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.

KING'S DAUGHTERS' MEDICAL CENTER 2201 LEXINGTON AVENUE ASHLAND, KY 41101 Oct. 12, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of facility's policies it was determined the facility failed to ensure patient rights were protected and promoted by failing to provide care and treatment in a safe setting for two (2) of ten (10) sampled patients (Patient #1 and #2). Patient #1 (MDS) dated [DATE], at approximately 2:19 PM with a known history of Autism (Asbergers' Syndrome, a Pervasive Developmental Disability) and was exhibiting increased stress and Anxiety. Patient #1's Guardian accompanied him/her to the ED and reported the increased stress and Anxiety were due to the recent deaths of his/her father and uncle. Patient #1 was taken to a treatment room and his/her Guardian accompanied the patient. The Guardian experienced low blood sugar and left to obtain food, leaving Patient #1 in the treatment room alone. Certified Medical Technician (CMT) #1 came into the treatment room while the Guardian was away and informed Patient #1 he/she had to remove his/her clothing and underwear and put on a gown. Patient #1 refused, CMT #1 informed the patient it was facility policy, and Patient #1 again refused. CMT #1 attempted to physically remove Patient #1's clothing, and the patient ran out of room. Patient #1 was stopped by the CMT and physically forced to the floor by CMT #1, sitting on the patient's chest and pinning his/her arms to the floor. Two (2) Security Officers arrived, and CMT #1 and Security Officers picked Patient #1 up and carried him/her back into the treatment room. Patient #1 was placed in four (4) point restraints. Patient #1's clothing and underwear were cut off of him/her.

Patient #1's Guardian/sister stated, this could have been prevented had she been allowed to return to Patient #1's treatment room with him/her as she had told him/her not to remove his/her clothing in front of strangers. She stated she could have explained to Patient #1 that it was all right to remove his/her clothing. According to the Guardian/sister, she taught Patient #1 not to remove his/her clothing in front of strangers due to the high risk of molestation to individuals with intellectual and developmental disabilities.

Additionally, the facility failed to ensure staff was trained to provide care for Patient #2, who had a diagnosis of Alzheimer's Disease. Patient #2 required a change of his/her brief while in an examination room, and ED staff "jerked" the patient's hands off the side rails and "roughly" pulled Patient #2 up in bed.The failure of the facility to esure patient rights were protected and promoted and care was provided in a safe environment placed patients at risk for serious injury, harm, impairment or death. The facility was notified on 10/10/12 that Immediate Jeopardy was determined to exist related to Patient's Rights. The facility initiated corrective actions and the Immediate Jeopardy was determined to be abated on 10/11/12, prior to exit on 10/12/12.

(Refer to A 0144)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review, and review of facility's policies it was determined the facility failed to ensure patient rights were protected and promoted by failing to provide care and treatment in a safe setting for two (2) of ten (10) sampled patients (Patient #1 and #2).

The facility failed to ensure staff was trained to provide care for Patient #1, who had a known history of Autism (Aspergers' Syndrome, a Pervasive Developmental Disorder) and Bipolar (Disorder). Patient #1 was admitted to the Emergency Department (ED), and physically forced to the floor, by a Certified Medical Technician (CMT) after refusing to remove his/her clothing. The CMT and two (2) Security Officers physically picked the patient up and carried him/her back to the ED treatment room where Patient #1 was placed in four (4) point restraints. The CMT stated he had never received training on caring for a patient with Autism or other Developmental or Intellectual Disabilities.

Additionally, the facility failed to ensure staff was trained to provide care for Patient #2, who had a diagnosis of Alzheimer's Disease. Patient #2 required a change of his/her brief while in an examination room, and ED staff "jerked" the patient's hands off the side rails and "roughly" pulled Patient #2 up in bed.

