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.

ST ALEXIUS HOSPITAL 3933 S BROADWAY SAINT LOUIS, MO 63118 Oct. 13, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review and policy review, the facility failed to ensure:
- Staff K, Patient Care Technician, was immediately removed from patient care after an allegation of abuse of Patient #7 (A-0144).
- A timely investigation of abuse or neglect allegations was completed for one staff member (Staff K) of one accused (A-0145).
- Staff education was started immediately to prevent further cases of abuse or neglect (A-0145).
- Patients were informed of, and consented to, Electroconvulsive Therapy (ECT, procedure, done under general anesthesia, where electric currents are passed through the brain) prior to receiving ECT for two patients (#24 and #27) of three patients reviewed for informed consent for ECT. This prevented the patient (or patient representative) from being informed about health care decisions and could affect all patients who received ECT (A-0131).
- Medicare Beneficiary's or their representatives were provided a copy of the Important Message From Medicare (IM) upon inpatient admission and discharge to ensure they were aware of their discharge and appeal rights (A-0117).

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient Rights.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, policy reviews and medical record reviews the facility failed to:
- Have a policy and procedure in place that ensured that patients understood and received a copy of the Important Message From Medicare (IM).
- Provide a copy of the IM to patients unless requested for nine Patients (#3, #4, #5, #17, #18, #19, #21, #22 and #23) of nine patients reviewed;
- Follow up or document when Patient #23 could not sign for the IM and the patient's representative could not be reached; and
- Have a process in place to ensure patients on 'Observation' (Observation services are hospital outpatient services given to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged ) status were provided an IM when converted to 'Inpatient' status for one patient (#21) of one patient reviewed on observation status.
These failed practices had the potential to affect all Medicare recipients from reviewing or accessing their discharge or discharge appeal options as a Medicare Beneficiary. The facility census was 101 with 51 current Medicare Beneficiaries.

Findings included:

1. Record review of the facility's policy titled, "An Important Message From Medicare," revised 05/29/15, showed:
- The Medicare beneficiary letter "An Important Message From Medicare" must be provided to all beneficiaries within 48 hours of the beneficiary's admission. This includes all inpatient or observation admissions.
- This letter must be given at the time of admission or within 48 hours of admission.
- Patients or their representatives will need to sign, date and time this notice acknowledging they have received the notice.
If the beneficiary is too ill to acknowledge or sign the notice, the following steps are to be taken:
- If unable to obtain from the patient or family and the notice is not received within forty-eight (48) hours from the time of admission, a telephone call is made to the next of kin or patient's representative. All efforts to contact the patient's next of kin or patient representative must be documented i.e. (date, time, phone number called, who was spoken too etc.).
- The Admitting Lead will review all Medicare patient registration the next business day to identify the notices missing, if any. If missing, the registrar on duty will need to go to the floor to deliver this notice and obtain the patients or their representative's signature.

2. During an interview on 10/11/16 at 2:45 PM, Patient #3 in the Intensive Care Unit (ICU) stated that he had not received his Patients' Rights and did not have a copy of the IM. He stated that he did not know his discharge or appeal rights afforded him as a Medicare Beneficiary.

During an interview on 10/11/16 at 3:00 PM, Patient #19 stated that he did not have a copy of the IM and wasn't aware of that piece of paper.

During an interview on 10/12/16 at 9:25 AM, Patient #5 stated that he didn't know what the IM was and had to trust his doctor and caregivers to do the right thing.

During concurrent interviews on 10/11/16 at 3:20 PM, Staff D, Director of Patient Financial Services, and Staff E, Supervisor Admitting and Operations, stated that the procedure for the IM is that it would be signed by the patient upon admission and discharge but the patient would not be given a copy unless they asked for one.

3. Record review of the medical records for Patients (#3, #4, #5, #17, #18, #19, #22 and #23) showed the original IM in the patients' medical record.

4. Record review of the medical record for Patient #23 showed that the patient had been admitted on [DATE] to the ICU. His IM in the medical chart was dated 09/20/16 and the Patient or Representative signature line read, "Left message for guardian". The facility could not provide any follow-up documentation or evidence that the patient's representative had ever been reached or that the IM had been given/mailed to either the patient or the representative.

5. Record review of the medical record for Patient #21 showed that that the patient had entered the facility on 09/30/16 on 'Observation' status and was changed to 'Inpatient' status 10/06/16. The patient was a Medicare Beneficiary but there was no IM in the patient's chart.

During an interview on 10/12/16 at 11:00 AM, Staff E stated that there was no clear process to give the IM to patients switching from Observation status to Inpatient status.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on interview, record review and policy review, the facility failed to ensure that patients were informed of and consented to Electroconvulsive Therapy (ECT, procedure, done under general anesthesia, where electric currents are passed through the brain) prior to receiving ECT for two patients (#24 and #27) of three patients reviewed for informed consent for ECT. This prevented the patient (or patient representative) from being informed about health care decisions and could affect all patients who received ECT. The facility conducts approximately 150 ECT procedures per month. The facility census was 101.

Findings included:

1. Record review of the facility policy titled, "Informed Consent," dated 02/2016, showed the following:
- All adults have the right to make decisions regarding their treatment and to be provided sufficient information in order to make informed decisions regarding their healthcare.
- Informed consent must be obtained and documented before proceeding with surgical or medical procedures, except in emergency situations.
- Informed consent was valid for a maximum of 30 days for inpatients and outpatients, unless there was a change in the patient's condition or revoked by the patient or patient representative.

Record review of the facility's policy titled, "Electroconvulsive Therapy," dated 06/2016, showed that an informed consent for ECT will be obtained from the patient and placed in the patient's medical record.

