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.

CRESTWYN BEHAVIORAL HEALTH 9485 CRESTWYN HILLS COVE MEMPHIS, TN Feb. 12, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy review, document review and interview, the Governing Body failed to assume responsibility and provide oversight and ensure all staff honored patient rights, and ensure the QAPI program performed an analysis of incidents and abuse and developed appropriate interventions for the prevention of abuse.

The findings included:

1. The Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible and ensured the safety of the patients in the hospital.
Refer to A 057.

2. The Governing Body failed to ensure abuse policies were implemented and that all patients were protected from all forms of abuse.
Refer to A 0115 A 0145.

3. The Governing Body failed to ensure the Quality Assessment Performance Improvement (QAPI) committee analyzed all incidents of abuse and implemented preventative actions to ensure the events did not reoccur.
Refer to A 0286 and A 0263.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of the facilty Plan of Correction dated 3/26/18 revealed the completion date for correcting this deficient practice was dated 3/26/18. A re-visit was conducted on 3/27/18. The facility did not have sufficient time to ensure the Plan of Correction would be effective ongoing. Therefore the Standard will be re-cited.

Based on facility documents, facility policy, medical record review and interview, the Chief Executive Officer (CEO) failed to be responsible for the management of the hospital and ensure the implementation of the abuse policy for 3 of 3 (Incident #1, #2 and #3) allegations of abuse reviewed.

The findings included:

1. Review of the "Patient Abuse and Neglect" policy revealed, "It is the policy of [name of hospital company] that no patient is to be mistreated or abused physically, verbally, psychologically or sexually while in our care....[Name of hospital company] maintains a Zero Tolerance policy for patient abuse and or neglect...Upon investigation and after an assessment of the findings, a final determination should be made by the Senior Facility Leader and senior management..."

2. Review of the facility's Incident Reporting Form (IRF) and investigation for Incident #1 revealed allegations that Staff #2 was verbally abusive to Patient #1.

Review of the facility's IRF and investigation for Incident #2 revealed allegations that Staff #4 was physically abusive to Patient #2.

Review of the facility's IRF and investigation for Incident #3 revealed allegations that Staff #1 was sexually abusive to Patient #3.

The facility's Zero Tolerance policy for abuse and or neglect was not met. The allegations for Incidents #1, 2 and 3 were not immediately reported and patients were not immediately protected. The allegations of abuse for Incidents #1, 2 and 3 were not thoroughly investigated in a timely manner.

3. In an interview on 2/5/18 at 3:15 PM the CEO stated the previous Risk Manager (#2) had destroyed documents and "sabotaged" the facility. The CEO was asked who was responsible for RM #2's performance and oversight. The CEO stated, "That would be me."

Refer to A 145.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, policy review, medical record review, observation and interview, the hospital failed to promote a hospital wide system that ensured abuse prevention and protection for all patients.

The findings included:

The hospital failed to ensure all patients were protected from all forms of abuse.
Refer to A 145
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the facilty Plan of Correction dated 3/26/18 revealed the completion date for correcting this deficient practice was dated 3/26/18. A re-visit was conducted on 3/27/18. The facility did not have sufficient time to ensure the Plan of Correction would be effective ongoing. Therefore the Standard will be re-cited.

Based on document review, policy review, medical record review, and interview, the facility failed to promote all patients' right to be free from abuse for 3 of 3 (Patients #1, 2 and 3) sampled patients reviewed with allegations of patient abuse.

The findings included:

1. Review of the "Patient Abuse and Neglect" policy revealed, "It is the policy of [name of hospital company] that no patient is to be mistreated or abused physically, verbally, psychologically or sexually while in our care....[Name of hospital company] maintains a Zero Tolerance policy for patient abuse and or neglect. Procedure: Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to: striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient...
Neglect would be failing to provide for the patient's basic emotional or physical needs or failing in any way that would endanger the patient's emotional or physical well-being. Failing to be fully engaged in promoting patient treatment plans would also be considered neglect...
All instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager [RM], a department head or supervisor. Failure to report witnessed patient abuse may result in disciplinary action up to and including termination...
Upon investigation and after an assessment of the findings, a final determination should be made by the Senior Facility Leader and senior management. Findings of patient abuse will be considered a violation of the standards of conduct and subject to immediate termination..."

