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Based upon review of policies and procedures, medical records and staff interviews, the hospital failed to meet the Condition of Participation for Patients Rights related to Care in a Safe Setting as evidenced by the hospital staff's failure to implement interventions when patients #1 and #7 exhibited behaviors that were not controlled by redirection or the administration of anti-psychotic medications that were ordered by the Psychiatrist. The hospital staff utilized local law enforcement officials to handcuff and remove these patients from the hospital when they exhibited destructive behaviors and physically attacked the hospital staff. (See findings under tag A144).

Based upon observations, review of hospital policy/procedures, and Administrative interviews, the hospital failed to ensure: 1) the address and telephone number for the State of Louisiana Department of Health and Hospitals--Health Standards Section were made available to patients/family members to file a complaint; 2) a person within the hospital (along with a telephone number) was identified and available for patients/family members to submit a complaint to the hospital; and 3) a policy/procedure was developed and implemented for dealing with grievances/complaints that met this standard regulation. Findings:

Observations conducted, on 10/24/12 at 1:30pm, revealed the hospital had posted the address and telephone number for the Office of Mental Health Advocacy; however, they failed to post the address and telephone number for the Louisiana Department of Health and Hospitals--Health Standards Section.

Continued observations revealed the hospital failed to identify an individual and telephone number to be used to file a complaint internally with the hospital; and the hospital did not make information relative to the grievance process available to patients/family members.

Interview, on 10/23/12 at 1:45pm, with S1 Chief Executive Officer (CEO) revealed he was questioned (as the surveyors conducted observations on the inpatient unit) if there was any other listed agencies to be posted for patients/family members to file a complaint, he replied, "We have the Office of Mental Health Advocacy posted here." (S1 CEO was referring to the hallway of the patient unit, where there were 4 areas down the hallway that were posted with the address and telephone number for the Mental Health Advocacy Office)

Interview, on 10/24/12 at 10:30am, with S3 Director of Nursing (DON) revealed when questioned regarding the hospital's policy/procedure for grievances/complaints, she supplied a copy of a policy titled "Grievance Procedure".

Review of hospital policy #14.2, titled "Grievance Procedure" revealed the following: "Policy/Procedure: ...has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by the U.S. Department of Health and Human Services regulations (45 C.F.R. Part 84), implementing Section 504 of the Rehabilitation Act of 1973 as amended (29 U.S.C. 794). Section 504 states, in part, that Any otherwise qualified disabled individual...shall solely...2. A complaint should be filed in the office of the Section 504 coordinator within 30 days after the person filing the complaint becomes aware of the alleged discriminatory act. 3. The Administrator, or designee, will investigate the complaint...4. The Administrator shall issue a written decision determining the validity of the complaint no later than 30 days after its filing...6. An individual...may pursue other remedies. This includes filing with: The Office for Civil Rights..."

According to the hospital's policy for Grievances, the hospital utilized "Section 504 Coordinator" for the filing of complaints. The surveyors were unable to obtain confirmation from S3 DON as to who, or where the "Section 504 coordinator" was physically located (an address) or their telephone number.

Interview, on 10/25/12 at 11:30am, with S2 Administrator revealed when questioned if the hospital had received any grievances/complaints or had incidents she replied, "No".

After the surveyors reviewed policy #14.2, (that was identified by S3 DON as the only policy the hospital had for their Grievance Procedure), it was discovered the policy was for discriminatory acts against persons who had disabilities. There failed to be documented evidence the hospital had developed and implemented a Grievance Policy that met the requirements set forth by this standard.

Based upon reviews of information given to patients on admission, the hospital's Grievance Procedure policy, and staff interview, the hospital failed to ensure: 1) a grievance policy was developed and implemented that met the requirements under this standard. The hospital's Grievance Procedure policy utilized the Rehabilitation Act of 1973 regarding discriminatory acts against persons with disabilities; and this policy identified a 30 day time frame for filing complaints related to the discriminatory act and failed to address patient grievances/complaints; and 2) patients/representatives were notified of the hospital's grievance process. Findings:

Review of the information packet given to patients (upon admission) included information regarding: orientation to therapy sessions and completion of assignments; Advance Directives/Living Wills; Confidentiality Statement; Medicare information relative to discharge; and patient rights and responsibilities.

Review of the Grievance Procedure Policy No. 14.2 titled "Grievance Procedure" revealed "Section: Procedure for Filing a Complaint, #2. A complaint should be filed in the office of the Section 504 coordinator (no telephone number or address given) within 30 days after the person filing the complaint becomes aware of the alleged discriminatory act." "#4. The Administrator shall issue a written decision determining the validity of the complaint no later than 30 after its filing."

