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.

LAKESIDE BEHAVIORAL HEALTH SYSTEM 2911 BRUNSWICK RD MEMPHIS, TN Feb. 13, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on facility policy, document review, record review, observation and interview, it was determined the facility failed to follow policies for patients' rights, protect patients from abuse neglect, promote patient rights to be free from physical restraints and seclusion, ensure all allegations of abuse neglect were investigated and ensure that all patients were protected from injuries.
The failure of the facility to protect patients from abuse neglect, provide care in a manner that prevented injuries, promote all rights for minor adolescent patients with low mental functioning and thoroughly investigate all allegations resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in an IMMEDIATE JEOPARDY and at risk for serious injuries and/or death.

The findings included:

1. The facility failed to follow policies and procedures to ensure all patients were free from abuse neglect.
Refer to A 145.

2. The facility failed to ensure all allegations of abuse neglect were thoroughly investigated.
Refer to A145 and A154.

3. The facility failed to ensure all patient rights to be free from restraints and seclusion were promoted.
Refer to A 154.
VIOLATION: GOVERNING BODY Tag No: A0043
Intakes: TN 918, TN 212
Based on policy review, document review, record review, observation and interview, it was determined the Governing Body failed to assume responsibility and provide oversight of the hospital to ensure all patient rights were promoted.
The failure of the Governing Body to assume responsibility and provide oversight resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in an IMMEDIATE JEOPARDY and at risk for serious injuries and/or death.

The findings included:

1. The Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible and ensured the safety of the patients in the hospital.
Refer to A057.

2. The Governing Body failed to be responsible and ensure all patients' right to be from abuse neglect, restraints and seclusion were promoted.
Refer to A145 and A154.

3. The Governing Body failed to ensure policies were implemented to ensure all patients were free of abuse neglect, restraints and seclusion and protected from injuries. The Governing Body failed to ensure the parent and/or guardian made all the decisions in an incident of sexual contact in accordance with facility policy.
Refer to A115, A145 and A 154.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, document review, record review, observation and interview, it was determined the Chief Executive Officer (CEO) failed to be responsible for the management of the hospital, ensure all patients rights to be free from all forms of abuse and restraints were promoted for 4 of 6 (Patients #1, 3, 5 and 6) sampled patients.

The findings included:

1. Record review revealed Patient #1 was a [AGE] year old patient with mental retardation and functioned at a 7 year old level. On admission the patient was identified to be at Imminent Risk for Sexual behaviors and required LOS supervision with peers. On 8/20/13 Patient #1 was not monitored appropriately and was in a male peer's room unsupervised for over an hour. The patient reported she and the male peer had sexual contact. Patient #1 also made an allegation that a staff member hurt her.
There was no documentation the incidents were appropriately investigated and reported. There was no documentation the patient's mother was allowed to "make all the decisions" in accordance with facility policy. The patient was not protected from abuse neglect.
Refer to A 145.

2. Record review revealed Patient #3 was a [AGE] year old male with Autism and documented to function at a 7 year old level. The patient was identified to be at Imminent risk for Suicidal, Homicidal and Psychotic problems The patient required LOS supervision. On 8/20/13 a female patient was in Patient #3's room for over an hour. The patient reported he and the female peer had sexual contact and intercourse. The mother stated reported the patient had not had sex prior to this incident.
There was no documentation the patient was appropriately physically assessed in accordance with the facility policy. The facility failed to ensure the patient was free of abuse neglect.
Refer to A 145.

3. Record review revealed Patient #6 was involuntarily admitted because he required supervision for protection and safety. On 2 occasions the facility inappropriately used restraints and seclusion resulting in the patient sustaining rib fractures. The facility failed to protect the patient from abuse neglect. The patient was not timely assessed and injuries treated timely.
Refer to A145 and A 145.

4. Record review revealed Patient #5 was an involuntary admission to the facility. The patient's mother filed a complaint on the patient's behalf and alleged the patient's physician yelled at the patient.
There was no documentation this allegation was investigated. There was no documentation the patient was protected from potential abuse neglect.
Refer to A 145.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, document review, medical record review and interview, the facility failed to follow its policy for investigation and resolution of grievances/complaints for 2 of 6 (Patient #1 and 5) sampled patients.

The findings included:

1. Review of the facility's "Grievance Policy" documented, "[The facility's name] provides an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients. All patients and their families have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately... Objective: To respond quickly and appropriately to patient/family concerns and to maintain high ethical standards. (within 24 hours)... The Patient Advocate will respond directly to the concern and document the actions/response... If the grievance cannot be resolved with the Patient Advocate, the Chief Clinical Officer and The Director of Nursing will be notified and will meet with the patient/family... Once the issue has been resolved, the Patient Advocate will provide the family/patient a written response."

2. Review of the facility's documentation revealed Patient #1 made an allegation on 8/22/13 that a Community Counselor (CC) "that found them [Patient #1 and #3] in her room [on 8/20/13]grabbed her arm in the hallway as she was leaving her room and her arm was now beginning to hurt..."

During a telephone interview on 2/10/14 at 12:30 PM the DRC/Q stated the investigation for that allegation was, "We watched the video and determined that her allegation did not occur and we x-rayed her wrist and there were no fractures." The DRC/Q stated this was included in the 8/20/13 incident investigation report.

There was no documentation of an investigation or assessment, other than watching the video and obtaining an x-ray of the patient's wrist. Patient #1 was assessed to have bruises on her bilateral arms when transferred to Hospital #2 on 8/21/13.

