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.

BRATTLEBORO RETREAT ANNA MARSH LANE PO BOX 803 BRATTLEBORO, VT Feb. 21, 2013
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0020
Based on record review and staff interview, the hospital failed to be in compliance with State of Vermont Statute Title 18, Chapter 42: Bill of Rights for Hospital Patients for 1 applicable patient. (Patient #10). Findings include:

1. Per State Statute 1852. Patients' Bill of Rights for Hospital Patients: "(1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity." However, per record review, from 11/21/12 through 12/21/12 Patient #10, admitted with a diagnosis Borderline Personality Disorder and Polysubstance Abuse, was frequently subjected to removing his/her clothes and mandated to wear paper scrubs often times without underwear. Per review on 2/21/13, a behavioral treatment plan, signed on 11/21/12 by the Osgood 3 interdisciplinary treatment team, states: "While in ALSA (low stimulation area) you [Patient #10] will be provided with paper scrubs to wear." If Patient #10 was wearing his/her own clothes at the time of an emergency procedure for restraint and/or seclusion, the patient was required to remove his/her clothes in front of female staff, a contraband search was often conducted and Patient #10 was then required to dress in paper scrubs. The mandating of paper scrubs often triggered Patient #10 to have increased agitation. Per Nursing Progress Note, on 12/9/12, "3 security staff and 5 staff escorted without hands on to Q.R. (seclusion) but did put hands on at 8:10 AM when patient refused to change into paper scrubs". Per progress note for 11/23/12 at 5:18 PM states "...Pt. tearing off paper clothing and threatening harm to himself/herself." Nursing Shift Progress Note, for 11/25/12 at 7:25 PM, states "Reports mood angry. Expressing desire to wear regular clothing stated that [s/he] could harm [himself/herself] with paper clothing, if [s/he] desired". Per Shift Progress Note, at 12/9/12 1:40 PM, states " ....ended up being put in restraints and [her/his] personal clothing was removed. After being released, client removed elastic waistband from paper clothes and wrapped it around [his/her] neck". Nursing Shift Progress Note for 12/10/12 at 10:00 AM report Patient #10 states "I'll just be running around naked" after,again, being mandated to wear paper scrubs.

Per interview on 2/21/13 at 10:15 AM an Osgood 3 charge nurse stated, when the paper scrubs rip, staff will put a towel over the exposed area.

Although, the paper scrubs were part of a treatment plan in an effort to maintain behavioral control and to manage Patient #10's self-harming behaviors, it also created an infringement of the patient's personal dignity.

2. Per State Statute 1852. Patients' Bill of Rights for Hospital Patients: "(5) The patient has the right to refuse treatment to the extent permitted by law. In the event the patient refuses treatment, the patient shall be informed of the medical consequences of that action and the hospital shall be relieved of any further responsibility for that refusal." Per review on 2/21/13, Patient #10 was admitted involuntarily, s/he had not been determined to be incompetent, a state appointed guardian was determined to be unnecessary and s/he had not designated a representative to participate in the patient's treatment plan. During the course of hospitalization , Patient #10 had periodically refused to have BS (blood sugar) testing or doses of Insulin administered. Per review of Nursing Shift Progress Notes staff document Patient #10 was aware of the consequences of not maintaining a proper diet, failing to have BS testing and accepting Insulin administration. However, both nursing and medical staff failed to acknowledge the patient's right to accept or refuse treatment. Per review of a Psychiatric Progress Note, dated 11/23/12, states ".....involuntary administration of insulin on the basis that [s/he] is at imminent risk of serious injury due to DKA (Diabetic Ketoacidosis). If [s/he] consistently refuses insulin finger sticks for 24 hours, a finger stick will be checked involuntarily on the basis that [s/he] is likely to be entering DKA which must be verified or refuted and treated accordingly." This treatment plan remained consistent throughout the patient's hospitalization as evidenced by the following documentation including physician orders and nursing notes: Per physician order for 11/27/12 at 10:55 AM: " May not refuse noon finger stick BS . May board (place patient in 6 point restraints on a board) for finger sticks blood sugar. Call Dr. X (hospital clinic physician) with noon finger stick BS results." A second physician order for 11/30/12 at 5:00 PM: "May not refuse insulin, get order to restrain if needed for D.O.C (doctor on call). Per Nursing Shift Progress Note, dated 11/29/12 at 12:50 PM, states Patient #10 had refused an injection of insulin. "Dr. X. called again and did not order med to be given involuntarily. Order for 4:30 PM BS which can not be refused written up as a standing order for 4:30 PM BS only". After the patient refused to receive a prescribed dose of Insulin the following Nursing Shift Progress Note, dated 12/10/12, states "At 5:45 PM [s/he].........refused [his/her] insulin. Orders were obtained for Thorazine 200 mg IM, restraints and to give [her/his] insulin at that time.....Meds were drawn up, hands on at 6:17 PM to restrain, on restraint board at 6:25 PM." Per review of Medication Administration Record notes both medications were administered as ordered while the patient was restrained.

Per interview on the afternoon of 2/21/13, the Vice President of Patient Care & CNO (Chief Nursing Officer) acknowledged staff per hospital policy could restrain a patient for the administration of an emergency medication such as Thorazine, however a court order would be needed to enforce the administration of Insulin. There was no evidence that the hospital obtained a court order forcing the patient to receive prescribed insulin.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on survey findings the Condition of Participation for Patient Rights was not met related to a failure to respect the patient's right to refuse treatment, failure to promote and maintain a physically and emotionally safe environment, failure to implement appropriate use of restraints and/or seclusion in accordance with federal requirements and facility policy and failure to report allegations of mistreatment in accordance with state and federal requirements. Refer to A-0131, A-0144, A-0145, A-0154, A-0162 and A-0167.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, the hospital failed to recognize and protect a patient's right to accept or refuse treatment for 1 applicable patient. (Patient #10) Findings include:

1. Per review on 2/21/13, Patient #10 was admitted on [DATE] with a diagnosis of Borderline Personality Disorder, Polysubstance Abuse and Insulin Dependent Diabetes. Although the patient was admitted involuntarily, s/he had not been determined to be incompetent, a state appointed guardian was determined to be unnecessary and s/he had not designated a representative to participate in the patient's treatment plan. During the course of hospitalization , Patient #10 had periodically refused to have BS (blood sugar) testing or doses of Insulin administered. Per review of Nursing Shift Progress Note staff document Patient #10 was aware of the consequences of not maintaining a proper diet, failing to have BS testing and accepting Insulin administration. However, both nursing and medical staff failed to acknowledge the patient's right to accept or refuse treatment as evidenced by the following documentation including physician orders and nursing notes:

Per physician order for 11/27/12 at 10:55 AM: "May not refuse noon singlestick BS. May board (place patient in 6 point restraints on a board) for fingersticks blood sugar. Call Dr. X(hospital clinic physician) with noon fingerstick BS results." A second physician order for 11/30/12 at 5:00 PM: "May not refuse insulin, get order to restrain if needed for D.O.C (doctor on call). Per Nursing Shift Progress Note dated 11/29/12 at 12:50 PM states Patient #10 had refused an injection of insulin "Dr. X. called again and did not order med to be given involuntarily. Order for 4:30 PM BS which can not be refused written up as a standing order for 4:30 PM BS only". After the patient refused to receive a prescribed dose of Insulin the following Nursing Shift Progress Note, dated 12/10/12, states "At 5:45 PM [s/he].........refused [his/her] insulin. Orders were obtained for Thorazine 200 mg IM, restraints and to give [her/his] insulin at that time.....Meds were drawn up, hands on at 6:17 PM to restrain, on restraint board at 6:25 PM." Per review of Medication Administration Record notes both medications were administered as ordered while patient was restrained.

Per review of Psychiatric Progress Note, dated 11/23/12, states ".....involuntary administration of insulin on the basis that [s/he] is at imminent risk of serious injury due to DKA (Diabetic Ketoacidosis). If [s/he] consistently refuses insulin finger sticks for 24 hours, a finger stick will be checked involuntarily on the basis that [s/he] is likely to be entering DKA which must be verified or refuted and treated accordingly." This plan remained consistent throughout the patient's hospitalization .

Per interview on the afternoon of 2/21/13, the Vice President of Patient Care & CNO acknowledged staff, per hospital policy, could restrain a patient for the administration of an emergency medication such as Thorazine, however a court order would be needed to enforce the administration of Insulin. There was no evidence that the hospital obtained a court order.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, patient and staff interviews and record review the facility failed to assure care was provided in an environment that promoted and protected the physical and emotional well being and safety of 3 of 13 patients. (Patients #1, #3 and #10). Findings include:

1. Per patient and staff interview and video and medical record review, staff failed to protect the emotional well being of Patient #1, who was admitted , involuntarily, on 9/7/12 with a diagnosis of Schizoaffective Disorder, Bipolar type. Per interview, conducted on the afternoon of 2/14/13, Patient #1 verbalized that s/he felt s/he had been treated in a disrespectful and uncaring manner by staff after disclosing that s/he had been involved in a recent sexual encounter with another patient. The patient stated that, although on the morning of 2/6/13, s/he had requested a specific medical intervention related to a recent sexual encounter, s/he was not seen by the medical clinician until several hours later in the afternoon. The patient stated s/he experienced increasing fear, that because of the delay in time, the medical intervention s/he had requested would not be effective.
A Psychiatry Progress Note, dated 2/6/13 at 10:00 AM, indicated that Patient #1 had disclosed to the psychiatrist, at that time, that s/he had recently been involved in a sexual encounter with another patient and had requested a specific medical intervention. The patient had refused to offer any further details about the encounter but "....Agrees to see a female from the med clinic to discuss this concern." A consult was faxed to the facility's medical clinic at 10:35 AM on 2/6/13 which stated: "Reports recent sexual activity. Unclear if [patient] claim is real or delusional.....will only discuss with a female." Despite the stated request the patient was not seen by a clinician until 3:00 PM, almost four and a half hours after the request for consult. During the assessment by NP (Nurse Practitioner) #1 the patient alleged that sexual assault by another patient had occurred on the evening of 2/5/13, and the patient was then transported to the ER (emergency room ) for evaluation and treatment. Upon return from the ER, that evening, the patient's room was changed, and s/he was located closer to the nursing station, and the following day, on 2/7/13, the patient was offered and accepted, a transfer to a separate unit in an effort to assure ongoing physical and emotional well-being and safety.
Review of a facility video tape, at 10:40 AM on 2/13/13, revealed the following: Patient #13 entered the room of Patient #1 at 7:16 PM, closed the door and exited the room 2 minutes later at 7:18 PM. Patient #13 returned to the room of Patient #1 at 7:21 PM, closed the door and exited the room, 7 minutes later, at 7:28 PM. Patient #13 again entered Patient #1's room at 7:29 PM and exited after only 20 seconds.
During interview, at 2:20 PM on 2/14/13, RN (Registered Nurse) #1, who had worked as the med nurse on 2/6/13, stated that at approximately 9:30 AM on that date Patient #1 had made, what the patient identified as a "strange request", for a specific medical intervention and disclosed that s/he had been involved in sexual activity within the previous 24 hours. The patient refused to provide any other information regarding the sexual encounter to RN #1. The RN stated s/he spoke with Patient #1's Psychiatrist about the issue. Nurse #1 further stated that s/he did hear Patient #1 getting more agitated later on that morning, pacing in the hall and yelling about getting the medical intervention s/he had requested earlier.
RN #2, the Nurse Manager of the Unit Patient #1 resided on at the time of the incident, stated, during interview at 2:28 PM on 2/14/13, that s/he had been made aware of the information disclosed by Patient #1 and, although s/he had not been alarmed by the information because Patient #1 "frequently made statements that were non reality based", s/he had followed up to assure an order had been written for a clinic consult. RN #2 further stated that later that morning Patient #1, who had become increasingly agitated, had demanded to see the medical clinician and receive the intervention s/he had requested.
Physician #1 confirmed, during interview at 1:15 PM on 2/14/13, that s/he had approached Patient #1 about the patient's concerns and the patient refused to answer any questions about sexual activity. S/he stated the patient did agree to see a female in the clinic because s/he wanted to receive a specific medical intervention.
NP (Nurse Practitioner) #1 confirmed, during interview at 10:48 AM on 2/19/13, that on the afternoon of 2/6/13 s/he had spoken with Patient #1, who alleged sexual assault by another patient had occurred the evening of 2/5/13 and Patient #1 had then been transferred to the ER for evaluation and treatment. NP #1 stated that s/he did not know why there had been a delay in Patient #1's assessment, for a period of greater than 4 hours from the time the consult was sent. S/he stated that there was nothing in the referral that led him/her to believe the consult was urgent or that there had been a sexual assault. The NP also indicated that Patient #1 had been delusional and made similar allegations on previous occasions.
Despite the fact that intimate contact between patients is prohibited as evidenced by the General Information provided to patients on the AIU (Adult Intensive Unit) upon admission which states, "Relationships....No touching, hugging, or kissing is allowed. Patients are not allowed to enter each other's rooms for any reason", staff failed to take seriously the potential implications of Patient #1's disclosure of involvement in recent sexual activity, failed to assure a clinical assessment and treatment was conducted in a timely manner, failed to recognize the patient's increasing agitation as being related to the delay in the clinic consult, and in so doing, failed to promote and protect the emotional safety and well-being of Patient #1.

