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.

LAKEWOOD HEALTH SYSTEM 49725 COUNTY ROAD 83 STAPLES, MN 56479 April 1, 2019
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0220
Based on observation, interview and document review, the facility was found not in compliance with 485.623 Condition of Physical Plant and Environment, when the faciliy failed to ensure the environment was free of ligature risk on the Reflections unit, the facility's inpatient geriatric psychiatric unit.

Findings include:

Refer to C222--The facility failed to maintain electrical, mechanical and patient care equipment in a manner to prevent ligature risk for all 8 patients who currently resided in the unit.
VIOLATION: MAINTENANCE Tag No: C0222
Based on observation, interview and record review, the facility failed to ensure the environment of the Distinct Part Unit (DPU) for geriatric Psychiatric Services, known as the Reflections Unit, was free of ligature risks. This had the potential to affect all eight patients(P1, P2, P3, P5, P6, P7, P8, P9) who currently resided in the 10-bed unit.

Findings include:

According to CMS (Centers for Medicare and Medicaid Services) S&C (survey and certification) memo 18-06; A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures.

On 4/1/19 at 11:00 a.m., a tour of the 10 bed locked geriatric psychiatric unit was conducted with the clinical assessment coordinator (unit supervisor). During the tour, two single rooms (Rooms 1 and 2), and four double rooms (Rooms 3 thru 6) were observed to have ligature risks:
-Patient rooms 1 and 2 were observed to have a single standard bathroom door in each room with exposed hinges and a movable door handle. The bathrooms had standard faucets, paper towel holders and dispensers. In addition, patient rooms 1 and 2 had single standard mechanical high to low beds with standard metal frames and bilateral side rails. Further, the nightstand in patient room one had a doorknob. During the tour, the unit supervisor confirmed the aforementioned points were a risk for ligature.

-Patient rooms 3, 4, 5 and 6 each had a single standard bathroom door with exposed hinges and a movable door handle. The bathrooms had standard faucets, paper towel holders and dispensers. Patient rooms 3, 4, 5, and 6 each had two standard mechanical high to low beds with standard metal frames and bilateral side rails. Further, each room had one nightstand per bed, and each nightstand had a doorknob. The supervisor confirmed the aforementioned points were a risk for ligature.

On 4/1/19, at 1:36 p.m. the unit supervisor stated the hallway which lead to all of the patient rooms had real time video surveillance and was monitored by nursing staff. She stated the patients were not typically alone in their rooms, were out on the unit during waking hours, and the hallways were blocked off during the day to prevent patients from wandering back to their rooms. In addition, the unit supervisor stated patients were monitored in the common area by staff at all times. The unit manager stated all patients were assessed for suicide/self-harm risks upon admission and throughout the duration of their stay as appropriate. The unit supervisor stated if a patient was identified at high risk prior to admission, the patient would likely not be accepted for admission.

On 4/1/19, at 2:28 p.m. during a group interview with the unit supervisor and the director of geriatric services, the unit supervisor stated she was aware of the ligature risks in each of the patient rooms and had completed an environmental safety evaluation to identify the ligature risks in patient rooms on an annual basis. The director of geriatric services and the unit supervisor confirmed a capitol funds request to change out the bathroom doors with continuous hinges and door closures that were non-weight bearing had been submitted in 2018. The unit supervisor stated there was no current plan to replace patient beds with ligature proof beds as the unit's patients were geriatric and oftentimes required assistance with activities of daily living.

Review of the facility's 2/2/18, Pro-Active Risk Assessment Form, indicated areas of the unit which had been identified as potential hazards to the patients who resided on the unit. The following were identified hazards, identified as presenting a ligature risk to patients, the likelihood of injury, risk level, and current measures that were in place:

-Patient bedroom nightstands with dresser knobs were identified as a potential ligature risks, identified as low risk and listed interventions of 15 minute checks and encouraging patients to be in the common area.
-Patient side rails were identified as a potential ligature risk, identified as low risk and listed interventions of 15 minute checks and encouraging patients to be out of their rooms.
- Bathroom faucets, paper towel holders and dispensers were identified as potential ligature risks, identified as low risk and listed interventions of 15 minute checks, encouraging patients to be out of their rooms and assisting patients in the bathrooms.
- Bathroom doors without continuous hinges and door closures which were non-weight bearing, were identified as potential ligature risks, identified as low risk and listed interventions which included accompany patients in the bathroom and encourage to remain out of their rooms.

Review of the facility's 2/18/17, Lake Net Observations and Precautions policy, identified it was the purpose of the policy to outline the levels of observation and types of precautions used on the behavioral health service unit based on assessed risk to assure patient safety. The policy outlined various levels of observation which included; routine observation safety rounds-minimum of at least every 15 minutes; 1:1 observation- staff are to remain at arm's length; 10-minute checks and close observation (constant visual monitoring.) The policy also outlined types of precautions that included; suicide, elopement, aggression, arson, falls and sexual acting out precautions. The policy indicated each patient was assessed upon admission to determine the level of observation and type of precautions each patient would need. Further, the policy indicated when a patient was found to be at high risk for self-harm, the nursing staff would initiate 1:1 observations.
VIOLATION: NURSING SERVICES Tag No: C0294
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and document review, the Critical Access Hospital (CAH) Distinct Part Unit (DPU) for Psychiatric Services, also known as the Reflection's unit, failed to ensure appropriate supervision was provided to prevent resident to resident abuse for 1 of 3 patients (P1) reviewed for resident to resident abuse.

