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Based on medical record reviews, review of quality information, staff and patient interviews, review of facility policies, and review of AMH staffing, the facility failed to protect and promote one (1- #7) of eleven (11) patient's right to receive care in a safe setting.

Cross Reference:

A - 0144 - Patient Rights: Care in a Safe Setting
A - 0392 - Staffing and Delivery of Care
A - 0385 - Nursing Services

Based on medical record reviews, review of quality information, staff and patient interviews, review of facility policies, and review of AMH staffing, the facility failed to protect one (1- #7) of eleven (11) patient's right to receive care in a safe setting.

Findings include:

Review of patient #7's medical record revealed the twenty (20) year old was admitted involuntarily on 1/17/2018 with a diagnosis of major depressive disorder.
The medical record did not contain evidence that the patient had received Patient Rights on admission.
Physician orders included continuous observation from 1/17/2018 to 1/23/2018 and routine observation (every thirty minutes) from 1/24/2018 to 3/5/2018 discharge.
Review of observation documentation revealed that observations had been performed as ordered on all days.
Review of General Notes revealed:
2/14/2018 at 8:30 PM: RN noted the patient was diaphoretic (sweaty), clammy, had stiffened hands and arms, and had minimal speaking. Heart rate was 160, and oxygen saturation was 98%. Vital signs at 6:45 PM were 98.1, heart rate 131, 142/95; at 7:15 PM were 98.1-126 -18 140/93. The nurse noted the physician was notified, and Benadryl (anti-histamine) 50 mg intramuscularly was administered per order.
2/15/2018 at 10:17 AM: The physician noted that patient #7 was hearing voices, seeing things, and experiencing paranoia regarding people being after him/her. The patient was depressed and had no physical complaints.
2/16/2018 at 2:26 PM: The physician noted that patient #7 had reported sexual advances toward him/her. A physical examination was performed, and no abnormalities were noted to the penis, groin, or perianal areas. No rectal exam was performed.

Review of facility quality reports revealed that on 2/15/2018 at 12:00 PM, during a family session, the patient stated he/she was sad because he/she had done gay things in his/her bedroom on AMH pod C. Patient #7 explained that his/her roommate, patient #11, had made him/her masturbate him/her more than one time, but he could not tell the exact number of times, or when it happened.

Review of patient #11's medical record revealed the forty (40) year old patient was admitted on 9/21/2017 with a diagnosis of schizoaffective disorder.
A Consent for Treatment was signed by the patient on 9/21/2017.
The medical record contained evidence that the patient had received Patient Rights information on admission.
A psychiatric examination was performed on 9/21/2017, which noted the patient seemed to have longer admissions due to complaining of auditory hallucinations. The patient denied being suicidal or homicidal. Patient #11's emotions ranged from labile and content to anger and frustration.
Physician orders included self-injurious precautions from 9/21/2017 to 9/24/2017 and routine observation from 9/25/2017 to 2/16/2018.
A Treatment/Recovery Plan was initiated on 9/21/2017, which noted:
Patient's history of being hyperverbal, hyper-religious, and hypersexual.
History of suicidal gestures by cutting his/her arm with a knife.
The plan did not include interventions for hypersexuality.
A Master Treatment/Recovery Plan was completed on 10/10/2017, which included:
Patient history of being hyperverbal, hyper-religious, and hypersexual
Did not include interventions for hypersexuality.
That the patient did not like females telling him/her what to do
That the patient could get aggressive towards females.
That this was the patient's seventh admission to the facility
That the patient was placed in groups but refused to attend
A Treatment/Recovery Plan was completed on 2/22/2018 which noted:
Patient history of being hyperverbal, hyper-religious, and hypersexual.
The patient was transferred from AMH to the Forensic 1 unit due to reported behaviors of having another patient masturbate him/her on the unit.
Reports indicate that patient has a history of self-harm, suicidal ideations, verbally and physically aggressive and intrusive and intimidating actions.
Reported to exhibit sexual predatory behavior in jail and a history of masturbating in public
After the patient was moved from pod C, the patient became upset, demanding to be taken back to pod C despite being told that he/she could not. The patient then began verbally threatening staff and proceeded to push all the lunch trays off the table, and unprovoked punched a peer who was exiting the restroom. The patient was placed in seclusion, where he/she kicked a large hole in the wall. The patient was restrained and received an injection of Haldol 10 mg intramuscularly (antipsychotic).

