED to receive injections..."
01/26/2016 - "Pt.'s aggressive behavior escalated and he broke through door on the unit again, then assaulted staff when approached..."
02/01/2016 - "Sudden onset of violent attack on staff member..."
02/02/2016 - "Patient went up behind male tech in dayroom and punched him in the back of the head..."
02/04/2016 - "Pt. became agitated and assaulted a male peer for no apparent reason..."

Because of the confined conditions, patients who were not involved in these events were at risk for injury because there was no place to retreat. Because they were locked out, patients could not go to their rooms when other patients began to act aggressively.

The incident reports for the events above had no documentation of staff awareness of increasing signs and symptoms of agitation. There was no documentation of non-physical interventions on the part of the staff. When patients showed signs of increasing agitation or aggressiveness, the staff did not allow patients to de-escalate by returning to their rooms and the staff did not afford the patients the opportunity to engage in another diversional activity. Instead, the staff responded to these behaviors immediately with physical restraint (CAPE holds). [CAPE refers to a philosophy described as "Creating A Positive Environment" that includes verbal and non-verbal skills for dealing with patients, including physical restraint.]

Staff engaged in aggressive interventions that were disproportionate to the circumstances.

A "therapeutic hold/seclusion and restraint" form dated, 08/05/2015 documented the following aggressive action on the part of staff, "Pt. standing very close to doors that staff go in and out... Attempted to redirect pt from doors... Pt. wouldn't move. Attempted to push patient back from doors, which she resisted..." The form documented the staff were "unable to draw upon less restrictive alternatives due to sudden onset of dangerous patient behavior" and that she was placed in seclusion and four point restraints.

On 04/27/2016 at 8:00 p.m., the surveyors witnessed the beginning of an altercation between two male patients. In response, the mental health tech placed himself physically between the patients to stop the behavior. The other patients who were in the immediate area had nowhere to go for safety in the event the altercation became violent.

Staff also engaged in behaviors that were threatening to patients.

A patient grievance dated 09/20/2015, documented, "Last night [09/19/2015] while watching movies and talking in the dayroom, I was seated with another client just in front of the staff desk, while others were seated in the rows of chairs facing the TV... I was startled to have one of the larger male staff members run into the day room right by me, causing me to reflexively jump up and turn... the staffer [name deleted] then leapt up on the staff desk either on his knee or foot but continued clear over the desk into another staffer in a chair causing everyone to jump up out of their seats... Everyone was visibly upset and anxious... Everyone on staff acted like it was no big deal, but to me it was... All the people involved don't seem to understand many of their clients have experienced violent trauma and this incident personally scared the [expletive deleted] out of me..."

The hospital had documentation it was aware of patient complaints regarding staff horseplay and unprofessional attitudes. On 09/29/2015, the quality director wrote the following in her response letter to the patient: "Based on thorough investigation of the information described..., we have determined that horseplay, running through the unit and jumping on tables has been addressed with the staff members involved. ...interviews were conducted with staff involved regarding the allegation of rudeness and poor attitudes and staff actions were addressed individually.."

On 04/27/2016 at 12:05 p.m. in the corridor near the nursing station, a mental health technician encouraged a patient to throw a "ball" made from rolled-up socks. The technician used his arm as a bat to swing and hit the ball. This occurred twice in the corridor that was crowded with other patients and a surveyor.

As of 04/29/2016, there was no evidence of counseling in the tech's employee file for the incident when he jumped over the desk, startling the patients. The unit manager stated the tech involved had been "re-trained." She stated documentation of the re-training was maintained in her office. A "Corrective Action Form" for the involved staff was found in the manager's file. The unit manager documented she had instructed the tech involved to have "no horseplay while on duty." She documented she spoke to the staff about the importance of maintaining professional behavior while on duty and documented, "Patients that have a history of trauma may become fearful with loud running and jumping, causing even more trauma."

2. The mental health unit was not originally designed for the safety and security of patients and staff. The nurses' station was open and without any doors or other barriers to prevent access by the patients. In addition, the doors out of the unit were easily breached by patients. The following incident reports document these conditions:

01/12/2016 - a female patient "jumped on top of the nurses station and tried to escape through the window, CAPED.."
01/24/2016 - a male patient "attempted to leave dept by going out back door. Required CAPE hold to stop him..."
01/25/2016 - a male patient "jumped up and ran to and kicked open locked door to patient rooms, then kicked open locked door to outside, jumped over fence and apprehended in hospital parking lot..."
01/26/2016 - a male patient "broke through door on unit again then assaulted staff..."
02/04/2016 - a male patient kicked through the door and tried to go AWOL. He was CAPED in the parking lot..."
02/20/2016 - Pt. agitated, said he wants out of here, tried to break open locked doors to patient rooms... broke out of exit locked doors..."

