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 99508 June 7, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on interview, observation, record and video review the hospital failed to ensure patients' rights were protected and promoted according to the Condition of Participation: CFR 482.13 Patient's Rights. Findings:

The hospital failed to:

Ensure the hospitals resolution of grievances was provided to the patient and/or the patients' representative. Reference at A tag 123.

Ensure patients received care in a safe setting. This failed practice placed those patients at immediate risk for injury and/or death due to the ligature risks identified. The facility was notified of the immediate jeopardy for the patients on 6/5/19 at 5:15 pm. Reference at A tag 144.

Ensure patients were protected from all forms of abuse or harassment. Reference at A tag 145.

The facility was out of compliance with the Condition during the investigation. These failed practices placed patients at risk for not having their rights protected, denied them the ability to receive care in a safe environment, and protect them from abuse and/or harassment.
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VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
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Based on interview, record review, and policy review the facility failed to ensure a notice of a grievance decision was provided for 2 patient (#s 27 & 37) grievances. Specifically, 1) there was no 7 day update letters or resolution letters within 30 days provided for the two grievances and 2) there was no documentation of follow up, interview with the patient, and/or resolution noted on the grievance form. This failed practice denied the patient the right to receive resolution, in a timely manner, for grievances filed. Findings:

During an interview on 6/4/19 at 1:00 pm, the Recovery Support Specialist (RSS) stated on 12/11/18 the facility made the decision to process all complaints submitted in writing as grievances.

Record review on 6/4/19 at 1:00 pm, of the written patient grievance log from April and May 2019, revealed grievance #19-044 was submitted on 4/5/19 by Patient #37.

Further review revealed no 7 day update letter was provided to the patient, the grievance contained no documentation follow up with the patient had occurred, that an investigation or outcome was completed on the grievance, and that a response letter was not provided to the patient with external agency contact information to pursue the grievance.

Record review on 6/4/19 at 1:00 pm, a second grievance, #19-048, submitted by Patient #27, on 5/17/19 did not have any evidence the patient was interviewed or of a written response to the patient regarding resolution and external agency contact information.

During an interview on 6/4/19 at 1:15 pm, the RSS stated that he/she did not know why there was no documentation or letters provided for these grievances. He/she stated they had been handled by another RSS who was no longer employed in the facility. When asked if they should have received a letter, he/she responded "probably."

Record review of the facility policy entitled, "Complaint and Grievance Policy" last updated 10/31/18, revealed, "API staff will take appropriate steps to address and resolve the complaint to the patient's satisfaction...Investigation of grievances will be facilitated by RSS ...API will strive to resolved patient grievances within 7 days. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the RSS will notify the patient or the patient's representative, in writing, that the hospital is still working to resolve the grievance and that the hospital will follow up with a written response within 30 days ...When the grievance has been resolved, the RSS will send the patient or the patient's representative written notice of the hospital's decision. The notice will include the name and contact number of the RSS, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The notice will contain notification of the patient's right to file a complaint with the State of Alaska Health Facilities Licensing and Certification, Disability Law Center, Adult Protective Services, the Office of Children's Services, and information for each agency."
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VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
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Based on observation, interview and policy review the facility failed to ensure the environment was free of ligature risks. Specifically, the facility failed to identify the door closing mechanism on the bedroom doors on 3 out of 5 patient units (Katmai, Susitna, and Denali) were free of ligature risks and the hand rails on all 5 units (Katmai, Susitna, Denali, Chilkat, and Taku) including the main corridor "main street" were ligature resistant. This failed practice placed all residents (based on a census of 34) at immediate risk for injury, harm and/or death from self-harming behaviors and suicide. Findings:

The facility was notified of the immediate jeopardy to the well-being and safety of the patients on the 3 units on 6/5/19 at 5:15 pm.

The facility put measures into place to remove the immediate risk for patients on the 3 units. The door mechanisms were removed by the facility with confirmation of this on June 6th, 2019, at 8:20 am, by the survey team on site.

Room Doors

Observations of the Susitna unit on 6/4/19 at 8:50 am, revealed patient bedroom doors, S1- S14 and KS1, were equipped with a door closure hardware that consisted of a metal bar with one end attached to the top of the door frame and one end attached to the door. The mechanism, when the door was open, exposed the door closure hardware, approximately a foot long. The doors opened into the patient rooms which concealed the door closer mechanism from line of sight of staff at the desk, in the corridor, or on the monitoring cameras. When the patient room doors were open, the door closer mechanism (metal bar) extended fully (approximately 12 inches) and was exposed and accessible.

Observations of the Katmai Unit on 6/5/16 at 11:00 am, revealed patient bedroom doors, K1- K14 and KS2-KS3, were equipped with a door closure hardware that consisted of a metal bar with one end attached to the top of the door frame and one end attached to the door. The mechanism, when the door was open, exposed the door closure hardware, approximately a foot long. The doors opened into the patient rooms which concealed the door closer mechanism from line of sight of staff at the desk, in the corridor, or on the monitoring cameras. When the patient room doors were open, the door closer mechanism (metal bar) extended fully (approximately 12 inches) and was exposed and accessible.

