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.

JOHNSON MEMORIAL HOSPITAL 201 CHESTNUT HILL ROAD STAFFORD SPRINGS, CT 06076 May 22, 2012
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on a review of clinical records, interviews and review of facility documentation for two of two patients (Patients #5 and 9) that required medication, the hospital failed to ensure that medications were administered as prescribed. The findings include:

a. Patient #5 was transferred from Hospital #2 on 5/20/12 at 5:18 P.M. via ambulance with diagnoses that included major depression with suicidal ideation, and alcohol dependence. Review of the physician orders, dated 5/20/12 at 6:00 P.M., directed the staff to administer Atenolol 25 milligrams (mg) by mouth every four hours as needed for blood pressure greater than 130/90 or heart rate greater than 100 beats per minute. Interview and chart review with Nurse Director #1, on 5/21/12 at 10:05 A.M., identified that on 5/20/12 at 5:00 P.M. the patient's blood pressure was 142/93 and his/her heart rate was 105 beats per minute and at 9:30 P.M. his her blood pressure was 165/82 and his/her heart rate was 113 beats per minute. Review of the record failed to identify that Patient #5 received the Atenolol as ordered and/or that the physician/provider was notified.

b. Patient #9 arrived at the Emergency Department (ED) on 5/16/12 at 6:19 P.M via ambulance and in police custody for alcohol intoxication with a past medical history that included post-traumatic stress disorder, schizoaffective disorder and alcohol dependence. Review of physician orders, dated 5/18/12 at no specific time, directed the staff to administer Tegretol 200 mg by mouth at night for four nights then administer Tegretol 200 mg by mouth two times a day(to start on 5/22/12). Review of hospital documentation, dated 5/21/12 at 10:55 P.M., identified that the night dose of Tegretol was missing. Interview and review of the documentation with Nurse Director #1, on 5/22/12 at 11:28 P.M., identified that he/she is not aware of this information. Subsequent interview with Nurse Director #1 and the Director of Accreditation and Regulatory Affairs, on 5/22/12 at 2:30 P.M., identified that LPN #1 administered an additional dose of Tegretol to Patient #9 on 5/21/12.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on review of the clinical record, interview and review of hospital documentation for one patient (Patient #11) that was discharged , the hospital failed to ensure that the medical record was completed. The finding includes:

a. During a tour of the Health Information Management (HIM) Department, on 5/22/12 from 11:37 A.M. to 12:10 P.M. and from 1:20 P.M. to 2:00 P.M. it was identified that Patient #11's record was not completed after thirty days. Review of Patient #11's record with the Director of HIM, on 5/22/12 during the tour, identified that MD #6 had not signed a verbal order dated 3/25/12. Review of the hospital's Medical Staff Bylaws, Rules and Regulations, identified that verbal orders are signed within twenty-four hours and if not signed within that time period the chart is identified as incomplete.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on a review of clinical records, interviews, review of facility documentation and policies, the facility failed to ensure a safe environment and/or that patient rights were promoted and/or protected.


Please refer to A 129, 132, 144, 145, 146, 174 and 178.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of the clinical record, facility documentation, policy, and interview the facility failed to inform the patient of the right to leave the hospital. The finding includes the following:

a. Patient #10 was admitted to the medical unit with pancreatitis and a history of alcohol abuse on 2/21/12. Review of the clinical record indicated that the patient was alert and oriented. The patient was evaluated by psychiatry on 2/21/12 and determined to be fully oriented with fair judgement and insight. There were no grounds for psychiatric admission. On 2/23/12, the patient was placed on constant observation as the patient was a flight risk and fall risk absent a physician's order. Review of the Hendrich fall assessments completed daily during the period of 2/23/12 through 2/26/12 identified that the patient scored a "2" (high fall risk is a score of 5 and greater). Review of the record failed to detail an assessment that determined the patient was a flight risk in accordance with policy. Review of the physician and/or Social Worker notes failed to identify that the patient required constant observation. The constant observation sheets dated 2/25/12 at 7:00 PM identfied that the patient "tried to leave the room", and on 2/26/12 at 4:00 PM was "attempting to leave the room". The clinical record failed to reflect that the option of leaving against medical advice was reviewed with the patient. Interview with Director #2 on 5/22/12 at 11:45 AM indicated that the patient was on constant due to being a flight risk and for safety.

Review of hospital documentation indicated that on 3/16/12, Patient #10 called the hospital to report that during the hospitalization on [DATE]-[DATE], s/he was maintained at the hospital against his/her will.

The Patient Rights policy identfied that the patient has the right to leave the hospital even against the advice of a physician.

