The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MERCY HOSPITAL SPRINGFIELD 1235 E CHEROKEE SPRINGFIELD, MO 65804 Jan. 6, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record review, Video/Audio recording review and policy review, the facility failed to:
- Ensure a safe environment when they failed to remove Staff O, Registered Nurse,
immediately from patient care after an allegation of abuse of Patient #47 (A0144);
- Ensure a safe environment when they did not remove three staff (U,T and S) from patient care during investigations of physical and verbal abuse of three of 21 discharged patients (#75,#74 and #78) reviewed (A144);
- To prevent, identify, assess or report allegations of physical or verbal abuse or implement interventions for five of 21 discharged patients (#74, #75, #76, #77 and #78) reviewed (A0145); and
- Ensure orders for restraint/seclusion were obtained for three of three patients (A0162);

These failures had the potential to affect all patients in the facility by placing patients in seclusion without a physician's order, face to face assessments or a medical exam and failure to identify, report, investigate and protect patients from abuse.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patients' Rights resulting in a condition of immediate jeopardy.

As of 01/06/17, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Immediate education of all patient care staff on de-escalation techniques for aggressive patients;
- Mock simulation drills will be performed and competency evaluated prior to each coworker working their next shift;
- Mock Codes will continue on each shift until patient care staff demonstrate competency at 100%, then daily on alternating shifts and locations until staff demonstrate expected competencies, then weekly for four weeks, and if at 100%, monthly for six months;
- Immediate education on recognizing and reporting of Abuse/Neglect;
- Mock abuse/neglect simulations;
- Immediate education on policy and process for restraint/seclusion situations.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observations, interviews, record reviews and policy and procedure reviews the facility failed to ensure that the patients or the patients' representative were provided an address or telephone number for lodging a grievance or complaint with the State agency. As part of its notification of patient rights, the hospital must provide the patient or the patient's representative a phone number and address for lodging a grievance with the State agency. The hospital must inform the patient that he/she may lodge a grievance with the State agency (the State agency that has licensure survey responsibility for the hospital) directly, regardless of whether he/she has first used the hospital's grievance process. The facility also failed to have a process in place to ensure that patients with a primary language other than English were provided the contact information in their language or documented in the patient's medical record that the information had been provided in any way to the patient or their representative for one patient (#45) of one patient identified with communication barriers. This had the potential to affect all patients in the hospital in being able to express concerns regarding their health care.
The facility census was 433.

Findings included:

1. Record review of the facility's policy and procedure titled, "PATIENT RIGHTS AND RESPONSIBILITIES," revised 03/2015, showed the following direction to staff:
- Notice to patients of their rights and responsibilities will be provided to all inpatients or outpatients in written form at the time of admission as an inpatient . . .
- Notice of patient rights may be provided by delivery of a copy of this policy or may be contained in the Patient Guide brochure or separate notice of patient rights brochure which is distributed to inpatients and outpatients or their representative and may also be displayed in postings throughout the organization.
- Staff of the facilities will be trained regarding the content and delivery of the Notice of Patient Rights and Responsibilities and will be provided access and a supply of current copies for distribution to patients.
- Patients have a right to information about their [care]. This includes: providing information to communicate with patients who have . . . needs and providing language interpreting and translation services as necessary.
Express Concerns or Grievances
- Patients have a right to voice any concerns that they may have regarding the care they have received and to have those concerns reviewed and resolved. Patients are encouraged to contact any staff present, the manager or director of that department, or Patient Relations who may be reached at (417)820-9272.
- The patient may also lodge a grievance with the following agencies directly, regardless of whether he/she has first used the facility's grievance process: Missouri Department of health and Senior Services, PO Box 570, Jefferson city, MO (573)751-6303.
Please note that this is not the information currently provided to patients or their representatives.

2. Record review of the facility's patient admission packet for the hospital showed that the State Agency contact information was not included in the Patients' Rights information but in an area separate from the Patients' Rights information.

Record review of the facility's patient admission packet for the Behavior Health Units A and B showed the following: "Any safety or quality concern that has not been addressed by the hospital management and/or Patient Relations to your satisfaction may be reported directly to: Missouri Department of Health and Senior Services, Bureau of Health Services Regulation, PO Box 570, Jefferson city, MO -0570 with a fax number". The State Agency contact information was not included in the Patients' Rights information but in an area separate from the Patients' Rights information. The State Agency Bureau should be referred to as the Bureau of Hospital Standards and the correct telephone number(s) of (573)751-6303 or (800)392-0210 should be provided not the fax number.

