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ANOKA-METRO REG TREATMENT CTR 3301 SEVENTH AVE NORTH ANOKA, MN 55303 Sept. 14, 2015
VIOLATION: NURSING SERVICES Tag No: A0385
A substantial allegation survey was conducted to investigate an alleged violation of the Conditions of Participation for hospitals participating in Medicare, specifically the Condition of Participation of Nursing Services at 42 CFR 482.23, related to complaint #H 68. Anoka Metro Regional Treatment Center was found not in compliance with the Condition of Participation of Nursing Services at 42 CFR, Part 482.

Based on observation, interview, and document review, the hospital failed to ensure sufficient Registered Nurse oversight of patient care, for 1 of 11 patients reviewed (P1), who struck his head during a fall in the shower while being supervised by unlicensed personnel. Unlicensed personnel did not report to Nursing that the patient fell and hit his head on a tile wall. The patient sustained redness and swelling to the left temporal area near the left eye, a five-inch abrasion on the left temporal area that extended into the hairline, and a headache which the patient rated a 10, on a scale of 1 - 10.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and document review, the hospital failed to ensure sufficient Registered Nurse oversight of patient care, for 1 of 11 patients reviewed (P1), who struck his head during a fall in the shower while being supervised by unlicensed personnel. Unlicensed personnel did not report to Nursing that the patient fell and hit his head on a tile wall. The patient sustained redness and swelling to the left temporal area near the left eye, a five-inch abrasion on the left temporal area that extended into the hairline, and a headache which the patient rated a 10, on a scale of 1 - 10.

P1's hospital record indicated that P1's primary diagnosis is pervasive developmental disorder. P1 was admitted for psychiatric hospitalization on [DATE] by Court commitment, after a failed community placement. P1's psychiatric assessment, dated 10/24/14, indicated that P1 had a history of rage reactions during which P1 became physically assaultive to others, without warning. P1's rage reactions were difficult to manage due to P1's strength and size. P1 is 5'10" tall and weighs 375 pounds. P1 needed constant supervision. P1 was unable to take care of himself. P1 needed to develop coping strategies to control his rage reactions and education skills for self-care. P1's support plan for daily morning hygiene, dated 06/08/15, was developed in response to P1's need for a structured, consistent routine to redefine P1's self-care habits. Staff were to prompt P1 with verbal cues for awakening each morning around 9:00 - 9:30 a.m., if P1 wasn't out of bed yet. Staff were to assist P1 with removal of soiled clothing, escort P1 to the shower, apply P1's soap products to a cloth, and prompt P1 to wash himself. Staff were to assist P1 with towel drying and dressing. Staff were to assist P1 with bed-making.

Previous incident reports, dated 05/24/15, 05/25/15, and 05/26/15, indicated that P1 had three consecutive falls, all which occurred in the morning right after P1 got up from bed and experienced dizziness. P1 did not sustain any injuries from these falls. Based on the clinical judgment of nurses, P1 was deemed to be at high risk for falls, even though P1's total fall risk score did not meet the criteria for Falls Risk. As a result of these three falls, P1 wore a yellow wrist band that signified he was at risk for falls. P1's room door marked with a red falls risk label to serve as a reminder to staff to keep P1's room floor free from debris and to ensure P1 had on appropriate footwear, including nonskid socks when in bed. P1 was to be observed by staff a minimum of every 15 minutes. P1 had no other falls, until the fall of 09/01/15.

An incident report, dated 09/01/15 at 10:10 a.m., indicated that P1 came out of his room and reported to staff that he fell while taking a shower. P1 had a 5-inch reddish area on the left side of his head that was swollen. The incident report indicated that P1 was at risk for falls.

The progress notes on 09/01/15 at 11:08 a.m. indicated that P1 came out of his room at 10:10 a.m. and alerted staff that he fell in the shower and hit his head. P1 had a 5-inch area of redness on the left side of his head and rated his pain as a 10, on a scale of 1 -10. RN/G and APRN/E both assessed P1. P1's neurological check was within normal limits. APRN/E ordered ice packs to P1's left temporal area, Tylenol for pain, and continued monitoring of P1's neurological status. The progress notes on 09/01/15 at 2:01 p.m. indicated that RN/F spoke to P1 about his fall in the shower. P1 told RN/F that the staff who assisted him with the shower directed him not to tell anyone about the fall.The unit staff schedule indicated that HST/L was the employee assigned to P1's morning care on 09/01/15.The progress notes on 09/01/15 at 2:53 p.m. indicated that while LPN/H was on her way to P1's room to assess P1's neurological status, Human Services Technician (HST)/L approached LPN/H and stated she did not know why P1 reported that he fell . HST/L denied that P1 fell in the shower that morning. HST/L followed LPN/H into P1's room and verbally challenged the veracity of P1's statements and stated to P1, "why did you say that, it never happened, I was in here." P1 looked away from HST/L and closed his eyes when HST/L made these statements to P1.

