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.

MENTAL HEALTH INSTITUTE 1251 NORTH CEDAR LOOP CHEROKEE, IA 51012 March 6, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




I. Based on document review and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure the hospital staff identify and report all instances of abuse. Please refer to A-0115 for additional information.

2. Ensure the hospital's administrative staff investigated allegations of abuse in a timely manner and staff failed to separate staff members accused of child abuse from other potential victims. Please refer to A-0115 for additional information.

3. Ensure the hospital's staff did not commit abuse when they did not follow the hospital's policies on moving patients. Please refer to A-0115 for additional information.

The cumulative effect of these failures resulted in the hospital's inability to ensure staff protected all patients on North 6 from all forms of abuse when the hospital's administration placed failed to separate 2 staff members from patients after allegations of abuse. The hospital's administrative staff identified a census of 9 inpatients on the North 6 inpatient mental health unit, which treated children 9-[AGE] years old.


II. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 2/21/19. The hospital staff removed the immediacy on 2/28/29, prior to the survey team exiting the complaint investigation, when the administrative staff took the following actions:

a. Developed and implemented mandatory training for all employees prior to their next shift. The training included information on identifying abuse, reporting abuse in a timely manner, and ways to de-escalate situations with patients.

b. Added information from the mandatory training to the new employee orientation.

c. Identified adequate retraining for the staff members accused of abuse to prevent a recurrence of the abuse.


The Condition level deficiency remained for the Condition of Patient's Rights (42 CFR 482.13).
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, staff interview, and document review, the psychiatric acute care hospital's administrative staff failed to provide each patient all information required to file a complaint in 4 of 4 inpatient care areas (North 2, North 4, North 6, and North 9). Failure of the hospital staff to provide required information may result in patient's inability to report complaints related to abuse, significant mental anguish, physical pain, or injury to the state agency. The hospital identified a census of 34 inpatients on entrance.

Findings include:

1. Observations on 2/12/19 at 4:00 PM during a tour of the North 2 inpatient unit, revealed the hospital staff posted information informing the patients of their rights in the halls of the inpatient unit. The patients' rights information lacked the complaint number for the Department of Inspections & Appeals (a separate state agency responsible for enforcing federal hospital regulations and determining if hospital staff abused patients in hospitals).

2. Observations on 2/13/19 at 12:45 PM during a tour of the North 4 inpatient unit, revealed the hospital staff posted information informing the patients of their rights in the patients' rights on the halls of the inpatient unit. The patients' rights information lacked the complaint number for the Department of Inspections & Appeals.

3. Observations on 2/12/19 at 4:10 PM during a tour of the North 6 inpatient unit, revealed the hospital staff posted information informing the patients of their rights in the patients' rights on the halls of the inpatient unit. The patients' rights information lacked the complaint number for the Department of Inspections & Appeals.

4. Observations on 2/12/19 at 4:40 PM during a tour of the North 9 inpatient unit, revealed the hospital staff posted information informing the patients of their rights in the patients' rights on the halls of the inpatient unit. The patients' rights information lacked the complaint number for the Department of Inspections & Appeals.

5. Review of the booklet "Patient Rights -- Adolescent/Children," revised 8/4/16, revealed the document lacked the phone number to file a complaint with the DIA.

6. During an interview on 2/19/2019 at 2:30 PM, AM Nurse Supervisor confirmed hospital did not post or distribute the DIA complaint number.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interviews, the psychiatric acute care hospital's administrative staff failed to ensure staff recognized and reported 2 of 3 incidents of possible child abuse (Patient #1 and Patient #2) in a timely manner. Failure to recognize and report incidents of possible child abuse in a timely manner resulted in the administrative staff allowing staff members to continue to work with mentally ill children after the staff members committed possible acts of child abuse. The hospital's administrative staff identified a census of 9 inpatients on the North 6 inpatient mental health unit, which treated children 9-[AGE] years old.

Findings include:

1. Review of the policy, "Patient Abuse and Neglect," effective 10/10/18, revealed in part, "Every hospital employee is a mandatory reporter of patient abuse ... Employees who believe that abuse ... may have occurred must make an abuse report directly ... employee should notify their immediate supervisor within one (1) hour ... CMHI has defined Work Rules that call for a higher standard of humane treatment than state law ... Please see CMHI Work Rules in addition to the ... definitions of abuse under Iowa Law. Upon notification, the supervisor will begin an investigation and complete an online report to the Iowa Department of Inspections and Appeals." "For all reportable allegations, notify the Iowa Department of Inspections and Appeals within twenty-four (24) hours."

