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.

RIVERVIEW PSYCHIATRIC CENTER 250 ARSENAL STREET AUGUSTA, ME March 29, 2013
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of the Riverview Psychiatric Center (RPC) staffing/acuity plan, actual staffing on Lower Saco Unit on March 16, 2013, incident reports, and clinical records of patients involved in incident on March 16, 2013, it was determined that RPC and its staff failed to have adequate nursing services.

The findings are as follows:

1. The hospital failed to have adequate numbers of nurses and mental health workers to provide nursing care to all patients as needed (see Tag A-0392 for further information).

2. The hospital failed to provide a safe environment for all patients on the Lower Saco Unit (see Tag A-0144 for further information).

3. The hospital failed to ensure that patients are free from all forms of abuse, including neglect (see Tag A-0145 for further information).


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review clinical records, nurse staffing plan, actual staffing and assignment sheet for March 16, 2013, policies and other information provided and interviews with key staff on March 27, 28, and 29, 2013 and April 1, and 2, 2013, it was determined that the hospital failed to provide adequate staff on duty to provide nursing care to all patients as needed.

The findings are as follows:

1. A review of the actual staffing and assignment sheet for Saturday March 16, 2013, excerpts from two clinical records, incident report and interviews with multiple staff were conducted on March 27, 28, and 29, 2013 and on April 2 and 3, 2013. These documents and interviews revealed that although numbers of staff on duty met the core requirement as in the nursing plan, the acuity level was high, some staff were off the unit for other duties and an incident occurred in which a staff person was seriously injured and a patient was the second responder to assist in getting the assaultive patient away from the victim. See Tags A-0144 and A-0145 for further information.

2. In an interview on April 28, 2013 at 0830, staff stated that rather than staff assist, it was another patient on the unit who assisted with moving other patients on the unit to the day room for their safety when this incident occurred on March 16, 2013.

3. The staffing plan for Lower Saco Unit stated the following: staffing plans are established to provide for safety of clients/staff and to assure resources for treatment planning and active treatment. Competent staff was assigned to client care areas on an as needed basis in response to unplanned acuity factors. Requirements for Lower Saco forensic Unit, described as a moderate length of stay unit had core staffing for 7-3 shift of RN & LPN 3, MHW 5 (1:6) (requirement of consent decree) and optimal RN & LPN 4 and MHW 7. This unit has potential for twenty clients and is divided by a keyless door into two sections. Sections are Special Care Unit (SCU) with six beds and Main Unit with 14 beds. This staffing plan covers both sections.

4. The staffing coordinator for all units of hospital was interviewed on March 27, 2013 at 2:45. She confirmed that staffing is not increased for first two patients who are on one to one observation or escorts to trip. She also stated that they are not allowed to staff by gender.

5. The assignment sheet noted one RN on main unit responsible for all clients, one RN on SCU responsible for all clients, and one LPN assigned to be medication nurse on main unit. At the time of the incident, there were four MHW's on the main unit, and three MHW's on the SCU. The census was 17, with 14 clients on main unit and three clients on the SCU. Of the three clients on the SCU, one was in locked seclusion with two prison guards by the door and one MHW at a monitor at the desk. At the time of the incident, one of the SCU patients was "guesting" on the main unit with a MHW from SCU monitoring him/her one to one. This left one MHW on SCU who was at the monitor, leaving no staff responsible for the one remaining patient on SCU. Of the four MHW's assigned to the main unit, one was out on pass with a client, and one was on break, leaving two MHW on the unit.

6. MHW1 was interviewed on March 27, 2013 at 1 p.m. She stated she was assigned to the SCU and was doing the one to one with client from SCU out on the main unit. They were by the nurses' station. She heard the scream from the MHW doing safety checks who was at the end of a long corridor of patient rooms. MHW1 ran down the hall to assist, leaving her assigned patient unattended because she did not see any other staff there. She stated there was not enough staff on the unit that shift; the unit was very acute. She stated that with seven staff for both sections, they have to provide coverage for the first two patients who are on one to one observation status. That day her assigned patient from the SCU was on one to one. Of the four MHW on main unit, one was out on pass with client, one was on break and that left two MHW on the main section. She stated with this high acuity unit, staff don't feel safe much of the time.

