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.

EASTERN STATE HOSPITAL 1350 BULL LEA ROAD LEXINGTON, KY March 12, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of facility's policies and documents, it was determined the facility failed to provide care in a safe setting for the patients in the Wendell Building due to one (1) patient, Patient #4, gaining access to a cigarette lighter and setting fire to his/her basket of clothes (see A0144). Patient #4 was admitted to the facility on [DATE] with a known history of self-harm by burning and a criminal history of robbery and murder. On admission, Patient #4 attacked staff, had auditory hallucinations, and expressed a desire to harm others if the opportunity arose. On 02/25/13, Patient #4 was placed on support supervision and allowed to go to the Recovery Mall and Gym. Mental Health Associate (MHA) #6 smelled smoke coming from the bathroom adjacent to the Gym. Patient #4 had just been in the bathroom. A search of the bathroom did not produce any contraband. A search of the patient and his/her room on Wendell 4 did not produce any contraband; however, ashes were discovered in his/her wardrobe in his/her room. No additional search of Wendell 4 was done at that time. On 02/26/13 at approximately 8:25 PM, smoke was discovered by MHA #7 coming from Patient #4's room on Wendell 4. Patient #4's basket of clothes, which he/she had just picked up after being laundered, was on fire. Staff extinguished the fire, and the fire department was called and came. No patients suffered any physical harm. Patient #4 then told MHA #5 that he/she had set his/her own basket of clothes on fire and showed the MHA #5 where he/she had hidden the lighter. The lighter was obtained and given to the fire investigator. Patient #4 stated he/she had found the lighter in the Recovery Mall in the relaxation room. Patient #4 was placed on one to one observation for the remainder of his/her time in the facility. Patient #4's room was searched on Wendell 4, but no other areas were searched. The failure of the facility to provide a safe environment and appropriate supervision and search placed patients at risk for serious injury, harm, impairment or death. The facility was notified on 03/08/13 that Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be abated on 03/12/13, prior to exit on 03/12/13. (Refer to A0144)
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of facility's policies and documents, it was determined the facility failed to ensure the results of a grievance investigation were communicated to one (1) of ten (10 ) patients, Patient #7.

The findings include:

Review of facility policy, "General Hospital Policies, Section 5, Ethics and Patient Rights Policies, Subsection K, Patient Grievance and Complaint," undated, revealed for grievances the Grievance Coordinator shall make inquiries into the matter and provide a verbal response to the patient within two (2) days. A written report shall be sent to the patient/guardian within five (5) working days. It further revealed that all patients/guardians will receive a written report concerning their grievance.

Review of facility policy, "General Hospital Policies, Section 3, Risk Management and Safety Policies, Subsection C.A.1.," revealed staff would be required to observe the patient and document at least every thirty (30) minutes from 7:30 AM to 9:00 PM for a support level of supervision.

Review of the medical record of Patient #7 revealed he/she was admitted on [DATE] with a diagnosis of Psychosis, Not Otherwise Specified. The "Patient Supervision Record," on 02/25/13 at 12:30 PM, further revealed Patient #7 was on a support level of supervision and was in the Dayroom on Gragg 3 exhibiting intrusive behavior. The Physician documented in "Progress Notes," dated 02/26/13 at 11:00 AM, that Patient #7 filed a grievance concerning the incident on 02/25/13 when the Dietician removed a piece of chicken from his/her lunch plate and put it in the garbage. Patient #7 then removed chicken from the garbage can. The Physician notes further revealed Patient #7 stated the Dietician grabbed his/her right wrist, and he/she now claimed there was an injury to the right wrist. The Physician notes also state there was no evidence of injury, no swelling or bruising and Patient #7 demonstrated full range of motion with his/her right wrist. The Physician notes also revealed Patient #7 was offered to have an x-ray of the wrist but refused.

Review of the facility "Incident Report Form" for Patient #7, dated 02/25/13 at 2:30 PM, revealed Patient #7 was in the Dayroom on Gragg 3 eating lunch on 02/25/13 when the Dietician removed a piece of chicken from his/her plate because there were four (4) pieces of chicken on Patient #7's plate. The Dietician removed a piece and threw it in the trash. Patient #7 retrieved the chicken and placed it back on his/her plate. The incident report further revealed Patient #7 was getting ready to eat the chicken when the Dietician came back to the table and placed his hand on Patient #7's hand, which he/she started waving back and forth. The incident report then stated Patient #7 later said the Dietician had injured his/her wrist. The incident report further revealed the Licensed Clinical Social Worker (LCSW) reviewed the grievance and passed it on to the Grievence Coordinator.

Interview with Patient #7, on 03/11/13 at 4:15 PM, revealed the incident was very embarrassing to him/her. Patient #7 stated the Dietician took a piece of chicken from his/her plate and touched his/her right hand and while doing so caused a struggle and made his/her hand red and sore. Patient #7 further revealed an x-ray of his/her hand was offered but he/she declined, stating the incident was more embarrassing than physical. Patient #7 also stated he/she filed a grievance the day of the incident but had not received a verbal or written response from the facility.

Interview with the Grievance Coordinator, on 03/12/13 at 1:30 PM, revealed he had not communicated, either verbally or in written form, with Patient #7 concerning the incident with the chicken on 02/25/13. He stated when the incident became reportable and safety was the primary focus, the grievance process was ignored. He further revealed the findings of the investigation should have been communicated to the patient, and he could not say if the issue had been resolved to Patient #7's satisfaction.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, video review and review of facility's policies and documents, it was determined the facility failed to ensure patients were in a safe environment by inadequate supervision of two (2) of ten (10) patients, Patient #1 and #4.

The facility failed to ensure Patient #1 was prevented from obtaining two (2) AA batteries from a television remote control and ingesting them and from obtaining a washer (a metal piece off a commode about the size of a quarter) and ingesting it. Patient #1 had a history of PICA (the persistent ingestion of nonnutritive substances for a period of a least one (1) month at an age for which this behavior is developmentally inappropriate).

The facility failed to ensure Patient #4 was prevented from obtaining a cigarette lighter and setting fire to his/her basket of clothes. Patient #4 had a history of self-harm through burning and a criminal history of robbery and murder, and on admission had auditory hallucinations, expressed a desire to harm others and assaulted staff.