The Abuse policy and procedures were requested on 2/5/18 at 11:20 AM. In an interview on 2/6/18 at 8:45 AM in the conference room, RM #1 stated there was no other abuse policy or procedures other than the "Patient Abuse and Neglect" policy provided.

2. Review of the "Expectation of Employee Behavior" conduct policy revealed, "...Patient Abuse...Abuse can take many forms...Using foul or hostile language or shouting at a patient would be considered verbal abuse. Any act that undermines treatment goals or serves to lessen the patient's feeling of security, self worth, or acceptance would be considered emotional abuse...It is your responsibility to report any actions by staff, other residents, or family members that could be considered abuse or neglect and to fully participate in any investigation into alleged abuse or neglect...Abuse, neglect, or failure to report abuse or neglect is a serious offense and will result in disciplinary action up to and including termination..."

3. Medical record review revealed Patient #1 was [AGE] years old and admitted on [DATE] with the diagnosis of Bipolar Disorder.

Review of the Incident Reporting Form (IRF) for Incident #1 revealed three (3) witnesses alleged that on 8/14/17 at 7:45 AM Staff #2 was verbally abusive to Patient #1. The IRF revealed Staff #2 stated to Patient #1, "...You will eat the rotten food and die. The coroner will take your picture and your family will pick your body up with your belongings by the interstate."

In an interview on 2/5/17 at 2:00 PM in the conference room RM #1 stated staff and patients that observed the incident occur were interviewed and all verified the incident occurred.

In an interview on 2/6/18 at 1:00 PM in the conference room RM #1 stated Staff #2 had worked from 8/13/17 at 6:45 PM thru 8/14/17 at 3:00 PM (20.25 hours), verifying the employee continued to work after the witnessed incident of verbal abuse.

Review of the "Daily Time and Attendance Report" confirmed Staff #2 worked 20.25 hours from 8/13/17 at 6:45 PM thru 8/14/17 at 3:00 PM. Review of the employee personnel file revealed Staff #2 was terminated on 8/15/17.

The facility failed to ensure all patients were free of abuse. The facility failed to ensure the incident was immediately reported and the patient was immediately protected from further abuse during the investigation.

4. Medical record review revealed Patient #2 was [AGE] years old and admitted on [DATE] with the diagnosis of Recurrent Severe Major Depressive Disorder.

Review of the admission Nursing assessment dated [DATE] revealed no documentation of bruising on admission to the hospital.

Review of the 9/24/17 "Nursing Reassessment" for 7:00 PM-7:00 AM revealed Staff #7 documented the patient was oriented to person, place and time, and had no aggression on this shift.

Review of the 9/27/17 "Progress Note" revealed a note for 9:33 AM. The note documented, "...large bruise was noted on legs...bruises are old [sign for and] healing..."

Review of the 9/27/17 "Progress Note" for 7:00 PM - 7:00 AM revealed Staff #8 documented, "Pt [patient] was tearful this evening due to an incident...over the weekend. She stated she was pushed by staff onto the floor which resulted in a bruise on Right leg...The bruise is purple in color and large..."

Review of the IRF for Incident #2 revealed allegations of physical abuse. The IRF revealed Patient #2 reported the incident on 9/17/17 at 9:00 PM and another section of the IRF revealed the incident date of 9/27/17. Patient #2 reported that Staff #4 pushed her. The patient reported she had a bruise from the incident.
The IRF documented, "...Bruise on right leg-extensive from groin to ankle. Photo taken." The IRF revealed RM #2 was notified of the allegations on 9/27/17 at 9:20 PM.
RM #2 documented she had reviewed the IRF on 9/28/17. The section titled "Actions Taken/Follow up/Recommendations as result of the Incident" revealed, "Allegation is Level 1 zero tolerance..." An additional note dated 2/1/18 revealed, "...2/1/18 per discussion w/ [with] corporate risk downgraded to level 3-unsubstantiated [initials of RM #1]."

In an interview on 2/6/18 at 10:30 AM in the conference room, RM #1 stated the corporate office was onsite the week of 1/29/18 and reviewed the IRFs to close out this and other incidents that had not been completed by the previous RM #2. RM #1 stated she thought the IRF dated 9/17/17 was a date error and actually occurred on 9/27/17. RM #1 stated she was unable to find the photos of the Patient #2's bruise, as referred to in the IRF. RM #1 stated there was no documentation of the patient having any bruising upon admission to the psychiatric hospital. RM #1 stated that Staff #4 was still employed by and working at the facility.