The findings include:

A review of the facility's policy titled "Patient's Rights and Responsibilities", dated 07/05/12, revealed information should be communicated in terms the patient can reasonably be expected to understand. The policy indicated when it was not medically advisable give information to the patient, the information would be made available to the next of kin or legally authorized individual. The policy stated the patient had the right to be cared for by staff who have been educated about Patient's Rights and their (staff's) role in supporting Patient's Rights. Further review revealed, the facility would be sensitive to all patient's needs including the needs of a disabled patient.

1. Review of Patient #1's Emergency Department (ED) record revealed the patient was admitted to the facility on [DATE] at 2:19 PM with diagnoses which included Autism (Aspergers' Syndrome, a Pervasive Developmental Disorder). It was noted the patient's Legal Guardian/sister accompanied him/her. Continued review revealed the Physician ordered at 3:58 PM, that Patient #1 be admitted to the facility as an inpatient to the Behavioral Medicine Unit.

Interview, on 10/09/12 at 10:45 AM, with Patient #1's Guardian/Sister revealed on 10/03/12, she took Patient #1 to the Emergency Department (ED) for an evaluation related to the patient exhibiting increased stress and anxiety, due to the recent deaths of his/her father and uncle. The Guardian stated, while waiting with the patient in an ED examination room she became Hypoglycemic (low blood sugar) and felt she required food. According to the Guardian, she left Patient #1 in the ED examination room to go get something to eat. When she returned to the ED, Security officers would not allow her back into the ED examination room. She stated she was not given any information concerning Patient #1. The Guardian stated she informed the Security officers that she was Patient #1's Legal Guardian and requested to be allowed to go back with the patient. She stated she was not informed by the Security officers that there was a physical altercation between Patient #1 and a Certified Medical Technician (CMT). The Guardian stated when she observed Patient #1 again it was on 10/04/12; and he/she had been admitted to the facility's Behavioral Medicine Unit. She stated Patient #1 informed her that he/she had been hit in the head and chest while in the ED on 10/04/12. The Guardian stated Patient #1 informed her the CMT had tried to force him/her to take off his/her clothes and underwear and put on a gown. Patient #1 reported to the Guardian that the CMT tugged at his/her clothing attempting to remove the clothing. The Guardian stated Patient #1 told her he/she became scared and ran out of the examination room. She said the patient told her that he/she was tackled to the floor by the CMT, who sat on his/her chest and then put into four (4) point restraints and his or her clothes cut of of him/her. She stated had she been allowed to return to Patient #1's bedside, the need for restraints could have been prevented. The Guardian stated she had taught Patient #1 not to take his/her clothing off in front of strangers, so when the CMT attempted to remove Patient #1's clothing the patient became scared. In addition, the Guardian stated Patient #1 was discharged from the facility on 10/04/12 and had complaints of shortness of breath and chest pain after discharge. She stated she took Patient #1 to another facility on 10/07/12, where he/she was diagnosed with contusions of the ribs.

Interview, on 10/10/12 at 3:15 PM, with CMT #1 revealed he was aware of Patient #1's diagnosis of Autism, however he stated he had no training in caring for a patient with this diagnosis. He stated he was assigned to Patient #1 on 10/03/12. According to CMT #1, he went in and informed the patient he had to take off his/her clothes and Patient #1 refused. He stated he explained to the patient he had to remove his/her clothing as he/she was being admitted to the Behavioral Medicine Unit. The patient refused again to remove his/her clothing and the CMT stated when he attempted to remove Patient #1's clothing, Patient #1 hit him and ran from the examination room. The CMT stated he did not notify the Nurse of the patient's refusal to remove his/her clothing. He stated he just attempted to remove Patient #1's clothing. He confirmed that Patient #1 was carried back into the treatment room, placed in four (4) point restraints and his/her clothes were cut off, in ordered to place the patient in a gown.

Review of the facility's job description for CMTs revealed the CMT was to assist with data collection by gathering objective information and reporting to the Registered Nurse (RN)/Licensed Practical Nurse (LPN).