Review of the Observation Status of Patients policy identfied that all patients will be assigned a level of observation required for their safety and therapeutic needs. This will be determined by the psychiatrist with input from the charge nurse and the multidisciplinary team members. Close Observation is defined as continuous visual contact with the need for proximity to be determined by the RN. Patients whose behavior presents a clinical picture of potentially significant, problematic behavior without continuous staff presence should be placed on Close Observation status.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on observation, review of clinical records, documentation, facility policy, and interviews, for three of eleven patients (Patients #5, 6 and 9) that were admitted , the hospital failed to ensure that the patients were provided information about formulating advanced directives. The findings include:

a. Patient #5 was transferred from Hospital #2 on 5/20/12 at 5:18 P.M. via ambulance with diagnoses that included major depression with suicidal ideation, and alcohol dependence. Review of the registration record, dated 5/20/12 at 5:18 P.M., identified that the patient did not have advanced directives. Review of the Advanced Directives Worksheet, dated 5/20/12, and completed by Registration Staff #1 identified that the patient had no advanced directives and documentation failed to reflect that Patient #5 and/or family members were provided with information about formulation of advanced directives. Interview and review of Patient #5's clinical record with the Director of Registration, on 5/21/12 at 1:55 P.M., identified that registration staff routinely ask each patient/family member if they want information about formulation of advanced directives although this information is lacking.
In addition, review of the nursing patient assessment, dated 5/20/12 at 5:00 P.M., identified that Patient #5 did not have advanced directives. The record failed to reflect that Patient #5 and/or family members were provided with information about formulation of advanced directives. Interview and review of the clinical record with Nurse Director #1, on 5/21/12 at 10:05 A.M., failed to identify that the patient was provided information pertaining to formulation of advanced directives.

b. Patient #6 arrived at the Emergency Department (ED) on 5/14/12 at 12:46 A.M. and was admitted for alcohol and opiate detoxification. Review of the nursing patient assessment, dated 5/14/12 at 8:15 P.M., identified that Patient #6 did not have advanced directives. The record failed to reflect that Patient #6 and/or family members were provided with information about formulation of advanced directives. In addition, review of the Advanced Directives Worksheet, dated 5/19/12, and completed by Registration Staff #1 identified that the patient had no advanced directives. Documentation failed to reflect that Patient #6 and/or family members were provided with information about formulation of advanced directives.

c. Patient #9 arrived at the Emergency Department (ED) on 5/16/12 at 6:19 P.M via ambulance and in police custody for alcohol intoxication and a past medical history that included post-traumatic stress disorder, schizoaffective disorder and alcohol dependence. Review of the nursing patient assessment, dated 5/17/12 at 3:30 P.M., identified that Patient #9 did not have advanced directives. The record failed to reflect that Patient #9 and/or family members were provided with information about formulation of advanced directives. In addition, review of the Advanced Directives Worksheet, dated 5/17/12, and completed by the registration staff identified that the patient had no advanced directives. Documentation failed to reflect that Patient #9 and/or family members were provided with information about formulation of advanced directives.

Observation, on 5/22/12 at approximately 8:22 A.M., identified that in the hospital lobby a binder contained information titled, "Your Rights to Make Health Care Decisions", dated 1993 in the English language.

Review of the policy and procedure, titled Advanced Directives, identified that at registration every patient over age eighteen will be asked if they have executed an advanced directive and will provide information about formulation of advanced directives if requested.

Review of a second policy and procedure, titled Patient Rights and Responsibilities, identified that each patient has the right to formulate and advance directive
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, interviews and review of facility policy for five of ten patients (Patient 8, 7, 4, 2, and 9) reviewed, the hospital failed to reassess the patient prior to discontinuation of monitoring checks to determine the individual needs of the patient and/or maintain a safe environment. The findings include the following:

a. Patient #8 was admitted on [DATE] with bipolar disorder and mild mental retardation. Review of the admission order dated 5/16/12 directed that the patient be monitored every fifteen minutes for twenty-four hours. Review of the psychiatric admission note identified that the patient's insight and judgement was fair to poor. The clinical record failed to reflect that the patient was reassessed prior to discontinuation of fifteen-minute checks to determine the individualized needs of the patient. Review of the Master Treatment Plan (MTP) on 5/21/12 indicated that the patient had active problems that included Suicidal ideation, post-traumatic stress disorder and potential for injury to self or others with interventions that included order level of observation as appropriate, monitor the patients mood liability and engage with staff. The MTP failed to identify specific interventions to ensure the patients safety and/or identify the level of monitoring the patient required.

Review of a nurse's note dated 5/20/12 at 11:55 PM identfied that another patient (#9)reported that he/she acted as a lookout so Patients #7 and 8 could engage in oral sex. The note indicated that Patient #8 was subsequently placed on close observation for protection.