3. Record review revealed Patient #5 was a [AGE] year old female involuntarily admitted to the facility on [DATE]. The patient's diagnoses included Psychotic Disorder and Personality Disorder.

An interview was conducted on 12/4/13 at 2:45 PM with the Director of Risk/Quality and the Director of Clinical Services related to the facility's system for investigating complaints and allegations of abuse. Review of the complaint log documented Patient #5's mother filed a complaint dated 8/26/13 alleging that Patient #5's physician yelled at the patient and other complaints that included the patient did not want to take the medications prescribed due to weight gain.
The Director of Clinical Services/LCSW provided a copy of the full investigation and actions taken regarding the mother's allegations.

Review of the 8/26/13 investigation into the allegations revealed there was no documentation the allegation against the physician yelling at Patient #5 had been investigated.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, document review, videotape review, record review, observation and interview, the facility failed to protect all patients from abuse, neglect and injuries, to adequately monitor high risk patients, to fully investigate all occurrences and all allegations of abuse and to appropriately assess patients after occurrences and incidents for 4 of 6 (Patients #1, 3, 5 and 6) sampled patients.
Failure of the facility to ensure patients were free from all forms of abuse resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries.

The findings included:

1. The facility's Patient Abuse or Neglect policy documented, "...Inappropriate staff conduct may include,but is not limited to... Not performing duties safely, omitting needed care and treatment... The patient or anyone aware may report incidents of inappropriate staff conduct... It will be the responsibility of the respective supervisor(s) or department head(s) to evaluate the nature and severity of the claim..."

The facility's Alleged Patient Abuse, Neglect, Exploitation policy documented, "...It is the policy of [Hospital #1] to report all incidents of patient abuse, neglect, and exploitation as soon as possible to appropriate agencies... The definition for 'Abuse' includes... rape or sexual assault of a patient... striking of a patient... the use of excessive force when placing a patient in bodily restraints... The definition for 'Neglect' includes... The failure to provide a safe environment for a patient, including the failure to maintain adequate numbers of appropriately trained staff... A Nursing assessment /reassessment post incident will be completed... In the case of a patient who is under [AGE]...the parent and/or guardian will be contacted to make all the decisions..."

The facility's Risk Reduction Guidelines policy documented, "...line of sight observation, where staff maintain a close physical proximity to the patient (a distance that allows staff to take immediate action if necessary)... A progress note entry by nursing staff should be documented in the medical record at least every shift, reflecting the patient's behavior, condition, mood and conversation... If at any time the Charge RN determines a patient may need increased staff supervision... the RN will take action to provide the additional supervision ... and contact the attending physician/designee for appropriate orders..."

The facility's Patient Observation Policy documented the Community Counselors were responsible to "...Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities...While monitoring hallways and patient care areas ensure patients are...not entering rooms not assigned to them...Observe patients on bed rest or when sleeping by...looking for the rise and fall of the chest...counting at least three respirations and making sure that the patient has moved from his/her previous sleeping position..."

The facility's Patient Care Classification System policy revealed designation of levels of supervision some patients may require: Care Class III - Special Observation (15-minute Checks)... may be ordered for patients... who are identified as moderate to low risk requiring a heightened or intermediate level of supervision a minimum of every 15-minutes... Special observations are defined for patients with acute suicidal, homicidal, assault, elopement, sexual aggression, sexual victimization, fall, medically compromised... and seizure risk... Care Class IV - Special Precautions (1:1 or Line of Sight)... may be ordered for patients... who are identified as high risk requiring an intensive level of supervision, as either 1:1 or line of sight [LOS]. Special precautions are defined for patients with acute suicidal, homicidal, assault, elopement, sexual aggression, sexual victimization... medically compromised... and seizure risk... Includes any patient who is involuntary prior to court date (unless otherwise ordered by the Physician)... If identified as sexual victimization or sexual perpetrator, may be given peer restrictions... Patients who are homicidal or suicidal and considered a high risk for elopement... Band Levels... Patients on a yellow band level require a nursing note a minimum of one (1) time per 24 hours... Red band level... level require a nursing note a minimum of once every eight (8) hours..."

2. Medical record review for Patient #1 and Patient #2 revealed:

a) Patient #1 was admitted to Hospital #4 on 8/14/13 with seizures and attempted suicide. The patient was transferred to Hospital #1 and was admitted on [DATE] for psychiatric treatment. Patient #1 was diagnosed with Mood Disorder, Post Traumatic Stress Disorder, Borderline Intellectual Functioning, Epilepsy with Grand Mal Seizures and a History of Sexual and Physical Abuse.

The 8/15/13 Comprehensive Psychosocial Assessment documented "...pt reports wanting to die on a regular basis ...extreme physical and sexual abuse ...hx of psychosis, sua [suicide] attempts and seizures....suicide attempt yesterday...cannot function in mainstream school...mildly delusional...poor impulse control...home [homicidal] thoughts and desires to hurt someone..."

The 8/15/13 INITIAL EVALUATION OF RISK TO SELF /OTHERS assessment documented, "...pt very hypersexual... mildly delusional...sexual aggression ...victim of sexual abuse..."

The High Risk Notification Alert documented the patient was at "Imminent Risk...Suicidal/Harm to Self...Homicidal/Harm to Others...Psychotic delusional...Sexual Acting Out...Seizures..."

The Adolescent unit was notified of these assessed problems and risks upon admission to the unit on 8/15/13 at 11:30 AM.