The findings include:

Review of the facility policy, "General Hospital Policies, Section 3, Risk Management and Safety Policies, Subsection C., "Patient Supervision," revised 05/2012, revealed the supervision level of "support" allowed the patient to go off the unit with supervision every thirty (30) minutes between the hours of 7:30 AM to 9:00 PM. The supervision level of safety did not allow the patient to go off the unit with supervision every thirty (30) minutes between the hours of 7:30 AM to 9:00 PM. The supervision level of safety, fifteen (15) minute checks did not allow the patient to leave the unit with supervision every fifteen (15) minutes and was used when the patient was at low risk for injury but identified risk factors were present. The supervision level of safety, close observation did not allow the patient to leave the unit and assigned staff must continually have patient in clear view and within twelve (12) feet and was used when the patient was assessed at moderate risk for injury. The supervision level of safety, one to one observation was used when the patient was at high risk for injury due to identified risk factors and required assigned staff to continually have the patient in clear view and be within a leg's length of the patient. Subsection C. D., "Area Supervision," revised 05/2012, revealed all areas on each unit to which patients have access shall be monitored by staff at the beginning and end of each shift to assess unit for environmental changes and/or hazards and documented on the Shift Assignment Sheet. It further revealed the Recovery Mall shall be monitored every thirty (30) minutes during hours of operation and documented on the Area Check Sheet. Subsection D., "Patient Search," revised 05/2012, revealed a search would be conducted on all patients presenting for admission as well as on all patients returning to the facility from leave or elopement. It also stated a patient's person, room, belongings or vehicle may be searched when there is reasonable cause to believe a patient may possess contraband or an item which is potentially hazardous. No requirements were listed that areas other than patient rooms, person and belongings would be searched if contraband was suspected.

Review of the facility policy, "General Hospital Policies, Section 6, Miscellaneous Patient Policies, Subsection A, Visitation Policy," revised 05/2012, revealed visitation would be established in an area off patient units, all visitors must check in at the Visitor Badging Station, all items brought to patients from visitors must be checked in and left at the Visitor Badging Station during visiting hours and personal belongings of visitors must be left in their vehicle or locked in secure lockers provided by the facility. There were no other requirements or security measures listed in the facility's policy for visitors.

Review of the, "Consumer & Family Handbook, We're All About Recovery," undated, revealed use of tobacco products and smoking was not allowed on facility grounds. However, it also revealed if the patient brought in tobacco and tobacco products, they would be labeled, and the patient would get them back at discharge from the facility.

1. Review of Patient #1's medical record revealed he/she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]. The record review revealed, since being at the facility he/she ingested one (1) AA battery on 09/05/12 and two (2) AA batteries on 09/18/12. His/her Personal Recovery Plan (PRP) on 02/12/13 revealed he/she exhibited self-injurious behaviors with PICA behaviors continuing such as swallowing non-food items (glasses lens, plastic cup). The record further revealed on 02/16/13 at 6:20 PM, Patient #1 gave a broken television remote control to MHA #1 in the Dayroom and stated he/she had swallowed two (2) AA batteries that had been in the remote control. The "Patient Supervision Record" on 02/16/13 revealed Patient #1 was on one to one supervision and was listed as being in the Dayroom from 5:15 PM to 6:15 PM. The record further revealed an abdominal x-ray was done 02/18/13, which showed the two (2) AA batteries were within the colon; another abdominal x-ray was done 02/25/13 which showed one (1) of the AA batteries had passed. The record then stated in the "RN Shift Assessment Form" on 02/25/13 that the second and remaining battery had passed and there was no evidence of blood. On 03/02/13 at 6:20 PM, Patient #1's record revealed he/she was in the restroom with one to one observation staff (MHA #2) and another buddy staff (MHA #3) when he/she swallowed a washer from the toilet. The physician was contacted but did not order any additional treatments.

Review of facility video taken 02/16/13 from 5:56 PM to 6:32 PM revealed Mental Health Associate (MHA) #1 came to work at the Intensive Support Unit (ISU) at 5:59 PM to begin one on one observation of Patient #1 whenever he received report and the care was transferred to him from MHA #4. It then revealed MHA #4 and Patient #1 going to the Dayroom at 6:00 PM. The video then showed two (2) brief periods, both under one (1) minute each and before 6:15 PM when Patient #1 was left alone without one to one observation in the Dayroom. The television was located in the Dayroom. The video was of the hallway going to the Dayroom and did not show the Dayroom. Patient #1 ingesting the two (2) AA batteries was not seen.

Review of the "Behavior Support Plan," implemented 02/21/13, for Patient #1, written by the Behavior Analyst, explained the "Buddy" staff which was one (1) additional MHA that was placed as a support for Patient #1 and his/her one to one staff from 7:00 AM to 11:30 PM. The "Buddy" would serve as a helper so that Patient #1 would never be left alone and would be a witness in high-risk allegation areas, such as the bedroom and bathroom.

Interview with Patient #1, on 03/07/13 at 4:30 PM, revealed he/she picked up the remote and ate the batteries but could not remember where the remote was located. He/she also stated he/she got the washer off the side of the toilet and swallowed it while two (2) MHA's were in the bathroom with him/her.

Interview with Registered Nurse (RN) #2, on 03/07/13 at 4:55 PM, revealed she worked on the ISU 02/16/13 beginning at 6:15 PM. At 6:20 PM, MHA #1 said he had gotten the remote from Patient #1, it was broken and Patient #1 stated he had swallowed two (2) AA batteries. RN #2 stated the Dayroom and Patient #1's room were searched, but no batteries were found. RN #2 stated she called the Shift Coordinator, did an assessment of Patient #1, notified the Physician and did a PICA sweep. She also stated PICA sweeps had been a requirement to be done three (3) times per shift since 12/2012.

Interview with the Shift Coordinator, on 03/01/13 at 4:12 PM, revealed he was called on the evening of 02/16/13 that Patient #1 had ingested two (2) AA batteries. He interviewed Patient #1, and he/she told him that he/she found the remote but did not say where it was found. The Shift Coordinator further revealed the remote should have been kept at the nurses' station where it was locked. He then stated he called the Administrator on Call (AOC) and Risk Management.

Interview with MHA #4, on 03/06/13 at 3:05 PM, revealed he worked on the ISU on 02/16/13 until around 6:15 PM when his replacement arrived. His duty was to do one to one observation with Patient #1. MHA #4 further revealed he had the remote in his hand at all times until around 5:30 PM when he gave it to another staff member whom he saw place it at the nurses station. MHA #4 also stated he did not remember leaving Patient #1 alone at any time.

Interview with MHA #1, on 03/11/13 at 11:45 AM, revealed he was the oncoming MHA on 02/16/13 and was supposed to take over Patient #1's one to one observation from MHA #4 at 6:30 PM. He stated he got back to the floor at around 6:12 PM and saw MHA #4 in the hallway without Patient #1. MHA #1 further revealed when he went to the Dayroom at around 6:20 PM, Patient #1 gave him the broken remote without the batteries and said he/she had swallowed them.

