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 document review and staff interview, it was determined there was no evidence that the hospital implemented facility wide corrective actions to prevent reoccurrence of identified problems. This was evident for Patient #s 1, 2, 3.

Findings include:

On 10/26/18 at 2:15 PM and 10/29/18 at 2:00 PM, Staff F, the Associate Director of Quality and Risk Management was interviewed regarding Adverse Events in the Comprehensive. Psychiatric Emergency Program (CPEP). Review of a document titled "Justice Center Incidents-CPEP" identified a list of eight (8) incidents that occurred within a timeframe from 6/8/18 to 9/10/18. Seven (7) of the eight (8) incidents were described as "Allegation of Abuse or Neglect" and "Wrongful Conduct." Staff F stated these incidents were reported to the Justice Center, four (4) were accepted and three (3) were designated for investigation by the hospital.

Documentation of the facility's investigation of the incidents states:
Patient #1 - On 6/9/18, in the course of being restrained in CPEP, a sheet was placed over the patient's face, on two occasions. The investigation concluded, standard of care was not met due to individual and systemic factors.

The Plan of Correction for this incident states "The assistant director of Nursing will reinforce with CPEP the importance of following policies and protocols currently in place and to adhere to the training given in PMCS." (Preventing and Managing Crisis Situations)

Staff F presented a document titled: "Preventing and Managing Crisis Situations (PMCS) Refresher," which was signed by one of the individuals identified in the incident. The date on this document is 1/26/17.

There is no documented evidence that the Plan of Correction was implemented.

Patient #2 - On 7/28/18 Staff P put his knee on the chest area of and Staff I put his hand around the neck of recipient. Staff F reported that the staff was released from duty.

There is no documented evidence of a Plan of Correction for this incident.

Patient #3 - On 9/18/18 a sheet was improperly utilized during the process of restraining the patient.
The investigation concluded, the standard of care was not met due to systems issues, specifically the lack of clear expectations for the management of emergency situations in the CPEP.

The Plan of Correction stated the CPEP leadership will identify and disseminate clear expectations regarding roles and responsibilities for specific staff members and specific disciplines in crisis situations. For the issue relating to the management of patients who are spitting, leadership will review their protocols for such situations with all CPEP staff and will share those protocols with the Hospital Police.

Staff F presented a document dated October 25, 2018, titled "Staff Meeting with Tour 1 and 2 and three (3) items are listed in the document. An attendance sheet signed by 12 staff was attached.

There was no evidence that this plan of correction was implemented for the entire CPEP and the Hospital Police Staff.
Based on documents review and interview, the hospital failed to develop a policy and procedure described the discharge planning process for all in patients.

Finding include:

Review of the hospital's policy and procedure titled "Discharge Planning Process," last reviewed 10/16, showed no evidence that the hospital describe the discharge planning process for all in patients.

During interview on 10/25/18 at 2:00 PM Staff A, Director of Social Work Services acknowledged the findings and stated that the hospital identified the issues and was in the process of writing a new policy and procedure for discharge planning.