2. Record review of Patient #24's medical record showed:
- Pre-typed orders dated 10/03/16 for ECT, which were not signed (indicated the order was incomplete);
- An operating room record for the patient's ECT procedure completed on 10/03/16 at 9:02 AM; and
- No consent for the ECT.

3. Record review of Patient #27's current medical record showed:
- A History and Physical (H&P) with 09/17/16 as the date of the patient's admission.
- Pre-typed orders for ECT dated 10/05/16, for the patient to receive ECT every Monday, Wednesday and Friday.
- No consent for the ECT.

During an interview on 10/12/16 at 11:15 AM, Patient #27 stated that he had not signed consent for the ECT treatments received during his current admission.

Record review of Patient #27's discharged medical record showed:
- A physician order dated 07/17/16 at 7:56 PM, to obtain consent for ECT treatment.
- A physician order dated 07/18/16 at 12:34 AM for ECT.
- No consent for the ECT.

Record review of Patient #27's preference card (an index card kept in the operating room, which documented the date, medication amounts, and electrical current used during ECT, showed that the patient received ECT on 07/18/16, 07/20/16, 07/22/16, 08/10/16, 08/17/16, 08/19/16, 08/24/16, 08/31/16, 09/02/16, 09/07/16, 09/23/16, 09/26/16, 09/28/16, 09/30/16, 10/03/16, 10/05/16, 10/07/16, 10/10/16 and 10/12/16.

During an interview on 10/12/16 at approximately 1:30 PM, Staff A, Quality Risk Manager, presented a consent form, signed by Patient #27 and dated 01/13/16, for the patient to receive 20 ECT treatments. Staff A stated that the consent covered the current ECT that the patient received (consent is good for up to 30 days, per hospital policy).
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 policy review, the facility failed to provide a safe environment on the Behavioral Health Unit (BHU) when they failed to remove one alleged perpetrator (Staff K) from patient care during an investigation of an incident of alleged physical abuse of one of one patient (#7). The failure to remove the alleged perpetrator from patient care resulted in an unsafe environment for all patients and had the potential to place all patients admitted to the facility at risk for abuse. The facility census was 101. The BHU census was 61.

Findings included:

1. Record review of the facility's policy titled, "Abuse and Neglect," dated 09/2016 showed that abuse was defined as the infliction of physical, sexual, verbal, or emotional injury or harm, including financial exploitation, by another person, firm or corporation. When allegations of abuse by a hospital employee were made, the manager of the area will immediately remove the staff member from patient care.

2. During an interview on 10/06/16 at 2:25 PM, Staff A, Quality and Risk Manager, stated that the Abuse and Neglect policy was revised on 09/13/16, and that prior to the revision, the policy did not give direction to immediately remove a staff member from patient care when there were allegations of abuse by that staff member.

3. Record review of Patient #7's medical record showed that he was a [AGE] year old male who was admitted to the facility's BHU on 08/22/16 with the diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal thought processes and inappropriate emotions), Dementia (a mental disorder caused by brain disease or injury that causes memory disorders, personality changes, and impaired reasoning), and Traumatic Brain Injury (a brain dysfunction caused by an outside force, usually a violent blow to the head). The record also showed the following:
- The patient had a court appointed guardian.
- He lived at a Skilled Nursing Facility (SNF), and was admitted to the BHU for aggression towards peers and staff at the SNF.
- Physician Progress Note dated 09/10/16 showed that the patient had a sitter (staff member who remains with the patient at all times) for safety due to being a high fall risk because of unsteady gait.
- Nursing Daily Focus Assessment Report (a daily documentation record of nursing assessment and plan) dated 09/10/16 showed that the patient had a 1:1 sitter for safety.
- Nursing Daily Focus Assessment Report dated 09/10/16 at 11:19 PM noted that, "patient stated that someone beat him up".
- Nursing Daily Focus Assessment Report dated 09/10/16 at 11:19 PM also showed assessment of injury to patients left forearm described as a skin tear, a small abrasion to the left eyebrow, scratches to the left side of chest and upper abdomen, and scratches to the right side of neck.

4. Record review of photographs of Patient #7 by Staff L, Registered Nurse (RN), on 09/10/16 at 10:30 PM showed the following:
- Right side of the neck had multiple red scratches running laterally (to the side),
below his right ear. At least five separate scratches were noted with one large scratch in the center. The document the photograph is placed on defined the size as 4 centimeters (cm, a unit of measurement) in length.
- Left side of the chest had multiple scratches of differing severity as well as less prominent scratches to left upper abdomen.
- Left eyebrow showed an abrasion with a red wound bed that was noted by Staff L to be 1.5 cm in length.
- Left forearm showed a 0.5 cm in length skin tear with a red wound bed that was surrounded by multiple long scratches.

5. Review of an email with the subject line,"MEMO For the Record", dated 09/12/16, written by Staff G, Nursing Supervisor of the timeline of events on 09/10/16 and 09/11/16 showed:
- On 09/10/16 at 11:30 PM, Staff H, PCT, reported that Staff K had punched and choked the patient.
- Staff G assessed Patient #7 and noted the injuries described in the photographs taken by Staff L.
- Staff K was removed as the sitter and replaced with Staff I, PCT.
- On 09/11/16 at 12:15 AM, Staff H confirmed she witnessed Staff K punch the patient in the head several times and choke him, and put her knee in his chest to hold him down.
- On 09/11/16 at 8:30 AM Message left for social services and Staff P, Director of Psychiatric Services was contacted. Message also left with the guardian.
- On 09/11/16 at 8:55 AM Staff K contacted and informed of suspension and need for investigation.

6. Record review of the facility timecard for Staff K, PCT showed that although Staff K was removed from Patient #7's care, she continued to work until 09/11/16 at 7:23 AM, when her shift ended.

