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.

DOVER BEHAVIORAL HEALTH SYSTEM 725 HORSEPOND ROAD DOVER, DE Sept. 20, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review, review of video surveillance, policy and document review and staff interview, it was determined that the hospital failed to ensure that patients were informed of their patient's rights (refer to A 117); failed to follow the time frames specified in the hospital's grievance process (refer to A 122); failed to provide written notice of the results of the grievance decision to the complainant (refer to A 123); failed to include the patient/patient representative in the development and implementation of the plan of care (refer to A 130); failed to ensure that patients were free from abuse (refer to A 145); failed to ensure the plan of care for restrained and/or secluded patients was modified to address the use of restraints (refer to A 166); and failed to ensure staff implemented proper restraint technique per hospital policy (refer to A 167). The cumulative effect of these deficient practices resulted in the hospital's inability to protect patient rights and provide services in a safe setting.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review and staff interview, it was determined there was no evidence that 1 of 5 patients (Patient #5) in the sample were informed of their patient's rights. Findings include:

The hospital policy entitled "Patient Responsibilities" stated, "...Upon admission to the hospital, each patient will receive a Patient Handbook identifying patient Rights and Responsibilities...The patient will sign a form stating they were given the Handbook and a copy of their Rights and Responsibilities..."

The hospital policy entitled "Patient's Rights Bill of Rights" stated, "...When the individual receiving services is unable or unwilling to sign document, which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signatures of the person who explained the rights and a third-party witness, preferably by a family member, legal guardian or friend, if available, or by another staff member..."

A. Review of Patient #5's medical record revealed:
- admitted [DATE]
- no evidence that Patient #5 was informed of his/her rights

This finding was confirmed by Nursing Director A on 9/20/16 at 10:50 AM.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on policy review, document review and staff interview, it was determined that for 4 of 7 complainants (Complainant #'s 1, 2, 4 and 7) in the sample that submitted grievances prior to 8/20/16, the hospital failed to follow the time frames specified in the hospital's grievance process. Findings include:

The hospital policy entitled "Patient and Family Grievances/The Role of the Patient Advocate" stated, "...At each level of this process, the facility staff will listen to the patient's complaint/grievances, consider the circumstances and context of the complaint/grievance, assure the patient that his/her concerns will be investigated and seek further information and input as needed...The patient advocate will provide a written notification to each patient and/or family member who made a grievance within 5 working days. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital will follow-up with a written response in 30 days of the date of the complaint..."

Review of the grievance file revealed no evidence of any investigation and/or resolution in the 30 days after the submission of the following grievances:

A. Complainant #1
- verbalized patient safety concern on 6/1/16

B. Complainant #2
- verbalized patient safety concern on 6/14/16

C. Complainant #4
- verbalized patient safety concern on 6/22/16

D. Complainant #7
- verbalized patient safety concern on 8/1/16

These findings were confirmed by Patient Advocate A on 9/20/16 at 1:55 PM.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on policy review, document review and staff interview, it was determined that for 4 of 6 complainants (Complainant #'s 1, 2, 4 and 7) in the sample who submitted verbal grievances prior to 8/20/16, the hospital failed to provide written notice of the results of the grievance decision to the complainant. Findings include:

The hospital policy entitled "Patient and Family Grievances/The Role of the Patient Advocate" stated, "...If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital will follow-up with a written response in 30 days of the date of the complaint..."

Review of the grievance file on 9/20/16 revealed no evidence that written notice of the results/decision were provided to the following complainants:

A. Complainant #1
- verbalized patient safety concern on 6/1/16

B. Complainant #2
- verbalized patient safety concern on 6/14/16

C. Complainant #4
- verbalized patient safety concern on 6/22/16

D. Complainant #7
- verbalized patient safety concern on 8/1/16

These findings were confirmed by Patient Advocate A on 9/20/16 at 1:55 PM.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review and staff interview, it was determined that for 4 of 5 patients (Patient #'s 1, 2, 3 and 5) in the sample that required plan of care representation, staff failed to include the patient/patient representative in the development and implementation of the plan of care. Findings include:

The hospital document entitled "Patient Rights and Responsibilities" stated, "...Every patient has the right to participate...in the development of his/her plan of care..."

