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.

CHRISTIAN HOSPITAL NORTHEAST-NORTHWEST 11133 DUNN ROAD SAINT LOUIS, MO 63136 Feb. 18, 2011
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0199
Based on observation, interview and record review the facility failed to ensure agency staff had training to provide appropriate care to patients with resistive behaviors in the Emergency Department (ED) for one of three patients reviewed with a mental health diagnosis and/or resistive behaviors requiring restraint (Patient #6). The facility census was 284.

Findings Included:

1. Review of a physician's consultation report dated 02/15/11, showed Patient #6 was admitted via the ED on 01/08/11, with a diagnosis of depression and suicidal ideations. The patient had attempted suicide by medication overdose. Patient #6 was placed in an isolation room in the ED related to his/her diagnosis.

Observation and interview on 02/15/11 at 10:50 AM, of a video monitor at the nurses' station in the ED, showed the video monitor feed of two examination rooms (rooms #16 and #17), considered isolation rooms, utilized for mental health patients that can be a safety risk. RN, ED Director, Staff C stated that the isolation rooms are used for mental health patients that may require more staff monitor or restraint. The video monitor feed was used to monitor the patient and staff for safety.

During an interview on 02/16/11 at 1:40 PM, Staff FF, Security Officer, stated that it was the facility ED policy for the patients admitted to isolation to remove their street clothes and put hospital scrubs on (for safety). Patient #6 was not cooperative, and did not want to remove his/her clothing. Security staff (three at the time) talked to the patient and attempted to calm the patient. The patient stated he/she would fight if they tried to remove his/her clothing. The patient was controlled by security and staff, but the patient fought them, spat and was verbal back and forth (yelling, cursing and calling Staff P fat) with agency RN Staff P. The patient was restrained with four-point leather restraints.

During an interview on 02/16/11 at 3:02 PM, Staff Q, Lead Security Officer, confirmed the above and also stated that Staff P walked through security, ignoring their attempts to calm the patient, and was the first to physically touch the patient. The patient became very combative. After the patient was restrained, Staff P still antagonized the patient by being verbal (telling the patient he/she could not do anything because he/she was restrained). Medications were administered to the patient by RN Staff R, the charge nurse, and Staff P was told not to cut the clothes off of the patient, to let the medication have time to work first. Staff P went ahead and cut the clothes off of the patient, further agitating the patient. Staff Q stated, at one point, another security staff told Staff P, that he/she had done enough to complicate the situation.

Observation on 02/16/11 at approximately 2:15 PM, of recorded evidence from the ED dated 01/08/11, provided by facility security staff, showed Staff P, pushing through the three security staff to physically restrain Patient #6. The patient resisted, spat and verbalized displeasure (threatening to fight, yelling, and cursing) at being forced to remove his/her clothes. The patient was medicated with an injection and soon after Staff P began cutting the clothes off of Patient #6. The patient was resisting, spitting, and verbal (cursing and yelling).

Review of Staff P's personnel file, on 02/16/11, showed Staff P began in the ED on 09/21/10. Neither the agency nor the facility could provide evidence of mental health training prior to, or since the start date.

2. Review of the facility's complaint/grievance logs for the prior six months showed an allegation of abuse and neglect by an agency ED RN on 12/14/10. This allegation involved the same Staff P. The allegation was not investigated; therefore, no intervention such as training was provided.

3. Review of further agency ED RNs' personnel files on 02/17/11, showed that six additional agency staff did not have any mental health training prior to or since hire. The facility staff failed to ensure agency staff had the appropriate training to work with patients' specific needs.

During an interview on 02/17/11 at 8:47 AM, Staff A, Manager of Patient Safety, stated that the facility did not provide Crisis Prevention Intervention training (training intended to assist in the care of mental health, resistive patients) to Staff P, and neither did the agency.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review the facility failed to ensure that patients admitted to the Geriatric and Adult Behavioral Units were provided care in a safe setting for all 33 patients by allowing non-suicide resistive shower water control knobs and exposed plumbing from the commode in seven of 20 patient bathrooms. The configuration of these water control knobs and exposed plumbing pipes create a looping hazard (material or a device could be looped around the knobs or plumbing to be used for choking, or strangulation).

-The facility failed to secure heavy furniture in 19 of 20 patient rooms, which could provide deadly projectiles, or can easily be maneuvered and positioned to barricade the room, or be placed under a protruding device as potential for hanging affecting all 33 patients in both units.

-The facility failed to provide continuous observation of high risk suicidal patients or replace old three door hinges in all 20 patient bathrooms. The hinge hardware create gaps between the door and the door jamb which were potential ligature attachment points affecting all 33 patients on both units.

