HospitalInspections.org

Based on record review, staff and patient interview, the hospital failed to be in compliance with the Condition of Participation for Federal, State and Local Laws. The hospital failed to be in compliance with The State of Vermont Statute Title 18, Chapter 42: Bill of Rights for Hospital patients for 1 applicable patient (Patient #5) and Title 33, Chapter 69 "Reports of Abuse, Neglect and Exploitation of Vulnerable Adults" for 1 applicable patient. (Patient #3). Findings include:

1. Per State Statute 1852 Patients' Bill of Rights for Hospital patients : "(1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her own personal dignity."

Per record review Patient #5, who had been admitted to the AIU (Adult Intensive Unit) on an involuntary basis on 3/10/13, was involved in 3 separate incidents, on 3/22/13, 4/10/13 and 4/14/13, respectively, in which staff treated him/her in a disrespectful and undignified manner as evidenced by the following:

a.) A nurse's note, dated 4/10/13 at 7:54 AM, stated Patient #5 had requested Seroquel 100 mg at 5:30 AM and when provided the patient bit the pill in half, "spit out, refused to comply with medication mouth check. When taught to regarding this safety issue threw dirty water (that [s/he] had been drinking when taking meds and allowing fluids from mouth back into cup). Instructed to QR (Quiet Room), refused, immediately escorted to QR - began kneeing and kicking staff....Refused to redirect - secluded for immediate risk of harm to others due to assaultive behavior." The note further indicated that the patient was grabbing at staff, attempting to exit the QR, and subsequently received an injection of zyprexa, at 5:50 AM. The note stated there had been an attempt to process the events leading to seclusion with the patient who reportedly stated his/her intent to continue to attempt to assault staff, engage in disruptive behavior with goal of expediting discharge and "stated, as well, intent of lodging allegations against staff/hospital..." The patient reportedly refused to contract for safety and remained in seclusion at the end of the shift.

During interview, at 4:05 PM on 4/15/13, Patient #5 stated s/he had some concerns with some staff whom s/he felt used restraints/seclusion as punishment. The patient gave examples of this concern stating that on one occasion s/he threw a cup of fluid at a staff member when angry, and that particular staff member engaged the patient in conversation which helped to de-escalate his/her anger. Patient #5 stated that, however, on other recent occasions, s/he had become angry when staff members had been, what s/he felt, was disrespectful in their treatment of him/her and s/he had thrown fluid at them. S/he stated the response had been to immediately punish him/her; by use of restraints, at times just grabbing his/her arms and causing pain, and/or seclusion. S/he further indicated that staff, at times make comments to him/her such as "I'm going to take you down". Patient #5 also stated that s/he has filed multiple complaints and staff didn't like that s/he reported them, but s/he would continue to report concerns related to treatment and safety.

Per interview, at 7:38 AM on 4/16/13 and at 7:50 AM on 4/17/13, both MHW (Mental Health Worker) #1 and MHW #2 stated, during each of their respective individual interviews, that they had been witness to the following events during the early morning hours of 4/10/13: at approximately 5:00 AM Patient #5 had requested a specific amount of Seroquel, was informed the only available dose was a larger dose and s/he agreed to take it. When Nurse #1 brought the medication the patient bit the pill in half, swallowed half and put the remaining piece back in the plastic med cup. Each MHW stated that Nurse #1 then started to speak to Patient #5 in a loud voice telling the patient s/he was tired of the patient manipulating his/her meds. The patient, who was sitting in a chair, became angry and threw the remaining water from the cup at Nurse #1 who immediately grabbed the patient by the arm, pulled him/her from the chair in which s/he was sitting, and placed him/her in locked door seclusion. Both MHWs stated there had been no attempt to verbally de-escalate the patient, no discussion at all prior to hands on by Nurse #1. Nurse #1 then left the ALSA unit and returned with Nurse #2 who brought medication for the patient to take by mouth..Nurse #1 made a statement that the patient had spit the medication out and then both Nurse #1 and Nurse #2 left and returned, within several minutes, to the seclusion room where Patient #5 was sitting quietly on the floor. The patient was placed in a face down position on the floor and restrained in that position by 3 staff members while Nurse #2 gave the patient an injection. All staff then left the room. MHW #1 stated that Nurse #1 continued to check on the patient every 10 to 15 minutes and discussed the conditions of release from seclusion. S/he stated that in addition to asking the patient if s/he could contract for safety and not be assaultive, Nurse #1 also asked the patient if s/he was going to continue to make allegations against staff.

Nurse #1 confirmed, during interview at 9:13 AM on 4/18/13, that the patient had been given Seroquel, broke the pill in half and returned half to the med cup. S/he stated that Patient #5 refused to allow a mouth check and became angry and threw the water (in which Nurse #1 felt the patient had spit oral secretions), into Nurse #1's face and the nurse responded by telling the patient, in a loud voice, "seclusion room now." Nurse #1 confirmed that there had been no attempt to employ less restrictive measures to de-escalate the patient's behavior. S/he also agreed that in hind sight s/he could have stepped away from the patient to give time to de-escalate but felt, based on past experience with the patient that the patient might attempt to assault staff. Nurse #1 stated that after being placed in LDS (Locked Door Seclusion) Patient #5 was given the option of taking Zyprexa (an antipsychotic drug) by mouth or injection. Nurse #1 stated the patient took the oral Zyprexa and spit it out. Nurse #1 stated s/he left the LDS and contacted the physician by phone and explained that s/he was not certain how much, if any, of the Zyprexa the patient had received orally. S/he stated that the physician ordered Zyprexa IM. The nurse confirmed that upon return to the LDS, despite the fact that Patient #5 was sitting quietly on the floor, s/he was placed in a face down position on the floor, and restrained by 3 staff members while Nurse #2 administered the IM Zyprexa. Nurse #1 further confirmed that s/he returned every 10 to 15 minutes to determine the patient's readiness to be released from LDS. S/he confirmed that s/he asked the patient if s/he was going to continue to assault staff and also asked the patient if s/he was going to continue to make false allegations against staff.

b). A Nurse's Note, dated 4/14/13 at 6:53 PM, stated that Patient #5 had been challenging staff on every request. "Pt didn't like redirection and threw red Gatorade on staff person wearing white shirt. Cold jarred staff badly, and jostled pt against wall." A CON (Certificate of Need), dated 4/14/13 at 10:15, indicated a therapeutic hold had been implemented for a period of 1 minute and stated the reason the emergency procedure had been employed; "pt had been challenging staff all day shift, attempting to get out of ALSA, threatening to throw items. At 10:15 pt threw drink at staff, threats of physical harm." Although the documentation indicated the patient had been challenging staff all day, the only less restrictive interventions employed prior to the therapeutic hold were reported as "pt has had negative responses to redirection by staff." Per review of the formal grievance, filed by Patient #5 and provided to the surveyor by the patient, MHW #3 had treated the patient in a non-therapeutic and disrespectful manner when, in response to the patient throwing Gatorade at MHW #3, the MHW grabbed him/her by the arms and held him/her against the wall and, in reaction to the patient stating "F--- You" to the MHW, MHW #3 responded by saying "F--- You" to the patient. Per review, statements documented by MHWs #4 & #5, both of whom witnessed the event, identified that MHW #3 had grabbed onto Patient #5's upper arms while facing him/her and pushed him/her against the wall. Both MHWs #4 & #5 also confirmed the above response by MHW #3 to Patient #5. MHW #5 further indicated that MHW #3 had stated to Patient #5 "I'm going to take you down" (meaning to the floor). During interview, at 1:11 PM on 4/17/13, the RN Unit Manager of AIU confirmed that MHW #4 had held onto the arms of Patient #5 and had made the statement, "F... You" to the patient. In addition to the above, the RN Unit Manager further stated that a separate, previous incident had occurred on 3/22/13 in which Patient #5 had stated "F...You" to another MHW #6 and that MHW had also admitted that s/he had responded "F---You" back to the patient.


2. Per State Statute Chapter 42: Bill of Rights For Hospital Patients 1852 "(18) The patient has the right to know the maximum patient census and the full-time equivalent numbers of registered nurses, licensed practical nurses, and licensed nursing assistants who provide direct care for each shift on the unit where the patient is receiving care".

Based on observations during a tour of the inpatient units beginning on 4/14/13 and 4/17/13 and staff interview, the facility failed to assure completion of staffing sheets and to post them in area that was accessible to patients. Findings include:

The " Direct Caregiver Full Time Equivalents " dated 4/9/13 to 4/16/13, which provided the number of RN ' s, LPN ' s and Mental Health Workers (MHW) was incomplete on Tyler 4 for the day shift from 4/12/13 to 4/14/13 and the evening and night shift on 4/11/13 and 4/12/13. In addition, the document was posted at the nurse ' s station in an area not accessible to patients. This was confirmed during interview with the Clinical Manager on 4/18/13 at 9:15 AM. The Clinical Manager stated the Charge Nurse was responsible for completing this document. Per observation on Tyler on 3 4/17/13, the " Direct Caregiver Full Time Equivalents " staffing sheet was not posted in an area accessible to patients. The documentation was incomplete and failed to display staffing for the previous 7 days. Per interview on the afternoon of 4/17/13 the Nurse Manager on Tyler 3 confirmed the form was not completed or displayed as required.


3. Based on record review and staff interview, the hospital failed to report to the appropriate State Agency allegations of alleged abuse and financial exploitation in 1 of 30 records review. ( Patient # 3 ) Findings include:

1. Per record review, Patient #3 has been hospitalized since December 5, 2012 with Schizophrenia - Paranoid Type. Physician notes on 3/14/13 stated the patient spoke "at length" about past sexual assaults "while in this facility as well as other hospitals. Doesn't think these beliefs are delusional or the result of hallucinated experiences". On 3/21/13, the physician documented that Patient #3 believed that an outside agency stole $106.00 from h/her. On 3/22/13, the physician documented that Patient #3 "repeats [h/her]request to have [h/her] treatment team investigate [h/her] report that #106.00 is missing from [h/her] possessions."

Based on interview on 4/17/13 at 10:10 AM, the physician confirmed that these allegations were not reported to Adult Protective Services in accordance with Vermont State Statute Title 33 Chapter 69 "Reports of abuse, Neglect and Exploitation of Vulnerable Adults" and facility policy.

The Condition is not met based on failure to implement appropriate use of restraints and/or seclusion in accordance with federal requirements and facility policy and to report allegations of mistreatment.

