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.

LAUREL OAKS BEHAVIORAL HEALTH CENTER 700 EAST COTTONWOOD RD DOTHAN, AL March 18, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
This condition was not met based on observation, review of video, review of medical records and interview it was determined the hospital failed to:

1. Post instructions informing patients of their right to file a grievance with the State agency.

2. Ensure restrained patients at the facility were safe from harm and restrained in an environment that had decreased stimuli without interruptions.

3. Ensure cameras were operational in the dayroom to allow observation of workers with patients

4. Have timely orders for restraints.

5. Have signed orders for restraints within 24 hours per hospital policy.

6. Have Multiple Restraints on the same patient monitored and put interventions in place to provide safe and therapeutic care.

7. Investigate all incidents of injury to a patient or staff as a result of restraint.

Findings include:

Refer to A 118, A 144, A 166 and A 168

The facility failed to recognize the emotional and physical safety of the patients and provided an unsafe environment. This had the potential to affect all patients served.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observations and an interview with administrative staff, it was determined the hospital failed to post instructions informing patients of their right to file a grievance with the State agency. This had the potential to affect all patients receiving services from the hospital.

Findings include:

During a tour of the hospital lobby and a review of the posted patient rights 3/14/16 at 9:30 AM it was observed the hospital did not have the toll free State Hot Line number posted for patients in the front hospital lobby and failed to have the number present on the printed patient rights form provided to the patients on admission.

In an interview with Employee Identifier #1, the Patient Advocate 3/14/16 at 11:00 AM confirmed the above.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of medical records (MR), review of video from the facility unit, policy and procedure and interview it was determined the facility failed to ensure restrained patients at the facility were safe from harm and restrained in an environment that had decreased stimuli without interruptions. The facility failed to ensure cameras were operational in the dayroom to allow observation of workers with patients.This affected MR # 5 and had the potential to affect all patients served by this facility.

Findings include:


Policies:

Subject: Physical Restraints

Policy: " Children and adolescents residing in this treatment facility have the right to be free of physical restraint. Physical restraint is a safety procedure of last resort and not a therapeutic intervention and is not an intervention implemented for the purpose of behavior management ...

Definition: Physical restraint is any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely to restrict the patients ' freedom of movement.

The approved physical restraint technique for this facility is the nationally recognized maneuvers of Handle with Care (HWC) ...

General Principles:

1. Restraint shall be implemented in a manner that protects and preserves the rights, dignity, and well being of a patient ... and is only used in accordance with a written order. As per the organization's policy each episode of restraint use shall be recorded and maintained in the consumer record ...

4. The parent and/or guardian shall be notified of the Emergency Physical Restraint (EPR) episode ASAP (as soon as possible) after the intervention, unless another notification preference is documented by the guardian ...The patients' assigned therapist is responsible for notification of the parent/guardian ...

7. Staffing numbers and assignments are sufficient to minimize circumstances leading to restraint and maximize safety when restraint is used ...

Initiation of EPR: Emergency physical restraint may be initiated only by order of a licensed independent practitioner (LIP) who is primarily responsible for the patient's care ...

As soon as possible but no longer than one hour after initiation of restraint a QRN (Qualified Registered Nurse):

1. Notifies and obtains an order (verbal or written) from the LIP ...

Characteristics and Limitations of Orders for Physical Restraint:

Orders for initial and continuing use of physical restraint have the following characteristics:
1. They are limited to one (1) hour ...
4. Specify the behavioral criteria necessary to be released from restraint.
5. If the physician provided the order via a telephone order for restraint, he/she must sign the restraint order as soon as possible but within 24 hours ...

Discontinuing Physical Restraint Before the Time-Limit of the Order Expires:

Each distinct episode of EPR must be documented on a new restraint form.
Reevaluation of the Patient in a Physical Restraint:
The licensed independent practitioner conducts an in-person re-evaluation every hour if patient remains in a restraint ...

Procedure for Multiple Restraints on the Same Patient:

In an effort to decrease the number of repeat restraint episodes each time the same patient is restrained twice or more a shift, two times within a 12 hour period, three times or more in a 24 hour period, 6 or more times in a week, 12 or more times in a month, or remains in restraint for more than 2 hours the Shift Leader of that unit or the LIP will be responsible for notifying the Clinical Director of the restraints. The Clinical Director may then coordinate a re-staffing of that patient ...

Review of EPR in Treatment Plan:

Instances of emergency physical restraint are reviewed in the treatment team planning meeting.

Reporting of Injuries Resulting Due to Restraint Use:

All incidents of injury to a patient or staff as a result of restraint are reported to Risk Management Department and investigated actions are taken post investigation to prevent re-occurrence ... "

Policy:
Subject: Incident Reporting

Policy: " It shall be the policy of this hospital that an incident report be completed whenever an unexpected occurrence happens with a patient ...

Procedure:

A. The staff member who witnesses or observes an unusual incident shall complete the Incident Report before that staff member leaves the shift on which the incident occurred ...