Interview, on 10/09/12 at 3:20 PM, with Registered Nurse (RN) #1 revealed CMT #1 did not report Patient #1's refusal to remove his/her clothing to her. She stated she heard CMT #1 inform the patient that it was facility policy to remove clothing prior to going to the Behavioral Medicine Unit. RN #1 stated she was in another room with a different patient and heard "scuffling" going on. She stated someone had called Security when she came out of the other patient's room.

Interview, on 10/10/12 at 10:20 AM, with RN #2 revealed normally the CMT would have informed the Nurse of the patient's refusal to remove his/her clothing; however, the Nurses were busy with other patients at the time. In another interview, on 10/10/12 at 10:45 AM, RN #2 revealed facility staff could have been more sensitive to Patient #1 due to his/her "special needs".

Interview, on 10/11/12 at 10:45 AM, with CMT #2 revealed he could not recall if he had ever received training on caring for patients with special needs.

Interview, 10/09/12 at 3:00 PM, with Security Guard Supervisor #1 revealed the Security Department was not medically trained and had no training to deal with patients with Intellectual or Developmental disabilities. He stated Security restricted Patient #1's Guardian from entering the ED treatment area; however, that was by request of the ED. The Security Guard Supervisor #1 stated when he responded to a call for assistance in the ED on 10/03/12, he observed CMT #1 "on top" of Patient #1 (who was on the floor).

Interview, on 10/09/12 at 3:10 PM, with Security Guard #2 revealed she was not aware Patient #1 had Autism. She stated she had not received training on how to handle patients with Intellectual or Developmental issues. Security Guard #2 stated she responded to a call for assistance in the ED on 10/03/12. When she arrived in the ED, Patient #1 was "pinned on the floor" by CMT #1. She stated she and the Security Guard Supervisor physically picked Patient #1 up off the floor and carried him/her back into room, and placed him/her in the bed.

Interview, on 10/09/12 at 3:30 PM, with the Director of Behavioral Medicine revealed she felt facility staff needed more education in behavioral management. She stated the ED staff should not have reacted to Patient #1's behavior, but to his/her condition (of Autism).

Interview, on 10/12/12 at 8:45 AM, with the Director of Quality revealed she had been informed of the incident involving Patient #1 on 10/03/12. She stated the CMT had not asked for help from the nurse as he should have done.

Interview, on 10/12/12 at 9:00 AM, with the Director of Risk Management revealed she became aware of the incident that occurred on 10/03/12 involving Patient #1 on 10/12/12 when she returned to work after being off. She stated the facility had the opportunity to improve related to Patient Rights and sensitivity to patients with developmental and intellectual disabilities.

2. Review of Patient #1's Emergency Department (ED) record revealed the patient was admitted on [DATE], with diagnoses which included Altered Mental Status and Dementia. Patient #2 presented to the ED with chills, fever and hematuria. Review of the ED Notes revealed the patient was triaged and taken to an examination room at 12:56 PM. The nurse documented Patient #2's family was at bedside at 12:58 PM. Continued review revealed, Patient #2 was catheterized for a urinalysis at 12:59 PM. Also, the ED record revealed at 12:59 PM a positive urine culture, indicating a urinary tract infection (UTI). Further, review of the ED record revealed, at 4:48 PM, Patient #2 was treated with Ciprofloxacin (Cipro) tablet 500 Milligram (Mg) and was discharged from the facility at 4:59 PM.

Interview, on 10/11/12 at 10:15 AM, with Patient's #2's family revealed, while in the ED, CMT #2 "acted aggravated" when she (Patient #2's spouce) asked him to change Patient #2's brief. Patient #2's spouse stated the patient had Alzheimer's Disease and did not always understand what was being said to him/her. The spouse stated while the CMT was changing Patient #2's brief, he rolled Resident #2 onto his/her side, causing the patient to grab at the side rail. Patient #2's spouse stated Resident #2 was "yelling" for CMT #2 to stop. The spouse stated CMT #2 did not stop and continued to hold Patient #2 on his/her side and "jerked" Patient #2's hand roughly from the side rail .