Refer to Tags: A-144, 145, 154, 162, 164, 166, 168, 178, 179

Based on patient and staff interviews and record review the facility failed to assure that care and services were provided in an environment that promoted the physical and emotional safety and well being of 1 patient. (Patient #5). Findings include:

Per record review Patient #5, who had been admitted to the AIU (Adult Intensive Unit) on an involuntary basis on 3/10/13, was involved in 3 separate incidents, on 3/22/13, 4/10/13 and 4/14/13, respectively, in which staff treated him/her in a disrespectful and intimidating manner as evidenced by the following:

a.) A nurse's note, dated 4/10/13 at 7:54 AM, stated Patient #5 had requested Seroquel 100 mg at 5:30 AM and when provided the patient bit the pill in half, "spit out, refused to comply with medication mouth check. When taught to regarding this safety issue threw dirty water (that [s/he] had been drinking when taking meds and allowing fluids from mouth back into cup). Instructed to QR (Quiet Room), refused, immediately escorted to QR - began kneeing and kicking staff....Refused to redirect - secluded for immediate risk of harm to others due to assaultive behavior." The note further indicated that the patient was grabbing at staff, attempting to exit the QR, and subsequently received an injection of Zyprexa, at 5:50 AM. The note stated there had been an attempt to process the events leading to seclusion with the patient who reportedly stated his/her intent to continue to attempt to assault staff, engage in disruptive behavior with goal of expediting discharge and "stated, as well, intent of lodging allegations against staff/hospital..." The patient reportedly refused to contract for safety and remained in seclusion at the end of the shift.

During interview, at 4:05 PM on 4/15/13, Patient #5 stated s/he had some concerns with some staff whom s/he felt used restraints/seclusion as punishment. The patient gave examples of this concern stating that on one occasion s/he threw a cup of fluid at a staff member when angry, and that particular staff member engaged the patient in conversation which helped to de-escalate his/her anger. Patient #5 stated that, however, on other recent occasions, s/he had become angry when staff members had been, what s/he felt, was disrespectful in their treatment of him/her and s/he had thrown fluid at them. S/he stated the response had been to immediately punish him/her; by use of restraints, at times just grabbing his/her arms and causing pain, and/or seclusion. S/he further indicated that staff, at times make comments to him/her such as "I'm going to take you down". Patient #5 also stated that s/he has filed multiple complaints and staff didn't like that s/he reported them, but s/he would continue to report concerns related to treatment and safety.

Per interview, at 7:38 AM on 4/16/13 and at 7:50 AM on 4/17/13, both MHW (Mental Health Worker) #1 and MHW #2 stated, during each of their respective individual interviews, that they had been witness to the following events during the early morning hours of 4/10/13: at approximately 5:00 AM Patient #5 had requested a specific amount of Seroquel, was informed the only available dose was a larger dose and s/he agreed to take it. When Nurse #1 brought the medication the patient bit the pill in half, swallowed half and put the remaining piece back in the plastic med cup. Each MHW stated that Nurse #1 then started to speak to Patient #5 in a loud voice telling the patient s/he was tired of the patient manipulating his/her meds. The patient, who was sitting in a chair, became angry and threw the remaining water from the cup at Nurse #1 who immediately grabbed the patient by the arm, pulled him/her from the chair in which s/he was sitting, and placed him/her in locked door seclusion. Both MHWs stated there had been no attempt to verbally de-escalate the patient, no discussion at all prior to hands on by Nurse #1. Nurse #1 then left the ALSA unit and returned with Nurse #2 who brought medication for the patient to take by mouth..Nurse #1 made a statement that the patient had spit the medication out and then both Nurse #1 and Nurse #2 left and returned, within several minutes, to the seclusion room where Patient #5 was sitting quietly on the floor. The patient was placed in a face down position on the floor and restrained in that position by 3 staff members while Nurse #2 gave the patient an injection. All staff then left the room. MHW #1 stated that Nurse #1 continued to check on the patient every 10 to 15 minutes and discussed the conditions of release from seclusion. S/he stated that in addition to asking the patient if s/he could contract for safety and not be assaultive, Nurse #1 also asked the patient if s/he was going to continue to make allegations against staff.

Nurse #1 confirmed, during interview at 9:13 AM on 4/18/13, that the patient had been given Seroquel, broke the pill in half and returned half to the med cup. S/he stated that Patient #5 refused to allow a mouth check and became angry and threw the water (in which Nurse #1 felt the patient had spit oral secretions), into Nurse #1's face and the nurse responded by telling the patient, in a loud voice, "seclusion room now." Nurse #1 confirmed that there had been no attempt to employ less restrictive measures to de-escalate the patient's behavior. S/he also agreed that in hind sight s/he could have stepped away from the patient to give time to de-escalate but felt, based on past experience with the patient that the patient might attempt to assault staff. Nurse #1 stated that after being placed in LDS (Locked Door Seclusion) Patient #5 was given the option of taking Zyprexa (an antipsychotic drug) by mouth or injection. Nurse #1 stated the patient took the oral Zyprexa and spit it out. Nurse #1 stated s/he left the LDS and contacted the physician by phone and explained that s/he was not certain how much, if any, of the Zyprexa the patient had received orally. S/he stated that the physician ordered Zyprexa IM. The nurse confirmed that upon return to the LDS, despite the fact that Patient #5 was sitting quietly on the floor, s/he was placed in a face down position on the floor, and restrained by 3 staff members while Nurse #2 administered the IM Zyprexa. Nurse #1 further confirmed that s/he returned every 10 to 15 minutes to determine the patient's readiness to be released from LDS. S/he confirmed that s/he asked the patient if s/he was going to continue to assault staff and also asked the patient if s/he was going to continue to make false allegations against staff.

b). A Nurse's Note, dated 4/14/13 at 6:53 PM, stated that Patient #5 had been challenging staff on every request. "Pt didn't like redirection and threw red Gatorade on staff person wearing white shirt. Cold jarred staff badly, and jostled pt against wall." A CON (Certificate of Need), dated 4/14/13 at 10:15, indicated a therapeutic hold had been implemented for a period of 1 minute and stated the reason the emergency procedure had been employed; "pt had been challenging staff all day shift, attempting to get out of ALSA (Adult Low Stimulation Area), threatening to throw items. At 10:15 pt threw drink at staff, threats of physical harm." Although the documentation indicated the patient had been challenging staff all day, the only less restrictive interventions employed prior to the therapeutic hold were reported as "pt has had negative responses to redirection by staff." Per review of the formal grievance, filed by Patient #5 and provided to the surveyor by the patient, MHW #3 had treated the patient in a non-therapeutic and disrespectful manner when, in response to the patient throwing Gatorade at MHW #3, the MHW grabbed him/her by the arms and held him/her against the wall and, in reaction to the patient stating "F--- You" to the MHW, MHW #3 responded by saying "F--- You" to the patient. Per review, statements documented by MHWs #4 & #5, both of whom witnessed the event, identified that MHW #3 had grabbed onto Patient #5's upper arms while facing him/her and pushed him/her against the wall. Both MHWs #4 & #5 also confirmed the above response by MHW #3 to Patient #5. MHW #5 further indicated that MHW #3 had stated to Patient #5 "I'm going to take you down" (meaning to the floor). During interview, at 1:11 PM on 4/17/13, the RN Unit Manager of AIU confirmed that MHW #4 had held onto the arms of Patient #5, placed the patient against the wall and had made the statement, "F---You" to the patient. In addition to the above, the RN Unit Manager further stated that a separate, previous incident had occurred on 3/22/13 in which Patient #5 had stated "F...You" to another MHW #6 and that MHW had also admitted that s/he had responded "F---You" back to the patient.

Based on record review and staff interview, the hospital failed to report to the appropriate State Agency allegations of alleged abuse and financial exploitation in 1 of 30 records reviewed. ( Patient # 3 ) Findings include:

1. Per record review, Patient #3 has been hospitalized since December 5, 2012 with Schizophrenia - Paranoid Type. Physician notes on 3/14/13 stated the patient spoke "at length" about past sexual assaults "while in this facility as well as other hospitals. Doesn't think these beliefs are delusional or the result of hallucinated experiences".

On 3/21/13, the physician documented that Patient #3 believed that an outside agency stole $106.00 from h/her. On 3/22/13, the physician documented that Patient #3 "repeats [h/her]request to have [h/her] treatment team investigate [h/her] report that $106.00 is missing from [h/her] possessions."

Based on interview on 4/17/13 at 10:10 AM, the physician confirmed that these allegations were not reported to Adult Protective Services in accordance with Vermont State Statute Title 33 Chapter 69 "Reports of abuse, Neglect and Exploitation of Vulnerable Adults" and facility policy.

Based on staff interviews and record review there was no indication of threat to the immediate physical safety of self or others warranting the need for restraint and/or seclusion for 1 of 12 applicable patients. (Patient #5). Findings include:


1. Per record review Patient #5, who had been admitted to the AIU (Adult Intensive Unit) on an involuntary basis on 3/10/13, was subjected to hands on restraint and/or LDS (Locked Door Seclusion), on 4/10/13 and 4/14/13, respectively, without indication to warrant the need for the procedures. A nurse's note, dated 4/10/13 at 7:54 AM, stated Patient #5 had requested Seroquel 100 mg at 5:30 AM and when provided the patient bit the pill in half, "spit out, refused to comply with medication mouth check. When taught to regarding this safety issue threw dirty water (that [s/he] had been drinking when taking meds and allowing fluids from mouth back into cup). Instructed to QR (Quiet Room), refused, immediately escorted to QR - began kneeing and kicking staff....Refused to redirect - secluded for immediate risk of harm to others due to assaultive behavior." The note further indicated that the patient was grabbing at staff, attempting to exit the QR, and subsequently received an injection of zyprexa, at 5:50 AM. The note stated there had been an attempt to process the events leading to seclusion with the patient who reportedly stated his/her intent to continue to attempt to assault staff, engage in disruptive behavior with goal of expediting discharge and "stated, as well, intent of lodging allegations against staff/hospital..." The patient reportedly refused to contract for safe behavior and remained in seclusion at the end of the shift.