Observation of the Denali Unit on 6/5/19 at 3:52 pm, revealed 9 bedroom doors (Rooms D2 - D10) were equipped with a door closure hardware that consisted of a metal bar with one end attached to the top of the door frame and one end attached to the door. The mechanism, when the door was open, exposed the door closure hardware, approximately a foot long. The doors opened into the patient rooms which concealed the door closer mechanism from line of sight of staff at the desk, in the corridor, or on the monitoring cameras. When the patient room doors were open, the door closer mechanism (metal bar) extended fully (approximately 12 inches) and was exposed and accessible. At the time of the survey the unit was closed to admissions with no patients housed on the unit.

During an observation on 6/5/19 at 4:30 pm, of Susitna bedroom doors, (S4 and S9), revealed when the patient room doors were open, the door closer mechanism (metal bar) extended fully (approximately 12 inches) and was exposed and accessible. The metal bar was in easy reach for a 5 foot 4 inch surveyor while standing on the floor.

During an interview on 6/5/19 at 4:35 pm, with the Project Coordinator (PC) and the Contract Safety Officer (CSO), when asked if they felt the bar was a ligature risk, they replied, "It sure looks like it could be." The PC further stated that the halls were always visually monitored by the staff at the nursing desk.

Observation of the open bedrooms S4 and S9 doorway, on 6/5/19 at 4:35 pm, from a distance of 5-6 feet away, revealed the corner of the door was extended and was not visible from the hall.

During an interview on 6/5/19 at 4:40pm, Psychiatric Nurse Assistant (PNA) #1, who was seated at the nursing desk, when asked if he/she could see the PC and CSO pulling on the door bar, the PNA stated he/she could not see them from the nurse's desk.

During an interview on 6/6/19 at 7:50 am, the Chief Executive Officer (CEO) stated, "I could actually do a pull up on it (the door hardware). It (the door hardware) was very strong." The CEO further stated the door hardware was a ligature risk.

Handrails

During multiple random observations on 6/3-7/19 of all units (Chilkat, Denali, Katmai, Susitna and Taku) revealed each unit had handrails on the walls that were not ligature resistant. It was possible a cord, rope, or other material that could be looped or tied to the handrails to form a point of attachment that had the potential to cause self-harm or loss of life.

In addition, it was observed 6/3-7/19 revealed "Main Street" had a handrail throughout the corridor. The circular silver handrails were attached to the walls throughout the main street corridor. Handrails were not visible to staff at all times. The handrails were not flush with the wall making it a possible ligature risk to patients by looping any material on the handrail to pass through the openings causing harm to the patients in the facility.

During an interview on 6/7/19 at 3:45 pm, the CEO confirmed the handrails on the units and main street corridor were ligature risks. The CEO further confirmed the areas could not be watched continually and the facility would need to do a review of the entire facility.

Review of the facility "Policy & Procedure EOC-100 Title: Safety Management Plan" effective date 4/15/18 revealed," ...The API Safety Management Plan describes how the organization provides a physical environment free of hazards and manages occupant activities to reduce the risk of injuries ... Procedure 1. MAINTAINING AND SUPERVISING API GROUNDS, FACILITY AND EQUIPMENT: ...in health care occupancy areas walk-through the 'Suicide Prevention: Environment of Care Risk Assessment' will be used to evaluate the environment for risk to the suicidal patient ... XIII.HAZARD SURVEILLANCE: The SO, Building Maintenance Superintendent, Maintenance Lead, and/or designees inspect all patient care occupancy areas ...for safety and regulatory compliance issues ..."
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VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
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Based on record review, video review and interview the facility failed to ensure 1 patient (#1) out of 30 sampled patients reviewed, was free from physical abuse. This failed practice resulted in 1 patient enduring physical abuse, less than optimal psychosocial well-being, and exposure to an unsafe environment. Findings:

Record review on 6/3-7/19 revealed Patient #1 was admitted to the facility with a diagnosis of schizoaffective disorder - bipolar type (a condition with symptoms such as hallucinations or delusions and episodes of mania and depression). Further review revealed the Patient had a history of delusional thoughts and extensive aggression with assaultive behaviors.

Video review on 6/5/19 at 2:00 pm, revealed on 5/8/19 at 3:21 pm, PNA #2 walked towards the nurse's station from the kitchen with a pitcher of water and cups. PNA #2 was standing at the nurses station when, at 3:22:03 pm, Patient #1 walked around the nurse's station. Patient #1 then walked towards the PNA and punched him/her in the face with a closed fist. PNA #2 stumbled backward. After this, both the Patient and the PNA walked towards each other. The PNA then grabbed the Patient's wrist with one arm and with the other struck the Patient and proceeded to strike the back of his/her head and neck with a closed fist.