2. Review of the "Cherokee Mental Health Institute, Employee Handbook/Work Rules," dated 12/4/18, revealed in part, "All hospital employees are mandatory reporters of abuse for the hospital patients. All employees are required to report incidents at the hospital ... 'Abuse' occurs when a caretaker ... fails to act or acts in a reckless manner, which has the consequences of causing that individual harm, or has the potential to cause such harm."

3. Review of the policy "Restraint and Seclusion Policy - Initiation of Restraint or Seclusion and Assessing, Monitoring, and Assisting Patients," revised 5/9/18, revealed in part, "Prohibited Actions: Pulling a patient by the limbs or dragging a patient ..."

4. During an interview on 2/20/19 at 6:40 AM, RN B revealed that on 1/24/19 at approximately 6:30 AM, Patient #1 got into an argument with another patient in the TV Bay area on North 6 Child/Adolescent unit. Patient #1 would not calm down. Patient #1 swung their arm, attempting to hit RN B. RTW (Residential Treatment Worker) G grabbed Patient #1's arm to stop Patient #1 from hitting RN B. Patient #1 fell and hit the right side of their head on the floor. Patient #1 laid in a fetal position on their left side. RN A then arrived at the scene. RN B and RTW G encouraged Patient #1 to go to Patient #1's room or the Comfort Room (a room where children can go to regain control of their emotions and calm down). RN B heard RN A say, "enough of this," and then RN A grabbed Patient #1 by both ankles and dragged Patient #1 into the Comfort Room.

Following the incident between RN A and Patient #1, RN B completed paperwork related to Patient #1 falling and striking their head, and RN A physically holding (restraining a patient in a manner to restrict the patient's movement against their will) Patient #1. RN B gave the paperwork to RN A and reminded RN A to continue checking Patient #1 for possible signs of bleeding in their brain since Patient #1 struck their head on the floor.

When RN B returned to work on 1/24/19 at 10:45 PM (approximately 16 hours later), RN B could not find the paperwork she completed on the incident between RN A and Patient #1 that morning. RN B informed the Night Nurse Supervisor of the discrepancy. At the end of RN B's shift, at approximately 06:30 AM on 1/25/19, RN B and the Night Nurse Supervisor spoke with the Administrator of Nursing and the AM Nurse Supervisor (approximately 24 hours after the incident). RN B informed them that RN A denied physically holding Patient #1 to RN B. RN B tried to explain that "something was amiss," and RN B could not locate the paperwork to document the physical hold and checks to ensure Patient #1 did not have bleeding in their brain. RN B felt the Administrator of Nursing and AM Nurse Supervisor did not understand RN B's concerns about the incident.

5. Observations during a tour of the North 6 Child/Adolescent unit on 2/14/19 at 5:40 AM revealed the TV Bay area was located approximately 15 feet from the Comfort Room.

6. During an interview on 2/14/19 at 5:45 AM, LPN (Licensed Practical Nurse) F revealed they witnessed RN A drag Patient #1 across the floor on 1/24/19. LPN F did not report the incident to the administrative staff, as they did not recognize the incident was possibly child abuse.

7. During an interview on 2/14/19 at 6:20 AM, RTW (Residential Treatment Worker) H revealed they witnessed RN A drag Patient #1 across the floor on 1/24/19. RTW H did not report the incident to the administrative staff, as they did not recognize the incident was possibly child abuse.

8. During an interview on 2/14/19 at 6:00 AM, RTW G revealed they witnessed RN A drag Patient #1 across the floor on 1/24/19. RTW G did not report the incident to the administrative staff, as they did not recognize the incident was possibly child abuse.

9. During an interview on 2/20/19 at 6:25 AM, LPN I revealed they witnessed RN A drag Patient #1 across the floor on 1/24/19. LPN I did not report the incident to the administrative staff, as they did not recognize the incident was possibly child abuse.

10. Review of an undated written statement by the Administrator of Nursing revealed in part, "Around 0630 [AM] on 1/25/19, [RN B's name] came to share concerns about the previous morning (1/24/19) incident with [Patient #1's name] ... [RN B's name] was upset that [RN B's name] had told [RN A's name] about the potential head injury and the need [to check Patient #1 for signs of bleeding in their brain]. States when [RN B's name] came to work at [10:45 PM] on 1/2/419 there was not a Neuro Check form for [RN B's name] to continue the checks ... [Night Nurse Supervisor's name], [AM Nurse Supervisor's name] and myself were discussing the documentation of Neuro Checks with [RN B's name] ... The morning of 1/29/19 at 0630 [AM] [Night Nurse Supervisor's name] informed me [RN B's name] had come to [Night Nurse Supervisor's name] during the night stating [RN B's name] couldn't believe we felt it was okay for staff to drag a patient by the feet. [Night Nurse Supervisor's name] reported to me that [RN B's name] states [RN B] told the supervisors about the dragging by the feet the morning of 1/25/19 when discussing Neuro Checks. If [RN B's name] had reported staff were dragging a patient by the feet I would have picked that up immediately. [RN B's name] was talking about the Neuro Checks and we were focused on why these were not started but there was not discussion about the situation on how the patient was taken into the open [Comfort Room]."

