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.

SAFE HAVEN HOSPITAL OF TREASURE VALLEY 8050 WEST NORTHVIEW STREET BOISE, ID April 15, 2016
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital failed to ensure 1 of 6 current patients (#11) was not given the opportunity to refuse treatment without being punished for refusing. This had the potential to affect all indigent patients who smoked. The inability to refuse treatment without punishment had the potential to interfere with treatment and to increase negative patient behaviors. Findings include:

A "UNIT SMOKE BREAK SCHEDULE," not dated, was posted on the nursing unit for patients to see. It listed 8 times when patients were allowed to smoke. Five of these times were highlighted.

The RN Charge Nurse was interviewed on 4/15/16, beginning at 1:45 PM. She stated if patients had their own cigarettes or could afford to buy them, they could smoke at all of the times posted on the schedule. She stated if patients were indigent, the hospital would provide them with 5 cigarettes a day. She stated the hospital provided these cigarettes at the times highlighted on the schedule. She further stated in accordance with unit rules, if indigent patients did not participate in therapeutic groups, they would not be allowed to smoke. She stated this rule did not apply to patients who had the means to supply their own cigarettes. She stated this was a unit rule and was not part of the care planning process.

Patient #11 was a [AGE] year old male admitted on [DATE]. A "PSYCHIATRIC TECHNICIAN NARRATIVE NOTE," dated 4/14/16 at 3:51 PM, stated "[Patient #11] has not been attending groups. [Patient #11] was upset when he did not get a unit cigarette."

The RN Charge Nurse was interviewed on 4/15/16 beginning at 1:45 PM. She stated cigarettes were withheld from Patient #11 on 4/14/16 because of his failure to attend groups.

Indigent patients were not allowed to refuse treatment without being punished.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of patient rights information, review of medical records, hospital policies, and patient and staff interview, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in the failure of the hospital to ensure each patient understood the process to file a written or verbal grievance, was allowed to refuse treatment, received care in a safe setting, was protected from abuse and harassment and restraints were used safely and appropriately by qualified staff to protect the patient or others from harm. Findings include:

1. Refer to A121 as it relates to the failure of the hospital to ensure all patients were clearly informed of the process to file a written or verbal grievance.

2. Refer to A131 as it relates to the failure of the hospital to ensure patients' have the right to refuse treatment without threat of reprisal.

3. Refer to A144 as it relates to the failure of the hospital to ensure care was provided to patients in a safe manner.

4. Refer to A145 as it relates to the failure of the hospital to ensure all vulnerable patients were fully protected from abuse and harassment.

5. Refer to A185 as it relates to the failure of the hospital to ensure the type of restraint interventions used on patients were clearly documented.

6. Refer to A188 as it relates to the failure of the hospital to ensure patients' responses to restraints, and the reason to continue restraints, was clearly documented.

7. Refer to A202 as it relates to the failure of the hospital to ensure employees were adequately trained in the safe application of physical restraints.

The cumulative effects of these negative systemic practices seriously impeded the ability of the hospital to protect patient rights and provide services in a safe setting.
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
Based on staff and patient interviews, and review of patient rights information and hospital policies, it was determined the hospital failed to establish a clearly explained procedure for the submission of patients' written or verbal grievances to the hospital. This had the potential to interfere with patients' exercising their right to file a grievance. Findings include:

The hospital's grievance policy, "GRIEVANCES/COMPLAINTS," dated 5/01/13, was reviewed. The policy stated, "Our facility will assist patients, their representatives, other interested family members, or patient advocates in filing grievances or complaints when such requests are made." The policy also included, "Grievances complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the patient or the person filing the grievance or complaint on behalf of the patient."

Patient rights documents that were included in the hospital's admission packets, and given to patients at the time of admission, were reviewed. The packet included the document, "Grievance Process," which stated "Grievances complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the patient or the person filing the grievance or complaint on behalf of the patient."

A female patient was interviewed on 4/13/16, at approximately 10:10 AM. When asked if she was informed about how to file a grievance or a complaint, she said she "couldn't remember." She said if she had a grievance, she would tell one of the nurses.

The Administrator was interviewed on 4/13/16, beginning at 11:30 AM. She stated she was the person to whom grievances were escalated. She said she received only grievances that were "documented by patients in writing." The Administrator said some complaints and grievances were verbalized by patients to nursing staff, but she was uncertain whether she was notified if the complaints or grievances were not in writing.

The RN Charge Nurse was interviewed on 4/15/16, beginning at 12:20 PM. When asked to explain how patients were instructed about the grievance process, she said patients must file grievances in writing. She said grievances must be in writing because they are escalated to a higher level.

The hospital did not clearly communicate a procedure to patients and/or patients' representatives, for the submission of a verbal and written grievance to the hospital.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of incident reports, quality documents, hospital policies and restraint information, it was determined the hospital failed to ensure care was provided in a safe manner. This directly affected the safety of 2 patients (#6 and #12) and had the potential to affect the safety of all patients at the hospital. The failure to evaluate processes after dangerous events occurred, had the potential to interfere with patient safety and missed opportunities for the hospital to assess its care and services. Findings include:

1. Patient #6 was a [AGE] year old male who was admitted on [DATE]. His diagnosis included schizoaffective disorder, [DIAGNOSES REDACTED], and methamphetamine use disorder. He was placed on a legal hold prior to admission. He also had a history of imprisonment between 2001 and 2005.