Further review of the camera footage revealed the following: 5/8/19 3:22:09 - PNA #2 stepped in front of the patient and placed his/her arm around the Patient's neck pulling the Patient forward. The Patient then struck the PNA across his/her face with his/her forearm and elbow. The PNA then placed his/her hand behind the Patient's head and pulled him/her into the PNA's body.

5/8/19 3:22:10 - PNA #3 came behind the Patient, grabbed his/her right arm. The Patient then placed his/her left arm around PNA #2's head and was pulling the PNA's head towards his/her body.

5/8/19 3:22:13 - PNA #4 pulled the Patient's left arm from around PNA #2's head and neck.

5/8/19 3:22:26 - PNA #2 pulled his/her arm away and backed away from the Patient while PNA #3 and PNA #4 maintained their holds on the Patient.

During video review of the incident between the Patient and PNA #2 with the facility's Project Coordinator, he/she confirmed PNA #2 had physically abused the Patient.

Record review from 6/3-7/19 of a document titled "MEMORANDUM ...Re: Review - UOR [Unusual Occurrence Report, the facility's review and investigation] 19-0701", dated 5/31/19, a documented interview with PNA #5, a certified Mandt [an approach to preventing, de-escalating and intervening when the behavior of an individual poses a threat of harm to themselves and/or others] instructor, revealed: "None of the actions or reactions on the part of PNA #2 comported to Mandt or NAPPI [Non-Abusive Psychological and Physical Intervention] training. The most severe departure was PNA [#2] striking the patient, after [he/she] [him/herself] had been struck. This was followed by the unauthorized use of holding the patient by the back of the head and neck."

Further review of the "MEMORANDUM" revealed: "Regardless of why the PNA reacted to the assault as he did ..., he physically assaulted the patient rather than utilizing the techniques he had been taught Mandt or NAPPI methods of de-escalation and non-abuse physical interventions. This departure from his training continued when he grabbed the patient by the back of the head and neck ... Such behavior on the part of the PNA constitutes 'abuse' per API policy LD-020-13.01."

Review of the facility's policy, titled "Abuse and Neglect Prevention Policy", effective date 3/14/19, revealed:"It is the policy of API for patients at API to have the right to treatment in a setting that provides physical and emotional safety and freedom from all forms of abuse or neglect.""Physical Abuse: Physical abuse is any physical act or threat of a physical act designed to inflict harm such as slapping, punching, and hair-pulling and kicking. Physical evidence such as bruises need not exist for the act to be physical abuse."

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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


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Based on employee record review, observations, and interview the facility failed to ensure 2 nursing staff employees were certified in Cardiopulmonary Resuscitation (CPR), out of 25 employee records reviewed. This failed practice places all patients (based on a census of 34) at risk for inadequate CPR intervention during a cardiac emergency. Findings:

Licensed Nurse (LN) #3

Employee record review on 6/4/19 revealed that LN #3's CPR certification expired on [DATE].

Random observations on 6/3-4/19 revealed LN #3 worked directly with patients, during the day shift rotation, on the Susitna Unit.

Psychiatric Nursing Assistant (PNA) #1

Employee record review on 6/4/19 revealed that PNA #6's CPR certification expired on [DATE].

Random observations on 6/3-4/19 revealed PNA #6 worked directly with patients, during the day shift rotation, on multiple units.

During an interview on 6/4/19 at 2:20 pm, the Human Resource Administrative Officer stated RN #1's and PNA #1's CPR certification were expired.

Review of the facility policy "Seclusion and Restraint: Emergency-Behavioral, Restraint, Seclusion," effective date 1/15/19, revealed: "Staff Training ...Staff will demonstrate competence in recognizing and responding to symptoms of physical distress, first aid procedures, and will be certified in cardiopulmonary resuscitation (CPR)."

Review of the facility policy "Nursing Staff Competency," effective date 9/19/12, revealed: "Purpose: To assess that ability of all nursing staff to fulfill the job expectations to assure safe quality patient care ...Each employee will be required to maintain their competency in specific areas by completing annual reviews, in-service classes, and self-directed learning sessions."
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VIOLATION: MEDICAL STAFF Tag No: A0338
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Based on medical staff bylaws review and interview the facility failed to ensure the hospital met the Condition of Participation for Medical Staff. The hospital failed to have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital according to CFR 482.22. Findings:

The facility failed to:

Ensure quality assessment tools for the medical staff peer review process met the standards of the bylaws and medical staff rules and regulations and 2) Ensure documentation for supervision and evaluations, in the form of proctoring reports and Focused Professional Practice Evaluation (APPE), were conducted as per the standards of the bylaws and medical staff rules and regulations. Reference at tag A-353.

Ensure the bylaws credentialing process to be fully credentialed with granted privileges was followed prior to having patient contact. Reference at tag A-363.

