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.

CRESTWYN BEHAVIORAL HEALTH 9485 CRESTWYN HILLS COVE MEMPHIS, TN 38125 Nov. 12, 2021
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy, document review and interview, the hospital failed to ensure staff followed written protocols for abuse allegation incidents and failed to communicate the potential allegations to appropriate hospital administration for 1 of 2 (Patient #1) abuse allegation reviewed.

The findings included:

1. Review of the facility's "ABUSE AND NEGLECT, PATIENT" policy dated 12/2020 revealed, "...shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members...other patients...Physical abuse is defined as acts of assault/battery...examples include...pushing, hitting, slapping, or striking a patient..."

Review of the facility's "Incident Reporting - Risk Management Program" policy dated 1/1/2016 and revised 1/2021 revealed, "...An "incident" is an unanticipated event which was not consistent with the standard of care and/or operation of the facility and may have occurred due to a violation of policy and procedure. It results in, or nearly causes, a negative impact on a patient(s) receiving care at the facility...will help...identifying potential areas of risk and implementing measures to improve the overall quality of care throughout the facility...Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an incident report before the end of the shift/work day...If the incident involves a patient, staff must chart relevant information in the patient's medical record...DEFINITIONS ON INCIDENT REPORT FORM...Patient Attacked Other Patient...Physical confrontation between patients where the "aggressor" is identified as the main party involved...Patient Injured by Other Patient...Physical confrontation between patients where the "victim" was injured and is identified as the main party involved..."

2. Medical record review revealed Patient #1 was seen in a local ED on 10/11/2021. Patient #1 had a prior history of suicide attempt on 9/7/2021 and was hospitalized at another psychiatric hospital. No current suicidal ideations, plan or intent. Patient #1 exhibited disorganized/illogical thinking, flight of ideas, racing thoughts, flight of ideas, and was unable to function in the community in his current state.

Patient #1 was involuntarily admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Bipolar Type.

Review of the Admission Orders dated 10/11/2021 at 8:16 PM revealed Patient #1 was on every (Q) 15 minutes Level of Observation and was not on any precautions.

The Psychiatry Progress Note dated 10/18/2021 at 4:00 PM revealed, "...Chief Complaint...'I'm pressing charges'...Argument with peer in the cafeteria...paranoid...responding to internal stimuli..."

There was no further documentation in the medical record regarding the "argument" Patient #1 had with another patient (Patient #4) in the medical record.

3. In an interview on 11/3/2021 at 10:40 AM, in the chapel, Registered Nurse (RN) #1 and #2 were asked about the argument between Patient #1 and #4. RN#1 verified she was working on the unit on 10/18/2021 from 3:00 PM - 7:00 PM and was also the Interim Director of Nursing. RN #2 verified she was working on the unit on 10/18/2021 from 9:30 AM - 3:00 PM. RN #1 revealed on 10/18/2021 around 4:00 PM, Patient #1 told her he had got into a fight in the caf at lunch. RN #1 revealed she asked Patient #1 if he had let his nurse know, and Patient #1 stated he did. RN #1 further revealed Patient #1 had superficial scratches on the side of his face. RN #2 verified she would have been the RN on duty at lunch. When asked if she was notified of a physical altercation involving Patient #1 on 10/18/2021, RN #2 stated, "...No."

In an interview on 11/3/2021 at 1:32 PM, in the chapel, Licensed Practical Nurse (LPN) #1 verified she witnessed the physical altercation between Patient #1 and #4 on 10/18/2021 in the caf. LPN #1 revealed she reported the altercation to RN #1 when she returned to the unit. LPN #1 further revealed she was the medication nurse and did not chart other documentation in the medical record.

In an interview on 11/3/2021 at 1:48 PM, in the chapel, the Director of Risk Management/Process Improvement verified an incident report was not completed at the time of the physical confrontation between Patient #1 & #4 on 10/18/2021.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review, and interview, the hospital failed to ensure orders for seclusion were never written on an as needed basis (PRN) for 1 of 1 (Patient #2) sampled patients in seclusion.

The findings included:

1. Review of the facility's "SECLUSION" policy approved 12/2020 revealed, "...Seclusion is the involuntary confinement of a person alone in a room or area from which the patient is physically prevented from leaving...POLICY...Orders for seclusion shall never be written as a standing order or on as needed basis...A registered nurse may initiate seclusion in the absence of a practitioner. The attending physician/covering practitioner will be contacted...order shall indicate reason...maximum duration of the seclusion..."

2. Medical record review revealed Patient #2 was admitted on [DATE] with diagnosis which included Schizophrenia.

The physician order dated 10/12/2021 at 12:36 PM revealed, "...seclusion-PRN aggression..."

3. In an interview on 11/3/2021 at 3:30 PM, in the chapel, the Director of Risk Management/Process Improvement verified the hospital does not use PRN seclusion orders. The Director also verified the physician did not sign the 10/12/2021 seclusion orders for Patient #2 included in the seclusion packet.