Review of nine (9) other medical records (#1, 2, 3, 4, 5, 6, 8, 9, and 10) revealed:
Two (2- #4 and 9) contained evidence that Patient Rights had been received.
Three (3- #1, 6 and 10) was noted to be unable to sign a confirmation of receipt of Patient Rights.
Two (2- #5 and 8) refused to sign a confirmation of receipt of Patient Rights.
Two (2- #s 2 and 3) did not contain evidence that Patient Rights had been received.

Interview with the Recovery Team Facilitator on 3/6/2017 at 10:15 AM in the conference room revealed that his/her responsibility was to put together care plans. He/she stated that his/her 2/22/2017 Treatment Plan documentation regarding resident #11 exhibiting sexual predatory behavior while in jail and history of masturbation was received from a staff member at an outpatient treatment center, (where the patient previously received treatment) in response to a phone call he/she made to inquire about the patient's reason for being incarcerated and behavior in the community. The facilitator explained that he/she had made the inquiry after patient #7's allegation of being forced to provide sexual stimulation to patient #11. The facilitator stated that he/she previously worked for the prison system, and knew patient #11 due to having worked with him/her for approximately two (2) years while he/she was in prison. The facilitator added that during the period of time that he/she worked with the patient, the patient masturbated and was sexually aggressive. The facilitator further stated that shortly after admission to AMH pod A, he/she had overheard staff members discussing patient #11 masturbating while peers were in crisis situations. The facilitator explained that patient #11 was admitted to AMH pod A, and was housed in a single patient room. Sometime later, the patient was moved to pod C (houses more stable patients) and had a roommate. The facilitator stated that patient #11 had not had any (other) problems/concern up until patient #7's allegation. The facilitator explained that patient #11's sexual behavior had not been addressed on the initial or 15-day treatment plans because behaviors had not been reported.

Per the Director of Quality on 3/6/2017, the assignment sheet indicated that patient #11 was moved from pod A to pod C on 1/31/2017, where he/she was housed with two (2) same gender roommates.

Interview with the AMH Nurse Manager on 3/6/2017 at 12:00 PM in the conference room revealed that he/she had been in his/her current position since 1/22/2018, and had served in the interim role for seven (7) months prior to that. The manager stated that he/she was trained in safety care annually. The manager explained that while patient #11 had never been sexually aggressive, approximately one (1) week prior to patient #7's allegation, he/she had noticed that patient #11 would frequently rub his/her private area whenever the manager was speaking to him/her. Although the manager had not witnessed patient #11 exposing him/herself, staff had reported that the patient exposed him/herself and masturbated in the dayroom, and that they had directed the patient to go to his/her room. Patient #11 was housed in pod A, in a single room at the time. The manager continued on stating that he/she was familiar with patient #11, and the patient was always hypersexual. He/she went on stating that staff generally tried to place hypersexual patients in a single room, but that at the time patient #11 was transferred to pod C (due to fighting with a peer), there were no single rooms available. The manager went on explaining that the AMH unit was the most appropriate location for patient #11, and he/she could not be transferred to pod B because it is a female unit. The manager also stated that observation would not normally be increased due to sexual behavior, or having roommates. The manager stated that patient #7 had never voiced complaints to him/her or other staff members about patient #11's sexual aggression, adding that staff should have reported to him/her if so.

Interview with the Health Service Technician (HST) Supervisor on 3/6/2017 at 12:15 PM in the conference room revealed that he/she had served in the position for approximately five (5) years, and was trained annually as an instructor for safety care. The supervisor stated that staff was aware of patient #11 behavior of exposing self and masturbating in open areas due to his/her having been a patient there previously. He/she explained that this was the reason that patient #11 was usually housed in pod A for all male staff and a single room. Although the supervisor could not recall when, he/she stated that patient #11 had previously been noted to touch female staff's buttocks. The supervisor also stated that patient #11 had never attempted to rape or assault anyone.
The supervisor continued on stating that he/she did not understand why the patient was transferred to C pod, and that he/she should have never gone there because of his/her behavior, the all female staff, and the fact that that pod housed calmer patients who were all on routine observations and went to the treatment mall daily from 9:00 AM to 2:00 PM. The supervisor explained that since patient #11 refused to attend the treatment mall, he/she would be transferred to the A pod during those hours to be monitored by male staff members. The supervisor also stated that the majority of pod A patients did not attend the treatment mall due to being a new admission, instability, or their behaviors. The supervisor stated that patient #7 had never complained about patient #11's sexual behavior to him/her or staff (who would report such to him/her).