The facility was out of compliance with the Condition during the investigation.
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VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
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Based on medical staff bylaws review and interview the facility failed to ensure medical staff enforced the medical staff bylaws. Specifically, the facility failed to:

1) Ensure quality assessment tools for the medical staff peer review process met the standards of the bylaws and medical staff rules and regulations. Specifically, the medical staff amended and used a peer review form without receiving prior approval for the amendments or its active use for quality assurance purposes; and

2) Ensure documentation for supervision and evaluations, in the form or proctoring reports and Focused Professional Practice Evaluation (FPPE), were conducted as per the standards of the bylaws and medical staff rules and regulations.

This failed practice placed the performance of medical staff at risk for a lower standard of practice and also placed the patients (based on a census of 34) at risk for receiving less than optimal care. Findings:

Review of the facility's "Medical Staff Bylaws," effective 01/2019, revealed: "The medical staff, regardless of category, will adhere to the responsibilities as outlined in the Medical Staff Rules and Regulations. This includes the following: Abide by the bylaws, rules and regulations, and policies and procedures of the medical staff and hospital ...participate in quality/performance improvement and peer review activities ..."

Peer Review

Review of the facility's "Medical Staff Rules and Regulations," effective 12/2018, revealed: "Peer Review is an activity of the Facility with respect to Licensed Independent Practitioners (LIPs). It is intended to be a mechanism for monitoring performance on a clinical level, to assist in improving the delivery of quality care, and as a check on compliance regarding applicable rules and regulations ...Further details for Peer Review practices are identified in P&P [policy & procedure] 040, 'Medical Staff Peer Review.'"

Review of the facility's policy "MS-040: Medical Staff Performance and Quality Improvement through Peer Review," effective 12/01/14, revealed: "It is the policy of API [Alaska Psychiatric Institute] to maintain an active and organized peer review process that is integrated into the Quality Improvement program and re-credentialing process ...The medical staff will review the selected cases using the Medical Staff Performance and Quality Improvement through Peer Review form. [The forms] first section is a self-evaluation of compliance with documentation standards and quality indicators. This reinforces corrections needed and develops individual accountability to established standards and norms for clinical staff. [The forms] second section is a Focused improvement for Performance section that is determined by the Medical Staff for a specified interval. These focused efforts will be utilized for new guideline, protocol, or performance expectations..."

During an interview on 6/6/19 at 9:50 am, the Credentialing Coordinator stated the medical staff changed the "Medical Staff Performance and Quality Improvement through Peer Review" form in October 2018 because the medical staff felt the previous form had too much information to review. The Credentialing Coordinator further stated the previous form, which was dated 01/2016, was also a revision from the original Peer Review form dated 11/1/14. He/she also stated that neither of these amended forms were approved through the governing body.

Review of the original "Medical Staff Performance and Quality Improvement through Peer Review" form, version 11/1/14, revealed:

- Section 1: Self-evaluation reviews "Admission Psychiatric Evaluation;" "Progress Notes;" "Seclusion/Restraints;" "Multidisciplinary Treatment and Discharge Planning;" and "Supervision of Students/Residents."
- Section 2: Reviews diagnoses from admission and discharge evaluations and compares that the diagnosis criteria met the DSM (Diagnostic and Statistical Manual of Mental Disorders) IV (4th edition) and applicable to the DSM V (5th edition) terminology. It also reviews progress notes for the presence of suicide risk assessment.

Review of the first alteration to the "Medical Staff Performance and Quality Improvement through Peer Review" form, dated 1/2016, revealed it was shortened to a 2 page review of the "Admission Psychiatric Evaluation."

Review of the second alteration to the "Medical Staff Performance and Quality Improvement through Peer Review" form, changed in 10/18, revealed a 1 page review of the APE (Admission Psychiatric Evaluation) completion and progress note content and frequency.

During an interview on 6/6/19 at 3:13 pm, LIP #1 stated the Peer Review form was modified to be more useful. He/she further stated that the current peer review process does not review the seclusion/restraints documentation, the multidisciplinary treatment plan (the care plan), or any supervision of students/residents.

Review of the document "Governing Body Alaska Psychiatric Institute Department of Health and Social Services State of Alaska," revised 3/21/19, revealed: "This document describes and defines the scope for authority for the Governing Body of the Alaska Psychiatric Institute ..." Further review revealed: "The API medical staff shall develop and adopt a Medical Staff Document with rules and regulations to establish a framework for self-governance of medical staff activities and provide accountability to the CEO [Chief Executive Officer] and the Governing Body. The CEO and API Governing Body must approve the Medical Staff Document, rules and regulations, and any amendments prior to becoming active ..."

During an interview on 6/6/19 at 3:08 pm, the Quality Assurance and Performance Improvement (QAPI) Director stated the Peer Review form should go through the governing body for approval for any amendments.