Findings include:

Review of P1's medical record revealed the patient had been admitted [DATE], with a primary diagnosis of dementia with behavioral disturbances. P1's medical record revealed she had been referred from a long- term care facility to the Reflection's unit due to pacing to the point of exhaustion, combativeness with cares, and physical aggression towards peers. P1's medical record revealed daily behavioral disturbance notes which identified P1 exhibited daily unprovoked physical aggression towards staff and other patients. P1's daily notes revealed various interventions which staff had implemented to decrease P1's behavior which included 15 minute checks, reassurance, calm approach, redirection and headphones with music. P1's daily notes revealed her aggression continued to escalate towards staff and other patients and indicated P1 received daily doses of an as needed antipsychotic medication, Zyprexa, which had varying degrees of effectiveness.

P1's behavioral health note dated 2/26/19, revealed P1 had increased physical aggression towards her peers and staff had initiated close observations (always within visual sight.) Further, the note indicated P1 was seen by her practitioner, and P1 had required multiple doses of as needed Zyprexa, and further medication adjustments would likely need to be made.

P1's progress note dated 2/27/19, revealed P1 had unprovoked aggression the entire evening shift against staff and peers. The note indicated P1 had received multiple doses of the Zyprexa, and an as needed dose of Gabapentin (antiseizure medication), before finally falling asleep. Further, the note indicated P1 continued under close observation.

P1's progress note dated 2/28/19, indicated P1 had exhibited physical aggression towards staff 20 times that day, and had become intrusive to her peer's personal space. The note revealed P1 was seated away from others during meals and continued to be on close observations. A later note from 2/28/19 revealed P1 had been seen by her practitioner and medication changes were made: Zyprexa was increased, ativan (anti-anxiety) was discontinued and Xanax (anti-anxiety) was initiated. Following that note, a note indicated while P1 had been under close observations of staff (within eye sight), P1 had hit another patient which had resulted in the other patient falling, as a result a 1:1 had been initiated while in the milieu for safety.

On 4/1/19, at 11:14 a.m. P1 was observed ambulating on the unit with registered nurse (RN)-A, who remained in contact guard with P1.

On 4/1/19, at 12:23 p.m. RN-A stated P1 remained under 1:1 observations while in the milieu due to her aggression towards other patients. RN-A stated she felt P1's aggression had been improving with the change in medication and was easier to distract and redirect from negative behavior. RN-A further indicated P1 was kept away from patients she had aggressed toward in the past.

On 4/1/19, at 12:30 p.m. nursing assistant (NA)-A stated P1 wandered the unit throughout the day and evening. She stated P1 would at times, become invasive to other residents and had struck out at staff almost on a daily basis. NA-A stated P1 remained under 1:1 observations and stated a staff member was always next to P1 due to aggression. Further, NA-A stated she felt P1's aggression had decreased within the last few weeks.

On 4/1/19, at 2:58 p.m. the unit supervisor confirmed the units' definition of close observation (supervision) was to have eyes on the patient at all times.

During an interview on 4/1/19, at 4:10 p.m. licensed practical nurse (LPN)-A, stated on 2/28/19, P1 had abruptly walked across the room to another resident, and had pushed her to the ground. LPN-A stated she did not believe P1 had not been within eye-sight at the time of the 2/28/19 incident. LPN-A stated RN-B had been standing directly next to P1 at the time of the event however, RN-B had turned away for a moment towards the hallway when P1 had pushed the other patient down.

On 4/1/19, at 4:12 p.m. a telephone call was placed to RN-B, a message was left for a return call. No return call was received.

On 4/1/19, at 4:28 p.m. the unit supervisor confirmed at the time of the incident where P1 struck out to hit another patient, P1 was on close observations. The unit supervisor stated P1 had been placed on increased supervision on 2/26/19, due to an increase in aggression and striking out. The unit manager stated P1 had also been seen by her practioner on 2/28/19, and medication changes had been made. The unit supervisor stated P1 had not previously targeted another peer, as she had on the day of the incident, however P1 should have been in eye-sight of the staff member at all times. The unit supervisor confirmed P1 was placed on 1:1 observations following the event and that her aggressive behaviors had improved.

Review of the facility's 2/18/17, Lake Net Observations and Precautions policy, identified it was the purpose of the policy to outline the levels of observation and types of precautions used on the behavioral health service unit based on assessed risk to assure patient safety. The policy outlined various levels of observation which included; routine observation safety rounds-minimum of at least every 15 minutes; 1:1 observation- staff are to remain at arm's length; 10-minute checks and close observation (constant visual monitoring.) The policy also outlined types of precautions that included; suicide, elopement, aggression, arson, falls and sexual acting out precautions. The policy indicated each patient was assessed upon admission to determine the level of observation and type of precautions each patient would need. Further, the policy indicated when a patient was found to be at high risk for self-harm, the nursing staff would initiate 1:1 observations.