E. Describe the person ' s condition before and after the Incident and the action taken. "

Medical Record findings:

1. MR # 5 was admitted to the facility 2/25/16 with diagnoses of Unspecified Depressive Disorder, Attention Deficit Hyperactivity Disorder, Combined Type, Unspecified Impulse Disorder, Unspecified Anxiety Disorder, Parent/Child Relational Problems and Rule Out Learning Disorder in Reading.

A review of the patient Observation Sheet dated 2/28/16 completed by the Mental Health Technician (MHT) documented the following:

2:18 PM through 3:14 PM the patient was visiting with his/her father in the cafeteria.

4:02 PM in the hallway acting out and in need of redirection.

4:18 PM through 4:47 PM in the dayroom acting out, needs redirection, oppositional/ defiant/ disruptive.

5:02 PM through 6:03 PM in the hall in physical restraint.

Restraint Documentation and Physician's Order was reviewed on 3/14/16 that confirmed an order from 4:55 PM until 5:50 PM for the the patient to be in a physical restraint in the hall outside of the dayroom. The patient remained in the hallway during the entire time of restraint with other patients and staff going and coming viewing use of restraints. The hospital failed to provide a space for the implementation of MR # 5's restraint in a quiet environment where environmental stimuli was reduced.

MR # 5 was placed in a standing physical restraint for safety of peers and staff by Employee Identifier (EI) # 5, MHT and relieved by EI # 6, MHT. In response to the Code called for assistance with the restraint the House Supervisor, EI # 7, conducted a face to face assessment at 4:57 PM documenting, " the patient remained uncooperative, attempting to rub face and head on wall."

A review of the video of the restraint on 2/28/16 noted EI # 7, House Supervisor point out to the MHT, EI # 6 an area of redness and abrasion to the right side of the face and forehead. EI # 7 is seen calling the MHT, EI # 5 out of the dayroom to see the patient's face.

In response to the question: Did patient incur any injury during the restraint? The following was documented, " Right side of his/her face around right eye 2 places noted where he rubbed his/her head against the wall area noted above his/her right eye on forehead also, appears to be red and there is an abrasion."

EI # 8, Registered Nurse documented a verbal order for the restraint at 7:00 PM on 2/28/16 which is longer than one hour after initiation of restraint and does not comply with the policy for ordering restraints.

The order for the restraint from 2/28/16 was not signed until 3/2/16 which is greater than 24 hours and the policy states, " must sign the restraint order as soon as possible but within 24 hours."

EI # 8 documented notification of the guardian at 6:30 PM regarding the use of restraint and a "scratch" to his/her face.

Interviews were conducted with all staff involved in the restraint of MR # 5 on 3/15/16:

EI # 8, RN was interviewed 3/15/16 at 12:15 PM; her work history does not include psychiatric nursing and she has been employed at this facility 7-8 months. EI # 8 stated the restraint was applied by EI # 5, MHT in the day room and when the patient was moved to the hallway outside the day room EI # 6, MHT took over the restraint for the remainder of the time, a total of 55 minutes.

EI # 8 noted the injury to the face of MR # 5 and stated that she ask the House Supervisor, EI # 7 about the injury. EI # 8 went on to say she cleaned the area with a cotton ball after the restraint ended and notified the father and took a picture of the abrasion/injury.

The surveyor asked EI # 8 if she felt there was enough staff scheduled to provide safe/therapeutic care for the patients. EI # 8 hesitated," most of the time there is". I think weekends are different.

EI # 5, MHT was interviewed on 3/15/16 at 2:15 PM and stated that she had worked here from May 2015 till August 2015 and returned in November 2015.

The surveyor asked EI # 5 what led to the use of the restraint on MR # 5. She stated, " I'm trying to recall, I just know he/she hit me, being aggressive toward other children, I restrained him/her after he/she hit me." She stated that she applied the restraint and EI # 7, House Supervisor asked her about the scratches. EI # 5 stated that she didn't notice the scratches.

The surveyor asked EI # 5 if she felt they have enough staff scheduled to provide safe/therapeutic care for the patients. EI # 5 stated, "Now we do, staffing issues no doubt, stable lately over the last 15 days it's better."

A telephone interview was conducted with EI # 7, RN (Registered Nurse) Supervisor 3/15/16 at 2:20 PM who stated she did not know what led to the restraint, who applied the restraint or how long it lasted. EI # 7 stated that she did see the red area on MR # 5's face.

EI # 6, MHT was interviewed 3/15/16 at 3:50 PM and stated that the she had worked here for 9 months.

EI # 6 stated that she responded to the code that was called and took over the restraint where EI # 5 who initiated the restraint could go back in the day room with the other children. EI # 6 stated MR # 5's face had the bruise on it when she got there, saying EI # 5 had MR # 5 up against the wall.

She (EI # 6) said that the bruise on the face it was there when she got there, MR # 5 hit their face according to EI # 5.

The surveyor asked EI # 6 if she felt they have enough staff scheduled to provide safe/therapeutic care for the patients. She stated from a MHT standpoint- sometimes it would help if everyone scheduled would show up, it would be fine.