-The facility admits patients with diagnosis of suicidal or homicidal risk, psychotic (mental disorder with loss of contact with reality) behavior and/or delusions (false belief inconsistent with one's knowledge and experience), severe mood disturbances, a danger to self and others, severe thought disorganization, seizure and fall precautions on both units.

The facility census was 284.

Findings Included:

1. Observation on 02/15/11 at 10:00 AM, of the Geriatric Behavioral Health Unit, 3-South, showed the following:

-All 10 semi-private rooms have furniture (night stands with removable drawers that are on rollers, over the bed tables that roll, hard plastic trash cans, straight chairs, and large lounge chairs) not secured or bolted to the floor or walls. The unsecured furniture can easily be maneuvered and positioned to barricade the room, or be placed under a protruding device as a potential for hanging for all 18 patients on the unit.
-Occupied rooms #315, #316, #317, and #318 bathrooms have five inches of exposed piping on the toilet. The piping is 20 inches from the floor and five inches from the wall with a three inch flush handle that protrudes out from the side of the plumbing. The exposed plumbing potentially provides a hanging, choking, or strangulation hazard for all 18 patients on the unit.
-Room's #315, #316, #317, and #318 showers showed exposed long stemmed water control knobs that could potentially be a looping hazard for hanging, choking or strangulation for all 18 patients on the unit.
-All 10 patient bathroom doors have three hinges in all 10 semi-private patient rooms. The hinge hardware created gaps between the door and the door jamb which are potential ligature attachment points effecting all 18 patients on the unit.
-Two telephones for patient use were located on wall across from the nurses station. Each phone has a long coiled cord (approximately 5 feet long when stretched) attached providing a potential hazard for hanging, choking or strangulation affecting all 18 patients on the unit.

During an interview on 02/15/11 at 2:20 PM, Staff T, Inpatient Behavioral Healthcare Manager, stated that the two phones in the Geriatric Unit are monitored by the staff at the nurse's desk, and that the cords are removed at night beginning at 10:30 PM on week nights, and 11:00 PM on weekends. Staff T further confirmed there is no one person assigned the daily task of watching the phones during the day.

2. Observation on 02/12/11 at 2:20 PM, of the Adult Behavioral Health Unit, 3-North, showed the following:

-Nine of the 10 occupied semi-private rooms have unsecured furniture (night stands with removable drawers that have rollers, over the bed table that roll, hard plastic trash cans, straight chairs, and large lounge chairs not secured or bolted to the floor or walls. This furniture potentially provides deadly projectiles, if thrown, and can easily be maneuvered and positioned to barricade the room, or be placed under a protruding device as a potential for hanging, choking or strangulation for all 15 patients on the unit.
-Room's #311, #313, #314 bathrooms have five inches of exposed piping on the toilet. The piping is 20 inches from the floor and five inches from the wall with a three inch flush handle that protrudes from the side of the toilet. The exposed plumbing provides a potential looping hazard for hanging, choking or strangulation for all 15 patients on the unit.
-Room's #311, #313, #314 showers showed exposed long stemmed water control knobs that could potentially be a looping hazard for hanging, choking or strangulation for all 15 patients on the unit.
-All 10 patient bathroom doors have the three hinges that provide potential looping hazards for hanging, choking or strangulation for all 15 patients on the unit. The hinged hardware created gaps between the door and the door jamb which are potential ligature attachment points. This affects 10 semi-private patient rooms.

During an interview on 02/15/11 at 10:15 AM, Staff T, Inpatient Behavioral Health Care Manager, stated that they admit suicidal ideation patients on both behavioral health units.

During an interview on 02/15/11 at 10:20 AM, Staff S, Director of Patient Care for both Inpatient and Outpatient Mental Health confirmed that all of the furniture is not bolted to the floor or wall in all rooms on both behavioral health units.

Observation on 02/15/11 at 3:00 PM, showed that all patient bathroom doors are unlocked on both units and potentially all patients could have access to any bathroom. All patient's on both units ambulate in the corridor at their will.

During an interview on 02/16/11 at 10:20, Staff U, Clinical Education Specialist for the Behavior Health Unit's, stated that there are no specific procedures for suicidal patients, and they could be admitted to any room on the units. The patients admitted or diagnosed with suicidal ideation's will be able to ambulate in the hallway of the unit, and stay in the day room allowing access to any room or bathroom on the unit.

3. During an interview on 02/17/11 at 8:45 AM, Staff QQ, Director of Facilities stated that all construction for the behavioral health units is in the facilities strategic plan that will be finalized in 2015. Room #311, #312, #313, and #314 bathrooms will be remodeled in 2013 with non-suicidal shower control knobs, and covering for the toilet plumbing.