Interview with Nursing Director #1 on 5/21/12 stated that all patients are placed on fifteen minute checks for the first twenty-four hours and then monitored every thirty-minutes unless otherwise specified.

b. Patient #7 was admitted on [DATE] with depression and substance abuse. Review of the admission orders dated 5/18/12 directed fifteen-minute observation for 24 hours. Review of the MTP dated 5/19/12 identfied problems that included suicidal ideation with interventions that included in part, implement appropriate level of observation. The clinical record failed to reflect that the patient was reassessed to determine level of observation, prior to discontinuation of fifteen-minute checks. Review of a nurse's note dated 5/20/12 at 11:55 PM identfied that another patient (#9) reported that he/she acted as a lookout so Patient #7 and 8 could engage in oral sex on 5/19/12 during the 3PM-11PM shift. The hospital failed to ensure that the necessary supervision was provided to Patient #7 and #8 to prevent a sexual encounter.

c. Patient #4 was admitted on [DATE] with bipolar disorder. Review of the admission order dated 5/14/12 directed fifteen-minute monitoring checks for twenty-four hours. The clinical record failed to reflect that the patient was reassessed prior to discontinuation of fifteen-minute checks to determine the individualized needs of the patient. Review of the MTP on 5/21/12 failed to reflect the patients observational level.

d. Patient #2 was admitted on [DATE] with depression and polysubstance abuse. Review of the admission order dated 5/4/12 directed fifteen-minute monitoring checks for twenty-four hours. Review of a nurse's note dated 5/4/12 identified that the patient was placed in seclusion due to running out of room and attempting to leave and was subsequently placed on close observation. The clinical record indicated that constant observation was discontinued on 5/6/12 at 3:00 PM. The clinical record failed to reflect that the patient was reassessed prior to discontinuation of the constant observation to determine the individualized needs of the patient.

e. Patient #9 arrived at the Emergency Department (ED) on 5/16/12 at 6:19 P.M via ambulance and in police custody for alcohol intoxication and a past medical history that included post-traumatic stress disorder, schizoaffective disorder and alcohol dependence. Patient #9 was admitted to South 2. Review of the physician orders, dated 5/17/12 at 5:55 P.M., directed the staff to monitor Patient #9 on a special observation status every fifteen minutes for twenty-four hours. Review of the clinical record, dated from 5/17/12 to 5/20/12 at 11:45 P.M., identified that staff monitored Patient #9 every fifteen minutes although no further orders for such monitoring was prescribed by the physician in accordance with facility policy.

Review of the facility policy indicated all patients will be assigned the level of observation required for their safety and therapeutic needs. This will be determined by the psychiatrist in conjunction with the charge nurse. Review of the facility policy indicated that special observation (every 15 minutes, close and 1:1) is initiated with an order by a clinician. The RN will ensure that the patients treatment plan reflects the observational status.

Review of a policy and procedure, titled Patient Rights and Responsibilities, identified that each patient has the right to personal safe environment and to receive care in a safe environment.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, facility documentation, review of policies/procedures, and interviews, the hospital failed to ensure that staff immediately reported an allegation of abuse for one patient (#1) and/or that incidents/allegations involving four patients (#7 #8, 9 and #10) were thoroughly investigated. The findings include the following:

a. Patient #1 was admitted on [DATE] with diagnoses that included bipolar disorder. The patient was a transfer to the facility on a Physicians Emergency Commitment (PEC). Review of the MTP identified problems that included psychosis/mania and potential for injury to self or others. Interventions to address these problems included monitor behavior, provide support with clear limit setting and expectation to maintain safe behavior, and encourage use of time out. Interview with MD#1 on 5/16/12 at 11:00 AM indicated that Staff Person #1 and 2 notified him (a few days following the incident) that they observed Director #1 place both hands around Patient #1's neck in a tight manner on 4/3/12. MD #1 stated that he encouraged staff to report the concern, however, they were fearful of losing their jobs. MD #1 identfied that he subsequently questioned Patient #1 about the allegation and was informed by the patient that Director #1 did place her hands around his/her neck and expressed agitation over previous physical contact that involved squeezing the patient's arms. MD #1 brought these concerns to the VP of Medical Affairs who directed MD #1 to obtain written statements. MD #1 provided the VP of Medical Affairs these written statements on 5/11/12.

Director #1 stated during an interview on 5/16/12 at 10:00 AM that she had two altercations with Patient #1, once when the patient's behavior had escalated and the patient raised his/her arms and Director #1 placed hands on the patient's upper arms and told the patient s/he could not hit anyone. And during the second encounter, Patient #1 lunged at Director #1 upon request to perform a mouth check following administration of as needed (prn) medication. The Director stated she placed a hand on the Patient's chest and told the patient to step back. Director #1 denied touching the patient's neck.

