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.

SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM 6262 SOUTH SHERIDAN ROAD TULSA, OK May 4, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview, the hospital failed to:


A. inform each patient who to contact to file a grievance,


B. provide a determined number of days for the hospital to respond to an unresolved grievance


Findings:


The surveyors requested documentation presented to patients describing the patient's right to file a grievance. Documents identified as the "admission packet" and the "Parent Handbook" showed no information regarding a patient'sright to contact the Oklahoma State Department of Health to file a grievance.


A document titled "Grievance Rights" showed no timeline for the hospital to respond to the unresolved grievance. The third paragraph under Processing the Grievance stated that, "If the grievance will not be resolved...the hospital will follow-up with a written response within a stated number of days..."


On 05/02/17 at 10:30 am, staff B and staff C, both stated the grievance process followed by the hospital did not conform to CMS regulations and did not provide information to contact the Oklahoma State Department of Health if they chose to file a grievance with the state agency.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on record review and interview, the hospital failed to provide specific time frames for the hospital to review and respond to unresolved grievances.


A document titled "Grievance Rights" showed no timeframe for the hospital to review and respond to an unresolved grievance. The third paragraph under Processing the Grievance states "If the grievance will not be resolved...the hospital will follow-up with a written response within a stated number of days..." The "stated number of days" was not defined or specified.


On 05/02/17 at 10:30 am with Staff B and Staff C, both stated the grievance process followed by the hospital did not conform to CMS regulations.
VIOLATION: GOVERNING BODY Tag No: A0043
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation, and interview, the Governing Body failed to ensure:

a. Medical Staff privileges were delineated and approved for services provided within the scope of the hospital. (see findings at Tag A-0044),

b. twelve year old children were admitted to a specified hospital unit by established criteria, for the purpose of providing an optimal therapeutic environment. (see findings at Tag A-0049)

c. the hospital's ongoing performance improvement program included the evaluation and reporting of quality of care and patient safety and included only hospital specific data and evaluation (see findings below), and

d. patients' rights were protected by established policies and processes. (see findings at Tags A-0115, A-0118, A-0122, A-0123, A-0144, A-0145, A-0165 and A-0186).


Findings:


The Governing Body Bylaws showed the board shall be accountable for the safety and quality of care, treatment and services of the facility.


The Board of Trustee Meeting minutes from 11/11/16 through 04/27/17 combined the acute hospital's and residential treatment center's operational and quality improvement topics, discussions, and actions. All topics were broadly discussed with minimal data and analysis presented to assist the Governing Body with the decision-making process necessary to ensure the provision of quality care to patients. There were no quality measurements for issues/ incidents at a unit level to ascertain problems unique for each patient care setting were adequately addressed and resolved. No evaluations or identifications of trends and root causes of the issues/incidents were discussed. No quality information was reported and discussed in detail in an effort to prevent recurrences of preventable patient incidents or events.


On 04/24/17, a serious event occurred on the adolescent unit which involved a [AGE] year old patient gaining access to a medication cart and ingesting a nonprescribed antipsychotic medication. The incident documentation described the patient as aggressive and while swinging arms, knocked glasses off the face of a staff member. The patient obtained the lens from a staff's broken glasses and used the lens to do self harm. There is no evidence that the Governing Body was made aware of this high risk incident. The risk manager's documentation for this incident was reviewed, and only the restraint/seclusion aspect of the event was evaluated. There was no performance improvement initiative to follow up on the child's ability to access and ingest the medication from the medication cart.


Within the Governing Body meeting minutes, restraints/seclusion were discussed in general terms such as number of events "increasing or decreasing." Nebulous action plans were documented, such as working with team on deflection, identify highly suicidal patients and improve rounds every 15 minutes, and re-implementation of video reviews and feedback form for staff.


The minutes did not discuss staff injuries per location/unit, and reported injuries increased 33 % in one month's meeting minutes and decreased 53% in the next month's meeting minutes.


The meeting minute's discussion of staffing documented significant decrease in turnover, and the same minutes, documented a 21% turnover rate. The meeting minutes showed there was recruitment efforts for nursing leadership and other nursing positions, but did not discuss the roles of supervisor or the current impact on the units in light of the unfilled positions. A goal for stabilizing nursing staff was documented, but no strategies for how to achieve the goal. The hospital document titled, "Shadow Mountain Terminations May 1/2016 - April 30, 2017" document 62 MHT were terminated compared to 5 RN and 9 LPN. No evidence was found within the minutes this significant turnover was discussed.


The minutes documented hospital acquired infection with numerical values only. 1 patient with Clostridium difficile was documented, but no discussion as to what location/unit or how the patient was managed. In February 2017, 9 cases of viral gastroenteritis was documented with no discussion as to location/unit or management of the situation.


