HospitalInspections.org

Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by:

Cross reference A-0144: Failure to ensure a patient bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk.

Cross reference A-0145: Failure to protect Patient #9 from potentially abusive behavior by Employee #15.

Cross reference A-0167: Failure to ensure restraints were conducted according to facility policy for proper technique.

Cross reference A-0175: Failure to ensure a patient requiring seclusion for a violent episode also received one to one observations during the seclusion to ensure safety.

Cross reference A-0178: Failure to ensure the patients were evaluated (seen face to face) by a physician or other appropriately trained Registered Nurse within one hour of the restraint.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on observation, review of documents and staff interviews, it was determined the Hospital failed to ensure a patient bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients.

Findings include:

Observation on tour on July 23, 2024, revealed patient bathroom paper towel dispensers were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point.

Interview with Employee #24 on tour confirmed that the issue had been identified but only six patient bathrooms had been fixed and did not have a timeframe for the rest.

Document titled "Environmental Ligature Risk Assessment" for January 2024 to June 2024, did not identify the issue.

Interview with Employee #1 and Employee #2 confirmed in an interview on July 23, 2024, that the paper towel dispensers were not flush creating a tie off point.

Based on a review of hospital record and interview, it was determined the hospital failed protect Patient #9 from potentially abusive behavior by Employee #15. This deficient practice poses the risk of further injury or death to patients while under the care of the facility.

Findings Include:

Review of facility policy titled "Patient Rights and Responsibilities" revealed "...18. The patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation by anyone including staff, students, visitors, other patients or family members. The hospital has oriented facility staff to assess and immediately report signs or suspicions of patient abuse or neglect. Any reports of patient abuse by the patient, their family or facility staff will be immediately followed up and investigated by hospital administration...."

Review of facility video titled "2024-07-13 19-30-00 4th Fl. Day Room South.106 (1).avi" revealed Patient #9 attempting to enter the Seclusion Anti Room at 17:35/1:15:01 of the video timer, Employee #15 exiting the Seclusion Anti Room at that time, placing his/her hands on Patient #9's upper body and pushing Patient #9 with enough force to move him/her backward and off-balance.

Employees #1 and #4 confirmed during a joint interview on July 24, 2024, that the video revealed Employee #15 did not use an approved physical restraint technique in his/her encounter with Patient #9. Employee #1 stated "(Employee #15) definitely pushes (Patient #9). Employee #4 confirmed an employee pushing a patient "is ordinarily an investigated incident", that "for egregious incidents" an employee would be sent to "Corporate training", and confirmed that the video showing Employee #15 pushing Patient #9 revealed an egregious incident. Employee #4 confirmed Employee #15 remains employed with the facility and has not received corrective action or training related to the incident.

Based on review of facility policies and procedures, review of facility video and employee interview, the Department determined the administrator failed to ensure restraints were conducted according to facility policy for proper technique. This deficient practice poses the risk of patient injury or death.

Findings include:

Policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revealed "...Definitions: ...Physical Escort: ...Using a 'light' grasp to escort a patient to a desired location...If the patient cannot easily remove or escape the grasp this would be a physical restraint...If physical restraint is indicated, at least 2 staff must participate in the physical hold application...Physical restraints (holds) may only be done using techniques trained through the aggression management program...Additionally, except in extreme emergency, one person holds are not to be used...

The following facility videos were reviewed and facility employee interviews accompanied each:

Patient #3:
Facility video titled "2024-06-21 08-12-00 4th Flr Activity North.110.avi" at 1:14/6:00 of the video timer revealed Employee #16 place his/her hands on the upper body of Patient #3, lift him/her off her feet and carry him/her with his/her right arm around the midsection of Patient #3, moving him/her to the doorway to the nurse's station hallway, at 1:19/6:00 of the video timer. Facility video titled "2024-06-21 08-12-00 4th Floor Nurse Station North.107.avi" at 1:19/6:00 of the video timer revealed Employee #16 continuing to move Patient #3 with his/her right arm around the midsection of Patient #3 and using both arms to attempt to place Patient #3 in a wheelchair next to the nurse's station. The hold was released at 1:22/6:00 of the video timer.

Employees #1 and #4 confirmed the hold within the videos titled "2024-06-21 08-12-00 4th Flr Activity North.110.avi" at 1:14/6:00 of the video timer and "2024-06-21 08-12-00 4th Floor Nurse Station North.107.avi" at 1:19/6:00 of the video timer was not an approved/trained physical restraint technique.