During an interview on 01/03/17 at 4:00 PM with Staff II, Director of Patient Safety, stated that the information was provided to the facility by "Corporate". She stated that she would have to get more information as to why the State Agency contact information was not within the Patients' Rights information provided to patients or their representatives. Staff II did not provide any evidence or further documentation regarding the State Agency contact information.

3. Observations on 01/04/16 at 3:30 PM with Staff N, Director of Nursing (DON), showed that the following common waiting areas on the following Unit/Floors had no information regarding Patients' Rights or contact information for the State Agency to file a complaint or grievance with health care concerns:
- 7th floor Burn Unit;
- 6th floor A- Intensive Care Unit (ICU);
- 6th floor B - Medical;
- 5th floor Labor and Delivery;
- 4th floor Cardiac Telemetry; and
- 3rd floor Surgical Post-Operative.

During an interview on 01/04/17 at 3:45 PM with Patient #45 it was necessary to procure an interpreter for the conversation. The Patient's primary language was Spanish and he could not understand the English language well enough to conduct a conversation without the interpreter. He was asked three different times in three different ways through the interpreter if he had received and knew his Patients' Rights. Each time the patient answered, "No".

4. Record review of Patient #45's medical record showed that he had received his Patients' Rights however there was no explanation that they had been provided either verbally or written in his primary language, or that it had been provided to a representative for interpretation in his language.

During an interview on 01/04/17 at 4:00 PM with Staff N, she agreed that Patient #45 did not understand the questions regarding Patients' Rights.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview, review of facility grievance files and policy review, the facility failed to provide a written notice of resolution of a patient's grievance for three (#86, #87 and #88) of nine grievance files reviewed. This had the potential to affect all patients and or patient's representatives who file a grievance by denying them needed information regarding their grievance. The facility census was 433.

Findings included:

1. Record review of the facility policy titled, "Patient Concern/Grievance Policy," dated 12/2015, showed the resolution letter regarding the grievance should not exceed thirty business days and shall include the name of the facility contact person, steps taken on behalf of the patient to investigate the concern, findings from the review, resolution of the complaint, date of resolution and their rights should they remain dissatisfied with this response.

2. Record review of the three grievances showed the following:
-Patient #86 filed a grievance on 10/25/16 and the grievance file contained no documentation showing a resolution letter had been sent to the patient.
-Patient #87 filed a grievance on 10/11/16 and the grievance file contained no documentation showing a resolution letter had been sent to the patient.
-Patient #88 filed a grievance on 11/22/16 and the grievance file contained no documentation showing a resolution letter had been sent to the patient.

During an interview on 01/05/17 at 4:02 PM, Staff II, Director of Patient Safety, stated there was no record of the resolution letters being sent to the patients who had filed the three grievances.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on video/audio recording, interviews, record reviews and policy review the facility failed to provide a safe environment for one of one current patient (#47) on the Behavioral Health Unit (BHU) when they failed to recognize staff to patient abuse and failed to remove the staff (O) from patient care. The facility also failed to provide a safe environment when they did not remove three staff (U,T and S) from patient care during investigations of physical and verbal abuse of three of 21 discharged patients (#75,#74 and #78) reviewed. These failures had the potential to affect the safety of all patients and had the potential for continued abuse and or injury. The facility census was 433 and the Behavioral Health Unit census was 24.

Findings included:

1. Record review of the facility's policy and procedure titled, "REPORTING PATIENT ABUSE AND NEGLECT CAUSED BY A CO-WORKER," dated 11/2016, showed the following:
- The facility prohibits all forms of abuse and neglect from co-workers. The hospital must ensure that patients are free from all forms of abuse and neglect.
- The purpose of this policy is to uphold the mission and values of the hospital by appropriately identifying and responding in situations of suspected abuse or neglect.
- Definitions: Abuse means the willful inflection of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.
Protection From Abuse:
- We must protect our patients from abuse during investigation of any allegations of abuse or neglect.
- We ensure, in a timely and thorough manner, objective investigation of allegations of abuse or neglect.
- Alleged abuse and neglect is defined as any report from family members, patients, or co-workers of abuse and/or neglect. These must be reported even if the co-worker does not believe the allegation is true.
- The Charge Nurse/Department Manager receiving a report will: Assess the patient; Co-worker will be immediately removed from patient care if abuse is suspected or witnessed.
- Primary physician will be notified to examine the patient if signs of abuse are present.
- Charge nurse/Department Managers will escalate to Vice President/Administrator on Call to initiate the investigatory leave.
- Co-worker(s) alleged to have committed abuse or neglect will be escorted from the hospital premises pending further investigation.