3. During tours of the mental health unit, many environmental hazards were identified by the surveyors that posed an immediate risk to the safety of patients and staff. Some of these hazards had been involved in patient incidents and had been reported by staff to hospital leadership. They included:

~ chairs with metal frames that were lightweight and easily thrown. This was documented in an incident report dated 01/24/2016 and these chairs were present during the survey.
~ plastic shower curtains that could be removed from the rods and used for suffocation or strangulation
~ plastic bag trash can liners that could be used for suffocation. The hospital had a policy that directed housekeeping staff staff to use plastic bags in the trash cans on the unit.
~ plastic sleeves on Styrofoam cups that could be used as a ligature
~ patient toilets with heavy porcelain tank lids that could be removed and used as a weapon.
~ a metal protective grill with sharp edges over a wall heating and cooling unit in the seclusion room
~ a refrigerator that was not bolted down in the nourishment area that had been overturned by a patient more than once
~ movable benches, chairs and tables in the patient court yard that could be used to climb over the fence for escape. The staff requested these items to be secured to the ground on 11/24/2015 and a maintenance report documented this request as well. However, the unsecured furniture was still present at the time of the survey.
~ the patient court yard was not secured. A maintenance request dated 11/24/2015 documented a patient pushed the gate open and eloped from the unit.
~ flat bed sheets from the unit were left in the court yard and not accounted for by staff. These could be used for strangulation or for escape.
~ patient possession of pens and pencils. On 01/10/2016, an incident report documented a patient stabbed a technician in the neck with a pen. These items remained on the unit at the time of the survey.
~ open nursing station accessible to patients. There was no barrier between the patients and unsafe items such as an unsecured fire extinguisher, ink pens, staplers and equipment that could be thrown such as telephones and computers. Two computers used for charting were positioned so that staff sat with their backs turned to the patients. At every observational visit, numerous patients were congregated in front of the nursing station and within reach of potentially harmful desk items. The Chief Nursing Officer and the Chief Executive Officer stated on 04/28/2016 they had discussed installing a Plexiglass barrier to protect the nurse's station, but no action had been taken to implement the project.

4. Patients were not treated with respect and dignity and basic comforts were not provided.

A patient grievance, dated 09/20/2015 documented, "... the two [techs] repeatedly made rude comments to me about how I would extend my stay with my attitude, a very direct threat to me as I don't want or need to be here... [Tech name deleted] has constantly made me feel uncomfortable and has repeatedly implied he is not intimidated by me while I have in no way tried to make him believe I have any animosity towards him personally. As a professional, he is a rude, arrogant, overbearing bully... His attitude is, however, suited to be a barroom bouncer... He is overly aggressive..."

A maintenance request log, dated 0111/2016, documented, "... Code green... went in and watched over what was going on. He [patient] was taken down and given a shot..."

An incident report, dated 02/09/2016, documented the following, "... Pt. was asked to get out of bed [in seclusion room] and he refused. He tried to assault techs when they pulled his blanket back and he was CAPED for safety of self and others..."

In addition to the lack of respect for the patient, the incident reflected an aggressive response by staff that was out of proportion to the situation.

On 04/27/2016 at 8:50 p.m., the surveyors observed the patients gathered together standing at the locked doors to get into the corridors leading to the patient rooms. The patients appeared anxious and restless. They were waiting for permission to go to bed for the night. The unit bedtime for all patients was set by the staff for 9:00 p.m.. The staff made comments to the patient such as, "Just a few more minutes and we will unlock the doors."

Because patients were locked out of their rooms for the day, the patients had to ask staff to open the shower rooms in the common area when they needed to use the toilet. Except when using the restroom, the patients had no access to handwashing facilities before meals and other times as needed.

During surveyors observations during the day, patients were observed sleeping in chairs and on the floors in the day area because they were not allowed to go to their rooms until the specified "nap time" set by the unit staff for 3:00 p.m. until 4:30 p.m.

