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 record review, observation and interview, the facility failed to ensure processes were in place for an effective abuse protection program and supported by policies/procedures. Specifically, the facility lacked policy and procedures for patient to patient assaults that included investigation and protection of the parties involved. In addition, the facility failed to ensure appropriate protections and investigations were provided and documented for 2 patients (#s7 and 11) out of 11 sampled patients. This failed practice placed all patients (based on a census of 70) at risk for physical and psychological harm. Findings:

Patient #7

Record review on 2/27-28/19 revealed Patient #7 was admitted to the facility with diagnoses that included PTSD (post-traumatic stress disorder- a mental health condition that's triggered by experiencing or witnessing a terrifying event) and ADHD (Attention deficit hyperactivity disorder).

An observation of the milieu, on 2/28/19 at 10:00 am, revealed Patient #7 had a bruise to the left eye socket.

During an interview with Patient #7 on 2/28/19 at 10:15 am, when asked about his/her blackened eye, Patient #7 stated he/she was invited to his/her friend's room to play cards when "they jumped me." Patient stated the incident happened on 2/21/19 in Patient #12's room. Patient #7 further stated Patient #12 shut the door and Patient #13 had thrown a blanket over him/her while patient #10 beat him/her up. Patient #7 stated he/she informed the staff.

During an interview on 2/28/19 at 11:00 am, Patient #12 asked if this was about the "(Patient #7) event?" Patient #12 stated that the door was partially shut, he/she went to the bathroom and when he/she returned, Patient #7 was crying with a swollen face by the nurse's station.

During an interview on 2/28/19 at 1:07 pm, the Assistant Director of Nursing (ADON) stated that he/she told Patient #7 to stick with staff to help keep him/her safe. The ADON stated that Patient #7 had enemies on all the units and that he/she was difficult to place on a different unit because the other patients didn't want anything to do with him/her. The ADON further stated that Patient #7 reported the incident to a nurse and Therapist #1. The ADON reviewed video and stated Patient #7 was in the room for 25 to 30 seconds. Patient was head banging in the corner around the same time and staff were able to redirect him. The bruised eye was noticed on 2/22/19 by nursing staff and attributed to the patient's head banging. There was no documentation of the investigation of the incident or the recommendations suggested to keep the patient safe.

During an interview conducted on 3/20/19 at 1:50 pm, Director of Quality Improvement (DQI) stated that he/she and the ADON spoke to Patient #7 and interventions were provided; however, he/she could not produce documentation of the interventions to keep Patient #7 safe.

Patient #11

Record review on 3/19-20/19 revealed Patient #11 was admitted to the facility with a diagnosis of Major Depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

Review of the "Nurses Daily Assessment/Progress note," dated 2/26/19 at 9:00 pm, revealed "A peer became agitated and hit [Patient #11] on the right cheek. [He/She] reported 2/10 [pain level] and requested an icepack. After an hour, [He/She] stated it felt better."

Review of the "Request for In-System Consult," dated 2/27/19 at 6:00 pm, revealed Patient #11 "c/o [complained of] [Patient] slapped [his/her] on side of head, c/o Right eye pain- must be seen tonight." Patient was assessed for Right eye pain and Tylenol (pain medication) was ordered for pain as needed.

During an interview on 3/19/19 at 9:00 am, DQI stated incidents of assault are triaged for level assignment (as described in "Healthcare Peer Review (HPR) Occurrence Reporting System"), investigated, then reported to the appropriate state agency. Prior to reporting, he/she would consult the "corporate risk manager" who would advise on further action.

During an interview on 3/20/19 at 12:50 pm, the Medical Director stated he/she was unsure if a policy on peer to peer assault or abuse existed. The Medical Director added the medical consult for Patient # 11 was ordered to appease the Patient and to let the Patient know he/she was being taken care of.

During an interview on 3/20/19 at 1:20 pm, Administrator #1 stated that there was no policy on peer to peer assault or abuse.

During an interview on 3/20/19 at 1:30 pm, DQI stated a Healthcare Peer Review (HPR) Occurrence was generated for all patients that touched another patient if that touch was unwanted.

Review of facility spreadsheet of patient to patient assaults created 3/19/19, revealed there were 160 documented patient to patient assaults between 1/19/19 and 3/19/19. Of those 160 documented incidents, 70 were reported as assault with injury. All assaults were classified at Level I or II. There was one incident classified as a Level III. Further review revealed there was no documentation for the 2/26/19 assault on Patient #11.

During an interview on 3/20/19 at 1:50 pm, DQI stated there was no policy on patient to patient abuse or assault. He/she stated that he/she works with staff involved to investigate incidents, which included chart review and interviews with patients and staff. He/she stated he/she does not document the investigation process or delegate documentation to another staff member. In addition, he/she stated there was no record of investigations other than the HPR incident reports. He/she further stated that incidents triaged as being Level III or higher would cause a PCR (probably claims report) that is reviewed by the corporate risk management team. There is no documentation of communication between the facility and corporate risk management because the communication was conducted by telephone.

Review of facility policy and procedure entitled "Healthcare Peer Review (HPR) Occurrence Reporting System," reviewed 03/16, revealed the facility's Risk Management process as a peer review process for internal use only. The policy lists the events of physical harm to a patient and violence as a reportable event through this system.