The hospital policy entitled "Nursing Standards of Care" stated, "...The patient's care will be guided by an individualized problem oriented plan of care which incorporates patient involvement as well as the involvement of family and/or significant others..."

The hospital policy entitled "Interdisciplinary Treatment Plan" stated, "...Patient Participation - the patient is invited to participate in the development and implementation of the treatment plan. The Master Treatment Plan will be reviewed and signed by the patient within twenty-four hours of development of the plan. Refusal or inability to participate or sign will be documented..."

Medical record review revealed no documented evidence that the patient/patient representative was involved and/or participated in the development and implementation of his/her plan of care for the following patients:

A. Patient #5 - admitted [DATE]

B. Patient #1 - admitted [DATE]

C. Patient #3 - admitted [DATE]

D. Patient #2 - admitted [DATE]

These findings were confirmed with Nursing Director A on 9/20/16 between 12:00 PM and 2:20 PM.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of video surveillance, medical record review, policy review and staff interview, it was determined that the hospital failed to ensure that 1 of 5 patients (Patient #1) in the sample was free from abuse. Findings include:

The hospital policy entitled "Patient's Rights Bill of Rights" stated, "...The patient has the right to be free from all forms of abuse, neglect, mistreatment, harm..."

The hospital policy entitled "Emergency Plan of Services" stated, "...Code Gray Psychiatric Emergency...Respect for...patient's rights shall be maintained throughout the...process...The charge nurse or other registered nurse should be notified immediately and should direct interventions to appropriately resolve the crisis..."

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusions" stated, "...Application of Physical Restraints: Physical restraints (holds) may be done using techniques trained through the aggression program. In no case may a patient be taken to the floor or held in a prone (lying face down) position..."

A. Review of Patient #1's medical record revealed:

1. "Progress Note" dated 9/3/16 at 11:15 PM, Registered Nurse (RN) B documented the following entry, "...Pt (patient) became aggressive following redirection...unable to have...hair products at that very moment...given verbal deescalation...continued to punch walls...slamming doors...brought to day room...began punching chairs...kicking staff and pushing staff. Pt was PRTed (Primary Restraint Technique - physically restrained) in seclusion...attempt to bite staff...banging...head. PRT removed at 2150 (9:50 PM). Pt was released from seclusion 2154 (9:54 PM)...now in Pt room."

2. "Progress Note" dated 9/4/16 at 1:50 PM, RN C documented, "Pt c/o (complained of) being upset about Code last night on the unit...showed the RN (right) side of upper lip which has a small cut, a jagged toenail on (left) foot...said was bleeding last night and a reddened area next to (right) eye..."

B. On 9/19/16 from 9:36 AM to 10:00 AM, video surveillance for the Flex Unit on 9/3/16 between 9:34 PM and 9:57 PM was reviewed and revealed the following:

1. Camera #27:

RN A:
a. pushed Patient #1 into chair
b. grabbed Patient #1's right arm and held it behind him/her
c. forced Patient #1 to floor and straddled the patient holding him/her on the floor

2. Camera #24:

a. While staff held Patient #1 on the floor in prone position:
- Patient #1 head butted the floor
- RN A grabbed Patient #1 by hair

3. Camera #15:

a. RN A pushed Patient #1 into corner of the seclusion room
b. While Patient #1 was lying on the floor in prone position, RN A:
- stepped on Patient #1's buttock area
- sat on Patient #1
- repeatedly placed foot on Patient #1's leg to prevent movement

C. Interviews with hospital staff revealed the following:

1. On 9/19/16 between 9:30 AM and 10:15 AM, Human Resources Manager A and Nursing Director A reported that RN B was:
- the Charge Nurse on the Flex Unit at the time of the 9/3/16 incident involving Patient #1 and RN A
- in charge of running the Code to de-escalate Patient #1 and the altercation between Patient #1 and staff

2. On 9/19/16 between 10:30 AM and 10:45 AM, Chief Executive Officer A verified that it was the expectation of all of the employees to have intervened and immediately removed RN A from the situation.