Interview with RN #3, on 03/06/13 at 3:25 PM, revealed she was the oncoming nurse on 03/02/13 for the ISU. She further revealed Patient #1 had swallowed a washer about the size of a quarter that came off the toilet between 6:00 PM and 6:30 PM. RN #3 stated MHA #2 and #3 had been in the bathroom with Patient #1 when he/she swallowed the washer. She further revealed she is the charge nurse and has the responsibility for doing PICA sweeps three (3) times per shift. She stated PICA sweeps involved scanning Patient #1's room, the hallway, the Dayroom and the bathroom for anything Patient #1 could get in his mouth. RN #3 stated she would not have thought it routine to check the bolts and washers on the toilet for looseness. She also revealed the bathroom door was always locked; so, when a patient needed to go to the bathroom, it was unlocked and staff looked in before allowing Patient #1 to enter so objects for ingestion could be removed.

Interview with MHA #3, on 03/06/13 at 4:20 PM, revealed he was working on 03/02/13 on ISU from 3:00 PM to 11:30 PM. He revealed he was either on one to one observation or the "buddy" for Patient #1. MHA #3 stated a PICA sweep had been done around 4:00 PM and another was not done before Patient #1 went into the bathroom; but MHA #2 and MHA #3 did accompany Patient #1 to the bathroom after 6:00 PM. He further stated he had his eyes on Patient #1 at all times and saw Patient #1 pick something off the side of the toilet or the ground. MHA #3 further revealed he grabbed Patient #1's arm to get the washer but he/she had already put it in his/her mouth and swallowed it. MHA #3 stated RN #3 was notified of the incident. MHA #3 also said he had been trained on doing PICA sweeps three (3) times per shift to look for objects that Patient #1 could ingest, but he did not think one was required before Patient #1 entered the bathroom.

Interview with MHA #2, on 03/06/13 at 5:27 PM, revealed he worked from 7:00 AM to 6:30 PM on 03/02/13 on the ISU and was on one to one observation with Patient #1. MHA #2 stated he did a visual sweep of the bathroom, looking for toilet paper, towels, soap, etc. and did not see anything on the floor before taking Patient #1 to the bathroom along with MHA #3 on 03/02/13 after 6:00 PM. He further revealed Patient #1 was always visible to him and MHA #3, but Patient #1 picked up the washer and was able to get it into his/her mouth before either MHA could stop him/her. MHA #2 further revealed the washer was about the size of a quarter and if it had been on the floor, he would have seen it when we entered the bathroom. MHA #2 then said maintenance came in around 7:00 PM and inspected the bathroom toilet, sink and walls.

Interview with the Wendell Building Nursing Leader, on 03/06/13 at 2:15 PM, revealed PICA sweeps started in 12/2012 and should include any area Patient #1 could be in, including his/her room, bathroom, Dayroom and hallway. He further revealed he would expect a PICA sweep to be done before Patient #1 entered the bathroom, but he would not expect the staff to check the bolts on the toilet or walls or anything that is fastened down.

2. Review of Patient #4's medical record revealed he/she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]. The "Admission History" also revealed a history of setting him/herself on fire and beating a woman to death for which he/she served ten (10) years in prison. Patient #4 also admitted to having thoughts and desires to hurt other people. The "Admission History" also stated he/she was placed on close observation, safety level because of his/her history of beating someone to death intentionally, command hallucinations and extreme irritability and anger. The record further revealed Patient #4 was started on Asenapine (an antipsychotic medication used to treat symptoms of [DIAGNOSES REDACTED]. Patient #4 was changed to the supervision level of support on 02/25/13 at 8:45 AM. According to the Physician notes, even though he/she had had episodes of acting out behavior, he/she was remorseful and adherent to the Asenpine regimen, thoughts were logical and goal oriented, and he/she was not exhibiting any evidence of psychosis. The "RN Shift Assessment" for 02/25/13, 3:00 PM to 12:00 PM, did not mention anything concerning patient and room search. The "RN Shift Assessment" for 02/26/13 at approximately 8:30 PM stated Patient #4 started a fire in his/her room by setting his/her clothes basket on fire with a lighter. The record further revealed Patient #4 admitted he/she set the fire and stated he/she would set another one. The record stated Patient #4 gave the lighter to staff. The record further revealed Patient #4 was placed on safety, close observation after the incident and remained on this level until he/she was discharged the next day, 02/27/13 at 11:45 AM. The record further revealed Patient #4 was arrested at time of discharge, being charged with first degree arson and taken to a detention center.

Review of the "Incident Report Form" for Patient #4, dated 02/25/13 at 6:40 PM, revealed Patient #4 was in the Recovery Mall at this time and had been in the bathroom next to the Gym. This report further stated a patient told staff that cigarette smoke was in the bathroom when Patient #4 came out. The bathroom was checked per staff without any contraband being found, and the unit, Wendell 4, was notified to search Patient #4. The report also stated that Patient #4 was searched and no contraband was found but ashes were found in his/her wardrobe.

Review of the "Recovery Mall, Comfort Room Sign-In Sheet," revealed Patient #4 did not sign in for the room on 02/25/13 but did on 02/26/13 at 3:45 PM. Review of the "Recovery Mall Area Checks" which included the relaxation or comfort room, revealed it was to be checked at 4:00 PM, upon closing of the area, but there was not a place for documenting this on the form.

Review of the "Visitation Attendance" from 02/20/13 to 02/27/13 revealed Patient #4 did not have any visitors during his stay at the facility.

Review of the Fire Department Report revealed the fire alarm went off at the facility on 02/26/13 at 8:25 PM; the fire department arrived at the facility at 8:29 PM; and the last unit was cleared at 10:17 PM. It also revealed the fire had been extinguished with a dry chemical extinguisher by facility staff by the time of the fire department's arrival, and their main tasks were to ventilate the area and to investigate the fire.

Interview with MHA #5, on 03/03/13 at 7:11 PM and 03/07/13 at 6:16 PM, revealed she was in the Dayroom on Wendell 4 with Patient #4 on 02/26/13 after the fire had been set and the fire department was on the premises. Patient #4 told MHA #5 he/she started the fire and was going to start another one. She further revealed Patient #4 showed her the lighter, a yellow BIC, that was hidden beneath a border on the hall bulletin board. MHA #5 further stated Patient #4 said he/she found the lighter in the "quiet" room in the Recovery Mall. She stated she gave the lighter to the fire investigator, and Patient #4 was put on close supervision. MHA #5 further revealed the lighter was not visible because it was behind the border, and she removed all the paper from the bulletin board that evening after the incident.