Interview, on 10/11/12 at 10:45 AM, with CMT #2 revealed he was on duty in the ED on 09/02/12 and was assigned to Patient #2. CMT #2 stated Patient #2's spouse had asked for the patient's brief to be changed. CMT #2 stated he, and Registered Nurse (RN) #3 changed the patient as requested. CMT #2 stated he turned and held Patient #2 over while RN #3 cleansed the resident's buttocks. CMT #2 stated Patient #2 was anxious and "grabbing" at the rails and yelling for them to stop. CMT #2 stated although Patient #2 was yelling for them to stop, they continued to change the patient's brief.

Interview, on 10/11/12 at 11:30 AM, with RN #3 revealed, she and CMT #2 went to change Patient #2's brief. RN #3 stated CMT #2 rolled Patient #2 onto his/her side and held him/her over while she cleansed the patient. RN #3 stated Patient #2 became resistive to the turning and was grabbing at the side rails and yelled for them to stop. RN #3 stated they continued to change the patient's brief, although he/she appeared scared.

The facility failed to provide a safe environment which placed patients at risk for injury, harm ,impairment or death. On 10/10/12 Immediate Jeopardy was determined to exist.

The facility initiated corrective actions. Those actions were as follows:

The facility retrained staff, on 10/11/12, on Patients Rights through an educational module, which was an online management program and was available to all facility staff, at www.teamkdmc.com. The facility managers were to contact nurses, CMT and Security Guards who were on vacation, leave of absence, or worked night shift to inform them they must complete the Patient Rights Education Module before they would be allowed to return to work.

The retraining on Patient Rights education was verified through interview of staff. The following interviews were conducted:

Interview, on 10/12/12 at 10:55 AM, with Registered Nurse (RN) #8, who worked 7:00 AM to 7:00 PM shift, revealed she had been educated on 10/11/12 on Patient's Rights and managing patients with intellectual and developmental disabilities through an online education module.

Interview, on 10/12/12 at 11:00 AM, with RN #9, who worked 7:00 AM to 7:00 PM shift, revealed she had been educated through an online module, on 10/11/12 on Patient's Rights and managing patient with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:05 AM, with RN #10, revealed she had received online training related to Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:08 AM, with Certified Medical Technician (CMT) #7 revealed he had been trained via an online module on Patient Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:10 AM, with RN #11 revealed she had received online module training on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:15 AM, with RN #12 revealed she had received training online on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:17 AM, with Licensed Practical Nurse (LPN) #2, revealed she had received online module training on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:22 AM, with CMT #6 revealed he had received online module training on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:25 AM, with RN #13 revealed he had received training online via a module on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:30 AM, with LPN #3 revealed she had received module training on Patient Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:40 AM, with RN #14, who worked the 7:00 PM to 7:00 AM, revealed she had received module training on Patients Rights and on managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 12:35 PM, with RN #15, who worked 8:00 PM to 8:00 AM, revealed she had received training online on Patients Rights and on managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 12:30 PM, with LPN #4, who worked 7:00 PM to 7:00 AM, revealed she had received module training online on Patient Rights and on managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12, at 12:45 PM, with RN #16 revealed she had received module training online on Patients Rights and on managing patients with intellectual and developmental disabilities.

On 10/11/12, 91% nurses, CMT's and Security Guards completed the Patient Rights education and electronically signed a statement of acknowledging their understanding of the education and agreement to utilize the knowledge in their practice. Review of the training modules was performed. The acknowledgments with staff's electronic signature was also reviewed.

Posters depicting a letter to caregivers from patients (copy provided to onsite surveyor) were distributed to nurse mangers on 10/11/12 for display by 10/12/12 in staff lounge and non-public areas of patient care areas. These posters promote enhanced sensitivity to individual needs. Observation on 10/12/12 revealed the posters were in place.