7. MHW2 was interviewed on March 27, 2013 at 3:30 p.m. He stated he was the team
leader MHW on duty March 16, 2013, and he made out the assignment. He has responsibility to coordinate unit, maintain safety, schedule to get people to appointments and treatment mall, etc. He stated they could have had one more that day. Staffing goes by numbers and the first two patients who are on constant observation have to be adsorbed by existing staff. Staff need breaks and lunch time, have to take clients to appointments and school [gave example of last week one MHW off unit for two hours with client at a dentist appointment], and they need two staff to accompany clients to cafeteria. The day of incident there were two patients on one to one observation status, one staff out with client and one staff on break at time of incident.

8. MHW3 was interviewed on March 28, 2013 at 12:30 p.m. He stated he was assigned to SCU on day of incident and was on SCU when the page went off for incident on the West Wing of main unit. The only staff left on SCU were the one MHW and two prison guards who are not allowed to leave their positions with a patient in locked seclusion. There was one patient other than the one in seclusion on SCU at time of incident. He stated the RN assigned to SCU goes back and forth between the two sections of the unit.

9. MHW4 was interviewed on March 28, 2013 at 1 p.m. She stated she was not on duty at time of incident but had concerns about ongoing staffing of Lower Saco Unit. Many times because of escorts to appointments or activities, there are just two MHW left in the milieu. She stated she does not feel safe.

10. Nurse 3 was interviewed on March 27, 2013 at 2 p.m. She stated she was assigned to SCU but was on the main unit with other nurse (other nurse fairly new to the unit) out in a room in back of the nurse's station. When she's on the main unit there is no nurse on SCU, just a MHW. She stated she had a lot of concerns about staffing on Lower Saco unit not being based on acuity; that they need more people on the unit with eyes open paying attention to where people are, and they also need one at the desk. On weekends, there is not the back-up from support staff such as nurse manager, rec staff, and social worker and treatment team coordinator who are all receptive to help on unit when there.

11. Nurse 4 was interviewed on March 28, 2013 at 8:30 a.m. She was the nurse assigned to the main unit on day of incident. She was not "thrilled" with the staffing on day of incident. She had a float LPN in the med room, and he had not listened to report so was not aware of milieu. The RN from the SCU was on main unit with her at time of the incident. She stated that she had asked for extra staff for the weekend and was denied. She stated that this unit is difficult to staff, and there are mostly new employees on the off shifts. She stated this unit is very acute with most clients having history of violence.

12. Based on a review of the staffing plan on March 28, 2013, it was determined that there had been no changes made to the staffing plan since the incident on March 16, 2013.

13. The potential outcome of the failure to provide adequate staff is that the hospital may be unable to provide nursing care to all patients as needed.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, record review and interviews with key staff members on March 27, 28 and 29, 2013 and April 1 and 2, 2013, it was determined that the hospital failed to have an effective governing body which was responsible for the conduct of the hospital.

The findings are as follows:

1. The governing body failed to ensure that patients receive care in a safe setting (see Tag A-0144 for additional information).

2. The governing body failed to ensure that patients are free from abuse, including neglect (see Tag A-0145 for additional information).

3. The governing body failed to implement quality assurance and performance improvement action which included feedback and learning throughout the hospital (see Tag A-0286 for further information).

4. The governing body failed to provide adequate nursing staff to provide nursing care which met the needs of patients (see Tag A-0392 for further information).

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of clinical records, policies and procedures, review of NAPPI (Non Aggressive Physical Psychological Intervention) staff training records, performance improvement plan and data, committee meeting minutes, and interviews with key staff on March 27, 28, and 29, 2013 and April 1, and 2, 2013, it was determined that the hospital failed to protect and promote the rights of patients.