Telephone interview with MD #9 on 3/6/2018 at 12:30 PM revealed that he/she did not recall patient #11, but stated that all patients are admitted on continuous observation. The MD also stated that it would be appropriate to order more frequent monitoring, such as continuous, for patients with hypersexual behavior. He/she also stated that the shift supervisor should decide the frequency of monitoring, and contact the physician for orders, if necessary.

Telephone interview with the Interim Clinical Director on 3/6/2018 at 1:04 PM revealed that for hypersexual patients, he/she would evaluate the patient to ascertain if behavior was due to the patient being off his/her medications, or if their judgement was impaired due to psychosis. The physician explained that he/she would order medication, then observe the patients' interactions - whether they were attending treatment mall, etc. until he/she heard otherwise from the staff. The MD stated that sexual behavior was unexpected, and staff would be concerned about safety. He/she went on stating that staff should have notified the physician to evaluate patient #11's situation, and possibly order more frequent observations; adding that patients could have continuous observation when housed with roommates to assure safety. The Interim Clinical Director also stated that he/she was never notified about patient #11's behavior, but was aware that the patient had spat on the attending MD, who had attempted to have the patient transferred to general mental health (GMH - houses fragile and cognitive impairment patients). The MD added that due to the patient's history, leadership did not think that transferring the patient to GMH was appropriate.

During a tour of AMH on 3/5/2018 at 11:19 AM, all pods were noted to have posted Patient Rights on the dayroom walls, and patients appeared to be adequately monitored.

Interview with patient #12 on 3/5/2018 at 11:55 AM revealed that he/she had been a patient on B pod for approximately four (4) months, and felt safe. The patient did not recall receiving Patient Rights on admission but was aware of the posted rights location and the patient advocate's name. Patient #12 stated that he/she had been involved in his/her treatment plan. He/she also stated that he/she felt that there was adequate staffing on the unit.

Interview with patient #13 on 3/6/2018 at 2:26 PM revealed that he/she had been a patient on C pod for twenty-seven (27) days. The patient did not recall receiving Patient Rights on admission but was aware of the posted rights location. He/she stated that there was adequate and felt safe. The patient also stated that he/she had not witnessed abuse or inappropriate sexual behavior.

Interview with patient #14 on 3/6/2018 at 2:35 PM revealed that he/she had been a patient on B pod for approximately two (2) months.

The patient did not recall receiving Patient Rights on admission, but was aware of the posted rights location. Patient #14 stated that he/she had been involved in his/her treatment plan. He/she also stated that he/she felt that there was adequate staffing on the unit and that he/she had not witnessed abuse or inappropriate sexual behavior.

Interview with patient #15 on 3/6/2018 at 2:45 PM revealed that he/she had been a patient on C pod for a couple of weeks. The patient stated that he/she had received Patient Rights information on admission and was aware of the posted rights location. Patient #15 stated that he/she did not feel safe due to having been punched by peers on two (2) occasions while housed on the A pod. The patient stated that staff had been present at the time he/she was punched and had intervened quickly. The patient also stated that he/she had not witnessed inappropriate touching, exposure, or masturbation.

Review of facility pamphlet titled Your Rights, What You Should Know About Your Rights While You Are at One of Georgia's Regional State Hospital, revealed that residents have the right to:
A safe, humane treatment that is free of neglect and physical, sexual, and verbal abuse.
Socialize with other consumers as long as you do not hurt yourself or harm or bother someone else in the hospital.

Review of facility policy #303970, Patients' Rights and Clients' Rights, 24-103, created 8/29/2012, reviewed and revised 7/23/2013, revealed that the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) recognizes and respects the rights of all individuals. Individuals receiving services in DBHDD hospitals, as well as staff who provide these services, are informed of these rights and their responsibilities.