Interview with Staff Person #1 and #2 on 5/16/12 at 12:35 PM and 1:40 PM identified that they both witnessed the Director #1 place both hands on the patient's neck in a tight manner. Staff Person #1 and 2 stated the incident was not reported for fear of retribution. Interview with Staff Person #3 on 5/16/12 at 2:15 PM indicated that he/she observed Director #1 place a hand on Patient #1's chest with index finger and thumb on the patient's collar bone and assumed an incident report was completed as "something out of the ordinary" had occurred.

Interviews with Staff Person #4 and #5 on 5/16/12 at 2:30 PM and 2:40 PM respectively, identfied that they observed Nurse Director #1 to put his/her hands in the air, however, did not lie hands on the patient.

Interview with the VP of Medical Affairs on 5/22/12 at 1:00 PM identified that he became aware of the incident on 4/25/12 and went to report it to the VP of Patient Care Services however he/she was on vacation so he waited until 5/2/12 to report the incident.

Interview with the VP of Patient Services on 5/16/12 at 1:20 PM stated that she met with the VP of Medical Services on 5/2/12 and was informed of the 4/3/12 incident. The VP of Patient Services stated an investigation was initiated by interviewing staff about the demeanor of the unit. The VP of Patient Care Services did mention to staff interviewed that an incident occurred on the unit. Three staff interviewed stated that Patient #1 was aggressive and that Director #1 raised her hands but did not touch the patient. Four staff interviewed stated they were not on duty on 4/3/12. Further interview with the VP of Patient Care Services identfied that the investigation was not concluded as of 5/16/12.

Review of the MIDAS reports (incident report) failed to reflect that South 2 nursing staff reported this 4/3/12 event between Patient #1 and Director#1.

Review of the Hotline & Non-Retaliation policy identfied that no individual shall suffer retaliation or retribution for reporting in good faith any suspected misconduct or non-compliance. Concerns should be addressed with the individuals' immediate supervisor, department director or vice president. If uncomfortable with bringing concerns through the chain of command, Human resources, Security, and/or Corporate Compliance Officer may be contacted. In addition, a corporate Compliance hotline can be utilized anonymously.
Review of the Corporate Compliance Program directed that reports of suspected noncompliance must be reported promptly and the Corporate compliance officer and management investigates allegations of misconduct to determine whether a violation has actually occurred, assess the seriousness of the offense, and suggest corrective actions.

Although systems to report allegations of abuse were in place, staff failed to utilize these resources and as a result, the allegation of physical abuse was not reported immediately and/or acted upon immediately once Administration was notified on 4/25/12.

b. Patient #8 was admitted on [DATE] with bipolar disorder and mild mental retardation. Review of a nurse's note dated 5/20/12 at 11:55 PM identfied that another patient (#9) reported that he/she acted as a lookout so Patients #7 and 8 could engage in oral sex. The note indicated that Patient #8 was subsequently placed on close observation for protection.
Interview with the Nurse Director on 5/21/12 at 10:45 AM indicated that she believed the act had occurred. The Director indicated that he/she had been notified by staff on 5/20/12 at 11:45 PM and had discussed the situation with the supervisor on duty. The Nurse Director stated that an investigation had not been initiated as of 5/21/12 at 10:45 AM.

Interview with Supervisor #1 on 5/22/12 at 8:30 AM stated once notified of the incident on 5/20/12, she went to the nursing unit with a decision to place Patient #8 on one to one supervision for safety. Supervisor #1 stated that an investigation was not started because it was "bedtime".

Interview on 5/21/12 with Director #1 and the VP of Patient Care Services indicated that the facility does not have a policy for investigating patient to patient contact.

Although Supervisor #1 was notified of the incident, the facility failed to ensure that an investigation of the incident was initiated.

Review of the Rights of Patients and Guide to South 2 identfied that physical contact between patients is not allowed.

c. Patient #9 arrived at the Emergency Department (ED) on 5/16/12 at 6:19 P.M via ambulance and in police custody for alcohol intoxication with a past medical history that included post-traumatic stress disorder, schizoaffective disorder and alcohol dependence. Patient #9 was admitted to South 2. Review of the frequent observation record (fifteen-minute checks), dated 5/20/12 at 9:15 P.M., identified that Patient #9 was in a fight with Patient #8. Review of the progress notes, dated 5/20/12 at 9:30 P.M., reflected that Patient #8 threw ice at Patient #9; Patient #9 threw water at Patient #8 and then Patient #9 slammed a chair and was yelling expletives loudly.

Interviews with APRN #1, on 5/21/12 at 2:32 P.M. and 5/22/12 at 12:15 P.M., identified that s/he was informed that Patient #9 was agitated, however was not told of the specific incident between Patients #8 and 9.