An "ADDENDUM" by a Nurse Practitioner, dated 1/30/16 but not timed, stated Patient #6 "...was admitted yesterday, still floridly psychotic, was going into other peoples' rooms, inappropriate with staff, exposing himself. Despite Ativan and Seroquel [anti-anxiety and antipsychotic medications] he continued to have difficulties. It was discovered that he had crystal meth in a condom likely in his rectum and when it was tried to be removed from him he became agitated, assaulted various staff members. [LEO] Police were called and he was taken to jail."

The female PT, who was assaulted by Patient #6, was interviewed on 4/14/16 beginning at 9:25 AM. She stated Patient #6's behavior was sexually inappropriate and he was physically threatening to her for much of the shift. She stated this included Patient #6 exposing his genitals and trying to push her into a storage room. She stated she did not feel safe and she eventually went behind the nursing station to limit Patient #6's access to her. She stated Patient #6 followed her behind the nursing station on multiple occasions. She stated she told the RN Charge Nurse about Patient #6's behavior but she said no change to his plan of care, such as assigning a male staff to monitor the patient on a 1 to 1 basis, was implemented. The PT stated she was not interviewed or debriefed as part of the investigation following the event.

A "PSYCHIATRIC TECHNICIAN NARRATIVE NOTE," dated 1/29/16 at 10:30 PM, stated Patient #6 "...was up @ the nurse's station and was harassing staff. Staff then noticed something blue in [Patient #6's] hand. Staff tried to get it from [him. Patient #6] put up a fight hurting two staff members. [Patient #6] was given a shot of meds and police were called. [Patient #6] had meth in a blue plastic rubberish bag [which] was given to police."

An "INCIDENT/ACCIDENT INVESTIGATION-STATEMENT FORM" by the male RN Charge Nurse on duty, was dated 1/30/16. It was not timed. It stated on 1/29/16 Patient #6 "...became increasingly erratic, bizarre, aggressive, assaultive throughout the eve. 2230 staff @ [nursing] station noticed a blue plastic bag protruding from [patient's right] hand. [Patient #6] became aggressive & struggle ensued. [Patient] physically restrained by this RN & [a male PT who got behind Patient #6 and held him from behind]. This RN struggled to release [patient's] grasp on [a female PT and Patient #6's] bag. [Patient #6] relinquished a blue condom containing approx. 6 grams of crystalline methamphetamine. [Patient #6] head butted this RN & caused injury to [the female PT's] right index & middle finger. Law enforcement called during event." The statement said Patient #6 was medicated with an antipsychotic medication. The statement said police arrived at 10:42 PM on 1/29/16 and took Patient #6 into custody on assault and possession charges."

An "INVESTIGATION SUMMARY" by the Quality Coordinator, dated 2/01/16, documented an investigation of Patient #6's assault on staff. It stated there was no injury to the patient. The summary did not explain how the conclusion was reached. The summary form included a question that stated "Current system in place to prevent this type of occurrence?" The box for "Not Applicable" was checked but there was no further explanation. The summary form included a question that stated "Additional follow up required?" The box for no was checked.

A document titled "Root Cause Analysis," dated 2/02/16, documented a meeting with the Quality Coordinator and the Education Coordinator. The document section labeled "Why" described the event. The section labeled "Assessment" described Patient #6's history. The section labeled "Implement" stated Patient #6 was given an antipsychotic medication and was physically held. The section labeled "Outcome" stated Patient #6 was arrested and said nursing staff would check to see if patients had a history of assault.

The review of the assault by Patient #6 focused solely on the actions of the patient. The review did not include an evaluation of the hospital's performance in response to the event. The review did not evaluate staffing or supervision levels. The review did not evaluate staff training. The review did not evaluate whether staff followed hospital policy. The review did not evaluate the adequacy of the documentation of the event. The review did not offer any suggestions to prevent future occurrences of this type.

The Education Coordinator was also the Interim Quality Coordinator. She was interviewed on 4/12/16 beginning at 1:30 PM. She stated the hospital's investigation of the event did not determine whether actions by staff were appropriate or whether documentation was complete. She was interviewed again on 4/14/16 beginning at 2:40 PM. She stated the adequacy of patient supervision was not evaluated. She stated the adequacy of staff training in relation to the use of restraints was not evaluated. She stated the investigation did not include recommendations to prevent future occurrences. She stated no changes had been implemented since the event that were directed at preventing similar events in the future.

The hospital failed to ensure practices were adequate to protect patients and staff from assaultive patients.

2. Patient #6 was physically restrained on 1/29/16. The medical record documented the incident as follows:

A physician order, "EMERGENCY TREATMENT OVER RIDE ORDERS FOR HOLD AND RESTRAINT," dated 1/29/16 at 10:45 PM, was reviewed. The document included an order for "Chemical and Physical Hold" and identified the chemical restraint as a one time order for an IM injection of an anti-psychotic medication. The reason for restraint was documented "Violent/Self-Destructive behavior to others."