The 8/15/13 Comprehensive Nursing Assessment documented the patient had frontal lobe brain damage resulting from the physical abuse and "...MR [mental retardation]... functions as 7 y/o [year old]..." The Body Identification Marks section of the assessment documented there were no "Lacerations... Abrasions... Scars... Burns... Moles/Birthmarks... Bruises... Other..." on the patient's body.

The 8/15/13 to 8/19/13 daily Medical Doctor (MD) orders documented to keep the patient in Line of Sight 24/7.

The 8/15/13 Nursing note documented at 7:30 PM the patient had Suicidal Ideations with a plan.

The 8/16/13 and 8/17/13 nursing notes documented the patient was impulsive and attention seeking.

The 8/18/13 nursing flow sheet note revealed a handwritten note at the top of the form that documented, "Watch with Selective male peer."

The 8/18/13 nursing note documented at 6:00 AM "...behavior...impulsive..."

The 8/19/13 Psychiatric Progress Note documented at 10:00 AM "...I have a crush..."

The 8/19/13 Social Service notes documented at 2:00 PM, "...Phone family session with patient's mother...She has been off her psych meds for about 3 weeks including her seizure meds due to not having insurance..."

The 8/20/14 physician's orders documented at 7:00 AM, "Special Precautions" the patient should be in line of sight (LOS) with peers.

The Nursing Flow Sheet / Progress Record nursing notes revealed there were no nursing notes documented for 8/20/13.
There was no documentation the nurse assessed or monitored the patient every 8 hours in accordance with the policy. There was no documentation in the medical record the patient was in LOS per physician's orders.

During an interview with the Administrator, DRC/Q and the NE on 2/10/14 at 12:30 PM the NE verified there were no notes for 8/20/13.

The 8/21/13 Nursing flow sheet assessment revealed RN #1 documented at 00:00 midnight on 8/20/13, "...Pt found with male pt in her room, both clothed and not touching. Pt denied initially any sexual content but recanted and said 'we did it'...." RN #1 documented the MD and mother were notified and, "...Pt placed on male peer restriction, line of sight 24/7 and never alone..." The patient was already on LOC orders.

Review of a Late Entry Note dated 8/22/13 at 12:00 PM revealed the Nurse Executive (NE) documented a late entry for 8/21/13 at 11:30 AM. The note documented at 11:30 AM the NE contacted Patient #1's mother to "update" her on the facility's process of investigation into Patient #1's alleged sexual behavior with a male peer. The NE informed the patient's mother "...that part of that process included contacting the State Department of Health as well as notifying the police department to get statements from [Patient #1's name] and the boy she was involved with. I specifically asked her permission to allow an officer to interview [Patient #1's name] in order to obtain facts of what specific events happened the previous night. [Patient #1's mother's name] stated, 'Oh yes, please do, please do...yes I want her to tell her story of what happened' I reassured her that [Facility's name] was taking this occurrence very seriously and we wanted to take all measures to ensure this never happens again...I'd like to have [Patient #1's name] call her after the interview [with] the police officer..."

The Psychiatric Progress Note documented on 8/21/13 at 10:00 AM, "...Sex [with] Patient last pm... required quiet area - cursing... remorse for upsetting mx [mother] [with] sexual bx [behavior]... 'killing anyone that pisses me off'... Transfer to ER [emergency room ] for Exam..."

The 8/21/13 physician's orders were documented as follows:
10:20 AM - "Transfer to ER for rape exam."
11:10 AM - "Order clarification Transfer to ER for rape exam for purposes of pelvic examination based on report of possible sexual activity."
1:15 PM - "Order x ray of R wrist - pt reports injury."
2:32 PM - "OK for Nurse Practitioner to do pelvic exam on the [unit at Hospital #1's name] today. D/C transfer to ER."
9:41 PM - "cervical culture for GC / Chlamydia."

The Routine Medication Administration Record documented on 8/21/13 the "Plan B 1 Step [morning after pill]" was administered at 11:00 AM to the patient. There was no documentation the mother's permission was obtained prior to administration of the medication.

The Physician's Orders revealed on 8/21/13 at 7:43 AM a Family Nurse Practitioner (FNP) note that documented, "...Client was reported to have had sexual intercourse [with] a male peer stated he penetrated her only for a minute and she performed [a sexual act] on him..." Oral exam conducted with no "lesions" noted.
A vaginal examination was performed in the facility by a FNP on 8/21/13 at 9:15 PM, almost 22 hours after the incident occurred and before the patient was transferred to Hospital #2. The FNP documented, "...Normal Pelvic Exam..."
There was no documentation a complete physical assessment was performed.
There were no other physical assessments or reassessments documented in accordance with facility policy after the incident that occurred on 8/20/13 between 10:20 PM and the time the patient was transferred to Hospital #2.

The cervical culture for Gonorrhea and Chlamydia, vaginal culture, wet prep and urine results from Hospital #1 for Patient #1 documented the collection date was 8/22/13 with no time of collection given and the results were documented as negative.
The Emergency Mobile Transport form revealed the patient left Hospital #1 on 8/21/13 at 11:05 PM and arrived at Hospital #2 on 8/21/13 at 11:30 PM.

The Mode of Transfer Transfer Authorization form dated 8/21/13 at 10:30 PM documented Patient #1 was being transferred to Hospital #2 for a "higher level of care."

The 8/22/13 physician's order documented at 9:00 AM, "Transfer to [Hospital #2] on 8/21/13."

The Discharge Summary documented, "..Intelligence below average...She was placed in a room alone and on line-of-sight while with peers secondary to vulnerable and sexual histories...8/21/13, she was noted to have eloped from her room to a male peer's room to solicit sex...family requested transfer to [Hospital #2's name]..."