Interview with RN #4, on 03/07/13 at 2:58 PM, revealed he was working on Wendell 4 the evening of 02/26/13 when the fire occurred. RN #4 stated he searched all three (3) patients that occupied the room where the fire was started, including Patient #4, and found nothing. He further stated the fire department personnel had searched the room where the fire was started and found nothing. RN #4 then stated once the lighter was found, no additional areas on Wendell 4 were searched because it was assumed we had the implement that had caused the fire and additional searches of rooms or areas were not necessary.

Interview with RN #2, on 03/07/13 at 4:55 PM, revealed she was working on Wendell 4 the evening of 02/25/13 and received a call from the Gym that Patient #4 might have been smoking in the bathroom. She further revealed she searched Patient #4's room thoroughly and found cigarette ashes on one of the shelves in his/her wardrobe. She also stated that another staff person searched Patient #4's person in the shower room because he/she was about to take a shower. RN #2 further revealed she was working the night of 02/26/13 when the fire occurred. She stated the whole unit was not searched, only the room and the three (3) occupants of the room where the fire was started because Patient #4 confessed to starting the fire and the lighter was found. She stated that it all happened very quickly.

Interview with the Recovery Mall Director, on 03/06/13 at 4:55 PM, revealed he was not aware that Patient #4 stated he/she found the lighter in the Recovery Mall. He further revealed there was a relaxation room that was locked most of the time, but when a patient went in, they could be by themselves for ten (10) to fifteen (15) minutes with a staff member sitting outside. He also stated that when the patient left the room, it was locked. The Director also stated that before a patient entered a room, staff was supposed to check for contraband.

Interview with the Nursing Unit Director of Wendell 4, on 03/07/13 at 5:20 PM, revealed she heard Patient #4 say on the morning of 02/27/13 that he got the cigarette lighter in the Recovery Mall, but he/she did not say where or when. She further revealed she believed Patient #4 probably stashed the lighter behind the bulletin board border on 02/25/13 or 02/26/13 so when he/she and his/her room was searched, it would not be found.

Interview with MHA #6, on 03/11/13 at 12:45 PM, revealed she was working in the Gym area the evening of 02/25/13 when a patient came out of the bathroom by the Gym and said a patient was smoking. She further revealed Patient #4 came out when she went in, and there was a heavy smoke odor. MHA #5 stated she searched the bathroom and found no lighter or cigarettes and then called Wendell 4 so a search could be done on Patient #4.

Interview with the Director of Nursing (DON), on 03/07/13 at 9:41 AM, revealed employees were instructed to keep personal belongings locked in the break rooms on their units and were not restricted from bringing in cigarettes or lighters. He stated patients were not searched after visits because they were supervised by facility staff, and visitors were not searched before patient visits. He revealed that the unit rooms on Wendell 4 and all patients on Wendell 4 were searched for contraband after the fire; and he was not sure if the Recovery Mall was searched for contraband after the fire on 02/26/13.

Interview with the DON, on 03/08/13 at 10:00 AM, revealed he was told by staff that the whole unit on Wendell 4 and all the patients on Wendell 4 had been searched after the fire on 02/26/13; but he stated he might have been told this in error. He further stated in addition to tobacco products, lighters were also being saved for patients and given back to them upon discharge. The DON then revealed there could be a brief period of time when the patient is awaiting discharge that their lighter would be in a patient area.
He also revealed, even though visitation was supervised, there was a chance that a visitor could pass a lighter or some other contraband to a patient without it being observed.by staff.

The facility failed to ensure patients at high risk for harming others were properly and adequately supervised and searched. This failure placed patients at risk for injury, harm, impairment or death. On 03/08/13, Immediate Jeopardy was determined to exist. The facility initiated the following corrective actions:

1) making it mandatory for patients to get undressed and into a gown in the Central Triage Center (CTC) for a skin assessment and body search with a new form developed which will follow patients to their units where another search will be done; 2) cigarettes and lighters will no longer be saved for patients and given to them at discharge but will be disposed of in the CTC; 3) staff will no longer be able to bring any tobacco products or lighters into the facility; they must be left in a locked car; 4) volunteer donations now have a process and policy whereby they are searched in a specific area for contraband before going to the units; 5) if anything suspicious is suspected, like cigarette ashes being found on a unit, the whole area(s) involved will be swept for contraband; 6) for visitation, the supervisory staff had been doubled, visitors come through one (1) entrance, visitors' personal belongings will be searched and a metal detector wand will scan their bodies; 7) after visitation but before patients go back to their units, they will be searched for contraband and a metal detector wand will scan their bodies; 8) after visitation when the patients go back to their units, they will be searched, along with their personal belongings; 9) the Performance Improvement Director will collect data on compliance with the new search sheets and processes and track incidents that happen related to them and will initially report the findings monthly at the Quality Committee; 10) the Recovery Mall will be swept for contraband twice per day, in the AM before any patients arrive and in the PM after patients have left, and a new sign off sheet had been developed for this activity; and 11) an individual had been named to head the Visitation Process and had been given accountability for its operation.

The new policies were placed in effect shortly after the Immediate Jeopardy was called on 03/08/13. Training on the new policies started on 03/08/13, and before exit eighty-five (85) percent of facility personnel had received the training. No staff member can work before receiving training, so it is ongoing until one hundred (100) percent of existing staff members have been trained. Interview with the Director of Nursing revealed new personnel will be trained on the new policies and procedures at orientation.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, video review and review of facility's policies and documents, it was determined the facility failed to ensure patients were protected from abuse for one (1) of ten (10 ) patients, Patient #7.

The findings include:

Review of facility policy, "General Hospital Policies, Section 3, Risk Management and Safety Policies, Subsection A.4.a.," revised 08/2012, revealed abuse was defined as the willful (not accidental) infliction of injury that resulted in physical or mental pain; and mental or psychological abuse included the mental harm or injury which occurred when the victim was humiliated, harassed, threatened, punished, deprived, coerced or intimidated. The policy also revealed the facility would seek to protect patients from all forms of abuse. Subsection C.A.1. revealed, for support level of supervision, staff would be required to observe the patient and document at least every thirty (30) minutes from 7:30 AM to 9:00 PM.