4. Record review of 15 minute check lists (all patient forms kept in separate notebook) showed that patient rounds were completed at the top of the hour and every 15 minutes thereafter. These predictable rounds allow time for potential self harm, or harm to other patients before the next rounds begin.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interview, the facility failed to follow physician orders for restraints and failed to obtain accurate physician orders for restraint use for three (#12, #13, #2) of five patients observed for restraint use. The facility census was 284.

Findings included:

1. Record review of the facility's policy titled, "Restraint Management Non-Violent and Documentation Guidelines", dated 01/10 showed the following direction:
- A physician's order must be written promptly after the application of the restraint. The order must include the following: a) the reason for the restraint; b) the type of restraint; c) start and end time (no longer than 24 hours). The restraint may be placed for no longer than 24 hours without a physician's bedside evaluation for continued need. If the restraint is to be continued, a new order must be written by the physician.
- Consult with the physician promptly after the application of a restraint to obtain an order for the restraint. It is the responsibility of the nursing staff to apply sticker for "restraint orders" on physician order sheet for initial order or renewal. The initial order may be verbal/telephone. All renewal orders are to be written by the physician. Document the reason for the restraint and the type of restraint ordered.

2. Observation on 02/15/11 at 1:23 PM, showed Patient #12 in bed with bilateral wrist restraints applied.

Review of Patient #12's medical record on 02/15/11 showed the patient was admitted on [DATE] with acute respiratory failure and chronic obstructive pulmonary (lung) disease. Review of restraint documentation from 02/10/11 through 02/15/11 showed the following:
- On 02/10/11, the patient wore bilateral wrist restraints all day. The physician's order wasn't signed by the physician until 12/11/11 at 12:58 PM, and did not include the start and stop times for restraint use and did not include the reason for restraint use.
- On 02/11/11, the patient wore bilateral wrist restraints until 10:20 AM, at which time the restraints were discontinued by nursing. A physician's order was written on 02/11/11 at 12:58 PM, for bilateral wrist restraints. However, the restraints were not in use and were not re-applied until 02/13/11 at 4:00 PM.
- On 02/12/11, the patient did not wear restraints all day. A physician's order for bilateral wrist restraints was written and signed by the physician on 02/12/11 at approximately 1:30 PM, (unable to read completely). In the section for "Restraint time limit", the "start" time was only shown to be 02/12 and the "end" time was only shown to be 02/13. No specific times were documented.
- On 02/13/11, the patient was placed back in bilateral wrist restraints at 4:00 PM. However, a physician's order for bilateral soft wrist restraints was signed by the physician at 2:15 PM, (1 hour and 45 minutes prior to application of the restraints). The section for "start" and "end" times for the restraint use was left blank on the physician order form.
- On 02/14/11, the patient wore bilateral soft wrist restraints all day. A physician's order was not signed by the physician until 02/15/11 at 8:20 AM. The physician's order did not include reason for the restraints or an end time.
- On 02/15/11, the patient had worn bilateral wrist restraints through time observed at 1:23 PM. The physician's order did not include a restraint time limit start and stop time.

During interview and through record review, Staff K, Director of Nursing, stated that restraint orders are to be written every 24 hours. Staff K stated that the restraint orders for 02/10/11 and 02/11/11 appear to have been signed by the physician at the same time on 02/11/11.

3. Observation on 02/15/11 at 1:35 PM, showed Patient #13 in bed with bilateral wrist restraints on.

Review of Patient #13's medical record on 02/16/11 showed the patient was admitted on [DATE] with weakness and [DIAGNOSES REDACTED] (low blood sugar). Review of restraint documentation from 02/11/11 through 02/16/11 showed the following:
- On 02/11/11, the patient wore bilateral wrist restraints from at least 5:38 PM, through the end of that day. A physician's order for bilateral wrist restraints was written on 02/11/11 at 3:00 PM, by someone other than the physician, but did not complete his/her signature and did not specify if the order was a telephone order. The physician signed the order on what appeared to be 02/14/11 (difficult to read). The section for "start" and "end" times for the restraint use was left blank on the physician order form.
- On 02/14/11, bilateral wrist restraints were removed at 8:05 AM and then re-applied at 10:00 PM. A physician's telephone order was written at 8:00 PM for bilateral soft wrist restraints. This order was not signed by a physician until 02/15/11 at 10:15 AM.

During interview and through record review, Staff N, Registered Nurse/Educator, confirmed that the order written on 02/11/11 did not show if it was a telephone order and was not signed by the nurse taking the order. Staff B, Risk Manager, confirmed that on 02/14/11 at 8:00 PM, a telephone order was written for bilateral wrist restraints, but the restraints were not applied until 10:00 PM.







4. Review of current Patient #2's medical record showed the patient was admitted on [DATE] with diagnosis of [DIAGNOSES REDACTED]

Review of restraint documentation from 02/08/11 through 02/15/11 showed staff documented the patient to be in soft bilateral wrist restraints on 02/12/11.