Facility video titled "2024-06-21 08-12-00 4th Flr Activity North.110.avi" at 2:44/6:00 of the video timer revealed Employee #17 holding Patient #3 from behind with both arms around the waist of Patient #3. The hold was released at 3:47/6:00 of the video timer.

Employees #1 and #4 confirmed the hold within the video titled "2024-06-21 08-12-00 4th Flr Activity North.110.avi" at 2:44/6:00 of the video timer was not an approved/trained physical restraint technique.

Patient #10:
Facility video titled "2024-07-13 19-30-00 4th Floor Nurse Station South.109.avi" revealed Employee #15 holding the upper body of Patient #10 from behind, with arms interlocked and hands on the shoulders of Patient #10, walking him/her through and outside the nurse's station at 16:40/1:15:00 of the video timer. Employee#15 and Patient #10 leave view of the video at 16:52/1:15:00 of the video timer. Facility video titled "2024-07-13 19-30-00 4th Fl. Day Room South.106 (1)avi" at 16:41/1:15:01 of the video timer revealed Employee #15 continuing to move Patient #10 outside the nurse's station, walking behind Patient #10 with arms and hands holding the upper body and arms of Patient #10. Employee #15 stopped at the door leading to the seclusion anti room. While an unidentified employee opened the seclusion anti room door, Patient #10 attempted to leave the hold and Employee #15 struggled to maintain the hold, grasping at the arms and upper body of patient #10, pulling and pushing him/her with force that caused Patient #10 collide with a linen cart and lose balance. Employee#15 and Patient #10 left view of the video at 17:26/1:15:01 of the video timer. Facility video titled "2024-07-13 19-30-00 4th FLR SECLUSION ANTI.105.avi" revealed Employee #15 continuing to move Patient #10 to the seclusion room. At 17:27/1:15:00 of the video timer Employee #15 is seen holding the shoulder area of Patient #10, his/her shirt lifted to shoulder level, and moving him/her into the seclusion room and closing the door with Patient #10 inside. The hold was released at 17:30/1:15:00 of the video timer.

Employees #1 and #4 confirmed the hold within the videos titled "2024-07-13 19-30-00 4th Floor Nurse Station South.109.avi" at 16:40/1:15:00 of the video timer, "2024-07-13 19-30-00 4th Fl. Day Room South.106 (1)avi" at 16:41/1:15:01 of the video timer, and "2024-07-13 19-30-00 4th FLR SECLUSION ANTI.105.avi" at 17:27/1:15:00 of the video timer was not an approved/trained physical restraint technique.

Patient #14:
Facility video titled "2024-06-21 08-12-00 4th Flr Activity North.110.avi" at 1:00/6:00 of the video timer revealed Employee #18 place his/her hands on the shoulders and upper body of Patient #14, first holding and pushing Patient #14 from the front away and from an unidentified patient, then with arms around the shoulders of Patient #14 and finally with hands grasping and holding the arms of Patient #14 from behind, holding and pulling him/her away from the unidentified patient. Employee #18 released the hold at 1:22/6:00 of the video timer.

Employees #1 and #4 confirmed the hold within the video titled "2024-06-21 08-12-00 4th Flr Activity North.110.avi" at 1:00/6:00 of the video timer was not an approved/trained physical restraint technique.

Employees #1 and #4 confirmed the holds listed above did not demonstrate approved restraint techniques.

Based on review of facility policy and procedure, facility video, document request and employee interview, , it was determined the hospital failed to ensure a patient requiring seclusion for a violent episode also received one to one observations during the seclusion to ensure safety. This failure poses the risk of a patient suffering injury during the seclusion episode and seclusion not being discontinued at the earliest possible time.

Findings include:

Review of facility policy revealed "Definitions: ...Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not [sic]...Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room...The physician/APP (Advanced Practice Provider) order for use of restraint or seclusion will be recorded in the medical record..."

Review of facility video titled "2024-07-13 19-30-00 4th Fl. Day Room South.106 (1).avi" revealed Employee #15 with his/her arms around the upper torso of Patient #10, holding and walking him/her into the Seclusion Anti Room at 17:26/1:15:01 of the video timer.

Review of facility video titled "2024-07-13 19-30-00 4TH FLR SECLUSION ANTI.105.avi" revealed Employee #15 with his/her arms around the upper torso of Patient #10, holding and walking him/her through the Seclusion Anti Room door, into the seclusion room and closing the seclusion room door with Patient #10 inside at 17:33/1:15:00 of the video timer. Employee was seen in the same video exiting the seclusion anti room at 17:36/1:15:00 of the video timer.

Physician order for seclusion was requested, none was provided.