The findings are as follows:

1. The hospital failed to provide a safe environment for all patients on the Lower Saco Unit (see Tag A0144 for further information).

2. The hospital failed to ensure that patients are free from all forms of abuse, including neglect (see tag A0145 for further information).


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a tour of the Lower Saco Unit (Forensic Unit), clinical record review, key staff interviews, review of the staffing plans, and review of the incident reports, it was determined that the hospital failed to provide a safe environment for patients.

The findings are as follows:

Lower Saco Unit

1. A tour was conducted of the Lower Saco Unit on March 28, 2013. The unit was divided into two distinct sections separated by a keyless locked system. One section was a six-bed unit called SCU (special care unit). Second section was a 14-bed unit called the Main Unit. It was considered one unit and staffed as such with staff assigned to each section. The main section had two corridors of patient rooms with a semi-circle nursing station facing the patient rooms. In back of the nursing station, there were two rooms used for charting and team meetings. There were patient monitors both out back and at the nurse's station. The SCU consisted of six individual patient rooms. There is a nurse's station with medication room to the side and charting room in the back.

Patient Assault

2. Upon review of Patient A's clinical record, it was noted that this patient was admitted to the Forensic Unit (Lower Saco) on February 6, 2006 after being found not criminally responsible on a charge of assault.

3. Nursing documentation from March 1, 2013 to day of incident included evidence that Patient A displayed labile mood and increased paranoia. On March 11, 2013, RN (Registered Nurse) noted: "Patient is not [his/her] usual self, and needs to observe for any 'different' actions that may 'set [him/her] off ." On March 15, 2013, it was noted that Patient A was informed by the nurse manager of the unit that his/her pass over weekend had been canceled. Nursing documentation on March 16, 2013 included the request by patient to go outside to walk and the refusal by nurse.

4. Nurse 4 was interviewed on March 28, 2013 at 8:30 a.m. She was the nurse assigned to the main unit on day of incident. She stated Patient A had been decompensating with increased paranoia. She had kept a calendar account of the client's paranoia and presented it to the nurse manager. She stated she did this because she had trouble having persons in charge agree with her assessments of the client's mental status.

5. Patient A's discharge summary written by a staff psychiatrist included the following: "During course of hospital this patient had months of stable mood and behavior punctuated by paranoid delusions which had resulted in serious assaults on male staff and peers. Most recently patient's mood had been irritable, and decision was made to cancel [his/her] planned staff supervised visit to [his/her] family the day before the planned trip. [His/Her] mood did not improve overnight and the next day Saturday March 16, [he/she] asked the nurse for permission to take a walk on hospital grounds. In her opinion [he/she] was too agitated to leave the ward and she refused [his/her] request. Shortly thereafter [he/she] assaulted a female staff member who was standing in the hallway doing checks stabbing her with a [pen]."

6. The Acting Director of Nursing, who was not on duty at time of incident, was interviewed on March 27, 2013 at 11 a.m. She stated Patient A had been increasingly paranoid, had been slated for visit home which was canceled due to the paranoia, and on the day of incident had requested to go out for walk and was assessed by the nurse on duty not to be safe, therefore the request was refused. She described incident as Patient A walked up to a MHW (Mental Health Worker), said "I ' m sorry," and proceeded to jab her with a red ink pen above and below her eye and in her hand. The injury was severe enough that she had to be taken to the general hospital emergency department.

7. MHW1 was interviewed on March 27, 2013 at 1 p.m. She stated she was assigned to SCU and was doing the one to one with client from SCU out on the main unit. They were by the nurses' station. She heard the scream from the MHW doing safety checks who was at the end of a long corridor of patient rooms. MHW1 ran down the hall to assist, leaving her assigned patient unattended because she did not see any other staff there. When she arrived on the scene, she observed the MHW in the corner protecting her head with her hands, and the client was stabbing her with the left hand and punching her with the right hand. She did a NAPPI Wrap from behind [him/her] and [he/she] turned as if to hit her. At that time, Patient B came out of [his/her] room which was in close proximity and put [his/her] fell ow client in a headlock. Then other staff came.