Per interview, at 7:38 AM on 4/16/13 and at 7:50 AM on 4/17/13, both MHW (Mental Health Worker) #1 and MHW #2 stated, during each of their respective individual interviews, that they had been witness to the following events during the early morning hours of 4/10/13: at approximately 5:00 AM Patient #5 had requested a specific amount of Seroquel, was informed the only available dose was a larger dose and s/he agreed to take it. When Nurse #1 brought the medication the patient bit the pill in half, swallowed half and put the remaining piece back in the plastic med cup. Each MHW stated that Nurse #1 then started to speak to Patient #5 in a loud voice telling the patient s/he was tired of the patient manipulating his/her meds. The patient became angry and threw the remaining water from the cup at Nurse #1 who immediately grabbed the patient by the right arm, pulled him/her from the chair in which s/he was sitting, and propelled him/her forward. At that point MHW #2 used a CPI (Crisis Prevention Intervention) technique to hold the patient's left arm and s/he was placed in locked door seclusion. Both MHWs stated there had been no attempt to verbally de-escalate the patient prior to the hands on procedure and there was no evidence of self harming behaviors or intent to harm others by Patient #5, until Nurse #1 put hands on the patient, at which point s/he began to kick and struggle. Nurse #1 then left the ALSA unit and returned with Nurse #2 who brought medication for the patient to take by mouth. Nurse #1 made a statement that the patient had spit the medication out and Nurse #1 and Nurse #2 then left and returned, within several minutes, to the seclusion room where Patient #5 was at that point sitting quietly on the floor. The patient was placed in a face down position on the floor and restrained in that position by 3 staff members while Nurse #2 gave the patient an injection. All staff then left the room. MHW #1 stated that Nurse #1 continued to check on the patient every 10 to 15 minutes and discussed the conditions of release from seclusion. S/he stated that in addition to asking the patient if s/he could contract for safety and not be assaultive, Nurse #1 also asked the patient if s/he was going to continue to make allegations against staff.

Nurse #1 confirmed, during interview at 9:13 AM on 4/18/13, that the patient had been given Seroquel, broke the pill in half and returned half to the med cup. S/he stated that because Patient #5 had previously been manipulating his/her medications, the nurse asked the patient to do a mouth check which s/he refused to allow. The nurse stated the patient then became angry and threw the water (in which Nurse #1 felt the patient had spit oral secretions), into Nurse #1's face and the nurse responded by telling the patient, in a loud voice, "seclusion room now." Nurse #1 confirmed that there had been no attempt to employ less restrictive measures to de-escalate the patient's behavior. S/he also agreed that in hind sight s/he could have stepped away from the patient to give time to de-escalate but felt, based on past experience with the patient, that the patient might attempt to assault staff. Nurse #1 stated that after being placed in LDS (Locked Door Seclusion) Patient #5 was given the option of taking Zyprexa (an antipsychotic drug) by mouth or injection. The patient took the oral Zyprexa which Nurse #1 stated s/he felt the patient spit out. Nurse #1 stated s/he left the LDS and contacted the physician by phone and explained that s/he was not certain how much, if any, of the Zyprexa the patient had received orally. S/he stated that the physician ordered Zyprexa IM. The nurse confirmed that upon return to the LDS, despite the fact that Patient #5 was sitting quietly on the floor, s/he was placed in a face down position on the floor, and restrained by 3 staff members while Nurse #2 administered the IM Zyprexa. Nurse #1 further confirmed that s/he returned every 10 to 15 minutes to determine the patient's readiness to be released from LDS. S/he confirmed that s/he asked the patient if s/he was going to continue to assault staff and the patient said yes. S/he also asked the patient if s/he was going to continue to make false allegations against staff and the patient responded yes.

Despite the lack of evidence of risk of immediate harm to self or others the patient was subjected to a restraint in the form of a hands on utilized to escort him/her to LDS where, despite sitting quietly on the floor s/he was further subjected to physical restraint for the purpose of a chemical restraint in the form of IM injection of Zyprexa.



2. A Nurse's Note, dated 4/14/13 at 6:53 PM, stated that Patient #5 had been challenging staff on every request. "Pt didn't like redirection and threw red Gatorade on staff person wearing white shirt. Cold jarred staff badly, and jostled pt against wall." A CON (Certificate of Need), dated 4/14/13 at 10:15, indicated a therapeutic hold had been implemented for a period of 1 minute and stated the reason the emergency procedure had been employed; "pt had been challenging staff all day shift, attempting to get out of ALSA, threatening to throw items. At 10:15 pt threw drink at staff, threats of physical harm." Although the documentation indicated the patient had been challenging staff all day, the only less restrictive interventions employed prior to the therapeutic hold were reported as "pt has had negative responses to redirection by staff." Per review of the formal grievance, filed by Patient #5 and provided to the surveyor by the patient, MHW #3 had treated the patient in a non-therapeutic and disrespectful manner when, in response to the patient throwing Gatorade at MHW #3, the MHW grabbed him/her by the arms and held him/her against the wall. Per review, statements documented by MHWs #4 & #5, both of whom witnessed the event, identified that MHW #3 had grabbed onto Patient #5's upper arms while facing him/her and pushed him/her against the wall. MHW #5 further indicated that MHW #3 had stated to Patient #5 "I'm going to take you down" (meaning to the floor). During interview, at 1:11 PM on 4/17/13, the RN Unit Manager of AIU confirmed that MHW #4 had held onto the arms of Patient #5 and had placed him/her against the wall.

Based on record review and staff interview, there was no evidence of violent or self-destructive behaviors that resulted in use of seclusion in 1 of 12 applicable patients reviewed. (Patient #4) Findings include:

1. Per record review Patient #4 was placed in seclusion on 4/9/13 for approximately one hour without evidence of violence or self-destructive behavior. Nursing progress notes dated 4/9/13 during the evening shift stated " .. pt yelled and refused to be redirected or quieted for a long time ... Pt yelled about peer having visitors. Pt yelling about peer yelling and " you never tell HIM to be quiet! " Pt put in quiet room with door open from approximately 3:45 to 4:45. Pt had prn Ativan 1 mg at 2:00 PM, and Zyprexa at 3:40. Pt finally quieted down, ate dinner, used the phone and went to sleep. This nurse does not see pt using spoons or anything to self-harm". The charge nurse confirmed during interview on 4/16/13 at 3:05 PM, that Patient # 4 was placed in seclusion and "was not allowed to leave".

The " Certificate of Need For Emergency Involuntary Procedures " form used by the facility, which identifies how the use of restraint and seclusion meets emergency criteria, less restrictive measures attempted, the RN or LIP 1-Hour assessment release from seclusion and patient response could not be found by the Clinical Manager which was confirmed during interview on 4/18/13 at 9:25AM. In addition, the physician's order did not include the reason for seclusion or the behavioral objectives for release.

Based on record review and staff interview, the facility failed to show evidence of less restrictive interventions being utilized prior to implementation of seclusion in 2 of 12 applicable records reviewed. ( Patients # 4, 5) Findings include:

1. Per record review, Patient #4 was placed in seclusion on 4/9/13 for approximately one hour without evidence of lesser restrictive interventions being attempted with the exception of prn medication. Nursing progress notes dated 4/9/13 during the evening shift stated " .. pt yelled and refused to be redirected or quieted for a long time ... Pt yelled about peer having visitors. Pt yelling about peer yelling and " you never tell HIM to be quiet! " Pt put in quiet room with door open from approximately 3:45 to 4:45. Pt had prn Ativan 1 mg at 2:00 PM, and Zyprexa at 3:40. Pt finally quieted down, ate dinner, used the phone and went to sleep. This writer does not see pt using spoons or anything to self-harm".

The " Certificate of Need For Emergency Involuntary Procedures " form used by the facility, which identifies how the use of restraint and/or seclusion meets emergency criteria, less restrictive measures attempted, the RN or LIP 1-Hour assessment release from seclusion and patient response could not be found. The physician order did not include the reason for seclusion and the behavioral objectives for release. The charge nurse confirmed during interview on 4/16/13 at 3:05 PM, that Patient # 4 was placed in seclusion and "was not allowed to leave".

2. Per record review Patient #5, who had been admitted to the AIU (Adult Intensive Unit) on an involuntary basis on 3/10/13, was subjected to the following procedures including hands on restraint and/or LDS (Locked Door Seclusion), on 4/10/13 and 4/14/13, respectively, without evidence that less restrictive interventions had been employed and determined to be unsuccessful prior to the individual procedures:

a. A nurse's note, dated 4/10/13 at 7:54 AM, stated Patient #5 had requested Seroquel 100 mg at 5:30 AM and when provided the patient bit the pill in half, "spit out, refused to comply with medication mouth check. When taught to regarding this safety issue threw dirty water (that [s/he] had been drinking when taking meds and allowing fluids from mouth back into cup). Instructed to QR (Quiet Room), refused, immediately escorted to QR - began kneeing and kicking staff....Refused to redirect - secluded for immediate risk of harm to others due to assaultive behavior." The note further indicated that the patient was grabbing at staff, attempting to exit the QR, and subsequently received an injection of Zyprexa, at 5:50 AM. The note stated there had been an attempt to process the events leading to seclusion with the patient who reportedly stated his/her intent to continue to attempt to assault staff, engage in disruptive behavior with goal of expediting discharge and "stated, as well, intent of lodging allegations against staff/hospital..." The patient reportedly refused to contract for safe behavior and remained in seclusion at the end of the shift.

Per interview, at 7:38 AM on 4/16/13 and at 7:50 AM on 4/17/13, both MHW (Mental Health Worker) #1 and MHW #2 stated, during each of their respective individual interviews, that they had been witness to the following events during the early morning hours of 4/10/13: at approximately 5:00 AM Patient #5 had requested a specific amount of Seroquel, was informed the only available dose was a larger dose and s/he agreed to take it. When Nurse #1 brought the medication the patient bit the pill in half, swallowed half and put the remaining piece back in the plastic med cup. Each MHW stated that Nurse #1 then started to speak to Patient #5 in a loud voice telling the patient s/he was tired of the patient manipulating his/her meds. The patient became angry and threw the remaining water from the cup at Nurse #1 who immediately grabbed the patient by the right arm, pulled him/her from the chair in which s/he was sitting, and propelled him/her forward. At that point MHW #2 used a CPI (Crisis Prevention Intervention) technique to hold the patient's left arm and s/he was placed in locked door seclusion. Both MHWs stated there had been no attempt to verbally de-escalate the patient prior to the hands on procedure and there was no evidence of self harming behaviors or intent to harm others by Patient #5, until Nurse #1 put hands on the patient, at which point s/he began to kick and struggle. Nurse #1 then left the ALSA unit and returned with Nurse #2 who brought medication for the patient to take by mouth. Nurse #1 made a statement that the patient had spit the medication out and Nurse #1 and Nurse #2 then left and returned, within several minutes, to the seclusion room where Patient #5 was at that point sitting quietly on the floor. The patient was placed in a face down position on the floor and restrained in that position by 3 staff members while Nurse #2 gave the patient an injection. All staff then left the room. MHW #1 stated that Nurse #1 continued to check on the patient every 10 to 15 minutes and discussed the conditions of release from seclusion. S/he stated that in addition to asking the patient if s/he could contract for safety and not be assaultive, Nurse #1 also asked the patient if s/he was going to continue to make allegations against staff.

