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.

HILL CREST BEHAVIORAL HEALTH SERVICES 6869 FIFTH AVENUE SOUTH BIRMINGHAM, AL 35212 March 31, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records (MR), policy and procedure, video and interview it was determined the facility failed to correctly use CPI (Crisis Prevention Intervention) training and holds to restraint 1 of 2 patient restraints reviewed. This affected MR # 1 and had the potential to affect any patient restrained in this facility.

Findings include:

Policy: Seclusion/Restraint of Patients
I. Policy Statement:
" Patients are assessed upon admission and on a continual basis throughout their hospitalization at Hill Crest Behavioral Health Services for behaviors that are potentially dangerous to self or others. Seclusion and Restraint (S/R) use is implemented as a last resort to ensure the safety of patients and others...S/R must not result in harm or injury to the patient or others...

Procedure:
4. The Physician/RN (Registered Nurse) assesses the need for restrictive intervention and a written or telephonic order is obtained from the physician for the S/R on the Seclusion/Restraint Order form as follows:
The physicians' orders specify the reason for restraint and seclusion usage, the type of restraint, specific behaviors required to terminate the S/R and their duration...
Ensures that S/R orders are not written as standing or PRN (as needed)orders...
8. If physical restraint is indicated, 2 staff must participate in the physical hold application..."

Medical Record findings:


1. MR # 1 was admitted to the facility on [DATE] with a diagnosis of Paranoid Schizophrenia.

An order was written 3/18/16 at 7:30 PM, " Pt (patient) may be restrained for up to one hour for safety and can be released once calm and cooperative."

The Seclusion and Restraint One Hour Face to Face Evaluation form documented the following:
" Initiation of Intervention 3/18/2016, time 1913 (7:13 PM)- Face to Face Evaluation 3/18/2016 at 2100 (9:00 PM) within one hour- no... Describe patient's response to intervention... The patient remained agitated and uncooperative, and slowly returned to baseline...Clinical summary of intervention- The patient escalated after a verbal confrontation with his peer; he became verbally and physically aggressive toward staff. He was restrained and released per protocol."

Staff Debriefing form documented 3/18/2016 at 2100 (9:00 PM), " Ask the patient- did not answer or cooperate in debriefing...the staff formed a team effort as the patient behavior escalated. The team managed the behavior effectively per protocol...type of restraint: Team control. Location of hold: Patient's room."

MR # 1 refused assessment by staff including the physician after the restraint/hold.

Nonviolent Crisis Prevention participant workbook (Reprinted 2014):

" CPI Team Control Position:

The CPI Team Control Position is used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist if needed. During the intervention, staff members who are holding the individual should:

Face the same direction as the acting-out person while adjusting, as necessary, to maintain close body contact with the individual.

Keep their inside legs in front of the individual.

Bring the individual's arms across their bodies, securing them to their hip areas.

Place the hands closest to the individual's shoulders in a C-shape position to direct the shoulders forward."

A review of the video of MR # 1 being restrained 3/18/16 shows 3 MHTs (Mental Health Technicians) in the hallway with MR # 1 up against the wall struggling and physically aggressive. The MHTs failed to position themselves in the same direction and failed to obtain control of MR # 1.

In an interview with Employee Identifier (EI) # 1, Chief Operations Officer,on 3/30/16 at 10:00 AM the above information regarding the correct hold was confirmed, EI # 1 stated they did not have control of MR # 1 in the hallway.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records (MR), policy and procedures and interview it was determined the facility failed to document an appropriate order for use of restraints. The order was written as "may" or to be interpreted as PRN (as needed). This affected MR # 1 and had the potential to affect all patients served at this facility.

Findings Include:

Policy: Seclusion/Restraint of Patients
I. Policy Statement:
" Patients are assessed upon admission and on a continual basis throughout their hospitalization at Hill Crest Behavioral Health Services for behaviors that are potentially dangerous to self or others. Seclusion and Restraint (S/R) use is implemented as a last resort to ensure the safety of patients and others...S/R must not result in harm or injury to the patient or others...

Procedure:
4. The Physician/RN (Registered Nurse) assesses the need for restrictive intervention and a written or telephonic order is obtained from the physician for the S/R on the Seclusion/Restraint Order form as follows:
The physicians' orders specify the reason for restraint and seclusion usage, the type of restraint, specific behaviors required to terminate the S/R and their duration...
Ensures that S/R orders are not written as standing or PRN (as needed)orders...
8. If physical restraint is indicated, 2 staff must participate in the physical hold application..."