8. Nurse 4 was interviewed on March 28, 2013 at 8:30 a.m. She was the nurse assigned to the main unit on day of incident. She stated another client gathered up rest of clients on the unit and got them to go to the day room.

9. Patient B's medical record was reviewed for documentation at the time of the incident in which he/she assisted staff to restrain Patient A. It was noted that he/she had later returned from Convalescent status to the Lower Saco Unit on March 20, 2013 with depressed mood. A progress note by Nurse 4 stated the following: "At 0925 another client [Patient A] attacked a female MHW outside of [his/her] room. [Patient B] exited [his/her] bedroom and placed [Patient A] in a headlock stating to client, "Calm down buddy." [Patient B and Patient A] went to the floor and [Patient B] assisted in restraining [him/her] until stat responders could relieve [him/her]. [Patient B] reported to staff that [he/she] has rug burn on [his/her] right leg but declined treatment. [He/She] also declined to speak with police officers stating that staff could do that."

10. In spite of personnel records demonstrating staff had received NAPPI training, a patient assault occurred in which a staff person was seriously injured and a patient was the responder to assist in getting the assaultive patient away from the victim. Additionally, it was a third patient who led other patients to the day room and out of harm's way.

11. The potential outcome of a patient assault in which other patients intervene is that the hospital may be unable to protect the patients' and staff members' emotional health and safety, as well as their physical safety.


Failure to Restrict Contraband

12. A review was conducted of the policy titled "Contraband and Building Search." The purpose of this policy stated: "To enhance safety by identifying and preventing dangerous items (contraband) from entering into therapeutic environment. Included in this policy were lists of items by categories such as "sharp objects, hanging risks, client owned electronics with Internet access, personal recording devices, office supplies which included metal spiral notebooks, and clothing associated with danger risk." Also in the policy was a list titled "Monitored Items" which referred to items commonly utilized in daily living and may be allowed in moderation dependent upon safeness associated with the individual use. These items were monitored by staff and kept in a safe place on the unit when not in use. Excessive amounts of any monitored item will not be permitted. Items include safety pens (on SCU only), steel toe boots, guitar, detachable cords for approved electronic devices, and personal hygiene items.

13. Based on documentation of a room search conducted by staff and documented on
March 16, 2013, the following items were removed from Patient A's room following the assault: two remote controls, one clock radio, one watch, one pair of sunglasses, one calculator, one heart monitor strap, one black bag papers removed, two gray hoodies, one yellow hoodie, two ties, and seven other items of clothing with strings. According to staff in interview on March 27, 2013, this patient was allowed to have pens because he/she attended a class in the community.

14. MHW1 was interviewed on March 27, 2013 at 1 p.m. She stated when search was done of Patient A's room, they found a lot of pens.

15. A tour was conducted of the Lower Saco Unit on March 28, 2013. One patient demonstrated a pen he/she was using. This pen was considered a safety pen, allowed on unit because it was rubber and bends, had been wrapped with tissue and was therefore no longer flexible. This pen had a sharp point and with the extra wrapping could be used as a weapon.

16. A tour was conducted of the main section on March 29, 2013 at 2 p.m. to review compliance with the policy titled "Contraband and Building Search" which stated: "searches are actions taken by hospital staff when (a) there is a reasonable belief that contraband may be present on a person or in an area that could endanger the health or safety of clients, staff or visitors (b) in routine safety rounds of units or (c) at anytime there is a reasonable belief that there is an imminent threat."

17. MHW4 was interviewed on March 28, 2013 at 1 p.m. She stated staff have concerns about amount of contraband allowed on unit. She stated she does not feel safe. One destructive client was allowed to have game boy.

18. A tour was conducted on the Lower Saco Unit with nursing personnel on March 29, 2013 at 2 p.m. In spite of the hospital policies on contraband, surveyors observed that one room contained shoes and boots with laces, alarm clock, spiral notebooks, multiple shelves of books, spiral notebooks, and shelves of clothing. This amount of personal items in one room would hamper any effort to determine if there were dangerous items in this room. Additionally, doors to rooms were not locked and were open at all times except when a client is in room with door closed. This sets up environments in which patients who were not allowed certain items have access to them in other rooms.