Nurse #1 confirmed, during interview at 9:13 AM on 4/18/13, that the patient had been given Seroquel, broke the pill in half and returned half to the med cup. S/he stated that because Patient #5 had previously been manipulating his/her medications, the nurse asked the patient to do a mouth check which s/he refused to allow. The nurse stated the patient then became angry and threw the water (in which Nurse #1 felt the patient had spit oral secretions), into Nurse #1's face and the nurse responded by telling the patient, in a loud voice, "seclusion room now." Nurse #1 confirmed that there had been no attempt to employ less restrictive measures to de-escalate the patient's behavior. S/he also agreed that in hind sight s/he could have stepped away from the patient to give time to de-escalate but felt, based on past experience with the patient, that the patient might attempt to assault staff. Nurse #1 stated that after being placed in LDS (Locked Door Seclusion). Patient #5 was given the option of taking Zyprexa (an antipsychotic drug) by mouth or injection. The patient took the oral Zyprexa which Nurse #1 stated s/he felt the patient spit out. Nurse #1 stated s/he left the LDS and contacted the physician by phone and explained that s/he was not certain how much, if any, of the Zyprexa the patient had received orally. S/he stated that the physician ordered Zyprexa IM. The nurse confirmed that upon return to the LDS, despite the fact that Patient #5 was sitting quietly on the floor, s/he was placed in a face down position on the floor, and restrained by 3 staff members while Nurse #2 administered the IM Zyprexa. Nurse #1 further confirmed that s/he returned every 10 to 15 minutes to determine the patient's readiness to be released from LDS. S/he confirmed that s/he asked the patient if s/he was going to continue to assault staff and the patient said yes. S/he also asked the patient if s/he was going to continue to make false allegations against staff and the patient responded yes.

A Nurse's Note, dated 4/14/13 at 6:53 PM, stated that Patient #5 had been challenging staff on every request. "Pt didn't like redirection and threw red Gatorade on staff person wearing white shirt. Cold jarred staff badly, and jostled pt against wall." A CON (Certificate of Need), dated 4/14/13 at 10:15, indicated a therapeutic hold had been implemented for a period of 1 minute and stated the reason the emergency procedure had been employed; "pt had been challenging staff all day shift, attempting to get out of ALSA, threatening to throw items. At 10:15 pt threw drink at staff, threats of physical harm." Although the documentation indicated the patient had been challenging staff all day, the only less restrictive interventions employed prior to the therapeutic hold were reported as "pt has had negative responses to redirection by staff." Per review of the formal grievance, filed by Patient #5 and provided to the surveyor by the patient, MHW #3 had treated the patient in a non-therapeutic and disrespectful manner when, in response to the patient throwing Gatorade at MHW #3, the MHW grabbed him/her by the arms and held him/her against the wall. Per review, statements documented by MHWs #4 & #5, both of whom witnessed the event, identified that MHW #3 had grabbed onto Patient #5's upper arms while facing him/her and pushed him/her against the wall. MHW #5 further indicated that MHW #3 had stated to Patient #5 "I'm going to take you down" (meaning to the floor). During interview, at 1:11 PM on 4/17/13, the RN Unit Manager of AIU confirmed that MHW #4 had held onto the arms of Patient #5 and had placed him/her against the wall.

Based on record review and staff interview, the hospital failed to assure that the plan of care was modified to reflect the use of restraint or seclusion in 2 of 12 applicable records reviewed. (Patients #4 & #5 Findings include:

1. Per review of the 4/2/13 "Certificate of Need for Involuntary Procedures" (CON) and progress notes, Patient #4 was placed in open door seclusion from 7:57 PM to 8:30 PM when h/she refused to return a plastic utensil, refused redirection, began banging on the walls and attempted to wrap the cord of a blood pressure cuff around h/her neck. The CON stated that Patient #4 made a suicidal threat a day earlier ( 4/1/13) and had a history of using utensils for self-harming behavior. Per record review, the use of seclusion related to this incident was not incorporated into interdisciplinary treatment plan, which was updated on 4/3/13.

Patient # 4 was placed in open door seclusion on 4/9/13 from 3:45 PM to 4:45 PM. Nursing progress notes stated "...pt. yelled and refused to be redirected or quieted for a long time. Pt yelled about peer having visitors. Pt yelled and peer yelling and "you never tell HIM to be quiet". Pt. had PRN Ativan 1 mg at 2PM and Zyprexa at 3:40 PM. Pt. finally quieted down, ate dinner, used the phone, and went to sleep".

Per record review, the interdisciplinary treatment plan, updated on 4/10/13, stated "Superficial attempts to hurt self yesterday secondary to distressed re :slowness of aftercare"... "remains labile with emotional outbursts, continually needing attention or limit setting.." However, the treatment plan did not reflect of the use of seclusion on 4/9/13.
This was confirmed during interview with the Clinical Manager on 4/18/13 at 9:25 AM.


2. Per record review staff had utilized restraints and/or seclusion for Patient #5 on multiple occasions from his/her involuntary admission on 3/10/13 through 4/14/13. The use of restraints and/or seclusion occurred on at least 10 episodes between the dates of 4/8/13 - 4/14/13, including up to 3 episodes on some days, for behaviors that included attempts to assault staff and several incidents in which the patient threw liquid from a cup at staff. Despite the frequent use of restraints and/or seclusion the patient's care plan did not reflect their use. Although a specific Behavior Plan had been developed, dated 3/27/13 and revised on 4/15/13, which reflected patient specific unsafe behaviors, the plan only addressed the consequences of unsafe behavior and the benefits of changing that behavior. There was no plan of care that identified interventions to employ to assist in preventing unsafe behavior exhibited by the patient or prevent escalation of that unsafe. The Clinical Manger of the unit on which Patient #5 resided, confirmed that the care plan did not reflect the use of restraints/seclusion, during interview on the morning of 4/18/13.

Based on interview and record review, the hospital failed to assure staff obtained an order from a physician for the use of seclusion and/or physical restraint for 3 of 12 applicable patients. (Patients # 4, 5, 23) Findings include:

1. Per review on 4/18/13, Patient #23 with a diagnosis of Schizoaffective Disorder and Depression, was admitted to the hospital involuntarily on 8/3/12. Over the course of several weeks, Patient #23 had several behavioral emergencies requiring both emergency medications and the use of seclusion. Both interventions require a physician order. On 10/22/12, the psychiatric progress note states "....remains quite psychotic, intrusive.....de-escalation techniques proved ineffective...." A nursing progress note states "...2 person hands escort to quiet room (seclusion)..." and further stating Patient #23 remained in quiet room for 20 minutes. Per review of physician orders for 10/22/12, no order was received or written for the use of seclusion during the morning intervention which occurred from 9:25 AM - 10:00 AM. This omission was confirmed on the afternoon of 4/18/13 with the nurse manager for the former Osgood 3 unit where Patient #23 was hospitalized.

2. Per record review, a stamped order dated 4/9/13 at 3:35 PM for the use of seclusion for Patient #4 was not signed by the physician in a timely manner. Per interview of 4/16/13 at 2:10 PM, the Clinical Manager and Charge Nurse confirmed that the telephone order had not been signed by the physician. The Clinical Manager and Charge Nurse said the expectation is for telephone orders to be signed within 24 hours and if the prescriber is not available, the covering physician would sign the order. The order was not signed until 4/17/13 at 9:00 AM.

3. Per record review Patient #5, who was admitted on 3/10/13, on involuntary admission status had a CON, dated 4/10/13, which indicated that at 5:40 AM the patient had been placed in seclusion and received involuntary medication (a chemical restraint) in response to: "Pt refused to comply with mouth check, assaulted staff throwing dirty (had been in Pt mouth) water in staff's face - escorted to QR - kneed and kicked writer - placed in QR & seclusion initiated secondary to assaultive bx" (behavior). Per separate, individual interviews, conducted on 4/17/13 and 4/18/13, respectively, two MHWs and the Unit Charge Nurse at the time of the incident, each confirmed that physical restraint in the form of hands on was utilized to escort Patient #5 to the seclusion room. In addition, the MHWs and the Charge Nurse also confirmed the use of physical restraint by 3 staff members who held the patient face down on the floor during the administration of involuntary IM medication. The Unit Charge Nurse, who was responsible for obtaining physician orders, further confirmed there was no physician order for use of restraints during the escort nor during administration of involuntary medications.

Based on record review, the hospital failed to assure nursing staff conducted an accurate and comprehensive assessment of patients 1 hour after the initiation of either a restraint or seclusion for 1 of 12 applicable patients. (Patient #23 ) Findings include:

1. Per review of the Certificate of Need for Emergency Involuntary Procedures (CON), staff failed to complete a 1 hour face-to-face assessment after the initiation of seclusion on 10/22/12 at 10:00 AM for Patient # 23. Patient #23's specific behaviors (physical threats to staff, extreme agitation, not re-directable) resolved prior to the 1 hour face-to-face assessment evaluation with seclusion being discontinued at 10:50 AM. However, hospital staff identified to be qualified to complete the evaluation (nursing staff) are still required to conduct the patient face-to-face and assess if further evaluation is necessary regarding the medical or psychological affects of seclusion, factors that may have contributed to Patient #23's behaviors and whether the intervention was appropriate.

Based on staff interview and record review the facility failed to assure that the face-to-face evaluations conducted within 1 hour after the initiation of restraints and/or seclusion included all elements of a medical and behavioral assessment, necessary to determine if other factors, such as drug or medication interactions, electrolyte imbalance, etc., could be contributing to the behavior that warranted the need for intervention for 1 of 12 patients. (Patients #5 ). Findings include:

1. Per record review, Patient #5, who was admitted involuntarily on 3/10/13, had multiple episodes of use of restraints and/or seclusion between the date of admission and 4/15/13. The CONs used by staff included a 1 Hour Assessment process that directed staff to: describe the patient's condition and circumstances leading up to the emergency procedure; identify if there was any patient injury; identify less restrictive measures tried; describe what interventions were authorized; document the patient's response to the intervention; and describe the nursing assessment of any physical problems as a result of the restraint, indicating the reason for the assessment is to determine any injuries or problems that resulted from the use of restraints/seclusion. The CON form did not include information regarding the patient's physical or medical condition. Per review of 9 separate CONs completed for use of restraints/seclusion for Patient #5 between the dates of 4/8/13 and 4/14/13 there was no evidence, in the 1 hour face-to-face evaluation, that an assessment of the patient's physical (including a complete review of systems) and medical condition had been conducted.