The Immediate Jeopardy was determined to be abated on 10/12/12 prior to exit of the survey on 10/12/2012.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, it was determined the facility failed to ensure the delivery of nursing services to two (2) of ten (10) sampled patient (Patients #1 and #2). Patient #1 presented to the Emergency Department (ED) of the facility on 10/03/12 at 2:19 PM with a known history of Autism /Asperger's Syndrome (a pervasive developmental disability) and Bipolar Disorder (a mood instability disorder), with his/her legal guardian/sister, due to Patient's #1's increased stress and anxiety related to the deaths of his/her father and uncle. Patient #1 was admitted to the treatment area with his/her Guardian accompanying. The Guardian experienced low blood sugar and left Patient #1 in the treatment area while she went to obtain food. Certified Medical Technician (CMT) #1 entered Patient #1's treatment room and informed the patient he/she had to remove his/her clothing and underwear and put on a gown. Patient #1 refused to do so, the CMT informed him/her it was hospital policy and Patient #1 again refused. CMT #1 did not inform the nurse of Patient #1's refusal, but attempted to remove Patient #1's clothing and the patient ran out of the room. The CMT stopped Patient #1 and forced him/her to the floor, sat on the patients chest and pinned the patient's arms to the floor. CMT#1 and two (2) security guards picked Patient #1 up off the floor, took him/her back into the treatment room and the patient was placed in four (4) point restraints. CMT #1 did not report to the Nurse when Patient #1, who had a diagnosis of Autism, refused to remove his/her clothing and underwear. The CMT did not wait for Patient #1's Guardian to return to his/her bedside to explain the reasons for the removal of clothing. CMT #1 did not request further assistance from other ED staff. The CMT stated he had not been trained in caring for individuals with Developmental and Intellectual disabilities. Additionally, the facility failed to ensure staff was trained to provide care for Patient #2, who had a diagnosis of Alzheimer's Disease. Patient #2 required a change of his/her brief while in an examination room, and ED staff "jerked" the patient's hands off the side rails and "roughly" pulled Patient #2 up in bed. Facility nursing staff failed to ensure the CMTs were educated on the care of individuals with Developmental and Intellectual disabilities and failed to provide adequate supervision of the CMT. The failure of the facility to provide adequate supervision and ensure the education of CMTs in the care of individuals with Developmental and Intellectual disabilities placed patients at risk for serious injury, harm, impairment or death. The facility was notified on 10/10/12 that Immediate jeopardy was determined to exist related to Nursing Services. The facility initiated corrective action on 10/10/12. It was determined the Immediate Jeopardy was abated on 10/11/12 prior to exit on 10/12/12.

(Refer to A0395)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review, and review of facility's policies it was determined the facility failed to ensure staff provided nursing care under the supervision of a registered two (2) of ten (10) sampled patients (Patient #1 and #2).

The facility failed to ensure staff was trained to provide care for Patient #1, who had a known history of Autism (Aspergers' Syndrome, a Pervasive Developmental Disorder) and Bipolar (Disorder). Patient #1 was admitted to the Emergency Department (ED), and physically forced to the floor, by Certified Medical Technician (CMT) #1 after refusing to remove his/her clothing. The Registered Nurse (RN) supervising CMT #1 was not informed of the patient's refusal to remove his/her clothing. CMT #1 and two (2) Security Officers physically picked the patient up and carried him/her back to the ED treatment room where Patient #1 was placed in four (4) point restraints and his/her clothes were cut off him/her. CMT #1 stated he did not report to the RN, that the patient had refused and had never received training on caring for a patient with Autism or other Developmental or Intellectual Disabilities.

Additionally, the facility failed to ensure staff was trained to provide care for Patient #2, who had a diagnosis of Alzheimer's Disease. Patient #2 required a change of his/her brief while in an examination room, and ED staff "jerked" the patient's hands off the side rails and "roughly" pulled Patient #2 up in bed.

The findings include:

A review of the facility's policy titled "Patient's Rights and Responsibilities", revealed, information should be communicated in terms the patient can reasonably be expected to understand. The policy indicated when it was not medically advisable give information to the patient, the information would be made available to the next of kin or legally authorized individual. The policy stated the patient had the right to be cared for by staff who have been educated about Patient's Rights and their (staff's) role in supporting Patient's Rights. Further review revealed, the facility would be sensitive to all patient's needs including the needs of a disabled patient.