A "CHEMICAL AND/OR PHYSICAL RESTRAINT 1:1 MONITORING" form, not dated, indicated Patient #6 was physically held from 10:30 PM through 11:00 PM, when he was "escorted out by [LEO]". Patient #6's restraint documentation did not include the type of hold used to physically restrain him, and it failed to identify all the individuals involved in the physical hold.

A female PT, who was working at the time Patient #6 was restrained and assaulted by him, was interviewed on 4/14/16, beginning at 9:15 AM. She stated Patient #6 was physically held by the male RN Charge Nurse and a male PT until the police arrived and escorted him out of the building. She said Patient #6 was at the nurses station, when she asked him to give her what he was holding in his hand. He responded by reaching across the nurses station counter and grabbing her hand and arm. She said he began to twist her fingers, hand and arm. She said the male RN Charge Nurse quickly arrived behind the desk and grabbed Patient #6 by the arm, holding his arm across the nurses station counter. She said the RN Charge Nurse managed to release her arm from Patient #6's grasp. She said a male PT arrived and held Patient #6 from behind, with his arms wrapped around Patient #6's waist. She said the RN Charge Nurse and PT held Patient #6 in this position until the police arrived. When asked how long she thought Patient #6 was held, the PT stated "It was maybe 10 minutes before the police arrived."

A policy, "Use of Restraints," dated 5/01/13, was reviewed. The policy documented "...Registered nurses who are trained, qualified deemed competent, and who have completed CPI training are authorized..."

The hospital's Administrator was interviewed on 4/12/16, beginning at approximately 12:30 PM. She stated "the hospital now uses Mandt restraint training, not CPI restraint training." She said all employees who interact with patients must be certified annually in Mandt restraint training. The "Use of Restraints" policy, which was available to staff at the time of the survey, did not contain accurate information about the type of restraint training the hospital required. The policy did not reference Mandt training.

Another policy, "EMERGENCY SERVICES Mandt Training," was reviewed. The policy documented "...All nursing services will be proficient and certified in MANDT and recertify once per year."

The Mandt Instructor Manual also included "...Individuals certified in the Mandt System do not use or demonstrate the prohibited practices. The prohibited practices include but are not limited to the following: ...hyper-extension of any part of the body, potential risk of hyper-extension of any body part beyond normal limits..."

The hospital's Mandt trainer, who was a certified Mandt Instructor according to the hospital's personnel records, was interviewed on 4/13/16, beginning at 9:00 AM, and 4/14/16, beginning at 11:50 AM. When asked if he was aware of the restraint incident involving Patient #6, he said he did not recall when he was informed, but he was not involved in any formal analysis or discussion of the incident. When the hold that was used to restrain Patient #6 was described to the Mandt Instructor, he indicated the hold from behind with the employee's arms wrapped around the waist of Patient #6, was a Mandt approved hold. He did not indicate holding Patient #6's arm, extended across the nurses station counter, was an approved hold.

A sample of employee training files was reviewed. All training files contained evidence of current Mandt training certification and indicated the last Mandt recertification occurred in March of 2016.

The Mandt Instructor Manual, last revised 12/09/14, was reviewed during the survey. Contained within the manual was the "Instructor Quick Guide." The guide included "Students...must be capable of demonstrating and explaining 100% of all practical (hands-on) physical portions of the skills taught in each chapter with 100% proficiency." Additionally, the guide included "...Annual Recertification of staff is required. The same standard of 100% proficiency is required..."

The hospital's Mandt trainer, who was a certified Mandt Instructor according to the hospital's personnel records, was interviewed on 4/13/16, beginning at 9:00 AM, and on 4/14/16, beginning at 11:50 AM. He said he offered the last Mandt recertification for employees in March of 2016. He said, during the last recertification, he did not require practice or return demonstration of the approved physical holds included in the Mandt Training course.

A PT was interviewed on 4/14/16, beginning at 9:15 AM. She said she attended the last Mandt Training recertification in March of 2016. She confirmed the employees were not required to physically demonstrate their proficiency with the various, required physical holds. She said they "watched a video, reviewed written information and took tests." The staff's proficiency related to the Mandt approved physical holds was not adequately evaluated during the most recent recertification.

By not updating policies as needed and adequately evaluating staff's proficiency related to restraint training, the hospital failed to provide patients and staff with a safe environment.

3. Patient #12 was a [AGE] year old male who was admitted on [DATE]. His diagnosis was schizoaffective disorder. He was discharged on [DATE]. He was placed on a legal hold prior to admission and remained on a hold for his entire stay.

The back of the hospital was surrounded by a 6 foot wooden fence. A "PATIENT OCCURRENCE REPORT," dated 1/12/16, stated Patient #12 scaled the fence and was later found by staff while still on hospital grounds. The report stated Patient #12 complained of hip pain following the event but no significant injury was documented.

An "INVESTIGATION SUMMARY" by the Quality Coordinator, dated 1/14/16, stated staff told Patient #12 to jump the fence. The summary stated Patient #12 eloped while on a smoke break. The summary stated during the break 6 patients were supervised by 1 PT. Neither the Occurrence Report nor the Investigation Summary stated whether staff was aware of Patient #12's absence before he was found.

