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.

ALASKA PSYCHIATRIC INSTITUTE 3700 PIPER STREET ANCHORAGE, AK Dec. 7, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
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Based on record review and interview the facility failed to effectively manage the hospital to protect patients from harm. Specifically, the facility's governing body (GB) failed to ensure processes related to medical staff bylaws; quality assessment and performance improvement (QAPI); review of contract services, and implementation of patient safety policies were effectively completed and/or implemented. This failed practice placed all patients (based on a census of 41) at risk for receiving less than optimal medical and psychiatric care. Findings:

1) The GB failed to ensure medical staff bylaws had been approved and implemented (A0047) and medical staff rules and regulations had been approved and implemented (A0048)

2) The GB failed to ensure contracted services were reviewed and performance improvement activities were implemented through QAPI program (A0083) and services were provided in a safe manner (A0084);

3) The GB of the hospital failed to ensure the maintenance and implementation of a functioning QAPI program (A0263) and improvement activities were identified and implemented (A0283);


4) The GB failed to ensure the processes and policies for the investigations of abuses and neglect were implemented to determine root cause analysis (A0283) and protected patients from potential harm (A0145).

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VIOLATION: MEDICAL STAFF - BYLAWS Tag No: A0047
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Based on record review and interview the Governing Body (GB), of the facility, failed to ensure medical staff had current bylaws in accordance with Federal Laws and regulations. This failed practice places all patients (based on a census of 41) at risk for less than optimal necessary care and services in a safe setting. Findings:

Record review, on 11/28-29/18 of the "[Alaska Psychiatric Institute - API] Governance Committee Urgent Meeting ...," dated 9/28/18, revealed "Medical Staff Bylaws Update The bylaws and medical staff rules and regulations need to be updated ...The [governing body] will review the electronic copy of the Medical Staff Bylaws to provide feedback and approval for implementation."

Review of a facility provided e-mail, dated 10/31/18, revealed the Chief Executive Officer (CEO) sent an e-mail to voting members of the Governing Body (GB) which stated "Attached are the Medical Staff Bylaws and Medical Staff Rules and Regulations that need approval for [Alaska Psychiatric Institute - API] to meet the Plan of Correction with [Center for Medicare and Medicaid - CMS] ...previously provided copies at the last in-person Governance Meeting ....this is a vital part of updating requirements in the plan of correction by noon, Thursday 11/2/18 or sooner ..."

Review of three Governing Body (GB) members' submissions for edits to the Medical Staff Documents revealed a multitude of edits and inquiries related to the Medical Staff Bylaws, Rules and Regulations. These edits and inquiries were submitted via e-mail from 10/31/18 to 11/1/18 (over a month after the effective date of the provided documents during the survey) in response to a request submitted by the Chief Executive Officer (CEO).

Review of a facility provided e-mail, dated 10/31/18, revealed the CEO sent an e-mail to voting members of the governing body which stated "Attached are the Medical Staff Bylaws and Medical Staff Rules and Regulations that need approval for [Alaska Psychiatric Institute - API] to meet the Plan of Correction with [Center for Medicare and Medicaid - CMS] ...previously provided copies at the last in-person Governance Meeting ....this is a vital part of updating requirements in the plan of correction by noon, Thursday 11/2/18 or sooner ..."

Review of the facility's Medical Bylaws and Rules and Regulations, dated 9/2018, revealed several edits were not corrected in the documents. Furthermore, no evidence was provided by the facility to show inquiries made by a GB member were addressed to the GB regarding the Medical Staff Documents. In addition, edits were submitted individually by the GB members without a formal presentation of all suggested edits being reviewed as whole by the GB.

During an interview on 11/29/18 at 10:38 am Office Staff (OS) #1 stated the Medical Bylaws and Medical Rules and Regulations were under review. The Medical Rules and Regulations only had suggestions made by the Chief of Psychiatry with no further comments by the governing body. During this interview the OS was only able to provide a draft copy of the Medical Bylaws, as well as, the Medical Rules and Regulations.