The minutes documented the training process was new and improved. There was no discussion as to what prompted the change in training and no evaluation of the program was documented.


Although the Governing Body had delegated the complaint/grievances process to a Grievance Committee, no evidence of grievance evaluation was seen within the Governing Body minutes.


The following hospital's complaints/grievance, restraint/seclusion, and incident logs all combined acute and residential data together: "Patient Complaint" log from July 2016-April 2016; Seclusion list from 05/01/16-4/28/17; Restraint list from 05/03/16-4/29/17.


A document titled ,"Incident Summary Report 2016-Client care incidents" also combined acute and residential patients, and contained strictly numeric information.


The Governing Body minutes did not contain evaluation of those patients' transferred to another acute facility. An untitled hospital document of transfers to acute facilities from 12/09/16 through 04/18/17 was reviewed. On 05/03/17 at 2:43pm, the COO stated transfers were not analyzed through the quality improvement program.


Generic percentage of injuries were documented in the Governing Body minutes and contained no evaluation of the injuries. An untitled hospital document of staff injuries from May 2016-April 2017 showed 12 of 21 injury events documented had occurred on 1 west, the adolescent unit.This document also mixed acute and residential data together.
VIOLATION: MEDICAL STAFF Tag No: A0044
Based on interview and record review, the Governing Body failed to grant privileges as part of the reappointment process of the medical staff.


This failed practice could potentially increase the risk of all patients receiving ECT (Electro Convulsive Therapy) services if the medical staff practiced outside the scope of practice designated by the hospital and beyond practitioners' qualifications.


Findings:


The hospital's Governing Body Bylaws were reviewed which documented that the medical staff must reapply for credentials and privileges every 2 years.


The credentialing files for 3 medical staff were reviewed. The Governing Body failed to approve the medical staff privileges in 2 of 3 medical staff (Staff P and Staff R).


On 05/04/17 at 10:00 am, the Electro Convulsive Therapy (ECT) Office manager stated that Staff P supervised the administration of monitored anesthesia care when provided by Staff Q, a CRNA. The credentailing file for Staff R did not indicate the privileges for the supervision of anesthesia services was granted. The privileges were dated 11/2014, which was from the prior reappointment period.


The credentialing document titled, "Delineation of Clinical Privileges" for Staff P was reviewed. The Governing Body failed to sign this document acknowledging approval of the requested privileges.


On 05/03/17, the CEO acknowledged these omissions in the credential of the 2 identifed staff.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to establish policies to segregate children and adolescents populations.


This failed practiced had the potential to negatively affect the younger children (ages 4-11 years) by exposing them to older adolescent patients (12 years) and creating a less therapeutic milieu.


Findings:


The hospital document titled, "Shadow Mountain Sheridan Campus - Parent Handbook- Adolescent and Child Unit" documented the segregation of patients as follows: "SW1 Pediatric Acute age 4-11 [years,] 1 West [AGE]-17 [years], and 3 West Transition [AGE]-14+ [years]".


The hospital's list of current acute care patients was reviewed. The list documented 5 twelve year old patients were admitted . 1 of 5 patients was admitted to the pediatric unit with the 4-[AGE] year old children.


On 05/03/17, the CEO stated twelve year old patients were admitted to the Pediatric Unit. He stated primarily developmentally delayed or intellectually challenged patients would be assigned to the pediatric unit as determined by the admitting physician. The CEO stated there was no Governing Body directive for the criteria to designate which unit the twelve year old patients could be admitted to the pediatric unit.


On 05/02/17, during an interview, Staff K stated the age for the pediatric unit was age 4-12 years. Staff K stated autistic and developmentally delayed patients were admitted to the pediatric, but higher functioning children of the [AGE] years were also admitted . Staff K stated the admittance of the higher functioning children affected the acuity of the unit.


On 05/03/17, the CEO stated the RN would receive a verbal order from the admitting physician and would generate the document titled , "Assessment Collaboration." This document designated the unit to which the patient was to be admitted .