During an interview on 6/6/19 at 3:11 pm, the Deputy Commissioner, who is on the governing body, stated it would be the governing body's expectation that any amendments to the Peer Review form should have been approved by the governing body first before being implemented.

Proctoring and FPPE

Review of the facility's "Medical Staff Bylaws," effective 01/2019, revealed: "The organized Medical Staff have ...defined the circumstances that require monitoring and evaluation of professional performance for practitioners that do not have documented evidence of competency for performing privileges requested at API [Alaska Psychiatric Institute] ...The Focused Professional Practice Evaluation (FPPE) process is time-limited ...Specific procedures and criteria for ...FPPE are detailed in the Medical Staff Rules and Regulations ...All LIPs initially requested privileges shall be subject to a period of FPPE ..."

Review of the facility's "Medical Staff Rules and Regulations," effective 12/2018, revealed: "Proctoring is part of the [FPPE] ...It is real-time observation of a practitioner, e.g. observation of clinical history and physical, review of treatment planning, treatment orders, and patient interaction ...Proctoring is documented on the "API Proctor Report: Focused Professional Practice Evaluation" form ..."

Review of the "API Medical Staff Proctoring Report," dated 2019, revealed: " ...You have been asked to proctor/monitor this practitioner to evaluate the quality of care provided ..." The following elements are assessed:
- Medical Knowledge;
- Clinical Judgement and execution;
- Medical records, labs, treatment planning;
- Interpersonal skills;
- Communication skills;
- Professionalism; and
- System-based practice (abides policies and guidelines)

During an interview on 6/6/19 at 9:17 am, the Credentialing Coordinator stated Advanced Nurse Practitioner (ANP) #1, was hired on 3/1/19 and was currently under a proctoring period for 6 months. He/she further stated ANP #1 was being proctored by the Director of Psychiatry (DOP) and would be going through FPPE for the 6 month period.

When the proctoring reports for ANP #1 were requested, the Credential Coordinator was unable to provide them. He/she stated no reports were documented at this time.

Review of the "Psychiatric Staff Privilege Form," dated 3/1/19, for ANP #1 revealed he/she was hired on this day as an active medical staff member. He/she is approved for core and coverage attending privileges (to admit, evaluate, diagnose, and treat patients of all ages ...who suffer from mental, behavioral, or emotional disorders).

Further review of the "Psychiatric Staff Privilege Form" revealed a "Comments" section that documented: "The Director of Psychiatry will meet with provider weekly for the first six months to discuss clinical case and concerns. 100% of provider notes will be cosigned by DOP or appointee for the first 2 months. Then after the DOP will complete random chart reviews on at least 2 charts per month until the six month probation period is complete. Documentation of meeting and reviews will be maintained in provider's file."

During an interview on 6/6/19 at 2:00 pm, ANP #1 stated that his/her proctoring encounters with the DOP were not documented to his/her knowledge.

During an interview on 6/6/19 at 2:30 pm, the DOP stated he/she does not document the proctoring encounters with ANP #1 on the proctor report form.
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VIOLATION: CRITERIA FOR MEDICAL STAFF PRIVILEGING Tag No: A0363
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Based on interview and medical staff bylaw review the facility failed to follow the bylaws credentialing process for 1 psychologist (#1). Specifically, the psychologist was allowed to have patient contact to perform forensic evaluations (a process to determine patient competency) prior to being credentialed and granted privileges. This failed practice superseded the bylaws stipulations, approved by the governing body, for medical staff competency assurance and quality of care. Findings:

During an interview on 6/5/19 at 8:54 am, the Credentialing Coordinator stated Psychologist #1 was a former employee of the facility, who had quit April 2019 while undergoing re-credentialing for reappointment of his/her credentialing and privileges. He/she stated Psychologist #1 was recently re-hired, under contract, and was going through the credentialing application process for privileges as his/her previous credentialing had lapsed.

The Credentialing Coordinator further stated Psychologist #1 had not been officially credentialed yet and therefore was not actively having patient contact. He/she further stated medical staff cannot actively have patient contact until they are credentialed and granted privileges.

During an interview on 6/7/19 at 2:31 pm, Psychologist #1 stated he/she performed forensic evaluations to determine competency of patients. Psychologist #1 further stated he/she had recently conducted face to face forensic evaluations at the facility. In addition, Psychologist #1 stated he/she was not credentialed at this time but was currently going through the process.

During an interview on 6/7/19 at 3:20 pm, the Quality Assurance and Performance Improvement (QAPI) Director stated Psychologist #1 had performed 4 forensic evaluations during May 2019 for patients admitted into the facility.

During an interview on 6/7/19 at 3:40 pm, the Credentialing Coordinator stated, at the beginning of the credentialing application process, he/she had told Psychologist #1 that no patient contact or forensic evaluations could be conducted without being credentialed. The Credentialing Coordinator was unaware Psychologist #1 was currently conducting forensic evaluations.

