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.

COLLEGE HOSPITAL 10802 COLLEGE PL CERRITOS, CA Dec. 16, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview, and record review, the facility failed to have an effective Governing Body that was legally responsible for the conduct of the hospital. The facility failed to meet the Condition of Participation in Governing Body, as follows:

1. The facility failed to protect and promote each patient's rights. The facility failed to meet the Condition of Participation (COP) for Patient Rights (Refer to A 115).

2. The facility failed to develop, implement and maintain an effective ongoing hospital wide, data-driven quality assessment performance improvement (QAPI) program. The hospital governing body failed to ensure the program reflects the complexity of the hospital's organization, services and focuses on indicators that improve health outcome, patient safety and quality of care and the prevention and reduction of medical errors and adverse events. The facility failed to meet the Condition of Participation in Quality Assessment Performance Improvement program (Refer to A 263).

3. The facility failed to ensure the nursing services was organized in providing adequate staffing and quality of care to meet the needs of each patient receiving nursing services. The facility failed to meet the Condition of Participation in Nursing Services (Refer to 385).

The cumulative effects of these systemic failures resulted in the hospital's governing body inability to maintain appropriate oversight to assure quality health care in a safe environment.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Because of the facility's failure to have a system in place to assure patient's safety as it relates to the failure to thoroughly investigate allegation of sexual abuse, the survey team declared an Immediate Jeopardy (IJ) on December 10, 2013 at 6:45 p.m., with the interim chief nursing officer, director of risk management (Admin 1), Nurse Manager 1 and Nurse Manager 3.

On December 13, 2013 at 2:05 p.m., the Immediate Jeopardy was abated in the presence of chief executive officer, medical director, interim chief nursing officer, director of risk management (Admin 1), Nurse Manager 1 Nurse Manager 3, and associate administrator. Admin 1 submitted an acceptable plan of correction (POC) in response to the Immediate Jeopardy. The POC indicated the facility continued the investigation into the sexual abuse allegation and documented on the investigation checklist. The facility had developed a new Abuse policy and procedure, an Investigation Procedures Policy and Procedure and Unusual Occurrence Investigation Checklist, inserviced hospital staff on abuse policies and procedures and assigned a licensed nurse who will be responsible for conducting surveillance on the unit to monitor patients for signs and symptoms of abuse and neglect.

Based on observation, interview and record review, the facility failed to meet the Condition of Participation (COP) for Patient Rights, as follows:

1. Failed to ensure the patients received care in a safe setting by failing to thoroughly investigate allegations of sexual assaults and physical abuse on 3 of 24 sample patients. The facility also failed to ensure that 1 of 24 sample patients (Patient 22) received care in a safe setting by failing to monitor her for inserting foreign objects in her body (Refer to A 144).


2. Failed to provide patient care in a setting free of abuse and harassment (Refer to A 145).


3. Failed to ensure the use of locked seclusion and/or restraint was in accordance with the physicians who were responsible for the care of 5 of 24 sampled patients (Refer to A 168).


4. The facility failed to monitor and assess the condition of the patients who were restrained and secluded for 4 of 24 sampled patients (Refer to A 175).

5. The facility failed to ensure the registered nurses who conducted face to face evaluations on 2 of 24 sampled patients within 1 hour after the initiation of seclusion and restraints made determination about the need for continued restraint and seclusion (Refer to A 179).

The cumulative effects of these systemic problems resulted in the facility's inability to protect and promote each patient's rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Because of the facility's failure to have a system in place to assure patient's safety as it relates to the failure to thoroughly investigate allegations of sexual abuse, the survey team declared an Immediate Jeopardy (IJ) on December 10, 2013 at 6:45 p.m., with the interim chief nursing officer, director of risk management (Admin 1), Nurse Manager 1 and Nurse Manager 3.


On December 13, 2013 at 2:05 p.m., the Immediate Jeopardy was abated in the presence of chief executive officer, medical director, interim chief nursing officer, director of risk management (Admin 1), Nurse Manager 1 Nurse Manager 3, and associate administrator. Admin 1 submitted an acceptable plan of correction (POC) in response to the Immediate Jeopardy. The POC indicated the facility continued the investigation the sexual abuse allegation and documented on the investigation checklist. The facility had developed a new Abuse policy and procedure, an Investigation Procedures Policy and Procedure and Unusual Occurrence Investigation Checklist, inserviced hospital staff on abuse policies and procedures and assigned a licensed nurse who will be responsible for conducting surveillance on the unit to monitor patients for signs and symptoms of abuse and neglect.


Based on observation, record reviews and interviews, the facility failed to ensure patients in the facility received care in a safe setting, by failing to thoroughly investigate allegations of sexual assaults and physical abuse for 4 of 24 sample patients (Patient 14, 7, 5 and 22). The facility also failed to ensure that 1 of 24 sample patients (Patient 22) received care in a safe setting by failing to monitor her for inserting foreign objects in her body.


1. Patient 14 alleged she was sexually assaulted by a male patient, sent to a general acute care hospital emergency department, diagnosed with vaginal contusion, and returned to the facility. The facility started an investigation, however, the patient was discharged the following day, without the facility conducting a thorough investigation of the incident.


2. Patient 7 alleged he was "sexually assaulted" by his roommate (Patient 21) in his room, both patients were sent to general acute care hospital for a rape exam, and Patient 7's Forensic Medical Report indicated physical findings that included red area on the penis glans and 2 scratches, red in color, 3 1/2 centimeters long, on the right buttocks area. There was no documented evidence the facility thoroughly investigated the patient's allegation of "sexual assault" involving another patient. There were no interviews conducted with staff members who worked on that day of the alleged incident or who may have knowledge of the alleged incident and other patients who may have knowledge regarding the alleged incident.


3. Patient 5 alleged that Mental Health Worker (MHW) 1 used a key to scratch her arm, three months ago, when the staff placed her in the seclusion room. There was no documented evidence that the facility reported this alleged incident to the Department and there was no evidence that the facility had thoroughly investigated the patient's allegation of physical abuse involving a staff member that included interviews with MHW 1, staff members who worked on the day of the alleged incident or who may have knowledge of the alleged incident and other patients who may have knowledge regarding the alleged incident.

4. Patient 22 was sent to a general acute care hospital for vaginal pain. "Status post insertion of foreign object 2 days ago." Patient 22 was diagnosed with cervicitis. The ED (emergency department) documentation indicated the patient stated she put a fork in her vagina, which was removed at the facility. There was no documented evidence that the incident had been thoroughly investigated and that patient 22 had been monitored to prevent this type of incident.

Findings:


1. On December 9, 2013 at 8:30 a.m., initial tour of the facility was conducted with Nurse Manager 3. In 1 North, there were five (5) patients in the middle Dayroom, another patient seated on the other end of the room with one staff. In 1 South (overflow for 1 North), a small Dayroom was empty. In 2 North at 9:20 a.m., there were five (5) staff observed by the nurses' station and there were six (6) patients in the day room with no staff present. At 9:35 a.m., Patient 14 was not in her room. At 9:55 a.m., there were six patients in the Dayroom and no staff present. There were four (4) staff in the nurses' station.

On December 10, 2013 at 3:05 p.m., Patient 14's medical record was reviewed. The Psychiatric Physician Admission Orders dated December 4, 2013, indicated admit to SICU, status involuntary (5150) with the diagnosis of psychosis. The application for the 72 hour detention for evaluation and treatment indicated a danger to herself and a danger to others. The patient crashed her vehicle on purpose with her children in it.

The Multidisciplinary Progress Notes dated December 8, 2013 at 7:57 a.m., indicated the patient approached the nurses' station and stated "I was sexually assaulted." The writer documented the patient stated, "He told me to go into the room, then staff immediately told me to get out. Then he later put two fingers in my vagina in the day room." Patient then stated "he did it in his room where he assaulted me." The writer then documented upon clarification, the patient stated again, "It was in the day-room." The patient complained of vaginal discomfort. The patient stated, "I think he was Hispanic, in his twenties, I don't remember exactly what time." The patient denied it was consensual. The patient told the officers, "He stuck his entire hand up my vagina." When asked if she would press charges the note indicated the patient stated, "No, I won't."