Review of the facility's statements on "Patient Concern Notification" form obtained regarding the physical abuse allegations revealed the following:
(a) A statement dated 9/24/17 that alleged, "...[Name of Staff #4] pushed me away from the nurses station. i [I] was only asking about [something that had been scribbled out] machine...Nurse [Name of Staff #7] was trying to call my Dr. [doctor]..."
(b) Staff #8 notified RM #2 on 9/27/17 at 9:00 PM. The statement revealed, "Call Risk Management to notify incident...Offered pt [patient] rest and prn [as needed] paint medication."
(c) Staff #7's typed statement dated 9/30/17, "On September 29, 2017 patient [Name of Patient 2] used her C-PAP machine at our facility for the first time...She seemed in good spirits that night, pleasant and generally cooperative...I did not at any time see any physical altercations between [Name of Staff #4] and the patient...[Name of Patient #2] did not voice any complaints to me about [Staff #4] at any time...I trust him [Staff #4] completely and have thoroughly enjoyed working with him.
The statement from Staff #7 was dated 9/30/17, 3 days after the allegation was made. The 9/30/17 statement documented the incident occurred on 9/29/17, which was not when the patient's allegations were made for this incident.
(d) Staff #4's undated typed statement, "I apologize for not correctly remembering the exact day in reference, but I am positive it was either Saturday, 9/23, or Sunday, 9/24, at approximately 9:30 PM...[Name of Patient #2] was pacing around the nurses station...[the patient] became somewhat aggressive with me at times, but a hold was never placed on her nor even hands placed on her...With the allegations made against me, I just wanted to clarify that I in no way made any physical contact with [first name of Patient #2]. I knew prior to this that she was on blood thinners [Aspirin 81 milligrams] which can cause someone to bruise very easily, so a physical intervention would be the last thing I would want to do, strictly because of possible allegations like this. As for how any bruising she may have accrued while being here, I have absolutely no idea..."

In a telephone interview on 2/7/18 at 3:07 PM Staff #7 stated, "...She [Patient #2] had been delusional...I was not standing there when she made the allegation. She [Patient #2] told me on that day [date the incident occurred] that he [Staff #4] pushed her and again said that a couple days later. I blew it off because after that she was going up to him [Staff #4] and didn't seem scared [of Staff #4]. I told her [Patient #2] that I had never been aware of him hurting anyone. She [Patient #2] said I know I thought he pushed me."

In a telephone interview on 2/8/18 at 2:40 PM Patient #2 stated the incident occurred the date her statement was written on 9/24/17.

On 2/6/18 at 3:00 PM, 2/8/18 at 3:45 PM and 2/8/18 at 4:15 PM RM #1 was asked to have Staff #4 and Staff #8 to call the surveyor for an interview.
On 2/7/18 at 10:30 AM the surveyor left a voice message for Staff #4.
On 2/7/18 at 11:06 AM the surveyor left a voice message for Staff #8. After multiple attempts the surveyor was unable to interview Staff #4 or Staff #8.

The facility failed to conduct a thorough investigation that identified the correct date the incident occurred. The incident investigation and conclusion were not completed until 2/1/18, over 4 months after the incident was reported, the employee continued to work. There was no evidence provided that the facility immediately reported, investigated and protected the patient(s) from abuse.

5. Medical record review revealed Patient #3 was [AGE] years old and admitted on [DATE] with the diagnosis of Recurrent Severe Major Depressive Disorder.

Review of the "History and Physical Examination dated 6/20/17 " revealed, "...Chief Complaint: Slit wrists-SA [suicide attempts]- 6/19 [with] ETOH [alcohol] & [and] Xanax...History of Present Illness: worsening depression [with] multiple SA in June 2017..."

Review of the 6/28/17 "Discharge Summary" revealed, "...admitted in for increased depression and poor coping skills...suicidal ideations with a history of thoughts of self-harm and suicide attempts..."

Review of the IRF for Incident #3 revealed allegations of "Body Exposure/Misconduct" with "Misconduct" identified with being circled. The "Nursing Evaluation & Medical/Other Interventions" section of the IRF revealed Patient #3 was "emotional trauma, upset, crying."