Review of the facility's job description for CMTs revealed the CMT was to assist with data collection by gathering objective information and reporting to the Registered Nurse (RN)/Licensed Practical Nurse (LPN). It further stated the clinical responsibility of the CMT was to assist the RN/LPN with routine patient care and treatment of patients and under the direct supervision of the RN.

1. Record review of Patient #1's Emergency Department (ED) record revealed the patient was admitted to the facility on [DATE] at 2:19 PM with diagnoses which included Autism (Aspergers' Syndrome, a Pervasive Developmental Disorder). Continued review revealed the Physician ordered at 3:58 PM, that Patient #1 be admitted to the facility as an inpatient to the Behavioral Medicin Unit.

Interview, on 10/09/12 at 10:45 AM, with Patient #1's Guardian/Sister revealed on 10/03/12, she took Patient #1 to the Emergency Department (ED) for an evaluation related to the patient exhibiting increased stress and anxiety, due to the recent deaths of his/her father and uncle. The Guardian stated, while waiting with the patient in an ED examination room she became Hypoglycemic (low blood sugar) and felt she required food. According to the Guardian, she left Patient #1 in the ED examination room to go get something to eat. When she returned to the ED, Security officers would not allow her back into the ED examination room. She stated she was not given any information concerning Patient #1. The Guardian stated she informed the Security officers that she was Patient #1's Legal Guardian and requested to be allowed to go back with the patient. She stated she was not informed by the Security officers that there was a physical altercation between Patient #1 and Certified Medical Technician (CMT) #1. The Guardian stated when she observed Patient #1 again it was on 10/04/12; and he/she had been admitted to the facility's Behavioral Medicine Unit. She stated Patient #1 informed her that he/she had been hit in the head and chest while in the ED on 10/04/12. The Guardian stated Patient #1 informed her the CMT had tried to force him/her to take off his/her clothes and underwear and put on a gown. Patient #1 reported to the Guardian that the CMT tugged at his/her clothing attempting to remove the clothing. The Guardian stated Patient #1 told her he/she became scared and ran out of the examination room. She said the patient told her that he/she was tackled to the floor by the CMT, who sat on his/her chest and then put into four (4) point restraints and his or her clothes cut of of him/her. She stated had she been allowed to return to Patient #1's bedside, the need for restraints could have been prevented. The Guardian stated she had taught Patient #1 not to take his/her clothing off in front of strangers, so when the CMT attempted to remove Patient #1's clothing the patient became scared. In addition, the Guardian stated Patient #1 was discharged from the facility on 10/04/12 and had complaints of shortness of breath and chest pain after discharge. She stated she took Patient #1 to another facility on 10/07/12, where he/she was diagnosed with contusions of the ribs. GAE SAME QUESTION HERE RELAED IF THIS WAS VERFIED??

Interview, on 10/10/12 at 3:15 PM, with CMT #1 revealed he was aware of Patient #1's diagnosis of Autism; however, he stated he had recieved no training in caring for a patient with this diagnosis. He stated he was assigned to Patient #1 on 10/03/12. According to CMT #1, he went in and informed the patient he had to take off his/her clothes and Patient #1 refused. He stated he explained to the patient he had to remove his/her clothing as he/she was being admitted to the Behavioral Medicine Unit. The patient refused again to remove his/her clothing and the CMT stated when he attempted to remove Patient #1's clothing, Patient #1 hit him and ran from the examination room. The CMT stated he did not notify the Nurse of the patient's refusal to remove his/her clothing in order to get further direction from the RN. He stated he just attempted to remove Patient #1's clothing. CMT #1 confirmed that he and the Security Officers carried Patient #1 back into the treatment room, placed the patient in four (4) point restraints and cut Patient #1's clothing and underwear off in order to place a gown on Patient #1.