Review of medical records from Hospital #2 revealed the Nursing assessment documented the patient had healed scars and "bruises" to bilateral arms. Hospital #2's psychiatric evaluation dated 8/22/13 documented, "...[Patient #1's]...intelligence is below average. Her insight and judgment are extremely poor..."

During an interview on 2/5/14 at 3:40 PM RN #2 stated she was on duty on 8/21/13, after the 8/20/13 incident and documented the above note. RN #2 stated, "[Patient #1's name] was having a melt down. She was a needy child...needed attention and she [was] mentally retarded or slow mentally. She was the initiator [of the 8/20/13 incident]...she told me that she had to show [Patient #3] how to do it and had to put his penis in her vagina...She [Patient #1] picked [Patient #3] because he was nice to her..." RN #2 stated "...I did talk with her after that and I know she [Patient #3's mother] was not happy and was concerned."

There was no documentation in the medical record regarding a "melt down" the patient was having.

There was no documentation to evidence the patient's mother was informed and immediately allowed to make all the decisions in accordance with facility policy for this minor with mental retardation and functional level of a 7 year old.
There was no documentation a complete nursing assessment or reassessment was conducted after the incident in accordance with facility policy.
There was no documentation the patient's mother was informed she had the right to be present during the police and facility questioning of the minor child or that the patient's mother had the right "to make all decisions" concerning examinations and medications.

b) Patient #3 was a [AGE] year old male who (MDS) dated [DATE] and was admitted on [DATE] with diagnoses that included Mood Disorder, psychotic Disorder, Pervasive Developmental Disorder and Asthma.

The 8/11/13 Comprehensive Psychosocial Assessment documented at 6:00 PM, "...Suicidal ideations with a plan ...Patient stated he wants to do bad things because his brother died (2008)...Homicidal ideations with a plan ...hearing sounds and whispers ...seeing ghosts talking to somebody else ...afraid he will hurt them ...judgment poor ...insight poor..."

The 8/11/13 Initial Evaluation of Risk to Self/Others documented, "... making homicidal threats ..." and Imminent Risk for Suicidal, Homicidal and Vulnerability.

The Adolescent unit was notified on 8/12/13 at 1:30 AM per the High Risk Notification Alert form that documented, "...Suicidal/Harm to Self... Homicidal/Harm to Others... Psychotic..."

The 8/12/13 Comprehensive Nursing Assessment performed at 1:15 AM documented the patient was admitted to the Unit #1 Adolescent unit, had Asthma and was Autistic.

The 8/12/13 Psychiatrist Evaluation/Admission History and Examination documented the patient had Hallucinations, delusions, agitation, anxiety, depression resulting in significant loss of functioning...Dangerous to self, others or property with need for controlled environment...Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care..." The assessment documented the patient experienced Suicidal Ideations, Homicidal Ideations and Auditory Hallucinations.

The 8/12/13 physician's orders documented to admit the patient. The physician ordered the patient to be placed on a red band level with routine every 15 minute checks. The physician ordered "Special Precautions" requiring either 1:1 or LOS for "...Suicidal ...Homicidal ...Psychotic ...medical Issues Spider Bite... Asthma Hx [history], Autistic..."

The 8/16/13 physician's orders documented the patient was placed on "Yellow Band."

The 8/19/13 Psychiatrist progress note documented the patient was improving, "but he continues to have irritable moods and auditory hallucinations telling him to harm himself and family."

The 8/19/13 Social Service notes documented at 1:45 PM, "Met with patient to discuss his frustrations today. He shared that he has been having conflict with a peer since last night that has been picking on him...having trouble getting this peer out of his head and dealing with the resulting anger..."

The 8/21/13 physician's orders documented, "... Line of sight 24/7...All female peer restrictions...Community restriction for 24 hours...HIV, RPR, Hepatitis C panel in am...Urine for Gonorrhea/Chlamydia...Client involved in sexual intercourse [with] female peer stated he penetrated her for a few minutes and performed oral sex..." The results of the HIV, RPR, Gonorrhea and Chlamydia test were performed on 8/21/13 with negative results.

The 8/21/13 progress note revealed at 9:45 AM the Nurse Executive documented, "...Met [with] pt's mother...was very upset [and] angry, stated her son had never had sex before...stated she would be getting [Patient #3's name] out of the hospital immediately..."

Review of the 8/21/13 physician's orders documented Discharge patient today.

The 8/21/13 Discharge Summary documented, "...[Patient #3] apparently has received a diagnosis of pervasive developmental disorder in the past...During the night prior to discharge, the patient may have had an inappropriate physical interaction with a female peer. This was being investigated at the time of discharge..."

The surveyor requested the assessments for 8/20/13 and 8/21/13. There was no documentation to evidence the facility performed a complete physical assessment after the 8/20/13 incident with Patient #1. There were no nursing assessment notes from 8/20/13 at 5:45 PM through the patient's discharge. This was verified with the NE on 2/10/14 at 12:30 PM.
There was no documentation in Patient #3's medical record that the patient's supervision was increased due to his behaviors.

c) The facility's investigation summary was provided for review:

The summary revealed the Director of Risk Management (DRM) and Director of Regulatory Compliance/Quality (DRC/Q) met with Patient #1 in the Adolescent unit's dayroom. "...[Patient #1] stated she gave [Patient #3] a note Wednesday [8/21/13 - after the incident occurred] night, asking him to be her BF [boyfriend]. [Patient #1] stated she watched the pattern of the CC's [Community Counselors] doing 15 minute checks and planned on going to [Patient #3's] room Tuesday [8/20/13] night during shift change. She put a pillow and dirty clothes in her bed to look like she was still in it during the checks. She said she ran across the hall into [Patient #3's] room and woke him up. [Patient #1] stated she laid on the floor...they touched and kissed a little. She stated she fell asleep on the floor and he woke her up and they went into his bathroom. She attempted to perform [a sexual act] on him but stated she did not know how to do it. She stated she had seen [this sexual act] performed many time while watching porn [pornographic] movies at home. She stated [Patient #3] attempted to [penetrate her anal area]...but they were unable to complete the act due to staff doing 15 minute checks. They decided to go to her room and the CC caught them going into her bathroom..."