Interview with RN #1, on 5/22/12 at 9:29 A.M., identified that on 5/20/12 a patient reported to MHW #2 who reported the information to RN #1 that Patients #8 and #9 were throwing paper at each other, then Patient #8 attempted to throw pieces of Italian ice at Patient #9, Patient #9 threatened to throw water at Patient #8, Patient #8 threw Italian ice at Patient #9 (in his/her face). Patient #9 left the area and returned with a cup of water and threw the water in Patient #8's face. RN #1 added that Patient #9 removed him/herself from the area, slammed a chair in the common area, was swearing loudly and APRN #1 was informed of the event and ordered Valium for Patient #9's agitation.

Interview with Nurse Supervisor #1, on 5/22/12 at 8:29 A.M., identified that RN #1 did not report any event that had occurred between Patients #8 and #9 on 5/20/12.

Interview and clinical record review with Nurse Director #1, on 5/21/12 at 11:40 A.M., identified that s/he was not aware of the event and an investigation had been started and/or completed.

Interview with the Vice President of Patient Care Services, on 5/21/12 at 12:04 P.M., identified that s/he was the administrator on call for 5/20/12 and was not informed that Patients #8 and 9 were involved in an event.

Although the facility submitted an immediate action plan to the Department on 5/18/12 to address reporting and investigating allegations, suspicion of patient abuse, and/or inappropriate staff behavior, the facility failed to ensure that the 5/20/12 incident that occurred between patient #8 and 9 was reported to supervisory staff as directed in the plan.

Review of a policy and procedure, titled Patient Rights and Responsibilities, identified that each patient has the right to personal safe environment, to receive care in a safe environment, to be free from all forms of abuse or harassment and are responsible for being considerate of the rights of other patients.

In addition, review of the Rights of Patients and Guide to South 2, dated 9/9/11, identified that the hospital reserves the right to expect that the patients will meet their responsibilities in maintaining a safe and therapeutic environment for patients.

d. Patient #10 was admitted on [DATE] with pancreatitis, and a history of alcohol abuse. Review of the clinical record indicated that the patient was alert and oriented. The consultation indicated that the patient was not appropriate for inpatient therapy, was competent and had refused detox programs. The clinical record indicated that on 2/23/12 the patient was placed on constant observation for flight/fall risks and remained on constant observation until discharged on [DATE].

Review of facility documentation on 5/22/12 indicated that on 3/16/12, Risk Management received a phone call from Patient #10 stating that while hospitalized in February of 2012, s/he was kept against his/her will and on 2/26/12, was "held" back by a nurse.

Review of facility documentation dated 3/27/12 identfied that Director #1 received a call from the State police related to the accusations voiced by the patient on 3/16/12. Director #1 subsequently sent an email to Director #2, the VP of Patient Services and the Director of QA regarding these allegations on 3/27/12.

Interview with Director #2 on 5/22/12 at 12:00 PM stated she first became aware of the patient's allegation on 3/28/12 and on that same day, interviewed the RN who worked on 2/26/12 during the 7:00 AM- 7:00 PM shift who stated that there was no physical restraints performed on the patient and that if any physical contact was made it was to assist the patient back to bed. Director #2 stated that she did not interview any other staff working on 2/26/12 to determine if the allegation occurred.

Review of the Patient Rights policy indicated that a member of Administration receiving communication of an inquiry of complaint related to patient services shall investigate the circumstance.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0146
Based on observation, interview and review of a policy and procedure, the hospital failed to ensure that the medical records were stored in a secured manner. The findings include:

a. During a tour of the Health Information Management (HIM) Department, on 5/22/12 from 11:37 A.M. to 12:10 P.M. and from 1:20 P.M. to 2:00 P.M. it was identified that sixty five boxes of patient records were stored unsecured and behind a wall, a location that was not observable by the HIM staff. The Director of HIM identified, during the tour, that the location of the identified records was the usual place.
Review of policy and procedure, titled Patient Rights and Responsibilities, identified that each patient has the right to confidentiality of medical records.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of clinical records, interviews and review of the facility policies and procedures for 2 of 2 patients restrained (#2 and #8) that the restraints were released and/or reduced at the earliest possible time. The findings include the following:

a. Patient #2 (MDS) dated [DATE] at 1:30 AM with angry outbursts, yelling and feelings of depression. The clinical record indicated that the patient was placed in four point restraints at 4:50 AM on 5/4/12 for running out of the room, and attempting to leave the ED. Review of the monitoring flow sheet indicated that the patient was threatening, biting and fighting when placed in restraints. The flow sheet indicated for the period of 5:45 AM through 6:30 AM the patient had no behaviors, verbal abuse and/or was quiet. The flow sheet failed to reflect that the patient's four point restraints had been decreased and/or removed until 6:35 AM.