Review of the physician's orders showed staff failed to obtain a physician's order for bilateral soft wrist restraints on 02/12/11.

During an interview on 02/15/11 at 11:15 AM, Staff E, ICU (Intensive Care Unit) manager stated that physician's orders for restraints can be found in the paper medical record. (The paper record contained physician orders). He/she reviewed the electronic medical record (containing nursing documentation about the patient's care) and stated nursing staff documented the patient had been in soft bilateral wrist restraints on 02/12/11. He/she reviewed the paper medical record, but could not find a physician's order for the restraints. Staff E stated that if the physician's order was not in the paper medical record then staff did not obtain a physician's order for the restraints.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on facility policy review, observation and interview facility staff failed to ensure patient medical information was secured to prevent unauthorized access for patients in three (radiation oncology unit, special procedures and the Gastro-Intestinal (GI) lab) of seven out-patient service areas and three (neurology/orthopedic unit, on the telemetry unit, and the acute medical care unit) of 11 inpatient units. The facility census was 284.

Findings included:

1. Record review of the facility's "Out-Patient Guide to Services" booklet given to patients on admission showed the following direction:
- You have the right to expect that all communications and records pertaining to your care should be treated as confidential, except in cases of suspected abuse or public health hazards.

2. Record review of the facility's policy titled, "Patient's Bill of Rights (Adopted from the American Hospital Association) Patient Responsibilities", dated 09/09 showed the following direction:
- The patient has the right to every consideration of privacy;
- The patient has the right to expect that all communications and records pertaining to care should be treated as confidential.

3. Observation on 02/17/11 at 12:25 PM, in the Radiation Oncology admission office showed open shelves containing patient records. The record contained patient name, address, date of birth, age, social security number and health information.

During an interview on 02/17/11 at 12:25 PM, Staff NN, Registered Nurse RN, stated that facility housekeeping staff are in this office after hours to clean. Staff NN stated that no staff is in attendance during cleaning procedures (vacuuming, and trash removal of oncology admission office).

4. Observation on 02/17/11 at 12:55 PM, in the Special Procedures unit showed a box on the desk in the viewing room. The box contained patient folders with patient names, date of birth and previously taken radiology films. These file folders are left in the open unsecured box overnight for physician review prior to special procedures.

During an interview on 02/17/11 at 12:55 PM, Staff OO, RN, stated that facility housekeeping is in the Special Procedure unit after hours and no department staff is present. Housekeeping staff by licensure requirements are not authorized to access patient records. Patient records contained privileged information.

5. Observation on 02/17/11 at 02:35 PM, in the GI Lab showed patient records in an open box at the central nurses' station. Patient records contained patient names, addresses, date of birth, age, social security number and health information.

During an interview on 02/17/11 at 02:35 PM, Staff MM, RN, stated that facility housekeeping staff are in the GI Lab office after hours. Staff MM stated that no staff is in attendance during cleaning procedures.





6. Observation on 02/15/11 at 10:44 AM, on the neurology/orthopedic floor showed a mobile computer on a stand unattended in the public hallway. Current Patient #10's medical record was viewable on computer monitor to anyone who may have passed through in the hallway. Staff FFF, RN (Registered Nurse), stated that the computer monitor should be minimized.

7. Observation on 02/15/11 at 10:46 AM, on the telemetry floor showed a patient log on the upper counter of the nurses' station. The log was unattended and contained several names of patients and diagnostic tests for each patient. The print on the log was large enough to be read by anyone if they stood in front of the log at the nurses' station.

During an interview, Staff L, RN, stated that the list was a fax that someone laid on the counter and wasn't sure who it belonged to, but may be for one of the transporters.

8. Observation on 02/15/11 at 11:15 AM, on the telemetry floor showed a sheet of paper with patient names in public view on the upper counter of the nurses' station. The paper contained the names of several patients, vital signs and notes pertaining to each patient. The print on the paper was large enough to be read by anyone if they stood in front of the paper at the nurses' station.

During an interview, Staff K, RN, Director of Nursing (DON), stated that the list was from the previous night shift. After inquiring about the purpose of the list, Staff K moved the list to the lower part of the nurses' desk, out of sight by visitors.

9. Observation on 02/15/11 at 1:15 PM, on the acute medical care unit showed cardiac monitors hanging on walls in public hallways on both sides of the nurses' station. The cardiac monitors showed the first initial and last name of patients and their room numbers.

10. Observation on 02/15/11 at 1:20 PM, on the acute medical care unit showed a chart (containing partial medical record) sitting at the nurses' desk with Patient #12's first and last name and room number clearly visible from the public hallway.

