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.

DIVINE PROVIDENCE HOSPITAL 1100 GRAMPIAN BOULEVARD WILLIAMSPORT, PA July 13, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility policies and procedures, facility documents, medical records (MR) and interview with staff (EMP), it was determined that the Governing Body failed to ensure the Chief Executive Officer (CEO) adequately managed the facility (A057) by failing to protect and promote each patient's rights (A115), by failing to ensure patients were not subjected to being sprayed with cayenne pepper spray by hospital staff and by failing to ensure one patient was not attacked by another patient (A144), and by failing to ensure the least restrictive intervention was implemented to protect the patient or others from harm (A165).

Findings include:

Review on July 13, 2012, of the "Bylaws Divine Providence Hospital of the Sisters of Christian Charity," dated 2011, revealed "... Article II, Purpose and Powers, Section 2.1. Purposes. ... This corporation is organized exclusively for religious, charitable and nonprofit purposes which embrace the entire Catholic health care apostolate. These health care purposes include: A. To perform and provide medical care and acts of Christian charity, particularly among the sick; ... M. To provide health care services to the corporation's service area through the adoption and implementation of compliance standards, a performance improvement program, a patient's bill of rights and safety and risk management programs. ..."

The cumulative effect of the failure of the Governing Body resulted in the hospital's inability to ensure patient's rights were maintained.

Cross reference:
482.12(b) Chief Executive Officer
482.13 Patient Rights
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(e)(3) Patient Rights: Restraint or Seclusion
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the Chief Executive Officer (CEO) failed to adequately manage the facility by failing to protect and promote each patient's rights (A115), by failing to ensure patients were not subjected to being sprayed with cayenne pepper spray by hospital staff and by failing to ensure one patient was not attacked by another patient (A144), and by failing to ensure the least restrictive intervention was implemented to protect the patient or others from harm (A165).

Findings include:

Review on July 13, 2012, of the facility's job description "President/[facility name] - Vice President/[system name]," revealed "Job Summary, Provide visionary leadership, strategic direction, and administration in the delivery of seamless services to internal and external customers of the [system name]. In conjunction with the strategic plan and corporate staff, provides results-oriented leadership, mission direction, and administration of all activities of Hospital to ensure quality health services at the most reasonable cost to our patients and community by promoting standards for health and education in conformance with the Hospital Bylaws and the Medical Staff policies; ... Major Tasks, Duties and Responsibilities ... 5. Develops and implements policies and procedures that guide and support the provision of services. ... Organization and Staffing ... 4. Develops, interprets, and enforces applicable operational policies and procedures, rules, techniques, and methodologies in accordance with current practices, standards, and regulations to achieve the goals and objectives. ..."
The cumulative effect of the failure of the CEO resulted in the hospital's inability to ensure patient's rights were maintained.

Cross reference:
482.13 Patient Rights
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(e)(3) Patient Rights: Restraint or Seclusion
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policies and procedures, facility documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to protect and promote each patient's rights by failing to ensure patients were not subjected to being sprayed with cayenne pepper spray by hospital staff, by failing to ensure one patient was not attacked by another patient (A144) and by failing to ensure the least restrictive intervention was implemented to protect the patient or others from harm (A165).

Findings include:

Review on July 10, 2012, of the facility's "Patients Rights and Responsibilities" policy, review date March 19, 2012, revealed "Purpose: To ensure that all rights of the patients are guaranteed. ... 8. You have a right to receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals. ... 10. You have the right not to be subjected to any harsh or unusual treatment. ... 13. You have the right to be free from physical or chemical restraints. 14. You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment, and involuntary seclusion. ..."

1) Review on July 10, 2012, of MR1 revealed that during MR1's third behavioral dyscontrol event on June 25, 2012, MR1 began to strike staff members. MR1 was maced by a hospital security guard. Prior to this episode MR1 had received Zyprexa (an atypical antipsychotic medication) 10 mg (milligram) po (by mouth) at 1:34 PM for agitation and Zyprexa 10 mg and Ativan (an antianxiety medication) 1 mg IM (intramuscular) at 5:31 PM. MR1 was also placed into seclusion at 5:31 PM.

Interview of EMP2 and EMP3 on July 10, 2012, at 10:30 AM confirmed a facility security officer did spray mace into the face of MR1 to subdue MR1 during a behavioral dyscontrol event.

Interview of EMP1 on July 10, 2012, at 11:50 AM confirmed that during a behavioral dyscontrol event in the seclusion room, MR1 attacked staff and was sprayed with mace by hospital security staff.

Interview of EMP4 on July 10, 2012 at 1:40 PM confirmed MR1 was sprayed with mace by hospital security staff on June 25, 2012.