A review of the facility's Emergency Follow-Up form indicated a diagnosis of vaginal contusion.

A review of the Medical Professional Orders sheet dated December 7, 2013 at 8:10 a.m., indicated a telephone order to transfer Patient 14 to 2 North. On December 8, 2013 at 8:40 a.m., indicated a telephone order to send out to Facility B (general acute care hospital) for vaginal pain status post alleged sexual assault. At 8:45 a.m., the orders indicated to call police department and inform of patient's allegation. On December 9, 2013 at 6:40 a.m., a telephone order indicated to discharge today, and at 11:42 a.m., the orders indicated follow up with primary medical doctor, vaginal contusion.

The progress notes by social services dated December 9, 2013 at 8:30 a.m., the social worker (Employee 1) met with patient 1:1 to confirm discharge plan. The patient's sister will pick up patient. There was no documentation regarding the incident.

During an interview on December 10, 2013 at 3:30 p.m., when asked regarding the allegation of sexual assault incident on December 8, 2013, the Director of Quality Improvement and Risk Management (Admin 1) stated she was not aware of the incident and she would get the nurse manager (Nurse Manager 1).

During an interview with Nurse Manager 1 at 3:40 p.m., the same day, he stated he had not reviewed the record and he had not investigated the incident. He stated he has not interviewed the patient and staff members who worked the week end. When informed that the patient had been discharged , he stated the facility could not keep the patient due to the allegation. He stated the house supervisor investigated the incident and informed him (Nurse Manager 1) of the incident. Nurse Manager 1 stated the police interviewed the patient and the patient refused to press charges and the case was closed. He stated the patient changed her story multiple times: it was in his room, in the day-room, two fingers then the entire hand. The nurse manager then handed the unusual occurrence report.

A review of the report indicated the incident was reported on December 8, 2013 at 7:57 a.m., in 2 North and alleged to have happened in small 1 South Dayroom. The patient alleged 2-3 days ago, a male patient wearing red sweater and sweat pants, about 5'7" or 5'8" who she believed to be Hispanic in origin asked her to go into the small day-room where "he put his fingers in my vagina" and patient denies it was consensual. Patient believes patient name was Kenny. The patient was sent to Facility B for vaginal discomfort, Sheriff called. The documentation further indicated that per police department the patient refused to give information and refused to press charges. Case closed.

During the same interview, Nurse Manager 1 stated there was no patient named "Kenny". When asked regarding vaginal contusion, he stated it can mean multiple things. He also stated the patient could have done it herself.

During an interview with the interim chief nursing officer (Admin 2), when asked about the allegation of sexual assault incident, Admin 2 stated she was not aware of the incident.

On December 10, 2013 at 6:45 p.m., an Immediate Jeopardy (IJ) was called with the interim chief nursing officer, director of risk management, 2 North nurse manager and 1 South nurse manager.

On December 12, 2013 at 8:30 a.m., Admin 1 stated the facility continued the investigation of the patient's sexual abuse allegation. A list of patients from the 2 units did not show any patient named "Kenny" on the unit she was on during her hospitalization . When asked if any patient would fit the description (male, about 5'7" or 5'8" who she believed to be Hispanic in origin), Admin 2 stated, "Yes".

At 9 a.m., the same day, during an interview, the social worker (Employee 1) stated she heard about the incident during the shift report. The patient was taken to the hospital and did not find anything. It was her understanding that it had been solved. Employee 1 stated she did not speak with the patient about it when she met with the patient to discuss the discharge plan. Employee 1 stated her focus was to make sure the kids were ok. When asked what was the procedure for allegation of sexual assault, Employee 1 stated, "I cannot think of the procedure."

On December 13, 2013 at 2:05 p.m., the Immediate Jeopardy was abated in the presence of chief executive officer, medical director, interim chief nursing officer, director of risk management (Admin 1), Nurse Manager 1 Nurse Manager 3, and associate administrator. Admin 1 submitted an acceptable plan of correction (POC) in response to the Immediate Jeopardy. The POC indicated the facility continued the investigation into the sexual abuse allegation and documented on the investigation checklist. The facility had developed a new Abuse policy and procedure, an Investigation Procedures Policy and Procedure and Unusual Occurrence Investigation Checklist, inserviced hospital staff on abuse policies and procedures and assigned a licensed nurse who will be responsible for conducting surveillance on the unit to monitor patients for signs and symptoms of abuse and neglect.

The emergency room (ER) record for Patient 14 dated December 8, 2013 was reviewed on December 16, 2013. The nursing notes dated December 8, 2013, timed at 1:04 p.m., indicated the patient was alert, oriented x 4, responds to verbal, responds to pain, speech coherent. The physician note indicated sexual assault 2 days ago, patient refused rape evaluation, states vagina "hurts". The ER Summary disclosed physical examination reveals no lesions or abrasions or injuries to the vagina or the perineum region and that it was too late for her to undergo any formal rape evaluation. The Discharge Impression included complaint of vaginal pain, status post possible sexual assault.






2. A review of the facility letter to the Department dated March 15, 2013, Patient 7 reported to the Adolescent DDMI (developmentally disabled mental illness) unit nurse that on the previous night (March 10, 2013) Patient 21 bent him over his bed and put his p_,_,_,_ in his butt. The facility letter also disclosed that the staff member conducting the rounds observed Patient 7 dancing naked near Patient 21's bed while Patient 21 was sleeping. The nurse manager interviewed both patients. Patient 21 denied sexually assaulting Patient 7. Patient 21 was removed from the room and placed into another room. The nurse manager notified the Sheriff's Department. A detective came to the facility and interviewed both patients. Patient 21 denied sexually assaulting Patient 7. Both patients were sent to the acute hospital for a rape exam. The results of the examination were unknown at this time. Upon return of each patient to the facility, they were placed on 1 to 1 observation. The facility letter indicated the facility believed the allegation made by Patient 7 was false.

On December 12, 2013, a review of the facility's Patient/Visitor Occurrence Report completed by House Supervisor (registered nurse) 1 on March 12, 2013, indicated the type of occurrence was "alleged sexual assault." Patient 7 notified the staff member and reported "My roommate last night pushed me down on the bed and stick his p,_,_,_,_ in my butthole. He held me down, put it in." The patient stated "I told the staff at night and they didn't listen." Further review of the Patient/Visitor Occurrence Report revealed no documentation of a follow-up, when it was completed, further action required and the box for quality improvement/risk management was left blank. There was no other documentation found regarding interviews with other patients who may have knowledge regarding the alleged sexual incident or staff members who worked on the night of the alleged incident or who may have knowledge of the alleged incident.

An email communication by Nurse Manager 2 was provided by Admin 1 (director of risk management) on December 12, 2013 at 9:30 a.m., and Admin 1 stated Nurse Manager 2 was no longer working for the facility.

The e-mail communication dated March 11, 2013 at 9:44 p.m., indicated Nurse Manager 2 received a phone call from the unit lead charge nurse (House Supervisor 1) that Patient 7 was making sexual allegation against Patient 21. Nurse Manager 2 talked with Patient 7 and he stated that last night (March 10, 2013) Patient 21 bent him over his bed and put his p,_,_,_,_. When asked why he did not ask for help, Patient 7 said that Patient 21 covered his mouth so he could not scream. Nurse Manager 2 also talked with Patient 21 who stated Patient 7 was being inappropriate that he was awoken by staff because the staff conducting the round observed Patient 7 naked dancing besides Patient 21's bed. Nurse Manager 2 went back to Patient 7 and confronted about the dancing naked. Patient 7 initially denied it and saying that it never happened. When the staff member who worked the night of the alleged incident confirmed this, Patient 7 said that it was true that he danced naked that night and that Patient 21 did put his p,_,_,_,_ in his butt. Nurse Manager 2 notified the psychiatrist, both parents, and the Sheriff's Department. At 11:45 a.m., on March 11, 2013, Detective 1 arrived at the facility and interviewed both patients. According to the email communication, Patient 7 changed his story but did say Patient 21 did put his did put his p,_,_,_,_ in his butt. At around 3:30 p.m., Patient 7 and Patient 21 were escorted by the mental health workers and accompanied by Sheriff 1 and 2 to the acute hospital.

