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 May 16, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and record review, it was determined that the facility failed to ensure that its governing body was effective and responsible for the conduct of the hospital.

Findings include:

Based on interview and record review, it was determined that the facility did not ensure that one of 20 patients was receiving care in a safe environment. Refer to tag A 0115

Based on interview and record review, it was determined that the facility did not ensure that one of 20 patients was receiving adequate supervision and accurate evaluations for the nursing care provided. Refer to tag A 0385
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, it was determined that the facility failed to ensure that one of 20 patients was receiving care in a safe environment. Refer to tag A 0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and record review, it was determined that the facility failed to ensure that one of 20 patients, was receiving care in a safe environment. Patient 4

Findings include:

Patient 4 was in a motor vehicle accident on 1/5/2013. During the investigation of the accident, patient 4 told the police officers she was going to commit suicide. The law enforcement officers determined patient 4 needed intervention so they transported her to a local hospital on a blue sheet (involuntary) admission. Patient 4 was seen and provided a crisis evaluation. After the crisis evaluation was performed, it was determined that patient 4 would benefit from inpatient treatment and was transferred to a local psychiatric hospital and involuntarily committed for treatment.

A review of patient 4's record revealed that she had a history of depression with suicide ideation , an eating disorder and substance abuse. Patient 4 had had several admissions to different facilities for treatment in the past.

Patient 4 was admitted to the women's unit and was placed on every 15 minute checks, was started on alcohol withdrawal protocol and other treatment modalities.

The initial care plan developed on 1/5/2013 included a problem of safety/suicide plan. One of the goals was that patient 4 would make no attempt to harm herself for 3 consecutive days. There were also plans for individual and group interventions. There was no evidence that the plan of care was updated from the date of admission to 1/15/2013, even though documented behaviors indicated a need to revise the plan.

Review of the record revealed that patient 4 was seen daily by a psychiatrist or a physicians assistant and was evaluated for progress and the need for medication change.

A review of the progress notes revealed that patient 4 was not improving. The nurses noted in the beginning that patient 4 was withdrawn, had a flat affect and isolated from others. She was compliant with her medications and was attending groups and individual therapy.

On 1/9/ , a nurse documented that patient 4's behavior was changing and was becoming paranoid. Patient 4 had began questioning her medications.

From that date on patient 4 became more agitated, hallucinating and confused. She was yelling and screaming and then would calm down and appear to be oriented. The behavior continued and she began to be aggressive to other residents. She was falling and running into walls and doors jambs. Multiple medications changes were made but patient 4 did not respond to the changes.

On 1/11/2012, patient 4 was transferred to the hospital CSU, "Crisis Stabilization Unit" due to her escalating behaviors. Patient 4 continued to be paranoid, increasing in confusion , and uncharacteristic acting out. Patient 4 was falling off chairs, running into doors, punching windows, hitting staff and jumped over the nursing station.

On 1/14/2012, the physician assistant in charge of her care turned her care over to the psychiatrist. Patient 4 was requiring more prn (when ever necessary) calming medications. She was requiring constant supervision and attention. She continued to be agitated and anxious. Patient 4's behavior became so out of control that she required one on one care and supervision. Patient 4 had to be placed into the seclusion room several times on 1/17/2013.

The Mental Health Technicians were documenting the same things about patient 4's behavior during her stay.

On 1/18/2012, patient 4's parents expressed concerns with patient 4's lack of progress. They were concerned about all the bruising she had on her body and that her eating disorder was not being addressed properly.

On 1/5/2012, the day of admission, a body check had been completed on patient 4. Review of the skin assessment done on 1/5/2013 revealed that patient 4 had scratches and bruises on her knees and contusions on both outer thighs.

On 1/18/2012 , the nursing manager asked the staff to do a complete body check on patient 4. The body check was done. During the assessment patient 4 was confused and disoriented. The body check revealed that patient 4 had extensive abrasions and bruising all over her body.

On 1/19/2013, the medical director was asked to evaluate patient 4. It was documented that patient 4 had signs and symptoms of dehydration. Patient 4 was transferred to a local hospital for evaluation of dehydration and possible anticholinergic delirium.

The receiving hospital immediately placed patient 4 in the intensive care unit. The physician that examined the patient in the emergency room documented that the "patient appears uncomfortable, shows apparent trauma and is dehydrated."

In an interview with Patient 4's father, he stated that he was so upset about patient 4's condition, he contacted the police department and reported that patient 4 appeared to have been assaulted while in the hospital and wanted an investigation done. The investigating officer had asked for an assessment by a forensic nurse.