The "Assessment Collaboration" forms were reviewed for 4 patients (Patients #22, 23, 24, and 25). In 4 of 4 patients, the document did not have a patient identifier, and the admitting physician had not authenticated the order. The form did designate the unit for patient admission, but for the [AGE] year old patient, did not provide the rationale for admission to the pediatric unit.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the hospital failed to ensure that the rights of patients were protected and promoted as evidenced by the following:


A. No contact information was provided to contact the Oklahoma State Department of Health to file a grievance. (see tag A-0118),


B. The hospital failed to specify a time frame for review of the grievance and provision of a response. (see tag A-0122),


C. The hospital failed to protect patients from all forms of abuse or harassment. (see tag A-0145),


D. The hospital failed to utilize the least restrictive intervention to protect the patient, staff or others from harm. (see tag A-0165), and


E. The hospital failed to document alternatives or other less restrictive interventions attempted prior to physical restraint. (see tag A-0186).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based of interview and record review, the hospital failed to:


A. enforce adequate de-escalation and proper restraint techniques. (see findings at Tag A-0145 and A-0165), and


B. ensure that patient's had no access to antipsychotic medication in the nursing area.


This failed practice had the potential to increase the risk of physical harm to all patients admitted to the acute hospital.


Findings:


Patient #22 medical record showed showed on 04/24/17 at 7:00 pm, patient #22 drank another patient's shampoo/body wash. Patient was in process of going into time-out when the patient grabbed a bottle of antispychotic medications from a medication cart located in the nursing station area. The documentation (narrative progress notes, daily nursing progress notes, seclusion/restraint observation recrod and restraint seclusion order) was vague as to how patient #22 was able to gain access to the medication from the medication cart. The nurse tried to retrieve the medication and multiple pills fell to the floor. Patient #22 attempted to ingest some pills. Additional staff arrived to assist with the situation. At that time, the patient appeared calm, but then spontaneously ran after the nurse into the nursing station. Patient #22 demonstrated aggressive behavior such as yelling, banging on the counter, and knocked glassess off the face of a MHT.


At 7:20 pm, Patient #22 was restrained for 2 minutes then released to time out. When the staff counted the medication, 1.5 - 2 tablets were not accounted for. Patient #22 managed to take possession of one of the plastic lens of the MHT's broken glasses from the altercation and used it to cut face and forearm.


At 7:25 pm, Patient #22 was restrained for 2 minutes then released to timeout. The house supervisor, physician, and DHS worker were notified of the event.


At 7:27 pm, the RN performed a face to face assessment, and superficial cut/scratch was noted of Patient's #22 face above the lip under nose, and a previous self harm area on left forearm was reopened.


On 05/03/07 at 2:00 pm , the Risk Manager was interviewed regarding the event. The Risk Manager provided an electronic summary of the incident. No documents were provided to show that an investigation was performed as to how patient#22 managed to access the medicaition from the medication cart. The 'Restraint Reduction Team Review Form" documented, patient #22 stated a desire to do self harm and wanted to go to residential and did not want to go home. The staff completing this form indicated a camera review was performed and positively critiqued the staff's response to the event.


On 05/02/17, surveyor reviewed camera footage from 04/18/17 to 05/01/17; the incident was not found. The CEO stated the camera video was retained for a 2 week period before new video footage was overlaid over the old tape.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review, observation, and interview, the hospital failed to follow its policy to protect patients from all forms of abuse or harassment by using approved restraint techniques, report incidents. and conduct an investigation for 1 (Patient #15) of twenty patients observed on video footage from 04/18/17 to 05/01/17.


This deficient practice had the potential to harm all patients admitted to the hospital who required restraint.


Findings:


Hospital policy #140.02 titled "Patient abuse, neglect, mistreatment and exploitation" states abuse is the intentional act or failure by a person rendering care which caused or may have caused injury to an individual with a mental illness. Including acts such as the use of excessive force when placing an individual in bodily restraints. The policy states all staff is to immediately report any form of abuse, all allegations of abuse are to be investigated, and staff is to be suspended pending the investigation.


On 05/02/17 surveyors observed camera video footage from 04/18/17 to 05/1/17. The video showed an encounter between patient #15 and Staff N on 04/18/17. The video showed take down methods inconsistent with hospital approved "Handle with Care" method and the system's primary restraint techniques.


Staff N was observed on the video physically engaging Patient #15 by grabbing her and driving her backward over a stool onto her back, and the back of the head of Patient #15 when no imminent danger was present. Video shows no effort to avoid physical confrontation by moving to put space between the patient and staff member or waiting for assistance and utilizing a team approach.


Staff N was seen on video leaving the day area while the patient was being attended to by the nurse, but quickly returned engaging in a second physical altercation which resulted in Staff N placing the patient in a headlock and wrestling her to the floor.


On 05/02/17 at 11:30 am, the Risk Manager stated that Staff N did not use approved methods of behavioral management nor did Staff N's methods of physically subduing the patient resemble any part of Handle with Care method.


Staff D stated that Staff N should not have been wearing a hoodie and covering her head, to be able to properly visualize and assess the patient's body language and increasing agitation so verbal de-escalation techniques could have been utilized.