The policy further addresses the "Classifying Severity" scale as,

"1. Level I- Occurrence: incidents where the potential for litigation is thought to be non-existent. No injury or outcome that alters a patient or visitor's function;

2. Level II- Non-serious: incidents where the potential for litigation is thought to be minimal. Minor injury or impairment in which a patient or visitor's function may be altered temporarily;

3. Level III- Serious: incidents where the potential for litigation is thought to be prevalent. Major injury or impairment in which the patient or visitor's function is altered long term or permanently;

4. Level IV- Tragic: incidents where the potential is that litigation could be initiated at any time. Worse negative patient, visitor, or employee outcome (i.e. permanent disability, coma, or death).

5. Violations of the law shall be classified at no less than a level III regardless of the evidence of patient injury."

The policy did not contain a procedure for the facility to address patient to patient assault and does not list patient to patient assault under the guidelines for classification.

Review of the facility policy and procedure entitled "Abuse Reporting", last reviewed 01/2019, revealed no mention of reporting, tracking, investigation, or follow up for incidents of violence between patients.

Review of facility policy and procedure entitled "Patient Rights", last reviewed 01/2019, revealed under #24: "The right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation."
Based on record review, interview, observation, and policy review, the facility failed to ensure the 1 patient (#8) out of 8 sampled patients was free from unnecessary seclusion. This failed practice had the potential to violate the patient's right to treatment in the least restrictive setting. Findings:

Review of Patient #8's medical record revealed that Patient #8 was admitted to the facility with diagnoses that included major depressive disorder with psychosis, attention deficit-hyperactivity disorder, and post-traumatic stress disorder.

During an interview on 3/20/19 at 8:30 am, Patient #8 stated that he/she had recently been in seclusion after being placed in a physical hold by staff. Patient #8 further stated that he/she would not have been able to leave the seclusion room until he/she was calm and safe.
Observation on 3/20/19 at 8:55 am of recorded video footage of an incident with Patient #8 that required restraint and seclusion, Licensed Nurse (LN) #2 and a second staff member were seen holding Patient #8 at 1:20 pm on 2/22/19 in a physical hold and escorting him/her to the seclusion room. After the physical hold was discontinued at 1:35 pm, the patient was observed to remain seated on the floor with his/her back to the wall. Patient #8 did not display any threatening or aggressive actions after he/she was released from the hold. LN #2 was observed to stand at the door until Patient #8 was allowed to leave the room at 2:18 pm.

During video footage review with LN #2 on 3/20/19, when asked if the patient could have left the room, LN #2 stated that Patient #8 would not have been able to leave. When asked if LN #2 considered Patient #8 in seclusion during the time frame being viewed, he/she said yes, the patient was considered in seclusion. The DON, who was also present during the video observation, added that he/she considered the Patient in seclusion.

Record review on 3/20/19 at 9:15 am of Patient #8's medical record revealed there was no seclusion documentation for the event that occurred on 2/22/19.

During an interview on 3/20/19 at 9:20 am, Administrator #2 verified there was no additional documentation of a seclusion for Patient #8 on 2/22/19.

Record review of the facility policy and procedure, Provision of Care: Seclusion and Physical Restraint last revised on 3/2018 defined seclusion as: "The involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving ..." The policy further stated, "The use of restraint/seclusion will be thoroughly documented in the patient's medical record. Documentation related to the restraint/seclusion included: The initial assessment of the patient related to restraint/seclusion use. The circumstances that led to the use of seclusion, specific behaviors, detailed description of the events leading up to the incident and other pertinent information, consideration or failure of non-physical interventions, written orders for use- including each order for continuation, the initial in-person and subsequent evaluations of the patient, 15 minutes assessments of the patient's status, continuous monitoring of the patient and care provided, debriefing of the patient with staff, any injuries that were sustained and treatment received for these injuries (including staff injury), time of the initiation and termination of the restraint/seclusion, and treatment plan review/revision follow the episode of restraint/seclusion will include treatment interventions to prevent future use."

Based on record review and interview the facility failed to ensure nursing staff maintained a current nursing care plan for 1 patient (#1) out of 8 sampled patients. This failed practice placed the patient at risk for not receiving care and services in response to identified nursing care needs. Findings:

Record review on 2/27-28/19 revealed Patient #1 was admitted to the facility with diagnoses that included ADHD (attention deficit hyperactivity disorder) and disruptive disorder (ongoing patterns for uncooperative and defiant behavior).

Review of a physician's order, dated 2/17/19, revealed Patient #1 was to have been evaluated for a right pinky finger injury that occurred on 2/15/19. The Patient's finger was pinched in-between two chairs. An out of system consult (an evaluation completed outside the facility) was completed, which revealed the finger was fractured and required surgery with pin placement for stabilization. A cast was placed and the Patient received pain medication for finger discomfort as needed.

Review of the most current care plan, dated 2/25/19, revealed no medical interventions regarding care of broken finger, post-surgery care, cast care or pain management.

During an interview on 2/28/19 at 11:21 am, Licensed Nurse (LN) #1 was unable to locate Patient #1's medical interventions in the Patient's care plan. LN #1 stated there should have been a medical care plan with interventions for Patient #1 after finger injury.

Review of facility policy "Interdisciplinary Treatment Plan," dated 6/2017, revealed "treatment plans should be updated throughout the course of treatment...after an out of system consult, after a patient injury..."