During an interview on 10/12/16 at 7:30 AM, Staff H, PCT, stated that on 09/10/16 she witnessed Staff K punch the patient, and swipe her foot under his foot in order to cause him to fall to the ground. Staff K then was on top of the patient with her knee on his chest and punched and choked him. She reported being shocked by what she had seen and the delay in immediately contacting the nurse or her supervisor was due to her shock over the event.

Staff K, PCT and alleged perpetrator, resigned on 09/23/16 prior to the facility's planned termination. Staff I, PCT and staff member that conspired with Staff K to tell nursing and leadership that the patient received his injuries due to a fall, was terminated by the facility on 09/27/16.

The Nursing Supervisor did not remove the alleged perpetrator from direct patient care after the allegation of abuse or neglect, and allowed Staff K to continue to work with direct patient care on another BHU in the facility, placing additional patients at risk for abuse.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility failed to prevent abuse of one patient (#7) out of one psychiatric patient allegedly abused on a Behavioral Health Unit (BHU), when a staff member punched and choked the patient. The facility also failed to complete a timely investigation of the event and begin immediate staff education regarding abuse and neglect. This failure had the potential to place all patients admitted to the facility at risk for their safety from abuse or neglect by staff members. The facility census was 101, the Behavioral Health census was 61.

Findings included:

1. Record review of the facility's policy titled, "Abuse and Neglect," dated 09/2016 showed:
- Abuse was defined as the infliction of physical, sexual, verbal, or emotional injury or harm, including financial exploitation, by another person, firm or corporation.
- Eligible adult was defined as a person of 18 years of age and older who is unable to protect his or her own interest or adequately perform or obtain services which are necessary to meet his essential human needs.
In regards to Abuse/Neglect by an employee:
- Nurse Manager to notify the Risk Manager and secure statements from all staff that worked the shift in question.
- Nurse Manager to obtain fact-based reports from the patient or other witnesses if they were able to make such a report.
- Documentation to be completed and a determination to be made to self-report to the hotline.
- An Abuse Checklist to be completed by the Nurse Manager and forwarded to the Supervisor of Social Services/Nurse Manager and Director of Quality and Risk Management to file for the case and inclusion in Abuse/Neglect Log that was maintained by Guest Relations/Social Services.
- Education: The hospital, during its orientation program, and through an ongoing training program, to provide all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection.

2. Record review of Patient #7's medical record showed that he was a [AGE] year old male who was admitted to the facility's BHU on 08/22/16 with the diagnosis of Schizoaffective Disorder (a mental disorder characterized by abnormal thought processes and inappropriate emotions), Dementia (a mental disorder caused by brain disease or injury that causes memory disorders, personality changes, and impaired reasoning), and Traumatic Brain Injury (a brain dysfunction caused by an outside force, usually a violent blow to the head). The record also showed:
- The patient had a court appointed guardian.
- He lived at a Skilled Nursing Facility (SNF), and was admitted to the BHU for aggression towards peers and staff at the SNF.
- Physician Progress Note on 09/10/16 showed that the patient had a sitter (staff member who remains with the patient at all times) for safety due to being a high fall risk because of unsteady gait (the manner in which a person walks).
- Nursing Daily Focus Assessment Report (a daily documentation record of nursing assessment and plan) on 09/10/16 showed that the patient had a 1:1 sitter (one staff member whose only assignment was to monitor the patient) for safety.
- Nursing Daily Focus Assessment Report on 09/10/16 at 11:19 PM noted that, "patient stated that someone beat him up" and scratches were noted on the patient's chest.
- Nursing Daily Focus Assessment Report on 09/10/16 at 11:19 PM also showed assessment of injury to patients left forearm described as a skin tear, a small abrasion to the left eyebrow, scratches to the left side of chest and upper abdomen, and scratches to the right side of neck.

3. Record review of photographs of Patient #7 taken by Staff L, Registered Nurse (RN), on 09/10/16 at 10:30 PM showed:
- Right side of the patient's neck had multiple red scratches which ran laterally below his right ear. At least five separate scratches were noted with one large scratch in the center, documented as 4 centimeters (cm, a unit of measurement) in length.
- Left side of his chest had multiple scratches of differing severity as well as less prominent scratches to left upper abdomen.
- Left eyebrow showed an abrasion with an open wound that was noted by Staff L to be 1.5 cm in length.
- Left forearm showed a 0.5 cm in length skin tear that was surrounded by multiple long scratches.

4. Review of an email with the subject line, "MEMO For the Record", dated 09/12/16, written by Staff G, Nursing Supervisor regarding the timeline of events and actions taken on 09/10/16 and 09/11/16 showed:
- 09/10/16 at 11:30 PM Staff G was called by Staff L, RN, who reported that Patient #7 had a near fall and was caught by Staff K, Patient Care Tech (PCT), but in the process of stopping the patient from falling, she had scratched him. Staff I, PCT, confirmed there was a fall.
- On 09/10/16 at 11:30 PM, Staff H, PCT, reported that Staff K had punched and choked the patient.
- Staff G assessed Patient #7 and noted the injuries described in the photographs taken by Staff L.
- Staff members still present (four out of the six involved) were asked to write statements.
- On 09/11/16 at 12:15 AM, Staff H confirmed she witnessed Staff K punch the patient in the head several times and choked him, and put her knee in his chest to hold him down.
- On 09/11/16 at 8:30 AM, Staff G left a message related to the incident for social services and contacted Staff P, Director of Psychiatric Services. A message was also left with the guardian.

During an interview on 10/12/16 at 7:30 AM, Staff H, PCT, stated that on 09/10/16 she witnessed Staff K punch the patient, and swipe her foot under his foot in order to cause him to fall to the ground. Staff K then was on top of the patient with her knee on his chest and punched and choked him. She reported being shocked by what she had seen and the delay in immediately contacting the nurse or her supervisor was due to her shock over the event.