Review of the facility video, taken on 02/25/13 starting at 12:30 PM of the Dayroom on Gragg 3, revealed Patient #7 was sitting at a table eating with other patients. A man, identified by the Risk Manager as the Dietician, came and took Patient #7's plate away, removing a piece of chicken. The Dietician threw this piece of chicken in the garbage can, located about four (4) feet behind the patient. After the Dietician left the area, Patient #7 went to the garbage and retrieved the piece of chicken. A staff member observed this and went to get the Dietician. He came back, took Patient #7's plate away again, placing his hand on his/her right hand/wrist, and threw the piece of chicken back in the garbage. A staff member stayed to observe from this point to ensure Patient #7 did not again retrieve the chicken from the garbage.

Review of the facility "Incident Report Form" for Patient #7, dated 02/25/13 at 2:30 PM, revealed Patient #7 was in the Dayroom on Gragg 3 eating lunch on 02/25/13 when the Dietician removed a piece of chicken from his/her plate because there were four (4) pieces of chicken on Patient #7's plate. The Dietician removed a piece and threw it in the trash. Patient #7 retrieved the chicken and placed it back on his/her plate. The incident report further revealed Patient #7 was getting ready to eat the chicken when the Dietician came back to the table and placed his hand on Patient #7's hand which he/she started waving back and forth. The incident report then stated Patient #7 later said the Dietician had injured her wrist.

Review of the medical record of Patient #7 revealed he/she was admitted on [DATE] with a diagnosis of Psychosis, Not Otherwise Specified. The "Patient Supervision Record," on 02/25/13 at 12:30 PM, further revealed Patient #7 was on a support level of supervision and was in the Dayroom on Gragg 3 exhibiting intrusive behavior. The Physician documented in "Progress Notes," dated 02/26/13 at 11:00 AM, that Patient #7 filed a grievance concerning the incident on 02/25/13 when the Dietician removed a piece of chicken from his/her lunch plate and put it in the garbage. Patient #7 then removed chicken from the garbage can. The Physician notes further revealed Patient #7 stated the Dietician grabbed his/her right wrist and he/she now claimed there was an injury to the right wrist. The Physician notes also state there was no evidence of injury, no swelling or bruising and Patient #7 demonstrated full range of motion with his/her right wrist. The Physician notes also revealed Patient #7 was offered to have an x-ray of the wrist but refused.

Interview with Patient #7, on 03/11/13 at 4:15 PM, revealed the incident was very embarrassing to him/her. Patient #7 stated the Dietician took a piece of chicken from his/her plate and touched his/her right hand while doing so which caused a struggle and made my hand red. Patient #7 further revealed an x-ray of his/her hand was offered but he/she declined, stating the incident was more embarrassing than physical. Patient #7 also stated he/she filed a grievance the day of the incident but had not received a verbal or written response from the facility.

Interview with the Dietician, on 03/11/13 at 2:12 PM, revealed the reason he went to retrieve the extra piece of chicken from Patient #7's plate on 02/25/13 at 12:30 PM was because he/she was only to receive extra portions at breakfast, and the kitchen had sent up extra portions for lunch. He also said Patient #7 was at an ideal weight, but he did not want Patient #7 to gain any weight during his/her stay at the facility; and they had agreed that only extra portions were to be given at breakfast. The Dietician further revealed that removing the piece of chicken was a spontaneous action, and he did not think Patient #7 would put up any resistance. He also said he did not grab Patient #7's wrist but used his thumb and forefinger to move his/her hand away from the plate. The Dietician further revealed that in hindsight he would have left the chicken on the plate and dealt with the kitchen about not sending extra portions except at breakfast.

Interview with the Directory of the Dietary Department, on 03/11/13 at 2:47 PM, revealed he was disappointed in the Dietician for his actions concerning the incident with Patient #7 on 02/25/13. He also stated the Dietician should have left the piece of chicken on Patient #7's plate and addressed the issue of extra portions later with the kitchen. The Director of Dietary further revealed he had counseled the Dietician about alternate ways to have handled this situation.

Interview with RN #1, on 03/12/13 at 10:55 AM, revealed she witnessed the incident with Patient #7, on 02/25/13, and Patient #7 was upset by it and stated his/her thumb on his/her right hand was sore. RN #1 further revealed pictures were taken of Patient #7's right hand, the Physician was notified and an incident report was completed on 02/25/13.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of facility's policies and documents, it was determined the facility failed to provide adequate nursing supervision and searches for a high risk patient with a history of hurting others and a stated intent to harm others for one (1) of ten (10) patients, Patient #4. This allowed him/her to gain access to a cigarette lighter and set fire to his/her basket of clothes (see A0395). Patient #4 was admitted to the facility on [DATE] with a known history of self-harm by burning and a criminal history of robbery and murder. On admission, Patient #4 attacked staff, had auditory hallucinations, and expressed a desire to harm others if the opportunity arose. On 02/25/13, Patient #4 was placed on support supervision and allowed to go to the Recovery Mall and Gym. Mental Health Associate (MHA) #6 smelled smoke coming from the bathroom adjacent to the Gym. Patient #4 had just been in the bathroom. A search of the bathroom did not produce any contraband. A search of the patient and his/her room on Wendell 4 did not produce any contraband; however, ashes were discovered in his/her wardrobe in his/her room. No additional search of Wendell 4 was done at that time. On 02/26/13 at approximately 8:25 PM, smoke was discovered coming from Patient #4's room on Wendell 4. Patient #4's basket of clothes, which he/she had just picked up after being laundered, was on fire. Staff extinguished the fire, and the fire department was called and came. No patients suffered any physical harm. Patient #4 then told MHA #5 that he/she had set his/her own basket of clothes on fire and showed the MHA where he/she had hidden the lighter. The lighter was obtained and given to the fire investigator. Patient #4 stated he/she had found the lighter in the Recovery Mall in the relaxation room. Patient #4 was placed on one to one observation for the remainder of his/her time in the facility. Patient #4's room was searched on Wendell 4, but no other areas were searched. The failure of the facility to provide a safe environment and appropriate nursing supervision and searches placed patients at risk for serious injury, harm, impairment or death. The facility was notified on 03/08/13 that Immediate Jeopardy was determined to exist related to Nursing Services. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be abated on 03/12/13, prior to exit on 03/12/13. (Refer to A0395)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, video review and review of facility's policies and documents, it was determined the facility failed to ensure patients were adequately supervised and searched by nursing personnel for two (2) of ten (10) patients, Patient #1 and #4.

The facility failed to ensure Patient #1 was prevented from obtaining two (2) AA batteries from a television remote control and ingesting them and from obtaining a washer (a metal piece off a commode about the size of a quarter) and ingesting it. Patient #1 had a history of PICA (the persistent ingestion of nonnutritive substances for a period of a least one (1) month at an age for which this behavior is developmentally inappropriate.