MR # 5 was discharged AMA (Against Medical Advice) 2/28/16 at 10:00 PM. Documentation by the nurse, " Parent understood about son being restrained but questioned why and how he managed to do the abrasions on his face and forehead, he stated he will call tomorrow and speak to administration."

The supervisor, Registered Nurse and 2 MHTs were aware of an injury caused by restraint and no one reported the injury resulting from the restraint to Administration per policy.

The failure to report an incident with injury to a patient resulted in a failure to investigate the incident and take appropriate actions to prevent re-occurrence of other incidents.

In an interview with EI # 1, Patient Advocate, on 3/16/16 at 11:20 AM it was confirmed she was not aware and neither was administration of an injury caused by restraint on MR # 5, stating no one was aware of the problem. EI # 1 stated that she would have already conducted an investigation if she had known about the injury and would start her investigation immediately.

The video camera was not maintained in the Acute dayroom for children from 2/25/16 until 3/1/16.

An interview was conducted on 3/16/16 at 9:15 AM with EI # 2, Director of Nurses. EI # 2 reported EI # 9, Chief Operating Officer was aware Friday 2/26/16 the camera in the Acute dayroom for children was not working.

EI # 1 notified Interim Plant Operations Manager, EI # 10 of the nonfunctioning camera on Monday 2/29/16. EI # 10, unable to correct the camera function then notified contracted services for camera servicing on 2/29/16.

The camera service in the Acute dayroom for children was restored Tuesday 3/1/16.

EI # 2 reported facility staff including Registered Nurses and the Patient Advocate were not aware of the nonfunctioning camera in the Acute dayroom for children.

In light of the nonfunctioning camera, facility management did not provide additional measures to ensure an acceptable level of safety for care was provided while facility camera was not functioning.

The failure of the video camera in the Acute dayroom for children from 2/25/16 until 3/1/16 prevented administration from reviewing an injury by staff allegation, to determine if abuse had occurred.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on the review of medical records (MR), review of video documentation, policies and procedures and interview it was determined the facility failed to:

1. Update the treatment plan to address needs of multiple restraints.

2. Monitor Multiple Restraints on the same patient and put interventions in place to provide safe and therapeutic care.

3. Investigate all incidents of injury to a patient or staff as a result of restraint in an environment that failed to have decreased stimuli without interruptions.


This affected MR's # 5, # 8 and # 9. This affected 3 of 6 patients restrained at this facility and had the potential to affect all patients receiving care at this facility.


Findings include:

Policies:
Subject: Physical Restraints

Policy: " Children and adolescents residing in this treatment facility have the right to be free of physical restraint. Physical restraint is a safety procedure of last resort and not a therapeutic intervention and is not an intervention implemented for the purpose of behavior management ...

Definition: Physical restraint is any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely to restrict the patients ' freedom of movement.

The approved physical restraint technique for this facility is the nationally recognized maneuvers of Handle with Care (HWC) ...

General Principles:

1. Restraint shall be implemented in a manner that protects and preserves the rights, dignity, and well being of a patient ... and is only used in accordance with a written order. As per the organization ' s policy each episode of restraint use shall be recorded and maintained in the consumer ' s record ...

4. The parent and/or guardian shall be notified of the Emergency Physical Restraint (EPR) episode ASAP (as soon as possible) after the intervention, unless another notification preference is documented by the guardian ...The patients ' assigned therapist is responsible for notification of the parent/guardian ...

7. Staffing numbers and assignments are sufficient to minimize circumstances leading to restraint and maximize safety when restraint is used ...

Initiation of EPR: Emergency physical restraint may be initiated only by order of a licensed independent practitioner (LIP) who is primarily responsible for the patient ' s care ...

As soon as possible but no longer than one hour after initiation of restraint a QRN (Qualified Registered Nurse):

1. Notifies and obtains an order (verbal or written) from the LIP ...

Characteristics and Limitations of Orders for Physical Restraint:

Orders for initial and continuing use of physical restraint have the following characteristics:
1. They are limited to one (1) hour ...
4. Specify the behavioral criteria necessary to be released from restraint.
5. If the physician provided the order via a telephone order for restraint, he/she must sign the restraint order as soon as possible but within 24 hours ...

Discontinuing Physical Restraint Before the Time-Limit of the Order Expires:
Each distinct episode of EPR must be documented on a new restraint form.
Reevaluation of the Patient in a Physical Restraint:
The licensed independent practitioner conducts an in-person re-evaluation every hour if patient remains in a restraint ...

Procedure for Multiple Restraints on the Same Patient:
In an effort to decrease the number of repeat restraint episodes each time the same patient is restrained twice or more a shift, two times within a 12 hour period, three times or more in a 24 hour period, 6 or more times in a week, 12 or more times in a month, or remains in restraint for more than 2 hours the Shift Leader of that unit or the LIP will be responsible for notifying the Clinical Director of the restraints. The Clinical Director may then coordinate a re-staffing of that patient ...

Review of EPR in Treatment Plan:

Instances of emergency physical restraint are reviewed in the treatment team planning meeting.

