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.

Based on observation, interview, and record review the facility failed to ensure patients rights were protected in the facility. This failed practice denied vulnerable underage patients, residing in the facility, necessary protections against abuse and neglect. Findings:

Random observations during the survey on 2/22/18, 2/23/18, and 2/26/18 revealed Patient #2 was separated from peers and the general population of the facility milieu, unreasonably confined, and kept in the locked ante-room where the quiet rooms were located.

The facility failed to ensure patients were provided with necessary goods and/or treatment in a reasonable manner.

Record review revealed several facility staff currently working with patients in the hospital, did not have evidence of current Handle with Care (crisis intervention and behavioral management) training. Documents provided by the facility post survey revealed four facility staff completed the required training on or after the survey entrance.

Refer to A-145 Patient Rights: Free from Abuse/harassment

The facility did not follow the grievance process and failed to ensure all grievances were investigated and the complainant received a letter detailing the resolution of their deviance.

Refer to A-123 Patient Rights: Notice of Grievance Decision
Based on record review and interviews, the facility failed to provide a written response of its investigation and outcomes related to written grievances filed by two complainants. This failed practice denied patients and their guardians the right to ensure concerns had been investigated and addressed. Findings:

Patient #6

Record review on 2/22/18 of the facility's Patient Advocate Report for January and February of 2018 revealed a grievance dated 2/8/18 for Patient #6 "a myriad of concerns about [Patient #6] ...concerns regarding treatment."

Record review on 2/23/18 of the grievance, dated 2/8/18, revealed no grievance response letter had been sent nor was there documentation of any verbal communication from the Patient Advocate to the complainant. There was no information about any extenuating circumstances warranting additional resolution time or steps taken in review of the grievance.

During an interview on 2/23/18 at 12:40 pm the Patient Advocate stated a written response had not been provided to the complainant regarding the grievance filed on 2/8/18.

Patient #9

During an interview on 2/22/18 at 2:10 pm, when asked about the grievance process, Patient #9 stated he/she was unaware of grievance process but stated he/she had been encouraged by staff to write a grievance two weeks ago. Patient #9 further stated staff had assisted him/her in filing a written grievance. Patient #9 stated he/she had not received any follow up on the grievance that had been submitted two weeks ago.

A review of the "Patient Advocate Report" for the month of February did not contain an entry for Patient #9's grievance.

During an interview with the Patient Advocate on 2/23/18 at 1:15 pm stated he had no record of a grievance filed by Patient #9 and therefore no documented verbal or written response of the grievance as required by the facility's policy and procedure.

During an interview on 2/26/18 at 1:00 pm, when notified Patient #9's grievance had not been addressed, the Chief Executive Officer, expressed doubt the Patient had ever filed one.

Review of the facility's policy and procedures, "Patient/resident Rights - Guidelines for Addressing Patient/Resident/Family Grievances" Policy-RI103.06 Revised date 1/14, revealed:.All investigations will be concluded within 7 days of receipt. In the event there is extenuating circumstances that delay must be communicated to the patient/resident/guardian with an anticipated time frame for completion (not to exceed 30 days). The patient advocate will communicate actions or resolutions to the patient/resident/guardian no later than the following business day following the conclusion of his/her investigation. This communication may be verbal, but must be accompanied by written notice to the patient/resident guardian containing: Name of the Patient Advocate; steps taken to review the complaint; steps taken to resolve the complaint; date of completion."
Based on record reviews, observations, and interviews the facility failed to implement necessary protections to prevent patients from potential abuse and/or neglect. Specifically, the facility failed to ensure: 1) one patient was free from unreasonable confinement, 2) patients had access to necessary services and/or goods, and 3) annual and ongoing training for crisis management to prevent abuse and/or neglect was provided to direct care staff currently working in the facility. These failed practices placed patients at risk for abuse and/or neglect. Findings:

Unreasonable Confinement

Record review from 2/22-26/18 revealed Patient #2 was had diagnoses that included developmental disabilities and Attention Deficit Hyperactivity Disorder.

Observation of the quiet room area, where patients were sent for seclusion, revealed 4 rooms connected by an ante-room that could be accessed through two doors. Each of the four rooms had metal locking doors. The doors to the ante-room, that connected the 4 seclusion rooms, also had heavy doors that locked. The entire area was bare, with no decor, furniture or place to sit and/or lay down. There were no outside windows in the seclusion rooms or the ante-room. The windows in the ante-room had a view of the nurses' station and the medication room.

Random observations from 2/22-23/18 revealed Patient #2 was in the quiet room area and/or ante-room area that connected all four quiet rooms. The doors to the quiet rooms remained open while the doors to the ante-room remained locked thus confining the Patient from the general milieu and restricting the Patient from participating in programming and activities with peers.

The Patient was observed sitting on a blanket on the floor of the locked ante-room. There was no furniture in the rooms, other than a chair the facility staff sat on, while monitoring the Patient.

During an interview on 2/23/18 Patient #2 stated he/she wanted to get out of the room but stated the staff wouldn't allow him/her to leave.

Review of physician's order, dated 2/22/18, in Patient #2's medical record revealed "Subunit in [Quiet Room] for [24 hour] each day."

Further review of the Patient's record revealed no assessment, order, or documentation for the confinement.