19. The potential outcome of failing to restrict contraband is that the hospital may be unable to prevent unstable patients from obtaining items which may be utilized as weapons.


Other Examples of Failure to Maintain a Safe Setting

20. Meeting minutes of "Environment of Care" meetings dated February 11, February 25, March 4, and March 11, 2013 included the following: "Program Service Director attended to discuss the high acuity level on LS [Lower Saco]. A client this weekend caused damage to the mirror again. EOC decided the mirror will not be replaced again and a bill will be sent to the client."

21. A tour was conducted of the Lower Saco Unit on March 28, 2013. During the tour of the SCU unit, it was observed that there had been damage done to unit walls as evidenced by patches in walls in the common area.

22. Nurse 4 was interviewed on March 28, 2013 at 8:30 a.m. She stated one patient who had destroyed a bathroom on the main unit the night before had been taken to the SCU, placed in five point restraints, and within a short time was taken back to the main unit. She had him transferred back to SCU.

23. A review was made of statistics related to patient to patient assaults for first three months of 2013 for the Lower Saco Unit. There were eight patient to patient assaults from January 26, 2013 to March 17, 2013.

24. A tour was conducted on the Lower Saco Unit with nursing personnel on March 29, 2013 at 2 p.m. Surveyor was unable to observe the SCU section as a patient had just pushed through the locked doors separating the SCU and main section, and was still considered to be dangerous.

25. The potential outcome of failing to provide a safe environment for patients and staff on the Lower Saco Unit is that the hospital may be unable to protect the patients' and staff members' emotional health and safety, as well as their physical safety.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of clinical records, nurse staffing plan, actual staffing and
assignment sheet dated March 16, 2013, policies and other information provided and interviews with key staff on March 27, 28, and 29, 2013, and April 1, and 2, 2013, it was determined that the hospital failed to provide necessary services to prevent all forms of abuse, including neglect.

The findings are as follows:

1. The Centers for Medicare and Medicaid services, State Operations Manual, stated: "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment , with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purposes of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

2. Personnel records demonstrated staff had received NAPPI training; however, as response to incident was described, there was no documented evidence that any staff on duty took leadership of the code or ensured that other patients on the unit were guided by staff to safety. For further information see Tag A-0144.

3. A review of the actual staffing and assignment sheet for Saturday March 16, 2013, excerpts from two clinical records, incident report and interviews with multiple staff were conducted on March 27, 28, and 29, 2013 and on April 2 and 3, 2013. These documents and interviews revealed that although numbers of staff on duty met the core requirement as in the nursing plan, the acuity level was high, some staff were off the unit for other duties, and an incident occurred in which a staff person was seriously injured and a patient was the second responder to assist in getting the assaultive patient away from the victim. For further information see Tag A-0392.

4. The staffing coordinator for all units of hospital was interviewed on March 27, 2013 at 2:45. She confirmed that staffing is not increased for first two patients who are on one to one observation or escorts to trip. She also stated that they are not allowed to staff by gender.

5. Staffing documentation and staff interviews also demonstrated that of the three clients on SCU at the time of the patient assault, one was in locked seclusion with two prison guards by the door and one MHW at a monitor at the desk. At the time of the incident, one of the SCU patients was "guesting" on the main unit with a MHW from SCU monitoring him/her one to one. This left one MHW on SCU who was at the monitor, leaving no staff responsible for the one remaining patient on SCU. Additionally, of the four MHW's assigned to the main unit, one was out on pass with a client, and one was on break, leaving two MHW on the unit.