Reporting of Injuries Resulting Due to Restraint Use:

All incidents of injury to a patient or staff as a result of restraint are reported to Risk Management Department and investigated actions are taken post investigation to prevent re-occurrence ... "

Medical Record Findings:

1. MR # 5 was admitted to the facility 2/25/16 with diagnoses of Unspecified Depressive Disorder, Attention Deficit Hyperactivity Disorder, Combined Type, Unspecified Impulse Disorder, Unspecified Anxiety Disorder, Parent/Child Relational Problems and Rule Out Learning Disorder in Reading.

A Restraint Documentation and Physician's Order was reviewed on 3/14/16 confirmed an order from 4:55 PM until 5:50 PM the patient was in a physical restraint in the hall outside of the dayroom. The patient remained in the hallway during the entire time of restraint with other patients and staff going and coming viewing use of restraints. The hospital failed to provide a space for the implementation of MR # 5's restraint in a quiet environment where environmental stimuli was reduced.

MR # 5 was placed in a standing physical restraint for safety of peers and staff by Employee Identifier (EI) # 5, MHT and relieved by EI # 6, MHT. In response to the Code called for assistance with the restraint the House Supervisor EI # 7 conducted a face to face assessment at 4:57 PM documenting, " the patient remained uncooperative, attempting to rub face and head on wall."

A review of the video of the restraint on 2/28/16 noted EI # 7, Supervisor point out to the MHT, EI # 6 an area of redness and abrasion to the right side of the face and forehead. EI # 7 is seen calling the MHT, EI # 5 out of the dayroom to see the patient's face.

In response to the question: Did patient incur any injury during the restraint? The following was documented, " Right side of his/her face around right eye 2 places noted where he/she rubbed his/her head against the wall area noted above his/her right eye on forehead also, appears to be red and there is an abrasion."

MR # 5 was discharged AMA (Against Medical Advice) 2/28/16 at 10:00 PM. Documentation by the nurse, " Parent understood about son being restrained but questioned why and how he managed to do the abrasions on his face and forehead, he stated he will call tomorrow and speak to administration."

The supervisor, Registered Nurse and 2 MHTs were aware of an injury caused by restraint and no one reported the injury resulting from the restraint to Administration per policy.

The failure to report an incident with injury to a patient resulted in a failure to investigate the incident and take appropriate actions to prevent re-occurrence of other incidents.

In an interview with EI # 1, Patient Advocate, on 3/16/16 at 11:20 AM it was confirmed she was not aware and neither was administration of an injury caused by restraint on MR # 5, stating no one was aware of the problem. EI # 1 stated that she would have already conducted an investigation if she had known about the injury and would start her investigation immediately.

2. MR # 8 was admitted to the facility 1/6/16 with a diagnosis of Mood Disorder Not Otherwise Specified.

MR # 8 was restrained 1/10/16, 1/14/16, 1/15/16 and 1/16/16. Four restraints in one week.

MR # 8 was restrained 1/20/16 (70 minutes), 1/22/16 ( 2 restraints) and 1/23/16. Four restraints in one week.

MR # 8 was restrained 1/24/16, 1/28/16 and 1/29/16. Three restraints in one week.

MR # 8 was restrained 11 times in January, the month of admission.

MR # 8 was restrained 2/1/16, 2/2/16 and 2/6/16 times two. Four restraints in one week.

On 2/6/16 MR # 8 was restrained from 6:10 PM-6:21 PM and a second time within 12 hours at 10:50 PM-11:47 PM (1 hour and 57 minutes).

MR # 8 was restrained 2/8/16 times two and 2/10/16. Three restraints in one week.

On 2/8/16 MR # 8 was restrained from 7:10 AM-8:00 AM and a second time within 12 hours at 11:12 AM-11:51 AM.

MR # 8 was restrained 2/16/16 and 2/18/16. Two restraints in one week.

MR # 8 was restrained 2/23/16 and 2/25/16. Two restraints in one week.

This patient was restrained 22 times from 1/6/16 through 2/26/16.

In an effort to decrease the number of repeat restraint episodes each time the same patient is restrained twice or more a shift, two times within a 12 hour period, three times or more in a 24 hour period or more than 2 hours the Shift Leader of that unit or the LIP will be responsible for notifying the Clinical Director of the restraints.

There was no documentation in the medical record or on the treatment plans that the Clinical Director or supportive staff was aware of the total number of times this patient had been restrained. There was no documentation of changes in therapist or other modalities to prevent the repeat restraints of this patient.

In an interview with EI # 2, Director of Nursing, on 3/16/16 at 1:30 PM when written questions were given to EI # 2 and in electronic responses received 3/18/16 at 7:00 AM the above information was confirmed.

3. MR # 9 was admitted to the facility 2/12/16 with diagnoses of Major Depressive Disorder, Intermittent Explosive Disorder, Conduct Disorder Order and Bipolar Disorder and Suicide Attempt.

MR # 9 was restrained 2/15/16, times two, 2/16/16, times two and 2/18/16. Five restraints in one week.

MR # 9 was restrained 2/22/16 and 2/24/16. Two restraints in one week.

MR # 9 was restrained 2/26/16. One restraint in one week.