2. On 8/17/12 Patient #5, [AGE], was involuntarily admitted to Tyler 3 with a diagnosis of Bipolar Disorder, PTSD (Post Traumatic Stress Disorder) with a past history of sexual abuse over a 4 year period. During this first psychiatric hospitalization , Patient #5 presented with manic symptoms, exhibiting hyper verbal and hypersexual talk, and threatening physical gestures toward staff. As a result of aggressive behavior, Patient #5 was placed on 1:1 observations and assigned and restricted to the LSA (Low Stimulation Area) which included his/her bedroom (room 306) and a seclusion room located opposite to room 306.

Per observation on 2/13/13 at 10:55 AM facility video recorded on 8/18/12 and time stamped beginning at 17:13 showed Patient #5 being placed in locked seclusion room. Shortly after, MHW #1 is observed sitting in a chair facing the locked seclusion door positioned approximately 3 feet from the door. Per "Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients", last approved 07/2012, states when a patient is placed in seclusion 1:1 constant monitoring must be provided. Per observation of the seclusion room within the LSA on 2/13/13 at 2:10 PM noted a small window within the seclusion room door measuring approximately 8 inch by 12 inches. Within the seclusion room was a mirror mounted in the left corner between the wall and ceiling. The clarity of the door window and mirror was fair, and the visibility of a patient through the window when standing at the window required the use of the mirror. A chair was placed at the location where MHW #1 had sat, as per the video. While sitting in the chair, visualization of the seclusion room using the door window was very limited due to the clarity of the window and the height of the window when viewing from a sitting position. Per interview on 2/13/13 at 2:50 PM, MHW #1 stated "I was watching [Patient #5] through the mirror on the wall ....I could see [Patient #5] reflection in the mirror ....I think you can just see the corner, you can't see when you look down ...it is difficult to see in there from anywhere". MHW #1 further stated "I could see movement ....I could hear [Patient #5] loud and clear". The MHW remained sitting for the majority of the 1 hour 1:1 constant observation assignment. Per interview at 3:00 PM on 2/13/13, the unit nurse manager stated " ....after seeing the video of the MHW sitting in the chair and our discussion, I want the chair out of the room ". (The "room" within this area of LSA is outside of the seclusion room, where staff are stationed during the provision of continuous 1:1 observation)

3. During observations on 2/13/13, of video recorded on 8/18/12, when not in seclusion, Patient #5 was frequently observed standing in the area (measured approximately 8 ft. by 12.5 ft) between room 306 and the seclusion room talking with MHWs and nursing staff. As noted in the Discharge Summary, Patient #5 upon admission " ....initially presented with manic behaviors .....[s/he] was hyperactive .....noted to be extremely disinhibited ". A Social Work progress note for 8/20/12 states; " ....struggled to be contained" and further describes Patient #5 as " ...agitated ...easily aggravated." The intent of the LSA is to provide a low stimulation environment to help patients separate from the milieu during a time when assaultive behavior and/or verbal aggression had played a role in their admission to LSA. However, per review of the video, during Patient #5's time in LSA on 8/18/12 over a 3 hour period, anywhere from 1 to 3 staff members at a time, were observed, on multiple occasions, entering and/or leaving the LSA, and walking through the LSA area to access a separate locked area behind the LSA. Doors were repeatedly opened into the section of LSA where Patient #5 was either standing, in seclusion or in room 306. The traffic of staff members was disruptive and also created an opportunity for Patient #5 to consider potential elopement from the restricted LSA. Patient #5 is observed at one point attempting to open the locked LSA door which lead to the restricted area behind the LSA. During the viewing of the video on 2/13/12, with the V.P. of Patient Care Services & CNO and the Senior Director of Regulatory Compliance, both agreed the traffic to and from the above mentioned restricted area was disruptive for the patient and not beneficial during treatment of Patient #5 who was in a hyperactive and agitated state.

4. Patient #10 was involuntarily readmitted on [DATE] with a diagnosis of Borderline Personality Disorder, Polysubstance Abuse and Insulin Dependent Diabetes. A treatment plan was implemented by the interdisciplinary treatment team on 11/21/12 in response to Patient #10's challenging behaviors. The consequences and response facilitated by the treatment plan and acted upon by staff included: "While in the ALSA you (Patient #10) will be provided scrubs to wear. If you disrobe, locked seclusion will be ordered; if you make an effort to injure yourself, mechanical restraints will be ordered; if you toilet in any location other then the toilet, your body waste is considered to be infectious and this will be considered an assault and locked door seclusion or mechanical restraints will be ordered; mechanical restraint will occur using the restraint board in the seclusion room. The board provides thigh and chest restraint capabilities".