During an interview on 6/7/19 at 3:50 pm, the QAPI Director stated that based on the medical staff bylaws terminology and description of the credentialing process, Psychologist #1 had recently had patient contact to perform forensic evaluations without being credentialed.

Review of the facility's "Medical Staff Bylaws," effective 01/2019, revealed: "The medical staff, regardless of category, will adhere to the responsibilities as outlined in the Medical Staff Rules and Regulations. This includes the following: Abide by the bylaws, rules and regulations, and policies and procedures of the medical staff and hospital ..."

Review of the facility's "Medical Staff Rules and Regulations," effective 12/2018, revealed:

- "Active Category Medical Staff: Members of this category must be ...a fulltime equivalent employee ...and be involved in and individually licensed for patient contact ...this includes ...licensed doctoral level psychologists authorized for independent practice (PsyD/PdD). A patient contact is defined as an inpatient admission, on-unit care, outpatient forensic evaluation..;"

- "Associate Category Medical Staff: The associate category is reserved for medical staff members who do not meet the eligibility requirements for the active category or choose not to pursue active status ...Doctoral level psychologists who are under direct supervision for licensure are eligible for Associate category as are fully licensed Masters level psychologists ...Associate category members will adhere to the responsibilities of the active category medical staff..;" and

- "All requests for applications for appointment to the Medical Staff and requests for clinical privileges will be forwarded to the Medical Staff office. On receipt of the request, the Medical Staff office will provide the applicant with an application package ...this package will enumerate the eligibility requirements for medical staff membership, privileges, and performance expectations for individuals granted medical staff membership or privileges."

Review of the "Professional Psychology Staff Privilege Form" (used to determine privileges for psychologists), revision 1/2013, revealed: "Qualifications & Criteria: To be eligible for core privileges as a psychologist, the applicant must meet the following qualifications and criteria for both clinical proficiency and formal certification: Clinical Proficiency: The applicant must be able to demonstrate the provision of psychological services ...Completion of formalized training in the area of Psychology ...Formal Certification/Licensure: Degree in Psychology ...Current licensure, in good standing, as a Psychologist ...Initial Appointment requirements requires the first five cases performed to be proctored by the Clinical Director and competency established."

Additional review of the "Professional Psychology Staff Privilege Form" revealed: "Additional Professional Psychology Privileges: To be eligible to apply for a special procedure privilege listed below, the applicant must demonstrate successful completion of an approved and recognized course or acceptable supervised training or other post graduate training program or acceptable experience; and provide documentation of competence in performing the procedure consistent with the criteria set forth in the medical staff policies governing the exercise of specific privileges or agree to proctoring."

Among the list of special procedure privileges listed was "Forensic Evaluation."
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on policy review and interview the facility failed to ensure the infection control program included: 1) reviewed and revised infection control policy and procedures (P&Ps); 2) a reduced legionella risk/water management program; and 3) a monitoring system for employee health to identify potentially infectious conditions. These failed practices placed all patients (based on a census of 34) at risk for the development and transmission of disease and/or infection. Findings:

Review on 6/6/19 of the "Alaska Psychiatric Institute Infection Control 2019 Plan," dated 6/3/19, revealed: "Hospital wide and departmental infection control procedures will be reviewed and revised as per hospital policy, in accordance with state, local, and federal regulations, CDC guidelines, Joint Commission standards, and current infection prevention & control literature."

Infection Control Policy and Procedures

Review of the facility policy "Infection Control Program" revealed this policy had not been reviewed and/or revised since 11/19/09. Further review revealed there were 48 separate P&Ps within the infection control program and only 1 policy was current this year. Additional review of the remaining 46 P&Ps revealed:

- 19 P&Ps have not been reviewed and/or revised since 2006;
- 16 P&Ps have not been reviewed and/or revised since 2007;
- 2 P&Ps have not been reviewed and/or revised since 2008;
- 4 P&Ps have not been reviewed and/or revised since 2009;
- 2 P&Ps have not been reviewed and/or revised since 2010;
- 1 P&P have not been reviewed and/or revised since 2013; and
- 2 P&Ps have not been reviewed and/or revised since 2015.

During an interview on 6/6/19 at 2:30 pm, the Infection Control Nurse stated the infection control P&Ps were out of date.

Review of the facility policy "Infection Control Program," effective date 11/19/09, revealed: "Infection Control policies and procedures are designed to meet: The Joint Commission's Standards on Infection Control; The Municipality of Anchorage Department of Health and Human Services Food Safety and Sanitation; and 18 AAC (Alaska Administrative Code), Chapter 31: The Alaska Food Code; and Center for Disease Control (CDC) recommendations ...Infection Control (IC) policies and procedures are created, revised, and reviewed and approved with a 3-year period ..."

Reduced Legionella Risk/Water Management Program

During an interview on 6/6/19 at 2:30 pm, the Infection Control Nurse stated the facility did not have a Legionella/Water Management Program in place, nor did the facility have P&Ps for this program.