Review of facility policy #3431354, Levels of Observation for Individuals in DBHDD Hospitals, 03-501, revealed that DBHDD hospitals utilize established procedures for three levels of observation that is commensurate with the clinical needs of individuals being served.
Definitions
Routine Observation:
Maintaining general awareness of the individual's whereabouts and status by visually observing the individual at least every 30 minutes.
Continuous Observation:
Maintaining continuous knowledge and awareness of the individual's whereabouts at all times through visual observation unless the ordering clinician makes provisions to modify the continuous observation to require only hearing during bathing, toileting, or similar actives where privacy is a concern.
One-to-One Observation:
Maintaining continuous knowledge and awareness of the individual's whereabouts at all times with at least one assigned staff that remains in such close proximity to the individual as to be able to intervene and prevent actions that are unsafe to the individual or others.
Team: Includes interdisciplinary recovery planning team for mental health and forensic services and interdisciplinary team for developmental disabilities services.
The primary purpose of observation is to provide safety for individuals during periods of distress when they are at risk of harm to themselves and/or others. It is essential this period is therapeutic; although the individual may perceive such observation as not needed at the time. At times, observation is used to provide an intensive period of assessment of a person's mental state.
Teams do not hesitate to use increased levels of observation when their judgment indicates it is clinically needed. However, they should be clear about its purpose and aware of the wider effects of this decision.
Observation Skills of Staff: In order to protect individuals, staff, and others, it is essential that staff have skills in detecting signs of impending aggression or violence. Staff receive training in techniques for the early identification, de-escalation, and management of aggression. Staff remain alert for behaviors that may indicate deterioration, or other change in the individual's mental state that may lead to negative outcomes. Observation of individuals who are experiencing acute symptoms of mental illness is a skilled task involving assessment of the individual's mental state, the risks involved, and the potential benefits for the individual and others.
Specific Procedures for Each Level of Observation
The physician, physician assistant (PA) or Advanced Practice Registered Nurse (APRN) orders the level of observation that is needed for each individual based upon their specific and immediate need. In the event the individual's known, observed and/or reported condition or behavior requires immediate implementation of a higher level of observation, a licensed nurse, licensed psychologist, shift supervisor or QIDP may evaluate the individual, implement the the appropriate special observation, document in the progress notes, and notify the on-call physician, physician assistant or APRN within one hour and the provider evaluating within two hours of notification.

Review of facility policy #195489, Recording and Monitoring Via Electronic Media, 03-701, effective, reviewed, and revised 2/14/2012, revealed that DBHDD enhances security and safety campus-wide with the appropriate use of available recording and monitoring equipment within DBHDD Hospitals.
A. Recording and monitoring are conducted in a professional, ethical and legal manner. Personnel using the recording and monitoring equipment are appropriately trained and supervised in the responsible use of technology.
B. Information obtained through recording and monitoring is used exclusively for safety, security, treatment and other legitimate purposes. Recording and/or monitoring are never used in lieu of staff presence.
E. Recording and monitoring of hospital areas is limited to uses that do not violate the reasonable expectation of privacy as defined by law.

Review of facility policies failed to reveal a policy which addressed housing location based on diagnosis.

Review of facility policy #3027324, Nursing Staff Scheduling, Holdover, and Staff Sharing, created, reviewed, and revised 12/1/2016, revealed:
A. Nursing Staff Scheduling
1. All staff scheduling periods are developed locally in accordance with the established core staff ratios for each unit by the Nurse Manager, Team Leaders or designees. When necessary, staff assignments may be changed by the Nurse Manager, Team Leaders, or designees in order to provide the appropriate level of care.
9. Staffing needs must be determined two to four (2-4) hours before the beginning of the next shift and adjusted accordingly. Additional staff may be necessary if acuity is high. Acuity is determined by the census as well as other factors, including but not limited to the following:
a. Off-unit activities (e.g. transports of individuals to outside appointments or planned activities)
b. Individuals' level of observation (e.g.1:1 or continuous observation)
10. If necessary, the Charge Nurse or designee requests assistance from the Nursing Supervisor in staffing the units.