During interview, at 9:33 AM on 4/17/13, the CNO (Chief Nursing Officer) confirmed that RN staff conduct the 1 hour face to face assessments of patients following initiation of restraints and/or seclusion. S/he further agreed that the CON form used for assessments did not direct staff to include all elements of the face to face assessment and stated that the assessments currently being conducted by RNs does not include assessment of the physical (including a complete review of systems) and medical conditions of the patient needed to make a determination of whether or not a physical or medical condition could be contributing to the patient behavior that warranted the use of restraints and/or seclusion.

Based upon observation, interview, and record review, the facility failed to assure that the nursing staff develops, and keeps current, a nursing care plan for 2 of 30 patients. (Patients #11,16) . Findings include:

1). Patient #11, whose diagnoses include Major Depressive Disorder with Psychotic Features and Attention Deficit Hyperactivity Disorder, has a Care Plan dated 3/21/13 for Risk of Harm to Others and/or Self resulting from Impaired Insight/Judgment. The Care Plan includes the intervention of ' Nursing will reinforce ...the " point system " ' . Per interview with the Unit Manager for Patient #11 on 4/16/13 at 10:35 A.M. the ' point system ' was " not working for (Patient #11) so we tried an individual plan " and confirmed that the Treatment Plan Update dated 3/28/13 states Patient #11 has " a behavior plan to address negative behavior " .

Per observation of Patient #11 ' s Treatment Team Meeting on 4/16/13 at 9:40 A.M., the patient 's Physician, a Licensed Social Worker, and the Unit Manager decided to place Patient #11 " back on the behavior plan " with regards to a recent change in behavior .The Unit Manager then stated that the behavior plan was never written down. The Physician stated " We came up with it, it was working, and we didn ' t write it down " . Per interview with the Unit Manager for Patient #11 on 4/16/13 at 10:35 A.M., h/she confirmed there was no documentation that Patient #11 ' s Plan of Care had been reviewed or revised since admission, that there was a recent change in Patient #11 ' s behavior, and a Behavior Plan that ' was working ' for the patient was never written down.

2). Per record review Patient #16, whose diagnoses include suicide ideation and psychosis, had 3 incidents between 3/22 & 3/23/13 for which a Physician ' s Order for restraint and seclusion was obtained, and a Care Plan regarding the behaviors was developed and dated 3/25/13. Per record review, another incident of restraint and seclusion for Patient #16 on 4/4/13 A Nursing Note one hour after the incident reports " a new plan for triggered and flashback management was developed with the patient " . Per interview with Patient #16 ' s Unit Manager on 4/18/13 at 12:05 P.M., the Unit Manager confirmed there was nothing in the patient ' s plan of care reflecting a new plan, and no documentation of any review or revision of Patient #16 ' s Care Plan since the initial implementation on 3/25/13. The Unit Manager confirmed that only the Nursing Notes dated 4/4/13 contained specific interventions that " probably " were part of the new plan. The Unit Manager stated the Nursing Notes would be read the next day during morning meeting, and passed on verbally shift to shift. The Unit Manager confirmed in order for the new treatment plan to be available for staff on the day of the interview (4/18/13), information would have had to be transferred verbally shift to shift for 14 days and to accomplish this would be " hard " and that some effective interventions of the new plan developed could have been lost or altered along the way.
The Unit Manager also confirmed an incident of restraint and seclusion of Patient #16 occurred later on 4/10/13 and there was no documentation that any new interventions had been developed or implemented in Patient #16 ' s Plan of Care.

Based on interview and record review, the facility failed to assure that telephone and verbal orders were being verified through a "read back" process. Findings include:

Per interview with the Unit Manager for Osgood 1 on 4/16/13 at 11:10 A.M. the Unit Manager stated " the only thing documented as read back is critical lab values " .
Per interview with the Unit Manager for Osgood 2 on 4/17/13 at 12:05 P.M. the Unit Manager stated " We do not mark that they (telephone and verbal orders) were read back. They are marked " TO " (Telephone Order). We used to mark them " TORB " (Telephone Order Read Back). I don ' t remember when we stopped that. " Per record review, physician orders on 10 patient charts from both Osgood 1 and Osgood 2 were reviewed regarding verification of telephone and verbal orders having been read back. Both Unit Managers confirmed there was no documentation verifying whether or not telephone and verbal orders had been read back to the practitioner at the time when an order was received.

Based upon observation and interview, the Director of Food Services failed to assure the facility ' s food services were effectively managed in regards to kitchen sanitation and infection control measures. Findings include:

1. Per observation in the facility ' s kitchen on 4/16/13 at 11:40 A.M. a food service worker in the dishwashing area moved a visibly soiled dish cart to abut a cart containing clean mugs and dishes. The Food Services Director [FSD] moved the dirty dish cart away from the cart containing the clean items. The food service worker then stated " I want it there " and moved the dirty cart back against the clean cart. Per interview with the facility ' s Infectious Disease Preventionist during a tour of the kitchen on 4/18/13 at 10:20 A.M. a dirty dish cart abutting a cart with clean dishes was " definitely " an infection control issue and the FSD moving the carts apart demonstrated that h/she recognized it as an issue.

2. Per observation on 11:40 A.M. on 4/16/13 the facility ' s kitchen contained an area approximately 8 ft. in length in the food prep area where tiles used for baseboard molding were missing, exposing the plaster wall. The plaster wall had areas which were cracked and crumbling, running behind an ice machine and a sink, where a hole in the plaster exposed pipes in the wall. Additionally, there was an approximate ? inch gap between the floor tiles and the length of wall.

Per interview with the FSD on 4/16/13 at 11:50 A.M. the Facilities staff had been " working on it for months " Per phone interview with the Facilities Manager [FM] on 4/17/13 at 1:30 P.M. the staff were working on replacing tile molding for ' a couple weeks ' and along with tile replacement the gaps between the floor and the wall were to be filled within ' a week ' .

Per review of FDA guidelines (www.fda.gov/ICECI/EnforcementActions/.../ucm256413.htm )
The " FDA recommends all flooring in food preparation and storage areas be smooth, non-absorbent, easily cleanable and durable (e.g., no cracks) " . Per interview with the facility ' s Infectious Disease Preventionist during a tour of the kitchen on 4/18/13 at 10:20 A.M. the areas of missing tile, crumbling plaster, and the gap between the floor and wall " absolutely " demonstrated an infection control issue.

3. Per observation on 11:40 A.M. on 4/16/13 the facility ' s kitchen contained a visibly soiled trash container in a food prep area with the container ' s lid raised due to overflowing trash.
Per interview with the FSD on 4/16/13 at 11:50 A.M. it is the kitchen manager ' s responsibility to empty the kitchen trash containers and h/she " usually does them but today is delivery day " . Per interview with the facility ' s Infectious Disease Preventionist during a tour of the kitchen on 4/18/13 at 10:20 A.M. the overflowing trash can in the food prep area represented an infection control issue.

4. Per observation on 11:40 A.M. on 4/16/13 the facility ' s walk-in refrigerator contained an approx. 12 oz. plastic container of tuna fish dated 4/15/13. Per interview with the Food Services Director [FSD] on 4/16/13 at 11:50 A.M. the facility ' s policy regarding perishable foods is the food is labeled with a ' use by ' date. At the end of the day on that date, the outdated items are disposed of by the kitchen manager. The FSD confirmed the tuna fish should have been thrown out previous day.

Based upon observation and staff interview the facility failed to maintain the facility ' s kitchen and food preparation areas in such a manner that the safety and well-being of patients is assured. Findings include:

Per review of FDA guidelines (www.fda.gov/ICECI/EnforcementActions/.../ucm256413.htm )
The " FDA recommends all flooring in food preparation and storage areas be smooth, non-absorbent, easily cleanable and durable (e.g., no cracks) " . Per observation on 11:40 A.M. on 4/16/13 the facility ' s kitchen contained an area approximately 8 ft. in length in the food prep area where tiles used for baseboard molding were missing, exposing the plaster wall. The plaster wall had areas which were cracked and crumbling, running behind an ice machine and a sink, where a hole in the plaster exposed pipes in the wall. Additionally, there was an approximate ? inch gap between the floor tiles and the length of wall.

Per interview with the Food Services Director on 4/16/13 at 11:50 A.M. the Facilities staff had been " working on it for months " . Per phone interview with the Facilities Manager on 4/17/13 at 1:30 P.M. the staff were working on replacing tile moldings for ' a couple weeks ' and along with tile replacement the gaps between the floor and the wall were to be filled within ' a week ' . Per interview with the facility ' s Infectious Disease Preventionist during a tour of the kitchen on 4/18/13 at 10:20 A.M. the areas of missing tile, crumbling plaster, and the gap between the floor and wall " absolutely " demonstrated an infection control issue.

Based on record review, policy review, and interview it was determined that in a sample of 10 records (A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10) the facility failed in 4 records (A4, A5, A6, and A9) to provide social work assessments that included conclusions and recommendations that described anticipated social work roles in treatment and discharge planning. This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment

Findings Include:

A. Record Review:

1. Patient A4: Admitted 4/6/13. Psychosocial Assessment dated 4/8/13 failed in the summary to describe a specific social work role in A4's inpatient treatment, instead listing "Medication adjustment," "Build distress tolerance and social skills," "Work with outpatient providers and referrals to support (Patient name) in the community"

2. Patient A5: Admitted 4/10/13. Psychosocial Assessment dated 4/11/13 failed in the summary to describe a specific social work role in A5's inpatient treatment, instead listing "Patient is working with the Howard Center and will continue with this"; "Patient wants to work with Suboxone provided as well. [S/he] will continue to go to AA."

3. Patient A6: Admitted 4/9/13. Social Work (SW) assessment lists "SW will work with Pt and Tx team to develop safe plan for discharge."

4. Patient A9: Admitted 3/28/13. SW assessment lists "SW will collaborate with patient, team, DCF guardian, and outpatient providers to craft a discharge plan to facilitate Pt.'s recovery, academic performance, and attainment and maintenance of sobriety."

B. Interview

Surveyor interviewed the Director of Social Services at 3:30 PM on 4/16/13. The above findings were presented to the Director who acknowledged them.