Review of the facility provided "Governance Document," dated 11/2/18, revealed the API medical staff shall develop and adopt a Medical Staff Document with rules and regulations to establish framework for self-governance of medical staff activities and provide accountability to the CEO and Governance. The CEO and API Governance must approve the Medical Staff Document, rules, and regulations, and any amendments prior to becoming effective. Neither body may unilaterally amend the Medical Staff Document.

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VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
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Based on record review and interview the facility failed to ensure medical staff bylaws and medical staff rules and regulations with revisions were approved and implemented by the governing body (GB). This failed practice placed all patients (based on a census of 41) at risk for receiving less than optimal medical and psychiatric care. Findings:

Review of the "[Alaska Psychiatric Institute - API] Governance Committee Urgent Meeting ...," dated 9/28/18, revealed "Medical Staff Bylaws Update The bylaws and medical staff rules and regulations need to be updated ...The [governing body] will review the electronic copy of the Medical Staff Bylaws to provide feedback and approval for implementation."

Review of a facility provided e-mail, dated 10/31/18, revealed the Chief Executive Officer (CEO) sent an e-mail to voting members of the Governing Body (GB) which stated "Attached are the Medical Staff Bylaws and Medical Staff Rules and Regulations that need approval for [Alaska Psychiatric Institute - API] to meet the Plan of Correction with [Center for Medicare and Medicaid - CMS] ...previously provided copies at the last in-person Governance Meeting ....this is a vital part of updating requirements in the plan of correction by noon, Thursday 11/2/18 or sooner ..."

Medical Staff Bylaws:

Review of a facility provided e-mail, dated 10/31/18, revealed GB Member #1 responded to the CEO's e-mail by stating the Medical Staff Bylaws had several corrections and formatting issues that needed to be made and provided an attachment with suggested edits.

Review of a facility provided e-mail, dated 11/1/18, revealed GB Member #2 stated the Medical Bylaws had several typo corrections and a clarification question regarding the Commissioner's designation of "ex officio".

During an interview on 11/29/18, Office Staff (OS) #1 stated the Medical Staff Bylaws were still in draft form but had been reviewed by the GB and the facility was still awaiting a final approval.

Review of the facility provided draft form of the Medical Bylaws provided 11/29/18 with an "Effective date 8/2018," revealed the front page stated "This document within is the bylaws for the Medical Staff of the Alaska psychiatric Institute and was approved by the sitting Medical Staff on September 2018." Further review revealed none of the provided changes by the GB were illustrated.

Review of a facility provided second draft form of the Medical Bylaws provided 12/10/18 with an "Effective date 8/2018," revealed the front page stated "This document within is the bylaws for the Medical Staff of the Alaska Psychiatric Institute and was approved by the sitting Medical Staff on September 2018." Further review revealed some of the changes by the GB were illustrated.

Review of a third copy of the Medical Bylaws provided 12/13/18 with an "Effective date of 9/2018," revealed the front page stated "This document within is the bylaws for the Medical Staff of the Alaska Psychiatric Institute and was approved by the sitting Medical Staff on September 2018." Further review revealed some of the suggested changes by the GB Member #2 were not illustrated.

No additional documentation was provided to show the GB's approval of all changes submitted by members. GB Member #2's inquiry regarding the concern with the Commissioner's designation of "ex officio" was not addressed in any documents provided by the facility. The three voting members that participated in the edits provided responses to the document, dated 9/2018, electronically to the CEO between 10/31/18 and 11/1/18.

Medical Staff Rules and Regulations:

Review of a facility provided e-mail, dated 11/1/18, revealed GB Member #2 stated the Medical Staff Rules and Regulations had typos and a clarification question regarding if a section of the document had been reviewed by legal staff. This e-mail was in response to the CEO's request via e-mail on 10/31/18.

During an interview on 11/29/18, OS #1 stated the Medical Rules and Regulations were reviewed by the Chief of Psychiatry and sent to the GB with no returned comments or changes at that time. In addition the OS #1 stated the Medical Staff Rules and Regulations still needed a completed signature page from the GB.

Review of the facility provided draft form of the Medical Rules and Regulations, provided on 11/29/18 with an "Effective date 8/2018," revealed none of the provided changes by the GB were illustrated.

