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CENTER FOR BEHAVIORAL MEDICINE 1000 E 24TH STREET KANSAS CITY, MO 64108 March 7, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to modify the treatment plan in response to the use of seclusion and restraint for six (#27, #26, #29, #3, #10, and #17) of seven patients. Facility had a total of 46 episodes of seclusion and restraint use in a 63-day period from 01/01/13 to 03/05/13, or approximately 44% of the survey sample. The failure to modify the treatment plan in response to seclusion and restraint use had the the potential to affect all patients. The facility census was 62.

Findings included:

1. Record review of the Missouri Department of Mental Health's (DMH-this facility is overseen by DMH) policy titled, "Use of seclusion and restraints" in psychiatric facilities dated 04/12/10 showed:
-Restraint is defined as any physical method, manual hold or mechanical device, material, or equipment that immobilizes or reduces the ability of an individual to move his or her arms, legs, body, or head freely;
-Upon application, there shall be a written modification to the treatment plan to reflect the use of restraint or seclusion and to identify methods of reducing the likelihood of reoccurrence; and
-The individual's treatment team shall review modification to the treatment plan made during the incident and develop a permanent plan for dealing with issues that led to the restraint or seclusion.

Record review of the facility's policy titled, "Use of Restraint/Seclusion" dated 09/12 showed:
-Restraint use will be minimized and its use will comply with DMH regulations;
-A manual hold is any restriction of a patient's voluntary movement by holding the individual according to the facility's approved aggression management program;
-Seclusion is the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving; and
-Full mechanical restraints are cuffs applied to all four extremities and secured to the bed frame (also known as four-point restraint) and with a belt secured at the waist or torso to the bed (five-point).

2. Record review of Patient #27's admission Medical-Psychiatric Evaluation, dated 01/07/13 at 12:26 PM, showed patient was admitted to the facility on [DATE] due to an increase in psychotic (suffering from psychosis, exhibited by a loss of contact with reality that usually includes false beliefs or seeing or hearing things that are not there) and depressive symptoms, and the inability to care for himself.

Record review of Patient #27's physician's orders and restraint documentation showed the patient had been restrained on nine occasions from admission to the date of the survey (03/05/12). One occurrence involved four-point mechanical restraints for threats of harm and combative behavior; and eight occurrences involved manual holds for injection of medication.

Record review of Patient #27's Comprehensive Treatment Plans and reviews since admission showed the patient had a diagnosis of schizoaffective disorder (a disorder that caused both a loss of contact with reality and mood problems). The plan showed that the facility failed to identify and/or modify the comprehensive treatment plan to include the restraint use. Facility staff failed to develop a goal related to the restraint use, add specific interventions related to restraint use, and methods to prevent future restraint use.

3. Record review of Patient #26's admission Medical-Psychiatric Evaluation dated 04/10/12 and an addendum dated 09/05/12 showed Patient #26 was admitted to the facility on [DATE] following an attempt to kill herself by hanging. The addendum showed she was diagnosed with schizoaffective disorder and post-traumatic stress disorder.

Record review of Patient #26's physician's orders and restraint documentation showed the patient had been restrained on six occasions from 01/02/13 to 03/05/13. Four occurrences involved four-point mechanical restraints for harm to self and others. One occurrence involved the use of seclusion for assaultive behavior towards others. One occurrence involved the use of manual hold for assaultive behavior and threats.

Record review of Patient #26's Comprehensive Treatment Plans and reviews since admission showed that the facility failed to identify and/or modify the Comprehensive Treatment Plan to include the restraint use. Facility staff failed to develop a goal related to the restraint use, add specific interventions related to restraint use, and methods to prevent future restraint use.

4. Record review of Patient #29's admission Medical-Psychiatric Evaluation, dated 11/06/12, showed the patient was court ordered for admission on 11/06/12 with a diagnosis of psychosis.

Record review of physician's orders and restraint documentation showed a manual restraint on 01/01/13 from 3:15 PM to 3:16 PM to inject emergency medication, Haldol 5 milligrams (mg, a psychiatric medication that is used to treat disorders such as psychosis and schizophrenia); and four-point mechanical restraint (one cuff on each limb) from 01/16/13 at 3:40 PM to 01/17/13 at 11:30 AM.

Record review of Patient #29's Comprehensive Treatment Plans and reviews since admission showed the facility staff failed to identify and/or modify the Comprehensive Treatment Plan to include the restraint use on 01/01/13 and on 01/16/13 to 01/17/13. Facility staff failed to develop a goal related to the restraint use, add specific interventions related to restraint use, and methods to prevent future restraint use.