b. Patient #9 arrived at the Emergency Department (ED) on 5/16/12 at 6:19 P.M via ambulance and in police custody for alcohol intoxication with a past medical history that included post-traumatic stress disorder, schizoaffective disorder and alcohol dependence. Review of the clinical record reflected that Patient #9 was attempting to leave; threatening to hurt others, swinging his/her arms around and was yelling loudly. The physician ordered, at 6:31 P.M., use wrist and ankle restraints. Review of the restraint flowsheet, from 8:15 P.M. to 1:15 A.M. (a period of five hours) reflected that Patient #9 was quiet. The facility staff failed to reduce the restraints during this period of time. Interview and review of the clinical record with Nurse Director #3, on 5/22/12 at 10:13 A.M., identified that the documentation does not reflect that staff trailed a restraint reduction for the time period identified.

Review of the facility policy indicated that patients must be released as soon as criteria are no longer met. Review of a policy and procedure, titled Patient Rights and Responsibilities, identified that each patient has the right to be free from restraints when not medically necessary.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the clinical record, interview and review of the facility policy the facility failed to ensure for 1 patient restrained that the face to face evaluation and re-assessment of the physician was documented based on the facility policy. The findings include the following:

a. Patient #2 (MDS) dated [DATE] at 1:30 AM with angry outbursts, yelling and feelings of depression. The clinical record indicated that the patient was placed in in four point restraints at 4:50 AM on 5/4/12 for running out of the room and attempting to leave the ED. Review of the restraint order form indicated that the verbal order for restraints was signed by the physician at 5:00 AM. The order reflected that the physician also signed the sections for re-order #1 and re-order #2 and the face to face assessment #2 prior to the patient needing further restraints.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a review of clinical records, facility documentation, policies, and interviews the facility failed to ensure that patients were assessed by a RN and/or that the MD was notified of incidents that occurred with five patients (#1, 2, 7, 8, and 9) and/or that a diagnostic test was completed in a timely manner for one patient (Patient #5). The findings include:

Cross Reference A-145
a. Patient #1 was admitted on [DATE] with diagnoses that included bipolar disorder. The patient was a transfer to the facility on a Physicians Emergency Commitment (PEC). Review of the MTP identified problems that included psychosis/mania and potential for injury to self or others. Interventions to address these problems included monitor behavior, provide support with clear limit setting and expectation to maintain safe behavior, and encourage use of time out. Patient #1 was a transfer to the hospital on [DATE] based on a Physicians Emergency Commitment (PEC). Interview with MD#1 on 5/16/12 at 11:00 AM indicated that Staff Person #1 and 2 notified him (a few days following the incident) that they observed Director #1 place both hands around Patient #1's neck in a tight manner on 4/3/12. MD #1 identfied that he subsequently questioned Patient #1 about the allegation and was informed by the patient that Director #1 did place her hands around his/her neck and expressed agitation over previous physical contact that involved squeezing the patient's arms.

Interview with Director #1 on 5/16/12 indicated that she had two physical interactions with Patient #1. Director #1 stated that on one occasion the patient's behavior had escalated and the patient raised his/her arms and Director #1 placed her hands on the patients upper arms and told the patient she could not hit anyone. The second incident involved Patient #1 lunging at Director #1 and she placed her hand on the Patient's chest and told the patient to step back. Review of the clinical record failed to identify that the physician had been notified after either incident and/or that the patient was physically and/or psychologically assessed.

b. Patient #2 was admitted on [DATE] with depression and polysubstance abuse. Review of the admission orders dated 5/4/12 identified that the patient was placed on every fifteen minute checks. Review of the nurse's note dated 5/4/12 identified that the patient was placed in seclusion due to behaviors and was placed on close observation. Review of the observational flow sheets indicated that on 5/5/12 at 4:30 PM the patient "fell ". Review of the clinical record failed to reflect that the patient was assessed for injury and/or that the clinician/MD was notified of the fall.

c. Patient #8 was admitted on [DATE] with bipolar disorder and mild mental retardation. Review of a nurse's note dated 5/20/12 at 11:55 PM identfied that another patient (#9) reported that he/she acted as a lookout so Patients #7 and 8 could engage in oral sex. The note indicated that Patient #8 was subsequently placed on close observation for protection. Interview with Director #1 on 5/21/12 at 10:45 AM indicated that she believed the act had occurred and that Patient #9 was "very reliable". Review of Patient #8's clinical record on 5/21/12 10:30 AM and on 5/22/12 at 11:00 AM failed to reflect that the physician/clinician had been notified of the incident and/or that the patient had been medically screened/assessed after the incident.