2. Record review of the video/audio recording of Patient #47 and staff interactions in the BHU at 01/03/17 from 4:52 AM to 5:06 AM showed:
- At 4:52 AM the patient stood in front of the nurse's station door (locked) talked to Staff PP, Behavioral Health Technician (BHT) through a solid glass window. BHT requested that the patient move away from the door so she could come out and take vital signs. Patient was defiant;
- The patient screamed something unintelligible and spit at Staff O, RN (sputum landed on RN's chest);
- RN stated, "Don't ever spit on me again" and began to move forward;
- The patient lifted his right arm and the RN put his left hand on patient's arm and pushed down;
- The patient punched the RN in the face with his left fist;
- The RN charged forward and struck the patient in the face/neck area, pushed patient backwards to a wall and had his arms under the patient arms in a bear hug position. The patient continued to strike the back of the RN's head and neck area;
- Staff PP was present and attempted to assist with control of the patient;
- The RN pivoted and twisted the patient's body and slammed the patient to the floor with the RN on top;
- At 4:54 AM Staff O stated, "That was a major mistake, I will press charges, guaranteed";
- At 4:54 AM patient remained in physical hold, on the floor as RN and BHT held patient down;
- At 4:54 AM second BHT arrived;
- At 4:55 AM second RN arrived;
- At 4:57 AM three security officers arrived;
- At 4:59 AM security moved patient to Acute Care Area (ACA);

3. Record review of Patient #47's medical record showed that he was a [AGE] year old male who was admitted to the facility's Behavioral Health Unit (BHU) on 01/03/17 at 4:41 AM, with a diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal thought processes and inappropriate emotions), hearing voices, and delusional (made statements that were not true). The record on 01/03/17 also showed that:
- When patient arrived on the BHU he became oppositional and defiant when staff requested to take his vital signs;
- He refused to move away from nurse's station door;
- He spit on Staff O, Registered Nurse (RN), struck Staff O in the face with his fist;
- The patient continued to punch the nurse during take down and was manually restrained on the floor until security arrived;
- Staff O documented care of the patient until the end of his shift at 7:00 AM;

During an interview on 01/04/17 at 3:30 PM Staff E, Manager of Behavioral Health, after the video was viewed stated, "I think that went as well as could be expected, he tried to keep the patient from going into the nurses station, the take down went pretty good". Staff E stated that Staff O continued to care for Patient #47 until the end of his shift on 01/03/17 at 07:00 AM. Staff E stated that no investigation had started, that she had not viewed the video until the surveyor requested, and that the police had come to make a report.

During an interview on 01/04/17 at 4:00 PM Staff F, Director of Nursing, stated that she had not seen the video until the surveyor requested it, no investigation had been initiated, and she thought the RN was a little aggressive in the interaction with Patient #47. Staff F stated that she was made aware of the altercation and that Staff O cared for Patient #47 until the end of his shift.

During an interview on 01/06/17 at 9:25 AM Staff O stated that:
- He was called to the nurse's station door by Staff PP who was afraid because the patient wouldn't move away from the door so she could get vital signs;
- "The patient asked if he would be raped and then he spit on me, and punched me in the face;
- "I pushed him to get him away from the door, then I held him and took him to the floor;
- "He tried to bite me so I held his face to the floor;
- "A Code 10 (patient out of control- call for help) was called and some other staff came and then security arrived and took the patient to the ACA;
- "I checked his orders and medicated the patient;
- "I was agitated about getting spit on and I knew the patient tried to provoke me;"

During a telephone interview on 01/05/16 at 3:00 PM Staff PP stated that:
- The patient was asked to move away from the door so she could get his vital signs;
- The patient stood at the door with a blank look on his face;
- Staff O came over and opened the door, with no warning the patient spit on him and hit Staff O in the face;
- Staff O moved the patient away from the door and got the patient to the floor;

The altercation between Staff O and Patient #47 was never identified as a potential abuse situation by the facility, so the staff member was not removed from patient care, which resulted in an unsafe patient care environment.

4. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed on 07/16/16 in the Emergency Department: Staff U, Registered Nurse (RN), slapped patient (#75) in an attempt to keep him from removing his Intravenous (IV - within the vein) line. The patient's wife stated that the nurse slapped his hand hard. Staff U admitted slapping the patient for his own good.

The Corrective Action Form completed after the investigation showed that Staff U was given a verbal corrective action that stated, "Spoke with [Staff U] about alternative methods that can be used to prevent patients from pulling out lines, drains and airways". Staff U continued to care for the patient and was not removed from patient care.

5. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed on 11/01/16 in the Medical Intensive Care Unit (MICU), Staff T, Registered Respiratory Therapist (RRT), yelled at Patient # 74, "Well if you don't like it, tell your doctor not to order it". The patient's family witnessed the incident and filed a complaint. The facility investigated the complaint and found it to be substantiated. Staff T admitted that she yelled at the patient. Staff T received a verbal discussion about the incident but was not removed from patient care during the investigation.

6. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed the following:
- On 11/07/16 on the Surgical Unit Patient #78 reported that Staff S, RN, threatened to "Beat the ass" of a male staff member. The RN admitted that she made this statement. The RN remained in patient care during the investigation. The event was described as "Behavioral" and was not identified as verbal abuse. The nurse was given a verbal counsel that stated, "[Staff S] was pulled from the floor and I spoke with her about language and demeanor. This was a coaching opportunity since this was the first time I had heard or had a complaint filed regarding her language. She assured me at the time of coaching she would watch her language on the floor and in front of coworkers and patients". The nurse was not removed from patient care during the investigation.

During a concurrent interview on 01/05/17 at 9:15 AM with Staff II, Director of Patient Safety, and Staff RR, Executive Director of Quality and Patient Safety, Staff II stated that the events with Patients #74, #75 and #78 were not identified as abuse. Staff II stated that the events should have been identified as abuse and staff should have been removed from patient care during the investigations.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on video/audio recording review, interviews, record reviews, and policy reviews, the facility failed to prevent, recognize and investigate abuse of one of one current patient (#47) on the Behavioral Health Unit (BHU), when a nurse had a physical altercation with the patient. Staff members, department management and hospital leadership were aware of this altercation. The facility also failed to begin immediate staff education regarding abuse and neglect. The facility failed to report abuse/neglect to the State Agency (SA) for investigation for four (#75, #74, #76 and #78) of 21 discharged patients reviewed. These failures had the potential to place all patients in the facility at risk for their safety from abuse or neglect by staff members. The facility census was 433, the Behavioral Health Unit census was 24.

Findings included:

1. Record review of the facility's policy and procedure titled, "REPORTING PATIENT ABUSE AND NEGLECT CAUSED BY A CO-WORKER," dated 11/2016, showed the following:
- The facility prohibits all forms of abuse and neglect from co-workers. The hospital must ensure that patients are free from all forms of abuse and neglect.
- The purpose of this policy is to uphold the mission and values of the hospital by appropriately identifying and responding in situations of suspected abuse or neglect.
- Abuse means the willful inflection of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.
- We must create and maintain a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
- We must protect our patients from abuse during investigation of any allegations of abuse or neglect.
- We ensure, in a timely and thorough manner, objective investigation of allegations of abuse or neglect.
- We must assure that any incidents of abuse or neglect are reported and analyzed, and appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.
- Co-workers will report witnessed abuse or neglect, alleged abuse or neglect, and signs of suspected abuse or neglect caused by a co-worker. Alleged abuse and neglect is defined as any report from family members, patients, or co-workers of abuse and/or neglect. These must be reported even if the co-worker does not believe the allegation is true.
- The hospital co-workers including contract and agency staff must report abuse and neglect to the charge nurse and/or their manager upon reported, suspected, or witnessed abuse or neglect.
- The Charge Nurse/Department Manager receiving the report will: Assess the patient; Co-worker will be immediately removed from patient care if abuse is suspected or witnessed.
- Interview the co-worker upon report or discovery of the abuse or neglect concern.
- Primary physician will be notified to examine the patient if signs of abuse are present.
- Charge nurse/Department Managers will escalate to Vice President/Administrator on Call to initiate the investigatory leave.
- Co-worker(s) alleged to have committed abuse or neglect will be escorted from the hospital premises pending further investigation.
- The Director of Patient Safety will report the witnessed abuse or neglect, alleged abuse or neglect or the suspected abuse or neglect by telephone to the State agency when the preliminary investigation has been completed within 24 hours of discovery.
- Director of Patient Safety will report confirmed abuse or neglect by telephone to State agency at the completion of the formal investigation, not to exceed 72 hours of discovery.
Documentation to be submitted to the SA:
- Copy of all policies and procedures which apply to the issue reported.
- Copy of the hospital's internal investigation of the event and corrective actions taken to protect the patient(s) involved and all other patients. This should include copies of all interviews, written statements, emails, etc. that document witness accounts of the event or were pertinent to the investigation.