2) Review on July 10, 2012, of MR2 revealed that on June 25, 2012, MR2 became upset with MR1 and hit MR1 on the back of the head. MR1 then punched MR2 on the left lower jaw, knocking MR2 to the floor causing unconsciousness. MR2 required evaluation at the local emergency department.

Interview of EMP1 on July 10, 2012, at 11:50 AM confirmed that on June 25, 2012, MR1 punched MR2 on the left lower jaw knocking MR2 to the floor. EMP1 also confirmed MR2 required evaluation and treatment at the local emergency department.

Cross reference:
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(e)(3) Patient Rights: Restraint or Seclusion
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure patients were not subjected to being sprayed with cayenne pepper spray by hospital staff and failed to ensure one patient was not attacked by another patient for two of two medical records reviewed (MR1 and MR2).

Findings include:

Review on July 10, 2012, of the facility's "Patients Rights and Responsibilities" policy, review date March 19, 2012, revealed "Purpose: To ensure that all rights of the patients are guaranteed. ... 8. You have a right to receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals. ... 10. You have the right not to be subjected to any harsh or unusual treatment. ... 13. You have the right to be free from physical or chemical restraints. 14. You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment, and involuntary seclusion. ..."

Review on July 10, 2012, of the facility's "Restraint/Seclusion" policy, last reviewed July 7, 2012, revealed "Purpose: To assure the right of the patient to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. Restraint and Seclusion, I. Definitions A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. 1. Exemptions - the following are not considered restraint under this policy: ... e. Forensic and correction restrictions used for security. A law enforcement officer will be present at all times when these devices are used on patients. SH (Susquehanna Health) Safety and Security Officers will not use handcuffs on patients. ..."

Review on July 10, 2012, of the facility's "Use of Cayenne Pepper Self-Defense Spray" policy, last reviewed October 10, 2009, revealed "Policy: 1. Only the cayenne pepper product approved and issued by The Department of Safety and Security shall be carried by security officer on duty. 2. Use of the cayenne pepper product shall only be permitted for the purpose of self-protection or the protection of others, not for the protection of property. 3. Use of cayenne pepper defense spray is limited to the exterior of the hospital buildings except in extreme cases where, regardless of the location, the officer's life or the life of another is in danger. 4. Only security officers properly trained in the use of this product may carry same on duty. Purpose: 1. To expand upon policy and procedure A-04, "Use of Force." 2. To assure that hospital security officers are able to protect themselves with non-lethal force in the event of a personal attack. 3. To assure that this protection mechanism is used only under extreme circumstances where an officer's life or safety may be in danger. Procedural Steps: Self Protection/Protection of Others, Reasonably evaluate the potential danger to yourself and the possibility of contamination of the atmosphere by the cayenne pepper self-defense spray. You may use only enough force to protect yourself, no more. If possible or practical, retreat or comply with a reasonable demand. If possible, call for backup by fell ow officers and/or help from the (local) Bureau of Police. If absolutely necessary to protect the officer's life or the life of another person, direct the cayenne pepper self-defense spray toward the face or [sic] the actor from a three (3) foot distance. Use the double tap method (spray again after actor attempts to open eyes), if necessary and then use only the amount of force necessary to gain and maintain physical control of the individual: no more. Remember, after use of the product, you may need to prevent the actor from injuring himself. Call immediately for police to arrest the actor and then process as a patient in ED (emergency department) to flush eyes. Be sure to have police file charges. Document event on Safety and Security Incident Report Form and notify on-duty/call Senior Officer to discuss event, ensuring all requirements of the P and P have been met. ... Training - All training shall be conducted by a certified police instructor for the product to be used. No exceptions. ..."

1) Review on July 10, 2012, of MR1 revealed MR1 was out of control in the seclusion room. While staff were escorting MR1 to another seclusion room MR1 began to physically attack staff. MR1 was maced by a hospital security guard. Local police arrived and MR1 was escorted by police and facility staff to the emergency department for evaluation. After treatment in the emergency department, MR1 was returned to the Inpatient Behavioral Unit (IBU) with facility staff and security guards accompanying MR1.

Review of the facility's "Safety and Security Department Incident Report" of June 25, 2012, completed by PF2 revealed PF2 was called to the IBU at 5:59 PM on June 25, 2012. PF2 and local police officers assisted staff in escorting MR1 to his room where medication was given to MR1. PF2 and local police officers assisted staff in escorting MR1 to the seclusion room. PF2 was called to the IBU again at 6:00 PM on June 25, 2012. MR1 had destroyed a bed frame in the seclusion room. MR1 was punching, kicking and banging on the door and yelling obscenities. Staff was concerned for MR1's safety and the decision was made to move MR1 to the other seclusion room. The bed frame was removed from the second room for added safety. The door to the seclusion room was opened with five staff present. MR1 became very violent and began striking anyone close to MR1. PF2 received a hard blow to the left temple and jaw area. PF2 saw that MR1 was on top of PF3, striking PF3 on the head and back. PF2 felt that the safety of staff was in severe jeopardy and made the decision to use the mace. MR1 immediately stopped their assault after sprayed with the mace. MR1 was then placed in the secure room. Regional police officers arrived to the area, secured MR1 with handcuffs, and transported MR1 to the emergency department at a local hospital. PF2 was also transported to the emergency room for evaluation due to their injuries.