Observations on 09/11/15 at 9:00 a.m. indicated that P1 resides on an all-male inpatient unit designed for patients with the highest acuity levels of volatile behavior. The unit census on 09/11/15 was 16 patients. The unit was staffed with 8 employees responsible for delivering patient care. The unit day room (patient common area) is visible from the central nurse's station. P1 resides in a private room that is located approximately 12 feet from the central nurse's station. The door to P1's room is visible from the nurse's station. P1's bed is the only furniture in P1's room. The foot of the bed is three feet from a direct entrance to P1's bathroom. The toilet in P1's bathroom is three feet further, in a straight direct path from the bathroom entrance. A sink and countertop abut the right side of the toilet. A walk-in shower stall with a shower curtain is located to the right of the sink, on an opposite wall. The shower and the bathroom floor are ceramic tile. There are no raised floor lips that separate the shower stall from the bathroom floor, which provides an even floor surface throughout the bathroom. P1's room and bathroom were clean and tidy without any odors. The floor was free from debris and obstacles.
P1 was interviewed on 09/11/15 at 8:40 a.m. P1 described his morning hygiene program and stated that staff help him undress, shower, dress, and make his bed. Staff stay in his bathroom while he showers but he can wash himself independently. He recently fell while taking a shower. The staff who was helping him that day wasn't in the bathroom with him while he showered, but the bathroom door was wide open. When he was finished washing himself, he opened the shower curtain and slipped while turning toward the sink to get a towel. He fell to the floor face-first, and hit the side of his head on the shower wall when he fell down. It really hurt. The "aide" saw him lying on the floor on his stomach but "she didn't care." He was able to get up off the floor by himself and he told the aide that he hit his head. The aide was making his bed. He did not know the aide's name and was unable to describe the aide. He later told the nurse about the fall. The nurse checked his blood pressure and put ice on his head. LPN/H was interviewed on 09/14/15 at 1:50 p.m. LPN/H stated that P1 had a morning hygiene program that was tailored to P1's needs and ability to succeed. LPN/H has done P1's morning hygiene program many times. P1 does not like to get up early. P1 likes to sleep late. It takes several staff prompts to get P1 up in the morning. Staff usually start prompting P1 around 9:00 a.m. P1 sleeps soundly through the night and is incontinent of urine every night, even though P1 is continent during the day. P1's bed is saturated with urine every morning, from the lower portion of the bed up to the pillow. As a result, P1 needs to shower every morning. Staff assist P1 with removal of wet clothing, otherwise P1 will get in the shower with his clothes on. Staff apply soap to P1's wash cloth and hand it to P1. Staff prompt P1 to wash himself or P1 sometimes does not wash his body parts and will just let the water run over him. Staff provide P1 with shampoo and prompt P1 to wash his hair. Staff remain outside P1's shower curtain while P1 showers, to continually prompt and monitor him. P1 is unsteady on his feet sometimes. P1 is at risk for falls and would not be wearing footwear during a shower. Staff assist P1 with towel-drying. Staff assist P1 with dressing. When P1's hygiene is complete, staff assist P1 to strip the bed, place soiled linens in a laundry receptacle, and make the bed. On 09/01/15, LPN/H was in P1's room a couple times that morning between 9:20 a.m. and 9:50 a.m. to prompt P1 to get up. HST/L was in P1's room the second time that LPN/H prompted P1 to get up. Both times, P1 was sleeping in bed on his stomach with the left side of his head facing LPN/H. The left side of P1's head had no injuries on either occasion when LPN/H prompted P1 to get up. LPN/H had also worked the previous day of 08/31/15. The left side of P1's head had no injuries on 08/31/15. LPN/H was sitting at the nurses's station on 09/01/15 sometime between 10:00 a.m. - 10:30 a.m. when LPN/H observed that P1 was up and in the day room. LPN/H approached P1 to go to the treatment room so LPN/H could take P1's daily blood pressure because P1 takes Inderal. LPN/H immediately noticed that P1's left temporal area was swollen and P1 had a big red abrasion on the left temporal area that extended into his hairline. LPN/H asked P1 "what happened" but P1 wouldn't answer. P1 followed LPN/H to the treatment room and LPN/H again asked P1 about the injury. P1 told LPN/H that he "didn't want to get into trouble." After LPN/H assured P1 that he would not get into trouble, P1 told LPN/H that he fell on the floor coming out of the shower and hit his head on the wall. P1 said he had a headache, which he rated a 10, on a scale of 1 -10. LPN/H immediately informed RN/G about P1's fall. RN/G assessed P1 and notified the medical provider of P1's fall. LPN/H asked Mental Health Program Assistant (MHPA)/J to sit with P1 and monitor him so P1 didn't try to ambulate until P1 was evaluated by the medical provider. Sometime after lunch on 09/01/15, LPN/H was in the hallway enroute to P1's room to conduct a neurological check. HST/L approached LPN/H in the hallway and said, "I don't know why (P1) said that happened (the fall)...it didn't...I was there in his room." LPN/H proceeded into P1's room to do the neurological check. HST/L followed LPN/H into P1's room. HST/L then directed comments to P1 in a challenging manner, "I don't know why you said that (P1)...it never happened...I was there the whole time." In response to HST/L's comments, P1 closed his eyes and looked away from HST/L. LPN/H stated that she felt HST/L's comments were inappropriate and intimidated P1 so LPN/H reported HST/L's behavior to the RN. LPN/H stated that P1 