The facility's investigation revealed RM #2 documented the following statements:
(a) Statement for Patient #3- Reporting that on 6/26/17 at 8:00 PM "[name of Staff #1] has been sexually harassing me. On Sunday night he stated...my yoga pants were inappropriate because he could tell I did not have any panties on. my roommate [name] overheard him say this...On Monday night, 6/27/17, he stated to me, 'You're [f***ing] fine' and 'Damn, you so sexy' and 'Where do you work-what club...On ...6/27/17, I was undressing and getting into the shower...[name of Staff #1] was knocking on my door and then came in anyways...He asked if he could see the tattoo on my ass...I was cold and he said only if you add me on Facebook...I am scared of him and want to tell someone..."
(b) Statement for Patient #3's roommate- "...I overheard [Name of Staff #1] tell my roommate that her yoga pants were inappropriate because he could see that she did not have any panties on...He is harassing [name of Patient #3] and she is scared..."
(c) Statement from Staff #3 dated 7/3/17- "I perceived the body language of staff with the patient [Name of Patient #3] was a little off. The next day...patient then told me...the staff member [Staff #1] asked about what club does she dance for...statements like 'let me see that Bart Simpson tattoo'...Also staff [Name of Staff #1] told the patient if she wanted an extra blanket she has to give up her Facebook name."
(d) Statement from Staff #1- "...we were able to establish confirmation of me denying these allegations...Once again I am for certain denying these allegations..."
(e) Review of an email from RM #2 to the Director of Nursing (DON) dated 7/16/17 documented, "...On Wednesday 6/28/17 at 17:15 [5:15 PM], [Names of Staff #3, #5 and #6] entered my office. [Staff #3] had been informed by [Patient #3] that [Staff #1]...was sexually harassing her on the unit for the previous three nights...She was scared...[Staff #5 and #6's names] indicated that [name of Staff #1's] body language around [Patient #1], was like he was trying to pick her up."
(f) An additional note was added for 8/15/17 that Patient #3's mother reported that Staff #1 was "stalking" Patient #3 via Facebook.

In an interview on 2/6/18 at 1:15 PM and 2:45 PM in the conference room, Staff #5 and Staff #6 told the same story, respectively. Staff #5 stated the incident was reported to RM #2 "...the day she [Patient #3] was discharged [6/28/18] and she [patient] was scared for other patients..."

In an interview on 2/6/18 at 2:15 PM in the conference room RM #1 stated Staff #1 worked 6:00 PM - 11:00 PM on 6/26/17 and worked 6:15 PM - 11:00 PM on 6/27/17 and provided a "Timesheet Audit Report" verifying Staff #1 worked after the reported sexual abuse.

In a telephone interview on 2/7/18 at 1:33 PM Staff #3 stated, "First off, she [Patient #3] told others in group her personal business and about her tattoos. She [Patient #3] said he [Staff #1] wanted to see her tattoo of Bart Simpson..." Staff #3 was asked when he reported the incident that Patient #3 reported to him. Staff #3 stated, "...The next day, cuz they [Administration and RM #2] had gone. I let [name of RM #2] know the next day..."

The facility failed to ensure staff immediately reported Staff #1's body language behaviors and Patient #3's allegations. The facility failed to protect all patients from abuse and failed to protect patients from further abuse after the allegations were reported.

6. In a telephone interview Confidential Interview (CI) #1 stated, "...they [staff] would beat those people [patients]...the staff get high [on marijuana] and go back to work..."

In a telephone interview CI #3 stated, "...very disorganized. Inappropriate staff behavior, the black staff are mean and abuse the white patients and then high five themselves for good job..." CI #3 stated they heard a staff member say "Where's the white girl [patient], Im gonna beat her ass...Lots of verbal abuse going on..." CI #3 stated the staff smoked marijuana while working.

In a telephone interview CI #2 stated, "...patients reported physical abuse and bruises. I saw the bruises..."
VIOLATION: QAPI Tag No: A0263
Based on facility policy review, document review and interview, the facility failed to ensure it maintained an effective and on-going Quality Assessment and Performance Improvement (QAPI) program to prevent patient abuse.