The "INVESTIGATION SUMMARY" did not mention staffing levels nor did it make a determination regarding the adequacy of staffing and patient supervision at the time of the event. The summary did not elaborate on the statement that staff told Patient #12 to jump the fence. The summary form included a question that stated "Current system in place to prevent this type of occurrence?" The box for yes was checked but there was no further explanation. Another question stated "Was a Root Cause Analysis indicated?" The box labeled "Not Applicable" was checked. The report did not state why a Root Cause Analysis was not indicated. The summary did not include what sources were reviewed or who was interviewed for the investigation. No determination of causation and no recommendations for the prevention of future incidents were included in the Occurrence Report and the summary.

The Interim Quality Coordinator was interviewed again on 4/14/16 beginning at 2:40 PM. She stated the hospital's investigation did not include an evaluation of the adequacy of staffing and supervision when Patient #12 eloped. She stated the investigation did not include recommendations to prevent future occurrences. She sated no specific action had been taken to prevent patients from eloping.

The hospital failed to ensure patients were adequately supervised to prevent elopement and to protect the safety of patients and the community.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, review of medical records and hospital policies, it was determined the facility failed to ensure the records of 1 of 2 patients (#6) for whom restraints were used, clearly documented the type of restraint interventions used. This resulted in the risk for patients being subjected to potentially harmful, restraint techniques. Finding include:

1. Patient #6 was a [AGE] year old male who was admitted on [DATE]. His diagnoses included [DIAGNOSES REDACTED].

An "ADDENDUM" by a Nurse Practitioner, dated 1/30/16 but not timed, stated Patient #6 "...was admitted yesterday, still floridly psychotic, was going into other peoples' rooms, inappropriate with staff, exposing himself. Despite Ativan and Seroquel [anti-anxiety and antipsychotic medications] he continued to have difficulties. It was discovered that he had crystal meth in a condom likely in his rectum and when it was tried to be removed from him he became agitated, assaulted various staff members. [LEO] Police were called and he was taken to jail."

A "PSYCHIATRIC TECHNICIAN NARRATIVE NOTE," dated 1/29/16 at 10:30 PM, stated Patient #6 "...was up @ the nurse's station and was harrassing staff. Staff then noticed something blue in [Patient #6's] hand. Staff tried to get it from [him. Patient #6] put up a fight hurting two staff members. [Patient #6] was given a shot of meds and police were called. [Patient #6] had meth in a blue plastic rubberish bag [which] was given to police.

A physician order, "EMERGENCY TREATMENT OVER RIDE ORDERS FOR HOLD AND RESTRAINT," dated 1/29/16 at 10:45 PM, was reviewed. The document included an order for "Chemical and Physical Hold" and identified the chemical restraint as a one time order for an IM injection of an anti-psychotic medication. The reason for restraint was documented "Violent/Self-Destructive behavior to others."

A "CHEMICAL AND/OR PHYSICAL RESTRAINT 1:1 MONITORING" form, not dated, indicated Patient #6 was physically held from 10:30 PM through 11:00 PM, when he was "escorted out by [LEO]". Patient #6's restraint documentation did not include the type of hold used to physically restrain him, and it failed to identify the individuals involved in the physical hold.

A female PT, who was working at the time Patient #6 was restrained and assaulted by him, was interviewed on 4/14/16, beginning at 9:15 AM. She stated Patient #6 was physically held by the male RN Charge Nurse and a male PT until the police arrived and escorted him out of the building. She said Patient #6 was at the nurses station, when she asked him to give her what he was holding in his hand. He responded by reaching across the nurses station counter and grabbing her hand and arm. She said he began to twist her fingers, hand and arm. She said the male RN Charge Nurse quickly arrived behind the desk and grabbed Patient #6 by the arm, holding his arm across the nurses station counter. She said the RN Charge Nurse managed to release her arm from Patient #6's grasp. She said a male PT arrived and held Patient #6 from behind, with his arms wrapped around Patient #6's waist. She said the RN Charge Nurse and PT held Patient #6 in this position until the police arrived. When asked how long she thought Patient #6 was held, the PT stated "It was maybe 10 minutes before the police arrived."

The hospital's restraint policy, "Use of Restraint," dated 5/01/13, was reviewed. The policy stated that restraint documentation should include the rational for selecting the type of intervention required.

Patient #6's record did not clearly document the type of restraint hold(s) used to restrain him. Nor did the documentation identify all staff members involved in the physical hold.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and staff interview, it was determined the hospital failed to ensure 1 of 2 restrained patients' medical records (#6) contained documentation of his response to physical restraint and the rationale for the continued use of restraint. This resulted in the inability of the hospital to evaluate the efficacy of restraint use. Findings include:

1. Patient #6 was a [AGE] year old male who was admitted on [DATE]. His diagnoses included [DIAGNOSES REDACTED].

An "ADDENDUM" by a Nurse Practitioner, dated 1/30/16 but not timed, stated Patient #6 "...was admitted yesterday, still floridly psychotic, was going into other peoples' rooms, inappropriate with staff, exposing himself. Despite Ativan and Seroquel [anti-anxiety and antipsychotic medications] he continued to have difficulties. It was discovered that he had crystal meth in a condom likely in his rectum and when it was tried to be removed from him he became agitated, assaulted various staff members. [LEO] Police were called and he was taken to jail."