A telephone interview was held with the supervisor of the forensic nurse that had been sent to the hospital by the investigation officer to assess patient 4's condition. The supervisor stated that the nurse that had completed the assessment of patient 4 at the acute hospital reported that she had never seen such extensive bruising and abrasions in her career and was very concerned for the patient.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, it was determined that the facility failed to ensure that one of 20 patients was receiving adequate supervision and accurate evaluations for the nursing care provided. Refer to tag A 0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review, it was determined that the facility failed to ensure that one of 20 patients was receiving adequate supervision and accurate evaluations for the nursing care provided. Patient 4

Findings include:

Patient 4 was in a motor vehicle accident on 1/5/2013. During the investigation of the accident, patient 4 told the police officers she was going to commit suicide. The law enforcement officers determined patient 4 needed intervention so they transported her to a local hospital on a blue sheet (involuntary) admission. Patient 4 was seen in the emergency room . and provided a crisis evaluation. After the crisis evaluation was performed, it was determined that patient 4 would benefit from inpatient treatment and was transferred to a local psychiatric hospital and involuntarily committed for treatment.

A review of patient 4's record revealed that she had a history of depression with suicide ideation , an eating disorder and substance abuse. Patient 4 had had several admissions to different facilities for treatment in the past.

Patient 4 was admitted to the women's unit and was placed on every 15 minute checks, was started on alcohol withdrawal protocol and other treatment modalities.

The initial care plan developed on 1/5/2013, included a problem of safety/suicide plan. One of the goals was that the patient would make no attempt to harm herself for 3 consecutive days. There were also plans for individual and group interventions. There was no evidence that the plan of care was updated from the date of admission to 1/15/2013, although documented concerns indicated the need for a care plan revision. There was no evidence that the treatment team had addressed the eating disorder.

Review of the record revealed that patient 4 was seen daily by a psychiatrist or a physicians assistant and was evaluated for progress and the need for medication change. The only indication that there was a team review of how the patient was responding to treatment was a checkmark on the top of the Medical Progress note. The only indication that there was a team review of how the patient was responding to treatment was a checkmark on the top of the medical Progress note. There were no details about the team discussion or the ongoing plan of care, or what was or was not working for the patient. Although the patient appeared to continue to decline, there was no information documented regarding appropriate treatment changes to address the decline. No changes to the care plan occurred even though steady decline in condition was documented.

A review of the progress notes revealed that patient 4 was not improving. The nurses noted in the beginning that patient 4 was withdrawn, had a flat affect and isolated from others. She was compliant with her medications and was attending groups and individual therapy.

On 1/9/ , a nurse documented that patient 4's behavior was changing and was becoming paranoid. Patient 4 had began questioning her medications. There was no indication that the nurses were evaluating adequate food and fluid intake.

From that date on patient 4 became more agitated, hallucinating and confused. She was yelling and screaming and then would calm down and appear to be oriented. The behavior continued and she began to be aggressive to other residents. She was falling and running into walls and doors jambs.

Multiple medication changes were made but patient 4 did not respond to the changes. Again, the nurses were not documenting anything about the patients hydration or nutrition nor were they documenting her overall condition and reaction to the medication changes.

On 1/11/2012, patient 4 was transferred to the hospital CSU, "Crisis Stabilization Unit" due to her escalating behaviors. Patient 4 continued to be paranoid, increasing in confusion , and uncharacteristic acting out. Patient 4 was falling off chairs, running into doors, punching windows, hitting staff and jumped over the nursing station.

On 1/14/2012, the physician assistant in charge of her care turned her care over to the psychiatrist. Patient 4 was requiring more prn (when ever necessary) calming medications. She was requiring constant supervision and attention. She continued to be agitated and anxious. Patient 4's behavior became so out of control that she required one on one care and supervision. Patient 4 had to be placed into the seclusion room several times on 1/17/2013.

The Mental Health Technicians were documenting the same things about patient 4's behavior during her stay.

On 1/18/2012, patient 4's parents expressed concerns with patient 4's lack of progress. They were concerned about all the bruising she had on her body and that her eating disorder was not being addressed properly.

Although the nurses were evaluating patient 4 on a daily basis, none of them had documented any physical changes or change in eating and drinking habits. It was not until the family expressed concerns that nursing intervention done to address the concerns.

On 1/5/2012, the day of admission, a body check had been completed. Review of the skin assessment done on 1/5/2013 revealed that patient 4 had scratches and bruises on her knees and contusions on both outer thighs.

On 1/18/2012 , the nursing manager asked the staff to do a complete body check on patient 4. The body check was done. During the assessment patient 4 was confused and disoriented. The body check revealed that patient 4 had extensive abrasions and bruising all over her body.

On 1/19/2013, the medical director was asked to evaluate patient 4. It was documented that patient 4 had signs and symptoms of dehydration. Patient 4 was transferred to a local hospital for evaluation of dehydration and possible anticholinergic delirium.

The receiving hospital immediately placed patient 4 in the intensive care unit. The physician that examined the patient in the emergency room documented that the "patient appears uncomfortable, shows apparent trauma and is dehydrated."

In an interview with Patient 4's father, he stated that he was so upset about patient 4's condition, he contacted the police department and reported that patient 4 appeared to have been assaulted while in the hospital and wanted an investigation done. The investigating officer had asked for an assessment by a forensic nurse.

A telephone interview was held with the supervisor of the forensic nurse that had been sent to the hospital by the investigation officer to assess patient 4's condition. The supervisor stated that the nurse that had completed the assessment of patient 4 had reported that she had never seen such extensive bruising and abrasions in her career and was very concerned for the patient.