The facility's summary revealed the DRM and the DRC/Q met with Patient #3 "...in the [Adolescent unit's name] Dayroom. [Patient #3] stated he and [Patient #1] had no plans to hook up, it just happened. [Patient #3] stated he walked by [Patient #1's] room and she gave him a note asking him to be her BF. [Patient #3] stated he was asleep when [Patient #1] came into his room and woke him up...[Patient #3] said [Patient #1] laid on the floor...so the CC could not see her. [Patient #3] stated they talked and touched each other for a long time then, they both went to the bathroom. [Patient #3] stated [Patient #1] attempted to perform [a sexual act]on him but, she did not know how. He stated he attempted to [penetrate her anal area] but did not complete the act due to staff doing checks. He stated they ran across the hall to [Patient #1's] room and he went into her bathroom. The male CC caught him going into the bathroom...."

The summary documented the DRC/Q and NE reviewed the surveillance video of the male counselor and Patient #1 coming out of her room. The facility determined there was no video evidence that the Male Community Counselor grabbed or touched Patient #1. The summary documented the police determined sexual intercourse did not occur and a rape kit would not be performed.

Review of the police report narrative dated 8/22/13 revealed no documentation that sexual intercourse had not occurred. The police report did document, "IT WAS DETERMINED THAT NO CRIME HAD BEEN COMMITTED."

Review of a facility statement dated 8/21/13 revealed Staff #3 documented he/she worked the 3 to 11 shift on the same unit that Patient #1 and Patient #3 were admitted . Staff #3 documented he/she "...noticed [Patient #1]...being flirtatious and inappropriate with her male peers...(speaking/talking). I often this day had to redirect this pt [patient] from boys...the day room had male [and] females together they were separated [and]...at one point we only had a counselor [and] nurse. that's why they were in the dayroom at one point, the other times it was more staff..."

There was no documentation in the facility's investigation that addressed these staffing issues during the day in the dayroom.

d) Surveyor review of Hospital #1's surveillance video recording related to the 8/20/13 incident between Patient #1 and Patient #3 revealed the following:

At 22:29 [10:29 PM] Patient #1 was observed to exiting from her room (2nd door on the right), go across the hallway and enter the 3rd door on the left which was Patient #3's room.

Between 22:44 [10:41] - 23:43 [11:43], the facility staff were observed going to each patient's doorway and standing briefly during the every 15 minute checks. There was no indication the staff were aware that Patient #1 was not in her room and was present in Patient #3's room for 1 hour and 12 minutes.

At 23:41 [11:41 PM] Patient #1 and Patient #3 were observed to exit Patient #3's room and enter Patient #2's room.

At 23:43:47 [11:43 PM] Staff #2 was observed entering Patient #1's room. Patient #1 was observed exiting through the right side of the doorway into the hallway. The patient's hair was swinging out and her arms were bent up with her hands at ear/neck area. As the patient turned to the left and began to walk towards the nursing station, the patient's left side was close to the hallway wall. As the patient walked down the hallway toward the nursing station, the patient's arms and hands were coming down from her ear/neck area.

An interview was conducted on 2/10/14 at 12:30 PM with the CEO, NE and DRC/Q present. The DRC/Q stated there were no other incidents that occurred with Patient #1 or Patient #3, other than Patient #1 made an allegation to the police. The DRC/Q stated Patient #1 told the police that the CC threw her against the wall and hurt her wrist. The DRC/Q stated she was unaware of this allegation until the patient reported it to the police. The DRC/Q stated the investigation for that allegation consisted of, "We watched the video and determined that her allegation did not occur and we x-rayed her wrist and there were no fractures." The DRC/Q stated this is the allegation in the summary report.

On 2/13/14 at 1:30 PM, the surveyor informed the facility that upon the surveyor's review of the video, it could not be determined if the alleged incident occurred or not due to the lack of clarity of the video picture. The facility had no response.

During a telephone interview on 2/11/14 at 2:30 PM Staff member #2 stated he found Patient #3 in Patient #1's room on the night of 8/20/13. Staff member #2 stated, "They were standing looking at each other in front of the bathroom. I talked with [Patient #3's name] and her [Patient #1] in the day room." Staff member #2 stated that Patient #1 had an attitude, kinda like she didn't care. But she came on out to the hallway..."

There was no documentation of an investigation or assessment, other than reviewing the video and an x-ray of the wrist. Patient #1 had bruised upon transfer and arrival at Hospital #2.

There was no documentation a physical assessment was conducted and all staff interviewed to determine if the male counselor had pushed and grabbed Patient #1 as she was exiting her room.

An interview was conducted on 2/5/14 from 7:00 PM to 7:30 PM with the Risk Manager, DRC/Q, CEO and NE. The NE stated the facility policy was to physically observe the rise and fall of 3 breaths on each patient when the staff are making the every 15 minute checks.