Based upon record review and interview it was determined that the hospital failed to assure that in 6 of 10 active sample records (A3, A5, A6, A7, A8, and A10) the Psychiatric Evaluation contained reports of findings of assessments of patient's orientation functioning. This compromises the data base from which the individualized treatment plan is formulated.

Findings include:

A. Record Review:

1. Patient A8, admitted 2/15/13. Psychiatric Assessment dated 2/16/13 made no mention of Orientation.

2. Patient A3, admitted 4/04/13. Psychiatric Evaluation dated 4/05/13 made no mention of orientation findings.

3. Patient A10, admitted 4/04/13. Psychiatric Assessment dated 4/05/13: Orientation reported as "Alert."

4. Patient A6, admitted 4/09/13. Psychiatric Evaluation dated 4/10/13: Orientation findings reported as "Alert."

5. Patient A7, admitted 4/10/13. Psychiatric Assessment dated 4/11/13: Orientation findings reported as "Alert."

6. Patient A5, admitted 4/10/13. Psychiatric Evaluation dated 4/11/13: Orientation findings reported as "Alert."

B. Interview:

Surveyor interviewed the Hospital Medical Director on 4/17/13 at 4 PM. The above findings were presented to the Medical Director who acknowledged them.

Based on record review and interview the facility failed to identify a diagnosis that served as the primary focus in the treatment plans of 9 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, and A9). This practice compromises the staff's ability to deliver clinically focused treatment.

Findings Include:

A. Record Review

1. Patient A8, admitted 2/15/13, Master Treatment Plan initiated 2/19/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

2. Patient A9, admitted 3/28/13, Master Treatment Plan initiated 3/29/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

3. Patient A2, admitted 4/2/13, Master Treatment Plan initiated 4/3/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

4. Patient A3, admitted 4/4/13, Master Treatment Plan initiated 4/5/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

5. Patient A1, admitted 4/5/13, Master Treatment Plan initiated 4/6/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

6. Patient A4, admitted 4/6/13, Master Treatment Plan initiated 4/8/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

7. Patient A6, admitted 4/9/13, Master Treatment Plan initiated 4/10/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

8. Patient A5, admitted 4/10/13, Master Treatment Plan initiated 4/11/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

9. Patient A7, admitted 4/10/13, Master Treatment Plan initiated 4/11/13: section titled Psychiatric Diagnosis (DSM-IV) was blank.

B. Interview

During an interview with the Manager of Performance Improvement and Risk Management on 4/16/13 at 9:10 AM, when shown a copy of the facility form titled "Interdisciplinary Treatment Plan Signature Page," section labeled "Psychiatric Diagnosis (DSM-IV)" she stated that "it is my understanding that this should be filled in but I will check." At 9:30 AM, the Manager Performance Improvement and Risk Management returned and stated "I spoke with one of the Nurse Managers and they tell me that this is not to be completed because it had been determined that the other forms (referring to pre-printed treatment plans that are problem specific) are a part of the treatment plan and they have been written in patient understandable language." The signature page for patient A10 was shown to the Manager by the surveyor who asked why this one in particular had a DSM diagnosis listed when none of the others did; the Manager replied "I can't answer that, you are right the diagnosis should be there."

Based on record review and interview the facility failed to provide treatment plans that identified patient-related long term goals stated in observable, measurable, behavioral terms for 10 of 10 active sample patients. Specifically, the facility failed to write long term goals that reflect behavioral outcomes for the patient (A1, A2, A3, A4, A4, A5, A6, A7, A8, A9 and A10). These goals were written in terms of expected behavior for staff. Short term goals were pre-printed and generic without individualization for 7 of 10 active sample patients (A1, A2, A3, A4, A8, A9 and A10). These failures hinder the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to patient stays beyond the resolution of the behaviors requiring admission.

Findings Include:

A. Record Review

1. Patient A8, admitted 2/15/13, Master Treatment Plan initiated 2/19/13 (based on interdisciplinary team signatures for the Psychiatrist, the nurse and the social worker) had the following long term goal written: "stabilize mood, evaluate alcohol use, develop effective discharge plan." Short term goals on preprinted treatment plans for the following problem titled "risk of harm to others and/or self, resulting from impaired insight/judgment" were pre-printed generic goals that were not individualized for this patient. Generic goals included "patient will take all medications as prescribed and patient will discuss effectiveness and side effects of medications with MD; and patient will demonstrate an improved ability to control impulses of aggression and self harm."

2. Patient A9, admitted 3/28/13, Master Treatment Plan initiated 3/29/13 had the following long term goal written: "medication management, psychiatric evaluation, collaborative outpatient plan, family meetings or DCF (Department of Children and Families) visit." Short term goals on preprinted treatment plans for the following problems titled "Adolescent with depression and suicidal ideation"; "Adolescent with self-harming behaviors" and "Adolescent with PTSD" all were pre-printed generic goals that were not individualized for this patient. Generic goal for both problems identified stated "patient will verbally commit to not self-harm."

3. Patient A2, admitted 4/2/13, Master Treatment Plan initiated 4/3/13 had the following long term goals written: "mood and symptom stabilization and diagnostic assessment and medication evaluation." Short term goals on preprinted treatment plan for problem titled "Risk of Harm due to Impulsive Behavior" were not individualized to include a specific number of days for which the "patient will follow unit-based schedule and days." Other goals for this problem included "patient will agree to follow parental rules or rules in current living situation and patient will demonstrate the ability to maintain personal safety."

4. Patient A3, admitted 4/4/13, Master Treatment Plan initiated 4/5/13 had the following long term goal written: "stabilize mood, develop effective discharge plan." Short term goals on pre-printed treatment plan for the problem titled "Suicidal with depression" were pre-printed generic goals that were not individualized for this patient. Generic goals included "the patient will comply with medication regime and report effectiveness."

5. Patient A10, admitted 4/4/13, Master Treatment Plan initiated 4/5/13 had the following long term goals written: "medication evaluation and adjustment as indicated; stabilization of symptoms and collaboration with providers and return to services." Short term goals on the pre-printed treatment plan for the problem titled "Psychosis interfering with functioning" were pre-printed generic goals that were not individualized for this patient. Generic goals included "patient will take all medications as prescribed, and patient will discuss effectiveness and side effects of medications with MD; patient will attend groups in order to interact with peers, practice appropriate social skills and/or improve interpersonal skills; patient will demonstrate an improved ability to care for himself/patient will demonstrate an ability to avoid being exploited by others and patient will evidence ability to adhere to treatment at a less restrictive level of care."

6. Patient A1, admitted 4/5/13, Master Treatment Plan initiated 4/6/13 had the following long term goal written: "mood and symptom stabilization and medication evaluation." Short term goals on pre-printed treatment plans for the following problems titled "Suicidal ideation and/or self- harming behaviors"; and "Risk of harm to others and/or self, resulting from impaired insight/judgment" were pre-printed generic goals that were not individualized for this patient. Generic goals included "patient will demonstrate future orientation; patient will take all medications as prescribed and patient will discuss effectiveness and side effects of medication with MD; and patient will demonstrate an improved ability to control impulses of aggression and self harm."

7. Patient A4, admitted 4/6/13, Master Treatment Plan initiated 4/8/13 had the following long term goal written: "stabilize mood." Short term goals on the pre-printed treatment plan form titled "Suicidal with depression" listed a pre-printed goal as "the patient will demonstrate no suicidal ideation for (blank) of days."

8. Patient A6, admitted 4/9/13, Master Treatment Plan initiated 4/10/13 had the following long term goals written: "opiod detox; monitor mood meds; safety."

9. Patient A5, admitted 4/10/13, Master Treatment Plan initiated 4/11/13 section had the following long term goals written: "suboxone referral; detox, increase coping skills and education for recovery and collaborate with outpatient."

10. Patient A7, admitted 4/10/13, Master Treatment Plan initiated 4/11/13 had the following long term goals written: "safely detox; Intensive Outpatient."

B. Interview

During an interview with the Vice President for Patient Care (Director of Nursing), on 4/16/13, at 4:50 PM, the treatment plans for patients A3 and A4 were reviewed, the Vice President stated "the treatment goals for these patients are written for the problems identified, but you are right because they are pre-printed they do not address the individual patient needs."

Based on record review and interview it was determined that the facility failed to assure on the Master Treatment Plans (MTP) patient specific physician, nursing, social work and therapeutic support services treatment interventions, and/or their frequency, and duration based on the individual needs of all of the active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10) These deficiencies resulted in a lack of guidance for staff in providing individualized patient treatment that was purposeful and goal-directed and results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment

Findings Include:

A. Record Review

1. Patient A8, admitted 2/15/13. MTP initiated 2/19/13. Generic Physician (Psychiatry) "modalities" were checked on a preprinted list of interventions. Example: "In collaboration with team MD will assess for and make any changes in any increase in privileges and/or decrease in degree of observation based on and safety risks [sic] related to degree of impaired judgment or insight." "MD will collaborate with outpatient prescriber and/or PCP (Primary Care Physician)." Generic nursing interventions included, "RN/LPN will administer medications, educate patient regarding medication, assess for effectiveness and observe for side effects." Social Work generic interventions included "Social Worker will collaborate with family or other caregiver to gather recent history and course of illness." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities was designated on the preprinted list.

2. Patient A9, admitted 3/28/13; MTP initiated 3/29/13. Generic Physician (Psychiatry) "modalities" were checked on a preprinted list of interventions. Examples are: "MD will complete a Psychiatric evaluation within 24 hrs to determine diagnosis." "MD will collaborate with outpatient prescriber and/or PCP re. Med plan. [sic]" "MD will prescribe medications and titrate for effectiveness." Generic nursing interventions included, "Nursing will administer medications as ordered and reinforce benefits and possible side effects." Social Work generic interventions included, "Social Worker will meet with patient, talk to parent/guardian and complete social history within 72 hours of admission." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities were designated on the preprinted list.

3. Patient A2, admitted 4/02/13; MTP initiated 4/3/13. Generic Psychiatry interventions were checked: "In collaboration with team MD will assess for and make any changes in any increase in privileges and/or decrease in degree of observation based upon demonstrated ability to control impulsive behavior." "MD will assess need for psychological testing and order if indicated." "MD will assess the patient for psychiatric disorders, and prescribe medications and titrate and monitor for effectiveness and side effects." Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities was designated on the preprinted list.