During an interview on 10/6/16 at 3:45 PM, Staff P, Director of Psychiatric Services, and Staff A, Quality and Risk Manager stated that:
- On 09/11/16, Staff P was made aware of the incident;
- On 09/12/16, Staff A was made aware of the incident, and Staff P reported she reviewed the medical record and assessed the patient. They contacted Staff H (witness to the alleged abuse by the AP) to obtain a verbal statement;
- On 09/13/16, Staff H's written statement was received. Staff P stated that after reviewing the written statement, it "filled in missing pieces" in regards to their understanding of the events.
- On 09/15/16, they interviewed Staff I, PCT, who initially confirmed the original story that the patient had fallen, and that there was no abuse. Staff I then admitted that Staff K had told him that she had "roughed up" the patient, and that he should have said something in the beginning.
- On 09/16/16, a formal in person interview was conducted with Staff H who confirmed her written statement.
- On 09/16/16 (six days after the alleged abuse) abuse and neglect education began with Nursing Supervisors and leadership.
- On 10/03/16 (23 days after the alleged abuse), abuse and neglect education began with patient care staff.
- They recognized the facility needed to improve their abuse and neglect investigation and reporting process.

Staff K, PCT and alleged perpetrator (AP), resigned on 09/23/16 prior to the facility's planned termination. Staff I, PCT and staff member that conspired with Staff K to tell nursing and leadership that the patient received his injuries due to a fall, was terminated by the facility on 09/27/16. Staff K and Staff I were unable to be contacted for interview.

Interviews were not immediately conducted following the allegation of abuse of Patient #7, and staff had difficulty determining what days the interviews were conducted and referred to multiple calendars to determine those dates when asked about the timeline. Education to Nursing Supervisors regarding the expectation of removal of staff from direct patient care after an accusation of abuse or neglect did not occur until 09/16/16, and general staff education did not begin until 10/03/16. The lengthy investigation process delayed education of staff members as well as reinforcement of expectations of leadership, and had the potential to expose all patients in the facility to the risk of continued abuse or neglect by staff members.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record reviews and interviews the facility failed to follow policy and procedure
when it allowed Nurse Practitioners (NP's) to order restraints and/or seclusion for six Patients (#27, #36, #37, #34, #35 and #38) of six patients reviewed on the Fourth Floor Behavioral Health Unit (BHU), Emergency Department (ED)and the Intensive Care Unit (ICU). This had the potential for a high risk of harm and safety for all patients placed in restraints. The facility census was 101.

Findings included:

1. Record review of the facility's policy titled, "Restraints or Seclusion," last reviewed 02/2016, showed:
- A Licensed Independent Practitioner (LIP) is a practitioner permitted by both law and the hospital as having the authority under his/her license to independently order restraints, seclusion, or medications for patients.
- Currently state law only permits physicians (MD, Medical Doctor or DO, Doctor of Osteopathy) to order restraints or seclusion.
- A physician who is responsible for the care of the patient must order the restraint or seclusion.

2. Record review of Patient #27's physician orders, showed a telephone order for restraints dated 10/02/16 at 6:07 PM, from Staff AA, NP. The patient was on the fourth floor BHU.
During an interview on 10/12/16 at 9:34 AM, Staff EE, BHU Director, stated that until September, 2016, NP's were unable to order restraints. Staff EE stated that the facility changed the restraint policy for behavioral health patients at that time, which allowed NPs to order restraints.

3. Record review of the facility's document titled, "Restraint Log," dated 08/2016, for the ED showed that Staff CC, NP, ordered locked seclusion for Patient #36.

4. Record review of the facility's document titled, "Restraint Log," dated 09/2016, for the ED showed that Staff BB, NP, ordered a four-point restraint (the application of limb restraints on both arms and legs at once) for Patient #37.

5. Record review of the facility's document titled, "Restraint Log," dated 06/2016, for the ICU showed that Staff OO, NP, ordered a four-point restraint (later changed to soft wrist) for Patient #34.

6. Record review of the facility's document titled, "Restraint Log," dated 07/2016, for the ICU showed that Staff OO, NP, ordered a soft wrist restraint for Patient #34.

7. Record review of the facility's document titled, "Restraint Log," dated 07/2016, for the ICU showed that Staff OO, NP, ordered a soft wrist restraint for Patient #35.

8. Record review of the facility's document titled, "Restraint Logs," dated 07/2016 and 08/2016, for the ICU showed that Staff OO, NP, ordered soft wrist restraints for Patient #38.

During an interview on 10/13/16 at 1:05 PM, Staff NN, Chief Nursing Officer (CNO), stated, "Yeah, Staff [P, Director of Psychiatric Services] said she called and asked the State if NPs could write orders for restraints and was told they could, but we'll need to change that".

During an interview on 10/13/16 at 1:55 PM, Staff A, Quality Risk Manager, stated that the logs were correct and the NP's had been writing orders for patients to be placed in restraints. She stated that the policy and procedure that Staff EE referred to was a draft and had not been approved by the Policy Committee that she chaired. She stated that they were not aware of the State law that prohibited NP's from writing orders for restraints/seclusion.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, record review and policy review the facility failed to:
- Acknowledge patient to patient violence as abuse, and failed to put interventions in place for four current patients (#16, #31, #32, and #33) out of four current patients reviewed on the Behavioral Health Units, who were at high risk for violent behavior. These failures had the potential to lead to injury and death, and could affect all patients in the facility (A-0395).
- Ensure an accurate medication administration process was in place for two patients (#24 and #27) out of three patients reviewed, who received Electroconvulsive Therapy (ECT, procedure, done under general anesthesia, where electric currents are passed through the brain). This failed practice could allow for medication errors and/or missed medications, which could affect patient outcomes for all patients who received ECT (A-0405).
- Accurately track the number of ECT treatments ordered for two current patients (#24 and #27) and one discharged patient (#45) of three patients reviewed who received ECT, which could lead to patients receiving less than or more ECT treatments than recommended or ordered (A-0395).
- Ensure pre-operative (pre-op) checklists were completed for two patients (#24 and #27) of two patients reviewed for ECT pre-op checklists, which could lead to errors related to the safety of the patient undergoing ECT (A-0395).