6. MHW2 was interviewed on March 27, 2013 at 3:30 p.m. He stated he was the team
leader MHW on duty March 16, 2013, and he made out the assignment. He has responsibility to coordinate unit, maintain safety, schedule to get people to appointments and treatment mall, etc. He heard the MHW scream and saw MHW1 go down the hall. He stated he came around the nurse's station, collided with the LPN coming out of med room and got on back side of client with MHW1. Another patient had the assaultive patient on the floor. MHW3 from SCU was second staff member to get to the scene. As for staffing, he stated they could have had one more that day. The day of incident there were two patients on one to one observation status, one staff out with client and one staff on break at time of incident.

7. MHW3 was interviewed on March 28, 2013 at 12:30 p.m. He stated he was assigned to SCU on day of incident and was on SCU when the page went off for incident on the West Wing of the main unit. He found the patient and the MHW1 securing the assaultive patient, and saw the MHW who had been assaulted in the corner bleeding from puncture wounds. Then other staff arrived. The only staff left on SCU were the one MHW and two prison guards who are not allowed to leave their positions with a patient in locked seclusion. There was one patient other than the one in seclusion on SCU at time of incident.

8. MHW1 was interviewed on March 27, 2013 at 1 p.m. She stated she was assigned to SCU and was doing the one to one with client from SCU out on the main unit. They were by the nurses' station. She heard the scream from the MHW doing safety checks who was at the end of a long corridor of patient rooms. MHW1 ran down the hall to assist, leaving her assigned patient unattended because she did not see any other staff there. She stated there was not enough staff on the unit that shift; the unit was very acute, Patient A had been "cycling" for awhile.

9. Patient B's medical record was reviewed for documentation at the time of the incident in which he/she assisted staff to restrain Patient A. It was noted that he/she had later returned from Convalescent status to the Lower Saco Unit on March 20, 2013 with depressed mood. A progress note by Nurse 4 stated the following: "At 0925 another client [Patient A] attacked a female MHW outside of [his/her] room. [Patient B] exited [his/her] bedroom and placed [Patient A] in a headlock stating to client, "Calm down buddy." [Patient B] and [Patient A] went to the floor and [Patient B] assisted in restraining [him/her] until stat responders could relieve [him/her]. [Patient B] reported to staff that [he/she] has rug burn on [his/her] right leg but declined treatment. [He/She] also declined to speak with police officers stating that staff could do that." A nursing note dated March 22, 2013 stated: "[Patient B] visibly distressed by room search and [as evidenced by] troubled facial expression and sitting with arms folded across chest, rocking in place."

10. Nurse 3 was interviewed on March 27, 2013 at 2 p.m. She stated she was assigned to SCU but was on the main unit with other nurse. She stated she had to meet with two clients who were visibly upset after the incident.

11. The potential outcome of failing to provide necessary services on Lower Saco Unit is that the hospital may be unable to prevent physical harm and mental anguish to patients.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of key documents, observation, and interviews with key staff on March 28 and 29, 2013, it was determined that the hospital failed to implement preventative quality action which included feedback and learning through the hospital

Findings are as follows:

1. The adverse event of a patient assault of a staff member occurred on March 16, 2013. For further information see Tags A-0144 and A-0145.

2. A document titled " Correction Plan: Licensing " was provided on March 28, 2013. The section entitled " Immediate Actions taken after the event on March 16th" included multiple team, administrative, and committee meetings to review the event. This document also included the actions of moving clients with privileges to other units, contacting law enforcement about additional officers, and placing Patient A in seclusion. However, none of these actions contained a date for completion.

3. The executive leadership committee minutes dated March 20, 2013 addressed the incident. The discussion stated: " [Superintendent] reports angst among staff wanting to know why the client who assaulted a MHW hasn't been arrested.....Immediate steps 1) move clients with privileges off the unit and 2) conduct a unit search [for contraband]."

4. On the unit tours conducted on March 28, 2013 at approximately 11:45 and on March 29, 2013 at approximately 1:45, surveyors observed that not all clients with privileges had been moved to other units and unit searches had not been conducted until March 22, 2013. However, surveyors observed contraband items in patient rooms during tour. For further information regarding observation see Tag A-0144.