From 11/21/12 through 12/21/12 Patient #10 was placed in seclusion and/or tied to a restraint board over 25 times. On several occasions, as per the behavioral treatment plan, staff required Patient #10 to remove his/her clothes, often including underwear, and required to wear a paper scrub suit which could be easily ripped by the patient. The mandating of paper scrubs often triggered Patient #10 to have increased agitation and emotional distress.. Per "Nursing Progress Note" 12/9/12 " 3 security staff and 5 staff escorted without hands on to Q.R. (seclusion) but did put hands on at 8:10 AM when patient refused to change into paper scrubs". Per "Shift Progress Note" at 12/9/12 1:40 PM states " ....ended up being put in restraints and her/his personal clothing was removed. After being released, client removed elastic waistband from paper clothes and wrapped it around his/her neck". Nursing Shift Progress Note for 12/10/12 at 10:00 AM report Patient #10 states "I'll just be running around naked" after being again mandated to wear paper scrub. Per interview on 2/21/13 at 10:15 AM an Osgood 3 charge nurse stated, when the paper scrubs rip, staff will put a towel over the exposed area". Although, the purpose of the paper scrubs was to assist in the management of Patient #10's self harming behavior, staff failed to identify the impact this plan played in the recognition of the patient's dignity.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interviews the facility failed to report to the appropriate SA (State Agency) allegations of abuse of 2 patients by care providers. (Patients #2 and #7). Findings include:

1. Per record review Patient #2, who was admitted , involuntarily, on 12/11/12, alleged an incident of staff mistreatment against him/her that was not reported to the appropriate SA. Per review a Psychiatry Progress Note, dated 1/10/13, stated; "... [Patient #2] reports that [Patient #2] was physically assaulted by a staff member during an altercation with a peer.......[Patient #2] has contacted patient advocate......and [Patient Representative] has also made a complaint on [Patient #2] behalf. [Patient #2] reported staff member in question grabbed [Patient #2] by the neck in a choking fashion. Today reports no injuries associated with the event. Examination of [Patient #2] neck shows no areas of [DIAGNOSES REDACTED]. Direct examination of [Patient #2] left thoracic rib cage reveals no ecchymosis and palpitation is without noted tenderness. The incident has been internally investigated with statements taken by individuals involved. This matter is being managed by unit clinical manager..."
Per interview, at 9:11 AM on 2/12/13, the Manager of Performance Improvement and Risk Management confirmed knowledge, as of 1/2/13, of the allegation by Patient #2 of abuse by a staff member on 1/1/13. S/he stated an investigation had been conducted in response to the allegation and "we didn't feel, after reviewing/investigating that it was abuse.........so didn't report it....but we did tell [Patient #2] could report it to APS him/herself if [Patient #2] wanted."

2. Per record review Patient #7, who was admitted , involuntarily on 12/11/12 with a diagnosis of [DIAGNOSES REDACTED][his/her] forearms." A Psychiatry Progress Note, dated 12/19/12 stated "Follow up with [Patient #7] on various grievances.....including a claim that [Patient #7] was assaulted over the weekend...by staff member." Although there is documentation by the RN Unit Manager, dated 12/20/12, that Patient #7 had alleged that, during the prior weekend, MHW #2 had struck him/her on the left arm twice, there is no evidence of when that allegation was first reported to staff. The documentation included notation that the physician had reported that Patient #7 told him/her that s/he may have fabricated the allegations as s/he was angry with staff members. The conclusion of the investigation indicated that, although there was no evidence of physical contact between Patient #7 and MHW #2, the patient had requested and been referred to, the Patient Advocate for further follow up. Despite the fact that an internal investigation was conducted, the facility did not report the allegation to the appropriate SA as required.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, there was no indication of threat to the immediate physical safety of patient, staff or others, to warrant the use of restraint or seclusion imposed on 3 of 6 patients.(Patients #3, #5 and #10). A behavioral treatment plan imposed the use of restraint and/or seclusion as a consequence for behaviors exhibited by Patient #10. Findings include:

Per review, the facility policy, Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients, last approved 07/2012, states in the Philosophy; "....Beginning with the admission assessment......specific individualized information is gathered to identify techniques, methods or tools that may help the patient manage his/her behavior by managing underlying distressing emotions, pre-existing conditions or physical disabilities and limitations that would place the patient at greater risk during restraint or seclusion, any history of sexual or physical abuse that would place the patient at greater psychological risk during restraint or seclusion." The policy further states "Non-restrictive, non-coercive, non-physical techniques are preferred in the management of behavior. If these techniques are ineffective or non-viable and an emergency as defined below exists, then seclusion or restraint may be initiated for safety purposes only...." The definition of Safety Emergency includes: "substantial risk of serious physical assault; Occurrence of serious physical assault; Substantial risk of self-destructive behavior; Occurrence of self-destructive behavior. The definition of restraint includes: "......holding a patient in a standing, seated or horizontal position i.e. 2 person walking escort or physical assist to the floor, in which the patient cannot remove himself/herself from the staff member's grip."

1. On 8/17/12 Patient #5, [AGE], was involuntarily admitted to Tyler 3 with a diagnosis of Bipolar Disorder, PTSD (Post Traumatic Stress Disorder) with a past history of sexual abuse over a 4 year period. During this first psychiatric hospitalization , Patient #5 presented with manic symptoms, exhibiting hyper verbal and hyper sexual talk, and threatening physical gestures toward staff. As a result of aggressive behavior, Patient #5 was placed on 1:1 observations and assigned and restricted to the LSA (Low Stimulation Area) which included his/her bedroom (room 306) and a seclusion room located opposite to room 306.

Per observation, on 2/13/13 at 10:55 AM, facility video recorded on 8/18/12 and time stamped beginning at approximately 17:13 showed Patient #5 sitting in a chair outside room 306. With his/her right hand, Patient #5 tosses something toward the MHW (Mental Health Worker), which was later identified by staff as a granola bar. The MHW was observed quickly getting up from his/her chair, secures a hand around Patient #5's right arm and leads the patient rapidly into the seclusion room and locks the door. Patient #5 immediately became agitated and began banging on the seclusion room door, yelling to get out. The physician telephone order, dated 8/18/12 at 5:23 PM, states the reason for seclusion was for "Assaultive behavior". However, per interview on 2/13/13 at 3:55 PM, the Tyler 3 Nurse Manager stated staff "...should not be putting him/her in locked seclusion for throwing a granola bar". In addition, per interview at 10:55 AM on 2/13/13, the VP for Patient Care Services and Chief Nursing Officer confirmed only a LIP (Licensed Independent Practitioner), MD or RN can authorize the use of seclusion, and a MHW is not permitted or authorized to place any patient in seclusion. The evening charge nurse placed Patient #5 in and out of seclusion on 8/18/12 for "...posturing and raised fists.." Each time Patient #5 was placed in seclusion, s/he became increasingly agitated and repeatedly hit the door and window of the seclusion room.