Interview, on 10/09/12 at 3:20 PM, with Registered Nurse (RN) #1 revealed CMT #1 did not report Patient #1's refusal to remove his/her clothing to her. She stated she heard CMT #1 inform the patient that it was facility policy to remove clothing prior to going to the Behavioral Medicine Unit. RN #1 stated she was in another room with a different patient and heard "scuffling" going on. She stated someone had called Security when she came out of the other patient's room. She stated CMT #1 should have informed her that Patient #1 was refusing to remove his/her clothing.

Interview, on 10/10/12 at 10:20 AM, with RN #2 revealed normally the CMT would have informed the Nurse of the patient's refusal to remove his/her clothing; however, the Nurses were busy with other patients at the time. In another interview, on 10/10/12 at 10:45 AM, RN #2 revealed facility staff could have been more sensitive to Patient #1 due to his/her "special needs".

Interview, on 10/11/12 at 10:45 AM, with CMT #2 revealed he could not recall if he had ever received training on caring for patients with special needs.

Interview, 10/09/12 at 3:00 PM, with Security Guard Supervisor #1 revealed the Security Department was not medically trained and had no training to deal with patients with Intellectual or Developmental disabilities. The Security Guard Supervisor #1 stated when he responded to a call for assistance in the ED on 10/03/12, he observed CMT #1 "on top" of Patient #1 (who was on the floor).

Interview, on 10/09/12 at 3:10 PM, with Security Guard #2 revealed she was not aware Patient #1 had Autism. She stated she had not received training on how to handle patients with Intellectual or Developmental issues. Security Guard #2 stated she responded to a call for assistance in the ED on 10/03/12. When she arrived in the ED, Patient #1 was "pinned on the floor" by CMT #1. She stated she and the Security Guard Supervisor physically picked Patient #1 up off the floor and carried him/her back into room, and placed him/her in the bed.

Interview, on 10/09/12 at 3:30 PM, with the Director of Behavioral Medicine revealed she felt facility staff needed more education in behavioral management. She stated the ED staff should not have reacted to Patient #1's behavior, but to his/her condition (of Autism).

Interview, on 10/12/12 at 8:45 AM, with the Director of Quality revealed she had been informed of the incident involving Patient #1 on 10/03/12. She stated the CMT had not asked for help from the nurse as he should have done and the CMT should have informed the nurse of Patient #1's refusal in order to get direction.

Interview, on 10/12/12 at 9:00 AM, with the Director of Risk Management revealed she became aware of the incident that occurred on 10/03/12 involving Patient #1 on 10/12/12 when she returned to work after being off. She stated the facility had the opportunity to improve related to Patient Rights and sensitivity to patients with developmental and intellectual disabilities.

2. Review of Patient #1's Emergency Department (ED) record revealed the patient was admitted on [DATE], with diagnoses which included Altered Mental Status and Dementia. Patient #2 presented to the ED with chills, fever and hematuria. Review of the ED Notes revealed the patient was triaged and taken to an examination room at 12:56 PM. The nurse documented Patient #2's family was at bedside at 12:58 PM. Continued review revealed, Patient #2 was catheterized for a urinalysis at 12:59 PM. Also, the ED record revealed at 12:59 PM a positive urine culture, indicating a urinary tract infection (UTI). Further, review of the ED record revealed, at 4:48 PM, Patient #2 was treated with Ciprofloxacin (Cipro) tablet 500 Milligram (Mg) and was discharged from the facility at 4:59 PM.

Interview, on 10/11/12 at 10:15 AM, with Patient's #2's family revealed, while in the ED, CMT #2 "acted aggravated" when she (Patient #1's spouce) asked him to change Patient #2's brief. Patient #2's spouse stated the patient had Alzheimer's Disease and did not always understand what was being said to him/her. The spouse stated while the CMT was changing Patient #2's brief, he rolled Resident #2 onto his/her side, causing the patient to grab at the side rail. Patient #2's spouse stated Resident #2 was "yelling" for CMT #2 to stop. The spouse stated CMT #2 did not stop and continued to hold Patient #2 on his/her side and "jerked" Patient #2's hand roughly from the side rail .