5. Record review of Patient #3's Medical-Psychiatric Evaluation dated 11/07/12 showed that the patient was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental disorder characterized by paranoia and delusions). The patient had a history of delusions that people attack/rape her.

Record review of Patient #3's physician's orders and restraint documentation showed a manual hold on 10/08/12 from 6:15 PM to 6:16 PM, and another manual hold on 10/08/12 from 6:17 PM to 6:18 PM, both to prevent physical harm to self and others.

Record review of an Incident Report dated 10/08/12 showed the patient was restrained by a manual hold in order to keep the patient from attacking a peer.

Record review of Patient #3's Comprehensive Treatment Plans from 05/25/12 through 03/07/13, showed that facility staff failed to identify and/or modify the Comprehensive Treatment Plan to include the restraint use. Facility staff failed to develop a goal related to the restraint use, add specific interventions related to restraint use, and methods to prevent future restraint use.

6. Record review of Patient #10's Admission Medical-Psychiatric Evaluation showed she was admitted to the facility on [DATE]. Patient #10's diagnosis included major depressive disorder (a mood disorder with one or more major depressive episodes), recurrent, in full remission and borderline personality disorder (a pattern of behavior characterized by impulsive acts, intense but chaotic relationships with others, identity problems, and emotional instability). She had a history of multiple suicide attempts and was admitted after a suicide attempt by cutting her wrist.

Record review of Patient #10's physician's order and restraint documentation showed a physician's verbal order on 03/02/13 at 11:35 PM for a manual hold due to an altercation with a peer.

Record review of Patient #10's Comprehensive Treatment Plans and reviews since 12/19/12 showed the facility staff failed to identify and/or modify the Comprehensive Treatment Plan to include the restraint use. Facility staff failed to develop a goal related to the restraint use, add specific interventions related to restraint use, and methods to prevent future restraint use.

7. Record review of Patient #17's Admission Medical-Psychiatric Evaluation showed he was admitted to the facility on [DATE]. Patient #17 had a long history of inappropriate sexual behavior, suicidal behavior, and making threats to harm others.

Record review of Patient #17's physician's orders for restraint/seclusion showed an order on 03/06/13 at 12:14 PM for a manual hold due to the patient's refusal to allow staff to administer an intramuscular (in the muscle) injection.

Record review of Patient #17's Comprehensive Treatment Plans and reviews since 01/09/13 showed the patient had diagnoses of conduct disorder (individuals with this diagnosis acted inappropriately, infringed on rights of others, and violated behavioral expectations of others) and mild mental retardation (intellectual functioning well below average with limitation in daily living skills). The treatment plan also showed facility staff failed to identify and/or modify the Comprehensive Treatment Plan to include restraint use. Facility staff failed to develop a goal related to the restraint use, add specific interventions related to restraint use, and methods to prevent future restraint use.

8. During an interview on 03/06/13 at 3:00 PM Staff A, Nurse Manager of unit 2B, stated that the facility had never reflected the use of restraints in the Treatment Plan.

9. During an interview on 03/07/13 at 9:00 AM, Staff J, Registered Nurse (RN) Incompetent to Stand Trial (IST) unit director, stated that modifications were not made to the treatment plan specifically for restraint use.

10. During an interview on 03/07/13 at 9:20 AM, Staff HH, RN, stated that he had not been told to put restraint use in the treatment plan.

11. During an interview on 03/07/13 at 9:40 AM, Staff CC, RN Nurse Manager, stated that they do not list restraint use as a problem in the treatment plan and the treatment plans were not specific to restraint use.

12. During an interview on 03/07/13 at 10:10 AM Staff B, Chief Nursing Executive (CNE) stated that the facility did not include restraint/seclusion in the Treatment Plan.

13. During an interview on 03/07/13 at 11:00 AM, Staff B, CNE, Staff II, Hospital Operation's Coordinator, and Staff Q, Chief Operating Officer, stated that they thought that by addressing the patients' behaviors in the treatment plan, they were also addressing the restraint issue. They stated that goals for restraint use were in the minds of the facility staff; however, it was not documented anywhere.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on observation, interview and record review, the facility failed to ensure laboratory and housekeeping/linen services had Quality Assessment and Performance Improvement (QAPI) projects, indicators, or any other trackable data/processes that were incorporated into the hospital-wide QAPI. The facility census was 62.