Medical Record findings:

1. MR # 1 was admitted to the facility on [DATE] with a diagnosis of Paranoid Schizophrenia.

An order was written 3/18/16 at 7:30 PM, " Pt (patient) may be restrained for up to one hour for safety and can be released once calm and cooperative."

An order was written 3/21/16 at 8:45 AM, "Order clarification of restraint 3/18/16 7:30 PM. Restrain for up to one hour for safety and release once pt is calm and cooperative.

In an interview on 3/29/16 at 1:30 PM with Employee Identifier (EI) # 2, Assistant Director of Nursing/Risk Manager confirmed she had the nurse re-write the order to clarify because the staff had been told not to use the word "may" as it leaves options and is PRN written a different way.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, review of facility policies and staff interview, it was determined the facility failed to ensure:

a) Medications available for use were not expired.

b) Medications were labeled when opened and discarded after 28 days.

c) Staff performed hand hygiene during medication administration and used patient identifiers per facility policy.

d) Staff performed and documented fingerstick blood sugar (FSBS) testing as ordered.

This affected Medical Record (MR) # 1, unsampled patient's # 1 and # 2 and MR's # 7 and # 4. This had the potential to negatively affect all patients treated at the facility.

Findings include:

Policy: Handwashing Techniques
Revised 01/12

I. Policy

" Handwashing is absolutely essential for the prevention and control of hospital acquired infections...

III. Procedure

Minimum times for washing hands:

At the beginning of each shift, just prior to beginning their work.
When hands are obviously soiled...
During performance of normal duties...
Before and after providing care to patients.
On leaving a patient's room...
On completion of duty."

Policy Med (Medication) Area Inspections

Policy:
" It is the policy of the Pharmacy Department that nursing unit medication dispensing areas (medication rooms, medication carts, medication storage closets, medication refrigerators...) be in compliance with all State and Federal Law and local standards of practice, all to the betterment of patient care.

Procedure:
At least once monthly...
C. Storage and labeling of injectables, specifically that injectables requiring refrigeration are refrigerated and that all open muti-dose vials possess an expiration date and initials and that muti-dose vials contain at expiration date 28 days from the date of opening.
D. Medications stored on the unit as floorstock will be in date and medications that have gone out of date or are about to go out of date will be removed from the nursing unit by the pharmacist and destroyed in the proper fashion."

Policy: Administration of Oral Medications.
Procedure:
" C. Wash hands
D. Prepare medications
E. Administration of medication:
1. The (2) two primary identifiers used for distribution of medications are the photo and date of birth...
F. Refusal of medication
1. The patient has the right to refuse medications when offered
2. The physician must be notified within 8 hours if a patient refuses medication
3. Medication may be retained and reoffered at a later time
4. If the medication has not been removed from the original package, it may be returned to holding container with other unopened medications.
5. If the medication has been removed from original package, it must be labeled and stored inside the medication cart, not to exceed 8 hours, then discarded..."






A tour of the nurse medication room on the Adult Progressive Intensive Care Unit (PICU) on 3/29/16 at 10:20 AM revealed the following observations:

a) One unlabeled syringe, filled with 0.75 cc (cubic centimeters) red color liquid solution in MR # 4's medication drawer.

b) One vial, 5 ml (milliliters) Influenza virus vaccine, expired 12/16/15 found in the locked medication refrigerator

c) One 10 ml vial Fluphenazine Hydrochloride 25 milligram (mg), open, not labeled found in floor stock

d) One prefilled Novolog Flex Pen, expiration date 10/17, facility labeled "Discard date-3/9/16" found in floor stock

In an interview on 3/29/16 at 10:40 AM, Employee Identifier (EI) # 11, Registered Nurse confirmed the syringe in the patient drawer should be labeled with medication name, dosage, time prepared and initials of person preparing. EI # 11 also confirmed medications must be labeled when opened and discarded within 28 days.

****

Observations of care included medication passes for three patients on 3/30/16 at 8:30 AM with EI # 11 and revealed the following:

EI # 11 performed hand hygiene and donned gloves. EI # 11 then administered 2 oral medications to unsampled patient # 1.

EI # 11 did not remove and discard gloves and perform hand hygiene between unsampled patient # 1 medication administration and prior to the administration of 2 oral medications to MR # 1.

EI # 11 failed to confirm MR's # 1 identity using 2 required methods of identification that included date of birth confirmation.

EI # 11 again did not remove gloves and perform hand hygiene after medication administration between MR # 1 and unsampled patient # 2. EI # 11 continued medication dispensing that included 5 oral medications and 2 inhalers to unsampled patient # 2 after administration of medications to MR # 1.

In an interview on 3/31/16 at 11:00 AM, EI # 3, Director of Nursing confirmed staff failed to follow facility policy for medication management, administration and hand hygiene.