On December 12, 2013, at 5 p.m., during an interview, Admin 1 stated that the outcome of the investigation was not documented and that she did not have anymore investigation reports regarding sexual assault allegation of Patient 7. Admin 1 stated that they do not have the result of the rape exam. Admin 1 stated the facility was not able to substantiate the sexual allegation made by Patient 7.

A review of the closed medical records of Patient 21 and Patient 7 revealed the following:

a. The Record of Admission indicated Patient 21 was admitted to the facility's Adolescent DDMI (2 South) Unit on March 6, 2013 and was discharged to home on March 18, 2013. The Psychiatric and Mental Examination dictated March 7, 2013, indicated the patient was admitted as danger to others, as he had been increasingly aggressive towards his sister and mother. The diagnoses included oppositional defiant disorder (pattern of disobedient hostile and defiant behavior toward authority figure, U.S. National Library Of Medicine) and rule out bipolar disorder (a condition which a person had periods of being externally happy or being irritable, U.S. National Library Of Medicine).

The Integrated Admission assessment dated [DATE], indicated Patient 21's Assault/Violence Risk Assessment score was "18" which placed the patient at high risk for assault/violence. The Sexual Acting Out Risk Assessment indicated the patient had a history of sexual abuse and the score for this assessment was a "5." A score of "0-5" identified the patient as low risk and placed the patient on routine 15 minutes checks.

The Multi-disciplinary Assessment & Initial Treatment Plan dated March 7, 2013 at 11 a.m. contained "Critical Impairments To Be Addressed This hospitalization " which included assaultiveness, rage, impaired concentration, and sexual abuse. The Interdisciplinary Treatment Plan dated March 9, 2013, disclosed the problem list for Patient 21 was aggression toward others and did not address the patient's sexual risk.

Patient 21's Treatment Plan dated March 6, 2013, indicated interventions for aggressive behavior and was hearing voices included monitoring for combative behavior every 15 minutes. The Treatment Plan did not address the patient's sexual risk.

During an interview on December 16, 2013 at 1:25 p.m., Admin 2 (interim chief nursing officer) stated that Patient 21 had a sexual acting out risk score of less than 10 (5), it did not place him at high risk and no treatment plan was developed.

The facility's Daily Nursing Flow Sheet dated March 10, 2013 for 3 p.m. to 11 p.m. shift, indicated Patient 21 was assessed as being alert and oriented to person, place and time. His memory was intact with no hallucinations or delusions. Patient 21's observation level was to check every 15 minutes with assault precautions. There was no other documentation regarding the alleged incident involving the patient's roommate (Patient 7) and no documentation Patient 21 was removed from the room.

The facility's Daily Nursing Flow Sheet dated March 10, 2013 at 8:30 p.m., indicated the patient had impulsive and unpredictable behavior. Patient 21 made "inappropriate sexual remark" toward a female patient. The detail of the sexual remark was not documented. A 1 to 1 interaction was given to the patient to direct him to go to his room.

The Patient Observation Records dated March 10, 2013, indicated that during the 15 minute rounds between 9:00 p.m. and 10:30 p.m., Patient 21 was awake in his room.

During an interview on December 16, 2013 at 1:25 p.m., Admin 2 stated that regarding Patient 21's "inappropriate sexual remark" toward a female patient, the staff should have assessed, investigate further and document it on the Daily Nursing Flow Sheet. Admin 2 stated add the sexually inappropriate behavior on the treatment plan.

The Daily Nursing Flow Sheet dated March 11, 2013, at 12:51 p.m. disclosed the patient was angry and suspicious. Patient 21 stated "he's lying about me." At 2:34 p.m., Patient 21 left the facility with a staff member to go to acute hospital accompanied by a Sheriff. At 4:10 p.m., Patient 21 returned to the facility and was placed on 1 to 1 monitoring.

b. The Record of Admission indicated Patient 7 was admitted to the facility's Adolescent DDMI (2 South) Unit on May 20, 2011 and was discharged to a group home on May 15, 2013. The Psychiatric and Mental Status Examination dated May 23, 2011, indicated the patient was admitted because of increasing assaultive behavior and inability to contain his behavior at a less restricted level of care. The diagnoses included autism and bipolar disorder.

The Integrated Admission assessment dated [DATE] (page 12), indicated Patient 7's Assault/Violence Risk Assessment indicated he was admitted as a danger to others, had unpredictable behavior, and had history of assault and strike out. The patient's Assault Risk Score was 23 (10 or greater is high risk) which placed the patient at a high risk for assault/violence.

The current Interdisciplinary Treatment Plan/Update completed on March 8, 2013, indicated Patient 7's risk assessment identified the patient was at risk for assault. The Medical Professional Orders indicated the 30 days Recapped (renewal) Order dated March 10, 2013 with the observation level order was every 15 minute check with precautions for AWOL (elopement), sexual and assault.

The facility's Daily Nursing Flow Sheet dated March 10, 2013 for 3 p.m. to 11 p.m. shift, disclosed Patient 7 was placed on precautions for assault, elopement and sexual, with observation every 15 minutes to monitor his location and activity. The patient was assessed as being alert and oriented to person, place and time. His memory was intact with no hallucinations or delusions.

The Patient Observation Records dated March 10, 2013, (the night of the alleged incident) indicated that during the every 15 minute rounds between 8:30 p.m. and 11:15 p.m., Patient 7 was awake in his room.

The facility's Daily Nursing Flow Sheets dated March 10, 2013 for 3 p.m. to 11 p.m. shift and March 11, 2013 for 12 a.m. to 7 a.m. shift, disclosed no documentation of any reports from Patient 7 to the nursing staff and there was no documentation of the patient dancing naked in his room in the presence of the roommate. There was no other documentation regarding the allegation of sexual assault reported by Patient 7. There was no documentation of interviews that had been conducted with other patients who may have had knowledge regarding the alleged sexual incident or staff members who worked on the night of the alleged incident or who may have knowledge of the alleged incident.

The facility's Daily Nursing Flow Sheet dated March 11, 2013, indicated Patient 7 was assessed as being alert and oriented to person, place, time and situation. His memory was intact with no hallucinations or delusions. At 10:46 a.m., an entry by the charge nurse disclosed Patient 7 notified the staff that on the previous night, his roommate pushed him down on the bed and stuck his p,_,_,_,_ in his butt. Patient 7 also stated, "I told the staff at night and they didn't listen. " When asked about the standing and dancing naked over his roommate, Patient 7 stated, "I did do that but that was before he put me down." Then the patient stated, "No I did it first then he humped me. " Patient 7 also stated, "he did put it in my butthole" and also stated, "but when he was done, I told them (staff) that he did it to me."

According to the Forensic Medical Report: Sexual Assault Suspect Examination dated March 11, 2013 at 4:05 p.m., Patient 7 reported that the "assault" happened on March 10, 2013 at 10:00 p.m. in the bed in the room. Patient 7 stated, "He (Patient 21) turned me over and put his thing in my butt." Patient 7 also stated that he was in his room, naked dancing around Patient 21 who was standing up. Patient 7 said the staff told him to go to bed. He did it again. The staff told him again to go to bed. Patient 7 stated, "I tried to call for help and scream but he put his hand over my mouth. He humped me." The Forensic Medical Report indicated the physical findings included red area on the p,_, _,_ ,_ glans and 2 scratches, red in color, 31/2 centimeters long, on the right buttocks area. The Treatment Recommendations form indicated Patient 7 received one dose of rocepin antibiotic, 250 milligrams, intramuscularly.

A review of the facility policy and procedure on "Observation and Monitoring" revised February 2013 stipulated the facility policy was to uphold the right of the patients to receive care in a safe and therapeutic environment. Staff members assigned to each unit will provide continuous monitoring precaution, oversight and intervention to provide for their safety and security.