Based on observations, hospital document review and staff interview, it was determined the hospital failed to require mental health staff to utilize interventions that were less restrictive before they implemented physical restraints and seclusion. The mental health staff also engaged in behavior that was provocative to patients that resulted in physical holds and restraints. These deficient practices resulted in immediate jeopardy to patient safety and psychological well-being.

Findings:

At the time of survey, patients were admitted to the mental health unit with symptoms that included suicidal and homicidal ideation, psychosis, aggression, and hallucinations. The staff stated many of the patients were involuntary admissions and had been brought to the hospital by law enforcement.

The hospital documented a high number of physical restraint holds, time in seclusion and the application of two or four point restraints while patients were in seclusion. Even though the hospital identified this as a problem early in 2015, these numbers continued to rise and were at an all-time high in the first quarter of 2016.

In October 2015, the hospital's Performance Improvement Action Committee for the mental health unit established a goal to "decrease usage of restraints/seclusion by 50% annually." The plan was to review all incidents of restraint/seclusion and "incidents that require physical holds."

Multiple incident reports of patient aggression with staff physical holds, seclusion and restraint were reviewed for the last quarter of 2015 and the first quarter of 2016. None of the reports documented any less restrictive interventions attempted before physical interventions were used. The reports documented the patient behaviors were "sudden onset" and could not have been anticipated. The staff continued to document that "nothing" could be done to de-escalate patients or prevent the need for physical holds.

A report, dated 01/01/2016, documented, "It was discovered after the patient was [restrained by staff] that he had told an agency tech not to intervene as he was fixing to cause a problem [and] he didn't want a female tackling him..." The staff did not intervene before the patient went into the nourishment area and over-turned the unit refrigerator.

The form documented there was no indication of escalating behavior before the event. The form also documented that nothing could have been done to prevent it.

Even though the records of seclusion and restraint prompted the staff to choose a variety of de-escalation strategies such as recognizing the signs of escalation sooner, earlier intervention, 1:1 intervention with staff, engaging patients in activities, offering time out and medications, these actions were not documented.

The hospital also provided documentation of staff actions that were provacative to patients that led to physical restraint and seclusion. The surveyors witnessed staff actions that could be considered provacative as well.

A "therapeutic hold/seclusion and restraint" form dated, 08/05/2015 documented the following aggressive action on the part of staff, "Pt. standing very close to doors that staff go in and out... Attempted to redirect pt from doors... Pt. wouldn't move. Attempted to push patient back from doors, which she resisted..." The form documented the staff were "unable to draw upon less restrictive alternatives due to sudden onset of dangerous patient behavior" and that the patient was placed in seclusion and four point restraints.

An incident report, dated 02/09/2016, documented the following, "... Pt. was asked to get out of bed [in seclusion room] and he refused. He tried to assault techs when they pulled his blanket back and he was CAPED for safety of self and others..."

On the evening of 04/27/2016, the surveyors observed many patients were congregated near the nursing station and in the corridor. In the presence of the surveyors, a patient raised his voice and pushed another patient. A mental health tech standing nearby stepped between the patients to separate them. The staff had not recognized any signs of escalation prior to this altercation and had not intervened verbally before physically stepping in between the patients.

Hospital leadership were provided with information about the increasing numbers of seclusion and restraint events on the mental health unit. The restraint and seclusion report for March 2015 through August 2015 documented 51 physical restraint events in a six month period. The same report for December 2015 through February 2016, a three month period, documented 42 physical restraints.

The "Seclusion and Restraint Quarterly Report 2014-2015" documented the following actions in response to the increase "... The Mental Health Department believes that on-going training will help decrease usage, by using better verbal skills to de-escalate patients when they become agitated. We will continue to discuss strategies to decrease restraint/seclusion and CAPE episodes..."

The 2015-2016 report reflected a significant increase in patient restraint holds for the mental health unit. The report documented the same actions in response to the increase "... The Mental Health Department believes that ongoing training will help decrease usage, by using better verbal skills to de-escalate patients when they become agitated. We will continue to discuss strategies to decrease restraint/seclusion and CAPE episodes..."

On 04/28/2016, the quality director stated she provided 2015 and 2016 data regarding staff and patient altercations, injuries, restraint and seclusion events, and patient satisfaction survey results to the Medical Executive Committee and the Governing Board.

Review of various committee and governing board meeting minutes had no documentation of actions taken as a result of these reports.