Employee #4 confirmed during interview conducted on July 13, 2024, that the videos noted above revealed Employee #15 holding and walking Patient #10 into the seclusion anti room and then into the seclusion room, shutting the door with Patient #10 inside and leaving the seclusion anti room with Patient #10 unsupervised. Employee #4 confirmed patients in seclusion are required to receive "constant supervision."

Based on facility records and staff interview, the hospital failed to ensure the patients were evaluated (seen face to face) by a physician or other appropriately trained Registered Nurse within one hour of the restraint. This deficient practice poses the risk of physical and/or psychological harm not identified and treated after the restraint.

Findings include:

Policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revealed: "...Face to Face evaluation by the Physician, RNP, or trained RN/PA...Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized RNP(APRN), or trained RN/PA...."

Patient #16 "Post Intervention Face to Face Evaluation" revealed "...To be completed by RN with at least 1 year of Behavioral Health experience within 1 hour of initiation of intervention...." Evaluation dated July 14, 2024 was signed by Employee #24 on July 14, 2024. Employee #24 was identified as an LPN.

Employee #4 confirmed in an interview on July 24, 2024, that Employee #24 does not have the required credentials to complete the assessment.

Based on the review of facility records and interviews it was determined that the Hospital failed to ensure:

Cross reference A0273: They measure, analyze, and track quality indicators by ensuring that the hospital followed their policies and procedures related to quarterly data analysis for episodes of restraint and seclusion.

Cross reference A0315: They evaluated if the hospital was provided with adequate personnel and resources to provide the adequate scope of services and care to patients.

The cumulative effect of these systemic problems directly related to patient care with regard to restraint, resulted in the hospital's inability to have an effective quality assurance performance improvement program to assess opportunities for improvement, and improve health outcomes.

Based on review of policies and procedures, facility documents, medical records, and interview, it was determined the facility failed to measure, analyze, and track quality indicators by ensuring that the hospital followed their policies and procedures related to quarterly data analysis for episodes of restraint and seclusion. This deficient practice poses a potential risk to the health and safety of patients when potential systemic issues or individual performance problems may not be addressed, resulting in potential patient harm or abuse.

Findings include:

Policy titled "Proper use and Monitoring of Physical/Chemical Restraints and Seclusion" revealed: "...Data is collected on all restraint/seclusion episodes, aggregated, analyzed, and reported to the Hospital Quality Council, medical Executive Committee, and Governing Body at least Quarterly...Data Includes:...Staff who initiated the process; Gender of the patient...Results of the debriefing...Analysis of data includes particular attention to...Multiple instances of restraint/seclusion use experienced by a patient within a 12 hour time frame...."

Review of medical records and restraint logs revealed at least three incidents of multiple seclusion or restraint within a 12 hour timeframe by three patients in January and February 2024.

Documentation demonstrating review and analysis of restraint and seclusion episodes by Governing Body was requested. Document titled "Medical Executive Committee...April 2024...Review 1st Qtr 2024...." was provided. This document did not address aggregate data or analysis of: Staff who initialed the process, gender of patients, and instances of multiple seclusion or restraint within a 12 hour timeframe by one patient. This document also failed to address results of debriefings.

Employee #3 and Employee #5 confirmed on July 25, 2024 that they did not have data to present on seclusion and restraint that met their policy requirements.

Based on the review of policy, hospital documents and staff interviews, it was determined the Governing Authority failed to ensure that they evaluated if the hospital was provided with adequate personnel and resources to provide the adequate scope of services and care to patients. This deficient practice poses a risk to the health and safety of patients if the hospital is unable to provide the proper care and resources to meet the patient's medical needs.

Findings include:

Policy titled "Plan for the Provision of Inpatient Care" states, "...Adjustments to the core staffing levels are made on the basis of acuity. Such adjustments for planned staffing are made daily by the CNO or their designee based on the individualized needs of those being served on the units...."

Policy titled "Appropriate Staffing Levels" revealed, "...The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences...."

Review of Seclusion and Restraint Staff Debriefing notes revealed:

Note for Patient #16 dated June 15, 2024, at 1305"...Procedures that can be implemented to prevent reoccurrence...." The staff completing the packet wrote: "...Increased staff...1 observation...."

Note for Patient #16 dated June 15, 2024, at 1446, states: "...Procedures that can be implemented to prevent reoccurrence...." The staff completing the packet wrote: "...Increase staff...1:1 observations...."

Note for Patient #16 dated June 21, 2024, at 1657, states: "...Procedures that can be implemented to prevent reoccurrence...." The staff completing the packet wrote: "...Increase staff...."