11. Observation on 02/15/11 at 1:25 PM, on the acute medical care unit showed a mobile computer on a stand in the public hallway with a patient's medical record visible and unattended. After surveyor approached the mobile computer, Staff K closed the computer screen so it was no longer easily viewed by public.

12. Observation on 02/15/11 at 1:30 PM, on the acute medical care unit showed a clipboard laying on the upper counter of the nurses' station holding a piece of paper that contained the name, room number, and diagnosis of several patients. Staff K stated that the list belonged to a physician and was not moved off of or away from the nurses' station.

13. Observation on 02/15/11 at 1:40 PM, on the acute medical care unit showed a chart (containing partial medical record) on the upper counter of the nurses' station with a piece of paper attached to the front of the chart showing the name of Patient #13. The name of the patient was easily viewable from the public hallway.

14. Observation on 02/15/11 at 2:14 PM, on the acute medical care unit showed five patients' charts in a rack at the nurses' station. The binder of these charts had the first and last name and room number of five patients. These names were easily viewable from the public hallway.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure informed consent was obtained prior to the procedure for two patients' (#11, #12) and failed to ensure a consent for treatment was obtained for one (#8) of 16 patients' records reviewed for consents. The facility census was 284.

Findings included:

1. Record review of the facility's policy titled, "Informed Consent Policy", dated 04/10, showed the following:
- Informed consent is a process by which a physician or LIP (Licensed Independent Practitioner) provides adequate information to a patient or a patient's representative to allow him/her to make an informed decision about the proposed treatment, including medications or procedures.
- Prior to the procedure or treatment, the health care provider should disclose to the patient or representative in a manner and language which the patient or representative understands, all significant medical information the health care provider believes is necessary to make an informed decision whether to undergo the procedure or treatment. The information should include but not be limited to:
The nature of the patient's condition;
The proposed treatment and treatment alternatives - including no treatment;
The risks, consequences and benefits of the proposed procedure or treatment as well as frequently occurring risks and benefits of the proposed treatment alternatives, including having no treatment;
The individuals who will be providing treatment (i.e. residents, fell ows, students, and others);
An opportunity to ask questions and receive additional information if requested.
- Informed consent shall generally be obtained before each medical and surgical treatment or procedure.
- The physician or LIP (Licensed Independent Practitioner) must document in the medical record, or on an approved hospital form if applicable, consent for all medical or surgical treatments or procedures.

2. Review of current Patient #11's medical record showed he/she was admitted on [DATE] with syncope (dizziness) and chest pain. On 02/13/11 at 11:55 PM, the patient signed a consent for a Cardiac Cath (Cardiac Catheterization - using a catheter inserted into the body to examine the flow of blood around the heart). The portion of the consent that stated, "This Operation is to be performed by Dr." was blank with no physician's name written in the blank space provided. The patient had the Cardiac Cath on 02/14/11.

3. Review of current Patient #12's medical record showed he/she was admitted on [DATE] for Acute Respiratory Failure and Chronic Obstructive Pulmonary (lung) Disease showed the following:
- A telephone consent was obtained from the patient's representative on 02/01/11 at 2:00 PM, on a facility document titled, "Consent to Test for Antibodies to the Human Immunodeficiency Virus (HIV [virus that causes AIDS])". The section of the document that stated, "I hereby certify that I have informed the patient of the nature of the procedure(s) to be performed and the inherent risks involved, including those outlined above" to be signed by the physician, was left blank with no physician signature.
- A telephone consent was obtained from the patient's representative on 02/10/11 at 5:00 PM, for Hemodialysis (procedure where tubes are connected to the patient's blood vessels and the blood is slowly removed from the patient and sent through a machine to remove toxins and extra fluid before the blood is pumped back into the patient). The section of the document that stated, "I hereby certify that I have informed the patient of the nature of the procedure(s) to be performed and the inherent risks involved, including those outlined above" to be signed by the physician, was left blank with no physician signature.

During an interview on 02/15/11 at 2:35 PM, Staff N, Registered Nurse/Educator, stated that he/she was not sure if a physician needed to sign the consent for hemodialysis or sign a consent to test for antibodies to the Human Immunodeficiency Virus (HIV). Staff N stated that they use the same consent form for everything. Note: The facility's form was titled, "Consent to Test for Antibodies to the Human Immunodeficiency Virus (HIV)" and had a section that stated, "I hereby certify that I have informed the patient of the nature of the procedure(s) to be performed and the inherent risks involved, including those outlined above" followed by a line that stated, "Signature of Physician", which was blank. Staff N contacted the laboratory and was told they do not need the physician's signature on the consent for HIV testing. It is not clear as to why the facility's form would prompt a physician's signature but not be required or how the consent was an informed decision.