Per review of Nursing Progress notes for 8/18/12, the evening charge nurse states "Pt. was frustrated at the beginning of this shift with remaining in the ALSA for the Assault Protocol" . Per review the Tyler 3 "Protocol for Assaultive Behavior", which is provided to patients on Tyler 3, states, "Any of the following behaviors will require time away from the community engaging in individual work to help make sense of what happened and understand the impact of your choices. These behaviors include: hitting, kicking, biting, punching, spitting or pushing of staff or patients ".

Continued review of the video of Patient #5, there was no evidence from what was visualized, the patient demonstrated behaviors identified in the "Protocol for Assaultive Behavior". Nursing progress note for the evening of 8/18/12 states Patient #5 continually used "...foul language, sexually inappropriate comments and racial slurs". Audio was not part of the video observed, however per the Discharge Summary dated 11/7/12, the attending psychiatrist states, "[S/he] was hyperactive with pressured speech. [S/he] was noted to be extremely disinhibited, engaging in sexual talk, making sexual gestures, using foul language ....[his/her] mood was elevated and quite irritable." However, the psychiatrist also noted during any discussion with the patient regarding his/her past history as a victim of sexual assault resulted in "[S/he] making explicit sexual comments and could not be redirected or refocused". The use of repeated seclusion lacked the consideration of Patient #5's past history of abuse and did not coincide with the hospital's Philosophy stated in the policy for "Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients" referenced above. In addition, the behaviors demonstrated by Patient #5 did not meet the facility's definition for the use of seclusion. There is no evidence a safety emergency existed as defined per hospital policy.

2. Per record review Patient #3 was restrained, through use of 2 person physical Escort, without indication that s/he presented immediate threat to the physical safety of self or others.
A Progress Note, dated 1/6/13 at 10:30 PM stated that at approximately 6:00 PM Patient #3 had required redirection for the use of foul language, was unable to accept the redirection and increased his/her use of foul language. The note indicated that although staff informed the patient s/he would need to take space and process his/her behaviors with staff, Patient #3 refused to cooperate and went to the CA (Community Area) to sit. Ongoing encouragement by staff for Patient #3 to voluntarily retire to his/her room or the open door QR (Quiet Room) was ignored by the patient who continued to refuse to cooperate. Despite the lack of evidence that a safety emergency, as defined in the policy, existed, the note stated that "At 6:34 PM hands on began as a two person CPI escort. Pt refused to walk in the escort and let [his/her] legs relax. Pt was lowered to the floor and the escort was broken at 6:35 PM. After several prompts Pt agreed to walk under escort to the open QR. Pt was escorted to the QR and released at 6:38 PM. Pt continued to verbally abuse staff, but remained in the QR....for 45 min." A physician order for the use of restraints, dated 1/6/13 at 6:50 PM, noted the type of restraint as 'Escort' and identified the reason for seclusion/restraint as; "Agitation, Belligerence, Defiance...Hx of assaultive bhx" (behavior).

During interview, at 2:50 PM on 2/13/12, RN #3, the Unit Manager for the unit Patient #3 resided on at the time of the incident, agreed there was no evidence that Patient #3 was a threat to self and others at the time of restraint. RN #3 further agreed that the physician order for the use of the Escort for agitation, belligerence defiance and a history of assaultive behavior is not an appropriate reason for use of restraints.

3. Patient #10 was involuntarily readmitted on [DATE] with a diagnosis of Borderline Personality Disorder, Polysubstance Abuse and Insulin Dependent Diabetes. A treatment plan was implemented by the interdisciplinary treatment team on 11/21/12 in response to Patient #10's challenging behaviors. The consequences and response facilitated by the treatment plan and acted upon by staff included: "While in the ALSA you (patient #10) will be provided scrubs to wear. If you disrobe, locked seclusion will be ordered; if you make an effort to injure yourself, mechanical restraints will be ordered; if you toilet in any location other then the toilet, your body waste is considered to be infectious and this will be considered an assault and locked door seclusion or mechanical restraints will be ordered; mechanical restraint will occur using the restraint board in the seclusion room. The board provides thigh and chest restraint capabilities".

Psychiatric Progress Note dated 11/26/12 states Patient #10 " ....had a tendency to act out in an effort to get herself/himself restrained " . It was also noted Patient #10 " ...finds involuntary procedures including physical holds, physical restraints and intramuscular administration of medications reinforcing and therefore will act out to force staff to implement these procedures. " It was further recommended " ...using strategies only when absolutely necessary to preserve his/her safety and to not think of them as consequences that will alter or mold his/her behavior ". A "Certificate of Need for Emergency Involuntary Procedures" for 11/23/12 at 5:30 PM demonstrated Patient #10's reinforced behavior when a "Therapeutic hold was used to place pt. on restraint board, pt. cooperative, wanted to use restraint board ." Staff documented justification for the use of emergency restraint and/or seclusion as a response to Patient #10 ' s threats to hurt herself/himself. However, also noted in the Psychiatric Progress Note " ....s/he has had numerous self injurious acts, her/his threats of suicide are frequently not genuine but rather tend to be attempts to get attention and cause herself/himself to be hospitalized , remain hospitalized or to receive in involuntary procedures.." Locked door seclusion and/or 6 point restraint board was initiated over 25 times from 11/21/12 through 12/21/12 with staff referencing the above mentioned behavioral treatment plan and initiating the consequences when Patient #10 was not compliant with the treatment plan.

Improper use of restraints were also ordered and used by staff for the purpose of administering non emergency medication and performing blood testing which had been refused by Patient #10. Per physician order for 11/27/12 at 10:55 AM: " May not refuse noon fingerstick BS. May board (place patient in 6 point restraints on a board) for finger sticks blood sugar ..... " Per Nursing Shift Progress Note for 12/10/12 at 5:45 PM, because the patient had urinated on the floor in ALSA and refused his/her insulin injection Patient #10 was placed in 6 point restraints and once restrained, was administered both Thorazine and Insulin.