The severity and cumulative effect of these failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.
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 policy review the facility failed to:
- Evaluate the risk for violent behavior, and put interventions in place to prevent violent patient to patient behavior for four (#16, #31, #32, and #33) out of four current patients on the Behavioral Health Units (BHU).
- Accurately track the number of electroconvulsive therapy (ECT, procedure, done under general anesthesia, where electric currents are passed through the brain) treatments ordered for two current patients (#24 and #27) and one discharged patient (#45) of three patients reviewed who received ECT, which could lead to patients receiving too few or too many ECT treatments.
-Ensure pre-operative (pre-op) checklists were completed for two patients (#24 and #27) of two patients reviewed for ECT pre-op checklists, which could lead to errors related to the safety of the patient undergoing ECT.
These failures had the potential to lead to injury and death, and could affect all patients in the hospital. The facility census was 101 and the BHU census was 61.

Findings included:

1. Record review of the facility's policy titled, "Abuse and Neglect," dated 09/2016 showed:
- It is the policy of the facility that employees shall assess for and report in compliance with Missouri Law, all suspected abuse and/or neglect of children, eligible adults, nursing home patients, residents of facilities, in-home service clients or any other adult receiving care or services from an individual or firm with a legal or contractual duty to provide such care or services.
- Abuse was defined as the infliction of physical, sexual, verbal, or emotional injury or harm, including financial exploitation, by another person, firm or corporation.
- Eligible adult was defined as a person of 18 years of age and older who is unable to protect his or her own interest or adequately perform or obtain services which are necessary to meet his essential human needs.

Record review of the facility's policy titled, "Close Observation/Sitter/1:1 monitoring," dated 07/2014 showed:
- Close Observation is defined as needed when a patient is at risk to physically injure themselves or others. Close Observation does not require a physician order, but is based on nursing judgement.
- Sitter is defined as needed when a patient is at risk to physically injure themselves or others, and requires a designated staff member to monitor activity. One staff member can monitor up to four patients in one room. Sitter designation does require a physician order.
- One to One (1:1) is defined as needed when a patient has verbalized or exhibited intent to harm themselves or others. One staff member will monitor one patient and is required to be within arms- reach of the patient at all times.
- All patients are assessed on admission and throughout the hospitalization for patient safety risks.
- If risks are identified, staff were to initiate the appropriate level of observation. They are to contact the Nurse Manager or Supervisor prior to obtaining a physician order to initiate a sitter or 1:1 monitoring.

Record review of the facility policy titled, "Dr. Ryan" (an overhead code that calls for multiple staff members to respond to the location and assist with managing the patient), dated 05/2012 showed:
- The purpose is to outline procedures for managing threatening or combative patients. To provide for the care, welfare, safety, and security of the patient and intervening staff.
- If staff were unable to de-escalate a potentially threatening situation verbally, they were to call a "Dr. Ryan".
- Crisis Prevention Institute (CPI, a training method utilized by facilities to assist staff with managing threatening situations) interventions shall be utilized by staff when attempting to manage a patient during a Dr. Ryan.
- If a patient was injured during a Dr. Ryan, an incident report shall be completed. The Nursing Supervisor, Risk Management, and family are to be notified as soon as possible. If medical attention was needed, the attending physician and emergency room (ER) physician must be notified to see the patient.
- Nursing staff or social worker were to document the patient debriefing and make changes to the treatment plan as applicable.

2. Record review of Patient #31's medical record showed that she was a [AGE] year old female who was admitted to the facility's BHU on 02/03/16 with the diagnoses of Bipolar Disorder (a mental disorder marked by alternating periods of happiness and sadness), and Borderline Personality Disorder (a mental illness that causes intense mood swings, impulsive behaviors, and severe problems with self-worth) with mixed emotional features (a disturbance of normal emotions and conduct). Review of the History and Physical (H&P) showed that the patient had a history of becoming verbally abusive, physically threatening, and had previously attempted to choke herself due to attention seeking behavior.

Record review of Patient #31's Daily Focus Nursing Assessment Report (a daily documentation record of nursing assessment and plan) dated 10/12/16 at 1:55 PM showed that the patient was in an altercation with another Patient (#33). Patient #31 received marks on her right breast and on the left side of her stomach. The Registered Nurse (RN) was able to redirect the patient to her room. Current safety precautions before the event were documented as Close Observation, and current safety precautions after the event were documented as Close Observation.

Record review of Patient #31's Daily Observation Flowsheet (a daily documentation record that allows for staff to time stamp and sign their monitoring of the patient based on a level of observation and precautions that are noted on the form) dated 10/12/16 showed the patient was on routine 15 minute observation due to fall risk and Close Observation status. There was no indication on the form that the patient was at risk for exhibiting physically threatening behavior.

3. Record review of Patient #33's medical record showed that she was a [AGE] year old female who was admitted to the facility's BHU on 09/13/16 with a diagnosis of Paranoid Schizophrenia (false beliefs that a person or some individuals are plotting against them or members of their family).

Record review of Patient #33's Emergency Department (ED) record showed that the patient was brought to the ED on 10/12/16 at 1:43 PM due to an altercation with another patient and a report of a contusion to the forehead. The patient had two Computed Tomography Scans (CT, a type of computer imaging) of her head and face. The patient was discharged from the ED with the diagnosis of a head injury and returned to the facility's BHU.

