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.

SALT LAKE BEHAVIORAL HEALTH 3802 SOUTH 700 EAST SALT LAKE CITY, UT April 3, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review, review of polices and interviews it was determined that the governing body failed to ensure that the facility protected and promoted each patients rights and failed to ensure that a patient was discharged to an appropriate facility.

Findings include:

Based on 10 record reviews, review of policies pertaining to patient rights and interviews with 3 staff members, it was determined that the facility failed to protect and promote patient's rights for 1 out of 11 sampled patients. (refer to Tags A 115, A 122, A 123 and tag A 131)

Based on 4 facility interviews and 10 record reviews it was determined that the facility failed to discharge a patient appropriately, which put staff, the patient and other residents at risk for 1 out of 10 sampled patients. (Refer to Tags A 799 and A837)
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, review of policies and interviews, it was determined that the facility failed to protect and promote each patient's rights for 1 out of ten sampled patients.

Findings include:

1. Based on record review and interview it was determined that the facility did not inform a patient's guardian of a significant occurrence in a patient's hospitalization for 1 patient out of 10 sampled patients.
(See tag A 131)

2. Based on facility policy review and interview, it was determined that the facility did not specify time frames for review of grievances and for the provision of a response. (See tag A 122)

3. Based on interview and a review of facility records, it was determined that the facility did not always supply written notice of its decisions that contain the steps taken for the investigation and the results or the date of completion for grievances. (See tag A 123)
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on a review of facility policy and interview, it was determined that the facility did not specify time frames for review of grievances and for the provision of a response.

Findings include:

A review of the facility "Patient and Family Grievance/ The Role of the Patient Advocate" policy was completed on 3/27/12. The policy did not have specified time frames for resolving and responding to grievances.

On 3/19/12 at 1:22 PM, an interview was held with the facility Risk Manager. He stated that he was not aware of the need to have specified time frames for resolving and responding to grievances. In addition he stated that the "Patient and Family Grievance/ The Role of the Patient Advocate" was the policy on how to handle
grievances.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview and a review of facility records, it was determined that the facility did not always supply written notice of its decisions that contains the steps taken for the investigation and the results or the date of completion for grievances. (Patient identifier: Supplemental patient 13)

Findings include:

On 3/22/12, the patient complaint/grievance log was reviewed. There was no documentation that letters had been sent to any of the complainants.

On 3/22/12, documentation of a resolved complaint by supplemental patient 13 (who had been an inpatient in October of 2011) was reviewed. No written notice of the facility's decision was found.

On 3/22/12, the Risk Manager was interviewed. He stated that he contacted patient 13 and "informed her" of the decision verbally. He stated that he doesn't always send written notices to the complainants.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, it was determined that the facility did not inform a patient's guardian of a significant occurrence in the hospitalization of a patient for 1 patient out of 10 sampled patients. (Patient identifier: 4)

Findings include:

1. On 3/21/12, patient 4's medical chart was reviewed.

Patient 4, who was a female under the age of 18 years, was admitted on [DATE] with diagnoses that included suicidal ideation, bi-polar disorder, borderline personality traits, and polysubstance abuse. Patient 4's guardian was her mother.

A "Registered Nurse (RN) Daily Reassessment/Progress Note" dated 3/4/2012, at 7:00 AM, was reviewed. It was documented that patient 4 "became very stressed when things escalated on the unit...When (patient 4) had a chance to be alone (patient 4) found a way to tie (her) blanket towards the middle of the sink where (she) tried to hang herself...(Patient 4) received some bruising on (her) neck from the attempt to hang (herself)."

An "Interdisciplinary Progress Note" dated 3/5/12 at 5:50 PM, was reviewed. It was documented that patient 4's Mother "was angry stating (patient 4) tried to hang (herself) last night & Mom got no call about this." In addition, it was documented that patient 4's Mother stated that she had not received any information on the plan of treatment since patient 4s admission on 3/2/12.

A"Care Plan" formulated on 3/4/12 was reviewed. It was documented that it was discussed with patient 4's Mother via telephone on 3/5/12 at 5:50 PM.

It was documented on a "Consent for Treatment Medication" form dated 3/3/12 at 1:20 AM, that patient 4's psychiatrist ordered "Seroquel" for the patient and that the Mom was notified of the need for this medication.

There was no documentation in patient 4's medical chart that patient 4's Mother or psychiatrist were notified of patient 4's attempt at suicide.

2. On 3/21/12, an incident report dated 3/4/12 at 5:00 AM, for patient 4 was reviewed. It was documented that patient 4 tried to hang herself on 3/3/12 at 8:30 PM. It was documented that patient 4 and her roommate told the nurse of patient 4's attempt at hanging herself in the bathroom. It was documented that another nurse told the first nurse "that the blanket tied to the sink was a serious and dangerous situation." There was no documentation that the Psychiatrist or that patient 4's Mother had been notified of patient 4's suicide attempt.