The facility staff failed to appropriately monitor the patients every 15 minutes as evidenced by failing to see 3 breaths rise and fall during the every 15 minute checks and in accordance with the facility's policy. The facility failed to ensure the patients were in line of sight with peers.

e) A tour of the facility was conducted on 2/5/14 beginning at 2:30 PM with the DRC/Q and the NE. The NE stated the girls and boys were usually separated on the hallway by a clear door that divided them. The unit had been flooded during the time that Patient #1 and #3 were admitted to the facility and both boys and girls were put on the same hallway during that time.

f) There was no documentation a full assessment and investigation into the lack of appropriate monitoring for Patient #1 and Patient #3,, or investigations of allegations of abuse, provision of safety, interventions, family involvement in decision making and adequate review and interpretation of video surveillance.

3. Record review revealed Patient #5 was a [AGE] year old female involuntarily admitted to the facility on [DATE]. The patient's diagnoses included Psychotic Disorder and Personality Disorder.

An interview was conducted on 12/4/13 at 2:45 PM with the Director of Risk/Quality and the Director of Clinical Services related to the facility's system for investigating complaints and allegations of abuse.

Review of the complaint log documented Patient #5's mother filed a complaint dated 8/26/13 alleging that Patient #5's physician yelled at the patient and other complaints that included the patient did not want to take the medications prescribed due to weight gain.

When requested by the surveyor for the 8/26/13 investigation into the allegations revealed there was no documentation the allegation against the physician yelling at Patient #5 had been investigated.

4. Medical record review revealed Patient #6 was a [AGE] year old male admitted to the facility on [DATE]. The patient's diagnoses included Paranoid Schizophrenia, Drug Abuse, Noncompliance with medications, History of Physical Abuse, Hypertension and Gastroesophageal Reflux. The patient was deemed to require involuntary admission to the facility for patient safety.

The 12/26/14 Physician Orders revealed the following orders:
Involuntary admission, Red Band level, Special Observations with every 15 minute checks related to the patient's "Suicidal [and] Psychotic" risk factors.

The 12/26/13 Comprehensive/Psychosocial Assessment documented at 1:25 PM, "...He's paranoid and depressed, wishes 'God would take me'. Locking self in bedroom, irrational fears that mother is in danger and hypervigilantly watching her...the patient won't let mother go to bathroom alone." The assessment documented the patient was rambling, talking to self, had paranoid/delusional thought content, poor judgment/decisions and limited coping skills.

Review of the 12/26/13 Involuntary Certificate for Need documented at 6:03 PM, The "Pt [patient] needs safety [and] security of inpatient facility..."

The 12/26/13 Initial Evaluation of Risk to Self/Others assessment conducted as a result of the Comprehensive Psychosocial assessment documented the patient was an "Imminent Risk" of "...Suicide/Homicide/Assaultive Behavior/Vulnerability."

The High Risk Notification Alert documented the patient was at high risk of "Suicidal/Harm to self...Psychotic [and an] ELOPEMENT RISK..." and this was reported 6:37 PM to RN #4 who was the Charge Nurse when the patient arrived on the admitting unit.

The 12/26/13 nursing note documented at 8:00 PM the patient went outside to smoke on the patio and refused to come in when asked to by the staff. The patient grabbed the bars on the fence and staff had to physically pry his hands loose, pick him up and carry him inside.

The 12/26/13 Seclusion / Restraint Order/Record documented at 8:05 PM a "Physical Restraint" was implemented with the "Clinical Justification for Intervention" because the patient was a "Danger to Self...Pt gripping bars on smoke patio refusing to release in process caused skin abrasions to self...Trying to elope through smoke patio smoke bars...Current physical/medical status...Complaint of injury sustained from intervention...Abrasions on both arms. [right] forearm skin tear [right] elbow abrasion. Abrasion [left] antecubital area..."

The 12/27/13 Nursing Flow Sheet note documented at 9:40 AM, "...Pt anxious and pacing unit; exit - seeking. Pt increasing agitation and became more difficult to redirect..."

The 12/27/13 Seclusion /Restraint Order/Record documented at 9:48 AM another Physical Restraint was implemented on the patient.

On 12/27/13 the nursing admission assessment was completed by the unit DON and the patient complained of "L [left] rib" pain for a day. An x-ray was ordered.

The 12/27/13 chest x-ray performed due to "chest pain" documented the report was read at 4:42 PM. The results documented, "...Nondisplaced fractures left 5th and 6th ribs laterally...Impression...Fractures of left ribs..."

The 12/27/13 "Physician's Orders" documented at 4:35 PM, "...icepacks to bruising on bilateral upper extremities...silvadene ointment...to ruptured blister...Nurses check blisters on hand for rupture...Bactroban to abrasions on bilateral upper extremities...CXR...trauma L chest..."

The 12/27/13 "Physician's Orders" documented at 9:05 PM "...Lortab...[every 6 hours as needed]...pain..."

The 12/28/13 "Physician's Orders" documented at 6:43 PM "...Pt has Fractures...Please avoid direct contact and pressure..."

The 12/28/13 "Consultation / Physical Evaluation" documented the patient had a history of MVA 20 years ago resulting in a back injury with surgical rods placed on the patient's spine.

The 12/31/13 Group Therapy Notes from 3:30 PM to 4:30 PM documented Patient #6 stated, "One way I cope with my mental illness is" I like to be outside."

Surveyor review of the 12/26/13 video revealed at "19:55:20 [7:55 PM]" Patient #6 was observed lying on the concrete floor of the smoking patio. Four male staff members were observed picking the patient up from the floor, each staff member holding an extremity, and walking toward the entrance of the building. The staff were observed lowering the patient onto the concrete floor and lifting him up again 4 times. When they reached the entrance door, one staff member opened the door and the other 3 staff members pulled the patient up from the concrete and carried him into the facility. While the patient was lowered to the concrete floor, one male staff members was observed kicking towards the patient 6 times.