Review of a facility provided second copy of the Medical Rules and Regulations, obtained 12/10/18 with an "Effective date 8/2018," revealed the provided edits from GB Member #2 had not been corrected.

No additional documentation was provided to show the GB's approval of all changes submitted by members. GB Member #2's inquiry regarding if a legal staff had reviewed a particular section was not addressed in any documents provided by the facility. No completed signature page was provided in relation to the Medical Staff Rules and Regulations.

Review of the facility provided "Governance Document," dated 11/2/18 revealed the "API Governance is responsible for approving facility medical staff or professional staff, Medical Staff Document, rules, and regulations ...." In addition the document revealed the API medical staff shall develop and adopt a medical Staff Document with rules and regulations to establish framework for self-governance of medical staff activities and provide accountability to the CEO and Governance. The CEO and API Governance must approve the Medical Staff Document, rules, and regulations, and any amendments prior to becoming effective. Neither body may unilaterally amend the Medical Staff Document.

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VIOLATION: CONTRACTED SERVICES Tag No: A0083
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Based on record review and interview the facility's Governing Body (GB) failed to ensure identified performance problems by contracted support services (WEKA- security staff hired within the facility to help with escalated situations who must comply with facility approved NAPPI hold techniques) was analyzed and implemented into Quality Improvement (QI) activities. This failed practice placed all patients (based on census of 41) in the facility at risk for injury/harm or having their rights violated. Findings:

Review of the facility policy "Quality Assurance and Performance Improvement (QAPI) Program," dated 10/31/18, revealed the QAPI plan established a system that included an ongoing assessment, using internal and external knowledge and experience to prevent errors and maintain and improve health care safety and quality. This was done by identifying and mitigate risk and medical errors by analyzing data, monitoring, improving and sustain performance.

During the survey the facility provided two policies entitled "Quality Assurance and Performance Improvement (QAPI) Program [QI-010-06.01]," dated 10/31/18. Review of both policies revealed they did not match under Executive Responsibilities and Prioritization.

During an interview on 11/29/18 the Chief Nursing Officer (CNO) stated the facility currently did not have a Quality Assurance Director or Risk Management Lead. In addition, she stated the staff who performed risk management duties was reassigned to conduct environment of care duties only. The position for Quality Assurance Director and Risk Manager were not occupied at the time of survey. The CNO stated the Quality Assurance and Performance Improvement (QAPI) program was to review audits conducted by nursing staff, but due to no QAPI program no audits have been analyzed at time of survey.

Review of the facility policy "Risk Management Plan," dated 12/7/12, revealed Risk Management was to work under the QAPI umbrella to facilitate identification, follow-up, corrective action or prevention of actual or potential problems/needs in patient care and safety.

During an interview on 11/29/18 the Chief of Operations (COO) stated the facility was lacking a QAPI department but the facility had attempted to hold a type of QAPI meeting but was unable to provide any meeting minutes or provide details of the outcome related to this meeting. The COO stated the Executive Team was attempting to develop sub-committees that would report to the Executive Team since the facility didn't have a QAPI program. The data would then be used by the Executive Team to determine QAPI projects, but the COO stated these committees were still in the beginning phases of development.

During an interview on 12/5//18 at 1:30 pm, when asked about an event in which WEKA staff had not implemented NAPPI (Non-Abusive Psychological and Physical Intervention - behavior assessment, de-escalation, and defusing skills for humane and effective response to violent and/or unsafe patient behavior) restraint techniques for 1 patient (#9), NAPPI Instructor #1 stated he/she completed the audit of this video on 12/2/18 at 6:30 pm and sent the report, which included the inappropriate NAPPI hold techniques, to the Chief Nursing Officer (CNO).

Review of the WEKA staff work schedule, from 12/2/18 to 12/7/18, revealed the facility could not provide an account of WEKA staff #1's and #2's hours worked within the facility after the inappropriate NAPPI techniques were identified and reported.

Review of the facility's policy "Seclusion and or Restraint," dated 6/1/18, revealed: "Those who apply the restraints ...and those who monitor patients while restrained ...will receive the training, and demonstrate the safe use of all approved restraint types, including physical hold techniques ..."