3. On 3/22/12, the Risk Manager, the Chief Nursing Offficer and the Chief Operating Officer were interviewed. They stated that if there was no documentation as to the notification of patient 4's guardian, then most likely the guardian wasn't notified of the incident.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on Interview and record review it was determined that the facility failed to discharge a patient appropriately, which put staff, the patient and other residents at risk for 1 out of 10 sampled patients.

Findings include :

Based on interview and record review it was determined that the facility failed to appropriately transfer a patient. The patient had a long history of combativeness and homicidal ideation The facility failed to provide all pertinent information to the facility that was receiving the patient and did not send all necessary medical information to ensure an appropriate transfer occured. (See tag A 837)
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review it was determined that the facility failed to transfer a patient, along with necessary medical information to an appropriate facility for 1 out of 10 sampled patients. (Patient identifier: 6)

Findings include:

1. On 3/19/12 and 3/20/12, patient 6's medical record was reviewed. Upon the initial review of patient 6's medical record it took 3 people a full day to organize the chart so that it was reviewable.

Patient 6, was a female patient, who was admitted on [DATE] for diagnoses that included schizophrenia, Bipolar 1 disorder, assaultive behaviors and schizoaffective disorder.

Two applications for involuntary commitment for patient 6 were reviewed.

It was documented in the application of involuntary commitment, dated 11/1/11, that the "Resident is an actual risk of harm to others, is combatant with staff and assaultive of other residents." It was signed by a social worker.

It was documented in the application of involuntary commitment, dated 11/14/11, that patient 6 was "Homicidal" and "aggressive....towards staff & patients ....Displays violent outbursts....needs constant supervision in a lock up safe place."

It was documented in patient 6's chart that she was discharged from the facility on 12/9/11 and then again on 2/13/12. It was documented in a "Patient Rounds Progress Note," dated 12/10/11, at 3:40 AM, by a mental health technician, that patient 6 "had an (sic) discharge today but apparently assaulted someone and returned to admit here at around 2000 (8:00 PM)..."

It was documented in the RN Daily Reassessment Progress Notes," dated 2/4/12, that patient 6 had "...anxiety, agitation hitting at staff during some of her cares...."

It was documented in the Interdisciplinary Progress (IDP) notes, on 2/7/12, at 9:25 AM, that "Placement cont.(inues) to be a problem - many NH (nursing homes) have been called & info.(information) faxed to them (patient 6) is functioning well on her meds.(medications) and becomes verbally aggressive rarely-she takes meds willingly-She has had a happy attitude most of the time now- 0 (no)physical aggression (unable to decipher signature but was an RN).

2) a. On 3/19/12 at 2:30 PM, patient 6' psychiatrist was interviewed. He stated that he has known and treated patient 6 for 4 years. He stated that patient 6 was a "tuff cookie." He stated that on the 2/13/12 transfer we sent 2 techs with patient 6 because "we did feel that the transfer would bring out her behaviors."

b. On 4/3/12 at 3:45 PM, Registered Nurse (RN) 1 was interviewed. She identified herself as one of the staff directly involved with the 2/13/12 discharge and transfer of patient 6. RN 1 stated that she was familiar with patient 6 and at one time patient 6 had assaulted her. She stated that staff from skilled nursing facility (SNF) 2 came to their hospital to visit patient 6, to review patient 6's chart and to interview staff. RN 1 stated that she told the staff from SNF 2 that patient 6 had not been violent in over 30 days, that patient 6 could be violent again but felt like she was prepared for discharge. When asked if RN 1 had told staff from SNF 2 that patient 6 had a failed discharge to another facility on 12/9/11 and had been involuntarily committed for admission on 11/1/11 into the hospital for homicidal ideation, she stated " "No." When asked if RN 1 was aware that patient 6 had attacked and caused loss of consciousness for a staff member at SNF 1 on 12/9/11 (patient 6's first attempted discharge), she stated that she was not aware of that incident and therefore could not have passed on that information.


c. On 03/19/12 at 1:22 PM, the facility Risk Management Director (RM) and the Chief Operating Officer (COO) were interviewed pertaining to patient 6.

The COO stated that patient 6 was "well known" in the medical community and is a little "DD" (Developmentally Delayed). The COO stated that patient 6 has aggressive behaviors. She "hits, claws, spits", and has a long history of violent behaviors. She stated that patient 6 "blew out multiple nursing homes which couldn't handle her." The COO stated that patient 6 had been discharge from "fifteen to twenty" nursing facilities through out the Wasatch front. She stated that there were a number of medications and treatments tried. She stated that it was difficult to change patient 6's behaviors. The COO repeatedly stated that patient 6 was a very "difficult" patient. The COO stated that many nursing homes refused her admission. She stated that the average length of stay at the present facility was 8 to 10 days and that it took four to five weeks to discharge patient 6 back to her last residence. The COO stated that patient 6's discharge on 12/9/11 only lasted a few hours before she returned to the hospital because she had difficulty handling the discharge/transition. The RM stated that patient 6's Psychiatrist was involved in the entire discharge process. Both the COO and the RM stated that patient 6 could get aggressive if she didn't get what she wanted.

d. On 4/3/12 at a little after 4:00 PM, an exit conference was held with 7 administrative facility staff.