3. On December 10, 2013, at 2 p.m., Patient 5's medical record was reviewed. Patient 5 was admitted to the facility's DDMI Adult Unit on June 24, 2013 with diagnosis of schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problem). The DDMI Wing 30 Day Progress Report for October 24, 203 to November 24, 2013, indicated the patient's diagnoses included schizoaffective disorder, impulse control disorder and mild mental retardation. Patient 5 had aggressive behaviors towards others and self-injurious behaviors. Patient 5 also had exhibited delusional thoughts and when she became upset and she frequently accused staff of abusing her. The medical record contained a picture of the patient's right arm dated September 9, 2013 at 5 a.m., that was described as "scratch."

According to the Multi-Disciplinary Progress Notes dated September 9, 2013, at 9:45 a.m., the physician note indicated the patient had an abrasion, 8 inches long, described as clean and healing on the right arm.

During an interview on December 10, 2013 at 5:30 p.m., when questioned about the patient's right arm, Nurse Manager 1 stated the allegation was a staff member got a key and used it to scratch her arm. Admin 1 (director of risk management), who was present during the interview with Nurse Manager 1, stated Patient 5 found a screw and use it to scratch her arm. Admin 1 stated the incident was documented on occurrence report.

A review of the Patient/Visitor Occurrence Report dated September 8, 2013 at 5:15 p.m., completed by RN 6, indicated that Patient 5 reported that she scratched her "LFA" (left forearm) with a screw from the bathroom and then flushed the screw down the toilet. Patient 5 claimed she scratched her arm because no one cares. Immediate action included 1:1 verbal report, search the room for contraband, and notified the physician, psychiatrist and nurse manager. However, according to the picture, the scratch was noted on the patient's right arm. There was no documentation that interviews were conducted with staff members who worked on the day of the alleged incident or who may have knowledge of the alleged incident and other patients who may have knowledge regarding the alleged incident. There was no documentation that the alleged incident was reported to the Department.

On December 12, 2013 at 11:25 .am., during an interview, Patient 5 stated MHW 1 (mental health worker) used a key to scratch her right arm and the incident happened in the seclusion room 3 months ago.

During the subsequent interview on December 12, 2013 at 9 a.m. and 3:25 p.m., Nurse Manager 1 stated that the staff member that was involved in the allegation was MHW 1. Nurse Manager 1 stated that he had talked with MHW 1 three weeks ago and today regarding Patient 5's allegation that MHW 1 used a key to scratch her right arm. Nurse Manager 1 stated that according to MHW 1, he was not assigned to Patient 5 for months and had not been involved in restraining Patient 5 in the seclusion room. Nurse Manager 1 stated he did not know if he had any documentation regarding his conversation with MHW 1 and could not remember if the other staff statements were documented. At 5 p.m., on the same day, during an interview with Admin 2, she stated they will place the staff on suspension pending investigation of Patient 5's abuse allegation.

A review of the facility's policies and procedures binder disclosed the facility's policies on reporting of abuse, reporting of unusual occurrence, patient/visitor occurrences, identifying and assisting victims of abuse, and sexual precautions. A review of these policies did not address procedures for investigation of abuse allegation including methods to protect the patient from abuse during the investigation of allegations.
















4. A review of Incident reports for Patient 22 on December 10, 2013 at 2:30 p.m., revealed reports of alleged sexual abuse, patient injuries from falls, patient aggression, and self injury including foreign body retention.

During an interview with Admin 1 on December 10, 2013 at 3:45 p.m., she stated all incident reports are thoroughly investigated and most are found to be unsubstantiated.

A review of Patient's 22 medical record on December 12, 2013 at 4:15 p.m., revealed on November 3, 2013 at 1:00 p.m., Patient 22 was sent to a general acute care hospital for vaginal pain. "Status post insertion of foreign object 2 days ago." Patient 22 was diagnosed with cervicitis. Documentation in the ED (emergency department) record disclosed the patient stated she had put a fork in her vagina, which was removed ( at the facility).

During an interview with Patient 22 on December 13, 2013 at 11:40 a.m., she stated she puts foreign objects in her body when she is "mad" at the staff. She admitted to inserting several items in herself in the past including a hairbrush, toothbrush, fork and a metal object. Patient 22 stated she sometimes goes to the hospital because of the foreign objects in her body.

During an interview with RN 3, on December 13, 2013 at 10:30 a.m., she was asked how do patients get brushes, forks, and other foreign objects, that are unaccounted for, she stated the patient might get them and hide them when not being monitored. When asked how does the staff know if a patient has retained a foreign body, RN 3 stated sometimes the patient might walk differently, or sometimes the staff would conduct a body check from head to toe including body cavities are checked and if an object is seen it is removed from a body cavity by the nurse and the physician is notified.

During an interview with Admin 2 on December 13, 2013 at 10:45 a.m., she stated there was no policy and procedure for body cavity searches and removal of foreign body from a patient, or to count objects used by patients.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review, the hospital failed to ensure each patient had the right to be free from all forms of abuse and harassment. The facility failed to prevent Patient 22 from sexual intercourse with another patient (Patient 23) with mental disability and mental illness. The facility failed to provide adequate monitoring to protect two adolescent patients, Patient 22 and Patient 23, with mental disability from sexual activity.

Findings:


During an interview with Patient 22 on December 13, 2013 at 11:40 a.m., she admitted to having sexual intercourse with Patient 23.


A review of the medical records on December 12, 2013 at 4: 25 p.m., revealed in the progress note dated December 2, 2013 at 11:23 a.m., it was documented that Patient 22 was out of sight from staff for a few minutes and was found in the bathroom with Patient 23. Patient 22 stated she had sexual intercourse with Patient 23. Charge nurse documented the incident as consensual. The investigation of the incident only involved Patient 22 and Patient 23 and concluded the incident was consensual. Both patients were sent to the acute hospital for examination of sexually transmitted disease.


On December 12, 2013 at 435 p.m., a review of the "DDMI 30 day report" for the period: October 2, 2013 to November 1, 2013, for Patient 22 documented a total of 8 incidents of inappropriate behavior including inappropriately touching self; disrobing infront of other staff and patients and sexual intercourse with another patient; and 2 incidents of self injurious behavior including banging head and inserting items in her vagina.

Tha facility policy and procedure titled, Sexual Precautions dated September 2008 indicated to monitor patients with sexual acting out behaviors every 15 minutes. Under section 3 titled "occurrence consensual," it states "staff members learning of suspected sexual activity between patients is to immediately report to the charge nurse." The charge nurse then notifies the nurse manager and the attending physician.

The medical record revealed Patient 22 is an adolescent with mental disability (mental retardation) and mental illness(schizoaffective disorder). The medical record revealed Patient 23 is an adolescent with mental disability ( mental retardation ) and mental illness( mood disorder). Both patients were on the adolescent DDMI unit.

On December 12, 2013 at 3:30 p.m., during an interview with Admin 2, she stated the charge nurse interviewed Patient 22 and Patient 23 and reported the sexual interaction as consensual based on her interview of the patients involved. The investigation was considered thorough by the facility's standards. When asked what is done to monitor and protect patients from what occurred to Patient 22 and Patient 23, Admin 2 stated the patients that are evaluated to be on sexual precautions are monitored for their behavior about every fifteen minutes and documented. When asked why the charge nurse identified what occurred between Patient 22 and Patient 23 consensual, she stated the charge nurse documented her finding as consensual based on the interview of the two patients.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review and interview, the facility failed to ensure the use of seclusion or restraint was in accordance with the order of a physician who was responsible for the care of 5 of 24 sample patients (Patient 1, 3, 4, 5 and 19). According to the facility's "Seclusion and Restraints Physical Hold Policy" revised March 2013, "Seclusion" is any involuntary confinement of a patient alone in a room where he or she is physically prevented from leaving. "Mechanical Restraint" is the application of or use of any mechanical device, material, or equipment attached to the patient's body that restricts freedom of movement or normal access to one's own body as a result of material or equipment attached or adjacent to the patient's body. Patient 1 was placed in mechanical restraints and seclusion on 2 occasions (November 26 and 30, 2013), and Patient 5 was placed in mechanical restraints and seclusion on 6 occasions (September 8, 22, October 4, 5, 6, 2013) without obtaining orders from the physicians for the use of locked seclusion. Patient 4 was placed in mechanical restraints and seclusion on 1 occasion (December 7, 2013) without a physician order for the use of locked seclusion. Patient 3 and Patient 19 were observed sitting in a wheelchair with a soft cloth tie (physical restraint that restricts freedom of movement) that was tied around the patients' upper body without a physician order for the use of a soft cloth tie. This deficient practice had the potential for the patients to be placed in unnecessary seclusion.