***

1. MR # 7 was admitted on [DATE] with diagnosis including Schizophrenic Disorder, Hypertension and Diabetes Mellitus.

Review of Admission Medications Orders dated 12/15/16 at 7:40 PM included Novolog insulin administration per sliding scale according to fingerstick blood sugar (FSBS) results performed at 7:00 AM, 11:00 AM, 4:00 PM and 9:00 PM.

Record review revealed no documentation FSBS testing was performed on the following dates:

12/25/15 at 9:00 PM
12/27/15 at 9:00 PM
01/02/16 at 4:00 PM
01/06/16 at 4:00 PM
01/17/16 at 7:00 AM
01/22/16 at 11:00 AM
01/23/16 at 4:00 PM
02/01/16 at 7:00 AM
02/07/16 at 4:00 PM
02/08/16 at 7:00 AM

In an interview conducted on 3/31/16 at 11:35 AM, EI # 3 confirmed staff failed to perform and document FSBS testing per physician orders needed to determine Novolog insulin requirements.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records (MR) review, policies and procedures and interviews, the hospital staff failed to:

1. Document the anatomical location of medication injection sites.

2. Document medications administered on the Medication Administration Record (MAR).

3. Document all PRN (as needed) medications on the MAR.


This affected MR's # 1, # 9, # 10, # 6, # 5, # 7 and # 4, 7 of 10 records reviewed and had the potential to affect all patients served by this facility.

Findings include:


Policy: Medication-Administration of Intramuscular (IM) Injection

II. Purpose: " To accurately prepare, administer and record individual IM injections.
E. Prepare Medication
IV. Method:
B. Select site of injection:
1. Gluteal region...
2. Deltoid and lateral thigh...
V. Clinical Record
Chart medication on MAR and in progress notes:
A. Drug name
B. Dosage
C. Route
D. Site
E. Time
F. Results."


Policy: Medication Administration Record (MAR)

I. Policy:
" It is the policy of Hill Crest Behavioral Health Services to maintain a MAR on all patients to serve the following purposes:
A. Serve as a permanent record for the medications administered to each patient.
B. Provide a tool to help reduce the possibility of medication errors.
C. Provide for immediate recording of the medication given...

III. Procedure:
2 d. After administering medications chart initials by correct hour under correct name. It is also required to enter your initials, signature and title on...
D. Regular insulin according to sliding scales:
3. After checking the glucose level and administering the prescribed dose, the nurse enters in the appropriate square, the glucose level, the amount of insulin given and his/her initials. The verifying nurse then initials in the co-signature (cosign) block...
G. PRN (as needed) Medications
1. All PRN medications are recorded on the PRN medication administration record...
5. When a nurse gives a PRN medication, next to the medication under date, enter vertically the date, time and initials for each dose given in ink corresponding to her tour of duty.

** Record all PRN medications in Nurse's Notes when administered. Include date and time of administration and site of administration. In 1 hour chart response to the PRN medication...

I. Transcription of Medication Orders Accuracy Check:
4. The 11-7 (7 PM-7 AM) nurse will complete a 24 hour check for transcription accuracy. If there is a discrepancy, it is considered to be a medication error..."

Medical Record findings:


1. MR # 1 was admitted to the facility on [DATE] with a diagnosis of Paranoid Schizophrenia.

MR # 1 requested medication for insomnia on 3/17/16, 3/19/16, 3/26/16 and 3/27/16. The patient was administered Vistaril 50 mg (milligrams) po (by mouth) from the Physician Orders Adult form dated 3/15/16.

A review of the MAR for these dates failed to reveal the drug Vistaril was added to the PRN page of the MAR. The only documentation of the medication being administered was on the nurses notes.

On 3/22/16 at 8:00 AM an order was received for Cortisporin (Hydrocortisone/Neomycin/Polmy) Eye drops to receive 2 gtts (drops) both eyes four times a day (QID) x(time) 7 days. The medication was received from the pharmacy at 10:50 AM on 3/22/16.

Two separate MAR pages were present in the MR, the first dated 3/18/16 through 3/24/16 identified 3/22/16 at 1:00 PM to start the medication. The Cortisporin Eye drops were initialed as being administered at 1:00 PM, 6:00 PM and 10:00 PM on 3/22/16. The next day 3/23/16 documented the medication was administered at 9:00 AM and 1:00 PM with the last two doses circled.

The second MAR page dated 3/18/16 through 3/24/16 identified 3/22/16 at 1:00 PM to start the medication. The date of 3/22/16 was blank, 3/23/16 the 9:00 AM and 1:00 PM doses were initialed as having been administered and all four doses were given on 3/24/16.