Further review revealed: "Only NAPPI approved techniques for physical intervention will be used ...High risk considerations for ...physical or mechanical restraint(s) include ...Restraint in supine position (laying down, face up) may result in aspiration. Restraint against a wall or other vertical surface is not permitted under any circumstances. Pressure placed on the neck may result in an obstructed airway, and is prohibited. Weight placed on the back, abdomen, or chest may result in asphyxiation."

Review of the facility's policy, "Quality Assurance Performance Improvement (QAPI) Program", dated 10/31/18, revealed no information about assessing the services provided by the contractor WEKA was reported to QAPI.

Review of the contract with the facility and WEKA, dated 3/15/18, revealed no information about evaluating performance and/or concerns and how the facility would ensure improvement of services.

During the survey from 11/27-30/18 and 12/5-6/18 the facility was asked to demonstrate evidence of its QAPI program for effectiveness and functionality. No evidence of QAPI meetings or activities, per facility policy, were provided by the end of survey.

Review of the facility provided "Governance Document," dated 11/2/18, revealed it was a responsibility of the Governing Body (GB) to assure the Chief Executive Officer (CEO) used appropriate and available resources to support the quality assessment and improvement functions and risk management functions related to patient care and safety. In addition, the document revealed the GB was responsible for the annual reporting and approval of the performance improvement plan, as well as, quarterly QAPI reports.

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VIOLATION: CONTRACTED SERVICES Tag No: A0084
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Based on record review, camera review, and interview the facility's governing body failed to ensure a contracted security service (WEKA) provided duties in a safe and effective manner. Specifically, the facility failed to ensure the safe application of NAPPI (Non-Abusive Psychological and Physical Intervention - behavior assessment, de-escalation, and defusing skills for humane and effective response to violent and/or unsafe patient behavior) restraint techniques by contracted personnel for 1 patient (#9), out of 6 sampled patients who experienced a seclusion or restraint. This failed practice placed the patient at risk for injury and created a non-therapeutic environment. Findings:

Record review on 11/27-30/18 and 12/5-6/18 revealed Patient #9 was admitted to the facility with diagnoses that included major depression and post-traumatic stress disorder (PTSD - anxiety and flashbacks triggered by a traumatic event). Further review revealed the Patient had a history of physical abuse.

Review of Patient #9's medical record revealed a Brief Manual Restraint (BMR - a method where one or more staff physically hold a patient to immobilize or reduce the ability of a patient to move his/her arms, legs, body, or head freely) occurred on 11/23/18 at 9:38 pm and 5- point restraint (a method of using a mechanical device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. 5-point restraint - 2 wrist restraint, 2 ankle restraints, and one restraint across the Patient's chest while the Patient is lying on his/her back) occurred at 10:12 pm.

Camera review on 12/5/18 at 1:15 pm, of the 11/23/18 incident revealed the following non-approved NAPPI techniques used by Psychiatric Nursing Assistants (PNAs) and WEKA support staff (contract security staff hired within the facility to help with escalated situations who must comply with facility approved NAPPI hold techniques):

- 9:38:00 pm - Patient #9 kissed a peer. To stop the behavior, PNA #4 placed his/her hand on Patient's forehead and pushed his/her head away from the peer. This caused the Patient to become assaultive.

- 9:38:09 pm - As Patient #9 stood up, PNA #4 grabbed the Patient from behind, over his/her arms, and the PNA locked his/her arms together in front of Patient's body (hugging him/her tightly from behind).

- 9:38:14 pm - Due to head butting behavior, PNA #5 was observed to grab the back of Patient #9's neck and place his/her other hand on Patient's forehead.

- 9:38:27 pm - Staff attempted to walk Patient #9 to the Oak Room (a separate room in the facility for seclusion or restraint) however the Patient was able to struggle free. At 9:38:29 pm, WEKA staff #1 and PNA #5 placed Patient #9 in another BMR by placing the Patient's chest against the wall.

- 9:38:31 pm - The audible comment "get [him/her] off the wall" can be heard (unknown who spoke).

- 9:38:32 pm - WEKA Staff #2 grabbed Patient #9's legs as the Patient was against the wall.