During an interview on 10/13/16 at 10:00 AM, Staff P, Director of Psychiatric Services, stated that she had reviewed the incident report from the Dr. Ryan that was called for Patient #31's assault on Patient #33. She stated that Patient #33 was upset with the actions of Patient #31. Patient #31 moved closer to Patient #33, but she was smiling and laughing and showed no sign of aggression prior to reaching out and striking Patient #33. Staff was within arms-length of the women at the time of the event. Following the event, Patient #33 was moved to a different unit to prevent any further issues.

The only intervention by nursing staff following the patient to patient abuse was to relocate one of the patients involved. The facility failed to add any new interventions for closer observation following the physical altercation. The inability to determine any signs of impending violence from Patient #31 and her aggressive behavior placed all patients and staff at risk.

4. Record review of Patient #32's medical record showed that she was a [AGE] year old female admitted to the facility's BHU on 08/29/16 with a diagnosis of Schizoaffective Disorder (condition in which a person experiences a combination of symptoms such as hallucinations or delusions, and mood disorder symptoms, such as mania or depression).

Record review of Patient #32's Daily Focus Nursing Assessment Report on 09/19/16 showed:
- 11:50 AM, threatened to hit another Patient (#16) all morning. The other patient came at this patient and attempted to hit her. Witness stated patient was not hit, only her hair was brushed slightly by Patient #32's hand as it moved near her head.
- 11:50 AM, Current Precautions: Close Observation
- 2:50 PM, Patient (#16) ran towards this patient. Patient #32 grabbed Patient #16's hair as she was running towards her and threw her to the ground. Patient #32 had been threatening and taunting the patient all day.
- 2:50 PM, Current Precautions: Close Observation

Record review of Patient #32's Daily Observation Flowsheet for 09/19/16 showed that the patient was on routine 15 minute observation due to suicide precautions, fall precautions, seizure precautions, and Close Observation. These levels were the same for the entire day, including before and after the events with Patient #16.

5. Record review of Patient #16's medical record showed that she was a [AGE] year old female who was admitted to the facility's BHU on 06/21/16 with the diagnoses of Schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), Mild Mental Retardation (MR, a developmental disability that causes below average intelligence levels and limitations in daily living skills), and Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). The H&P noted that the patient had a history of physical aggression towards staff and residents at the long term care center in which she lived. Patient #16 also was noted to have a history of self harm without suicidal intent, and a history of becoming assaultive at times.

Record review of Patient #16's Daily Focus Nursing Assessment Report on 09/19/16 showed:
- 9:50 AM, stated that she was hearing voices to hurt herself and had a tearful episode where she was yelling loudly. Stated that another patient kept stating she was going to hit her.
- 9:50 AM, Current Precautions: Close Observation
- 11:45 AM, attempted to hit another Patient (#32). Per staff witness, Patient #16 did not make contact, but only brushed across the hair.
- 11:45 AM, Current Precautions: Close Observation
- 2:15 PM, went running after another Patient (#32) who grabbed this patient's hair and pulled her to the floor and her head hit the door.
- 2:15 PM, Current Precautions: Close Observation
- 2:55 PM, Patient transferred to another unit due to an altercation with the same patient twice in one day.

Record review of Patient #16's Daily Observation Flowsheet on 09/19/16 showed that the patient was on routine 15 minute observation due to fall precautions, seizure precautions, and Close Observation. These levels were the same for the entire day, including before and after the events with Patient #32.

Despite multiple events that occurred over a short period of time, no new interventions were implemented by nursing to provide for the safety of these two patients, and possibly prevent any further incidents of violence.

During an interview on 10/12/16 at 1:30 PM, Staff MM, Clinical Leader, stated that Patient #16 enjoyed being a victim, and that a 1:1 observation would just increase problems and validate her behavior. She noted that she was an MR patient, so she does act out and was unable to understand restraint and seclusion. They did not increase her observation status to 1:1 because it would have given her what she wanted.

During an interview on 10/13/16 at 10:00 AM, Staff P, Director of Psychiatric Services, stated:
- They can't always reason or keep patients away from one another.
- All situations were assessed, but patients were not always placed on 1:1 after an assaultive event.
- They had a multi-disciplinary meeting after an event with nursing, leadership, and the provider to determine if there needed to be a medication change or an increase in observation.
- In general the patient to patient events were usually a negative interaction between two people that was a direct result of some issue between the two.
- If the event was an assault of "all" (meaning random with no direct issue that drove the violence), then the patient was placed on 1:1.
- These incidents were viewed as assaults and not abuse.
- The guardian was always contacted and asked about pressing charges.
- They did not consider all patients in the BHU vulnerable adults, if they were alert and oriented and were considered to be in a culpable mental state, then they were a culpable adult and not vulnerable.

During an interview on 10/13/16 at 1:10 PM, Staff NN, Chief Nursing Officer, stated:
- Many times with patient to patient events it was a sudden blow up, so they focus on early detection and diffused situations early.
- After an event, the process was to split the two apart by moving one patient off of the current unit, medication was sometimes administered, the physician and guardian were contacted, the patient was taken to the ED if necessary, and they kept those patients apart for the remainder of their stay.
- 1:1 observation should be utilized for violent patients, patients who were prone to falling, or patients with inappropriate sexual behaviors.
- There was no doubt that psychiatric patients were vulnerable.

Facility policy directed 1:1 observation of patients that had verbalized or exhibited intent to harm themselves or others, but the facility failed to implement these actions after multiple events of patient to patient violence.