This patient was restrained 8 times from 2/12/16 through 2/29/16.

There was no documentation in the medical record or on the treatment plans that the Clinical Director of supportive staff were aware of the total number of times this patient had been restrained. There was no documentation of changes in therapist or other modalities to prevent the repeat restraints of this patient having had restraints two times a day for two days the first week of admission.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on the review of medical records (MR), policies and procedures and interview it was determined the facility failed to:

1. Have orders for restraints.

2. Have signed orders for restraints within 24 hours.

This affected MR # 2, # 5, # 8, # 4 and # 9, 5 of 6 restrained patients and had the potential to affect all patient served in this facility.

Findings include:


Policies:

Subject: Physical Restraints

Policy: " Children and adolescents residing in this treatment facility have the right to be free of physical restraint. Physical restraint is a safety procedure of last resort and not a therapeutic intervention and is not an intervention implemented for the purpose of behavior management ...

Definition: Physical restraint is any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely to restrict the patients ' freedom of movement.

4. The parent and/or guardian shall be notified of the Emergency Physical Restraint (EPR) episode ASAP (as soon as possible) after the intervention, unless another notification preference is documented by the guardian ...The patients ' assigned therapist is responsible for notification of the parent/guardian ...

Initiation of EPR: Emergency physical restraint may be initiated only by order of a licensed independent practitioner (LIP) who is primarily responsible for the patient ' s care ...

As soon as possible but no longer than one hour after initiation of restraint a QRN (Qualified Registered Nurse):

1. Notifies and obtains an order (verbal or written) from the LIP ...

Characteristics and Limitations of Orders for Physical Restraint:

Orders for initial and continuing use of physical restraint have the following characteristics:
1. They are limited to one (1) hour ...
4. Specify the behavioral criteria necessary to be released from restraint.
5. If the physician provided the order via a telephone order for restraint, he/she must sign the restraint order as soon as possible but within 24 hours ..."

Medical Record Findings:

1. MR # 2 was admitted on [DATE] with a diagnosis of Bipolar Disorder, Unspecified.

Record review included 2/24/16 Restraint documentation that MR # 2 was restrained from 3:07 PM to 3:35 PM. The date of the physicians' order was 2/24/16 at 5:15 PM, 1 hour 30 minutes later.

Record review included 2/29/16 Restraint documentation MR # 2 was restrained from 10:25 AM to 11:00 AM. The date of the physicians' order was 2/29/16 at 12:10 PM, 1 hour 10 minutes later.

Record review included 2/29/16 Restraint documentation MR # 2 was restrained from 2:40 PM to 3:10 PM. The date of the physicians' order was 2/29/16 at 5:57 PM, 1 hour 47 minutes later.

Record review included 3/11/16 Restraint documentation MR # 2 was restrained from 4:45 PM to 5:30 PM. The date of the physicians' order was 3/11/16 at 7:30 PM, 2 hours later.

The facility failed to obtain orders for restraints within 1 hour of restraint initiation per facility policy.

2. MR # 5 was admitted to the facility 2/25/16 with diagnoses of Unspecified Depressive Disorder, Attention Deficit Hyperactivity Disorder, Combined Type, Unspecified Impulse Disorder, Unspecified Anxiety Disorder, Parent/Child Relational Problems and Rule Out Learning Disorder in Reading.

A Restraint Documentation and Physician's Order was reviewed on 3/14/16 confirmed an order from 4:55 PM until 5:50 PM the patient was in a physical restraint in the hall outside of the dayroom.

Employee Identifier (EI) # 8, Registered Nurse documented a verbal order for the restraint at 7:00 PM which is 2 hours and 5 minutes after initiation of restraint at 4:55 PM and does not comply with the policy for ordering restraints.

The order for the restraint was not signed until 3/2/16 which is greater than 24 hours and the policy states, " must sign the restraint order as soon as possible but within 24 hours."

In an interview with EI # 1, Patient Advocate, on 3/16/16 at 11:20 AM the above information was confirmed.


3. MR # 8 was admitted to the facility 1/6/16 with a diagnosis of Mood Disorder Not Otherwise Specified.

MR # 8 was restrained 1/20/16 (70 minutes), 1/22/16 ( 2 restraints) and 1/23/16. Four restraints in one week.

The restraint order for additional time on 1/20/16 does not have the time order received documented in the correct area on the form.

MR # 8 was restrained 1/24/16, 1/28/16 and 1/29/16. Three restraints in one week.

The restraint order for 1/29/16 was not co-signed by the ordering physician until 2/3/16, 5 days after the order was given.

In an interview with EI # 2, Director of Nursing, on 3/16/16 at 1:30 PM when written questions were given to EI # 2 and in electronic responses received 3/18/16 at 7:00 AM the above information was confirmed.

4. MR # 4 was admitted to the facility on [DATE] with diagnoses of Bipolar Disorder-Current Episode Mixed, Attention Deficit Hyperactivity Disorder- Combined Type, Oppositional Defiant Disorder and Conduct Disorder- Childhood Onset.