The facility failed to ensure Patient #4 was prevented from obtaining a cigarette lighter and setting fire to his/her basket of clothes. Patient #4 had a history of self-harm through burning, a criminal history of robbery and murder, auditory hallucinations, expressed a desire to harm others and had assaulted staff.



The findings include:

Review of the facility policy, "General Hospital Policies, Section 3, Risk Management and Safety Policies, Subsection C., "Patient Supervision," revised 05/2012, revealed the supervision level of support allowed the patient to go off the unit with supervision every thirty (30) minutes between the hours of 7:30 AM to 9:00 PM; safety did not allow the patient to go off the unit with supervision every thirty (30) minutes between the hours of 7:30 AM to 9:00 PM; safety, fifteen (15) minute checks did not allow the patient to leave the unit with supervision every fifteen (15) minutes and was used when the patient was at low risk for injury but identified risk factors were present; safety, close observation did not allow the patient to leave the unit and assigned staff must continually have patient in clear view and within twelve (12) feet and was used when the patient was assessed at moderate risk for injury; and safety, one to one observation, was used when the patient was at high risk for injury due to identified risk factors and required assigned staff to continually have the patient in clear view and be within a leg's length of the patient. Subsection C. D., "Area Supervision," revised 05/2012, revealed all areas on each unit to which patients have access shall be monitored by staff at the beginning and end of each shift to assess unit for environmental changes and/or hazards and documented on the Shift Assignment Sheet. It further revealed the Recovery Mall shall be monitored every thirty (30) minutes during hours of operation and documented on the Area Check Sheet. Subsection D., "Patient Search," revised 05/2012, revealed a search would be conducted on all patients presenting for admission as well as on all patients returning to the facility from leave or elopement. It also stated a patient's person, room, belongings or vehicle may be searched when there is reasonable cause to believe a patient may possess contraband or an item which is potentially hazardous. There were no requirements listed that areas other than patient rooms, person and belongings would be searched if contraband was suspected.

Review of the facility policy, "General Hospital Policies, Section 6, Miscellaneous Patient Policies, Subsection A, Visitation Policy," revised 05/2012, revealed visitation would be established in an area off patient units. All visitors must check in at the Visitor Badging Station. All items brought to patients from visitors must be checked in and left at the Visitor Badging Station during visiting hours. Personal belongings of visitors must be left in their vehicle or locked in secure lockers provided by the facility. There were no other requirements or security measures listed in teh policy for visitors.

Review of the, "Consumer & Family Handbook, We're All About Recovery," undated, revealed use of tobacco products and smoking was not allowed on facility grounds. However, it also revealed if the patient brought in tobacco and tobacco products, they would be labeled and the patient would get them back at discharge from the facility.

1. Review of Patient #1's medical record revealed he/she was admitted on [DATE] with diagnoses which included Impulse Control Disorder and Mild Mental Retardation. He/she was admitted on a seventy-two (72) hour court order because of a danger to self and others. The record further revealed on admission he/she had a history of ingesting multiple inedible objects; since being at the facility he/she ingested one (1) AA battery on 09/05/12 and two (2) AA batteries on 09/18/12. His/her Personal Recovery Plan (PRP) on 02/12/13 revealed he/she exhibited self-injurious behaviors with PICA behaviors continuing such as swallowing non-food items (glasses lens, plastic cup). The record further revealed on 02/16/13 at 6:20 PM, Patient #1 gave a broken television remote control to MHA #1 in the Dayroom and stated he/she had swallowed two (2) AA batteries that had been in the remote control. The "Patient Supervision Record" on 02/16/13 revealed Patient #1 was on one to one supervision and was listed as being in the Dayroom from 5:15 PM to 6:15 PM. The record further revealed an abdominal x-ray was done 02/18/13 which showed the two (2) AA batteries were within the colon; another abdominal x-ray was done 02/25/13, which showed one (1) of the AA batteries had passed. The record then stated in the "RN Shift Assessment Form" on 02/25/13 that the second and remaining battery had passed and there was no evidence of blood. On 03/02/13 at 6:20 PM, Patient #1's record revealed he/she was in the restroom with one to one observation staff (MHA #2) and another buddy staff (MHA #3) when he/she swallowed a washer from the toilet. The physician was contacted but did not order any additional treatments.

Review of facility video taken 02/16/13 from 5:56 PM to 6:32 PM, revealed Mental Health Associate (MHA) #1 came to work at the Intensive Support Unit (ISU) at 5:59 PM to begin one on one observation of Patient #1 whenever he received report and the care was transferred to him from MHA #4. It then revealed MHA #4 and Patient #1 going to the Dayroom at 6:00 PM. The video then showed two (2) brief periods, both under one (1) minute each and before 6:15 PM when Patient #1 was left alone without one to one observation in the Dayroom. The television was located in the Dayroom. The video was of the hallway going to the Dayroom and did not show the Dayroom. Patient #1 ingesting the two (2) AA batteries was not seen.

Review of the "Behavior Support Plan," implemented 02/21/13, for Patient #1, written by the Behavior Analyst, explained the "Buddy" staff which was one (1) additional MHA that was placed as a support for Patient #1 and his/her one to one staff from 7:00 AM to 11:30 PM. The "Buddy" would serve as a helper so that Patient #1 would never be left alone and would be a witness in high risk allegation areas, such as the bedroom and bathroom.

Interview with Patient #1, on 03/07/13 at 4:30 PM, revealed he/she picked up the remote and ate the batteries but could not remember where the remote was located. He/she also stated he/she got the washer off the side of the toilet and swallowed it while two (2) MHA's were in the bathroom with him/her.

Interview with Registered Nurse (RN) #2, on 03/07/13 at 4:55 PM, revealed she worked on the ISU 02/16/13 beginning at 6:15 PM. At 6:20 PM, MHA #1 said he had gotten the remote from Patient #1, it was broken and Patient #1 stated he had swallowed two (2) AA batteries. RN #2 stated the Dayroom and Patient #1's room were searched, but no batteries were found. RN #2 stated she called the Shift Coordinator, did an assessment of Patient #1, notified the Physician and did a PICA sweep. She also stated PICA sweeps had been a requirement to be done three (3) times per shift since 12/2012.

Interview with the Shift Coordinator, on 03/01/13 at 4:12 PM, revealed he was called on the evening of 02/16/13 that Patient #1 had ingested two (2) AA batteries. He interviewed Patient #1, and he/she told him that he/she found the remote but did not say where it was found. The Shift Coordinator further revealed the remote should have been kept at the nurses station where it was locked. He then stated he called the Administrator on Call (AOC) and Risk Management.