During an interview on 02/15/11 at 2:38 PM, Staff K, Director of Nursing, stated that a physician's signature was not needed for the hemodialysis consent. There was no evidence to show how the patient's (or representative's) consent was informed.




4. Record review of current Patient #8's medical record showed he/she was admitted for treatment of gastritis, nausea and vomiting on 02/13/11 through the Emergency department. The record did not contain a general consent for treatment.

During an interview on 02/15/11 at 3:00 PM, Staff H, Registered Nurse Supervisor reviewed the patient's medical record and verified the record did not contain a consent for treatment. He/she then called the admission department and the admissions department did not have the consent for treatment. Staff H stated that the consent for treatment, "fell through the cracks".
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, interview, and record review the facility failed to provide patient privacy by turning off a video monitor while the patient was physically exposed for one (#6) of one patient's video recording reviewed and failed to provide privacy of patient's location in the facility for 35 of 57 patients on the 7th floor Telemetry Unit. The facility census was 284.

Findings Included:

1. Record review of a facility policy titled, "Security Search of Patients in the Emergency Department" dated 08/16, showed direction for facility staff to be as non-stigmatizing and unobtrusive as possible when searching patients. The policy also showed direction for facility staff to turn the video camera off while the patient changes from street clothes to paper scrubs.

2. Review of a physician's consultation report dated 02/15/11, showed Patient #6 was admitted via the Emergency Department (ED) on 01/08/11 with a diagnosis of depression and suicidal ideations. The patient had attempted suicide by medication overdose.

During an interview and by observation of the video monitor at the nurses' station on 02/15/11 at 10:50 AM, showed the video monitor feed of two examination rooms (rooms #16 and #17) in the ED can be turned off temporarily to provide the patient privacy. Staff C Registered Nurse Director, and Staff EEE Unit Secretary, both stated that the security dispatch staff monitor rooms #16 and #17 after notification a patient has been placed in one of these rooms. The security dispatch staff focus their video camera lense, from a generalized area in the ED, and point it toward the video monitor at the ED nurses' station showing the ED video feed of these two rooms; however, the ability to turn the camera on/off is solely at the discretion of the ED staff because the on/off switch is physically located on the video monitor in the ED at the nurses' station.

During an interview on 02/15/11 at 2:07 PM, Staff G, Security Manager, stated that staff in the ED have control of patient privacy. The video monitor viewed by the security dispatch is clear and recorded.

Observation on 02/16/11 at approximately 2:15 PM, of recorded video evidence from the ED dated 01/08/11, provided by the facility security, showed facility staff removing Patient #6's clothing. The patient was completely physically exposed (without clothing) to all staff in the ED examination room , those watching the video monitor at the nurses' station and the security dispatch staff. The Unit Secretary at the nurses' station failed to turn the video camera off.





3. Observation on 02/16/11 at 1:15 PM, of the 7 th floor, Telemetry Unit, showed a telemetry monitor placed in the hallway where public passes that had the full last name, first initial, and the room number and bed location of patients' that was clearly visible.

4. Observation on 02/16/11 at 1:30 PM, of the 7 th floor, Telemetry Unit, showed two nurses in the corridor working at a computer on wheels, This computer on wheels had a screen that had patients' full last name that was clearly visible to the public at approximately two feet away from the computer monitor.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to:

-Ensure agency Registered Nurse (RN) staff had training to provide appropriate care to patients with resistive behaviors in the Emergency Department (ED).
-Thoroughly investigate an allegation of abuse (Patient #41); therefore, failed to develop interventions to prevent a further allegation of abuse (Patient #6) involving the same agency RN.
-Report these alleged abuse incidents regarding Patients #6 and #41 to the State agency per regulation.
-Ensure patient safety by allowing Staff P, agency RN, to continue to work for one and one-half hours after an alleged incident of abuse regarding Patient #6.

Three patients were reviewed with a mental health diagnosis and/or resistive behaviors in the ED. The facility census was 284.

Findings Included:

1. Review of a facility policy titled, "Complaint Management, Service Recovery and Grievance," revised 12/28/09, showed direction for staff to document complaints/resolutions by entering the information into the complaint management database.

Review of a facility policy titled, "Abuse or Neglect of Adult," revised 01/10, showed the following:

-Direction for staff to immediately report circumstances which would reasonably result in abuse or neglect.
-When recording suspected or observed abuse, it is necessary that thorough documentation be completed.
-Training of employees will include how to prevent and manage aggressive and violent patients.
-Individuals under investigation will be suspended immediately.
-An investigation will be conducted by the head of the department with the assistance of Risk Management and Human Resources.

Review of a physician's consultation report dated 02/15/11, showed Patient #6 (MDS) dated [DATE] with a diagnosis of depression and suicidal ideations. The patient had attempted suicide by medication overdose. Patient #6 was placed in isolation room #17 in the ED related to his/her diagnosis.