The MAR dated 3/25/16 through 3/31/16 documented on 3/26/16 initials circled at 1:00 PM and 6:00 PM and on 3/28/16 initial circled at 6:00 PM and 10:00 PM.

In an interview on 3/31/16 at 10:29 AM with Employee Identifier (EI) # 3, Director of Nursing confirmed she did not locate Vistaril on any MAR for this patient and confirmed the Cortisporin documentation was confusing and did not follow the policy.

2. MR # 9 was admitted to the facility 3/23/16 with diagnoses of Unspecified Psychosis, Bipolar Disorder, Schizophrenia and Anitsocial Personality.

MR # 9 requested medication for insomnia on 3/26/16 and 3/27/16. The patient was administered Vistaril 50 mg po from the Physician Orders Adult form.

A review of the MAR for these dates failed to reveal the drug Vistaril was added to the PRN page of the MAR. The only documentation of the medication being administered was on the nurses notes.

In an interview on 3/31/16 at 10:48 AM with EI # 3, confirmed she did not locate Vistaril on any MAR for this patient.

3. MR # 10 was admitted to the facility on [DATE] with a diagnoses of Schizophrenia Disorder Paranoid and Rule Out Bipolar Disorder.

MR # 10 requested medication for insomnia on 3/19/16, 3/20/16 and 3/27/16. The patient was administered Vistaril 50 mg (milligrams) po (by mouth) from the Physician Orders Adult form.

In an interview on 3/31/16 at 10:46 AM with EI # 3 confirmed she did not locate Vistaril on any MAR for this patient.





4. MR # 6 was admitted on [DATE] with diagnoses of Impulse Disorder, Unspecified, Anxiety Disorder and Essential Hypertension.

Review of physicians' orders dated 1/29/16 at 10:00 AM included Bactrim DS (double strength) 1 po twice daily for 7 days for soft tissue infection.

Review of the medication administration record revealed Bactrim was ordered at 9:00 AM and 6:00 PM. There was no documentation staff administered the 1/29/16 6:00 PM Bactrim dose.

Review of physician's orders dated 1/30/16 at 1:00 PM included "Ativan 1 mg IM Now doses Hypertension".

Review of the 1/30/16 1:00 PM Nurse progress note documentation revealed MR # 2 complained of headache. BP 185/111. Received order Ativan 1 mg IM x (for) now dose. Will continue to monitor.

There was no documentation of the anatomical injection site where the medication was injected.

In an interview on 3/31/16 at 11:30 AM, EI # 3 confirmed the above findings.

5. MR # 5 was admitted on [DATE] with diagnoses of Dementia secondary to Traumatic Brain Injury.

Record review revealed a Medication Reconciliation document signed by the physician on 2/15/16 at 11:10 AM that included Risperdal 2 mg 1 po twice daily.

Review of the Medication Administration Record (MAR) revealed Risperdal 2 mg oral twice daily was scheduled as of 2/15/16 for 9:00 AM and 6:00 PM administration.

Review of the MR # 5's MAR did not include documentation Risperdal was administered at 6:00 PM as ordered on [DATE], 3/1/16, 3/2/16, 3/8/16 and 3/9/16.

An interview conducted on 3/31/16 at 11:40 AM, EI # 3 confirmed the above findings.

5. MR # 7 was admitted on [DATE] with diagnosis including Schizophrenic Disorder, Hypertension and Diabetes Mellitus.

Review of MR # 7's Admission Medications Orders dated 12/15/16 at 7:40 PM revealed the following medications were ordered and not documented as administered:

Acyclovir 400 mg po twice daily at 9:00 AM and 6:00 PM. There was no documentation Acyclovir was administered on the following dates:
12/18/15 at 6:00 PM
12/25/15 at 6:00 PM
1/11/16 at 6:00 PM
1/14/16 at 6:00 PM
2/4/16 at 6:00 PM

Depakote ER (extended release) 1000 mg po twice daily at 9:00 AM and 6:00 PM. There was no documentation Depakote ER was administered on the following dates:
12/18/15 at 6:00 PM
12/25/15 at 6:00 PM
1/11/16 at 6:00 PM
2/4/16 at 6:00 PM

Fluphenazine 2.5 mg po twice daily at 9:00 AM and 6:00 PM. There was no documentation Fluphenazine was administered on 12/18/15 at 6:00 PM.