6. Record review of the facility's policy titled, "Electroconvulsive Therapy," dated 06/2016, showed that an informed consent for ECT will be obtained from the patient and placed in the patient's medical record, and should include a specific treatment course or a period of continuation/maintenance ECT.

7. Record review of Patient #24's pre-typed ECT orders dated 10/03/16 at 8:20 AM showed:
- The date and time of the order was handwritten, but there was no physician signature, or nurse signature to indicate who ordered the ECT.
- Nursing staff should obtain consent for a total number of ECT treatments but the number of ECT treatments ordered was left blank.
- The patient would receive ECT treatments on Mondays, and not on Wednesdays or Fridays.

During an interview on 10/12/16 at 10:35 AM, Staff HH, Director of Surgical Services, stated that Patient #24's ECT orders should reflect the total number of ECT treatments the patient was scheduled to receive. He received ECT on Mondays and Fridays. Staff HH added that the total number of ECT treatments the patient should receive would also be listed on the patients ECT consent form.

Record review of Patient #24's medical record showed no consent for ECT.

During an interview on 10/12/16 at 1:15 PM, Staff EE, Behavioral Health Unit Director, stated that she confirmed with Staff HH, that Patient #24 received ECT on Monday 10/03/16, Friday, 10/07/16 and Monday, 10/10/16.

Record review of Patient #24's ECT preference card (hand written index card maintained in the Operating Room which documented the date, the number of ECT treatment, medication dosages, and the amount of electrical current used for each ECT treatment the patient received), showed that the patient received ECT on 10/03/16 (documented as treatment #3), 10/07/16 (#4) and 10/10/16 (#5).

During an interview on 10/12/16 at 2:32 PM, Staff JJ, ECT RN, stated that:
- She was the one who maintained the preference cards.
- Patient #24 received ECT on 10/03/16 (#3), 10/07/16 (#4) and 10/10/16 (#5).
- The information documented on the preference card, such as medication dosages and electrical current used, verified that Patient #24 received ECT on those dates.
- The preference cards were 97 percent correct when she referred to her accuracy with documentation (indicated that her records were not accurate).

Record review of Patient #24's ECT Treatment and Anesthesia Records, showed no documentation of the patient receiving ECT on 10/07/16, and also showed that the 10/10/16 record indicated the patient received ECT treatment #4 (and not #5 as indicated on the patient's preference cards and verified by Staff JJ).

During an interview on 10/12/16 at 3:03 PM, Staff KK, Psychiatrist, stated that on 10/07/16, Patient #24 was scheduled to receive ECT but did not because the patient ate breakfast, and because he had eaten the ECT could not be performed.

8. Record review of a physician order dated 10/05/16, showed that staff were to obtain written consent for a total number of ECT treatments for Patient #27. The number was left blank.

During an interview on 10/13/16 at approximately 1:30 PM, Staff A, Quality Risk Manager, presented a consent form, signed by Patient #27 and dated 01/13/16, for the patient to receive 20 ECT treatments. Staff A stated that the consent covered the current ECT the patient received.

Record review of Patient #27's preference card showed that the patient received 27 ECT treatments between 06/06/16 (documentation started on that date as treatment #8 and was the earliest documented date provided by the facility) and 10/12/16. The card also showed that on 07/20/16, the patient received ECT treatment #17, and on 07/22/16, the patient received ECT treatment #1.

During an interview on 10/13/16 at approximately 1:30 PM, Staff A along with Staff JJ were unable to explain the variance in the documented number of treatments.

The facility was unable to provide additional consents or physician orders which specified that Patient #27 should have received the additional ECT treatments, and was unable to explain the variance in the documented number of treatments the patient had received.

9. Record review of discharged Patient #45's court order dated 04/17/16, showed that the court authorized the treating physician to administer ECT treatments, not to exceed 60 treatments, within a year from the date of the order.

Record review of Patient #45's ECT Treatment and Anesthesia Record, showed that on 04/18/16, the patient received ECT treatment #35 (should have been ECT treatment #1 according to the court order).

Record review of Patient #45's ECT preference card showed that on 04/18/16, the patient was on ECT treatment #35. Further review of the preference card showed that on 07/11/16, the patient received ECT #46, and on 07/18/16, the patient received ECT treatment #17. The final date on the card, 10/10/16, showed that the patient was on ECT treatment #26.

According to the date of the court order and the date ECT began for the court order, Patient #45's ECT treatment for 04/18/16 should have been treatment #1 and the most recent documented treatment on 10/10/16, should have been treatment #22.

During an interview on 10/12/16 at approximately 1:30 PM, Staff JJ, ECT RN, verified that she documented the patient information on the preference card, but could not explain why the ECT treatment numbers did not correlate with the court order because it was before her time of employment with the facility.

10. Record review of facility policies showed no policy related to the ECT pre-op checklist.

11. Record review of the facility's form titled, "Checklist" showed that prior to ECT, staff should ensure that the following tasks were completed:
- Patient Identification, allergy and blood (necessary if the patient would require a blood transfusion) band should be on;
- Patient labels were available on the chart;
- Informed consent should be completed and signed;
- Anesthesiologist Evaluation, H&P Examination, Chest X-ray, Lab, Pregnancy test and Electrocardiogram (electronic tracing of the patient's heart rhythm) should be on the chart;
- Pre-Operative (Pre-op, prior to a procedure) and procedure teaching was completed;
- Pre-Operative medications were administered; and
- Skin and bowel prep were done.

12. Record review of Patient #24's ECT Treatment and Anesthesia Records, showed the patient received ECT on 10/03/16 and 10/10/16.

Record review of Patient #24's pre-op checklists showed no checklist completed for ECT treatments on 10/03/16 or 10/10/16.

13. Record review of Patient #27's "Reported Procedures (a list of completed procedure specific to the patient)" included ECT treatments completed on 09/28/16, 09/30/16, 10/03/16, 10/05/16, 10/07/16, 10/10/16 and 10/12/16.