Interview with EMP2 and EMP3 on July 10, 2012, at 10:30 AM confirmed a hospital security guard sprayed mace into the face of MR1 when the patient began physically attacking the security guard on June 25, 2012. EMP2 stated PF2 did not want to press charges against MR1 for the attack, as the patient was receiving treatment for psychiatric issues. EMP2 and EMP3 also confirmed the facility had a policy for the use of Cayenne Pepper Self-Defense Spray, and PF2 was authorized to carry and use the Cayenne Pepper Self-Defense Spray.

Interview with EMP1 on July 10, 2012, at 11:50 AM confirmed a hospital security guard sprayed mace into MR1's face during a behavior outburst on June 25, 2012. Police officers then escorted MR1 to the emergency department of another hospital for treatment of MR1's eyes, due to the mace. After treatment, MR1 was returned to the IBU by hospital security staff.

Interview of EMP4 on July 10, 2012 at 1:40 PM confirmed MR1 was sprayed with Cayenne Pepper Self-Defense Spray by a hospital security guard on June 25, 2012. EMP4 confirmed MR1 was out of control and hitting the security officer.

2) Review on July 10, 2012, of MR2 revealed MR2 had a history of a traumatic brain injury and had limited cognitive ability, expressive aphasia (impairment of language ability), and impaired insight and judgment. On June 25, 2012, MR2 was punched on the left lower jaw by MR1, knocking MR2 to the floor. MR2 was sent via EMS (Emergency Medical Services) to the emergency department for evaluation and treatment. Further review of MR2 revealed that MR2 had an order, dated May 2, 2012, for modified 1:1 supervision, which involved staff remaining within view of MR2 at all times.

Interview with EMP1 on July 10, 2012, revealed MR2 was assigned a staff member to be present with them at all times to provide monitoring due to effects from the patient's head injury. This staff was unable to intervene and prevent the attack on MR2 by MR1.

Interview with EMP5 at 10:30 AM on July 13, 2012, confirmed that MR1 was on modified 1:1 staff supervision on June 25, 2012. EMP5 stated this meant that the 1:1 staff was to remain within view of MR2 at all times and was to oversee MR2's social interactions and intervene if necessary.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure the least restrictive intervention was implemented to protect the patient or others from harm in one of one medical record reviewed (MR1).

Findings include:

Review on July 10, 2012, of the facility's "Restraint/Seclusion" policy, last reviewed July 7, 2012, revealed "Purpose: To assure the right of the patient to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. Restraint and Seclusion, I. Definitions A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. 1. Exemptions - the following are not considered restraint under this policy: ... e. Forensic and correction restrictions used for security. A law enforcement officer will be present at all times when these devices are used on patients. SH (Susquehanna Health) Safety and Security Officers will not use handcuffs on patients. ... III. General Guidelines ... B. Alternatives to restraint: ... 4. When restraint is indicated, the least restrictive method of restraint will be chosen. ..."

Review on July 10, 2012, of MR1 revealed on June 25, 2012, MR1 had three behavioral dyscontrol episodes which were not controlled by medication or seclusion. During the third episode MR1 was maced by hospital security staff. MR1 was escorted by police to the emergency department for treatment. Hospital security and staff returned MR1 to the facility after their emergency department visit.

Interview of EMP2 and EMP3 on July 10, 2012, at 10:30 AM confirmed the hospital security staff maced MR1 during a behavioral dyscontrol episode on June 25, 2012.

Interview of EMP1 on July 10, 2012, at 11:50 AM confirmed MR1 was maced by hospital security staff on June 25, 2012. EMP1 also confirmed that medication and seclusion were attempted to control MR1's behavior, without success. EMP1 stated the use of four-point restraints was not considered.

Interview of EMP4 on July 10, 2012 at 1:40 PM revealed that on June 25, 2012, MR1 had received several doses of prn (as needed) medications and was placed into seclusion in an attempt to control the patient's agitated, aggressive behaviors. EMP4 considered the use of four-point restraints to be more restrictive than the medication and seclusion.

Cross reference
482.13(c)(2) Patient Rights: Care in Safe Setting