does not make things up, if he says he fell then she believes that he fell . In addition to P1's statement that he fell , P1's injuries were consistent with the fall he described. HST/L should have immediately reported P1's fall. P1 should have been assessed by nurses before P1 got up from the floor. LPN/H has worked with HST/L on previous occasions when HST/L didn't follow the patient programs. RN/G was interviewed on 09/14/15 at 9:00 a.m. RN/G stated that sometime during the mid-morning of 09/01/15, LPN/H alerted RN/G about P1's fall. RN/G immediately assessed P1. P1 had a red abrasion on his left temporal area that extended about 5 inches into his hairline. P1 told RN/G that he fell to the floor and hit his head. RN/G obtained P1's vital signs and conducted a neurological exam, which were at baseline. RN/G called APRN/E about P1's fall because P1 had a very noticeable head injury and a headache. RN/G stated that the normal staffing pattern on P1's unit is a total of 8 employees which consists of RNs, LPNs, MHPAs, and HSTs, all whom deliver patient care. RN/G reviewed the staffing schedule for 09/01/15. On 09/01/15, P1's unit was staffed with 8 employees, per usual. HST/L was assigned to P1's care on 09/01/15. RN/G stated she was not aware of any concerns regarding HST/L's work performance or care of patients.APRN/E was interviewed on 09/11/15 at 1:45 p.m. APRN/E stated she sees P1 on a daily basis. Care givers need to keep things simple when communicating with P1, due to P1's developmental disability. P1 needs a lot of prompting and verbal cues to carry out tasks like changing his clothes and showering. On 09/01/15, she evaluated P1 around 10:30 a.m. after being notified that P1 fell that morning. The left parietal side of P1's head was scraped and P1 said he had a headache. P1 had no neurological deficits and P1's vital signs were within normal limits. APRN/E ordered Tylenol for P1's headache, an ice pack to P1's left temporal area, and ongoing neurological checks. When APRN/E reassessed P1 the following day of 09/02/15, the red abrased area on the left side of P1's head had faded and was barely visible. P1 had no complaints of a headache. All of the neurological exams completed by unit nurses were normal so APRN/E discontinued further monitoring. APRN/E did not know of any occasions when P1 had falsely reported something. On 09/01/15, P1 had an injury consistent with the fall he reported. P1 has a prior history of falls. RN/F was interviewed on 09/14/15 at 10:03 a.m. RN/F stated she was the Charge nurse on P1's unit on 09/01/15. RN/F conducted several of P1's neurological checks on 09/01/15 after P1 fell . RN/F observed that P1 had swelling and a reddish-purple abrased area on his left temporal area that extended into his hairline. P1 told RN/F that he fell to the floor while getting out of the shower that morning and the aide in his room told him "not to tell" anyone that he fell . RN/F reported P1's statements to leadership staff for follow-up. RN/F stated the hospital's standard practice is for all staff to immediately report patient falls to Nursing to facilitate timely evaluation of the patient's status. Patients are to be assessed by Nursing before they are moved, when a patient has fallen to the floor. P1 is a Falls Risk with a prior history of falls to the floor. P1 had been free from falls for several months, until 9/01/15. RN/F had no reason to doubt P1's statements. P1 does not make up stories. RN/F has worked with HST/L for a few years. HST/L works a lot of overtime hours and at times can be tired and irritable. HST/L sometimes "bends the rules" but RN/F had never known HST/L to leave a patient unsupervised. MHPA/J was interviewed on 09/14/15 at 10:45 a.m. MHPA/J stated that he has performed P1's morning hygiene program many times. P1 is at risk for falls, especially during showers when P1 is without footwear. The employee assisting with P1's shower stands in the bathroom doorway, which is an arm's reach from the shower curtain. While P1 is in the shower, it is necessary for staff to hand all hygiene items to P1 and continually prompt P1 to wash. Staff need to help P1 dry off and put on his clothes. Staff then help P1 with bedmaking. P1 is generally cooperative with staff but requires cuing and encouragement to complete tasks. P1 does not engage in complex thinking. P1 does not make up stories.
Interview of MHPA/I on 09/11/15 at 2:15 p.m. was consistent with the information provided by MHPA/J HST/L was interviewed on 09/14/15 at 8:05 a.m. HST/L stated she was assigned to P1's care on 09/01/15. HST/L has done P1's morning hygiene program more than 100 times. HST/L stated that P1 was lazy and had to be prompted by staff quite a few times before he would get up in the morning. The morning of 09/01/15 was no different than any other day. After P1 got up on 09/01/15, HST/L helped him undress and get into the shower. HST/L applied soap and shampoo to washcloths and handed them to P1. HST/L put towels on the sink counter and on the bathroom floor. HST/L then went to P1's bed and stripped the wet linen and put clean linen on P1's bed. Staff are not required to remain in the bathroom with P1 while he showers. Rather, staff are only required to remain in "the suite," which includes P1's room. When P1 finished washing in the shower, HST/L helped P1 dry off, put on deodorant, and get dressed. The morning was completely routine. P1 did not fall. HST/L does not know why P1 said he fell when he didn't. HST/L stated she was in P1's room the whole time and would have heard him fall because he is a large individual. HST/L denied that she told P1 not to tell anyone about his fall. HST/L stated she is aware that staff are to immediately report all falls to Nursing because the nurses assess the patient before the patient is moved. HST/L was unable to explain the injury P1 had on 09/01/15 immediately following his shower. HST/L stated that P1 has told lies in the past.