Review of facility policy #3542968, Minimum Staff Ratio, 03-922, created, reviewed and revised 5/1/2017, revealed:
Procedures
A. Establishment of Minimum Staff Ratios
1. The Associate Regional Hospital Administrator, in conjunction with the Residential and Program Directors, establishes and approves minimum staff on duty by living area and shift. The minimum staff on duty for each shift is based upon the needs of the individual group assignments. Minimum ratios for each living area are maintained in the Unit Office, according to Maintaining Unit Records, 03-708.
3. Minimum ratios are determined in accordance with the acuity level of the living areas, and individuals requiring increased levels of observation. For every two individuals on continuous observation, one additional staff is added. For individuals whose observation level is one-to-one, one additional staff is added.

Review of facility policy titled Staffing Guidelines, Section III.3, effective March 9, 2016, revealed:
1. Nursing staff shall consist of Registered Professional Nurses and Licensed Practical Nurses
2. The nurse manager shall have 24-hour overall nursing management responsibilities for assigned units. The Charge Nurse shall assume responsibility for staffing during the Nurse Manager absence.
3. When the activity, acuity level or census on any unit warrants additional coverage, the unit charge nurse shall endeavor to secure additional coverage by contacting the Charge Nurse. The Charge Nurse shall contact the Nurse Manager if unable to meet staffing guidelines/coverage.
Minimum staffing for the Adult Mental Health Unit was:
Day shift: 3 RNs, 3 LPNs, and 14 HSTs
Evening shift: 2 RNs, 3 LPNs, and 12 HSTs
Night shift: 2 RNs, 3 LPNs, and 10 HSTs

Review of AMH staffing for a three (3) week period (2/4-2/10/2018, 2/18-2/24/2018, and 2/25-3/3/2018) revealed:
Pod A - staffing was short on sixty-three (63) of sixty-three (63) shifts
Pod B - staffing was short on sixty-three (63) of sixty-three (63) shifts
Pod C - staffing was short on sixty-three (63) of sixty-three (63) shifts

Review of five (5) employee files revealed:
Two (2- #s 1 and 3) did not contain an application, including education and reference
Four (4- #s 1, 2, 4, and 5) did not contain job descriptions
One (1- #1) did not contain evidence of a pre-employment or subsequent health screening examinations, or TB testing.
All had received annual training which included safe patient handling
All had current CPR certification

Based on review of facility policies, and review of AMH staffing, the facility failed to have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.

Findings include:

Cross reference tags;
A- 0115 - Patient Rights
A - 0144 - Patient Rights: Care in a Safe Setting
A - 0392 - Staffing and Delivery of Care

Review of facility policy #3027324, Nursing Staff Scheduling, Holdover, and Staff Sharing, created, reviewed, and revised 12/1/2016, revealed:
A. Nursing Staff Scheduling
1. All staff scheduling periods are developed locally in accordance with the established core staff ratios for each unit by the Nurse Manager, Team Leaders or designees. When necessary, staff assignments may be changed by the Nurse Manager, Team Leaders, or designees in order to provide the appropriate level of care.
9. Staffing needs must be determined two to four (2-4) hours before the beginning of the next shift and adjusted accordingly. Additional staff may be necessary if acuity is high. Acuity is determined by census as well as other factors, including but not limited to the following:
a. Off-unit activities (e.g. transports of individuals to outside appointments or planned activities)
b. Individuals' level of observation (e.g.1:1 or continuous observation)
10. If necessary, the Charge Nurse or designee requests assistance from the Nursing Supervisor in staffing the units.

Review of facility policy #3542968, Minimum Staff Ratio, 03-922, created, reviewed and revised 5/1/2017, revealed:
Procedures
A. Establishment of Minimum Staff Ratios
1. The Associate Regional Hospital Administrator, in conjunction with the Residential and Program Directors, establishes and approves minimum staff on duty by living area and shift. The minimum staff on duty for each shift is based upon the needs of the individual group assignments. Minimum ratios for each living area are maintained in the Unit Office, according to Maintaining Unit Records, 03-708.
3. Minimum ratios are determined in accordance with the acuity level of the living areas, and individuals requiring increased levels of observation. For every two individuals on continuous observation, one additional staff is added. For individuals whose observation level is one-to-one, one additional staff is added.