-9:38:36 pm - WEKA Staff #1, #2, and PNA #5 took Patient #9 to the floor in a controlled manner. Staff restrained the Patient on the floor for 6 minutes, patient positioned on his/her back and staff holding all limbs. Patient #9 walked to the Oak Room at 9:44:13 pm after other staff arrived.

- 10:04:43 pm - Patient #9 became assaultive in the Oak Room, BMR on the restraint bed initiated (Patient placed on his/her back). WEKA Staff #2 was observed to place his/her right knee on Patient #9's right arm (the arm was raised, bent at 90 degrees, back of hand lying flat on the restraint bed), at the elbow and upper arm junction. The WEKA Staff #2 apply pressure with his/her knee to keep arm stationary. WEKA Staff #2 restrained the arm in this manner for 2 minutes and 15 seconds.

- 10:10:54 pm - A release from the BMR was attempted, to lock Patient #9 in seclusion, however he/she became assaultive again. As BMR was re-initiated (Patient was standing), WEKA Staff #2 was observed to put his/her right hand on Patient's left facial cheek and grab the back of Patient #9's neck with his/her left hand. WEKA Staff #2 pushed Patient's head down onto the restraint bed, forcing Patient #9 to bend over, face to bed.

- 10:12:16 pm - As restraints were being placed (Patient laying on back on restraint bed), it was observed that WEKA Staff #2 leaned his/her left elbow onto Patient #9's chest and pushed down with his body weight to restrain Patient's shoulder and chest.

During an interview on 12/5/18 at 1:30 pm, NAPPI Instructors #1 and #2 stated these non-approved techniques are not safe and should not have been used:

- Neck holds, as seen multiple times in the camera review, are extremely dangerous and could injure the neck.

- A Patient cannot be held against a wall or hard surface, as this can impede breathing.

- WEKA Staff #2 increased the risk to Patient #9, as well as WEKA #1 and PNA #5 when he/she immobilized the Patient's legs as the Patient was held against the wall. This could have caused the group to trip and fall, which could have potentially caused injury.

- WEKA Staff #2 increased the risk of injury to Patient #9's arm by restraining it with his/her knee.

- WEKA Staff #2 increased the risk of breathing difficulty when he/she leaned onto Patient #9's chest.

During an interview on 12/6/18 at 2:45 pm, the Chief of Operations stated he reviewed WEKA Staff interactions and concluded the actions taken by the contracted staff were inappropriate and unacceptable.

Review of the "API Governance Committee Urgent Meeting ...," dated 9/28/18, revealed "Staff Safety A contract has been in place with [Security Support] to provide security serves from morning till evening at API. This has been successful model, and the contract is currently under review. There was no information about prior reviews and how the GB monitored contacted staff to ensure the safety and well-being of the patients.

Review of the State of Alaska Amendment to Professional Services Contract, dated 10/31/18 revealed an Appendix C - Amendment 3 that stated "API requires the presence and engagement of security staff on API clinical units on campus so as to ensure patient and staff safety ...Security Staff Training ...The contractor must ensure all security staff meet the requirements outlined in the original contract prior to provision of any of the service components outlined in this contract."

Review of the Standard Agreement Form for Professional Services, dated 3/15/18 revealed Appendix C - Descriptions of Services. Review of Appendix C revealed "Should physical patient contact occur, Contractor shall use only minimally necessary force to gain control of the situation."

Review of the facility's policy "Seclusion and Restraint," dated 6/1/18, revealed: "Those who apply the restraints ...and those who monitor patients while restrained ...will receive the training, and demonstrate the safe use of all approved restraint types, including physical hold techniques ..."

Further review revealed: "Only NAPPI approved techniques for physical intervention will be used ... High risk considerations for ...physical or mechanical restraint(s) include ... Restraint in supine position (laying down, face up) may result in aspiration. Restraint against a wall or other vertical surface is not permitted under any circumstances. Pressure placed on the neck may result in an obstructed airway, and is prohibited. Weight placed on the back, abdomen, or chest may result in asphyxiation."