3. On 9/19/16 between 11:33 AM and 11:45 AM, Nursing Director A confirmed:
- RN A physically abused Patient #1 during the altercation observed in video surveillance of the Flex Unit on 9/3/16 between 9:34 PM and 9:57 PM
- RN B (Charge Nurse) failed to provide supervision during the Code to ensure patient safety and protect the patient's rights

4. On 9/20/16 at 11:50 AM, Risk Management Director A reported that RN B and RN Supervisor A failed to supervise and prevent the abuse of Patient #1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on medical record review, policy review, video surveillance review and staff interview, it was determined that the medical records for 2 of 3 restrained and/or secluded inpatients (Patient #'s 2 and 3) in the sample, lacked a written modification to the plan of care addressing the use of restraints. Findings include:

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusions" stated, "...Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restrain/seclusion were indicated, a review and modification of the treatment plan is indicated...the RN (registered nurse) shall review the plan and update the treatment plan within 8 hours..."

Medical record review revealed:

A. Patient #2

1. "Restraint/Seclusion Order/Record" dated 9/19/16 at 6:50 PM revealed:
- was placed in physical restraint for approximately 3 minutes

2. No evidence to support that the plan of care was updated to include the use of a physical restraint.

Interview with Nursing Director A on 9/20/16 at 12:00 PM confirmed this finding.

B. Patient #3

1. "Restraint/Seclusion Order/Record" dated 9/3/16 at 10:55 PM included an order for physical restraints

2. On 9/19/16 from 9:36 AM to 10:00 AM, video surveillance for the East Unit on 9/3/16 at 9:48 PM was reviewed and the following was observed:
- Patient #3 was placed in a physical restraint

3. No evidence to support that the plan of care was updated to include the use of a physical restraint.

Interview with Nursing Director A on 9/20/16 at 3:35 PM confirmed this finding.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on medical record review, video surveillance review, policy review and staff interview, it was determined that for 1 of 3 patients (Patient #1) in the sample who were placed in a restraint, hospital staff failed to implement proper restraint technique per hospital policy. Findings include:

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusions" stated, "...Application of Physical Restraints: Physical restraints (holds) may be done using techniques trained through the aggression program. In no case may a patient be taken to the floor or held in a prone (lying face down) position..."

The hospital training manual entitled "Handle With Care Behavioral Management System Participant Manual (No Prone Edition)" stated, "...Set up your first 'hook'...and your second hook, finishing with a good PRT (Primary Restraint Technique)...Kicks...A (staff) steps back, blocks, then catches the ankle with an 'X' block. Pausing an instant, he parries (wards off) the attackers legs: moving quickly to the outside...stabilize the head (to prevent head butting...) by gently placing your hands...on the sides of the head...An additional staff person can help protect the back of the client's head from any contact that could produce injury..."

A. Review of Patient #1's medical record revealed:

1. "Progress Note" dated 9/3/16 at 11:15 PM, Registered Nurse (RN) B documented the following entry, "...Pt (patient) became aggressive following redirection...unable to have...hair products at that very moment...given verbal deescalation...continued to punch walls...slamming doors...brought to day room...began punching chairs...kicking staff and pushing staff. Pt was PRTed (physically restrained) in seclusion...attempt to bite staff...banging...head. PRT removed at 2150 (9:50 PM). Pt was released from seclusion 2154 (9:54 PM)...now in Pt room."