Glipizide 5 mg 1 po twice daily at 9:00 AM and 6:00 PM. There was no documentation Glipizide was administered on the following dates:
12/18/15 at 6:00 PM
12/25/15 at 6:00 PM
1/1/16 at 6:00 PM
1/11/16 at 6:00 PM
2/4/16 at 6:00 PM

Metformin 1000 mg po twice daily at 9:00 AM and 6:00 PM. There was no documentation Metformin was administered on the following dates:
12/25/15 at 6:00 PM
1/4/16 at 6:00 PM
1/11/16 at 6:00 PM
2/4/16 at 6:00 PM

Seroquel 300 mg 1 po daily at bedtime, 10:00 PM. There was no documentation Seroquel was administered on the following dates:
12/23/15 at 10:00 PM
2/4/16 at 6:00 PM

Record review revealed MR # 7's urinalysis collected 12/16/15 was positive for bacteria and a urine culture resulted in a 12/24/15 physicians' order for Macrodantin 100 mg po four times daily, at 9:00 AM, 1:00 PM, 6:00 PM and 10:00 PM for 3 days for a Urinary Tract Infection.

Review of the MAR revealed no documentation staff administered Macrodantin on 12/25/16 at 6:00 PM.

An interview conducted on 3/31/16 at 11:35 AM with EI # 3 confirmed the above findings.

6. MR # 4 was admitted on [DATE] with a diagnosis of Paranoid Schizophrenia, Acute Exacerbation. Admission orders and treatment plan included Invega Sustenna 234 mg, IM q (every) month, Haldol 5 mg IM with Ativan 2 mg IM every 8 hours as needed for severe agitation. Review of the MAR revealed Haldol 5 mg and Ativan 2 mg was administered on 1/31/16 at 9:00 AM and 3/13/16 at 6:00 PM. There was no documentation by the Registered Nurse (RN) regarding the anatomical injection site where the medication was injected. Review of the MAR revealed Invega Sustenna was administered 2/5/16 at 9:00 AM. There was no documentation by the RN regarding the anatomical injection site where the medication was injected.

Further review of the MAR failed to reveal documentation staff administered Invega Sustenna monthly as ordered during the month of March.
In an interview conducted on 3/31/16 at 11:38 AM, EI # 3 confirmed the above findings.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation of the patient rooms and interview, it was determined the patient care areas had not been maintained and areas of damage in the rooms could cause harm to the patients. This had the potential to affect all patients.

Findings include:

During a tour of the Acute Unit conducted 3/29/16 at 9:25 AM with Employee Identifier (EI) # 1, the Chief Operations Officer and EI # 2, the Assistant Director of Nursing/Risk Manager the following were observed:

Room 301: Heavy presence of rust on the grate of the heating/cooling unit under the window
Room 300: The wooden window sill had rotten broken areas of wood and rusted grate of the heating/cooling unit
Room 302: A box of uncover toiletries including shampoo and liquid soap were sitting on the shelves and rust on the grate of the heating/cooling unit
Room 304: Rust on the grate of the heating/cooling unit and paint peeled on the window sill
Room 305: Rust on the grate of the heating/cooling unit and the mattress on bed # 1 had several holes through the cover
Room 306: Rust on the grate of the heating/cooling unit, paint needed around the window
Room 307: Rust on the grate of the heating/cooling unit and graffiti on the wall; Metal screw not flush to the vent
Room 308: Rust on the grate of the heating/cooling unit
Room 309: Rust on the grate of the heating/cooling unit, loose baseboards around the bottom of the wall
Room 310: Missing baseboard under window sill
Room 312: Rust on the grate of the heating/cooling unit
Room 313: Mildew on the walls in the handicapped bathroom
Room 311: Rust on the grate of the heating/cooling unit and an area open through the side of the unit to the outside wall
Room 312: Rust on the grate of the heating/cooling unit
Room 314: Rust on the grate of the heating/cooling unit
Room 316: A hole is present through the wall behind the door
Room 317: One bottle of mouthwash present in bathroom.

The above inventoried items were noted by EI # 1 who immediately on 3/29/16 notified maintenance to began repair to the identified areas.

The tour continued on the PICU (Patient Intensive Care Unit) on 3/29/16 at 10:00 AM, the following problems were identified:

Room 213: Window sill paint peeling
Room 211: Bookshelves are loose from the wall, below the window sill holes in the paint
Room 210: Odor to the room and a blanket and pillow were present in the bathroom floor
Room 295: Concrete block wall graffiti words written in pen on the walls
Room 249: Words randomly written about room, needs painting
Room 248: Artwork on the concrete wall and a hole present between blocks with small items of paper trash stuck in the opening.

The above inventoried items were noted by EI # 1 during an interview on 3/29/16 at 10:30 AM, who immediately notified maintenance on 3/29/16 to began repair to the identified areas.