During an interview on 2/23/18, when asked why the Patient could not leave the locked room while the unit was empty, Floor Staff #1 stated the facility didn't want to let the Patient out of the ante-room because facility staff feared the Patient would not voluntarily go back into the ante-room.

During an interview on 2/23/18 Licensed Staff #1 confirmed Patient #2 was confined when in the locked ante-room.

During an interview on 2/23/18 Licensed Staff #2 stated not allowing the Patient to leave the ante-room was considered confinement by verbal methods in addition to the locked entry doors.

During an interview on 2/23/18 Licensed Staff #3 stated placing a patient in a locked ante-room matched the facility's definition of seclusion.

During multiple interviews on 2/23/18 Floor Staff #2 stated the doors were locked on 2/23/18 from 7:30 am to 11:30 am and staff was not to allow the patient out of the subunit (ante-room). Further interview revealed the facility had not offered an alternative program (any activities) for Patient #2 while in the locked subunit.

During an interview on 2/23/18 Clinical Staff #1 stated he/she had not made adjustments to the established special program for Patient #2.

During an interview on 2/23/18 Clinical Staff #2 stated the clinical staff should have made an alternative program when Patient #2 was confined to the ante-room. In addition, the Clinical Staff stated the current special program worked better when the Patient was in the normal milieu with other peers.

During an interview on 2/26/18 Physician #1 stated the purpose of keeping the someone in the subunit was to keep the Patient out of the milieu and away from peers. The Physician stated the Patient had been assaultive towards facility staff. Physician #1 stated floor staff and clinical staff should have offered a programming option as close to the normal milieu as possible.

During an interview on 2/26/18 the Chief Nursing Officer (CNO), when asked what would define a seclusion, the CNO stated the removal of a patient from the milieu and placing them in the quiet room area. When asked if placing a patient in the ante-room outside the quiet room with locked doors was considered seclusion from the milieu, the CNO replied it would have been considered a seclusion as well (except for the presence of facility staff the Patient was not secluded but confined).

Additional review of Patient #2's medical record, dated from admission to 2/23/18 revealed no seclusion or confinement paperwork pertaining to the multiple hours of being restricted to the ante-room.

During an interview on 2/26/18, when asked about the confinement of Patient #2 to the ante-room, the Chief Executive Officer stated the Patient was highly aggressive and there were no other options available to maintain safety on the unit for the patients and staff.

Review of the "North Star Hospital Monitoring Precautions Record and Sleep log," dated 2/23/18, revealed the Patient was either compliant or free from negative behaviors from 2/23/18 at midnight until released from ante-room at 11:45 am. Further review of the medical record revealed no criteria that identified when the Patient could leave his/her confinement and return to the milieu.

Review of the facility's policy "Provision of Care Seclusion and Physical Restraint," reviewed date 5/2017, revealed "DEFINITIONS ...Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. IF a patient is restricted to a room alone and staff are physically intervening to prevent the patient form leaving the room or giving the perception that threats the patient with physical intervention if the patient attempts to leave the room, the room is considered located, whether or not the door is actually locked or not."

Further review of the facility's policy "Provision of Care Seclusion and Physical Restraint," review date 5/2017, revealed "It is the policy of North Star Behavioral health to support each patient's right to be free from restraint or seclusion ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion ...Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing ...Restraint or seclusion will be discontinued as soon as possible."

Additional review revealed "The physician's order for use of ...seclusion ...Time limits not to exceed 2 hours for children and adolescents ages 9 to 17 ...Discontinuation of Restraint/Seclusion: ..The use of a restraint/seclusion is discontinued once the unsafe situation ends, regardless of the scheduled expiration/maximum time of the order.

The facility did not have a policy on the use of confinement and involuntarily removing patients from the milieu for extended time periods when the patient is not demonstrating aggressive behaviors.

Necessary Goods and/or Services

During an interview on 2/22/18 at 1:20 pm, Patient #6 stated the "staff are rude, they yell at us for asking for things". Patient #6 stated he/she requested topical cream for a rash in personal item storage. He/she stated the staff refused the request stating "I don't have time to go back and forth to get you stuff." Patient #6 stated he/she did not receive the cream and was too frightened to ask again.

During an interview on 2/22/18 at 1:40 pm, Patient #8 stated the "staff aren't doing what they're supposed to do". Patient #8 further stated that facility staff did not respond to patients' requests for necessary items, such as hygiene items. The Patient stated not being listened to often caused mental distress.

During an interview on 2/23/18 at 9:30 am, Patient #10 stated that patients have to wait up to an hour to get things they need. The Patient stated that he/she felt facility staff could respond more promptly to requests.

Annual and Ongoing Training to Prevent Abuse and/or Neglect

Record Review on 2/22-23/18 of a current facility staff list of staff revealed 48 staff listed were over due to complete training and "off schedule until complete" for "Handle with Care" (A CMS compliant Crisis Intervention and Behavior Management System) training.

Record review of the Daily Staffing report for 2/7/18-2/21/18 revealed that 5 staff members, staff whom were scheduled to work during the survey period, had not completed with facility mandated training.

During an interview 2/22/18 at 1:00 pm, Human Resource Staff #s 1 and 2, stated the facility staff list was current.

Review of the facility policy, "Abuse Reporting", approved 3/17, revealed "All employees will receive training in recognizing and reporting abuse. Training with handouts will occur during orientation regarding Abuse/Neglect Reporting and annual updates will be provided.