During an interview on 2/5/14 at 4:30 PM RN #4 stated she was the Charge Nurse on 12/26/13 and "He [Patient #6] wanted to smoke, so I let him go out to smoke because I had other stuff to take care of. I went back to get him to come in. I stood at the door to the smoking patio and called for him to come in. He wouldn't come back in and started trying to squeeze his head through the bars. I verbally talked to him trying to get him to come in [from the door of the patio] Other staff came by and went out to unlock [pry] him from the bars and I went to call the doctor, leaving them [4 staff members] out with the patient trying to pry his hands apart. The MD ordered medication to give him. It was cold outside..."

A tour of the facility was conducted on 2/5/14 beginning at 2:30 PM with the DRC/Q and the NE. Observations of the smoke patio area revealed the area was approximately 30 to 40 feet wide and 50 to 75 feet long. The entire are was enclosed with a metal bar fence. The metal bars were approximately 4 to 5 inches apart. The overhead area was also enclosed.

On 1/10/14 the facility reported to the State Department of Health an Allegations Report that documented, "On 12/26/13 a patient [Patient #6] attempted to elope from the facility...The patient required intervention by staff to le
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, document review, record review, observation and interview, the facility failed to ensure all patients received safe care to prevent injuries in a setting and appropriately used physical restraints and seclusion only when a patient was an imminent threat for 1 of 1 (Patient #6) sampled patients who was placed in physical restraints.
The failure of the facility to ensure all patients' patients received safe care to prevent injuries and appropriately use restraints and seclusion resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in an IMMEDIATE JEOPARDY and at risk for serious injuries and/or death.


The findings included:

1. Review of the Therapeutic Hold policy documented, "...to provide a safe treatment environment for all patients...A therapeutic hold...used when a patient is in imminent danger of harming him/herself or others...As part of the initial nursing assessment, the RN [Registered Nurse] will assess the patient for any special physical or medical considerations that may influence use of specific behavior management techniques..."

Review of the Seclusion [and] Restraint policy documented, "...It is the policy...to support each patients' right to be free from seclusion/restraint and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others...An emergency situation is an instance in which there is imminent risk of an individual harming him/herself or others. Such circumstances include: Physically assaultive behavior by a patient...if no immediate intervention is initiated, may result in serious injury;...a patient actively engaged in self-harm that...may result in serious injury...The patient's rights, dignity, privacy, safety, and well-being will be supported and maintained...Physical Restraints...(also named therapeutic hold, protective hold, or manual restraint)...At the time of admission, the nurse will obtain information about the patient that could help in minimizing the use of seclusion / restraint. This assessment can be documented as part of the Psycho-social Nursing Assessment or as a separate De-escalation or Safety Assessment...Components of the assessment include...Pre-existing medical conditions or any physical disabilities and limitations that would place the patient at greater risk during seclusion/restraint such as...musculoskeletal deficits...Any patient in a physical (manual) restraint will have a staff person who is not participating in the hold observing him/her for any signs of distress or incorrect holding procedures...Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not..."

2. Record review revealed Patient #6 was a [AGE] year old male admitted to the facility on [DATE]. The patient's diagnoses included Paranoid Schizophrenia, Drug Abuse, Noncompliance with medications, History of Physical Abuse, Hypertension and Gastroesophageal Reflux. The patient was deemed to require Involuntary Admission to the facility for patient safety.

Review of the 12/26/13 Involuntary Certificate for Need documented at 6:03 PM, the patient required an "Involuntary" admission to the facility because "Pt [patient] needs safety [and] security of inpatient facility..." for protection.

The Initial Evaluation of Risk to Self/Others assessment documented the patient was at "Imminent Risk" of "Suicide /Homicide/Assaultive Behavior/Vulnerability."

The High Risk Notification Alert documented the patient was at a high risk of "Suicidal/Harm to self...Psychotic [and an] ELOPEMENT RISK..."

The High Risk Notification Alert risks were reported to RN #4 the Charge Nurse at 6:37 PM when the patient arrived on the admitting unit.

The 12/26/13 Observation Record documented:
At 7:45 PM the patient was at the nurses' station.
At 8:00 PM the patient was outside in the smoking area.
At 8:15 PM the patient was outside in the smoking area.
At 8:30 PM the patient was in his room.

The 12/26/13 nursing note documented at 8:00 PM the patient went out to smoke on the patio and refused to come in. The patient grabbed the bars in the smoking area and would not come back and had to be "taken" from the smoking area.

The 12/26/13 Seclusion /Restraint Order/Record for the use of the hold used for the patient to be "taken" from the smoking area documented at 8:05 PM a physical restraint was implemented with the Clinical Justification for Intervention because the patient was a "Danger to Self...Pt gripping bars on smoke patio refusing to release in process caused skin abrasions to self..." The "Less Restrictive Interventions Attempted...Verbal de-escalation/redirection...Time out/Time away."

The One Hour Post Intervention Assessment documented at 8:15 PM the patient's behavior/emergency situation necessitating use of seclusion/restraint was "Pt gripped bars on smoke patio. Refusing to let go. Refusing directions. Trying to elope through smoke patio smoke bars..Abrasions on both arms. [right] forearm skin tear [right] elbow abrasion. Abrasion [left] antecubital area...Strategies to prevent future injuries to patient or staff: none. He held onto the bars refusing to release arms..."