A "PSYCHIATRIC TECHNICIAN NARRATIVE NOTE," dated 1/29/16 at 10:30 PM, stated Patient #6 "...was up @ the nurse's station and was harrassing staff. Staff then noticed something blue in [Patient #6's] hand. Staff tried to get it from [him. Patient #6] put up a fight hurting two staff members. [Patient #6] was given a shot of meds and police were called. [Patient #6] had meth in a blue plastic rubberish bag [which] was given to police."

A physician order, "EMERGENCY TREATMENT OVER RIDE ORDERS FOR HOLD AND RESTRAINT," dated 1/29/16 at 10:45 PM, was reviewed. The document included an order for "Chemical and Physical Hold" and identified the chemical restraint as a one time order for an IM injection of an anti-psychotic medication. The reason for restraint was documented "Violent/Self-Destructive behavior to others."

A "CHEMICAL AND/OR PHYSICAL RESTRAINT 1:1 MONITORING" form, not dated, indicated Patient #6 was physically held from 10:30 PM through 11:00 PM, when he was "escorted out by [LEO]." The form included Patient #6 presented with "...Severely aggressive behavior which is a danger to others." Patient #6's restraint documentation did not include a thorough description of his response to being physically held. Nor did the documentation include the rational for continued use of physical restraint.

A female PT, who was working at the time Patient #6 was restrained and assaulted by him, was interviewed on 4/14/16, beginning at 9:15 AM. She stated Patient #6 was physically held by the male RN Charge Nurse and a male PT until the police arrived and escorted him out of the building. She said Patient #6 was at the nurses station, when she asked him to give her what he was holding in his hand. He responded by reaching across the nurses station counter and grabbing her hand and arm. She said he began to twist her fingers, hand and arm. She said the male RN Charge Nurse quickly arrived behind the desk and grabbed Patient #6 by the arm, holding his arm across the nurses station counter top. She said the RN Charge Nurse managed to release her arm from Patient #6's grasp. She said a male PT arrived and held Patient #6 from behind, with his arms wrapped around Patient #6's waist. She said the RN Charge Nurse and PT held Patient #6 in this position until the police arrived. When asked how long she thought Patient #6 was held, the PT stated "It was maybe 10 minutes before the police arrived." Additionally, the PT stated Patient #6 continued to fight the RN Charge Nurse and the male PT during the time he was physically held. She said Patient #6 "head-butted and kicked at" the Charge Nurse and male PT, while yelling, "I'm going to kill you when I get loose."

Patient #6's response to physical restraint, or the rationale for the continuation use of physical restraint, was not clearly documented.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies, staff interview and review of personnel training records and restraint training information, it was determined the hospital failed to ensure staff was adequately trained in the use of physical restraint holds. This impacted 1 of 2 patients, (#6) whose record was reviewed for use of restraints, and had the potential to affect all patients admitted to the facility. Findings include:

A policy, "Use of Restraints," dated 5/01/13, was reviewed. The policy documented "...Registered nurses who are trained, qualified deemed competent, and who have completed CPI training are authorized..."

The hospital's Administrator was interviewed on 4/12/16, beginning at approximately 12:30 PM. She stated "the hospital now uses Mandt restraint training, not CPI restraint training." She said all employees who interact with patients must be certified annually in Mandt restraint training. The "Use of Restraints" policy, which was available to staff at the time of the survey, did not contain accurate information about the type of restraint training the hospital required. The policy did not reference Mandt training.

Another policy, "EMERGENCY SERVICES Mandt Training," was reviewed. The policy documented "...All nursing services will be proficient and certified in MANDT and recertify once per year."

A sample of employee training files was reviewed. The training files contained evidence of current Mandt training certification and indicated the last Mandt recertification occurred in March of 2016.

The Mandt Instructor Manual, last revised 12/09/14, was reviewed during the survey. Contained within the manual was the "Instructor Quick Guide." The guide included "Students...must be capable of demonstrating and explaining 100% of all practical (hands-on) physical portions of the skills taught in each chapter with 100% proficiency." Additionally, the guide included "...Annual Recertification of staff is required. The same standard of 100% proficiency is required..."

The Mandt Instructor Manual also included "...Individuals certified in the Mandt System do not use or demonstrate the prohibited practices. The prohibited practices include but are not limited to the following: ...hyper-extension of any part of the body, potential risk of hyper-extension of any body part beyond normal limits..."

The hospital's Mandt Instructor, who was a certified Mandt Instructor according to the hospital's personnel records, was interviewed on 4/13/16, beginning at 9:00 AM, and on 4/14/16, beginning at 11:50 AM. He said he offered the last recertification for employees in March of 2016. He said, during the last recertification, he did not require practice or return demonstration of the approved physical holds included in the Mandt Training course.

A PT was interviewed on 4/14/16, beginning at 9:15 AM. She said she attended the last Mandt Training recertification in March of 2016. She confirmed the employees were not required to physically demonstrate their proficiency with the various, required physical holds. She said they "watched a video, reviewed written information and took tests." The staff's proficiency related to the Mandt approved physical holds was not adequately evaluated during the most recent recertification.