Observation and interview on 02/15/11 at 10:50 AM, of a video monitor at the nurses' station in the ED, showed the video feed of two examination rooms (rooms #16 and #17), considered isolation rooms and utilized for mental health patients that can be a safety risk. Staff C, RN ED Director stated that the isolation rooms were used for mental health patients. The video monitor feed was used to monitor the patient and staff for safety.

Observation on 02/16/11 at approximately 2:15 PM, of recorded evidence from the ED, dated 01/08/11 from 11:10-11:35 AM, provided by facility security staff, showed Staff P pushing through three security staff to physically restrain Patient #6. The patient resisted, spat and verbalized displeasure (yelled, cursed, and threatened to fight) at being forced to remove his/her clothes. ED Charge Nurse, Staff R medicated the patient with an injection and, soon after, someone in the room (difficult to tell who) began cutting the clothes off of Patient #6, despite what Staff R had stated in the ED examination room. Staff R directed all staff not to cut the clothing off of Patient #6, to let the medication have time to take effect. The patient was resisting, spitting, and verbal (yelling, cursing and threatening). The resistance continued until Staff P held the patient's head and turned his/her face/head away from himself/herself and other staff. In order to direct the patient's face away from all staff, Staff P had to reach over the patient, placing his/her chest over the patient's chest (turning the patient's face toward the farthest side rail from Staff P).

During an interview on 02/16/11 at 11:48 AM, Staff R stated the patient had been very combative and had to be put in four-point restraints. Staff R medicated the patient and Staff P was told not to cut the clothes off of the patient. Staff R stated that he/she had witnessed Staff P to have a short fuse before, but nothing physical until this incident. Staff R stated that Staff P continued working with patients for one and one-half hours after this incident/allegation.

During an interview on 02/16/11 at 1:40 PM, Staff FF, Security Officer, stated that it was the ED facility policy for the patients admitted to isolation to remove their street clothes and put hospital scrubs on (for safety). Patient #6 was not cooperative, and did not want to remove his/her clothing. Security staff in the ED isolation room #17 (three at the time) talked to and attempted to calm the patient. The patient stated that he/she would fight them if they tried to remove his/her clothing. The patient was controlled by security and staff, but the patient fought them, spat and was verbal back and forth (calling Staff P fat, yelling and cursing, and Staff P telling the patient he/she could not do anything as he/she was restrained) with Staff P. The patient was restrained with four-point leather restraints. Staff FF stated Staff P was borderline rough with the patient. Staff FF stated the facility staff had not interviewed him/her regarding this alleged abuse.

During an interview on 02/16/11 at 3:02 PM, Staff Q, Lead Security Officer, confirmed the above and also stated that Staff P walked through the security staff, ignoring their attempts to calm the patient, and was the first to physically touch the patient. The patient became very combative. After the patient was restrained, Staff P still antagonized the patient by being verbal (arguing, yelling and cursing). Medications were administered to the patient by Staff R and Staff P was told not to cut the clothes off of the patient, to let the medication have time to work first. Staff P went ahead and cut the clothes off of the patient, further agitating the patient. Staff Q stated that Staff P pushed the patient down in the bed (after the patient spit) and held the patient's face (all per the video-not actually witnessed). Staff Q stated, at one point, another security staff told agency Staff P, that he/she had done enough to complicate the situation. Staff Q stated the facility staff had not interviewed him/her regarding this alleged abuse.

Review of the facility's internal investigation, undated, of the alleged abuse showed the following:
-A Security Incident Report filed by Staff Q reporting the events witnessed submitted to the Security Manager and Risk Management.
-An e-mail from the house Supervisor, RN Staff DDD, to additional administrative staff alerting them to the incident. This e-mail documented that Staff P was informed he/she was suspended at 1:15 PM, or two hours after the incident.
-Interview of six staff members by Risk Management, none of which were in the ED examination room #17 at the time of the incident. They based their responses on the video.
-Facility staff failed to interview the patient, Staff P, two ambulance staff, and the three security officers witnessing most of the situation.

During an interview on 02/17/11 at 12:38 PM, Staff B, Risk Manager, stated that the House Supervisor contacted her/him on 01/08/11 (a Saturday) to explain the incident and the need to send Staff P home. Staff B investigated the incident for the ED Director as she/he was new to the department. Staff B stated she/he did not interview the patient, ambulance staff, or security witnesses. Staff B stated she/he did not review Staff P's personnel file or training. Staff B stated the video was compelling, Staff P was sent home and ultimately terminated. Staff B stated he/she thought all was done. Staff B stated she/he was unaware all alleged abuses needed to be reported to the State agency. Staff failed to thoroughly investigate and/or determine interventions to prevent further occurrence.