The Chief Executive Officer stated that patient 6 had been at the facility for 105 days and that was the longest that he had heard of a patient being at an acute psychiatric facility. He stated that the last 30 days that patient 6 was here at the facility, that the facility could not receive payment for her care because she was not appropriate to be here. The Administrator then stated that patient 6 had reached her baseline and did not need acute psychiatric care. He stated that patient 6 would be, "difficult to manage the rest of her life".

3. On 3/22/12, skilled nursing facility (SNF) 2, that patient 6 was discharged to from the psychiatric hospital the second time, was visited. The Administrator and the Director of Nursing (DON) were interviewed in person and the Patient Advocate (PA) was interviewed via telephone pertaining to patient 6's admission to the nursing home.

a. At 2:30 PM, the SNF PA was interviewed via telephone. He stated that he went up to the facility that patient 6 was residing at on 2/8/12 in the afternoon, to observe patient 6. He stated that he was told by staff that patient 6 had been admitted to the facility because she had stopped taking her medication. He stated that he asked staff if patient 6 had any violent behaviors. He stated that he was told not that they were not aware of any; that she was doing great. The PA also stated that he was never informed that patient 6 had been involuntarily committed into the facility for homicidal ideation nor that patient 6 had knocked unconscious a staff person from her failed discharge attempt on 12/9/11. The PA then stated that upon patient 6's admission, the patient was fine for 2 hours and then immediately threatened to punch him and then hit another staff member.

b. At approximately 2:45 PM, the SNF DON was interviewed. She stated that she specifically asked the nurse and discharge planner if patient 6 had a history of violent behaviors. The DON stated that she was told that "she was very sweet and very cooperative." She stated that she was told that patient 6 was admitted to the hospital because she refused to take her medications. The DON also stated that she was never informed that patient 6 had been involuntarily committed into the facility for homicidal ideation nor that patient 6 had knocked unconscious a staff person from her failed discharge on 12/9/11.

c. On 3/22/12 at 1:55 PM, the SNF Administrator was interviewed. He stated that he and his staff were lead to believe that patient 6 was manageable and not combative. He stated that patient 6 was transferred to SNF 2 on 2/13/12. He stated that within the first 24 hours that patient 6 was in the facility she had physically and verbally attacked two staff and was sent to the emergency room (ER) at a local hospital. In addition, the Administrator stated that he tried to contact social worker 1 on 2/15/12 three times pertaining to patient 6's behaviors. It wasn't until 2/16/12 that the social worker and the Executive Administrator returned his calls. He stated that until the SNF had received the "Discharge Summary" on the day of her admission into the SNF on 2/13/12, were they made aware of her "assaultive behaviors".

d. On 3/22/12, the following incident reports (IR) and nursing notes (NN) were reviewed at SNF 2:

NN - On 02/13/12 at 11:51 PM., " Pt. was admitted today at 1330 (1:30 PM) from (hospital). Refused to let C.N.A. (certified nursing assistant) on PM take vitals ...Pt. kept walking into kitchen and staff touched her arm to tell her she couldn't go in and pt swung around and slapped cook on the arm ....Kept telling nurse, " F "you ....Pt. is not alert or oriented to even self at times "

NN - On 02/13/12 at 6:45 PM "...(Patient 6) in the kitchen reported to nurse (staff) that (patient 6) was trying to get into the kitchen, when (staff) tried to tell her she couldn't go in there and (patient 6) slapped (staff). "

NN - On 02/14/12 @ 12:25 PM ...(patient 6 said), "your too stupid and I am going to punch you". She then clinched her fist and took a step backward our (sic) reach and she looked around and saw the nurse and three nursing aids in the room. She then unclenched her fist and took her meds"

IR - On 02/14/12 at 3:00 PM, "While doing (Patient 6's) vitals, (staff) was just trying to get (patient 6) to let me by joking with her. That was not helpful so she get mad and tried pinching (staff) but missed and hit me (the RN filing out the form) in the stomach."

Per an interview with the Administrator at 1:55 PM, he stated that the patient was then taken to the emergency room (ER) at a local hospital where they administered 5 mg of Haldol intermuscular (IM) to calm her down after attacking the ER triage nurse. He stated that a while later patient 6 was administered an additional 10 mg of Haldol and sent back to the SNF.

