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.

SEVEN HILLS BEHAVIORAL INSTITUTE 3021 W HORIZON RIDGE PKWY HENDERSON, NV 89052 March 8, 2019
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on interview, record review and policy review, the facility's Chief Executive Officer failed to identify ongoing deficiencies in the facility's handling of complaints/grievances involving patient initiated complaints; the facility's Patient Advocate and Risk Manager failed to identify, investigate, review, resolve complaints/grievances and issues which evolved into abuse (incident reports).

Findings include:

On 3/8/19 in the late afternoon, the Chief Executive Officer acknowledged shared responsibility of the grievance process and abuse investigations along with the Chief Nursing Officer/Interim Risk Manager.

The Chief Executive Officer failed to identify the following deficiencies in the facility's handling of complaints/grievances and abuse identification/investigation:

The facility's Governing Body failed to effectively operate the grievance process, review and resolve grievances (Cross-Reference A0119).

The facility failed to identify and investigate allegations of verbal/physical/sexual abuse (Cross-Reference A0145).
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review, interview and policy review, the facility's Governing Body failed to effectively operate the grievance process, review and resolve grievances on behalf of 1 of 25 patients (Patient #10) according to policy.

Findings include:

Patient #10

On 4/22/18, Patient #10 was admitted on a legal hold with schizoaffective disorder, bipolar type.

On 6/28/18, the facility received a letter of complaint via an insurance company regarding the patient being inappropriately touched.

On 7/2/18, the Risk Manager responded to the insurance company revealing no complaints were received from the patient regarding inappropriate touching and closed the complaint.

On 3/6/19 at 4:00 PM, the Chief Nursing Officer/Interim Risk Manager acknowledged there was no attempt to investigate inappropriate touching once the facility was informed.

On 3/8/19 in the late afternoon, the Chief Executive Officer (CEO) acknowledged shared responsibility for abuse investigations and the grievance process along with the Chief Nursing Officer/Interim Risk Manager.

The Grievance Process/Patient Complaint policy (RM-007, last revised 2/7/18) documented the facility provided an effective mechanism for handling patient/family grievances. The facility CEO should designate a Patient Advocate, who will act as a liaison between the patient and the facility to facilitate these problem-solving actions when necessary. All patients were informed of the grievance process.

Grievances include situations where a patient or patient's representative telephones the hospital with a complaint regarding his/her patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more Condition of Participation. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with Centers for Medicare and Medicaid Services (CMS) requirements were considered to be grievances.

The Patient Advocate will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. Due to the nature and complexity of the grievance, if a written response cannot be made within seven (7) calendar days, the Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance. Any grievance received after a patient was no longer in the facility's system should be documented by the staff member receiving the complaint and forwarded to the Patient Advocate.


Complaint #NV 570
Complaint # NV 148
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview and policy review, the facility
1) failed to obtain a co-signer when informed consent had been obtained via telephone for 2 of 25 patients (Patient #20 and #22);
2) failed to obtain informed consent for a medication for 1 of 25 patients (Patient #20), and
3) failed to ensure a patient's right to be informed or not be informed of the cost of care was honored for 1 of 25 patients (Patient #23).

Findings include:

Patient #20

On 2/4/19, Patient #20 (adolescent) was admitted with bipolar disorder, attention deficit hyperactivity disorder and suicidal ideation.

On 2/5/19 at 10:30 AM, a Registered Nurse (RN) documented informed consent obtained via telephone for as needed medications: Milk of Magnesia, Mylanta, Senokot, Tylenol and Vistaril.

The informed consent lacked documented evidence of a co-signer.

On 2/5/19 at noon, a physician ordered Seroquel 50 milligrams twice daily.

The medication administration record showed twice daily administrations of Seroquel starting with the evening of 2/5/19.

On 3/5/19 at 11:30 AM, the medical record lacked documented evidence of an informed consent to receive the Seroquel.

On 3/5/19 at 11:30 AM, a Registered Nurse and the Chief Nursing Officer acknowledged the absence of a required co-signer for informed consent obtained via telephone and informed consent for the scheduled Seroquel administration.

Patient #22

On 2/28/19, Patient #22 (adolescent) was admitted with major depressive disorder.

On 3/2/19, a physician ordered Protein Shakes three times daily with meals, Phenergan 25 milligrams every eight hours as needed, and Zyprexa 5 milligrams three times daily as needed.

On 3/2/19, a Registered Nurse documented informed consent obtained via telephone for the Protein Shakes, Phenergan and Zyprexa.

The informed consent lacked documented evidence of a co-signer.

On 3/5/19 at 2:00 PM, the Chief Nursing Officer acknowledged the absence of a required co-signer for informed consent obtained via telephone for all three items.

Procedure #4.7 of the Authorization For Psychotropic Medications policy (PHR-154, last reviewed 3/2014) revealed another staff member would verify the verbal/telephone informed consent from the substitute decision maker/guardian and serve as a witness. Both nurse and staff member attested to the verbal/telephone informed consent by signing the informed consent.