Findings:

1. On December 9, 2013, a review of Patient 1's medical record revealed Patient 1 was placed in 5 point mechanical restraints (physical restraint applied on the patient arms, legs and waist area) and seclusion on two (2) occasions. There was no physician order for the use of locked seclusion.

a. Patient 1's Seclusion and Restraints Flow Sheet dated November 26, 2013, indicated the patient was placed in seclusion and restraints at 1:46 p.m. and was out of restraints and seclusion at 4 p.m.

Patient 1's Behavioral Restraint/Seclusion Physician Order Form dated November 26, 2013 at 1:40 p.m. indicated the patient was danger to self and others as evidenced by hitting the wall with elbow, hitting the wall with closed fist, banging the head on the wall, attempting to choke herself, attempting to bite the staff, hitting and kicking the staff. A telephone physician order was obtained for 5 points restraints but there was no physician order for the use of locked seclusion.

b. Patient 1's Seclusion and Restraints Flow Sheet dated November 30, 2013 indicated the patient was placed in seclusion and restraints at 8 p.m. and was out of restraints and seclusion at 9:35 p.m. Patient 1's Behavioral Restraint/Seclusion Physician Order Form dated November 30, 2013 at 8 p.m., indicated the patient was danger to others as evidenced by kicking staff, cursing at staff, non-redirectable. A telephone physician order was obtained for 5 points restraints but there was no physician order for the use of locked seclusion.

During an interview on December 9, 2013, at 2 p.m., Nurse Manager 1 stated that the staff should check off the box next to locked seclusion of the Behavioral Restraint/Seclusion Physician Order form when obtaining seclusion order from the physician.

2. On December 10, 2013, a review of Patient 5's medical record revealed Patient 5 was placed in 5 point mechanical restraints and seclusion on six (6) occasions. There was no physician order for the use of locked seclusion.

a. Patient 5's Seclusion and Restraints Flow Sheet dated October 6, 2013 indicated the patient was placed in seclusion and restraints at 7 a.m. and was out of restraints and seclusion at 9:15 a.m. Patient 5's Behavioral Restraint/Seclusion Physician Order Form dated October 6, 2013 at 7 a.m., indicated the patient was danger to self as evidenced by banging her head against the wall, hitting herself and disrobing and danger to others as evidenced by hitting the staff, hitting the roommate and kicking a male staff member. A telephone physician order was obtained for 5 points mechanical restraints but there was no physician order for the use of locked seclusion.

b. Patient 5's Seclusion and Restraints Flow Sheet dated October 6, 2013, indicated the patient was placed in seclusion and restraints at 10 a.m. and was out of restraints and seclusion at 2 p.m. Patient 5 s Behavioral Restraint/Seclusion Physician Order Form dated October 6, 2013 at 10 a.m. indicated the patient was danger to self as evidenced by banging head on the wall, kicking doors and punching the window, biting her arm and throwing herself on the floor. The patient was also danger to others as evidenced by assaulting the staff, kicking, spitting, punching and attempting to bite the staff. A telephone physician order was obtained for 5 points restraints but there was no physician order for the use of locked seclusion.

c. Patient 5's Seclusion and Restraints Flow Sheet dated October 5, 2013 indicated the patient was placed in seclusion and restraints at 5:15 p.m. and was out of restraints and seclusion at 9:15 p.m. Patient 5's Behavioral Restraint/Seclusion Physician Order Form dated October 5, 2013 at 5:15 p.m. indicated the patient was danger to self as evidenced by slamming the doors, banging her head against the wall, hitting herself and shouting. The patient was danger to others as evidenced by throwing food from her tray at another peer and staff. A telephone physician order was obtained for 5 points restraints but there was no physician order for the use of locked seclusion.

d. Patient 5's Seclusion and Restraints Flow Sheet dated October 4, 2013 at 6 p.m., indicated the patient was placed in seclusion and restraints at 6 p.m., and was out of restraints and seclusion at 7:30 p.m. Patient 5's Behavioral Restraint/Seclusion Physician Order Form dated October 4, 2013 at 6 p.m. indicated the patient was danger to others as evidenced by hitting, kicking and spitting at the staff. A telephone physician order was obtained for 5 points restraints but there was no physician order for the use of locked seclusion.

e. Patient 5's Seclusion and Restraints Flow Sheet dated September 22, 2013 at 7:20 a.m., indicated the patient was placed in seclusion and restraints at 7:20 a.m., and was out of restraints and seclusion at 10:15 a.m. Patient 5's Behavioral Restraint/Seclusion Physician Order Form dated September 22, 2013 at 7:20 a.m. indicated the patient was danger to self and others as evidenced by screaming, cursing, throwing herself on the floor, banging her head on the floor, pulling her hair, kicking and spitting at the staff. A telephone physician order was obtained for 5 points restraints but there was no physician order for the use of locked seclusion.

f. Patient 5's Seclusion and Restraints Flow Sheet dated September 8, 2013 at 5:30 p.m., indicated the patient was placed in seclusion and restraints at 5:30 p.m., and was out of restraints and seclusion at 6:25 p.m. Patient 5's Behavioral Restraint/Seclusion Physician Order Form dated September 8, 2013 at 5:30 p.m., indicated the patient was danger to self and others as evidenced by scratching and banging her head, hitting, kicking and spitting at the staff. A telephone physician order was obtained for 5 points restraints but there was no physician order for the use of locked seclusion.

During an interview on December 10, 2013, at 11 a.m., Nurse Manager 1 stated that the staff should check off the box next to locked seclusion of the Behavioral Restraint/Seclusion Physician Order form when obtaining seclusion order from the physician.

3. On December 10, 2013, a review of the Behavioral Restraint/Seclusion Physician Order Form dated December 7, 2013 at 6:20 p.m. indicated Patient 4 was placed in 5 points restraints and locked seclusion. However, there was no physician order for the use of locked seclusion. The Seclusion and Restraints Flowsheet dated December 7, 2013 indicated the patient was placed in restraints and seclusion at 6:20 p.m. and was out of restraints and seclusion at 9 p.m.

4. On December 9, 2013, at 9:20 a.m., in the Day Room, Patient 3 was observed sitting in a wheelchair and a soft cloth tie was placed around his upper body and tied at the back of the wheelchair. A review of the medical record did not reveal an order nor assessment for the use of a soft tie restraint.

During an interview on December 10, 2013 at 9:10 a.m., Nurse Manager 1 stated Patient 3 did not need a soft tie tied around his upper body when up in a wheelchair.

A review of the facility's policy and procedure on "Seclusion and Restraint Physical Hold Policy" revised March 2013, stipulated the telephone order for the use of seclusion and restraint is obtained by the registered nurse that assessed the patient for the need for restricted intervention. The registered nurse is to document the telephone order on the "Seclusion/Restraint Order form."





5. During the initial tour of the facility on December 9, 2013 at 9:10 a.m., Patient 19 was observed in the dayroom in a wheelchair with a soft cloth tie around her waist, mittens on her hands and a helmet on her head.

During an interview with RN 3, on December 9,2013 at 3 p.m., she stated Patient 19 is ambulatory but falls a lot and has self-injurious behavior. She stated the patient's mother brought the wheel chair to the hospital and, the patient likes to sit in the wheel chair.

A review of Patient 19's medical record on December 9, 2013, disclosed there was no physician's order for the soft cloth tie and wheelchair. There was no documented care plan for a wheelchair.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to monitor and assess the condition of the patients who were restrained and secluded for 3 of 24 sample patients (Patient 1, 5, and 4) by failing to:
1. assess and reassess the patient's needs and safety such as vital signs, pain, presence of injury, nutrition, hydration, hygiene/elimination, circulation/range of motion, and patient's current pain level, and whether or not the patient met release criteria when the patient was placed and removed from restraints and seclusion.