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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
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Based on record review, camera review, and interview the facility failed to ensure the safe application of NAPPI (Non-Abusive Psychological and Physical Intervention - behavior assessment, de-escalation, and defusing skills for humane and effective response to violent and/or unsafe patient behavior) restraint techniques for 1 patient (#9), out of 6 sampled patients who experienced a seclusion or restraint. This failed practice placed the patient at risk for injury and created a non-therapeutic environment. Findings:

Record review on 11/27-30/18 and 12/5-6/18 revealed Patient #9 was admitted to the facility with diagnoses that included major depression and post-traumatic stress disorder (PTSD - anxiety and flashbacks triggered by a traumatic event). Further review revealed the Patient had a history of physical abuse.

Review of Patient #9's medical record revealed a Brief Manual Restraint (BMR - a method where one or more staff physically hold a patient to immobilize or reduce the ability of a patient to move his/her arms, legs, body, or head freely) occurred on 11/23/18 at 9:38 pm and 5- point restraint (a method of using a mechanical device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. 5-point restraint - 2 wrist restraint, 2 ankle restraints, and one restraint across the Patient's chest while the Patient is lying on his/her back) occurred at 10:12 pm.

Camera review on 12/5/18 at 1:15 pm, of the 11/23/18 incident revealed the following non-approved NAPPI techniques used by Psychiatric Nursing Assistants (PNAs) and WEKA support staff (contract security staff hired within the facility to help with escalated situations who must comply with facility approved NAPPI hold techniques):

- 9:38:00 pm - Patient #9 kissed a peer. To stop the behavior, PNA #4 placed his/her hand on Patient's forehead and pushed his/her head away from the peer. This caused the Patient to become assaultive.

- 9:38:09 pm - As Patient #9 stood up, PNA #4 grabbed the Patient from behind, over his/her arms, and the PNA locked his/her arms together in front of Patient's body (hugging him/her tightly from behind).

- 9:38:14 pm - Due to head butting behavior, PNA #5 was observed to grab the back of Patient #9's neck and place his/her other hand on Patient's forehead.

- 9:38:27 pm - Staff attempted to walk the Patient #9 to the Oak Room (a separate room in the facility for seclusion or restraint) however the Patient was able to struggle free. At 9:38:29 pm, WEKA staff #1 and PNA #5 placed Patient #9 in another BMR by placing the Patient's chest against the wall.

- 9:38:31 pm - The audible comment "get [him/her] off the wall" can be heard (unknown who spoke).

- 9:38:32 pm - WEKA Staff #2 grabbed Patient #9's legs as the Patient was against the wall.

-9:38:36 pm - WEKA Staff #1, #2, and PNA #5 took Patient #9 to the floor in a controlled manner. Staff restrained the Patient on the floor for 6 minutes, patient positioned on his/her back and staff on all limbs. Patient #9 walked to the Oak Room at 9:44:13 pm after other staff arrived.

- 10:04:43 pm - Patient #9 became assaultive in the Oak Room, BMR on the restraint bed initiated (Patient placed on his/her back). WEKA Staff #2 was observed to place his/her right knee on Patient #9's right arm (the arm was raised, bent at 90 degrees, back of hand lying flat on the restraint bed), at the elbow and upper arm junction. The WEKA Staff #2 apply pressure with his/her knee to keep arm stationary. WEKA Staff #2 restrained the arm in this manner for 2 minutes and 15 seconds.

- 10:10:54 pm - A release from the BMR was attempted, to lock Patient #9 in seclusion, however he/she became assaultive again. As BMR was re-initiated (Patient was standing), WEKA Staff #2 was observed to put his/her right hand on the Patient's left facial cheek and grab the back of Patient #9's neck with his/her left hand. WEKA Staff #2 pushed Patient's head down onto the restraint bed, forcing Patient #9 to bend over, face to bed.

- 10:12:16 pm - As restraints were being placed (Patient laying on back on restraint bed), it was observed that WEKA Staff #2 leaned his/her left elbow onto the Patient #9's chest and pushed down with his/her body weight to restrain the Patient's shoulder and chest.

During an interview on 12/5/18 at 1:30 pm, NAPPI Instructors #1 and #2 stated these non-approved techniques are not safe and should not have been used:

- It is never authorized to push a Patient's head away with staff's hands, this could injure the Patient's neck.