The following patient example demonstrated that the most recent recertification of Mandt restraint training, provided by the hospital, was incomplete and failed to follow the Mandt instructor training guidelines:

1. Patient #6 was a [AGE] year old male who was admitted on [DATE]. His diagnoses included [DIAGNOSES REDACTED].

An "ADDENDUM" by a Nurse Practitioner, dated 1/30/16 but not timed, stated Patient #6 "...was admitted yesterday, still floridly psychotic, was going into other peoples' rooms, inappropriate with staff, exposing himself. Despite Ativan and Seroquel [anti-anxiety and antipsychotic medications] he continued to have difficulties. It was discovered that he had crystal meth in a condom likely in his rectum and when it was tried to be removed from him he became agitated, assaulted various staff members. [LEO] Police were called and he was taken to jail."

A "PSYCHIATRIC TECHNICIAN NARRATIVE NOTE," dated 1/29/16 at 10:30 PM, stated Patient #6 "...was up @ the nurse's station and was harrassing staff. Staff then noticed something blue in [Patient #6's] hand. Staff tried to get it from [him. Patient #6] put up a fight hurting two staff members. [Patient #6] was given a shot of meds and police were called. [Patient #6] had meth in a blue plastic rubberish bag [which] was given to police."

A physician order, "EMERGENCY TREATMENT OVER RIDE ORDERS FOR HOLD AND RESTRAINT," dated 1/29/16 at 10:45 PM, was reviewed. The document included an order for "Chemical and Physical Hold" and identified the chemical restraint as a one time order for an IM injection of an anti-psychotic medication. The reason for restraint was documented "Violent/Self-Destructive behavior to others."

A "CHEMICAL AND/OR PHYSICAL RESTRAINT 1:1 MONITORING" form, not dated, indicated Patient #6 was physically held from 10:30 PM through 11:00 PM, when he was "escorted out by [LEO]." Patient #6's restraint documentation did not include the type of hold used to physically restrain him, and it failed to identify all the individuals involved in the physical hold.

A female PT, who was working at the time Patient #6 was restrained and assaulted by him, was interviewed on 4/14/16, beginning at 9:15 AM. She stated Patient #6 was physically held by the male RN Charge Nurse and a male PT until the police arrived and escorted him out of the building. She said Patient #6 was at the nurses station, when she asked him to give her what he was holding in his hand. He responded by reaching across the nurses station counter and grabbing her hand and arm. She said he began to twist her fingers, hand and arm. She said the male RN Charge Nurse quickly arrived behind the desk and grabbed Patient #6 by the arm, holding his arm across the nurses station counter. She said the RN Charge Nurse managed to release her arm from Patient #6's grasp. She said a male PT arrived and held Patient #6 from behind, with his arms wrapped around Patient #6's waist. She said the RN Charge Nurse and PT held Patient #6 in this position until the police arrived. When asked how long she thought Patient #6 was held, the PT stated "It was maybe 10 minutes before the police arrived."

The hospital's Mandt Instructor, who was a certified Mandt Instructor according to the hospital's personnel records, was interviewed on 4/13/16, beginning at 9:00 AM, and 4/14/16, beginning at 11:50 AM. When asked if he was aware of the incident regarding Patient #1, he said he did not recall when he was informed, but he was not involved in any formal analysis or discussion of the incident. When the hold that was used to restrain Patient #6 was described to the Mandt Instructor, he indicated the hold from behind with the employee's arms wrapped around the waist of Patient #6, was a Mandt approved hold. He did not indicate holding Patient #6's arm, extended across the nurses station counter, was an approved hold.

By not adequately evaluating staff's proficiency and knowledge, the hospital failed to provide staff with complete restraint education and training.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of incident reports and quality documents, it was determined the hospital failed to ensure the causes of adverse patient events were analyzed and actions were taken to prevent further incidents. This affected the care of 3 of 6 patients (#6, #12, and #13) who were mentioned in incident reports. The failure to analyze adverse patient events interfered with the hospital's ability to implement systems to keep patients safe. Findings include:

1. Patient #6 was a [AGE] year old male who was admitted on [DATE]. His diagnosis included schizoaffective disorder, [DIAGNOSES REDACTED], and methamphetamine use disorder. He was placed on a legal hold prior to admission. He had a history of imprisonment between 2001 and 2005.

An "ADDENDUM" by a Nurse Practitioner, dated 1/30/16 but not timed, stated Patient #6 "...was admitted yesterday, still floridly psychotic, was going into other peoples' rooms, inappropriate with staff, exposing himself. Despite Ativan and Seroquel [anti-anxiety and antipsychotic medications] he continued to have difficulties. It was discovered that he had crystal meth in a condom likely in his rectum and when it was tried to be removed from him he became agitated, assaulted various staff members. [LEO] Police were called and he was taken to jail."