Interview with MHA #4, on 03/06/13 at 3:05 PM, revealed he worked on the ISU on 02/16/13 until around 6:15 PM when his replacement arrived. His duty was to do one to one observation with Patient #1. MHA #4 further revealed he had the remote in his hand at all times until around 5:30 PM when he gave it to another staff member whom he saw place it at the nurses station. MHA #4 also stated he did not remember leaving Patient #1 alone at any time.

Interview with MHA #1, on 03/11/13 at 11:45 AM, revealed he was the oncoming MHA on 02/16/13 and was supposed to take over Patient #1's one to one observation from MHA #4 at 6:30 PM. He stated he got back to the floor at around 6:12 PM and saw MHA #4 in the hallway without Patient #1. MHA #1 further revealed when he went to the Dayroom at around 6:20 PM, Patient #1 gave him the broken remote without the batteries and said he/she had swallowed them.

Interview with RN #3, on 03/06/13 at 3:25 PM, revealed she was the oncoming nurse on 03/02/13 for the ISU. She further revealed Patient #1 had swallowed a washer about the size of a quarter that came off the toilet between 6:00 PM and 6:30 PM. RN #3 stated MHA #2 and #3 had been in the bathroom with Patient #1 when he/she swallowed the washer. She further revealed she is the charge nurse and has the responsibility for doing PICA sweeps three (3) times per shift. She stated PICA sweeps involved scanning Patient #1's room, the hallway, the Dayroom and the bathroom for anything Patient #1 could get in his mouth. RN #3 stated she would not have thought it routine to check the bolts and washers on the toilet for looseness. She also revealed the bathroom door was always locked; so, when a patient needed to go to the bathroom, it was unlocked and staff looked in before allowing Patient #1 to go in so objects for ingestion could be removed.

Interview with MHA #3, on 03/06/13 at 4:20 PM, revealed he was working on 03/02/13 on ISU from 3:00 PM to 11:30 PM. He revealed he was either on one to one observation or the "buddy" for Patient #1. MHA #3 stated a PICA sweep had been done around 4:00 PM and another was not done before Patient #1 went into the bathroom; but MHA #2 and MHA #3 did accompany Patient #1 to the bathroom after 6:00 PM. He further stated he had his eyes on Patient #1 at all times and saw Patient #1 pick something off the side of the toilet or the ground. MHA #3 further revealed he grabbed Patient #1's arm to get the washer but he/she had already put it in his/her mouth and swallowed it. MHA #3 stated RN #3 was notified of the incident. MHA #3 also said he had been trained on doing PICA sweeps three (3) times per shift to look for objects that Patient #1 could ingest, but he did not think one was required before Patient #1 entered the bathroom.

Interview with MHA #2, on 03/06/13 at 5:27 PM, revealed he worked from 7:00 AM to 6:30 PM on 03/02/13 on the ISU and was on one to one observation with Patient #1. MHA #2 stated he did a visual sweep of the bathroom, looking for toilet paper, towels, soap, etc. and did not see anything on the floor before taking Patient #1 to the bathroom along with MHA #3 on 03/02/13 after 6:00 PM. He further revealed Patient #1 was always visible to him and MHA #3, but Patient #1 picked up the washer and was able to get it into his/her mouth before either MHA could stop him/her. MHA #2 further revealed the washer was about the size of a quarter and if it had been on the floor, he would have seen it when we entered the bathroom. MHA #2 then said maintenance came in around 7:00 PM and inspected the bathroom toilet, sink and walls.

Interview with the Wendell Building Nursing Leader, on 03/06/13 at 2:15 PM, revealed PICA sweeps started in 12/2012 and should include any area Patient #1 could be in, including his/her room, bathroom, Dayroom and hallway. He further revealed he would expect a PICA sweep to be done before Patient #1 entered the bathroom, but he would not expect the staff to check the bolts on the toilet or walls or anything that is fastened down.

2. Review of Patient #4's medical record revealed he/she was admitted on [DATE] with diagnoses which included Schizoaffective Disorder, Bipolar Type, history of Posttraumatic Stress Disorder, and [DIAGNOSES REDACTED]. Patient #4 attempted to assault staff and was admitted on a seventy-two (72) hour court order. The "Admission History" also revealed a history of setting him/herself on fire and beating a woman to death for which he/she served ten (10) years in prison. Patient #4 also admitted having thoughts and desires to hurt other people. The "Admission History" also stated he/she was placed on close observation, safety level because of his/her history of beating someone to death intentionally, command hallucinations and extreme irritability and anger. The record further revealed Patient #4 was started on Asenapine (an antipsychotic medication used to treat symptoms of [DIAGNOSES REDACTED]. Patient #4 was changed to support level of supervision on 02/25/13 at 8:45 AM because, according to the Physician notes, even though he/she had had episodes of acting out behavior, he/she was remorseful and adherent to the Asenpine regimen, thoughts were logical and goal oriented, and he/she was not exhibiting any evidence of psychosis. The "RN Shift Assessment" for 02/25/13, 3:00 PM to 12:00 PM, did not mention anything concerning patient and room search. The "RN Shift Assessment" for 02/26/13 at approximately 8:30 PM stated Patient #4 started a fire in his/her room by setting his/her clothes basket on fire with a lighter. The record further revealed Patient #4 admitted he/she set the fire and stated he/she would set another one. The record stated Patient #4 gave the lighter to staff. The record further revealed Patient #4 was placed on a supervision level of safety, close observation after the incident and remained on this level until he/she was discharged the next day, 02/27/13 at 11:45 AM. The record further revealed Patient #4 was arrested at time of discharge for first degree arson and taken to a detention center.

Review of the "Incident Report Form" for Patient #4, dated 02/25/13 at 6:40 PM, revealed Patient #4 was in the Recovery Mall at this time and had been in the bathroom next to the Gym. This report further stated a patient told staff that cigarette smoke was in the bathroom when Patient #4 came out. The bathroom was checked per staff without any contraband being found, and the unit, Wendell 4, was notified to search Patient #4. The report also stated that Patient #4 was searched and no contraband was found but ashes were found in his/her wardrobe.

Review of the "Recovery Mall, Comfort Room Sign-In Sheet," revealed Patient #4 did not sign in for the room on 02/25/13 but did on 02/26/13 at 3:45 PM. Review of the "Recovery Mall Area Checks" which included the relaxation or comfort room, revealed it was to be checked at 4:00 PM, upon closing of the area, but there was not a place for documenting this on the form.

Review of the "Visitation Attendance" from 02/20/13 to 02/27/13 revealed Patient #4 did not have any visitors during his stay at the facility.