Note for Patient #16 dated June 21, 2024, at 1905, states: "...Procedures that can be implemented to prevent reoccurrence...." The staff completing the packet wrote: "...Increase staff...Increase observation...."

Note for Patient #3 dated June 21, 2024, at 1109, states: "...Procedures that can be implemented to prevent reoccurrence...." The staff completing the packet wrote: "...Increase staff/observation...."

Note for Patient #16 dated June 29, 2024, at 1830, states: "...Procedures that can be implemented to prevent reoccurrence...." The staff completing the packet wrote: "...Staffing ratios...."

Note for Patient #10 dated July 14, 2024, at 1830, states: "...Procedures that can be implemented to prevent reoccurrence...." The staff completing the packet wrote: "...Staffing to acuity...."

Request for documentation that the CNO reviews ongoing staffing requirements based on outcomes and restraint was requested. None was provided.

Interview with Employee #3 and Employee #4 on July 24, 2024, confirmed that they did not have documentation that review of the above incidents were reviewed and action taken on the documenting staffs continual notes of inadequate resources.

Based on facility records and staff interview, the hospital failed to a registered nurse supervised and evaluated the nursing care for each patient by allowing a LPN to conduct an assessment without oversight. This deficient practice could result in patient harm and not receiving appropriate care after a restraint.

Based on review of facility policy and procedure, facility documents, facility video, and employee interview, the Department determined the administrator failed to ensure patient observation rounds occurred and was documented according to facility policy. This deficient practice resulted in Patient #1 choking himself/herself to unconsciousness with his/her sweatshirt.

Findings include:

Policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revealed: "...Face to Face evaluation by the Physician, RNP, or trained RN/PA...Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized RNP(APRN), or trained RN/PA...."

Patient #16 "Post Intervention Face to Face Evaluation" revealed "...To be completed by RN with at least 1 year of Behavioral Health experience within 1 hour of initiation of intervention...." Evaluation dated July 14, 2024 was signed by Employee #24 on July 14, 2024. Employee #24 was identified as an LPN.

Employee #4 confirmed in an interview on July 24, 2024, that Employee #24 does not have the required credentials to complete the assessment and operated outside their scope of practice.

Based on review of facility policy and procedure, facility documents, facility video, and employee interview, the Department determined the administrator failed to ensure patient observation rounds occurred and was documented according to facility policy. This deficient practice poses the risk that patients left unsupervised may engage in self-injurious behavior, leading to injury or death.

Findings include:

Review of facility policy titled "Patient Observation Rounds/Level of Observation" revealed "...1. Q15 Minute Observations...Staff assigned to complete patient observation rounds will: ...a. Review and update patient observation forms...d. Observe each patient a minimum of every 15 minutes and according to precaution level, and document observation on the patient observation form..."

Review of facility document titled "Patient Safety Log by Date of Incident" revealed Patient #1 involved in an incident on 07/04/2024 at 1737, documented as "...Suicidal Behavior...Outcome/Injury...Loss of Consciousness..."

Review of facility document titled "Patient Observation Record & Milieu Group" and dated "7/4/24" revealed the Level of Observation for Patient #1 to be Q15 and at 1730 documented "Behavior...3. Isolative...Location...QR: Quiet Room...Position...B-Back..." The entry was initialed by Employee #8, who documented entries on 17:00, 17:15, 17:30, and 17:45.

Review of facility document titled "Employee Corrective Action Report" revealed "...On 7/4/24 (Employee #8) falsified documentation on a patients Q-15 round sheet for 4 rounds (42 minutes) without getting up to check the patient's location and wellbeing. Patient was left unattended in the music room throughout this time. During this time the patient tied a sweater around his/her neck attempting suicide..." The document also revealed "...Corrective Action...Termination..."

Review of facility video titled "2024-07-04 16-30-00 4th Floor Patient Hall Look West.91.avi" revealed Employee #25 opening the door to the "Quiet Room" door at 22:18/1:30:01 of the video timer, observed Patient #1 enter the room and the door close. Employee #25 then walked down the unit hallway to the nurse's station. No employee is seen on the video completing observation with Patient #1 until Employee #25 returns and opens the "Quiet Room" door at 1:02:01/1:30:01 of the video timer.

Employee's #3 and #4 confirmed during a joint interview conducted on July 12, 2024, that Employee #8 was assigned to perform observation with Patient #1 from 17:00-18:00 on July 4, 2024. Employee #3 confirmed an internal facility investigation determined Employee #8 was found to have falsified documentation on the Patient Observation Record & Milieu Group log from 17:00-18:00 on July 4, 2024, that Employee #8 did not complete observation of Patient #1 during this time/on this date, and it was during this time/on this date that Patient #1 choked himself/herself to unconsciousness with his/her sweatshirt. Employee #3 confirmed Employee #8 was terminated from employment.