- Placing a Patient in a hug from behind could impede the Patient's breathing.

- Neck holds, as seen multiple times in the camera review, is extremely dangerous and could injure the neck.

- A Patient cannot be held against a wall or hard surface, as this can impede breathing.

- WEKA Staff #2 increased the risk to Patient #9, as well as WEKA #1 and PNA #5 when he/she immobilized the Patient's legs as the Patient was held against the wall. This could have caused the group to trip and fall, which could have potentially caused injury.

- WEKA Staff #2 increased the risk of injury to Patient #9's arm by restraining it with his/her knee.

- WEKA Staff #2 increased the risk of breathing difficulty when he/she leaned onto Patient #9's chest.

In addition, NAPPI Instructor #1 stated he/she completed the audit of this video on 12/2/18 at 6:30 pm and sent the report, which included the inappropriate NAPPI hold techniques, to the Chief Nursing Officer (CNO).

Review of the WEKA staff work schedule, from 12/2/18 to 12/7/18, revealed the facility could not provide an account of WEKA staff #1's and #2's hours worked within the facility after the inappropriate NAPPI techniques were identified and reported.

Review of the facility's policy "Seclusion and or Restraint," dated 6/1/18, revealed: "Those who apply the restraints ...and those who monitor patients while restrained ...will receive the training, and demonstrate the safe use of all approved restraint types, including physical hold techniques ..."

Further review revealed: "Only NAPPI approved techniques for physical intervention will be used ...High risk considerations for ...physical or mechanical restraint(s) include ...Restraint in supine position (laying down, face up) may result in aspiration. Restraint against a wall or other vertical surface is not permitted under any circumstances. Pressure placed on the neck may result in an obstructed airway, and is prohibited. Weight placed on the back, abdomen, or chest may result in asphyxiation."

Additional review of the policy revealed: "Intentional misuse of a restraint technique or any handling of a patient with more force than reasonable for a patient's proper control, treatment or management will be reported as abuse per the [Alaska Psychiatric Institute] Conduct Involving Patients policy (see P&P LD-020-13 "Conduct Involving Patient") ..."

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VIOLATION: QAPI Tag No: A0263
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Based on record review and interview the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) Program was effectively implemented and functioning to ensure improved outcomes and improve patient care services through systemic collection of hospital wide performance data. This failed practice limited the hospitals ability to identify problems and formulate action plans and reduced the likelihood of sustained improvements in clinical care and patient outcomes. Findings:

The facility failed to:

1) ensure their QAPI program was operational and functioning in a manner to conduct a though analysis of problems and concerns (Reference A-0283)

2) utilize data from performance reviews and unusual occurrence reports to utilize analysis of performance of employees and contracted staff to identify problem areas. (Reference A-0308);

3) develop a formalized QAPI committee structure (Reference A-0309);

4) ensure nursing care plans were kept up to date (Reference A-0396); and

5) ensure review of supervision of contract staff (A-084).

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VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
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Based on record review and interview the governing body failed to maintain and implement a quality assurance and performance improvement (QAPI) plan to monitor, evaluate, and improve the quality of patient care services through analysis of performance reviews. The failure to monitor the quality of care limited the hospitals ability to identify problems and formulate action plans, thus reducing the likelihood of systemic corrections in patient care. Findings:

Record review of the facility policy, on 11/28-29/18, revealed "Quality Assurance and Performance Improvement (QAPI) Program," dated 10/31/18, revealed the QAPI plan establishes a system that includes an ongoing assessment, using internal and external knowledge and experience to prevent errors and maintain and improve health care safety and quality. This is done by identifying and mitigate risk and medical errors by analyzing data, monitoring, improving and sustain performance.

During the survey the facility provided two policies entitled "Quality Assurance and Performance Improvement (QAPI) Program [QI-010-06.01]," dated 10/31/18. Review of both policies revealed they did not match under Executive Responsibilities and Prioritization.