The findings included:

1. The facility failed to ensure the QAPI committee implemented appropriate preventative actions to prevent abuse.
Refer to A 283
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of the facilty Plan of Correction dated 3/26/18 revealed the completion date for correcting this deficient practice was dated 3/26/18. A re-visit was conducted on 3/27/18. The facility did not have sufficient time to ensure the Plan of Correction would be effective ongoing. Therefore the Standard will be re-cited.

Based on document review, policy review, medical record review, observation and interview, the facility's Quality Assessment Performance Improvement (QAPI) Committee failed to ensure an ongoing hospital-wide program that identified, fully analyzed and addressed all allegations to prevent abuse for 3 of 3 (Incidents #1, 2 and 3) abuse incidents reviewed that involved 3 of 3 (Patients #1, 2 and 3) sampled patients reviewed.

The findings included:

1. The facility's complaints/grievances and allegations of abuse from June 2017 - January 2018 were requested in the entrance conference with Risk Manager (RM) #2 on 2/5/18 at 11:20 AM. Incidents #1, #2 and #3 were sampled for review.

a. Review of Incident #1 revealed allegations that Staff #2 was verbally abusive Patient #1 in August of 2017.

b. Review of Incident #2 revealed allegations that Staff #4 was physically abusive to Patient #2 in September of 2017.

c. Review of Incident #3 revealed allegations that Staff #1 was sexually abusive to Patient #3 in June of 2017. Review of the facility Incident Report Form (IRF) revealed the "...type of Incident" was identified by the facility as "Misconduct."

In an interview on 2/5/18 at 2:10 PM in the conference room RM #1 stated there were no allegations of abuse for June 2017. The surveyor asked for the incident involving Patient #3.

In an interview on 2/5/18 at 3:35 PM in the conference room the CEO, with RM #1 present, stated they were informed by the corporate office, "...once an investigation is closed we do not turn it over to the State."

In an interview on 2/5/18 at 3:50 PM in the conference room with the CEO, RM #1 and Corporate Risk via phone conference the facility agreed to provide the information. RM #1 provided information and stated what was provided is "...all we have..."

In an interview on 2/6/18 at 2:00 PM in the conference room, RM #1 stated 11/17/17 was the last day of employment for RM #2. RM #1 stated she started as RM #1 in January 2018.

The facility failed to ensure the Zero Tolerance policy for abuse and or neglect was met. The abuse allegations were not immediately reported and patients were not immediately protected. The allegations of abuse were not thoroughly investigated in a timely manner. The facility failed to provide corrective measures to ensure all patients were free of abuse or neglect.

2. An interview was conducted on 2/6/18 at 3:00 PM in the Administration conference room with the Chief Executive Officer (CEO) and RM #1. The CEO and RM #1 were informed that the facility could provide any corrective action measures, if they chose to, that addressed the abuse problems. The CEO and RM #1 were asked to provide that information by 10:00 AM on 2/7/18, if they chose to do so.

On 2/7/18 at 10:01 AM the surveyor received an electronic mail (email) which included a 7 page attachment titled "[Name of the psychiatric hospital] Allegations of Abuse or Neglect" policy with the date 4/30/16 for approval. The policy revealed, "...[Name of the psychiatric hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members...3. Management of Suspected Abuse/neglect: A. Cases of suspected sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly...III. To protect the patient from real or suspected mental, physical, sexual and verbal abuse, neglect and/or exploitation, staff will safeguard the patient from the offending individual(s)...a. If allegations are made that a patient is experiencing abuse, neglect or exploitation caused by a staff member(s), all staff member(s) involved in the allegations will be placed on administrative suspension pending investigation by the hospital. b. While allegations exist...that staff member(s) will not return to work until the allegation and incident investigation are completed and the allegations are proven to be founded or unfounded...e. All allegations should be immediately and thoroughly investigated until conclusion..."

In a telephone interview on 2/8/18 at 3:45 PM, RM #1 was asked if this was a policy that was in effect prior to the complaint investigation or if it was going to be initiated as a corrective action. RM #1 stated, "let me get back with you."
Review of an email dated 2/8/18 at 4:03 PM from RM#1 revealed, "...Per our conversation, I wanted to provide follow-up regarding the Allegations of Abuse and Neglect Policy. It has been in effect since 04/30/2016, the problem was locating it during your visit due to the stated issues with the previous RM [RM #2]..."

There was no information provided by the facility that revealed the facility's QAPI program had implemented corrective actions and monitoring to address the system problems identified related to patient abuse.