11. During an interview on 2/12/19 at 12:25 PM, the AM Nurse Supervisor revealed that on 1/25/19, the AM Nurse Supervisor discussed the incident between Patient #1 and RN A with the Night Nurse Supervisor. Then, on the morning of 1/29/19, the Night Nurse Supervisor informed the AM Nurse Supervisor and the Administrator of Nursing that RN B informed the Night Nurse Supervisor about RN A dragging Patient #1 by their feet on the morning of 1/24/19.

The AM Nurse Supervisor began an investigation into the incident, which occurred on 1/24/19, on 1/29/19 (5 days later).

12. Review of the "Supervisor Checklist for Investigation & Mandatory Reporting of Alleged Child or Dependent Adult Abuse Occurring within the Hospital," revealed in part:

"1/29/19... receipt of verbal report of alleged abuse ..." (5 days after the incident)
"1/29/19 ... interview the alleged victim ..." (5 days after the incident)
"1/29/19 ... ensure the patient is safe from further abuse ..." (5 days after the incident)
"1/29/19 ... will re-assign or place on administrative leave, the employee who allegedly committed the abuse ..." (5 days after the incident)
"1/30/19 ... Within twenty-four (24) hours, all [instances of] alleged abuse ... must be reported ... to the the Iowa Department of Inspections and Appeals ..." (6 days after the incident)

The Administrator of Nursing, AM Nurse Supervisor, or Night Nurse Supervisor initialed and dated each entry, indicating they completed the task.

13. Review of a letter to RN A, dated 1/31/19, signed by Administrator of Nursing and RN A, revealed in part, "Per our conversation today, 1/31/19 you are being placed on administrative leave with pay pending the outcome of an investigation regarding possible employee misconduct."

14. Review of staffing schedules between 1/24/19 and 1/31/19, revealed RN A worked 5 shifts (6:30 AM to 3:00 PM) on the North 6 Child/Adolescent Inpatient Unit and both Adult Inpatient Units, after RN A was first accused of possible child abuse on 1/24/19 and potentially exposing other mentally ill children and adults to abuse from RN A.

15. During an interview on 2/20/19 at 3:30 PM, Teacher C revealed that on 1/29/19 at approximately 2:20 PM, they worked with 4 children from the North 6 inpatient child/adolescent mental heath unit. Patient #2's (a [AGE] year old patient) behavior became disruptive to the learning environment. Teacher C repeatedly instructed Patient #2 to sit down and quit creating a disruption to the learning environment. Patient #2 continued to engage in disruptive behaviors, including walking around the classroom, passing notes, and talking with other students.

Teacher C became very frustrated and yelled, in a very loud voice, "you need to sit down and shut up." Teacher C informed the Administrator of Nursing, following the incident, they had yelled at a student.

16. During an interview on 2/12/19 at 9:10 AM, Para-Educator E revealed that on 1/29/19 at approximately 2:30 PM, they heard yelling and screaming coming from Teacher C's classroom. Para-Educator E heard Teacher C yell "shut up!" Patient #2 responded, "don't talk to me like that!" Para-Educator E then saw Patient #2 standing in the doorway to Teacher C's classroom. Patient #2 was crying after the interaction with Teacher C.

Para-Educator E removed Patient #2 from Teacher C's classroom. Following the incident, Patient #2 asked to talk with Para-Educator E about what happened with Teacher C. Para-Educator E asked Patient #2 to write out their concerns about the incident, and then provided Patient #2 with paper, a pencil, and an envelope for the paper. Para-Educator E reported Patient #2's concerns to the AM Nurse Supervisor on 1/29/19, following the incident.

17. Review of a letter signed by Patient #2, dated as received 1/30/19 by the Administrator of Nursing, revealed in part, "my teacher said shut up to me. ... I was crying after [Teacher C] said that. Then I ran outside the room."

18. Review of Patient #2's medical record of an entry on 1/29/19 at 2:40 PM by Para-Educator E, revealed in part, "Down at school, heard yelling 'Shut up and sit down' .... why does [he] ... talk to me like that ... [he's] not very nice.'"