2. Record review of the facility's document titled, "Self Report Guidelines," dated 02/28/15, showed the following direction:
Potential Incidents to Self Report:
- Patient Abuse/Neglect (sexual, physical, verbal) by another patient, employee, vendor, or visitor.
- Hospital Self Reports to the State Agency: There are several benefits to patient safety that may occur as a result of hospitals reporting incidents of patient abuse/neglect. These reports:
- Provide the hospital an opportunity to demonstrate compliance with regulations prior to, or in lieu of, an onsite investigation by the State Agency (SA).
- Provide an opportunity for the hospital and SA to communicate in a timely manner to assure the investigation is thorough and patients are protected.
- Provide for timely investigation of incidents where the alleged perpetrator (AP) is an employee and referral for potential inclusion on the Employee Disqualification List (EDL) may be required. Failure of the hospital to self-report employees who have abused/neglected patients allows the AP/employee to change employment and abuse patients in other hospital or health care settings.
- Whenever possible, please initiate the self report within 24 hours of a reportable incident.

3. Record review of Patient #47's medical record showed that he was a [AGE] year old male who was admitted to the facility's Behavioral Health Unit (BHU) on 01/03/17 at 4:41 AM, with a diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal thought processes and inappropriate emotions), hearing voices, and delusional (made statements that were not true). The record on 01/03/17 also showed that:
- The patient was a voluntary admission;
- He had been physically aggressive towards his wife earlier in the day;
- When the patient arrived on the BHU he became oppositional (angry/irritable)and defiant when staff requested to take his vital signs;
- He refused to move away from the nurse's station door;
- He spit on Staff O, Registered Nurse (RN), then struck Staff O in the face with his fist;
- The patient continued to punch the nurse during take down and was manually restrained on the floor until security arrived;
- The patient was taken to the Acute Care Area (ACA, an area in this psychiatric unit for highly agitated, violent, and acutely psychotic patients), medication was administered, and the patient continued to scream nonsensical (made no sense) rambling;
- Staff O documented care of the patient until the end of his shift at 7:00 AM.
[The record contained no documentation related to patient condition after this altercation or that the patient's physician was notified per the facility policy.]
- At 12:37 PM, Staff RR, Medical Doctor (MD), documented a physical examination (part of every admission to the BHU) that showed, "mild periorbital (surrounding the eye) bruising and swelling noted on the left" but, in general, the patient did not cooperate with the examination;
- At 2:52 PM Staff P, RN documented that patient was uncooperative, aggressive, and threatening to staff and was restricted to ACA.

4. Record review of Video/Audio recording of Patient #47 and staff interactions in the BHU on 01/03/17 from 4:52 AM to 5:06 AM showed:
- At 4:52 AM the patient stood in front of the nurse's station door (locked) talked to Staff PP, Behavioral Health Technician (BHT) through a solid glass window. The BHT requested that the patient to move away from door so she could come out and take his vital signs. The patient was defiant;
- Staff O, RN, moved in front of the BHT, opened top half of door and requested that the patient sit down so vital signs could be taken. Staff O opened the bottom half of door and continued to explain that the vital signs must be taken.
- At 4:53 AM Staff O pushed the vital sign machine between him and the patient.
- The patient stated he did not want to be touched, asked Staff O if he was going to rape him;
- Staff O responded, "Nobody is going to touch you we just need to get your vital signs, and, excuse me, no, ain't nobody here going to rape anyone, have a seat so we can get your vital signs;"
- Staff O stated six more times that vital signs must be obtained;
- The patient screamed something unintelligible and spit at Staff O, RN (sputum landed on RN's chest);
- RN stated, "Don't ever spit on me again" and began to move forward toward the patient;
- The patient lifted his right arm and the RN put his left hand on patient's arm and pushed down;
- The patient punched the RN in the face with his left fist;
- The RN charged forward and struck the patient in the face/neck area, pushed patient backwards to a wall and had his arms under the patient arms in a bear hug position. The patient continued to strike the back of the RN's head and neck area;
- Staff PP was present and attempted to assist with control of patient;
- The RN pivoted and twisted the patient's body and slammed the patient to the floor with the RN on top;
- At 4:54 AM Staff O stated, "That was a major mistake, I will press charges, guaranteed;"
- At 4:54 AM patient remained in physical hold, on the floor as RN and BHT held patient down;
- Patient moaned, "Do you love me, do you love me, and continued to struggle;"
- At 4:54 AM second BHT arrived;
- At 4:55 second RN arrived;
- At 4:57 AM three security officers arrived;
- At 4:59 AM security moved patient to the ACA;

Continued review of Patient # 47's medical record showed that as of 01/06/17 at 10:00 AM the patient remained in the ACA, his behavior and demeanor remained unchanged.