The Risk Manager stated that Staff N had received a disciplinary action, which required her to repeat Handle with Care training. There was no incident report filed concerning the use of excessive force per hospital policy. There was no documentation to indicate further investigation was conducted.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on record review, observation, and interview, the hospital failed to follow its policy to use the least restrictive intervention to manage behavior. In one (Patient #15) of twenty patients observed on video footage from 04/18/17 to 05/01/17, the least restrictive means to protect patient, staff or others was not utilized.


This failure had the potential to harm every patient admitted to the hospital requiring restraint.


Findings:


Hospital policy #320.01 titled, "Restraint and Seclusion" stated:

~A restraint is any manual method that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Restraints should only be used as an emergency measure and where there is an imminent probability of harm, to protect the patient or others.

~Restraints or seclusion shall only be used when other intervention strategies and less restrictive techniques have been attempted and have failed.


On 05/02/17 surveyor reviewed camera video footage from 04/18/17 to 05/01/2017. Video observed from 04/27/2017 showed a premature use of a physical restraint in response to verbal communication.


Video footage showed, at approximately 6:42 pm on 04/27/17, Patient #15 got up from her mattress and begin speaking in the direction of Staff O. After a brief verbal exchange Staff O is seen grabbing Patient #15, spinning her around, and holding her arms behind her back.


No physical act of aggression or attempt to harm self or others is seen on video prior to the patient being placed in the restraint.


The Restraint Reduction Team Review Form states that Handle with Care techniques were not utilized and recommended counseling and re-training for Staff O.


An interview was conducted with the Risk Manager on 05/02/17 at 1:00 pm. The Risk Manager stated the physical restraint appeared premature from what was seen in the video footage.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
Based on observation, record review, and interview, the hospital failed to document alternatives or other least restrictive interventions attempted prior to physical restraint. This deficient practice has the potential to affect all patients admitted to the hospital.


Findings:


Hospital policy #320.01 titled "Restraint and Seclusion" stated that restraints and/or seclusion shall be used only when other intervention strategies and less restrictive techniques have been attempted and have failed. Justification for restraint and/or seclusion must be documented including less restrictive measures attempted prior to initiation of the physical hold.


Patient record review for Patient #15 showed staff G documented, on 04/27/17 at 7:45 pm, that Patient #15 woke up from a nap and immediately began threatening Staff O and began swinging and spitting at staff. This resulted in Staff O placing Patient #15 in a physical restraint.


Hospital staff reviewed video footage of this event and stated on the "Restraint Reduction Team Review Form," according to staff, the patient woke up irritable and unpredictable. The patient had been on 1:1 for the past two weeks and verbal threats made Staff O feel threatened.


No physical aggression or imminent danger was noted on the form. The team's suggested plan of action to avoid premature restraints, included distraction or deflection techniques should have been used, or that Staff O should have traded with another staff member to remove the trigger from the situation.


The restraint reduction team recommended Staff O be counselled and re-trained in "Trauma Informed Care" and "Handle with Care."


On 05/02/17 surveyor observed video footage of the moments prior to the physical restraint on 04/27/17. No swinging or spitting by Patient #15 toward staff was observed.


An interview was conducted with the Risk Manager on 05/02/17 at 1:00 pm. The Risk Manager stated the physical restraint appeared premature from what was seen in the video footage.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview and record review, the hospital failed to follow their policy regarding RN to patient ratios on the acute units.


This failed practice potenitally affected all patients on the unit by not receiving optimal nursing care.


Findings:


The hospital's policy titled, "Change of the Report, Staffing Levels, and Unity Acuity Levels 03/13" documented a registered nurse will be assigned for every 15 clients on the acute unit.


On 05/01/17 and 05/02/17, on 1 West/ adolescent unit, the census was 16 patients, there was one RN per 12 hour shift.


05/03/17 at 12:00 pm, Staff G stated the staffing pattern for the unit was 1 RN for current census of 16 patients, have 2nd nurse (LPN) and 3 MHT.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, record review, and interview, the hospital failed to maintain an acceptable level of safety in the ECT room.


During a tour of the ECT room on 05/03/17, surveyors observed the room to be unlocked and no staff persons were in the room.


A review of records for the ECT crash cart showed there were no logs or records for the review of the ECT crash cart. Staff B stated the Office Manager (an unlicensed person) was responsible for checking the AED daily, and the anesthesiologist/CRNA maintained the contents of the crash cart. No logs were kept documenting these activities.


A document titled "Provision of Medications" stated that the ECT room will be locked at all times when not in use. Medications will be stored in a locked cabinet or refrigerator with access only by the ECT nurse, ECT physicians and/or pharmacy personnel.


On 05/03/2017, staff A and staff B both stated the office manager (an unlicensed person) reviewed the crash cart medications and checked the AED.