The female PT who was assaulted by Patient #6 was interviewed on 4/14/16 beginning at 9:25 AM. She stated Patient #6's behavior was sexually inappropriate and he was physically threatening to her for much of the shift. She stated this included Patient #6 exposing his genitals and trying to push her into a storage room. She stated she did not feel safe and she eventually went behind the nursing station to limit Patient #6's access to her. She stated Patient #6 followed her behind the nursing station on multiple occasions. She stated she told the RN Charge Nurse about Patient #6's behavior but she said no change to his plan of care, such as assigning a male staff to monitor the patient on a 1 to 1 basis was implemented.

The PT stated she was not interviewed or debriefed as part of the investigation for the Root Causal Analysis.

A "PSYCHIATRIC TECHNICIAN NARRATIVE NOTE," dated 1/29/16 at 10:30 PM, stated Patient #6 "...was up @ the nurse's station and was harassing staff. Staff then noticed something blue in [Patient #6's] hand. Staff tried to get it from [him. Patient #6] put up a fight hurting two staff members. [Patient #6] was given a shot of meds and police were called. [Patient #6] had meth in a blue plastic rubberish bag [which] was given to police."

An "INCIDENT/ACCIDENT INVESTIGATION-STATEMENT FORM" by the male Charge Nurse on duty, was dated 1/30/16. It was not timed. It stated on 1/29/16 Patient #6 "...became increasingly erratic, bizarre, aggressive, assaultive throughout the eve. 2230 staff @ [nursing] station noticed a blue plastic bag protruding from [patient's right] hand. [Patient #6] became aggressive & struggle ensued. [Patient] physically restrained by this RN & [a male PT who got behind Patient #6 and held him from behind]. This RN struggled to release [patient's] grasp on [a female PT and Patient #6's] bag. [Patient #6] relinquished a blue condom containing approx. 6 grams of crystalline Methamphetamine. [Patient #6] head butted this RN & caused injury to [the female PT's] right index & middle finger. Law enforcement called during event." The statement said Patient #6 was medicated with an antipsychotic medication. The statement said police arrived at 10:42 PM on 1/29/16 and took Patient #6 into custody on assault and possession charges."

An "INVESTIGATION SUMMARY" by the Quality Coordinator, dated 2/01/16, documented an investigation of Patient #6's assault on staff. It stated there was no injury to the patient. It was unclear how the Coordinator determined this since Patient #6 was not examined by hospital staff after the incident. The summary did not explain how the conclusion was reached. The summary form included a question that stated "Current system in place to prevent this type of occurrence?" The box for "Not Applicable" was checked but there was no further explanation. The summary form included a question that stated "Additional follow up required?" The box for no was checked.

A document titled "Root Cause Analysis," dated 2/02/16, documented a meeting with the Quality Coordinator and the Education Coordinator. The document section labeled "Why" described the event. The section labeled "Assessment" described Patient #6's history. The section labeled "Implement" stated Patient #6 was given an antipsychotic medication and was physically held. The section labeled "Outcome" stated Patient #6 was arrested and said nursing staff would check to see if patients had a history of assault.

The review of the assault by Patient #6 focused solely on the actions of the patient. The review did not include an evaluation of the hospital's performance in response to the event. The review did not evaluate staffing or supervision levels. The review did not include input from all staff directly involved in the event. The review did not evaluate staff training. The review did not evaluate whether staff followed hospital policy. The review did not evaluate the adequacy of the documentation of the event. Finally, the review did not offer any suggestions to prevent future occurrences of this type.

The Education Coordinator was also the Interim Quality Coordinator. She was interviewed on 4/12/16 beginning at 1:30 PM. She stated the hospital's investigation of the event did not determine whether actions by staff were appropriate or whether documentation was complete. She was interviewed again on 4/14/16 beginning at 2:40 PM. She stated the investigation did not include determinations regarding the adequacy of staff supervision. She also confirmed the PT, who was injured in the assault by Patient #6, was not included in the investigation. She stated the investigation did not include recommendations to prevent future occurrences.

The hospital failed to ensure the assault by Patient #6 was thoroughly investigated and preventative actions were implemented.

2. Patient #12 was a [AGE] year old male who was admitted on [DATE]. His diagnosis was schizoaffective disorder. He was discharged on [DATE]. He was placed on a legal hold prior to admission and remained on a hold for his entire stay.

The back of the hospital was surrounded by a 6 foot wooden fence. A "PATIENT OCCURRENCE REPORT," dated 1/12/16, stated Patient #12 scaled the fence and was later found by staff while still on hospital grounds. The report stated Patient #12 complained of hip pain following the event but no significant injury was documented.

An "INVESTIGATION SUMMARY" by the Quality Coordinator, dated 1/14/16, stated staff told Patient #12 to jump the fence. The summary stated Patient #12 eloped while on a smoke break. The summary stated during the break 6 patients were supervised by 1 PT. Neither the Occurrence Report nor the Investigation Summary stated whether staff was aware of Patient #12's absence before he was found.

The "INVESTIGATION SUMMARY" did not mention staffing levels nor did it make a determination regarding the adequacy of staffing and patient supervision at the time of the event. The summary did not elaborate on the statement that staff told Patient #12 to jump the fence. The summary form included a question that stated "Current system in place to prevent this type of occurrence?" The box for yes was checked but there was no further explanation. Another question stated "Was a Root Cause Analysis indicated?" The box labeled "Not Applicable" was checked. The report did not state why a Root Cause Analysis was not indicated. The summary did not include what sources were reviewed or who was interviewed for the investigation. No determination of causation and no recommendations for the prevention of future incidents were included in the Occurrence Report and the summary.