During an interview on 01/06/17 at 9:25 AM Staff O stated that:
-He was called to the nurse's station door by Staff PP who was afraid because the patient wouldn't move away from the door so she could get vital signs;
- The patient had only been on the unit for a few minutes and security had warned him that the patient was prone to violent outbursts;
- "The patient postured in an aggressive position but I had to get him away from the door;
- "The patient asked if he would be raped and then he spit on me, and punched me in the face;
- "I pushed him to get him away from the door, then I held him and took him to the floor;
- "He tried to bite me so I held his face to the floor;
- "A Code 10 (patient out of control- call for help) was called and some other staff came and then security arrived and took the patient to the ACA;
- "I checked his orders and medicated the patient;
- "I was agitated about getting spit on and I knew the patient tried to provoke me;
- "I probably should have kept security around for a while after they brought the patient from the Emergency Department, or maybe kept the door closed until he calmed down;
- "I did not see any injury to the patient; I did not contact the doctor. To my knowledge the doctor was not contacted."

During an interview on 01/04/17 at 3:30 PM Staff E, Manager of Behavioral Health, after the video was viewed stated, "I think that went as well as could be expected, he tried to keep the patient from going into the nurses station, the take down went pretty good." Staff E stated that Staff O continued to care for Patient # 47 until the end of his shift on 01/03/17 at 07:00 AM. Staff E stated that no investigation had started, that she had not viewed the video until the surveyor requested, and that the police had come to make a report. Staff E stated that she was previously aware of this altercation.

During an interview on 01/04/17 at 4:00 PM Staff F, Director of Nursing, stated that she had not seen the video until the surveyor requested it, no investigation had been initiated, and she thought the RN was a little aggressive in the interaction with Patient # 47. Staff F stated that she was previously aware of this altercation.

During a telephone interview on 01/05/16 at 3:00 PM Staff PP stated that:
- "The patient was asked to move away from the door so I could get his vital signs;
- "The patient stood at the door with a blank look on his face;
- "Staff O came over and opened the door, with no warning the patient spit on and hit Staff O in the face;
- "Staff O moved the patient away from the door and got the patient to the floor."

During a telephone interview on 01/05/17 at 2:40 PM Staff OO, RN, stated that:
- The patient arrived with security who reported that the patient was unpredictable;
- The BHT tried to get vital signs but the patient wouldn't move away from the door;
- Staff O talked to the patient and tried to get him to sit down;
- The patient spit and struck Staff O in the face;
- Staff O got the patient in a bear hug and moved him to the floor;
- They did the best they could;
- Security arrived and took the patient to the ACA;
- No mock drills were held on the unit, just annual education.

During a telephone interview on 01/05/17 at 5:25 PM Staff QQ, BHT, stated that;
- He arrived after the Code 10 was called and assisted with control of the patient while on the floor;
- Code 10's are unusual, staff can usually get the patients under control without them;
- This seemed like a textbook event, everything ran smoothly, security arrived quickly and moved patient to the ACA;
- All staff in the area are trained on all phases of de-escalation, management of aggression and take downs;
- To his knowledge there were no mock drills done for training on Code 10's.

During an interview on 01/06/17 at 10:45 AM Staff NN, RN, stated that:
- He responded to the Code 10 after he finished with the patient he cared for;
- When he arrived he saw three people held the patient down;
- Staff O had a cut on his face;
- He went to the patient's head and tried to talk to him and calm him down and hold his arm;
- He stated that this was a unique situation because staff are usually able to control the patients;
- Staff get a lot of training about aggression management, de-escalation and physical control if needed.

The facility failed to protect patient's when staff failed to follow policy and report witnessed abuse, proactively identify and investigate a potential abuse situation, and assess a patient after a physical altercation. The faciity failed to provide education to staff regarding abuse/neglect.

5. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed the following:
- On 07/16/16 in the Emergency Department: Staff U, RN, slapped patient (#75) in an attempt to keep him from removing his Intravenous (IV, within the vein) line.
- The patient's wife stated that the nurse slapped his hand hard.
- Staff U admitted slapping the patient for his own good.
- The Corrective Action Form completed after the investigation showed that Staff U continued to care for the patient and was not removed from patient care. She was given a verbal corrective action that stated, "Spoke with [Staff U] about alternative methods that can be used to prevent patients from pulling out lines, drains and airways".
This substantiated physical abuse was not reported to the State Agency (SA).

6. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed the following:
- On 11/01/16 in the Medical Intensive Care Unit (MICU), Staff T, Registered Respiratory Therapist (RRT), yelled at Patient # 74, "Well if you don't like it, tell your doctor not to order it".
- The patient's family witnessed the incident and filed a complaint.
- The facility investigated the complaint and found it to be substantiated. Staff T admitted that she yelled at the patient.
- Staff T received a verbal discussion about the incident but remained at work during the investigation.
The substantiated verbal abuse was not reported to the SA.

7. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed that on 11/03/16 in the BHU, Unit A, Patient #77 entered Patient #76's room and "Punched him in the face". This happened on two different occasions on the same day and the report stated: "Restless patient entered another patient's room and punched him in the face on his left cheek. No apparent injury".
The patients' were not assessed for injury by a medical professional after an observed physical assault directly to the patient's face. The physical assaults were not identified as physical abuse.
The physical abuse of Patient #76 was not reported to the SA.

8. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed the following:
- On 11/04/16 in the BHU, Unit A in the seclusion room, Patient #77 assaulted Patient #76 who was also in seclusion. The report stated, "Another patient [Patient #76] was awaiting his food by the nurses door and suddenly Patient #77 got up and did a tackle movement on the other patient. The other patient was close to the wall so he didn't fall and was not injured in any way. Staff had to pull Patient #77 off of Patient #76 then Patient #77 went back to eating his meal.
- The patients were not assessed for injury.
- The staff did not identify the patient to patient assault as physical abuse.
The physical abuse was not reported to the SA.

9. Record review of the facility's document titled, "Abuse - Neglect Events," dated 07/01/16 through 12/31/16, showed the following:
- On 11/07/16 on the Surgical Unit Patient #78 reported that Staff S, RN, threatened to "Beat the ass" of a male staff member.
- The RN admitted that she made this statement.
- The RN remained in patient care during the investigation. The facility described the event as "Behavioral" and was not identified as verbal abuse. The nurse was given a verbal counsel that stated, "[Staff S] was pulled from the floor and I spoke with her about language and demeanor. This was a coaching opportunity since this was the first time I had heard or had a complaint filed regarding her language. She assured me at the time of coaching she would watch her language on the floor and in front of coworkers and patients".
The substantiated verbal abuse was not reported to the SA.

During a concurrent interview on 01/05/17 at 9:15 AM with Staff II, Director of Patient Safety, and Staff RR, Executive Director of Quality and Patient Safety, Staff II stated that the events with Patients #74, #75, #76, #77 and #78 were not identified as abuse and were not identified as substantiated by the event committee. She stated, "I'm beginning to understand what substantiated means". Staff II stated that the events should have been identified as abuse and should have been reported to the SA for investigation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
Based on audio/video recording review, observation, interviews, record reviews and policy review the facility failed to obtain physician restraint/seclusion physician orders when one of one current patient (#47) was physically held and transported to seclusion during an altercation and one of one current patient (#48) and one of one discharged patient (#95) were placed in seclusion for behavioral concerns.
The failure to obtain physician orders to place a patient in restraint/seclusion puts all patients on the Behavioral Health Unit (BHU) at risk for unsafe care. The facility census was 433. The BHU census was 24.

Findings included:

1. Record review of facility policy titled, "Restraint and Seclusion," dated 03/05/14 showed direction for staff that:
- Seclusion is defined as the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving;
- Restraint is defined as any manual method or physical devise that a patient cannot easily remove, that restricts freedom of movement or normal access to one's body;
- Documentation related to restraint/seclusion episodes should include each event, circumstances that led up to restraint/seclusion, rationale for the restraint/seclusion, notification of family, patient's response to restraint/seclusion, criteria to discontinue, 15 minute monitoring, any injury;
- Registered Nurses (RN) who have been trained may make the determination to seclude or restrain a patient on an emergency basis and obtain order from the attending psychiatrist as soon as possible after initiation.

2. Observation on 01/04/17 at 10:55 AM of the BHU "A" hall showed a room behind the nurse's station. This room was referred to as the Acute Care Area (ACA). The ACA had four small rooms with a bed in each room. Each room was lockable. There was no closet/storage, chair or sink in the rooms. There were no windows to the outside in these rooms. There was an ante room area in front of the four rooms about 10 feet by 20 feet with a few chairs bolted to the floor. There was a bathroom with entry from the ante room. There was a row of windows that enabled view of the ACA from the nurse's station. There was a locked door between ACA and the nurse's station.

Upon entry into the nurse's station Patient #47 was standing in ACA, behind the locked door, his face very close to the window in the door, and he shouted multiple times, "I have psychosis."

During an interview on 01/04/17 at 11:15 AM Staff E, RN Manager of BHU, stated that:
- Patients in the ACA are not in seclusion. If they were locked into the individual rooms, that would be seclusion," but we never do that";
- Patients cannot get out of the ACA, but all staff have a key to get into that area;
- The patient's eat their meals in that area;
- Patients are placed in that area if they are acting out, intrusive, aggressive, for their safety from other patients, for other patient's safety
for staff safety and other reasons;
- Physicians can write an order for a patient to be placed in this area but nurses can independently decide that a patient can be place there for behavioral reasons;
- "We do not get an order for restraint/seclusion to put patients in this area;
- "We rarely put more than one patient at a time in the ACA;
- "The last episode of restraint/seclusion that we had to get an order for was on 10/01/16;
- "I have been here for over ten years and we have never considered patients that were placed into the ACA as being in seclusion;
- "Patients on the general BHU are locked in and can't leave, it's just like that."