Procedure #4.8 of the Authorization For Psychotropic Medications policy (PHR-154, last reviewed 3/2014) revealed the facility would utilize the form whereby the patient signed with each new psychotropic medication prior to its admission. Informed Consent was to be completed for all medications to include psychotropic medications, supplements and medications used for medical conditions for adolescents and patients assigned to a guardian.





Patient #23

Patient #23 (P23) was voluntarily admitted on [DATE], with diagnoses including major depressive disorder with suicide ideation and plan.

On 03/05/19 in the afternoon, P23 reported to have been approached on the second or third day after admission by an employee from the business office. P23 named Employee #9 (E9). P23 claimed to recall having two encounters with E9 and reported, neither were good.

P23 indicated at the first encounter, E9 informed P23 a large sum of money P23 was required to pay upon discharge from the hospital. P23 claimed to have become very upset and began to cry. P23 claimed to have felt harassed and threatened during this encounter. E9 had requested P23 provide proof of P23 spouse's income. P23 reported to have requested E9 contact P23's spouse to obtain needed information. P23 reported E9 returned a couple of days later requesting further information regarding payment and P23 again asked E9 to contact the spouse.

Review of E9's job description titled, Financial Counselor (dated 08/2015) revealed the employee was responsible to meet with patients regarding their financial rights and obligations.

On 03/06/19 at 10:22 AM, E9 explained the process of meeting with patients after admission to inform them of insurance coverage and any payment that may be due upon discharge. E9 recalled having met with P23 three times. E9 confirmed P23 had become upset during the first meeting and started to cry. E9 denied P23 had asked the spouse to be contacted to review the insurance and discharge payment during the initial visit and claimed this was requested by P23 at the second encounter.

E9 indicated E9 had not discussed the patient right to decline to be informed of financial costs or offer to provide the information at a time that was preferred by the patient.

Review of E9's Collection Follow-Up notes dated 02/26/19, indicated E9 informed P23 of the monetary balance that was due upon the day of discharge. The note lacked documentation E9 had informed P23 of the right to receive or decline to receive this information. The entry documented, P23 got teary eyed after being informed of the amount of money due at discharge and expressed inability to pay the amount due. The note indicated P23 informed E9 the spouse was the sole provider for the family.

On 03/01/19, E9 approached P23 who informed E9 the insurance plan was through the spouse and advised E9 to contact the spouse. The notes dated 03/04/19, indicate E9 again approached P23 who became frustrated and again asked E9 to contact the spouse. The record indicated at this time E9 placed a call to the spouse and left a voice message requesting a call back. The record lacked documented evidence E9 had made attempts prior to 03/04/19 to contact P23's spouse to provide information regarding financial information.

On 03/08/19 at 9:40 AM, during an interview with E9, the Business Office Manager and the Chief Financial Officer confirmed if a Financial Counselor attempted to make contact with a patient family member this should be documented in the notes at the time of the attempted contact. E15 confirmed P23's record lacked documented evidence E9 had made attempts to contact P23's spouse on multiple occasions as E9 had indicated in an earlier interview. E15 confirmed a patient did have the right to decline to review cost of care information and/or delegate this to a family member.

The Patient Rights policy (Revised 01/11/17), indicated the patient had the right to be informed of the cost of care and the right to refuse.


Complaint #NV 148
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review, interview and policy review, the facility failed to identify and investigate allegations of verbal/physical/sexual abuse for 6 of 25 patients (Patient #1, #10, #12, #14, #15 and #16).

Findings include:

Patient #1 (victim) and #7 (reporter of abuse only)

On 8/31/18, Patient #1 was admitted for suicidal ideation and brief psychotic disorder.

On 9/2/18, Patient #7 was admitted on a legal hold with depression, anxiety and insomnia.

On 9/6/18, a psychiatric progress note revealed Patient #7 was concerned about roommate (Patient #1), allegedly being assaulted by a staff member. The physician documented nursing and risk management would be notified, and there would be an investigation.

Facility census information showed Patient #7's roommate during the entire stay was Patient #1.

On 3/6/19 at 4:00 PM, the Chief Nursing Officer (CNO) acknowledged the facility lacked documented evidence the allegation had been reported and investigated.

Patient #10

On 4/22/18, Patient #10 was admitted on a legal hold with schizoaffective disorder, bipolar type.

On 6/28/18, the facility received a letter of complaint via an insurance company regarding the patient being inappropriately touched.

On 7/2/18, the Risk Manager responded to the insurance company revealing no complaints were received from the patient regarding inappropriate touching and closed the complaint.

On 3/6/19 at 4:00 PM, the CNO indicated there was no attempt to investigate inappropriate touching once the facility was informed.

Patient #12

On 2/11/18, Patient #12 was admitted on a legal hold with suicidal and auditory hallucinations.