B. On 9/19/16 from 9:36 AM to 10:00 AM, video surveillance for the Flex Unit on 9/3/16 between 9:34 PM and 9:57 PM was reviewed and revealed the following:

1. Camera #27:

RN A:
a. pushed Patient #1 into chair
b. grabbed Patient #1's right arm and held it behind him/her
c. forced Patient #1 to floor and straddled the patient holding him/her on the floor

2. Camera #24:

a. While staff held Patient #1 on the floor in prone position:
- Patient #1 head butted the floor
- RN A grabbed Patient #1 by hair

3. Camera #15:

a. RN A pushed Patient #1 into corner of the seclusion room
b. While Patient #1 was lying on the floor in prone position, RN A:
- stepped on Patient #1's buttock area
- sat on Patient #1
- repeatedly placed foot on Patient #1's leg to prevent movement

Review of video surveillance revealed and interview with Risk Management Director A on 9/19/16 between 9:34 AM and 9:45 AM, confirmed that RN A failed to follow hospital policies regarding the use of restraints.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
I. Based on medical record review, video surveillance review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #1) in the sample, the registered nurse (RN) failed to supervise the nursing staff. Findings include:

The hospital policy entitled "Nursing Standards of Care" stated, "...The nurse will...Respect and protect the patient's rights..."

The hospital job description entitled "Registered Nurse" stated, "...Nursing staff will be responsible for the care of Adolescent and Adult patients...May serve as back-up charge nurse for unit or shift, supervision routine task assignments of RN's...Comply with safety and security policies and procedures, including those regarding incidents and injuries...Will adhere to all safety policies and safe work practice..."

The hospital job description entitled "Nurse Supervisor" stated, "...The Nurse Supervisor...is a working supervisor. Supervising and participating in the provision of general nursing care services. Spending time on each unit throughout their assigned shift to mentor nursing staff, assess unit needs...acts as an advisor...in direct relation to patient safety and clinical care..."

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusions" stated, "...Any patient in a physical (manual) restraint will have a staff person who is not participating in the hold observing him/her for any signs of distress or incorrect holding procedures..."

The hospital policy entitled "Emergency Plan of Services" stated, "...Code Gray Psychiatric Emergency...The charge nurse or other registered nurse should be notified immediately and should direct interventions to appropriately resolve the crisis..."

A. Review of Patient #1's medical record revealed:

1. "Progress Note" dated 9/3/16 at 11:15 PM, RN B documented the following entry, "...Pt (patient) became aggressive following redirection...unable to have...hair products at that very moment...given verbal deescalation...continued to punch walls...slamming doors...brought to day room...began punching chairs...kicking staff and pushing staff. Pt was PRTed (Primary Restraint Technique - physically restrained) in seclusion...attempt to bite staff...banging...head. PRT removed at 2150 (9:50 PM). Pt was released from seclusion 2154 (9:54 PM)...now in Pt room."

2. "Progress Note" dated 9/4/16 at 1:50 PM, RN C documented, "Pt c/o (complained of) being upset about Code last night on the unit...showed the RN (right) side of upper lip which has a small cut, a jagged toenail on (left) foot...said was bleeding last night and a reddened area next to (right) eye..."

B. On 9/19/16 from 9:36 AM to 10:00 AM, video surveillance for the Flex Unit on 9/3/16 between 9:34 PM and 9:57 PM was reviewed and revealed the following:

1. Camera #27:

RN A:
a. pushed Patient #1 into chair
b. grabbed Patient #1's right arm and held it behind him/her
c. forced Patient #1 to floor and straddled the patient holding him/her on the floor

2. Camera #24:

a. While staff held Patient #1 on the floor in prone position:
- Patient #1 head butted the floor
- RN A grabbed Patient #1 by hair

3. Camera #15:

a. RN A pushed Patient #1 into corner of the seclusion room
b. While Patient #1 was lying on the floor in prone position, RN A:
- stepped on Patient #1's buttock area
- sat on Patient #1
- repeatedly placed foot on Patient #1's leg to prevent movement

Review of video surveillance revealed and interview with Risk Management Director A on 9/19/16 between 9:34 AM and 9:45 AM, confirmed that RN A failed to follow hospital policies regarding the use of restraints.