Review of Patient #7's clinical record on 5/21/12 10:30 AM failed to reflect that the physician/clinician had been notified and/or that the patient had been medically screened/assessed after the incident. Patient #7 was subsequently discharged on [DATE]. Interview on 5/22/12 at 12:15 PM with the APRN #1 stated she was on call on 5/20/12 and not notified of the incident. APRN #1 stated that she became aware of the incident "in passing".


d. Patient #9 arrived at the Emergency Department (ED) on 5/16/12 at 6:19 P.M via ambulance and in police custody for alcohol intoxication with a past medical history that included post-traumatic stress disorder, schizoaffective disorder and alcohol dependence. Patient #9 was admitted to South 2. Review of the frequent observation record (fifteen-minute checks), dated 5/20/12 at 9:15 P.M., identified that Patient #9 was in a fight with Patient #8. Review of the progress notes, dated 5/20/12 at 9:30 P.M., reflected that Patient #8 threw ice at Patient #9; Patient #9 threw water at Patient #8 and then Patient #9 slammed a chair and was yelling expletives loudly.

Interviews with APRN #1, on 5/21/12 at 2:32 P.M. and 5/22/12 at 12:15 P.M., identified that s/he was informed that Patient #9 was agitated, however was not told of the specific incident between Patients #8 and 9.

Interview with RN #1, on 5/22/12 at 9:29 A.M., identified that on 5/20/12 a patient reported to MHW #2 who reported the information to RN #1 that Patients #8 and #9 were throwing paper at each other, then Patient #8 attempted to throw pieces of Italian ice at Patient #9, Patient #9 threatened to throw water at Patient #8, Patient #8 threw Italian ice at Patient #9 (in his/her face). Patient #9 left the area and returned with a cup of water and threw the water in Patient #8's face. RN #1 added that Patient #9 removed him/herself from the area, slammed a chair in the common area, was swearing loudly and APRN #1 was informed of the event and ordered Valium for Patient #9's agitation.

Interview with Nurse Supervisor #1, on 5/22/12 at 8:29 A.M., identified that RN #1 did not report any event that had occurred between Patients #8 and #9 on 5/20/12.

Interview and clinical record review with Nurse Director #1, on 5/21/12 at 11:40 A.M., identified that s/he was not aware of the event.

Interview with the Vice President of Patient Care Services, on 5/21/12 at 12:04 P.M., identified that s/he was the administrator on call for 5/20/12 and was not informed that Patients #8 and 9 were involved in an event.

Review of the facility policy indicated that the Charge Nurse should notify the Administrative Manager of patient issues and safety issues as well as ensure that the multidisciplinary team is informed in an accurate, timely and consistent manners of issues.


e. Patient #5 was transferred from Hospital #2 on 5/20/12 at 5:18 P.M. via ambulance with diagnoses that included major depression with suicidal ideation, and alcohol dependence. Review of the physician orders, dated 5/20/12 at 6:00 P.M., directed the staff to complete an Electrocardiogram (EKG). Interview and chart review with Nurse Director #1, on 5/21/12 at 10:05 A.M., identified that the EKG had not been completed.
Review of the clinical record, on 5/22/12 at 10:35 A.M., with Nurse Director #1 identified that the EKG was completed for Patient #5 on 5/21/12 at 10:40 A.M.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of clinical records, interviews and review of facility policy the facility failed to ensure for seven of eleven patients (Patient 1, 2, 4, 7, 8, 9 and 10) that master treatment plans and/or careplans were comprehensive to meet the individual needs of the patients. The findings include the following:

a. Patient #1 was admitted on [DATE] with diagnoses that included bipolar disorder. The patient was a transfer to the facility on a Physicians Emergency Commitment (PEC). Review of the MTP identified problems that included psychosis/mania and potential for injury to self or others. Interventions to address these problems included monitor behavior, provide support with clear limit setting and expectation to maintain safe behavior, and encourage use of time out. The treatment plan failed to identify specific groups and/or patient specific interventions to achieve the stated goals. The treatment plan failed to identify the patients observational level.
Interview with MD#1 on 5/16/12 at 11:00 AM indicated that Staff Person #1 and 2 notified him that they observed Director #1 place both hands around Patient #1's neck in a tight manner on 4/3/12.
Director #1 stated during an interview on 5/16/12 at 10:00 AM that she had two altercations with Patient #1, once when the patient's behavior had escalated and the patient raised his/her arms and Director #1 placed hands on the patient's upper arms and told the patient s/he could not hit anyone. And during the second encounter, Patient #1 lunged at Director #1 upon request to perform a mouth check following administration of as needed (prn) medication. The Director stated she placed a hand on the Patient's chest and told the patient to step back. Director #1 denied touching the patient's neck.
Review of the treatment plan failed to address the incident that occurred on 4/3/12.