Review of the Fire Department Report revealed the fire alarm went off at the facility on 02/26/13 at 8:25 PM; the fire department arrived at the facility at 8:29 PM; and the last unit was cleared at 10:17 PM. It also revealed the fire had been extinguished with a dry chemical extinguisher by facility staff by the time of the fire department's arrival, and their main tasks were to ventilate the area and to investigate the fire.

Interview with MHA #5, on 03/03/13 at 7:11 PM and 03/07/13 at 6:16 PM, revealed she was in the Dayroom on Wendell 4 with Patient #4 on 02/26/13 after the fire had been set and the fire department was on the premises. Patient #4 told MHA #5 he/she started the fire and was going to start another one. She further revealed Patient #4 showed her the lighter, a yellow BIC, that was hidden beneath a border on the hall bulletin board. MHA #5 further stated Patient #4 said he/she found the lighter in the "quiet" room in the Recovery Mall. She stated she gave the lighter to the fire investigator, and Patient #4 was put on close supervision. MHA #5 further revealed the lighter was not visible because it was behind the border, and she removed all the paper from the bulletin board that evening after the incident.

Interview with RN #4, on 03/07/13 at 2:58 PM, revealed he was working on Wendell 4 the evening of 02/26/13 when the fire occurred. RN #4 stated he searched all three (3) patients that occupied the room where the fire was started, including Patient #4, and found nothing. He further stated the fire department personnel had searched the room where the fire was started and found nothing. RN #4 then stated once the lighter was found, no additional areas on Wendell 4 were searched because it was assumed we had the implement that had caused the fire and additional searches of rooms or areas were not necessary.

Interview with RN #2, on 03/07/13 at 4:55 PM, revealed she was working on Wendell 4 the evening of 02/25/13 and received a call from the Gym that Patient #4 might have been smoking in the bathroom. She further revealed she searched Patient #4's room thoroughly and found cigarette ashes on one of the shelves in his/her wardrobe. She also stated that another staff person searched Patient #4's person in the shower room because he/she was about to take a shower. RN #2 further revealed she was working the night of 02/26/13 when the fire occurred. She stated the whole unit was not searched, only the room and the three (3) occupants of the room where the fire was started because Patient #4 confessed to starting the fire and the lighter was found. She stated that it all happened very quickly.

Interview with the Recovery Mall Director, on 03/06/13 at 4:55 PM, revealed he was not aware that Patient #4 stated he/she found the lighter in the Recovery Mall. He further revealed there was a relaxation room that was locked most of the time, but when a patient went in, they could be by themselves for ten (10) to fifteen (15) minutes with a staff member sitting outside. He also stated that when the patient left the room, it was locked. The Director also stated that before a patient entered a room, staff was supposed to check for contraband.

Interview with the Nursing Unit Director, Wendell 4, on 03/07/13 at 5:20 PM, revealed she heard Patient #4 say, on the morning of 02/27/13, that he got the cigarette lighter in the Recovery Mall, but he/she did not say where or when. She further revealed she believed Patient #4 probably stashed the lighter behind the bulletin board border on 02/25/13 or 02/26/13 so when he/she and his/her room was searched, it would not be found.

Interview with MHA #6, on 03/11/13 at 12:45 PM, revealed she was working in the Gym area the evening of 02/25/13 when a patient came out of the bathroom by the Gym and said a patient was smoking. She further revealed Patient #4 came out when she went in, and there was a heavy smoke odor. MHA #5 stated she searched the bathroom and found no lighter or cigarettes and then called Wendell 4 so a search could be done on Patient #4.

Interview with the Director of Nursing (DON), on 03/07/13 at 9:41 AM, revealed employees were instructed to keep personal belongings locked in the break rooms on their units and were not restricted from bringing in cigarettes or lighters. He stated that patients were not searched after visits because they were supervised by facility staff, and visitors were not searched before patient visit. He revealed the unit rooms on Wendell 4 and all patients on Wendell 4 were searched for contraband after the fire; and he was not sure if the Recovery Mall was searched for contraband after the fire on 02/26/13 by staff.

Interview with the DON, on 03/08/13 at 10:00 AM, revealed he was told by staff that the whole unit on Wendell 4 and all the patients on Wendell 4 had been searched after the fire on 02/26/13. He stated he might have been told this in error. He further stated in addition to tobacco products, lighters were also being saved for patients and given back to them upon discharge. The DON then revealed there could be a brief period of time when the patient is awaiting discharge that their lighter would be in a patient area.
He also revealed, even though visitation was supervised, there was a chance that a visitor could pass a lighter or some other contraband to a patient without it being observed by staff.

The facility failed to ensure patients at high risk for harming others were properly and adequately supervised and searched. This failure placed patients at risk for injury, harm, impairment or death. On 03/08/13, Immediate Jeopardy was determined to exist. The facility initiated the following corrective actions: These actions were as follows: 1) making it mandatory for patients to get undressed and into a gown in the Central Triage Center (CTC) for a skin assessment and body search with a new form developed which will follow patients to their units where another search will be done; 2) cigarettes and lighters will no longer be saved for patients and given to them at discharge but will be disposed of in the CTC; 3) staff will no longer be able to bring any tobacco products or lighters into the facility; they must be left in a locked car; 4) volunteer donations now have a process and policy whereby they are searched in a specific area for contraband before going to the units; 5) if anything suspicious is suspected, like cigarette ashes being found on a unit, the whole area(s) involved will be swept for contraband; 6) for visitation, the supervisory staff had been doubled, visitors come through one (1) entrance, visitors' personal belongings will be searched and a metal detector wand will scan their bodies; 7) after visitation but before patients go back to their units, they will be searched for contraband and a metal detector wand will scan their bodies; 8) after visitation when the patients go back to their units, they will be searched, along with their personal belongings; 9) the Performance Improvement Director will collect data on compliance with the new search sheets and processes and track incidents that happen related to them and will initially report the findings monthly at the Quality Committee; 10) the Recovery Mall will be swept for contraband twice per day, in the AM before any patients arrive and in the PM after patients have left, and a new sign off sheet had been developed for this activity; and 11) an individual had been named to head the Visitation Process and had been given accountability for its operation.

The new policies were placed in effect shortly after the Immediate Jeopardy was called on 03/08/13. Training on the new policies started on 03/08/13, and before exit eighty-five (85) percent of facility personnel had been trained on the new policies. No staff member can work before receiving training, so it is ongoing until one hundred (100) percent of existing staff members have been trained. Interview with Director on Nursing revealed that new personnel will be trained on the new policies and procedures at orientation.