There was no documentation the patient received an initial nursing assessment to assess for any special physical or medical considerations prior to the use of restraint/seclusion in accordance with the facility policy. There was no documentation the patient was an imminent threat to himself or others. There was no documentation a staff member observed the patient during the restraint/hold for signs of distress of incorrect hold procedures.

The 12/27/13 Nursing Flow Sheet note documented at 9:40 AM the patient was physically restrained due to, "...Pt anxious and pacing unit; exit - seeking. Pt increasing agitation and became more difficult to redirect..."

The 12/27/13 Seclusion /Restraint Order /Record documented at 9:48 AM a physical restraint was implemented with the Clinical Justification for Intervention because the patient was a "Danger to Self ... Attempting to elope, hostile [and] aggressive" The assessment documented the Less Restrictive Interventions Attempted were "Verbal de-escalation/redirection ... Reality orientation ...1:1 processing."

The 10:51 AM One Hour Post Intervention Assessment documented the patient's behavior/emergency situation necessitating use of seclusion/restraint was, "Pt attempting to elope from unit. Pt escalating refusing to leave ladies dayroom. Pt walking up to staff in threatening manner." The assessment documented the use of the restraint was appropriate. The Patient reaction to intervention was, "...Pt yelling for staff to 'let him go..."

There was no documentation the patient received an initial nursing assessment to identify any special physical or medical considerations prior to the use of restraint/seclusion in accordance with the facility policy. The patient was on a locked unit related to his involuntary admission status. There was no documentation the patient was an imminent threat to himself or others.

Review of the patient's Nursing Assessment revealed the assessment was not completed until 12/27/13 at 3:00 PM. The COMPREHENSIVE ASSESSMENT TOOL Admission Nursing Assessment documented, "...Patient is out of contact [at] present will not answer questions..." The Body Identification Marks section documented the patient had bruises cuts and abrasions to both the left and right arms and abrasions to the buttocks area. The patient also had old scars to the back from previous back surgeries.

The 12/28/13 Consultation /Physical Evaluation documented the patient had a history of MVA 20 years ago resulting in a back injury with surgical rods placed on the patient's spine.

3. Review of the facility's investigation regarding the 12/26/13 incident with Patient #6 revealed the NE documented a statement on 12/27/13. The NE documented, "It was reported to me today [12/27/13] that there was a therapeutic hold...on [Patient #6's name] during the 3-11 shift on 12/26/13. Upon investigation...he [Patient #6's name] had rib pain...The x-ray report results confirmed that [Patient #6's name] did have 2 fractured ribs..."

4. Review of the 12/26/13 video revealed at 19:55:20 [7:55 PM] Patient #6 was lying on the concrete floor of the smoking patio. At 7:55 PM, four male staff members were observed entering the smoking patio. The four men took hold of each of the patients' extremities and lifted the patient from the floor and carried him toward the facility door entrance. The four men were observed lowering the patient back to the floor, then lifting him again on 4 different occasions. Staff member #4 was observed kicking upward and toward the patient 6 times as they taking him to the facility entrance. As they got to the facility entrance door, one male staff member opened the door while the three other male staff members continued to pull the patient into the facility. There was no observation on the video of a staff member, who was not participating in the restraint/hold observing the patient for signs of distress or for incorrect hold procedures.

5. During an interview on 2/5/14 at 9:00 AM when the surveyor questioned about the incident, Staff #5 stated Patient #6 arrived on the unit, walked outside onto the smoking patio and stated when RN #4 asked the patient to come back inside, the patient refused to come in. Staff #5 stated, "He [Patient #6] was holding the fence and locked to it with [his] legs and arms, trying to get his head through [the bars of the fence]"

During an interview on 2/5/14 at 9:30 AM when RN #3 was questioned about the incident the RN stated, "He [Patient #6] went out to smoke and wouldn't come back in. He was out there about 30 minutes..."

During an interview on 2/5/14 at 6:00 PM when Staff Member #6 was questioned about the incident the staff member stated, "...I knew we weren't handling him [Patient #6] right, but they [other staff] had been here longer than me..."

During an interview on 2/5/14 at 4:15 PM when questioned about the incident RN #3 stated after the incident on the smoke patio, Patient #6 was taken to the "Seclusion room [with] the door open...One of the techs stayed at the door..." RN #3 stated they wanted to "clarify if we could let him out or put him in seclusion..."

During an interview on 2/5/14 at 4:30 PM when questioned about the incident RN #4 stated she was the Charge Nurse on 12/26/13 and, "He [Patient #6] wanted to smoke, so I let him go out to smoke because I had other stuff to take care of. I went back to get him to come in. I stood at the door to the smoking patio and called for him to come in. He wouldn't come back in and started trying to squeeze his head through the bars. I verbally talked to him trying to get him to come in [from the door of the patio] Other staff came by and went out to unlock him from the bars and I went to call the doctor, leaving them [4 staff members] out with the patient trying to pry his hands apart. The MD ordered medication to give him. It was cold outside..."

RN #4 was asked how the decision was made to forcefully bring the patient in, potentially risking injury to the patient versus the risk of injury related to his behaviors in refusing to come back in the facility. RN#4 stated "I guess I should have called the MD and got medication to administer to him in the smoke area."

During an interview on 2/11/14 at 9:00 AM when questioned about the incident, Staff Member #4 stated, "Trying to get the man [Patient #6] from outside..."
Staff member #4 is no longer employed at the facility related to allegations the he (Staff member #6) kicked Patient #6, Six (6) times during the incident.