C. Interviews with hospital staff revealed the following:

1. On 9/19/16 between 9:30 AM and 10:15 AM, Human Resources Manager A and Nursing Director A reported that RN B was:
- the Charge Nurse on the Flex Unit at the time of the 9/3/16 incident involving Patient #1 and RN A
- in charge of running the Code to de-escalate Patient #1 and the altercation between Patient #1 and staff

2. On 9/19/16 between 10:30 AM and 10:45 AM, Chief Executive Officer A verified that it was the expectation of all of the employees to have intervened and immediately removed RN A from the situation.

3. On 9/19/16 between 11:33 AM and 11:45 AM, Nursing Director A confirmed:
- RN A physically abused Patient #1 during the altercation observed in video surveillance of the Flex Unit on 9/3/16 between 9:34 PM and 9:57 PM
- RN B (Charge Nurse) failed to provide supervision during the Code to ensure patient safety and protect the patient's rights

4. On 9/20/16 at 11:50 AM, Risk Management Director A reported that RN B and RN Supervisor A failed to supervise and prevent the abuse of Patient #1.

II. Based on medical record review, policy review and staff interview, it was determined that nursing staff failed to follow physician's orders for 1 of 5 patients (Patient #3) in the sample. Findings include:

The hospital policy entitled "Diabetic Care" stated, "...Initial and ongoing assessment shall include the current status of blood sugar...Blood glucose levels will be tested ...High and low levels will be reported immediately to the attending physician or consulting physician..."

A. Review of Patient #3's medical record revealed:

1."Medication Orders" dated 9/4/16 included orders to:

- monitor blood glucose before meals and at bedtime
- administer Lispro (insulin) 100 unit/ml (milliliter) before meals and at bedtime according to the following sliding scale:

Blood sugar: units of insulin
150 - 200: 2 units
201 - 250: 4 units
251 - 300: 6 units
301 - 400: 8 units
401 - 500: 10 units
greater than 500 or less than 70: notify physician

2. "Progress Record" documentation by the RN included the following blood glucose levels:

9/5/16 6:00 AM: 51
9/17/16 10:30 AM: 47

3. "Observations" form revealed the RN documented a blood glucose of 517 on 9/11/16 at 11:34 AM.

4. No evidence to support that nursing staff informed the physician of the blood glucose results that were less than 70 (on 9/5 and 9/17/16) and greater than 500 (on 9/11/16).

Interview with Nursing Director A on 9/20/16 at 3:40 PM confirmed this finding.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #2) in the sample, staff failed to develop and/or revise the plan of care to reflect current needs. Findings include:

The hospital policy entitled "Interdisciplinary Treatment Plan" stated, "...Within 72 hours of admission, members of the treatment team shall develop the Master Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status. The team will consist of the physician, the nurse, the social worker and representatives..."

The hospital policy entitled "Nursing Standards of Care" stated, "...The nurse formulates nursing care problem statements...The nursing care problem statements constitute the nursing plan of care which is part of the interdisciplinary plan of care...The nurse reviews and updates the nursing plan of care on a regular basis..."

Medical record review on 9/20/16 revealed:

A. Patient #2

1. Physician admission orders dated 9/16/16 10:23 AM included an order for "Elopement Precautions"

2. "Progress Record" dated 9/16/16 10:30 PM documented the following entry:
- "...Pt (patient) tried walking out of the gym to front door. Focused on leaving..."

3. No evidence that the nursing care plan was revised to include "Elopement Precautions".

Interview with Nursing Director A on 9/20/16 at 12:04 PM confirmed this finding.