On 2/13/18, the facility's complaint log revealed the patient complained about verbal abuse, including the use of profanity directed from a staff member.

On 3/6/19 at 8:15 AM, the Patient Advocate acknowledged the incident. The resolution the Patient Advocate documented was to speak with both individuals at the nursing station.

On 3/6/19 at 10:45 AM, the Risk Manager reported abuse investigations resulted in the administrative hierarchy being brought together to investigate and review surveillance, if any. The hierarchy consisted of the Administrator, CNO and Risk Manager.

On 3/6/19 at 4:00 PM, the CNO indicated a temporary suspension would have been in order for the described incident pending further investigation. The CNO acknowledged there was no further investigation beyond what the complaint log had documented.

Patient #14

On 4/15/18, Patient #14 was admitted with schizoaffective disorder, bipolar type.

On 5/2/18, the facility's complaint log revealed the patient complained about physical abuse with fresh bruising. The complaint log lacked documentation of an investigation/resolution.

On 3/6/19 at 8:15 AM, the Patient Advocate indicated the complaint was forwarded to the Risk Manager. No camera angles showed physical contact.

On 3/6/19 at 4:00 PM, the CNO felt there was an explanation for the bruising and reviewed the medical record. After several minutes of review, the medical record showed the patient was admitted with bruising all over the body. The admission body check documentation coincided with the allegations in the complaint log. The CNO acknowledged the information to unsubstantiate the complaint was not documented.

Patient #15 and #16

On 5/28/18, Patient #15 was admitted with suicidal thoughts on a legal hold.

On 5/21/18, Patient #16 was admitted with a psychotic episode and amphetamine abuse.

On 5/31/18, the facility's complaint log revealed Patient #15 complained about a Mental Health Technician who targeted the patient for physical intimidation. Patient #15 indicated Patient #16 would corroborate with similar experience. Patient #16 also accused the same Mental Health Technician of similar behavior. The complaint log did not show an investigation or resolution.

On 3/6/19 at 8:15 AM, the Patient Advocate verbalized being busy at the time and may not have looked at the video.

On 3/6/19 at 4:00 PM, the CNO acknowledged there was no documented evidence of any investigation.

On 3/6/19 at 8:15 AM, the Patient Advocate indicated complaints were typically handled in person or by voicemail. Patients used to document on forms, but those were no longer used often. Some documentation of complaints was locked away in a cabinet, but the Patient Advocate did not have access. Staff members tried to handle complaints quickly on the units.

A request was made multiple times throughout the investigation for the additional complaint documentation via the Patient Advocate, Risk Manager and Chief Nursing Officer at various times. None of the information was provided by the time of the exit on 3/8/19.

Incident Reporting and Severity policy (RM-002, last revised 2/1/18) revealed under Procedure 2.001d:
Allegation of Physical Abuse or Neglect by Staff. Procedure 2.001e: Allegation of Verbal Abuse: staff use of offensive and/or intimidating language that can provoke or upset a patient.

Procedure 2.001f: Altercation/Threat: any demeaning, insulting or deprecating verbal threat from patient to staff or patient to peer or staff to patient.

Patient Abuse or Neglect by Staff policy (ERR-006, last revised 2/1/18) revealed employees were responsible for thoroughly completing incident reports in the event of abuse allegations.

Abuse or Neglect Reporting policy (RM-013, last revised 2/1/18) revealed any alleged incident of patient abuse or neglect will be reported immediately to the charge nurse or immediate supervisor, who will ensure that an incident report is filled out and delivered to the Chief Clinical Director who will then notify the CEO of the hospital. The CEO will initiate an investigation to determine the facts of the allegation of abuse or neglect. The investigation will involve confidential interviews with all individuals related to the alleged incident of abuse or neglect. Upon conclusion of the interviews, a timeline of events and facts will be formulated to help identify any factors that support the alleged abuse or neglect.

Complaint #NV 570
Complaint #NV 148
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on observation, interview and document review, the facility failed to ensure patient medical information was kept confidential for 1 unsampled patient (Patient #26).

Findings include:

On 03/08/19 at 1:00 PM, the receptionist was overheard responding to a telephone call in the lobby of the hospital. A visitor was observed seated near the receptionist. The receptionist was overheard discussing a medication with the caller. The receptionist asked the name of the caller and then asked the caller to spell their name. The receptionist was then heard confirming the spelling of the callers name by verbally repeating each letter, thus identifying the name of the patient in a public setting in front of persons in the lobby.

On 03/08/19 at 1:05 PM, the Chief Nursing Officer confirmed this incident was a concern related to the violation of the patients right to confidentiality.

On 03/08/19 at 2:10 PM, the receptionist claimed to have only spelled the last name of the patient. The receptionist indicated speaking about a patient in a public location was a violation of the patient's right to confidentiality.

The hospital policy Patient Rights (Revised 4/26/13) document indicated the patient had the right to have medical information kept confidential.