Per interview on the afternoon of 2/21/13, the Vice President of Patient Care & CNO acknowledged staff, per hospital policy, could restrain a patient for the administration of an emergency medication such as Thorazine, however a court order would be needed to enforce the administration of Insulin. There was no evidence the hospital obtained a court order.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the hospital failed to ensure the use of seclusion for Patient #5 would only be used for the management of violent or self-destructive behavior. (Findings include:

On 8/17/12 Patient #5, [AGE], was involuntarily admitted to Tyler 3 with a diagnosis of Bipolar Disorder, PTSD (Post Traumatic Stress Disorder) with a past history of sexual abuse over a 4 year period. During this first psychiatric hospitalization , Patient #5 presented with manic symptoms, exhibiting hyper verbal and hypersexual talk, and threatening physical gestures toward staff. As a result of aggressive behavior, Patient #5 was placed on 1:1 observations and assigned and restricted to the LSA (Low Stimulation Area) which included his/her bedroom (room 306) and a seclusion room located opposite room 306.

Per record review and observation of video recorded during the evening of 8/18/12, staff repeatedly placed Patient #5 in locked door seclusion or confined the patient in the seclusion room while the door was left opened. The behaviors demonstrated by Patient #5 did not meet the definition for the use of seclusion. There is no evidence a safety emergency existed as defined per hospital policy as: " Substantial risk of serious physical assault; occurrence of serious physical assault; substantial risk of self-destructive behavior or occurrence of self-destructive behavior ". The patient expressed anger, yelled obscenities, made sexual gestures toward staff and at times had raised his/her fists, however these behaviors did not jeopardize the immediate physical safety of the patient, a staff member or others.

One episode, observed on video on 2/13/13, resulted in locked door seclusion, on 8/18/12, for 30 minutes after Patient #5, while sitting in a chair, tossed a granola bar at a MHW. Locked door seclusion was again initiated at 8:23 PM after Patient #5 became agitated and per Nursing progress note "began threatening and using sexually explicit language", followed by "...threatening posture and raised fists.......and moved quickly and aggressively toward female 1:1 staff ". No other interventions were attempted, and the nurse is seen on video placing hands on the patient and directing him/her into seclusion. In addition, the physician's order for seclusion dated 8/18/12 at 8:34 PM did not provide a reason for the use of seclusion nor where behavioral objectives for release from seclusion documented.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the implementation of seclusion by a MHW was not in accordance with hospital policy for 1 applicable patient. (Patient #5) Findings include:

On 8/17/12 Patient #5, [AGE], was involuntarily admitted to Tyler 3 with a diagnosis of Bipolar Disorder, PTSD (Post Traumatic Stress Disorder) with a past history as a victim of sexual abuse over a 4 year period. During this first psychiatric hospitalization , Patient #5 presented with manic symptoms, exhibiting hyper verbal and hypersexual talk, and threatening physical gestures toward staff. As a result of aggressive behavior, Patient #5 was placed on 1:1 observations and assigned and restricted to the LSA (Low Stimulation Area) which included his/her bedroom (room 306) and a seclusion room located opposite to room 306.

Per observation, on 2/13/13 at 10:55 AM, facility video recorded on 8/18/12 and time stamped beginning at approximately 17:13 showed Patient #5 sitting in a chair outside room 306. With his/her right hand, Patient #5 tosses something toward a MHW (Mental Health Worker), which was later identified by staff as a granola bar. The MHW was observed quickly getting up from his/her chair, secures a hand around Patient #5's right arm and leads the patient rapidly into the seclusion room and locks the door. Per review of "Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients", last approved
07/2012 states only a LIP (Licensed Independent practitioner), MD or specially trained RN with current competency can authorize restraint or seclusion if a patient exhibits an imminent risk to self or others."

Per interview at 10:55 AM on 2/13/13, the VP for Patient Care & CNO confirmed a MHW does not have the authority to place a patient in seclusion.
VIOLATION: QAPI Tag No: A0263
Based on survey findings the Condition of Participation for Quality Assessment and Performance Improvement was not met related to the failure to identify deficient practice and opportunity for improvement regarding a patient's right to refuse treatment and ongoing inappropriate use of restraints and or seclusion.

Refer to A-0283
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and video and medical record review the facility failed to identify deficient practice and opportunity for improvement related to patient rights, including the patient's right to refuse treatment and inappropriate use of restraints/seclusion. Findings include:

Per review, the facility policy, titled Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients, states; "Non-restrictive, non-coercive, non-physical techniques are preferred in the management of behavior. If these techniques are ineffective or non-viable and an emergency as defined below exists, then seclusion or restraint may be initiated for safety purposes only...." The definition of Safety Emergency includes: "substantial risk of serious physical assault; Occurrence of serious physical assault; Substantial risk of self-destructive behavior; Occurrence of self-destructive behavior. In addition the definition of restraint includes: "....Restraints includes holding a patient in a standing, seated or horizontal position i.e. 2 person walking escort or physical assist to the floor, in which the patient cannot remove himself/herself from the staff member's grip."

1. On 8/17/12 Patient #5, [AGE], was involuntarily admitted to Tyler 3 with a diagnosis of Bipolar Disorder, PTSD (Post Traumatic Stress Disorder) with a past history of sexual abuse over a 4 year period. During this first psychiatric hospitalization , Patient #5 presented with manic symptoms, exhibiting hyper verbal and hypersexual talk, and threatening physical gestures toward staff. As a result of aggressive behavior, Patient #5 was placed on 1:1 observations and assigned and restricted to the LSA (Low Stimulation Area) which included his/her bedroom (room 306) and a seclusion room located opposite to room 306.

Per observation, on 2/13/13 at 10:55 AM, facility video recorded on 8/18/12 and time stamped beginning at approximately 17:13 showed Patient #5 sitting in a chair outside room 306. With his/her right hand, Patient #5 tosses something toward the MHW (Mental Health Worker), which was later identified by staff as a granola bar. The MHW was observed quickly getting up from his/her chair, secures a hand around Patient #5's right arm and leads the patient rapidly into the seclusion room and locks the door. Patient #5 immediately became agitated and began banging on the seclusion room door, yelling to get out. The physician telephone order, dated 8/18/12 at 5:23 PM, states the reason for seclusion was for "Assaultive behavior". However, per interview on 2/13/13 at 3:55 PM, the Tyler 3 Nurse Manager stated staff "...should not be putting him/her in locked seclusion for throwing a granola bar". In addition, per interview at 10:55 AM on 2/13/13, the VP for Patient Care Services and Chief Nursing Officer confirmed only a LIP (Licensed Independent Practitioner), MD or RN can authorize the use of seclusion, and a MHW is not permitted or authorized to place any patient in seclusion. The evening charge nurse placed Patient #5 in and out of seclusion on 8/18/12 for "...posturing and raised fists.."