2. describe the patient's behavior every 15 minutes after 1:40 p.m. and before 3:30 p.m. as indicated in the nursing notes.

This deficient practice had the potential for not monitoring the safety and need of the patients while placed in restraints and seclusion.

Findings:

1. A review of Patient 1's QRN Seclusion and Restraint Assessment (facility's form to document pertaining to the patient's restraint and seclusion) indicated the patient was placed in seclusion and restraints on December 7, 2013 at 10:05 p.m. The RN Hourly Assessment indicated patient was assessed at 11:05 p.m. for nutrition, hydration, hygiene/elimination, circulation/range of motion and current behavior/condition/response. The patient was still agitated and the patient did not meet the release criteria. The Seclusion and Restraints Flow Sheet indicated the patient was out of restraints and seclusion at 11:40 p.m. and there was no reassessment of the patient's needs and safety such as vital signs, pain, presence of injury, nutrition, hydration, hygiene/elimination, circulation/range of motion, and patient's current pain level, and whether or not the patient met release criteria as indicated in the form.

2. A review of Patient 5's QRN Seclusion & Restraints assessment dated [DATE] indicated the patient was placed in seclusion and restraints on August 30, 2013 at 1:30 p.m. The Seclusion and Restraints Flow Sheet indicated the patient was out of restraints and seclusion at 2:10 p.m. The Seclusion and Restraints RN Hourly Assessment disclosed there was no assessment of the patient needs and safety such as vital signs, pain, presence of injury, nutrition, hydration, hygiene/elimination, circulation/range of motion, patient's current pain level, and whether or not the patient met release criteria as indicated in the form.

3. A review of Patient 4's Seclusion and Restraints Flow Sheet dated December 7, 2013 indicted the patient was placed in seclusion and restraints at 6:20 p.m. The Seclusion and Restraints RN Hourly Assessment indicated the last assessment was completed at 8:20 p.m. and the patient did not meet the release criteria. At 9:00 p.m., the patient was out of restraints and there was no reassessment of the patient needs and safety that included vital signs, presence of pain or injury, nutrition, hydration, hygiene/elimination, circulation/range of motion, current behavior/condition/response and whether or not the patient met release criteria.

During an interview on December 10, 2013 at 11:20 a.m., Nurse Manager 1 stated that the RN was supposed to conduct an assessment of the patient's condition as indicated on the form when the patient was removed from the restraints and seclusion.

4. Patient 1's Seclusion and Restraints Flow Sheet (facility's form to document pertaining to the patient's restraint and seclusion)dated November 26, 2013 indicated the patient was placed in restraints and seclusion at 1:40 p.m. and was out of restraints at 4 p.m. The Q15 Nursing Notes section did not indicate description of the patient's behavior every 15 minutes after 1:40 p.m. and before 3:30 p.m. as indicated in the nursing notes.

Patient 1's Seclusion and Restraints Flow Sheet dated November 21, 2013 indicated the patient was placed in restraints and seclusion at 5:20 p.m. and was out of restraints at 9 p.m. The Q15 Nursing Notes section did not indicate the times when the patient behavior was described as indicated in the nursing notes.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that the registered nurses who conducted face to face evaluations (face to face observations) on 2 of 24 sample patients (Patient 1 and 5) within 1 hour after the initiation of seclusion and restraints made determination about the need for continued restraint and seclusion.

This deficient practice had the potential for patients to be placed in restraints and seclusion that were not justified and may pose risk to the patient's medical and pscyhological well-being when there was no documented evidence of a determination about the need for continued restraint and seclusion.

Findings:

1. On December 9, 2013, a review of Patient 1's QRN (registered nurse) Seclusion & Restraint Assessment (facility's form to document the patient's restraint and seclusion) dated December 7, 2013 at 10:38 p.m., indicated the RN completed a Face to Face evaluation but failed to indicate whether the criteria for seclusion and restraints were met or not met. The Seclusion and Restraints Flow Sheet indicated the patient was placed in seclusion and restraints at 10:05 p.m. and out of restraints and seclusion at 11:40 p.m.

During an interview on December 9, 2013, at 2 p.m., Nurse Manager 1 stated the staff was supposed have checked the box that indicated the criteria for seclusion and restraints were met on the facility's form, "QRN (registered nurse) Seclusion & Restraint Assessment."

According to the facility's policy and procedure on "Seclusion and Restraint Physical Hold Policy" revised March 2013, the purpose of conducting a face to face assessment of the patient in restraint and seclusion was to determine if the use of restraint and seclusion is justified to prevent the patient from causing harm to self or others. It is also completed to ensure the use of restraint and seclusion poses no undue risk to the patient's medical and pscyhological well-being.

2. A review of Patient 1's a review QRN Seclusion & Restraint assessment dated [DATE] at 9:30 a.m., indicated the RN completed a Face to Face evaluation and checked the box to indicate criteria for seclusion and restraints were not met. The Seclusion and Restraints Flow Sheet dated September 11, 2013 indicated the patient was placed in seclusion and restraints at 7:50 a.m. and out of seclusion and restraints at 10:30 a.m.

During an interview on December 9, 2013 at 2 p.m., Nurse Manager 1 stated the staff should have checked the box that indicated the criteria for seclusion and restraints were met on the facility's form, "QRN (registered nurse) Seclusion & Restraint Assessment."

3. On December 10, 2013, a review of Patient 5's QRN Seclusion & Restraints assessment dated [DATE] at 8:15 a.m., indicated the RN completed a Face to Face evaluation and did not indicate if the patient met criteria for seclusion and restraint. The Seclusion and Restraints Flow Sheet dated September 22, 2013 indicated the patient was placed in seclusion and restraints at 7:20 a.m. and was out of restraints and seclusion at 10:15 a.m.

During an interview on December 10, 2013 at 11 a.m., the staff should have checked the box that indicated the criteria for seclusion and restraints were met on the facility's form, "QRN (registered nurse) Seclusion & Restraint Assessment."
VIOLATION: QAPI Tag No: A0263
Based on record review and interview, the hospital failed to develop, implement and maintain an effective ongoing hospital wide, data-driven quality assessment performance improvement (QAPI) program. The hospital governing body failed to ensure that the program reflects the complexity of the hospital's organization and services and focuses on indicators that improve health outcome, patient safety, quality of care and the prevention and reduction of medical errors and adverse events. The facility failed to meet the Condition of Participation in QAPI, as follows:

Findings:

1. The facility failed to prioritize its performance improvement activities that: Focus on high-risk, high-volume, or problem prone areas; consider the incidence, prevalence, and severity of problems in those areas and affect health outcome patient safety and quality of care (Refer to A 283).

2. The facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on these projects (Refer to A 297).

3. The facility's governing body, medical staff, and administrative officials failed to ensure a hospital wide QAPI program addressing priorities for improved quality of care and patient safety and evaluate all improvement actions (Refer to A 309).

The cumulative effect of these systemic failures resulted in the hospital's governing body inability to maintain appropriate oversight to assure quality health care in a safe environment.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interview and record review, the hospital failed to prioritize its performance improvement activities that: Focus on high-risk, high-volume, or problem prone areas; consider the incidence, prevalence, and severity of problems in those areas and affect health outcome ,patient safety and quality of care.

Findings:

On December 13, 2013 at 1:00 p.m., during an interview with the Quality Improvement Risk Management(QI/RM) director she stated she was in charge of data collection. QAPI is included in QI/RM. She stated the Quality improvement data is collected monthly and presented to the Medical executive committee and the Board of directors Quarterly. She stated she did not have a QAPI project available that tracked and trended date over time with sustainable performance improvement to patient care and safety.

On December 10, 2013 at 3:45 p.m., a review of the data collected for the 3rd quarter of 2013 had 21 quality indicators. There were no QAPI studies focused on the hospitals' high risk, high volume or problem areas. There was monthly reporting of all 21 quality indicators with no prioritizing tracking trending or analyzing and interpreting the data collected to improve patient care.