Interview, on 10/11/12 at 10:45 AM, with CMT #2 revealed he was on duty in the ED on 09/02/12 and was assigned to Patient #2. CMT #2 stated Patient #2's spouse had asked for the patient's brief to be changed. CMT #2 stated he, and Registered Nurse (RN) #3 changed the patient as requested. CMT #2 stated he turned and held Patient #2 over while RN #3 cleansed the resident's buttocks. CMT #2 stated Patient #2 was anxious and "grabbing" at the rails and yelling for them to stop. CMT #2 stated although Patient #2 was yelling for them to stop, they continued to change the patient's brief.

Interview, on 10/11/12 at 11:30 AM, with RN #3 revealed, she and CMT #2 went to change Patient #2's brief. RN #3 stated CMT #2 rolled Patient #2 onto his/her side and held him/her over while she cleansed the patient. RN #3 stated Patient #2 became resistive to the turning and was grabbing at the side rails and yelled for them to stop. RN #3 stated they continued to change the patient's brief, although he/she appeared scared.


The facility failed to provide a safe environment which placed patients at risk for injury, harm ,impairment or death. On 10/10/12 Immediate Jeopardy was determined to exist.

The facility initiated corrective actions. Those actions were as follows:

The facility retrained staff, on 10/11/12, on Patients Rights through an educational module, which was an online management program and was available to all facility staff, at www.teamkdmc.com. The facility managers were to contact nurses, CMT and Security Guards who were on vacation, leave of absence, or worked night shift to inform them they must complete the Patient Rights Education Module before they would be allowed to return to work.

The retraining on Patient Rights education was verified through interview of staff. The following interviews were conducted:

Interview, on 10/12/12 at 10:55 AM, with Registered Nurse (RN) #8, who worked 7:00 AM to 7:00 PM shift, revealed she had been educated on 10/11/12 on Patient's Rights and managing patients with intellectual and developmental disabilities through an online education module.

Interview, on 10/12/12 at 11:00 AM, with RN #9, who worked 7:00 AM to 7:00 PM shift, revealed she had been educated through an online module, on 10/11/12 on Patient's Rights and managing patient with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:05 AM, with RN #10, revealed she had received online training related to Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:08 AM, with Certified Medical Technician (CMT) #7 revealed he had been trained via an online module on Patient Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:10 AM, with RN #11 revealed she had received online module training on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:15 AM, with RN #12 revealed she had received training online on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:17 AM, with Licensed Practical Nurse (LPN) #2, revealed she had received online module training on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:22 AM, with CMT #6 revealed he had received online module training on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:25 AM, with RN #13 revealed he had received training online via a module on Patients Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:30 AM, with LPN #3 revealed she had received module training on Patient Rights and managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 11:40 AM, with RN #14, who worked the 7:00 PM to 7:00 AM, revealed she had received module training on Patients Rights and on managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 12:35 PM, with RN #15, who worked 8:00 PM to 8:00 AM, revealed she had received training online on Patients Rights and on managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12 at 12:30 PM, with LPN #4, who worked 7:00 PM to 7:00 AM, revealed she had received module training online on Patient Rights and on managing patients with intellectual and developmental disabilities.

Interview, on 10/12/12, at 12:45 PM, with RN #16 revealed she had received module training online on Patients Rights and on managing patients with intellectual and developmental disabilities.

On 10/11/12, 91% nurses, CMT's and Security Guards completed the Patient Rights education and electronically signed a statement of acknowledging their understanding of the education and agreement to utilize the knowledge in their practice. Review of the training modules was performed. The acknowledgments with staff's electronic signature was also reviewed.

Posters depicting a letter to caregivers from patients (copy provided to onsite surveyor) were distributed to nurse mangers on 10/11/12 for display by 10/12/12 in staff lounge and non-public areas of patient care areas. These posters promote enhanced sensitivity to individual needs. Observation on 10/12/12 revealed the posters were in place.

The Immediate Jeopardy was determined to be abated on 10/12/12 prior to exit of the survey on 10/12/2012.