2. Per record review Patient #3 was restrained, through use of 2 person physical Escort, without indication that s/he presented immediate threat to the physical safety of self or others.

A Progress Note, dated 1/6/13 at 10:30 PM stated that at approximately 6:00 PM Patient #3 had required redirection for the use of foul language, was unable to accept the redirection and increased his/her use of foul language. The note indicated that although staff informed the patient s/he would need to take space and process his/her behaviors with staff, Patient #3 refused to cooperate, went to the CA (Community Area) and continued to swear and use foul language. Despite the lack of evidence that a safety emergency, as defined in the policy, existed, the note stated that "At 6:34 PM hands on began as a two person CPI escort. Pt refused to walk in the escort and let [his/her] legs relax. Pt was lowered to the floor and the escort was broken at 6:35 PM. After several prompts Pt agreed to walk under escort to the open QR. Pt was escorted to the QR and released at 6:38 PM. Pt continued to verbally abuse staff, but remained in the QR....for 45 min." A physician order for the use of restraints, dated 1/6/13 at 6:50 PM, noted the type of restraint as 'Escort' and identified the reason for seclusion/restraint as; "Agitation, Belligerence, Defiance...Hx of assaultive bhx" (behavior).

During interview, at 2:50 PM on 2/13/12, RN #3, the Unit Manager for the unit Patient #3 resided on at the time of the incident, agreed there was no evidence that Patient #3 was a threat to self and others at the time of restraint. RN #3 further agreed that the physician order for the use of the Escort for agitation, belligerence defiance and a history of assaultive behavior is not an appropriate reason for use of restraints.

3. Patient #10 was involuntarily readmitted on [DATE] with a diagnosis of Borderline Personality Disorder, Polysubstance Abuse and Insulin Dependent Diabetes. A treatment plan was implemented by the interdisciplinary treatment team on 11/21/12 in response to Patient #10's challenging behaviors. The consequences and response facilitated by the treatment plan and acted upon by staff included: "While in the ALSA you (Patient #10) will be provided scrubs to wear. If you disrobe, locked seclusion will be ordered; if you make an effort to injure yourself, mechanical restraints will be ordered; if you toilet in any location other then the toilet, your body waste is considered to be infectious and this will be considered an assault and locked door seclusion or mechanical restraints will be ordered; mechanical restraint will occur using the restraint board in the seclusion room. The board provides thigh and chest restraint capabilities".

Psychiatric Progress Notes indicated that Patient #10 had a tendency to act out in an effort to force staff to implement involuntary procedures including physical holds, restraints and injections of medications as a means of reinforcement of his/her behaviors. The acting out behaviors identified included numerous self injurious acts and threats of suicide "....that are frequently not genuine but rather tend to be attempts to get attention and cause [herself/himself] to be hospitalized , remain hospitalized or to receive involuntary procedures.." The recommendation by the Psychiatrist was to use involuntary procedure strategies only when absolutely necessary to preserve the patient's safety and to not think of them as consequences that would alter or mold the patient's behavior.

A "Certificate of Need for Emergency Involuntary Procedures" for 11/23/12 at 5:30 PM demonstrated Patient #10's "reinforced behavior" when a "Therapeutic hold was used to place pt. on restraint board, pt. cooperative, wanted to use restraint board ." Staff documented, on this occasion, justification for the use of emergency restraint and/or seclusion as a response to Patient #10's threats to hurt herself/himself. Locked door seclusion and/or 6 point restraint board was initiated over 25 times from 11/21/12 through 12/21/12 with staff referencing the above mentioned behavioral treatment plan and initiating the consequences when Patient #10 was not compliant with the treatment plan. When informed Patient #10 had been restrained and/or placed in seclusion 13 times (from 11/21/12 - 11/26/12) the Vice President for Patient Care Services and Chief Nursing Officer stated on 2/21/13 at 2:10 PM " All these CONs (evidence of restraint/seclusion use) in one week, something isn't working".

Improper use of restraints were also ordered and used by staff for the purpose of administering non emergency medication and performing blood testing which had been refused by Patient #10. Per physician order for 11/27/12 at 10:55 AM: " May not refuse noon fingerstick BS. May board (place patient in 6 point restraints on a board) for finger sticks blood sugar ....." Per Nursing Shift Progress Note, for 12/10/12 at 5:45 PM, because the patient had urinated on the floor in ALSA and refused his/her insulin injection Patient #10 was placed in 6 point restraints and once restrained, was administered both Thorazine and Insulin.

Per interview on the afternoon of 2/21/13, the Vice President of Patient Care & Chief Nursing Officer acknowledged staff , per hospital policy, could restrain a patient for the administration of an emergency medication such as Thorazine, however a court order would be needed to enforce the administration of Insulin. There was no evidence that the hospital obtained a court order.

During interview, on 2/12/13 at 10:18 AM, the Manager of Performance Improvement and Risk Management stated that review of the video tapes by facility staff, referencing Patient #5, had occurred in August of 2012 following a request for the video by an outside agency at that time. S/he stated that a complaint was made to the facility in December of 2012 or January of 2013 regarding Patient #5. S/he further stated s/he again reviewed the video as did the Unit Manager, who stated s/he had no concerns regarding the care and treatment of Patient #5.

Despite the fact that the aforementioned video had been reviewed by the Manager of Performance Improvement and Risk Management, and although all episodes of restraints and seclusion are reviewed for quality purposes, as confirmed by the Manager of Performance Improvement and Risk Management, during interview on the afternoon of 2/21/13, the facility failed to identify the above cited examples of inappropriate use of restraint and/or seclusion, and failed to identify a violation of a patient's right to refuse medication, which led to a failure to identify opportunities for improvement.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and record review nursing staff failed to assess the health conditions and care needs of two patients each of whom exhibited a change in condition. (Patients #6 and #7): Findings include:

1. Per record review Patient #6, who was admitted on [DATE], underwent an outpatient surgical procedure to the right wrist to repair a damaged nerve on 6/1/12. Although the patient returned to the facility at approximately 2:30 PM on 6/1/12, there is no evidence assessment of the hand or surgical site had been conducted, until almost 24 hours later, at 1:00 PM on 6/2/12 when the note indicated the patient had returned movement in fingers and sensation in thumb of right post surgical hand. In addition, although the patient complained of and was treated for ongoing pain in the hand, the only nursing assessment of the condition of the hand was a note on 6/3/12 at 7:00 PM that stated the dressing had been changed, the wound site was clean and dry and without evidence of infection. A Medical Clinic Consultation request, dated 6/5/12, stated that the patient's plaster splint had gotten wet, that nursing staff "modified" with plaster and gauze and the patient was in need of wrist stabilization. An assessment was conducted by the PA (Physician Assistant), on 6/5/12, and the plan was to place in large cock up splint, allowed to remove when showering. Although subsequent nurses notes, on 6/7/12, at 7:35 PM and 6/8/12 at 2:45 PM, respectively, indicated that the patient had complained that his/her right wrist splint was too small and s/he had pain in the wrist, also complaining on 6/9/12, "feels like electric shocks going through my arm " and again, at 8:00 PM on 6/9/12, "about having more nerve pain in hand", there was no evidence of any assessment of the condition of the wrist/hand until 3 days later on 6/10/12. A medical clinic Consultation report, dated 6/10/12, stated the reason for the consultation was: "R wrist pain - evaluate for splint size". The consultation stated that the patient complained of continued Rt wrist pain with numbness of thumb; "States cast got wet and it wasn ' t recasted. Had splint but it was too small. Having increased pain with movement, numbness of thumb." The plan indicated a larger splint was applied, to be worn except when bathing. The patient had a follow up appointment, on 6/12/12, with the surgeon who had performed the surgery on 6/1/12 and, because of ongoing problems, the patient, subsequently underwent a second surgery of the right wrist, on 6/15/12.

The VP of Patient Care & CNO confirmed the lack of assessment by nursing during interview on the afternoon of 2/21/13.

2. Per record review, Patient #7, who was admitted , involuntarily on 12/11/12, had a medical clinic Consult, dated 12/18/12 that stated; Reason for consultation: "Pt reports falling, injuring R knee. Increased pain, limited ROM (Range of Motion). Pt also requests pictures be taken of bruising on......forearms". Despite the request and documentation by RN#2, dated 12/20/12, that Patient #7 had alleged that, during the prior weekend, MHW #2 had struck him/her on the left arm twice, there is no evidence that any assessment of the condition of the forearms had ever been conducted.

During interview on the morning of 2/21/13 at 10:05 AM, RN #3, who had completed the clinic consult form stated that Patient #7 had approached the RN and requested to see a doctor, stating s/he had fallen and felt his/her knee was broken. RN #3 further stated that the patient had also asked to have some pictures taken of bruises on his/her forearms. The RN stated s/he remembered looking at the patient's forearms and did not remember seeing bruising, but did not recall doing any other assessment. The VP of Patient Care & CNO, who was present during the interview, confirmed the lack of nursing assessment.

In addition, NP #2 stated, during interview on 2/20/13 at 2:00 PM, that s/he had spoken with RN #3, [prior to conducting the patient's assessment], about the request to have pictures taken, and had informed the RN that they did not need someone medical to take pictures. The NP further confirmed that s/he had evaluated the patient's knee but did not assess the patient's arms.

3. Per record review, staff failed to conduct observational checks of Patient #1 in accordance with physician orders. A physician order, dated 2/5/13 at 8:40 AM, stated to "Change from 30 minute checks to 15 minute checks" and identified "paranoia" as the rationale for the order. Per review of the Level of Observation flow sheets, although staff continued the 30 minute observations of the patient they did not begin to conduct 15 minute checks until 1:00 PM, a period of greater than 4 hours after the order was written.

The Senior Director of Regulatory Compliance confirmed, during interview at 1:05 PM on 2/19/13, that staff failed to conduct observation checks in accordance with physician orders.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and record review nursing staff failed to revise the care plan to reflect the current care needs for 1 patient. (Patient #6). Findings include:

Per record review, the care plan for Patient #6, who was admitted on [DATE], had not been revised to address the patient ' s care needs following a surgical procedure, on 6/1/2012, to repair a damaged nerve. Although the patient returned to the facility following the same day surgical procedure, with a dressing and plaster splint on the right hand there was no plan of care identified to meet those needs.

The VP of Patient Care & CNO confirmed, during interview on the afternoon of 2/21/2013, the care plan did not address the patient's post surgical status and care needs related to the surgical wound.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation and staff interview, the hospital failed to ensure medical records were accurately written, and properly filed and accessible. Findings include:

1. During the days of survey, records were difficult to review due to the "thinning" of documentation by staff on Patient Units. Upon review of specific records of patients hospitalized on Osgood 3, it was difficult to review components of the record due to the removal of physician orders and progress reports. Documentation was scattered among folders and files. When requesting on 2/20/2013, the previous admission record for Patient #10 the record provided was disorganized in multiple folders and chart. The "Certificate of Need for Emergency Involuntary Procedures", physician orders, progress notes and other pertinent information, improperly filed and out of sequence. On the morning of 2/21/13, the Director of Medical Records, confirmed staff on the patient units were disassembling records incorrectly.

2. Per review, Patient #13's medical record contained a written statement on a Progress Note, that was not dated, timed or signed by the author. The context of the note, which stated; "Pt said that peer [Patient #13] told [him/her] I haven't had sex in a while, but I was tested before then", did not appear to accurately reflect any information that would belong in Patient #13's record.

The RN Unit Manager confirmed, during interview at 2:28 PM on 2/14/13, the lack of dates, time and authentication of documentation, and agreed that the context of the Progress Note did not appear to be an accurate reflection of information that would belong in Patient #13's record.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on staff interviews and record review the facility failed to assure that all entries in the medical records were dated, timed and authenticated. Findings include:

Per review, Patient #13's medical record contained a written statement on a Progress Note, that was not dated, timed or signed by the author. The note, which stated "Pt said that peer [Patient #13] told [him/her] I haven't had sex in a while, but I was tested before then", did not appear to even belong in Patient #13's record. In addition, there was a Level of Observation flow sheet beginning at 7:00 PM and ending at 6:45 AM that lacked the date.

The RN Unit Manager confirmed, during interview at 2:28 PM on 2/14/13, the lack of dates, time and authentication of documentation, and agreed that the Progress Note did not appear to belong in Patient #13's record.