The Interim Quality Coordinator was interviewed again on 4/14/16 beginning at 2:40 PM. She stated the hospital's investigation did not include an evaluation of the adequacy of staffing and supervision when Patient #12 eloped. She stated the investigation did not include recommendations to prevent future occurrences.

The hospital failed to ensure the elopement was thoroughly investigated and preventative actions were implemented.

3. Patient #13 was a female who was admitted on [DATE] and discharged on [DATE]. Her diagnosis was schizoaffective disorder, bipolar type.

An occurrence report, dated 1/01/16, stated Patient #13 walked up to an unidentified male patient who was being discharged . The report stated she grabbed his genitals and made suggestive comments. An "INVESTIGATION SUMMARY," dated 1/05/16, stated Patient #13 was redirected following the event and did not act sexually inappropriately after that. The summary did not evaluate levels of supervision prior to the event nor did it include any follow up with the male patient she grabbed. The summary form included a question that stated "Additional follow up required?" The box for no was checked without explanation.

The Interim Quality Coordinator was interviewed again on 4/14/16 beginning at 2:40 PM. She stated an investigation of the event was not documented. She stated no recommendations to prevent future occurrences were documented.

The hospital failed to ensure the incident was thoroughly investigated and preventative actions were implemented.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of patient records, hospital policies and incident reports, the hospital failed to investigate and report an allegation of abuse for 1 of 4 vulnerable psychiatric patients (#3), whose closed records were reviewed. This interfered with the hospitals plan and policy to fully protect all vulnerable, adult patients from any type of abuse, neglect and/or harassment. Findings include:

A policy, "Emergency Services Suspected Rape & Physical Abuse," dated 5/01/13, included the following:

a. "Patients of [name of the hospital] who are suspected to be victims of rape, or physical abuse are referred to the appropriate outside medical provider or Adult Protective Services, or as appropriate."

b. "Patients admitted to the hospital who have complaints of abuse or exhibited suspected physical findings are assessed by the treatment team."

c. "...The RN notifies the appropriate outside agencies such as Adult Protective Services, Family Service Alliance, and the appropriate police agencies."

d. "...The RN completes an incident report as a formal notification to the DNS."

The hospital did not adhere to this policy as follows:

1. Patient #3 was a [AGE] year old female who was admitted on [DATE]. Her diagnoses included bipolar type I, with psychotic features versus schizoaffective disorder, gastroparesis, status post intestinal torsion and surgical resection, chronic constipation and abdominal pain. She was placed on a legal hold prior to admission, but did not meet criteria for involuntary commitment and was discharged to her home on 2/22/16.

The "INITIAL PSYCHIATRIC ASSESSMENT," dated 2/21/16 and signed by a physician, included, "This patient has a history of bipolar disorder. Patient went in to [Acute Care Hospital]...She talked with a social worker there, made statements about the [LEO] police physically and sexually abusing her a month prior...patient expressed that she felt like her psychiatric medications were not working well..The patient has a history of significant manic episodes in the past where she becomes hyper religious, has bizarre behavior, gets disorganized, has flight of ideas..."

The "Initial Assessment for Admission," dated 2/20/16 at 7:10 PM and signed by an RN, included, "Patient accused [LEO] of sexual, physically and verbally abusing her."

The "Social Services Progress Note," dated 2/21/16 at 8:34 AM and signed by a SW, included, "She also reported that [Meridian PD] beat and raped her a month ago on [Location] in an attempt to break patients will."

The hospital's DNS was interviewed on 4/11/16, beginning at 11:35 AM, and again at 1:15 PM the same day. He reviewed Patient #3's record and said he thought someone at the facility contacted [Acute Care Hospital ED], at the time of admission, to determine whether the allegation of abuse was investigated and reported to the appropriate jurisdictional agency. However, the DNS was unable to provide evidence of an investigation. Documentation of phone calls to the ED and/or PD could not be found. Additionally, the DNS confirmed an incident report had not been completed.

At approximately 1:15 PM on the same day, 4/11/16, the DNS stated the SW began an investigation, after our earlier discussion at 11:35 AM, and reported the allegation of abuse to the [LEO].

On 4/12/16 at approximately 9:15 AM, the DNS presented a "Social Services Progress Note," dated 4/11/16 at 4:17 PM. The note included the SW contacted the [LEO] to discuss the allegation of abuse by Patient #3. The note documented the SW spoke with a police sergeant, and the note stated "...the police were at the ED but did not file a report...as there was already a report filed and investigated one month prior when [Patient #3] reports the sexual assault happened...This SW requested both records on this date and will file the requests with this note."

The Director of Social Services was interviewed on 4/13/16, beginning at 2:40 PM. She confirmed Patient #3's allegation of abuse against the [LEO] was not reported or investigated until the week of this survey, 4/11/16.

By failing to follow their policy to report and investigate allegations of abuse, the hospital did not protect the rights of a vulnerable, adult, psychiatric patient, (#3).