The Infection Control Nurse further stated she had seen the Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality memo, published 6/2/17 and revised 7/6/18, "Requirement to Reduce Legionella Risk in healthcare Facility Water Systems to Prevent Cases and Outbreaks of legionnaires Disease (LD)" which indicated the process and expectation to make a Water Management Program for the monitoring of Legionella, however had not initiated the program yet.

Review of the "Alaska Psychiatric Institute Infection Control 2019 Plan," dated 6/3/19, revealed no documentation for a Legionella/Water Management program.

Employee Health Monitoring

During an interview on 6/6/19 at 2:30 pm, when asked to provide the employee illness documentation/tracking, the Infection Control Nurse stated the tracking of employee illness or infection was completed by the nurse managers in the nursing office. She further had not been a part of this surveillance, tracking, or trending of employee illness or infection.

During an interview on 6/7/19 at 1:12 pm, the Infection Control Nurse stated when the employee illness documentation/tracking was requested, the Assistant Director of Nursing (ADON) stated the practice of monitoring employee illness or infection had stopped and there currently was no process in place for this surveillance or tracking.

Review of the facility policy "Infection Control Program," effective date 11/19/09, revealed: "Employee Health is a part of Infection Control and supports the health of the employees to minimize the transmission of infection from staff to patients, and to offer protection from patient infection."

Review of the facility policy "Employee Health Program," effective date 8/30/07, revealed: "The Employee Health Program will ...Institute measures for the prevention and detection of infection and communicable diseases in its employees ...Investigate, track and trend employee injuries, reports of hospital-acquired illnesses, infections, communicable diseases and other illnesses in order to improve prevention efforts and to promote the safety and wellness of API [Alaska Psychiatric Institute] employees."

Review of the Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality memo "Requirement to Reduce Legionella Risk in healthcare Facility Water Systems to Prevent Cases and Outbreaks of legionnaires Disease (LD)," published 6/2/17 and revised 7/6/18, revealed: "Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility:"

- "Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens ...could grow and spread in the facility water system;"
- "Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit;"
- "Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained;" and
- "Maintains compliance with other applicable Federal, State, and local requirements ..."

Further review of the memo revealed " ...Health care facilities are expected to comply with CMS requirements and conditions of participation to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for non-compliance."

Review of the "Alaska Psychiatric Institute Infection Control Risk Assessment 2019" revealed a "risk" scoring system of -2 (negative 2) being the best possible score, and 6 being the worst possible score, as well as, a "current systems" rating of none, poor, fair, or good. The risk assessment assessed and scored the following:

- "Lack of current policies and procedures" Risk: "0" and Current Systems: "good"
- "Healthcare-associated infection: Legionellosis" Risk: "2" and Current Systems: "Fair"
- "Employee Safety: Lack of employee health medical surveillance follow-up/documentation" Risk: "0" and Current Systems: "Good"

Further review of the risk assessment revealed "Any component scoring greater than or equal to a 3 or any component for which the current system is scored as poor or non-existent will be a priority for the infection control program.
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VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


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Based on record review and interview the facility failed to ensure a Registered Nurse (RN) assessed 1 patient's (Patient # 15), out of 30 patients reviewed, care needs; provided interventions; and evaluated response(s) to those interventions. This failed practice resulted in a delay of medical/nursing assessment and potential treatment. Findings:

Record review on 6/3-7/19 revealed Patient #15 was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]. Other issues include Chronic Obstructive Pulmonary Disease (COPD - an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, and refractory (non-reversible) asthma. An EKG, (electrocardiogram - a test that measures the electrical activity of the heartbeat), performed on 5/17/19, showed "changes consistent with old anteroseptal infarct (myocardial infarction; 'heart attack')."

Further record review revealed a nurse's note titled "Information Note", dated 5/23/19 at 5:17 pm, submitted by Licensed Nurse (LN) #1 revealed "Patient was able to state [he/she] was not having any issues with breathing, or shortness of breath associated with COPD. Patient denied any pain however did state that [he/she] had 'chest pain a while ago' patient was unable to state when and [he/she] reported that it 'lasted 45 minutes' Patient stated that [he/she] felt better and had not had anymore [any more] episodes of chest pain ...RN educated patient on importance of telling RN or other staff if experiencing chest pain quickly. Patient stated understanding and reported [he/she] had no further medical concerns."

Further review of Patient #15's medical record revealed no further documentation of additional nursing assessment, intervention or evaluation.

Review of an Unusual Occurrence Report (UOR), #19-0780, dated 5/24/19, signed by LN #2 , revealed " ....Affected Body Part: pt complained of 45 minutes of chest pain to RN and RN didn't follow up".

Further review revealed LN #2 discovered no documentation of any further nursing follow up interventions or evaluation.