During a review of the policy and procedure for the hospital On December 10, 2013 at 3:40 p.m., titled "Organizational performance improvement plan." Indicated that the hospital will "aggregate and analyze data elements collected" and "intensified assessments will be carried out when indicated by data analysis as required by Joint Commission standards or other regulation."
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on interview and record review, the hospital failed to document what quality improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on these projects.

Finding:

During an interview with Admin 1 on December 13, 2013 at 1:15 p.m., she stated there were no QAPI studies in place that tracked and trended data or projects that were implemented from the analysis of data collected.

A review of the QI/RM program revealed data collected included : restraints and seclusion, fall, elopement. There was lack of focus on high volume and problem prone areas that had high incidence and prevalence specific to the hospital. Data was collected monthly and presented quarterly to the Medical Executive Board and the Board of Directors. No documentation was provided of QAPI projects, using the gathered data to: track and trend; analyze the data and implement projects that improve patient care and safety.

The hospital failed to provide documentation of any QAPI projects implemented and a description of the project results. The number and scope of the QAPI projects were not representative of the complexity and scope of the hospital.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interview and record review, the hospital's governing body, medical staff, and administrative officials failed to ensure a hospital wide QAPI program addressing priorities for improved quality of care and patient safety and evaluate all improvement actions.

Findings:

A review of the Medical Executive Committee minutes dated April 26, 2013, and at the Board of Directors dated May 6, 2013, indicated Admin 1 presented monthly data. There was no tracking or trending analyzing or interpreting of data collected. No QAPI projects were presented that could improve patient health and safety.

During a review of the facility policy and procedure on December 10, 2013 at 4:50 p.m., titled "Organizational performance improvement plan titled " Governing Body", indicated the Board of Directors which is the governing body for the hospital, had "ultimate authority and responsibility to require and support a performance improvement program at the hospital, prone areas that had incidence prevalence and severity of problems in this surgery center.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, the facility failed to ensure the nursing services was organized to provide adequate staffing and quality of care to meet the needs of each patient receiving nursing services. The facility failed to meet the Condition of Participation in Nursing Services as follows:

1. The facility failed to ensure the nursing service had adequate numbers of staff to respond to the appropriate nursing needs and care of the patient of each nursing unit (Refer to A 392).

2. The facility failed to document the assessment of 1 of 24 sampled patients (Patient 10) after the patient was assaulted by another patient (Patient 9). The facility also failed to evaluate the nursing care for 2 of 24 sample patients (Patient 5 and 4) when an assessment was not conducted for Patient 5's multiple bruises to her arms and legs and when a physician order for emergency psychoactive medication of Thorazine 50 milligrams by intramuscularly was not documented as given in Patient 4's medical record (Refer to A 395).

3. The facility's licensed nurse failed to develop care plans for the use of hand mittens, develop a treatment plan within eight hours of patient admission in accordance with the policy and procedure, and failed to address a patient's aggression towards others in the treatment plan based on patient assessment for 3 of 24 sample patients (Patient 2, 8, and 9)
(Refer to A 396).

The cumulative effects of these systemic failures resulted in the facility's inability to assure quality health care in a safe environment.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record review and interview, the facility failed to ensure the nursing service had adequate numbers of staff to respond to the appropriate nursing needs and care of the patient of each nursing unit.

Findings:

1. On December 13, 2013, at 8:55 a.m., during an interview, a staff member stated it was hard to work in the DDMI Adult unit (5 South) when there were two mental health workers assigned to 8 patients during the weekend to provide care such as doing every 15 minute rounds, vital signs, passing/setting up meal trays, morning group orientation/unit rules and assisting with activities of daily living like showers. The staff member stated one more mental health worker is needed in order to provide the care timely. The staff member stated in the morning they had to stop passing breakfast trays in order to conduct the every 15 minute rounds. The staff member stated the patients get anxious when there was a short of staff and one patient would start yelling in the day room when he does not get his breakfast. Between 11 a.m. and 12:15 p.m., the staff members are taking their lunch and lunch for the patients would start at 12 p.m. and sometimes there would be one mental health worker working on the floor.

On December 13, 2013 at 10:15 a.m., in another interview, the staff member stated that the patients in the in the DDMI Adult Unit (4 North) were low functioning and required a lot of care. The staff member stated that one mental health worker was assigned to 7 patients to conduct every 15 minute rounds, vital signs, passing meal trays, and assist with the activities daily of living. Although the registered nurse (RN) and the licensed psychiatrist technician (LPT) or licensed vocation nurse (LVN) assist the mental health workers with the passing with meal trays, showers and vital signs, the staff member stated one more mental health worker is needed in order to perform the necessary care to meet the needs of the patients. In another interview at 10:45 a.m., the staff member stated that it was hard when there was a short of staff and it would be better if additional mental health worker is added in the staffing during the day time.

The facility's floor plan indicated DDMI Adult Unit is divided into three sections: 4 North, 4 South and 5 South.

A review of the facility's Staffing revised February 2013 was reviewed. The policy indicated the facility would provide adequate number of qualified staff to provide safe and quality patient care. Staffing levels are to be reviewed and adjusted as necessary to meet the patient and unit needs. The procedure stipulated that all units are staffed at the patient/staff ratios during the AM (morning) and PM (evening) shifts. In the DDMI Adult, for AM, PM, and 7 a.m. to 7:30 p.m. (Sunday), the staffing matrix is 1 staff member to 3 patients (1:3).

According to the DDMI Staffing Matrix 3:1 Ratios for AM, PM, and Sunday 7 a.m. to 7:30 p.m., the staffing is as follows:
Census=6: 2 MHWs, 1 LVN/LPT, and 1 shift supervisor.
Census=18: 6 MHW, 1 LVN/LPT and 1 shift supervisor
Census=24: 7 MHW, 1 LVN/LPT, I licensed nurse, and 1 shift supervisor.

The Patient Care Assignments were reviewed on December 13, 2013 at 11:10 a.m., in the presence of the staffing coordinator. The Patient Care Assignment in DDMI Adult dated December 7, 2013 for the 7 a.m. to 7 p.m. shift indicated the staffing was not followed as indicated in the facility's staffing matrix 3:1 ratios in that some MHWs were assigned as 1:4 or 1:5 as follows:
4 North: Census 10, 2 (1:1), 1 RN, 1 LVN, 2 MHW (1:1), 2 MHW (1:4)
4 South: Census= 11, 2 (1:1), 1 RN, 1 LVN, 2 MHW (1:1), 1 MHW (1:5), 1 MHW (1:4)
5 South: Census=12, 4 (1:1), 1 RN, 1 LPT, 4 MHW (1:1), 2 MHW (1:4)

The Patient Care Assignment in DDMI Adult dated December 12, 2013 for the A.M. shift indicated the staffing was not followed as indicated in the facility's staffing matrix in that 1 MHW was assigned as 1:7 as follows: 4 North: Census 11, 4 (1:1), 1 RN, 1 LPT, 3 MHW (1:1), 1 MHW (1:7).

2. The Staffing policy revised February 2013 also indicated the Patient/Staff Ratios for the AM and PM shifts for Adolescent DDMI was 1:3 and Youth Services staffing matrix is 1:4 ratio.

A review of the Patient Care Assignment for DDMI Adolescent Unit (2 south) dated March 10, 2013 for Sunday 7 p.m. to 7 a.m. shift indicated the census was 13 with 2 patients on 1:1. There were 1 RN, 1 LVN and 4 MHW. There was no documentation of # patients including the patient names assigned to each MHW. There was no documentation of who were assigned as relievers when other staff members were on break time. Although observations were documented in 15 minute increments on the Patient Observation Records dated March 10, 2013 for Patient 7 and Patient 21, the medical records of Patient 7 and Patient 21 and forensic report for Patient 7, revealed Patient 7's allegation of sexual assault incident happened during this shift. According to medical record of Patient 7, Patient 7 reported that he danced naked over his roommate in his room prior to the alleged sexual assault incident. Patient 7 reported that after the sexual assault incident, he told them (staff) that he (Patient 21) did it to him. There was no documentation on the evening of March 10, 2013 that a registered nurse had assessed Patient 7's sexual risk and his level of observation. The facility's Observation and Monitoring policy and procedure revised October 2012 stipulated the RN may increase the level of observation if the patient condition changes. The physician would be notified as soon as possible of the change in condition to obtain an order for a specific observation level.