In addition, this patient had one episode of physical hold and locked seclusion documented on 4/2/13; the treatment plan for this patient failed to include interventions or modalities that could be utilized to prevent the further use of physical hold and/or locked seclusion.

4. Patient A3, admitted 4/04/13; MTP initiated 4/5/13. Generic Physician (Psychiatry) "modalities" were checked on a preprinted list of interventions. Generic psychiatry interventions included "MD will assess previous suicide attempts and current suicide plans or intent, with special emphasis on lethality of methods, intent to die, previous attempts and family history of suicide; MD will coordinate care with previous and future prescribers to discuss treatment plan and possible adjustments; MD will assess whether the patient requires a significant change in medication or other treatment regimen including considerations of ECT and combination medications; MD will assess medication adherence, and promote adherence by removing barriers and developing strategies; MD will recommend Depression workbook or other reading material; MD will evaluate and recommend treatment for co-occurring disorders, especially related to PTSD or Trauma." Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Generic Social Work interventions included, "Social Worker will meet with patient and complete social history and assessment." In addition, the section titled "Therapeutic Services Staff" was left blank.

5. Patient A10, admitted 4/04/13; MTP initiated 4/5/13. Generic Psychiatry interventions were checked on the preprinted list of modalities: "MD will complete a Psychiatric evaluation within 24 hours to determine Axis1, 2, 3 diagnoses." "MD will collaborate with outpatient prescriber and/or PCP re. Med plan. [sic]" "MD will prescribe medications and titrate for effectiveness." Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects" Generic Social Work interventions included, "Social Worker will collaborate with family and providers." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities were designated on the preprinted list.

6. Patient A1, admitted 4/05/13; MTP initiated 4/6/13. Generic Psychiatry interventions were checked on the preprinted list of modalities. Examples are: "MD will complete a Psychiatric evaluation within 24 hours to determine Axis1, 2, 3 diagnoses." "In collaboration with team MD will assess for and make any changes in any increase in privileges and/or decrease in degree of observation based on and safety risks [sic] related to degree of impaired judgment or insight." "MD will collaborate with outpatient prescriber and/or PCP." Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Generic Social Work interventions included, "Social Worker will complete psychosocial within 72 hours of admission." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities was designated on the preprinted list.

7. Patient A4, admitted 4/06/13; MTP initiated 4/8/13/ 13. Generic Physician (Psychiatry) "modalities" were checked on a preprinted list of interventions. Examples are: "Contact patient's PCP if necessary for collaboration in managing medical issues." "Collaborate with medical clinic LIP's in managing patient's pain, and consider non medication approaches." Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Generic Social Work interventions included, "Social Worker will meet with patient and complete the Social History and Assessment." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities was designated on the preprinted list.

8. Patient A6, admitted 4/9/13; MTP initiated 4/10/13. Generic Physician (Psychiatry) "modalities" were checked on a preprinted list of interventions. Examples are: "MD will complete a Psychiatric evaluation within 24 hours to determine Axis1, 2, 3 diagnoses." "MD will collaborate with outpatient prescriber and/or PCP re. Med plan [sic]." Generic Social Work interventions included, "Social Worker will meet with patient and gather social history and assessment." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities was designated on the preprinted list.

9. Patient A5, admitted 4/10/13; MTP initiated 4/11/13. Generic Physician (Psychiatry) "modalities" were checked on a preprinted list of interventions. Examples are: "MD will complete a Psychiatric evaluation within 24 hours to determine Axis1, 2, 3 diagnoses." "MD will order lab tests and medical consults as needed and incorporate results into the treatment plan." Generic Social Work interventions included, "Social Worker will meet with patient and gather social history and assessment." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities was designated on the preprinted list.

10. Patient A7, admitted 4/10/13; MTP initiated 4/11/13. Generic Physician (Psychiatry) "modalities" were checked on a preprinted list of interventions. Examples are: "MD will complete a Psychiatric evaluation within 24 hours to determine Axis1, 2, 3 diagnoses." "MD will order lab tests and medical consults as needed and incorporate results into the treatment plan." Generic Social Work interventions included, "Social Worker will meet with patient and gather social history and assessment." In addition, the section titled "Therapeutic Services Staff" was left blank. No frequency or duration of modalities were designated on the preprinted list.

B. Interview

1. During an interview, on 4/16/13 at 11:00 AM, Clinical Manager 1 was questioned about the blank areas noted under therapeutic services on the treatment plans for patients A1 and A2. Clinical Manager 1 stated "because nursing has really picked up the groups and activities from this section when the changes occurred with the activities department, we really should be including these interventions in our section, under nursing." During this same interview, Clinical Manager 1 acknowledged that "staff does put check marks next to the interventions and in many cases all are selected but you are right there is nothing that individualizes these interventions from patient to patient." Clinical Manager 1 further acknowledged that after patient A2 experienced a physical hold restraint and locked seclusion episode, "nursing did not modify interventions for this patient."

2. Surveyor interviewed the Hospital Medical Director on 4/17/13 at 4 PM. The above findings were presented to the Medical Director who acknowledged them.

Based on record review and interview the facility failed to ensure that the name of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans for 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). This practice resulted in the facility's inability to monitor staff accountability for specific modalities.

Findings Include:

A. Record Review

1. Patient A8, admitted 2/15/13, Master Treatment Plan initiated 2/19/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutic support activities sections of the treatment plan.

2. Patient A9, admitted 3/28/13, Master Treatment Plan initiated 3/29/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutic support activities sections of the treatment plan.

3. Patient A2, admitted 4/2/13, Master Treatment Plan initiated 4/3/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutic support activities sections of the treatment plan.

4. Patient A3, admitted 4/4/13, Master Treatment Plan initiated 4/5/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutic support activities sections of the treatment plan.

5. Patient A10, admitted 4/4/13, Master Treatment Plan initiated 4/5/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutic support activities sections of the treatment plan.

6. Patient A1, admitted 4/5/13, Master Treatment Plan initiated 4/6/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutic support activities sections of the treatment plan.

7. Patient A4, admitted 4/6/13, Master Treatment Plan initiated 4/8/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutic support activities sections of the treatment plan.

8. Patient A6, admitted 4/9/13, Master Treatment Plan initiated 4/10/13 had no responsible person identified for carrying out the interventions identified in the nursing or therapeutic support activities sections of the treatment plan.

9. Patient A5, admitted 4/10/13, Master Treatment Plan initiated 4/11/13 had no responsible person identified for carrying out the interventions in the therapeutic support activities section of the treatment plan.

10. Patient A7, admitted 4/10/13, Master Treatment Plan initiated 4/11/13: no responsible person was identified for carrying out the interventions identified in the physician, social work, nursing or therapeutics activities sections of the treatment plan.

11. Facility policy titled "Treatment Planning Policy and Procedure," dated 09/2011 states "a patient's treatment plan will provide documentation of interventions with the name of the staff member responsible."

B. Interview

1. During an interview, on 4/16/13, Clinical Manager 1 was asked how it is determined who has the responsibility for carrying out a particular intervention. She stated "everyone is responsible, the charge nurse each shift should have this responsibility for nursing." She agreed that the treatment plans of patients A1 and A2 did not identify any particular person in any discipline that has the ultimate responsibility for carrying out the interventions. She also stated when questioned about the blank areas, noted under therapeutic services, on the treatment plans for patients A1 and A2 "because nursing has really picked up the groups and activities from this section when the changes occurred with the activities department, we really should be including these interventions in our section, under nursing. We had a meeting a few weeks ago but the forms have not been revised yet."

2. During an interview with the Vice President for Patient Care (DON), on 4/16/13, at 4:50 PM, the treatment plans for patients A3 and A4 were reviewed. She stated "nursing should have included those interventions from the section on therapeutic activities by writing them in under the pre-printed section for nursing."

Based on record review and interview it was determined that the Medical Director failed:

1. To assure that treatment plans for 10 of 10 active sample patients records (A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10) were individualized. Physician interventions were generic, and similar for all treatment plans, regardless of the patients' problems. These deficiencies resulted in a lack of guidance for staff in providing individualized patient treatment that was purposeful and goal-directed. Refer to B122 for examples of generic physician interventions.

2. To assure that the facility identified a diagnosis that served as the primary focus in the treatment plans of 9 of 10 active sample patients. Refer to B120.

Based on record review and interview the Vice President for Patient Care (Director of Nursing) failed to:

1) Implement policies and procedures for proper training of RNs who were authorized to conduct 1-hour face-to-face evaluations of patients placed in restraint and/or seclusion. The training did not include instruction on how to assess for medical causes of behavior that may require restraint, and the form used to document the evaluation did not include a section that promoted the performance and documentation of a medical evaluation. In addition, in the case of patient A2, who was placed in restraint, the 1-hour face-to-face evaluation was performed by a RN with no documentation of any training at all. This resulted in patient A2 not being properly assessed to determine the clinical reason for the assaultive behavior, and could result in the same outcome for other patients who require seclusion and/or restraint.


2) Ensure that nursing completed a proper debriefing of patient and staff after an incident of physical restraint and locked seclusion on patient A2, and ensure the patient's Master Treatment Plan included interventions directed at de-escalation techniques to be utilized prior to the future need for seclusion or restraint.

These failures have the potential for staff to control patient behaviors by the most restrictive measures, because triggers leading to aggressive/assaultive behaviors are not being evaluated post episode.


3) Ensure that nursing interventions provided a treatment focus and responsible person for 10 of 10 active sample patients (A1, A2,A3, A4, A5, A6, A7, A8, A9 and A10) rather than implementing interventions that were generic routine functions expected of the nursing discipline. This results in a lack of treatment clarity;


4) Ensure that the responsibilities of therapeutic activity modalities delegated to nursing be included in the patient' s treatment plan for 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10). This failure results in the interventions not being included to assist the patient in meeting their treatment goals.


Findings include:

Face to Face Evaluation

A. Record Review

1. Patient A2, admitted 4/2/13, required a physical hold (6:11-6:12 PM) and locked seclusion on 4/6/13 (6:12 PM-6:49 PM) for assaultive behavior. The face to face evaluation required to be completed within one hour of the episode of physical hold and locked seclusion was documented as completed at 7:54 PM on 4/6/13 by RN1. The face to face evaluation completed by RN1 did not include a comprehensive physical assessment of the patient. The one hour assessment form utilized by the facility did not include a component for completion of a physical assessment of the patient.

2. Facility Policy titled "Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients" last approved 4/2013, in the section titled "In-Person Evaluation of Patient" states, "all Brattleboro Retreat RN's shall complete one hour face to face competency prior to performing this evaluation." Section "Patient record notation" #1 states, "1 hour face to face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior [sic]."