A review of the Progress Note for 2/27/16 revealed documentation, " 6:57 PM, Patient restrained from 4:41 PM-4:54 PM. Patient restrained because she/he hit a peer. No injuries involved."


A review of the Progress Note for 2/28/16 revealed documentation, " 1105, Spoke to ... about above restraint."


The restraint order for 2/27/16 was not co-signed by the ordering physician until 3/2/16, 4 days after the order was given.

MR # 4 was restrained 3/10/16 from 4:15 PM till 4:30 PM. The restraint order for 3/10/16 was not co-signed by the ordering physician until 3/12/16, 2 days after the order was given.

In an interview with EI # 2 on 3/16/16 at 1:30 PM when written questions were given to EI # 2 and in electronic responses received 3/18/16 at 7:00 AM the above information was confirmed.

5. MR # 9 was admitted to the facility on [DATE] with diagnoses of Major Depression Disorder, Intermittent Explosive Disorder, Conduct Disorder Order and Bipolar Disorder and Suicide Attempt.


MR # 9 was restrained 2/29/16 at 10:42 PM.

The restraint order for 2/29/16 was not co-signed by the ordering physician until 3/11/16, 11 days after the order was given.

In an interview with EI # 2 on 3/16/16 at 1:30 PM when written questions were given to EI # 2 and in electronic responses received 3/18/16 at 7:00 AM the above information was confirmed.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records (MR), policy and staff interviews, it was determined staff failed to administer medications as ordered by the MD (Medical Doctor) and document the effectiveness of PRN (as needed) medications per facility policy and procedure.

This affected 3 of 10 records reviewed, which included MR # 2, # 6 and # 9 and had the potential to affect all patients treated at the facility.

Policy #: NSG-K.005
Subject: Medication Administration
Revision Date: 10/11

"Purpose

To establish guidelines for the safe and effective administration of medications to patients...

Procedure

E. Administration of all medications will occur as outlined:

6. The nurse will sign the MAR (medication administration record) or if patient refuses any or all of his/her medication, the date will be circles to indicate.
7. Follow through documentation will include observation of ....effectiveness of PRN (as needed) medications..."

Policy#: NSG-K.008
Subject: Medication Administration Record Form
Revision Date: 4/11

Policy

"It is the policy...to maintain a Medication Administration Record (MAR) on all patients...

D. To provide for monitoring of safe prescription and administering of medications...
F. Document effectiveness of psychotropic ...medications..."

Findings include:

1. MR # 2 was admitted on [DATE] with a diagnosis of Bipolar Disorder, Unspecified.

Review of the medical record on 3/17/16 revealed Focalin XR (extended release) 20 mg (milligram) was ordered 2/23/16 at 2:20 PM.

Review of the MAR failed to include initials of the person administering Focalin XR 20 mg on 2/28/16. There was no documentation MR # 2 refused the medication.

Record review revealed physicians' orders dated 3/3/16 that included Focalin 10 mg 1 by mouth at noon for ADHD (attention deficit hyperactive disorder).

Review of the MAR failed to include initials of the person administering Focalin 10 mg on 3/9/16 at noon. There was no documentation MR # 2 refused the medication.

Record review included physician's orders dated 3/9/16 at 4:35 PM for Ativan 1 mg IM (intramuscular) now x (for) 1 dose and on 3/10/16 at 4:35 PM Ativan 1 mg IM now x 1 dose.Review of the MAR revealed Ativan injection was administered 3/9/16 at 4:45 PM and again on 3/10/16 at 5:00 PM. There was no documentation on the MAR by the Registered Nurse (RN) regarding MR #2's response and the effectiveness of the injectable Ativan.

In response to written questions submitted on 3/16/16 at 2:45 PM, Employee Identifier (EI) #2, Director of Nursing confirmed on 3/18/16 at 10:00 AM staff failed to document the effectiveness of Ativan.

2. MR # 6 was admitted to the facility 2/12/16 with diagnoses including Major Depression.

Review of physicians' orders dated 2/13/16 at 2:30 PM for "attention and impulse" and again on 2/26/16 at 9:00 AM, Vynase 30 mg po q (every) morning (ADHD) x (for) 14 days was ordered.

Review of the MAR failed to include documentation of the initials or name of the RN (Registered Nurse) administering ordered Vynase on 2/26/16 at 9:00 AM and on 3/3/16 at 9:00 AM. There was no documentation MR # 6 refused the medication.

Review revealed MR # 6 received Tylenol 650 mg at 1:23 PM on 2/23/16 for complaints of headache. There was no documentation of the effectiveness/results of the Tylenol or the route of administration.

In response to written questions submitted on 3/16/16 at 2:45 PM, EI #2, confirmed on 3/18/16 at 10:00 AM staff failed to administer medications as ordered and document the effectiveness of as needed medication.






3. MR # 9 was admitted to the facility 2/12/16 with diagnoses of Major Depressive Disorder, Intermittent Explosive Disorder, Conduct Disorder Order and Bipolar Disorder and Suicide Attempt.

MR # 9 was restrained 2/15/16, times two, 2/16/16, times two and 2/18/16. Five restraints in one week.