Findings included:

1. Record review of a facility policy titled, "Performance Improvement Program and Plan," revised 10/12 showed the facility was committed to improving organization performance to ensure that new processes are designed well and that they systematically monitor, analyze, and improve their performance. The process included identification and improvement of a process that was initiated and evaluated by a team made up of those people who are directly involved in the process.

2. Observation on 03/06/13 at 9:17 AM, showed a blue, moderately loose weave, blanket on Patient #20's bed, on the 3-C unit. This blanket had holes in it and the hemmed edge was tattered, allowing loose threads to dangle.

3. Observation and concurrent interview on 03/06/13 at 1:07 PM, showed that there was one additional blue blanket, with holes and tattering, available for patient use, on one of the three units (3-D). Staff B, Chief Nurse Executive (CNE) stated that he was not aware of how old these blue blankets were, or how they were monitored for wear and/or replacement.

4. During an interview on 03/07/13 at 8:30 AM, Staff EE, the Director of Hospital Support Services, stated that torn, tattered linen should be sorted out by facility staff when handling the clean linen. Staff EE stated that the blue blankets were the oldest ones they had, but the patients preferred them as they were warmer. Staff EE stated there was no documented QAPI for linen services.

5. During an observation and concurrent interview on 03/07/13 at 9:14 AM, Staff FF, Linen Services Manager, stated that linen was counted as it went out to be cleaned; however, not counted when it returned (so there was no way for facility staff to know if they received the right amount of linen, or if they were being charged appropriately). Staff FF stated that linen was not weighed. Staff FF stated that the worn blue blankets had not been removed from service because the patients preferred them over others. There were three blue blankets in the clean storage area, all of which had holes, and tattered hems.

The facility failed to develop any quality projects, indicators, and/or process improvements for linen service that could be monitored and analyzed as dictated in their policy. Therefore, no data was presented to the hospital-wide QAPI.

6. Record review on 03/06/13 at 1:20 PM of department evaluations showed no indicators for data collections to ensure quality control measures were in place for the laboratory.

7. During an interview on 03/07/13 at 11:35 AM Staff Q, Chief Operating Officer stated that she was not aware that the laboratory needed to be involved in the hospital-wide QAPI. The facility did not have any QAPI data for the laboratory.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation and interview and record review, the facility's Director of the Dietary Services failed to establish and maintain a sanitary environment in a kitchen where hot meals are prepared and served three times daily and potentially hazardous foods (PHF-foods that are required to be maintained at temperatures below 45 degrees or above 160 degrees to prevent growth of potential bacteria) are refrigerated and stored, affecting the facility census and multiple staff. The facility census was 62.

Findings included:

1. Observation on 03/06/13 from 9:10 AM through 10:45 AM, showed floor tile at entrances and walkways in the kitchen were stained and darkened with unidentified food debris and soil, dark brown to black colored stains in corners, under sink cabinets, prep tables, counters, under the three basin sink and dishwashing trays. The most soiled areas were dark brown and black accumulations on the floor under large, fixed appliances, beneath the low bottom shelf of prep tables, under the three basin sink near the automatic dishwasher in the dishwashing room, and under the pass-through refrigerator/warmer units on the cook line.

Observation also showed unprotected wall and floor tile surfaces of at least 10 of 10 corners, columns and partial walls had sustained repeated damage from carts, tables and other equipment. The broken tile with missing chips, and smashed corners of broken sheet rock exposed rough surfaces to contamination and mold because the surfaces could no longer be easily cleaned and sanitized. The wall covering behind the tilt skillet was partially detached and peeled away from the sheet-rock wall, which created another difficult area to access and clean. Dark streaks, dirt, crumbs and food residues had accumulated in the floor tile grout and was noticeably darker in heavily trafficked areas between prep tables and ovens. This debris was not being removed by regular cleaning or deep cleaning.

Poor sanitation in the walk-in freezer and refrigerators due to uncontrolled moisture levels, evidenced as follows:
-Large deposits of ice accumulated on the ceiling, plumbing and light fixture in the walk-in freezer.
-Condensation and water droplets on the ceiling, pooled water on the floor, ice on the cooling units and pipes in the walk-in refrigerator and the walk-in produce refrigerator.
-Dark streaks, soil marks, and stains on the trafficked areas of the walk in refrigerator.
-No secondary thermometers in walk-in refrigerator and freezer and none in the pass-through refrigerators to ensure accurate interior temperatures were monitored and maintained.
-Partially used box of frozen hamburger patties left with open plastic wrapping exposed the contents to freezer burn.