According to the medical record of Patient 21, a staff member documented on the medical record at 8:30 p.m., on March 10, 2013 that the patient made "inappropriate sexual remark" toward a female patient. The detail of the sexual remark was not documented.

Admin 2 stated on the interview on December 16, 2013 at 1:25 p.m. that the staff should have assessed further and investigate Patient 21's "inappropriate sexual remark" and addressed this in the treatment plan.

3. A review of the Patient Care Assignment for DDMI Adolescent Unit (2 South) dated March 11, 2013 for the AM Shift and PM Shift indicated the census was 13 with 1 patient on 1:1. There were 1 RN, 1 LVN/LPT and 5 MHW. There was no documentation of # patients including the patient names assigned to each MHW. There was no documentation of who were assigned as relievers when other staff members were on break time.

A review of the Patient Care Assignment for DDMI Adolescent Unit (2 South) dated March 11, 2013 during the Night Shift indicated the census was 13 with 4 patients on 1:1. There were 1 RN, 1 LVN , 4 MHW on 1:1, 1 MHW had 6 patients and 1 MHW had 5 patients. The staffing coordinator stated during the interview on December 16, 2013 at 11:30 a.m. the night shift was short of 1 MHW.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interview, the facility failed to document the assessment of 1 of 24 sampled patients (Patient 10) after the patient was assaulted by another patient (Patient 9). The facility also failed to evaluate the nursing care for 2 of 24 sample patients (Patient 5 and 4) when an assessment was not conducted for Patient 5's multiple bruises to her arms and legs and when a physician order for emergency psychoactive medication of Thorazine 50 milligrams by intramuscularly was not documented as given in the medical record.


Findings:

1. On December 9, 2013 at 8:30 a.m., initial tour of the facility was conducted with Nurse Manager 3. In 1 North, there were five (5) patients in the middle Dayroom, another patient seated on the other end of the room with one staff. In 1 South (overflow for 1 North), a small Dayroom was empty. In 2 North at 9:20 a.m., there were five (5) staff observed by the nurses' station and there were six (6) patients in the day room with no staff present. At 9:35 a.m., Patient 14 was not in her room. At 9:55 a.m., there were six patients in the Dayroom and no staff present. There were four (4) staff in the nurses' station.

A review of the Behavioral/ Restraint/Seclusion Physician Order Form dated December 8, 2013 at 10:30 a.m., indicated Patient 9 threw coffee in one patient's face unprovoked, then proceeded to punch another patient multiple times, also unprovoked.

During an interview on December 10, 2013 at 9:10 a.m., Nurse Manager 3 stated Patient 9 assaulted Patient 10.

A review of the medical record for Patient 10 indicated the patient was admitted on [DATE] with diagnosis of Bipolar disorder. There was no documentation Patient 10 was assaulted and no documentation the patient was assessed after the incident.

During an interview with Nurse Manager 3 at 9:15 a.m., he reviewed the medical record and stated there was no documentation of the incident and patient assessment after the incident. Nurse Manager 3 stated the staff are supposed to do incident report and document in the nursing notes.





2. On December 10, 2013, at 2 p.m., Patient 5's medical record was reviewed. Patient 5 was admitted to the facility's DDMI Adult Unit on June 24, 2013 with diagnosis of schizoaffective disorder. The DDMI Wing 30 Day Progress Report for October 24, 2013 to November 24, 2013, indicated the patient's diagnoses included schizoaffective disorder, impulse control disorder and mild mental retardation. Patient 5 had aggressive behaviors towards others and self-injurious behaviors. Patient 5 also had exhibited delusional thoughts and when she became upset and she frequently accused staff of abusing her. The medical record contained pictures of the bruises to both arm and legs of Patient 5. The pictures were dated September 9, 2013 at 5 a.m. Further review of the medical record disclosed no assessment of the patient's bruises that included the appearance, color, size in order to identify possible cause of bruises such as injury and medical disorders.

During an interview on December 12, 2013 at 9 a.m., Nurse Manager 1 stated the patient's bruising may be related when she was placed in restraints. He stated that they investigated but did not document the investigation. Nurse Manager 1 also confirmed there was no assessment in the medical record regarding the patient's bruises.

3. A review of Patient 4's Medical Professional Orders dated December 1, 2013 at 6:20 p.m. indicated an order for emergency psychoactive medication of Thorazine 50 milligrams by intramuscularly. However, there was no documentation in the medical record that the patient received Thorazine medication.

During an interview on December 10, 2013 at 11;20 a.m., the registered nurse stated there was a mistake with the date the Thorazine ordered. He stated he gave Thorazine medication to the patient on December 7, 2013 and failed to document on the medication administration record. He stated he also filled out the form titled, Emergency Use of Medication Assessment Flowsheet for the administration of Thorazine, however, the form was misplaced.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interview, the facility's license nurse failed to develop care plans for the use of hand mittens, failed to develop treatment plans within eight hours of patient admission in accordance with the policy and procedure, and failed to address a patient's aggression towards others in the treatment plan based on patient assessment for 3 of 24 sample patients (Patient 2, 8, and 9).


Findings:

1. On December 9, 2013 and December 10, 2013 at 9:15 a.m. and 9:05 a.m., Patient 2 was observed wearing hand mittens on both hands. On December 10, 2013, at 9:05 a.m., Patient 2 was observed lying in bed with mittens to both hands. An inspection of the left hand after the mental health worker removed the mitten revealed pressure mark noted on the left wrist area where hand mitten was previously applied. During an interview at the same time of the observation, Nurse Manager 1 stated that hand mitten was not use as a restraint.

A review of the medical record revealed no documentation of an assessment for the use of hand mittens and there was no physician order for the use of hand mittens. According to the DDMI Wing 30 Day Progress Report dated for September 8, 2013 to October 9, 2013, Patient 2 was a threat to self, due to his self-harming behaviors such as swallowing rocks, batteries, and sheets of paper towel. Mittens must stay on at all times. A review of the Treatment Plan disclosed no documentation that addressed the use of hand mittens.







2. On December 9, 2013 at 8:50 a.m., Patient 8 was observed in bed, asleep in the Seclusion room. The door to the room was closed but not locked. Nurse Manager 3 stated the patient was not in seclusion, but requested to be in the room to sleep.

At 1:10 p.m., the clinical record for Patient 8 was reviewed. Patient 8 was admitted voluntarily to the facility on [DATE] at 2:15 a.m., with diagnosis of schizoaffective disorder. The Risk Assessment indicated the patient was a suicide risk with a score of 9 indicating moderate risk. For moderate risk, the patient is to be monitored every 15 minutes for safety and initiate for self harm treatment plan.

A review of the Interdisciplinary Treatment Plan disclosed a blank problem list.

During an interview at 1:15 p.m., the same day, Nurse Manager 3 reviewed the clinical record and stated there was no self harm treatment plan.

On December 10, 2013 at 8:50 a.m., RN 1 stated treatment plan should be initiated upon admission.

A review of the Interdisciplinary Planning policy and procedure indicated within eight hours of patient admission, the RN shall initiate the Interdisciplinary Treatment Plan, including the Master Problem List.

3. On December 9, 2013 at 9 a.m., Patient 9 was observed in bed, asleep.

A review of the clinical record on December 9, 2013 at 2:15 p.m., indicated Patient 9 was admitted to the facility on on [DATE] at 6:05 p.m. The patient was on 5150 due to danger to himself and danger to others.

The Behavioral/ Restraint/Seclusion Physician Order Form dated December 8, 2013 at 10:30 a.m., indicated the patient threw coffee in one patient's face unprovoked, then proceeded to punch another patient multiple times, also unprovoked.

The Interdisciplinary Treatment Plan listed Altered Thought problem on December 7, 2013.

During an interview at 2:50 p.m., RN 3 reviewed the record (behavior restrain/seclusion, the assessment and treatment plan) and stated that Aggression Towards Others should be listed in the problem list but it's not.