b. Patient #2 (MDS) dated [DATE] at 1:30 AM with angry outbursts, yelling and feelings of depression and was admitted on [DATE] with depression and polysubstance abuse. The clinical record identfied that the patient was placed in four point restraints at 4:50 AM on 5/4/12 for running out of room, and attempting to leave the ED. Review of the monitoring flow sheet indicated that the patient was threatening, biting and fighting when placed in restraints. The flow sheet indicated that the restraints weren't removed until 6:35 AM. Review of the admission orders dated 5/4/12 identified that the patient was placed on every fifteen minute checks. Review of the nurse's note dated 5/4/12 identified that the patient was placed in seclusion at approximately 11:00PM due to trying to leave and was placed on close observation after the episode of seclusion. Review of the observational flow sheets indicated that on 5/5/12 at 4:30 PM the patient "fell ". Review of the treatment plan dated 5/4/12 identified the patients active problems in part as suicidal ideation, depression and fall risk The MTP failed to identify interventions and/or address that the patient required restraint and/or seclusion or the patients actual fall.

Review of the facility policy indicated that the use of restraints and/or seclusion should be entered on the treatment plan.


c. Patient #4 was admitted on [DATE] with Bipolar disorder. Review of the MTP dated 5/15/12 identified active problems in part of depression, suicidal ideation and anxiety. Review of the MTP failed to identify interventions and/or specific groups to assist the patient in achieving the stated goal. The treatment plan failed to identify the patients observational level as directed by policy.

d. Patient #7 was admitted on [DATE] with depression and substance abuse. Review of the admission orders dated 5/18/12 directed fifteen-minute observation for 24 hours. Review of the MTP dated 5/19/12 identfied problems that included suicidal ideation with interventions that included in part, implement appropriate level of observation. The MTP failed to identify the patient's observational level, specific groups and/or interventions to assist the patient in achieving the identified goals. Review of a nurse's note dated 5/20/12 at 11:55 PM identfied that another patient (#9) reported that he/she acted as a lookout so Patient #7 and 8 could engage in oral sex on 5/19/12 during the 3PM-11PM shift. Review of the MTP failed to reflect that the MTP had been reviewed and/or revised after the incident of 5/20/12.

e. Patient #8 was admitted on [DATE] with bipolar disorder and mild mental retardation. Review of the admission order dated 5/16/12 directed that the patient be monitored every fifteen minutes for twenty-four hours. Review of the psychiatric admission note identified that the patient's insight and judgement was fair to poor. Review of the Master Treatment Plan (MTP) on 5/21/12 indicated that the patient had active problems that included Suicidal ideation, post-traumatic stress disorder and potential for injury to self or others with interventions that included order level of observation as appropriate, monitor the patients mood lability and engage with staff. The MTP failed to identify groups, specific interventions to meet the stated goals and/or the level of monitoring the patient required.
Review of the every fifteen minutes monitoring sheets dated 5/20/12 indicated that at 10:15 PM the patient had a "fight with a peer". A nurse's note dated 5/20/12 at 11:55 PM identfied that another patient (#9) reported that he/she acted as a lookout so Patients #7 and 8 could engage in oral sex. The note indicated that Patient #8 was subsequently placed on close observation for protection.
Review of the MTP failed to identify that the plan was reviewed and/or revised after the incidents of 5/20/12.


f. Patient #9 arrived at the Emergency Department (ED) on 5/16/12 at 6:19 P.M via ambulance and in police custody for alcohol intoxication with a past medical history that included post-traumatic stress disorder, schizoaffective disorder and alcohol dependence. Patient #9 was admitted to South 2. Review of the clinical record and hospital documentation identified that on 5/20/12 and 5/21/12 Patient #9 was involved in two conflicts with another patient that concluded in each patient throwing items at each other. Review of Patient #9's clinical record and interview with Nurse Director #1, on 5/22/12 at 11:28 A.M., identified that the treatment plan does not reflect these events.

g. Patient #10 was admitted on [DATE] with pancreatitis, and a history of alcohol abuse. Review of the clinical record indicated that the patient was alert and oriented. The psychiatric consultation indicated that the patient was not appropriate for inpatient therapy, was competent and had refused detox programs. The clinical record indicated that on 2/23/12 the patient was placed on constant observation for flight/fall risks and remained on constant observation until discharged on [DATE]. Review of the care plan identified that the patients active problems were nutrition and social service needs. The care plan failed to be reviewed and/or revised to reflect the patients need for "constant observation".

Review of the policy and procedure, titled Individualized Multidisciplinary Treatment Plan, is developed for the members of the health care team to communicate, collaborate and develop a therapeutic plan of care for the patient, including the problem and methods to achieve identified short term and long term goals.