The hospital's policy on Fall Prevention and Assessment, dated 11/15/14, defined a fall as the failure of a patient to maintain an upright position resulting in sudden, unintentional relocation to the ground..."if a patient is found on the floor, it should be assumed that they have fallen."The hospital's policy on Incident Reporting and Management, dated 01/16/14, indicated that "all incidents must be managed, documented, reported, reviewed, and investigated." An incident was defined as "any situation or occurrence that adversely affects the safety or well-being of clients." The policy indicated that the employee who witnessed or discovered the incident was required to report the event immediately to program leadership.
HST/L's training records showed that HST/L received Falls Prevention/Falls Management training as recently as 01/01/15.
HST/L's job description, signed by HST/L on 08/06/13, indicated that the HST "monitors patients as assigned by Charge Nurse per AMRTC procedure...monitors the environment and observes patients per procedure...conducts safety checks as assigned and reports identified problems to the Charge Nurse...reviews assigned patients plan of care and is aware of special problems or needs...assists each patient as needed to meet hygiene needs...provides patient education regarding personal care and hygiene as directed by plan of care...reports all changes in patients physical condition to Charge Nurse...provides continuous monitoring of patients during escorting per established procedure and guideline."
HST/L's most recent performance appraisal, dated 09/25/14, rated HST/L's performance as "Marginal," the second lowest rating possible. The performance appraisal indicated that HST/L's job performance was inconsistent, had decreased over the last year, and that HST/L appeared distracted and failed to consider a range of alternatives when making decisions. The performance appraisal was not signed by HST/L and indicated that HST/L was "on sick leave" at the time the performance appraisal was completed. The hospital had no evidence that the performance appraisal was ever reviewed with HST/L. HST/L's personnel file also indicated that HST/L's function to escort patients off grounds had been removed from HST/L's role since 2009, after two incidents when patients eloped during HST/L's inadequate supervision of them.

The hospital had no evidence that a performance improvement plan was developed for HST/L or that a mechanism was implemented to increase supervision of HST/L 's nursing care to patients. Neither RN/F nor RN/G, who were both working on 09/01/15 when P1 fell , had any knowledge about the need for increased Nurse oversight of HST/L's care to patients.