19. Review of the "Supervisor Checklist for Investigation & Mandatory Reporting of Alleged Child or Dependent Adult Abuse Occurring within the Hospital," revealed in part:

"1/30/19... receipt of verbal report of alleged abuse ..." (1 day after the incident)
"1/31/19 ... interview the alleged victim ..." (1 day after the incident)
"1/30/19 ... ensure the patient is safe from further abuse ..." (1 day after the incident)
"1/31/19 ... will re-assign or place on administrative leave, the employee who allegedly committed the abuse ..." (2 days after the incident)
"1/31/19 ... Within twenty-four (24) hours, all [instances of] alleged abuse ... must be reported ... to the the Iowa Department of Inspections and Appeals ..." (2 days after the incident)

The Administrator of Nursing initialed and dated each entry, indicating they completed the task.

20. During an interview on 2/20/19 at 8:00 AM, the Administrator of nursing revealed they first became aware of the incident between Teacher C and Patient #2 on 1/29/19, when Teacher C spoke with the Administrator of Nursing shortly after the incident occurred. Teacher C informed the Administrator of Nursing that Patient #2 was behaving in a very challenging manner. Teacher C admitted they yelled at Patient #2 and told Patient #2 to shut up.

Para-Educator E informed the Administrator of Nursing about the incident between Teacher C and Patient #2 on 1/29/19, shortly after the incident occurred.

The Administrator of Nursing admitted they failed to identify that yelling at a patient and telling them to shut up was potentially abuse, when the staff members reported the incident on 1/29/19. The Administrator of Nursing received Patient #2's letter on 1/30/19, and that was when the Administrator of Nursing began to consider the incident in terms of potential abuse. The Administrator of Nursing began an investigation into potential child abuse on 1/30/19.

21. Review of a letter signed by the Administrator of Nursing and Teacher C on 1/31/19, revealed in part, "Per our conversation today, 1/31/19 you are being placed on administrative leave ... pending the outcome of an investigation ... In regard to your Allegation of abuse."

22. Review of the staffing schedule for the week of 1/25/2019 - 1/31/2019, revealed Teacher C worked 2 days, 1/30/2019 and 1/31/2019, after Teacher C was first accused of possible child abuse on 1/29/19 and potentially exposing other mentally ill children to abuse from Teacher C.

23. During an interview on 2/21/19 at 10:20 AM, the Administrator of Nursing acknowledged they failed to investigate the incidents within the timeframe mandated by the hospital's policy and then failed to notify the Iowa Department of Inspections and Appeals within 24 hours of the incidents occurring.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on staff interviews and document review, the psychiatric acute care hospital administrative's staff failed ensure the nursing staff did not destroy the nursing documentation for 1 of 1 patient (Patient #1) who required monitoring for signs of bleeding in their brain. Failure of the nursing staff to not destroy nursing documentation could potentially result in the nursing staff failing to identify changes in a patient's behavior after the patient struck their head, potentially fail to identify the warning signs of a patient experiencing bleeding in their brain, and potentially result in the patient dying. The hospital's administrative staff identified a census of 9 inpatients on the North 6 inpatient mental health unit, which treated children 9-[AGE] years old.

Findings include:

1. During an interview on 2/20/19 at 6:40 AM, RN (Registered Nurse) B revealed that on 1/24/19 at approximately 6:30 AM, Patient #1 was involved in an altercation with another patient. During the altercation, Patient #1 fell to the floor and struck their head. RN B reported they heard a "thud" when Patient #1's head hit the ground.

RN B started documenting on paperwork which documented Patient #1's responses to serial assessments of Patient #1's brain functioning, the Neurologic Check Flowsheet. RN B handed the paperwork to RN A at approximately 07:00 AM on 1/24/19. When RN B returned to work on 1/24/19 at approximately 10:45 PM, RN B could not find the Neurologic Check Flowsheet that RN B started 16 hours earlier.

2. Review of the policy "Collection and Processing of Records/Data," revised 5/26/16, revealed in part, "Patient information must never be deleted, erased, or defaced."

3. Review of the policy "Retention and Retrieval of Records," revised 5/26/16, revealed in part, "Records will be destroyed only after they have been microfilmed or scanned into the electronic medical record storage or determined not to be permanently retained."

4. During an interview on 2/14/19 at 8:05 AM, RN A revealed he shredded (destroyed) Patient #1's Neurologic Check Flowsheet. The Neurologic Check Flowsheet contained a record of 2 separate neurological assessments of Patient #1's brain function and 2 separate sets of vital signs (clinical measurements to assess the body's essential functions) for Patient #1.

RN A could not provide an explanation why he destroyed the Neurologic Check Flowsheet for Patient #1.