MR # 9 was restrained 2/22/16 and 2/24/16. Two restraints in one week.

MR # 9 was restrained 2/26/16. One restraint in one week.

This patient was restrained 8 times from 2/12/16 through 2/29/16.

Record review included physician's orders dated 3/1/16 at 5:05 PM for Ativan 2 milligram (mg) IM (intramuscular) x (for) 1 dose, Haldol 10 mg IM x 1, Cogentin 2 mg IM x 1 dose.


Review of the MAR recieved by email 3/18/16 revealed no documentation the Ativan 2 mg IM x 1, Haldol 10 mg IM x 1, Cogentin 2 mg IM x 1 dose was administered.


Record review included physician's orders dated 3/6/16 at 7:24 PM for Ativan 2 mg IM x 1, Haldol 10 mg IM x 1, Cogentin 2 mg IM x 1 dose.


Review of the MAR recieved by email 3/18/16 revealed 3/6/16 Ativan 2 mg IM x 1, Haldol 10 mg IM x 1, Cogentin 2 mg IM x 1 dose was administered 3/6/16 at 7:40 PM. There was no documentation on the MAR by the Registered Nurse (RN) regarding MR #9 's response and the effectiveness of the medication administered.


In response to written questions submitted on 3/16/16 at 2:45 PM, Employee Identifier (EI) #2, Director of Nursing confirmed the above information.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review, and interviews, the hospital failed to document the anatomical location of medication injection sites.

This did affect Medical Records (MR) # 2, # 9 and # 8, 3 of 10 inpatient records reviewed and had the potential to affect all patients served.Findings include:
1. MR # 2 was admitted on [DATE] with a diagnosis of Bipolar Disorder, Unspecified.

Record review revealed physician's orders dated 3/9/16 at 4:35 PM for Ativan 1 milligram (mg) IM (intramuscular) now x (for) 1 dose and 3/10/16 at 4:50 PM, Ativan 1 mg IM now x 1 dose.Review of the Medication Administration Record (MAR) revealed the Ativan injection was administered 3/9/16 at 4:45 PM. There was no documentation on the MAR by the Registered Nurse (RN) as to the anatomical injection site location. Review of the MAR revealed Ativan 1 mg IM was administered by a RN on 3/10/16 at 5:00 PM. The 3/10/16 MAR documentation did not include the anatomical injection site location.
In response to written questions submitted 3/16/16 at 2:45 PM, Employee Identifier (EI) #2, Director of Nursing confirmed on the above findings on 3/18/16 at 10:00 AM.






2. MR # 9 was admitted to the facility 2/12/16 with diagnoses of Major Depressive Disorder, Intermittent Explosive Disorder, Conduct Disorder Order and Bipolar Disorder and Suicide Attempt.

Record review included physician's orders dated 3/6/16 at 7:24 PM for Ativan 2 mg IM x 1, Haldol 10 mg IM x 1, Cogentin 2 mg IM x 1 dose.


Review of the MAR received by email 3/18/16 revealed 3/6/16 Ativan 2 mg IM x 1, Haldol 10 mg IM x 1, Cogentin 2 mg IM x 1 dose was administered 3/6/16 at 7:40 PM. There was no documentation on the MAR by the Registered Nurse (RN) as to the anatomical injection site location.



In response to written questions submitted 3/16/16 at 2:45 PM, Employee Identifier (EI) #2, Director of Nursing confirmed on the findings above on 3/18/16 at 10:00 AM.


3. MR # 8 was admitted to the facility 1/6/16 with a diagnosis of Mood Disorder Not Otherwise Specified.

Record review included physician's orders dated 2/6/16 at 11:30 PM for Ativan 2 mg IM x 1 and Haldol 5 mg IM x 1 now.

A late entry was written 2/7/16 at 6:50 AM, " Pt (patient) was restrained on 2/6/16 from 10:50 PM-11:47 PM...v/o (verbal order) received for Haldol and Ativan IM d/t (due to) extreme agitation (administered by Registered Nurse) and again at 11:52 PM..."

There was no documentation on the MAR or the Progress Note by the Registered Nurse (RN) as to the anatomical injection site location.



In response to written questions submitted 3/16/16 at 2:45 PM, EI #2, Director of Nursing confirmed on the findings above on 3/18/16 at 10:00 AM.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, medical records (MR) and interview, it was determined the facility failed to ensure:

1. All medical record entries were signed and dated by the appropriate staff

2. All medical record entries were factual and accurate.

This affected MR # 1, # 10 and # 6 and 3 of 10 records reviewed and had the potential to affect all patients served.

Findings include:

Policy #: RTC-C.005
Subject: Medical Records
Revision Date: 04/11

"...Purpose

To assure that adequate, complete and organized medical records are kept on all...patients.

Procedure:

A. Individual patient records shall contain all pertinent clinical information and shall contain at least the following...

8. Individual record of all medications administered by staff...

B. Entries are legible, sequential, signed and dated."

Policy #: RTC-C.002
Subject: Clinical Documentation and Charting
Revision Date: 02/05

Procedure

"...C. Documentation by staff shall describe...response to interventions...Each entry should include the date..."