NN - On 02/15/12 @ 1:48 PM, patient 6 was up at 1000 and took her meds after one at a time biting them in half and saying things about hurting me while taking them. ....

NN - On 02/15/12 @ 13:52 (1:52 PM) ...administer medications, (patient 6) attempted to strike me with the back of her right hand. I was sitting to the right of her and was able to grab her hand to avoid being hit ...she was verbally aggressive and agitated.

NN - On 02/15/12 @ 2:39 PM, (Patient 6) "refused to sign the admittance paperwork and when we were attempting to use peanutbutter (sic) to get her to sign the paperwork she attempted to hit the Director of Nursing...."

NN - On 02/16/12 at 3:52 PM, patient 6 "...refused first attempt at giving her medication ...Resident was yelling and making verbal threats stating " I will pull your f---face off" and "how about I shove you against the cupboard.(sic)"...she continued to refuse to take any and continued to verbally threaten nurse....resident did take after the redirection from other staff members but continued to be threatening ...approximately 38 minutes to get her to take her morning medication."

NN - On 02/16/12 @ 21:55 (9:55 PM) ...patient 6 "has called C.N.A. a "stupid f-----" and an "a--hole" resident also told C.N.A. that he was "full of sh-t" when he offered her dinner ...Resident has been saying many things that are completely out of context and random. "

IR- On 02/16/12 at 5:30 PM, patient 6, "told me I was "full of sh-t" and refused to eat when I offered her her (sic) dinner. Resident also said she was going to make sure I got what I deserved."

NN - On 02/17/12 at 1:50 PM patient 6 ... "would not take them (medications) stating that I (nurse) was trying to poison her and she would get sick and throw up ...All together it took 45 minutes for her to take her medications"

IR - On 02/17/12 at 6:30 PM, patient 6 "got up in my face and called me a 'stupid F.....' and an 'a--hole' when I asked her to allow the female aid to help her with the x large BM in her pants."

IR - On 02/17/12 8:00 PM, patient 6 "agreed to shower then when I started bathing her she got aggressive quickly (and) scratched me, I got her to calm down then out of nowhere she slapped me across the face tried a 3rd time but I grabbed her arm."

NN - On 02/17/12 11:05 PM, patient 6, "has been up wandering the halls in the facility today. She went into the bathroom while a male resident was in there and refused to come out. She used the shower chair as a toilet while he was using the toilet. Tonight when the aid tried to get her to shower, she refused a shower from the aid. The aid asked me to talk to her because her pants were soaked and her face and arms had mustard and ketchup on them. She agreed to get a shower for some peanut butter. When we got to the shower room and the aid started undressing her she started to get agitated and told the aid she no longer wanted a shower. I tried to explain to her that she needed to get cleaned up and into clean clothes..She slapped me in the mouth and said, "I don't think this fat lady knows what she is doing, I don't know she is the nurse maybe. (laughing) " I notified the DON at 20:20 (8:20 PM) and she instructed me to call 911 and have the police take her to the hospital to be admitted into the psych unit. The cops came at 2030 (8:30 PM) and had to call medical to come and transport her by ambulance to the hospital. She left the facility at 2100 (9:00 PM).'

Per interview with the Administrator at 1:55 PM, patient 6 also was combative with the police and was pinked slipped (police committed) at the local ER.

4. On 3/22/12, skilled nursing facility (SNF) 1, the SNF that patient 6 was originally discharged from and also discharged from after only a couple of hours on 12/9/11, was visited.

On 3/22/12 at 4:35 PM, SNF 1's licensed clinical social worker (LCSW) was interviewed. She stated that when patient 6 had resided here, she had worked with patient 6 frequently. She stated that patient 6 lived here at the SNF for a while. She stated that the last 6 months that patient 6 had resided here she had become increasingly difficult to manage with aggressive and combatant behaviors. The LCSW stated that patient 6 was sent to the psychiatric hospital from the SNF because she had become an actual harm to others, she was combatant with staff and assaultive with residents. She stated that on 12/9/11, patient 6 had been brought back to the SNF from the hospital. She produced an incident report from 12/9/11 pertaining to patient 6's behaviors upon admission to SNF 1.

It was documented by the CNA that was injured on 12/9/11 at 5:30 PM, on 12/12/11, on an "Employee Accident/incident Report" that patient 6 "grabbed my hair as I was ducking and I was bent over she had hold of my hair and she started pounding the back of my head." It was further documented hat the CNA doesn't remember much else. It was witnessed by 2 nurses and another CNA. It was documented that the CNA did not go for medical treatment immediately but did go to an instacare and it was found that "one pupil was bigger than the other." It was documented that the instacare sent the CNA to an ER where a CAT (computerized axial tomography) scan was performed. It was documented that the patient was diagnosed with a concussion.