During an interview on 02/18/11 at 9:00 AM, Staff DDD, House Supervisor, stated that the charge nurse told him/her that Staff P used excessive force to control the patient. Before viewing the tape, Staff DDD told Staff P to discontinue patient care. Staff DDD later (at 1:15 PM) told Staff P he/she was suspended pending an investigation and security walked Staff P out of the building. Staff DDD failed to interview the ambulance staff, or all of the security witnesses. Staff DDD stated that the expectation of the charge nurse, Staff R, after witnessing Staff P antagonizing the situation, would be to remove him/her from the patient before further agitation could occur.

During an interview on 2/24/11 at 3:02 PM, Staff P stated other nurses in the ED requested his/her help with Patient #6 in room #17. Staff P was unaware security staff were already in the room and had been talking to the patient for about 15 minutes. Staff R, told them enough talk, just do what we need to do (take clothes off). We (security and Staff P) moved slowly toward the patient. The patient was threatening to fight, kicking. After controlled with four-point restraints, the patient began trying to bite and spit. A paper nose/mouth mask was applied, but the patient bit it off. Staff R, gave the patient an injection and a paramedic (did not know name) began cutting off the patient's clothes. Patient #6 was spitting again so Staff P turned the patient's face away and held his/her head until another spit mask could be placed on. Staff P told the patient the restraints could be taken off if he/she would calm down. The patient apologized and Staff P left the room. Staff P continued to care for patients in the ED for approximately two hours before he/she was told he/she needed to leave the premises.

Review of documented evidence of computer log-ins, undated, by Staff P showed he/she logged in on three separate patients from 12:33 PM through 1:05 PM.

Review of Staff P's personnel file, on 02/16/11, showed Staff P initially began in the ED on 09/21/10. Neither the agency nor the facility could provide evidence of mental health training prior to, or since the start date for Staff P.

2. Review of an Incident Report (We Care) dated 12/14/10, showed Patient #41 complained that Staff P "Pushed me into the wall when I was in a wheelchair. My right foot got jammed." Patient #41 pointed to a scab and stated that it was from the injury (occurred in the ED on 12/12/10).

Review of the facility's complaint/grievance logs for the prior six months showed Patient #41 complained on 12/14/10 of physical abuse by Staff P. The allegation was not investigated; therefore, no intervention such as training was provided.

During an interview on 02/18/11 at 10:59 AM, Staff T, Manager Psych unit, stated that Patient #41 was admitted on [DATE]. The patient had a small scab (pea-sized) on the foot. Staff T could not remember which foot or where on the foot the scab was. Staff T stated the report of abuse was documented and reported to the manager of the ED, RN Staff C. A request of documented investigation was refused by Staff T.

During an interview on 02/18/11 at 12:15 PM, Staff C stated he/she had no idea what was done with the above investigation. Staff C stated the previous manager would have done the investigation and it could not be found. Staff failed to investigate this allegation of abuse, and failed to develop interventions to prevent recurrence as evidenced by the incident on 01/08/11, less than one month later, by the Staff P.

3. Review of further agency ED RNs' personnel files on 02/17/11, showed that six additional agency staff did not have any mental health training prior to or since hire. The facility staff failed to ensure agency staff had the appropriate training to work with patients' specific mental health needs.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review, and interview the facility:
- failed to provide a safe environment for 33 of 40 patients by allowing non-suicide resistive shower water control knobs and exposed plumbing from the toilet in seven of 20 patient bathrooms. The configuration of these water control knobs create a looping hazard (material or a device could be looped around the knobs/plumbing for choking or strangulation) (A-144);
- failed to provide a safe environment by not securing furniture in 19 of 20 behavioral health rooms, which could be thrown or easily positioned and used as a barricade or placed under a device used for hanging (A-144);
- failed to provide continuous observation of high risk behavioral health patients or replace old door hardware in 20 of 20 patient bathrooms, which can be a looping hazard (A-144);
- failed to thoroughly investigate an allegation of abuse (A-145);
- failed to develop interventions to prevent a further allegation of abuse (A-145);
- failed to report alleged abuse incidents to the State agency per regulation (A-145);
- failed to ensure patient safety by allowing the agency RN Staff P to continue to work for one and one-half hours after an alleged incident of abuse (A-145).

Due to the severity of the situation and the potential harm to all patients in the facility, this resulted in overall noncompliance with the Condition of Participation: Patient Rights CFR 482.13 and demonstrates an unsafe patient care environment. This situation constituted a condition of Immediate Jeopardy.

At the time of the exit conference at 3:20 PM on 02/18/11, the facility had implemented actions to abate this immediate jeopardy situation.

The facility census was 284.