Record review of Patient #27's pre-op checklists showed no checklist completed for ECT treatments on 09/28/16, 09/30/16. 10/03/16, 10/05/16, 10/07/16, 10/10/16 or 10/12/16.

When the facility failed to ensure pre-op checklists were completed for patients, it placed the patient at risk for allowing ECT to be performed without ensuring that the patient was appropriately prepared for the procedure.

During an interview on 10/12/16 at 9:21 AM, Staff EE stated that both she and Staff P, Director of Behavioral Health Services, recognized concerns with the ECT procedure process, including concerns about incomplete physician orders, incomplete or missing consents and communication. Staff EE stated that she was unaware of process breakdown related to pre-operative checklist completion and tracking the number of ECT treatments administered.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview, record review and policy review, the facility failed to ensure an accurate medication administration process was in place for two patients (#24 and #27) out of three patients reviewed, who received Electroconvulsive Therapy (ECT, procedure, done under general anesthesia, where electric currents are passed through the brain). This failed practice could allow for medication errors and/or missed medications, which could affect patient outcomes for all patients who received ECT. The facility conducts approximately 150 ECT procedures per month. The facility census was 101.

Findings included:

1. Record review of the facility's policy titled, "Medication Administration," dated 07/2014, showed that "blanket orders" such as "Resume/Continue Pre-Operative (Pre-Op, prior to a procedure) Orders" will not be accepted. Each medication must be ordered individually by the physician. If a physician should write a blanket order, the nurse will call the physician to review previous orders. The physician must re-order or discontinue each medication individually. When a physician order is received, the medication orders need to specify the name of the medication, dose, frequency and route.

Record review of the facility's policy titled, "Electroconvulsive Therapy (ECT)," dated 06/2016, showed pre-ECT responsibilities included a physician order for ECT and the necessary medications will be written.

Record review of the facility's policy titled, "Hospital Chart Completion, Documentation and Security," dated 04/21/16, showed that it was the responsibility of the clinician/individuals/staff members who make a chart entry (prescribe orders) to authenticate (sign, date and time) that item, and that each entry much be authenticated.

2. Record review of the facility form titled, "Checklist" showed that prior to ECT, staff should ensure that Pre-op medications were administered.

3. Record review of Patient #24's medical record showed:
- Pre-typed ECT orders dated 10/03/16 at 8:20 AM (date and time was handwritten), for Pepcid (medication which reduces stomach acid), 20 milligrams (mg, unit of measure) by mouth; Reglan (medication used to reduce nausea and vomiting), 10 mg by mouth; and Robinal (medication used to reduce drooling), 0.2 mg intramuscularly (IM, into the muscle) to be administered 30 minutes prior to ECT treatment. The order was not authenticated by a physician, or a nurse as a verbal or telephone order (indicated an incomplete order).
- There was no checklist completed for 10/03/16 to verify the patient received his pre-ECT medications.
- An ECT note dated 10/03/16 at 9:13 AM, that documented the patient received ECT.
- The medication administration record (MAR, area where medications that were administered are documented), showed no ECT related medications were administered prior to the patient's 10/03/16 ECT treatment.
- A physician order dated 10/10/16 at 8:00 AM, to "follow pre-ECT orders" (blanket order, individual medications were not ordered by the physician).
- The MAR dated 10/10/16, which documented that the Patient #24 received ECT related medications of Pepcid, Reglan and Robinal were administered prior to the patient's ECT treatment (should not have been administered without order clarification, according to facility policy).

During interviews on 10/12/16 at approximately 11:20 AM:
- Staff P, Director of Psychiatric Services, stated that the physician order to "follow pre-ECT orders" meant to continue with medications and orders which were in place prior to the patient receiving ECT.
- Staff HH, Director of Surgical Services, stated that the physician order to "follow pre-ECT orders" meant to continue with medications and orders which were in place prior to the patient receiving ECT.
- Staff EE, Director of the Behavioral Health Unit, stated that the physician order to "follow pre-ECT orders" meant to administer medications specific to the ECT procedure, prior to the ECT treatment.
- Staff II, Licensed Practical Nurse, stated that the physician order to "follow pre-ECT orders" meant to administer medications specific to the ECT procedure, prior to the ECT treatment.

During an interview on 10/12/16 at 3:03 PM, Staff KK, Psychiatrist, stated that patients who receive ECT should have a "pre-ECT" order set, and should receive medications before their ECT treatment. Staff KK added that with each consecutive ECT treatment, a verbal order to follow pre-ECT orders (including medication) directed nurses to administer ECT specified medications prior to each ECT treatment, and confirmed that she understood the verbal or written order to "follow pre-ECT orders" could be confusing to staff.

4. Record review of Patient #27's medical record showed:
- A physician's order dated 09/30/16 at 7:00 AM, for Pepcid, Reglan and Robinal to be administered 30 minutes prior to ECT treatment.
- There was no checklist completed for 09/30/16 to verify that the patient received his pre-ECT medications.
- There was no pre-ECT medications administered to the patient.
- "Reported Procedures (list of completed patient specific procedures)" and included an ECT treatment completed on 09/30/16.

During an interview on 10/12/16 at 9:21 AM, Staff EE stated that both she and Staff P recognized concerns with the ECT procedure process, including concerns with medication orders and communication.

During an interview on 10/12/16 at 1:07 PM, Staff NN, Chief Nursing Officer, stated that blanket orders, such as what the physician's wrote for pre-ECT medications, were no longer acceptable.

The process showed that Physician's were not appropriately and safely ordering medications, the patient's were not consistently receiving medications, and the patients received the ECT treatment without standard pre-medication to ensure optimal patient outcomes.