Medical record findings:

1. MR # 1 was admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder.

In response to a request for restraint order for 3/6/16 submitted to Employee Identifier (EI) # 2, Director of Nursing in written questions 3/16/16 at 1:30 PM, EI # 2 responded 3/17/16 by email that the patient was not in a restraint. " The therapist made an error in her documentation with her group note. We have submitted her group participation work along with her round sheet which indicates she was in the dayroom participating and not in restraint. The errant entry has been corrected by our therapist." per email from EI # 1, Patient Advocate.

A review of submitted data from EI # 2 included a Clinical Progress Note dated 3/6/16 which had a hand written comment added to the typed note. The hand written information stated, " This is an error that has been corrected."

A second handwriting on the same note documented, " Patient was not in a restraint. She participated in group. Group work attached." Initials are by the first entry but no date of entry, no time of entry, no late entry and no signature on the original note.

The staff failed to follow the policy for clinical documentation.






2. MR # 10 was admitted to the hospital 3/8/16 with a diagnosis of Major Depression.

Review of the Master Treatment Plan Update/Clinical Staffing Worksheet dated 3/10/16 did not include the date and time the psychiatrist approved the Master Treatment Plan Update.

In response to written questions submitted on 3/16/16 at 2:45 PM, EI #2, confirmed the above finding 3/18/16 at 10:00 AM during a phone interview.

3. MR # 6 was admitted to the hospital 2/12/16 with a diagnosis of Major Depression.

Record review revealed nursing progress note documentation on 3/4/16 at 8:20 AM, a "face to face assessment (was) done and communicated to MD (medical doctor) and discharge approved on the day of discharge.. pt (patient) discharged home...per MD order...Nursing discharge summary...aftercare discharge, transfer plan given...patient and guardian..."

On 3/17/16, review of the Laurel Oaks Aftercare Discharge/Transfer Plan document failed to include the attending Physician's signature, 13 days after MR # 6's discharge.

Written questions submitted on 3/16/16 at 2:30 PM were received on 3/18/16 at 8:30 AM. EI # 2 reported during a phone interview the "physician's signature should have been completed by now."
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation of the patient rooms, review of daily equipment check logs and interview it was determined the patient care areas had not been maintained and areas of damage in the rooms were potentially hazardous and could cause harm to the patients.

The emergency medical equipment daily checklist was not maintained for availability and safe use for the patients. This had the potential to affect all patients served in this facility.

The video camera was not maintained in the Acute dayroom for children from 2/25/16 until 3/1/16.

Findings include:

On 3/14/16 at 9:40 AM the surveyors toured the acute care hallways.

The surveyors were accompanied by Employee Identifier (EI) # 1, the Patient Advocate on the tour.

In room 222 profanity was written on the wall and the soap dispenser was oozing soap and had caused paint to peel at the sink area.

Room 218 had water damage on the ceiling.

Room 216 had rust in the storage area peeling.

The second time out room on Acute had paint peeling off of the concrete wall to the left of the camera.

In room 203 the paint is peeling behind bed 2. Acute dayroom # 2 paint is peeling inside the door.

In room 208 the soap dispenser is draining down to the sink leaving mildew on the wall.

In room 211 water was standing on the floor outside the bathroom door.

In room 219 two pieces of ceiling plaster was peeling on the ceiling.

In an interview with EI # 1 on 3/14/16 at 11:00 AM the above information was confirmed.

***
During a tour of the Acute unit, the Emergency Medical Equipment was observed. A daily Emergency Medical Equipment Daily Checklist for February 2016 was observed. The Emergency Medical Equipment Daily Checklist had not been completed daily. The following dates were not checked off and no initials or signature was present:
February 1, 2, 3, 4, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20 and 24. Sixteen days of twenty-nine for the month of February. The nurses failed to ensure safe and maintained equipment would be available for an emergency.

The AED (Automated Electronic Defibrillator) daily check sheet failed to have 2 days of 29 signed as reviewed.

In an interview 3/14/16 at 11:00 AM with EI # 3, the Acute Child Nurse Manager confirmed the equipment had not been checked daily.

***

An interview was conducted on 3/16/16 at 9:15 AM with EI # 2, Director of Nurses. EI # 2 reported EI # 9, Chief Operating Officer was aware Friday 2/26/16 the camera in the Acute dayroom for children was not working.

EI # 1 notified Interim Plant Operations Manager, EI # 10 of the nonfunctioning camera on Monday 2/29/16. EI # 10, unable to correct the camera function then notified contracted services for camera servicing on 2/29/16.

The camera service in the Acute dayroom for children was restored Tuesday 3/1/16.

EI # 2 reported facility staff including Registered Nurses and the Patient Advocate were not aware of the nonfunctioning camera in the Acute dayroom for children.

In light of the nonfunctioning camera, facility management did not provide additional measures to ensure an acceptable level of safety for care was provided while facility camera was not functioning.

The failure of the video camera in the Acute dayroom for children from 2/25/16 until 3/1/16 prevented administration from reviewing an injury by staff allegation, to determine if abuse had occurred.