Review of facility policy titled Staffing Guidelines, Section III.3, effective March 9, 2016, revealed:
1. Nursing staff shall consist of Registered Professional Nurses and Licensed Practical Nurses
2. The nurse manager shall have 24 hour overall nursing management responsibilities for assigned units. The Charge Nurse shall assume responsibility for staffing during the Nurse Manager absence.
3. When the activity, acuity level or census on any unit warrants additional coverage, the unit charge nurse shall endeavor to secure additional coverage by contacting the Charge Nurse. The Charge Nurse shall contact the Nurse Manager if unable to meet staffing guidelines/coverage.

Minimum staffing for the Adult Mental Health Unit was:
Day shift: 3 RNs, 3 LPNs, and 14 HSTs
Evening shift: 2 RNs, 3 LPNs, and 12 HSTs
Night shift: 2 RNs, 3 LPNs, and 10 HSTs

Review of AMH staffing for a three (3) week period (2/4-2/10/2018, 2/18-2/24/2018, and 2/25-3/3/2018) revealed:
Pod A - staffing was short on sixty-three (63) of sixty-three (63) shifts
Pod B - staffing was short on sixty-three (63) of sixty-three (63) shifts
Pod C - staffing was short on sixty-three (63) of sixty-three (63) shifts

Based on review of facility policies, and review of AMH staffing, the facility failed to have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.

Findings include:

Cross reference tag 0144 - Patient Rights: Care in a Safe Setting

Review of facility policy #3027324, Nursing Staff Scheduling, Holdover, and Staff Sharing, created, reviewed, and revised 12/1/2016, revealed:
A. Nursing Staff Scheduling
1. All staff scheduling periods are developed locally in accordance with the established core staff ratios for each unit by the Nurse Manager, Team Leaders or designees. When necessary, staff assignments may be changed by the Nurse Manager, Team Leaders, or designees in order to provide the appropriate level of care.
9. Staffing needs must be determined two to four (2-4) hours before the beginning of the next shift and adjusted accordingly. Additional staff may be necessary if acuity is high. Acuity is determined by census as well as other factors, including but not limited to the following:
a. Off-unit activities (e.g. transports of individuals to outside appointments or planned activities)
b. Individuals' level of observation (e.g.1:1 or continuous observation)
10. If necessary, the Charge Nurse or designee requests assistance from the Nursing Supervisor in staffing the units.

Review of facility policy #3542968, Minimum Staff Ratio, 03-922, created, reviewed and revised 5/1/2017, revealed:
Procedures
A. Establishment of Minimum Staff Ratios
1. The Associate Regional Hospital Administrator, in conjunction with the Residential and Program Directors, establishes and approves minimum staff on duty by living area and shift. The minimum staff on duty for each shift is based upon the needs of the individual group assignments. Minimum ratios for each living area are maintained in the Unit Office, according to Maintaining Unit Records, 03-708.
3. Minimum ratios are determined in accordance with the acuity level of the living areas, and individuals requiring increased levels of observation. For every two individuals on continuous observation, one additional staff is added. For individuals whose observation level is one-to-one, one additional staff is added.

Review of facility policy titled Staffing Guidelines, Section III.3, effective March 9, 2016, revealed:
1. Nursing staff shall consist of Registered Professional Nurses and Licensed Practical Nurses
2. The nurse manager shall have 24 hour overall nursing management responsibilities for assigned units. The Charge Nurse shall assume responsibility for staffing during the Nurse Manager absence.
3. When the activity, acuity level or census on any unit warrants additional coverage, the unit charge nurse shall endeavor to secure additional coverage by contacting the Charge Nurse. The Charge Nurse shall contact the Nurse Manager if unable to meet staffing guidelines/coverage.

Minimum staffing for the Adult Mental Health Unit was:
Day shift: 3 RNs, 3 LPNs, and 14 HSTs
Evening shift: 2 RNs, 3 LPNs, and 12 HSTs
Night shift: 2 RNs, 3 LPNs, and 10 HSTs

Review of AMH staffing for a three (3) week period (2/4-2/10/2018, 2/18-2/24/2018, and 2/25-3/3/2018) revealed:
Pod A - staffing was short on sixty-three (63) of sixty-three (63) shifts
Pod B - staffing was short on sixty-three (63) of sixty-three (63) shifts
Pod C - staffing was short on sixty-three (63) of sixty-three (63) shifts