During an interview on 01/04/17 at 11:20 AM Staff Q, Behavioral Health Technician (BHT), seated in front of a monitor in the nurses station, stated that the ACA was always monitored by camera.

During an interview on 01/04/17 at 11:25 AM Staff MM, BHT, stated that a doctor can write an order for a patient to be placed into the ACA, but an RN can decide also, they don't need permission to place a patient there. Some patients are moved into the area physically (by force). Security would be called to do that.

3. Record review of video/audio recording of Patient #47 and staff interactions in the BHU at 01/03/17 from 4:52 AM to 5:09 AM showed:
- The patient screamed something unintelligible and spit at the RN (sputum landed on RN's chest);
- RN stated, "Don't ever spit on me again" and began to move forward;
- The patient lifted his right arm and the RN put his left hand on patient's arm and pushed down;
- The patient punched the RN in the face with his left fist;
- The RN charged forward and struck the patient in the face/neck area, pushed the patient backwards to a wall and had his arms under the patient arms in a bear hug position. The patient continued to strike the back of the RN's head and neck area;
- Staff PP was present and attempted to assist with control of patient;
- The RN pivoted and twisted the patient's body and slammed the patient to the floor with the RN on top;
- At 4:54 AM patient remained in physical hold, on the floor as RN and BHT held patient down;
- At 4:54 AM second BHT arrived, at 4:55 second RN arrived;
- All staff were involved in physically keeping the patient on the floor;
- At 4:57 AM three security officers arrived;
- At 4:59 AM security moved the patient to bed in ACA;
- Security physically held the patient down on bed until 5:09 AM.

Record review of Patient #47's current medical record on 01/04/17 at 2:35 PM showed no restraint order related to the physical hold event of 01/03/17 at around 5:00 AM.

During an interview on 01/05/17 at 10:15 AM Staff RR, Executive Director of Quality and Patient Safety, stated that after review of the video, the event was definitely a restraint and an order should have been obtained.

During an interview on 01/04/17 at 4:00 PM Staff F, Director of Nursing, stated that the event was definitely a restraint and an order should have been obtained. Staff F stated that the ACA is like a little locked Intensive Care Unit where patients can't leave, it's not seclusion.

During an interview on 01/06/17 at 8:55 AM Staff F stated that on 01/05/17 at 7:00 PM a physician order was written for Patient #47 to be in seclusion in ACA.

4. Record review of current Patient #48's "Shift Narrative" (area in the medical record where staff can make freehand notes about patient condition, changes and concerns), showed that on 12/19/16 at 4:06 PM Staff TT, RN, documented that:
- Patient rated her anxiety and depression at 10 (highest possible);
- Patient was very manic (impulsive speaking fast, disorganized) and said she knew other patients are cops;
- Patient called one patient a bitch;
- Patient then started screaming and yelling;
- Patient was moved into the ACA because she was not able to control herself.

Record review of Patient #48's Physician Progress Note showed that on 01/03/17 at 5:00 AM the patient was moved to the ACA for her own safety due to agitated and violent peer.

Patient had been in ACA for 15 days with no order for seclusion.

5. Record review of Patient #95's "Shift Narrative" showed that on 12/26/16 at 1:11 PM, Staff SS, RN, documented:
- Patient #95 had been observed going into peer's room and had been asked and redirected frequently not to do this;
- Patient had been observed sitting on another patient's bed and stroking his arm;
He was firmly redirected not to go into that room and it was not
appropriate to do such activity;
- Patient responded that he would stay out of the room and not 15 minutes later he was found kneeling at this patient's bedside;
- He was placed on Sexually Acting Out (SAO) precautions and put into the ACA.

On 12/28/16 at 4:48 AM Staff O documented in the "Shift Narrative,":
- Patient was quiet, pleasant and cooperative at this time;
- Patient expressed concern about being directionally disoriented in the ACA;
- Patient expressed desire to move from ACA back to the "A" unit with other patients;
- Patient was advised that the doctor would need to decide that.

On 12/28/16 at 10:46 AM Staff P, RN, documented in the "Shift Narrative" that patient was moved to "A" unit and stated that his directional confusion was gone.

During these three events there were no other patient's in the ACA. When Patient #47 was placed in this unit, Patient #48 had to be moved out. The facility used the ACA as seclusion to isolate patients because of behavioral acts. The facility did not recognize this action as seclusion so no orders or other restraint monitoring was put into place.