During an interview on 11/29/18 the Chief Nursing Officer (CNO) stated the facility currently did not have a Quality Assurance Director or Risk Management Lead. In addition, she stated the staff who performed risk management duties was reassigned to conduct environment of care duties only. The position for Quality Assurance Director and Risk Manager were not occupied at the time of survey. The CNO stated the Quality Assurance and Performance Improvement (QAPI) program was to review audits conducted by nursing staff, but due to no QAPI program no audits have been analyzed at time of survey.

Review of the facility policy "Risk Management Plan," dated 12/7/12, revealed Risk Management was to work under the QAPI umbrella to facilitate identification, follow-up, corrective action or prevention of actual or potential problems/needs in patient care and safety.

During an interview on 11/29/18 the Chief of Operations (COO) stated the facility was lacking a QAPI department but the facility had attempted to hold a type of QAPI meeting but was unable to provide any meeting minutes or provide details of the outcome related to this meeting. The COO stated the Executive Team was attempting to develop sub-committees that would report to the Executive Team since the facility didn't have a QAPI program. The data would then be used by the Executive Team to determine QAPI projects, but the COO stated these committees were still in the beginning phases of development.

During an interview on 11/29/18 RN #8 and RN #9 stated the facility did not have a QAPI program.

During the survey from 11/27-30/18 and 12/5-6/18 the facility was asked to demonstrate evidence of its QAPI program for effectiveness and functionality. No evidence of QAPI meetings or activities, per facility policy, were provided by the end of survey.

Review of the facility provided "Governance Document," dated 11/2/18, revealed it was a responsibility of the Governing Body (GB) to assure the Chief Executive Officer (CEO) used appropriate and available resources to support the quality assessment and improvement functions and risk management functions related to patient care and safety. In addition, the document revealed the GB was responsible for the annual reporting and approval of the performance improvement plan, as well as, quarterly QAPI reports.
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VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
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Based on record review and interview the facility failed to ensure a functional Quality Assurance and Performance Improvement (QAPI) program that maintained an ongoing program to identify problems and formulate action plans. This failed practice reduced the likelihood of sustained improvements hospital practice. Findings:

Record review, on 11/28-29/18, of the facility policy "Quality Assurance and Performance Improvement (QAPI) Program," dated 10/31/18, revealed the QAPI plan establishes a system that includes an ongoing assessment, using internal and external knowledge and experience to prevent errors and maintain and improve health care safety and quality. This is done by identifying and mitigate risk and medical errors by analyzing data, monitoring, improving and sustain performance.

During the survey the facility provided two policies entitled "Quality Assurance and Performance Improvement (QAPI) Program [QI-010-06.01]," dated 10/31/18. Review of both policies revealed they did not match under Executive Responsibilities and Prioritization.

During an interview on 11/29/18 the Chief Nursing Officer (CNO) stated the facility currently did not have a Quality Assurance Director or Risk Management Lead. In addition, she stated the staff who performed risk management duties was reassigned to conduct environment of care duties only. The position for Quality Assurance Director and Risk Manager were not occupied at the time of survey. The CNO stated the Quality Assurance and Performance Improvement (QAPI) program was to review audits conducted by nursing staff, but due to no QAPI program no audits have been analyzed at time of survey.

Review of the facility policy "Risk Management Plan," dated 12/7/12, revealed Risk Management was to work under the QAPI umbrella to facilitate identification, follow-up, corrective action or prevention of actual or potential problems/needs in patient care and safety.

During an interview on 11/29/18 the Chief of Operations (COO) stated the facility was lacking a QAPI department but the facility had attempted to hold a type of QAPI meeting but was unable to provide any meeting minutes or provide details of the outcome related to this meeting. The COO stated the Executive Team was attempting to develop sub-committees that would report to the Executive Team since the facility didn't have a QAPI program. The data would then be used by the Executive Team to determine QAPI projects, but the COO stated these committees were still in the beginning phases of development.

During an interview on 11/29/18 RN #8 and RN #9 stated the facility did not have a QAPI program.

During the survey from 11/27-30/18 and 12/5-6/18 the facility was asked to demonstrate evidence of its QAPI program for effectiveness and functionality. No evidence of QAPI meetings or activities, per facility policy, were provided by the end of survey.

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