3. The employee orientation and annual training file for RN1 was reviewed for documentation of training on how to conduct a face to face evaluation for restraint and/or seclusion. No evidence of training was found in the file.

B. Interview

1. On 4/17/13 at 9:05 AM, Clinical Educator 1 validated that "there is no evidence of training in this nurse's (RN1's) file."


2. During an interview with Clinical Educator 1 on 4/17/13 at 10:00 AM, a copy of the facility "RN Face to Face Assessment of the Patient in Restraint and Seclusion" packet was reviewed, with discussion that there was no section for evaluation of a physical component that would affect the patient's behavior. The Clinical Educator stated, "I was not aware that there is an expectation that the assessment was to determine if there is a medical or other reason for the patient's behavior. I teach the RN's that they are to look at if there were physical complications or injuries as a result of the restraint."

Patient and Staff Debriefing

A. Record Review

1. Patient A2, admitted 4/2/13, required a physical hold (6:11-6:12 PM) and locked seclusion, 4/6/13 (6:12 PM-6:49 PM) for assaultive behavior. After the incident there was no debriefing completed with the patient and/or staff and no addition made to the patient's treatment plan, which had been initiated for "risk of harm due to impulsive behavior" on 4/3/13.

2. Facility policy titled, "Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients," dated 04/2013, notes "a debriefing will occur with all staff that participated in the restraint or seclusion or physical hold and be documented on the staff debriefing form."

B. Interview

During an interview with the Clinical Manager 1, at 10:50 AM on 4/16/13, she stated "we should have done a debriefing and I think that may have gotten lost with our transition to the electronic medical record...."

Treatment Plans

A. Record Review

1. Patient A8, admitted 2/15/13; MTP initiated 2/19/13. Generic nursing interventions included, "RN/LPN will administer medications, educate patient regarding medication, assess for effectiveness and observe for side effects." Nursing also did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan. Additionally, no nurse was identified as a responsible person for carrying out the interventions.

2. Patient A9, admitted 3/28/13; MTP initiated 3/29/13. Generic nursing interventions included, "Nursing will administer medications as ordered and reinforce benefits and possible side effects." Nursing also did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan. Additionally, no nurse was identified as a responsible person for carrying out the interventions.

3. Patient A2, admitted 4/02/13; MTP initiated 4/3/13. Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Nursing also did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan. Additionally, no nurse was identified as a responsible person for carrying out the interventions.

4. Patient A3, admitted 4/04/13; MTP initiated 4/5/13. Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Nursing also did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan. Additionally, no nurse was identified as a responsible person for carrying out the interventions.

5. Patient A10, admitted 4/04/13; MTP initiated 4/5/13. Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Nursing also did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan. Additionally, no nurse was identified as a responsible person for carrying out the interventions.

6. Patient A1, admitted 4/05/13; MTP initiated 4/6/13. Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Nursing also did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan. Additionally, no nurse was identified as a responsible person for carrying out the interventions.

7. Patient A4, admitted 4/06/13; MTP initiated 4/8/13/ 13. Generic nursing interventions included, "RN/LPN will administer medication, educate patient regarding medication, assess for effectiveness, and observe for side effects." Nursing also did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan. Additionally, no nurse was identified as a responsible person for carrying out the interventions.

8. Patient A6, admitted 4/9/13; MTP initiated 4/10/13. Nursing did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan.

9. Patient A5, admitted 4/10/13; MTP initiated 4/11/13. Nursing did not take responsibility for incorporating the therapeutic activities, which had been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan.

10. Patient A7, admitted 4/10/13; MTP initiated 4/11/13. Nursing did not take responsibility for incorporating the therapeutic activities, which has been delegated to them with the elimination of the Support Services Department, under their section of the treatment plan.

B. Interview

1. During an interview, on 4/16/13, Clinical Manager 1 was asked how it is determined who has the responsibility for carrying out a particular intervention. She stated "everyone is responsible, the charge nurse each shift should have this responsibility for nursing." She agreed that the treatment plans of patients A1 and A2 did not identify any particular person in any discipline that had the ultimate responsibility for carrying out the interventions. When questioned about the blank areas noted under therapeutic services on the treatment plans for patients A1 and A2 she stated, "because nursing has really picked up the groups and activities from this section when the changes occurred with the activities department, we really should be including these interventions in our section, under nursing. We had a meeting a few weeks ago but the forms have not been revised yet."

2. During an interview with the Vice President Patient Care (DON), on 4/16/13, at 4:50 PM, the treatment plans for patients A3 and A4 were reviewed; she stated "nursing should have included those interventions from the section therapeutic activities by writing them in under the pre-printed section for nursing."

Based upon record review, policy review, and interview it was determined that the Director of Social Services failed:

1. To assure the completeness of the Psychosocial Assessments. Assessments did not include specific roles for the Social Worker in the inpatient care of each patient. (Refer to B-108)

2. To assure that the Master Treatment Plans of 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10) included social work interventions. The listed social work interventions were generic social work activities. This deficiency can result in the lack of integrated focus for patient treatment and fragmented care coordination.

Findings Include:

A. Record Review

1. Patient A8, admitted 2/15/13; MTP initiated 2/19/13. Social Work generic interventions included, "Social Worker will collaborate with family or other caregiver to gather recent history and course of illness."

2. Patient A9, admitted 3/28/13; MTP initiated 3/29/13. Social Work generic interventions included, "Social Worker will meet with patient, talk to parent/guardian and complete social history within 72 hours of admission."

3.Patient A2, admitted 4/2/13; MTP initiated 4/3/13. Social Work generic interventions included, "Social Worker will collaborate with family or caregiver, with particular reference to ability to manage impulsive behaviors in a variety of settings."

4. Patient A3, admitted 4/4/13; MTP initiated 4/5/13. Generic Social Work interventions included, "Social Worker will meet with patient and complete social history and assessment."

5. Patient A10, admitted 4/04/13; MTP initiated 4/5/13. Generic Social Work interventions included, "Social Worker will collaborate with family and providers."

6. Patient A1, admitted 4/05/13; MTP initiated 4/6/13. Generic Social Work interventions included, "Social Worker will complete psychosocial within 72 hours of admission."

7. Patient A4, admitted 4/06/13; MTP initiated 4/8/13/ 13. Generic Social Work interventions included, "Social Worker will meet with patient and complete the Social History and Assessment."

8. Patient A6, admitted 4/9/13; MTP initiated 4/10/13. Generic Social Work interventions included, "Social Worker will meet with patient and gather social history and assessment."

9. Patient A5, admitted 4/10/13; MTP initiated 4/11/13. Generic Social Work interventions included, "Social Worker will meet with patient and gather social history and assessment."

10. Patient A7, admitted 4/10/13; MTP initiated 4/11/13. Generic Social Work interventions included, "Social Worker will meet with patient and gather social history and assessment."

B. Interview

Surveyor interviewed the Hospital Director of Social Services on 4/17/13 at 3:30 PM. The above findings were presented to the Director of Social Services who acknowledged them.

Based on record review and interview the facility failed to provide qualified staff to assure that the therapeutic activities being conducted are meeting the needs of the individual patients. Specifically, the facility failed to develop a formal structure for training of staff and monitoring of the activity therapy program. This failure resulted in the lack of therapeutic interventions being incorporated into the individual patient treatment plans to assist the patient in meeting their goals for 10 of 10 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9 and A10).

Findings Include:

A. Record Review

1. Patient A8, admitted 2/15/13, Master Treatment Plan initiated 2/19/13. The section titled Therapeutic Services Staff intervention was left blank.

2. Patient A9, admitted 3/28/13, Master Treatment Plan initiated 3/29/13. The section titled Therapeutic Services Staff intervention was left blank.

3. Patient A2, admitted 4/2/13, Master Treatment Plan initiated 4/3/13. The section titled Therapeutic Services Staff intervention was left blank.

4. Patient A3, admitted 4/4/13, Master Treatment Plan initiated 4/5/13. The section titled Therapeutic Services Staff intervention was left blank.

5. Patient A10, admitted 4/4/13, Master Treatment Plan initiated 4/5/13. The section titled Therapeutic Services Staff intervention was left blank.

6. Patient A1, admitted 4/5/13, Master Treatment Plan initiated 4/6/13. The section titled Therapeutic Services Staff intervention was left blank.

7. Patient A4, admitted 4/6/13, Master Treatment Plan initiated 4/8/13. The section titled Therapeutic Services Staff intervention was left blank.

8. Patient A6, admitted 4/9/13, Master Treatment Plan initiated 4/10/13. The section titled Therapeutic Services Staff intervention was left blank.

9. Patient A5, admitted 4/10/13, Master Treatment Plan initiated 4/11/13. The section titled Therapeutic Services Staff intervention was left blank.

10. Patient A7, admitted 4/10/13, Master Treatment Plan initiated 4/11/13. The section titled Therapeutic Services Staff intervention was left blank.

B. Interview

1. During an interview with Clinical Manager 1 and Clinical Manager 2, on 4/16/13 at 11:15 AM, they discussed the changes that have occurred with the elimination of the therapeutic activities department in November 2012. Clinical Manager 1 verified with Social Worker 1, via a telephone call, that the activities assessment that had previously been completed by the Activity Therapy staff was currently being done as part of the psychosocial assessment. Social Worker 1 identified the particular component of the psychosocial assessment that currently included the therapeutic activities component. Clinical Manager 1 stated "groups and activities are being done by various people but most are done by nursing, particularly the Mental Health Workers (MHWs)." When questioned what type of training for staff, particularly MHWs was done to prepare for the elimination of the therapeutic activities department, Clinical Manager 2 stated "we have done some training on groups, but it was not mandatory." Later during the day, 3:50 PM, on 4/16/13, Clinical Manager 2 reported to the surveyor that 5 different group training sessions, on different topics, had been offered since December 2012. Currently there are "175 MHW's, but only about 9% of the MHW's attended the training because it was not mandatory." The employee training files for MHW1, MHW2 and MHW3 were reviewed by the surveyor with Clinical Manager 2 who validated that there was no evidence of training on groups in any of these files either as part of orientation upon new hire or during annual training. Clinical Manager 2 stated "this is still very new for us, we are still identifying what training we need to put into place, but certainly 9% is not good."

2. As a result of the changes made in November, 2012, currently there is no one person responsible for monitoring the provision of the therapeutic activities. This information was acknowledged by the Vice President of Patient Care during the interview on 4/16/13 at 4:50 PM.