Record review of a "Progress Note", dated 5/24/19 at 10:48 am, signed by Physician #1, revealed "[Patient #15] is a [AGE] year-old ...with history of COPD, tobacco use, and schizoaffective disorder who was seen today for episode of chest pain that occurred yesterday lasting approximately 45 minutes resolving with rest. It is unclear what time of the day chest pain occurred, patient was uncooperative with my interview, and no further history of this event is available."

On 6/12/19 at 10:43 am, during a telephone interview with the Health Program Manager IV, he/she confirmed LN #1 should have followed up on Patient #15's symptoms with an assessment and LIP notification in a timely manner.

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VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
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Based on record review, interview and observation the facility failed to ensure nursing staff had the competencies to meet the needs of: 1) dementia patients and; 2) those patients who may require the use of oxygen and suctioning. These failed practices placed the patients (based on a census of 34) at risk for less than optimal care and created a risk for physical and/or psychological harm from staff and/or other patients. Findings:

Dementia care

Record review on 6/4-7/19 revealed Patient #17 was admitted to the facility with a diagnosis of dementia.

Record review of Patient #17's treatment plan, initiation date of 5/8/19 revealed, " ...Issue Sheet ...Disturbed thought process ...1. Pt will express a desire to interact with others in a meaningful and reality based manner by discharge to maintain healthy interactions in the community... Interventions 1. Nursing staff will engage with patient in reality based conversation at least twice per shift. 2. Nursing staff will provide reality reorientation when pt. expresses thoughts that are not based in reality ..."

During an interview on 6/5/19 at 9:40 am, Psychiatric Nurse Assistant (PNA) #7 stated when working with dementia patients "try to keep them grounded, reality based."

During an interview on 6/5/19 at 10:10 am, Licensed Nurse (LN) #4 stated reality based is reorienting the patient the best you can to a level of understanding of the real time.

During an interview on 6/6/19 at 4:30 pm, the Training Specialist stated reality based orientation for dementia patients need to be what their reality is present day reality.

During an interview on 6/7/19 at 2:15 pm, the Acting Director of Nursing (ADON) stated dementia patients should not be reoriented to present time. It should be in the patient reality at the time of interaction. The ADON further stated treatment plans should not have reality orientation for dementia patients. She further stated trying to reorient a dementia patient to current orientation could cause increased agitation and behavior for the patient.

Oxygen Tank

During an observation on 6/5/19 at 10:40 am, LN #4 demonstrated how to turn the oxygen tank, located on the side of the emergency cart, on and off. The LN struggled with getting the equipment to turn on. The Surveyor verbally prompted the LN in turning on/off the oxygen tank.

During an observation on 6/5/19 at 11:18 am, LN #5 demonstrated how to turn on/off the oxygen tank on the side of the emergency cart. The LN turned the oxygen tank to the on position releasing the oxygen then was unable to get the oxygen tank to turn off. The oxygen tank continued to release oxygen for approximately 2-3 minutes while the LN worked to get it turned off. The surveyor prompted the LN and the oxygen tank was properly turned off.

During an interview on 6/5/19 at 11:22 am, LN #5 was asked if the facility did drills to practice with the equipment for emergency use. The LN stated he/she has been at the facility for over 4 years and has never been involved in a "Code Blue" (Code used for a medical emergency) drill.

Suction Machine

During an observation on 6/5/19 at 10:40 am, LN #4 was asked to turn on the suction machine which was on top of the emergency cart. The LN was unable to get the suction machine turned on and needed to be prompted by the surveyor to plug in the suction machine and where the on/off switch was located on the machine.

During an interview on 6/5/19 at 10:40 am, LN #4 stated nursing staff complete-skills check offs for equipment yearly.

During an interview on 6/7/19 at 2:15 pm, the ADON stated the nurses should be able to use the medical equipment in the hospital. The ADON further stated the facility should be doing "mock codes" (a simulated emergency training) with return demonstrations by staff.

Record review of the facility's policy "Medical Equipment Management Plan," effective date 9/15/15 revealed, " ..."G. Providing equipment orientation and competency assessment program to ensure competencies in: 1. Capabilities, limitations and special applications of equipment. 2. Basic operating and safety procedures for equipment use ...Staff Competencies in equipment management: 1. Staff are required to complete ...competency assessment tools during orientation and at intervals ...2. Staff are randomly questioned about equipment maintenance and safety issues during Environment of Care Rounds ..."

Record review of the facility's procedure "Nurse Responsibilities date effective 4/06/15" revealed, " ...Policy: Patient care and safety are always the first priority ..." Further review of the document revealed an "ER (emergency room ) DRUG BOX LOCK, O2 (oxygen) PRESSURE CHECK, OPEN MULTI-DOSE VIALS & SUCTION MACHINE LOG ...RN IS RESPONSIBLE TO CHECK THE VALVE/O2 BOTTLE & SUCTION MACHINE TO ASSURE THEY ARE FUNCTIONING PORPERLY ..."

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