Based on a review of facility policies and procedures, facility documents, observation during on-site tour and employee interview on July 12, 2024, the Department determined the administrator failed to ensure that four (4) of four (4) emergency code carts, located on Units #2, #3, #4 and Intake, were sufficiently checked to ensure no expired medical supplies were in use. This deficient practice poses a potential risk to patient health and safety, including death, if the required emergency supplies are expired and no longer efficacious.

Findings include:

Review of facility policy titled "Medical Equipment Management Plan" revealed "...The Director of Plant Operations, in conjunction with clinical director and/or medical equipment vendors/contractors, identifies, in writing, the activities used for maintaining, inspecting, and testing all medical equipment on the inventory to assure safety and maximum useful life...."

Review of facility documents titled "Emergency Medical Equipment Daily Checklist" for April 2024 through July 12, 2024, revealed instructions that included "...Once per week, locks should be opened, all supplies should be accounted for and checked for expiration dates, ensure no rips or tears are noted to emergency supply packaging..." and identified no expired supplies or ripped/torn emergency supply packaging.

Observation during on-site tour revealed:

Unit #2

Urethral Catheterization Tray - Expiration Date 2019-10-31

Unit #3

Laerdal Suction Unit NiMH Battery - Install before 2023-11

Unit #4

Laerdal Suction Unit NiMH Battery - Install before 2023-11

Intake

Laerdal Suction Unit NiMH Battery - Install before 2023-11
Medical Suction Tube, Lot No: 20220715, Art No: WKT47/FR30, Size: FR30/1.8m, Single Use - Package Open and Unsealed

Employee #4 confirmed in interview conducted during on-site tour on July 12, 2024, that the emergency medical supplies identified in the emergency code carts noted above were expired and/or packaging was open and unsealed.

Condition of Participation: Special Staff Requirements for Psychiatric Hospitals
The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

Based on the review of facility records and interviews it was determined that the Hospital
failed to ensure:

Cross reference A1600: Ensuring a Registered Nurses (RN) were present on a unit overseeing patient care of unqualified staff and to provide active treatment measures.

The egregious nature of this deficient practice on multiple dates for extended periods of time could result in patient's not being properly monitored and placed at risk for harm.





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Based on review of policy and procedures, facility video footage, and interview, the Department determined the facility failed to ensure Registered Nurses (RN) were present on a unit overseeing patient care of unqualified staff and to provide active treatment measures. This deficient practice could result in patient's not being properly monitored and placed at risk for harm.

Findings include:

Policy titled "Appropriate Staffing Levels" states, "...It is the policy of Quail Run Behavioral Health Hospital (QRBH) to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients...The staffing will include a combination of Registered Nurses (RN's) and unlicensed nursing support personnel in sufficient quantities to meet the needs of the population served...Each patient care unit will have a minimum of one RN at all times. If only one RN is scheduled to a unit for a shift, relief coverage for the RN will be planned and documented, including a coverage plan for meal/break times...A minimum of two staff will be assigned to all units, one of which will be an RN on each shift. In addition, if a unit has more than one patient a minimum of 1 RN and 1 additional nursing personnel member will be scheduled on that unit...."

Chief Nursing Officer (CNO) email titled "LPN Scope of Practice" states, "...An RN must be present on the unit at all times...If the door in the adolescent nursing station is closed, there must be an RN on both sides...."

Review of unit video footage revealed:

On July 18, 2024, an adolescent patient was observed on a unit from 1411 to 1552, and again from 1900 to 1952, with an Employee identified as a Behavioral Health Technician (BHT). The door between the units and the door in the nursing station was closed At no time was an RN identified in the footage.

On July 19, 2024, an adolescent patient was observed on a unit from 0900 to 1030, 1200 to 1300, and 1800 to 1900, with an Employee identified as a Behavioral Health Technician (BHT). The door between the units and the door in the nursing station was closed At no time was an RN identified in the footage.

On July 21, 2024, an adolescent patient was observed on a unit from 1902 to 1953, with an Employee identified as a Behavioral Health Technician (BHT). The door between the units and the door in the nursing station was closed At no time was an RN identified in the footage.

Employee #2 and #3 confirmed in an interview on July 23, and July 24, 2024, during video review, that the unit had a patient present and the unit was not appropriately staffed with a minimum of 2 staff, one of which was an RN, to provide active treatment measures.