The interior and exterior cooking surface of several kitchen appliances, including stove, ovens, stack ovens and tilt skillet were contaminated with crumbs, dried splatters, and burned food residue that had accumulated and was not removed by daily or deep cleaning as follows:
-Four burner (gas) stove top with lumpy carbonized food deposits on the cast metal frame above each burner. The backsplash of the stove top was blackened with burned grease residue.
-Front back sides and interior of both Blodgett stack ovens were brown and black with grease-smoke stained surfaces, and black, carbonized food deposits on the bottom and racks in each oven.

Other kitchen equipment that showed signs of poor, irregular cleaning were as follows:
-Ventilation hoods showed signs of being wiped down, but small grease condensates/droplets and yellowed deposits showed lighter streaks between darker ones, presumably due to incomplete or infrequent cleaning.
-Accumulations of food crumbs around the interior channel and rim of drawers under all prep tables so equipped with drawers.
-Large deposits of carbonized grease residue had accumulated on the base inside of the deep fryer unit located on the cook line.
-Dried white splatters under the head of the floor mixer.
-Dried white and brown food material on the blade of the table-top can opener.
-Dust on can racks.

2. Record review of a document titled, "FY 13 Dietetic Services Quality Indicator Results Prepared for WISE Committee" (internal "mock" survey by disinterested hospital staff) showed the refrigerators and freezers had been malfunctioning since initially noted on 07/02/12. The document noted numerous problems with refrigerator and freezer. Problems reported included missed daily recording of temperatures by staff, refrigerators and freezers not holding temperature, reported to Maintenance several times, at least one unit noted as not repairable, then due to be surplused out.

3. During interviews on 03/06/13 at 9:10 AM and 03/07/13 at 9:50 AM, Staff U, Registered Dietitian/Director of Dietary Services stated that the refrigerators seemed to be sealed poorly. He stated that they were older and that age might be a factor. He stated that the problems have been reported to maintenance a number of times and they seem to fix what they can, but the moisture comes back and re-freezing of condensation. He stated he instructed staff to keep the doors closed and avoid leaving it open for long periods of time, but he was not always present to enforce his instruction.

Regarding cleaning the equipment, daily and deep cleaning of the kitchen, he stated that all the kitchen staff were trained and inserviced regularly. He stated that he had not developed policies for cleaning the kitchen, but had distributed and assigned the tasks for preparation, cooking and cleaning among what staff that he has. He stated that there were no overnight shifts in the kitchen. He stated that he expected them to clean up their areas after the meal was prepared and served, but some have higher standards of what cleaning means than others and some seem to think they shouldn't have to clean up at all. He stated that occasionally they have to have a cleaning session at late evening or when meals were not being prepared. He stated that the most difficult thing to keep clean was the grout between the tiles on the kitchen floor. He stated that he did not think he had adequate procedures and cleaning schedules for individual pieces of equipment. He stated that he could see he needed to provide more oversight and hold his staff responsible when they fail to meet pre-set standards.

4. During an interview on 03/06/13 at 2:45 PM, Staff S, Operations Manager, stated that Maintenance had documented all the maintenance issues in the kitchen and he already had a proposal completed to fix corners and cover with fiberglass corner guards. He stated that he was waiting on his supervisor to accept it and forward it to the medical staff for approval and tell him he could order supplies and begin. He stated that the problems with condensation in the walk-in freezer, the walk-in refrigerator and produce cooler had been ongoing. He stated that the facility did not have a refrigeration mechanic and did not have authorization from DMH (Department of Mental Health) to hire one. He stated that they had caulked, cleaned, removed caulk, and re-caulked several times with only limited progress. He stated there has been speculation that the doors to the walk-ins are carelessly being left open or not closed tightly for long periods of time, which caused the makeup condenser to freeze and motors to overheat. He stated that there is also a possibility that portions of the walls surrounding the walk-ins are poorly insulated and the batting is inconsistently dispersed, which could leave pockets of un-insulated space, and make the unit more difficult to regulate.

5. During an interview on 03/07/13 at 8:30 AM, Staff EE, Director of Support Services, stated that Housekeeping helped the kitchen only on request. She stated that housekeepers had not done a deep cleaning in there for over a year.