Interview with Patient #4, 10/24/12 at 3:20pm, revealed when questioned relative to what to do if he had a complaint/grievance, he replied he was not sure. Patient #4 was asked if he had received information regarding filing complaints/grievances and he stated he could not recall.

The review of the patient rights and responsibilities (that the patient information packet contained), failed to have documented evidence the hospital had included information relative to the grievance/complaint process.

Interview with S3 DON on 10/24/12 at 10:30 AM, revealed the above grievance policy was what the hospital utilized for all grievances/complaints.

According to the hospital's policy for Grievances, the hospital utilized the Rehabilitation Act of 1973, "Section 504 Coordinator" for the filing of grievances/complaints. The surveyors were unable to obtain confirmation from S3 DON as to who, or where the "Section 504 coordinator" was physically located (an address) or their telephone number.

Review of the Grievance Procedure utilized by the hospital, revealed there failed to be a clearly defined policy/procedure for patients to file a complaint/grievance with the hospital; instead the hospital's policy defined how a disabled patient could file a discriminatory complaint.

Based upon review of hospital policy/procedure for Grievance Procedure and interviews, the hospital failed to ensure the contact individual to whom complaints/grievances should be filed was identified along with their telephone number. Findings:

Review of hospital policy #14.2, titled "Grievance Procedure" revealed the following: "Policy/Procedure: ...has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by the U.S. Department of Health and Human Services regulations (45 C.F.R. Part 84), implementing Section 504 of the Rehabilitation Act of 1973 as amended (29 U.S.C. 794). Section 504 states, in part, that Any otherwise qualified disabled individual...shall solely...2. A complaint should be filed in the office of the Section 504 coordinator within 30 days after the person filing the complaint becomes aware of the alleged discriminatory act. 3. The Administrator, or designee, will investigate the complaint...4. The Administrator shall issue a written decision determining the validity of the complaint no later than 30 days after its filing...6. An individual...may pursue other remedies. This includes filing with: The Office for Civil Rights..."

The surveyors were unable to obtain confirmation from S3 Director of Nursing as to who, or where the "Section 504 coordinator" was physically located (an address) or telephone number.

Interview with S3 DON on 10/24/12 at 10:30 AM revealed she confirmd the above policy was the procedure the hospital utilized for the Grievance Policy; however, this policy failed to identify an acutual grievance procedure and was for discriminatory acts against persons with disabilities.

Based on review of patient closed medical records (patient #1 and 7), Hospital Patient Rights and Responsibilities form and interview, the hospital failed to ensure each patient's right to participate in the development of the plan of care including revisions as the patient's condition changed.

Findings:

Review of the closed medical record for Patient #1 revealed she was admitted 10/16/12 under PEC (physician's emergency certificate). Review of the Master Treatment Plan revealed the diagnoses were: Axis I: Schizoaffective Paranoid, acute exacerbation versus Schizoaffective disorder Bipolar.
Problem #1 was identified as "Psychosis" with the Short Term Goal (STG) "Patient will have decrease hallucinations and disorganized thoughts" and Long Term Goal "Patient will achieve optimal level of functioning relative to patient capabilities". Review of pre-printed Treatment Plan revealed "Psychosis" was listed as the problem with the following STGs and interventions:
1) STG: "Patient will have decrease in hallucinations and disorganized thinking. AEB (As Evidenced By): Less attention to internal stimuli. Intervention: Evaluate prescribed meds as needed. Administer meds as ordered, monitor response. Encourage reality orientation. Staff: Nursing and All staff."
2) STG: "Patient will demonstrate increased trust and a decrease in paranoia by 10/22/12. AEB: Increase in interactions with peers and staff. Attend 50% of recreational and therapy groups by 10/23/12. Participate in discussion with therapist on family therapy. Interventions: Provide opportunity to develop 1:1 therapeutic relationship. Provide daily therapy groups. Provide individual therapy PRN (as needed) times a week. Provide exercise and recreational groups daily."
3) STG: "Patient will have 6-8 uninterrupted sleep for 5 nights by 10/22/12." Intervention: "Monitor/record sleep hours."
4) STG: "Patient will comply with medication regimen and report side effects to staff by 10/22/12." Interventions: "Educate on importance of medications and potential side effects."

Review of the medical record revealed documentation on 10/19/12 that Patient #1 exhibited aggressive and violent behaviors. Patient #1 went out to the smoking area (10/19/12), where she used her fist to hit S8 MHT about the head and left ear. Interview on 10/25/12 at 10:15 AM with S8 MHT revealed patient #1 had exhibited destructive behaviors earlier that day.

Review of the treatment plan failed to identify appropriate short term goals and interventions related to the patient's aggressive and violent behaviors that were exhibited on 10/18/12 and 10/19/12. Further review revealed the hospital failed to make revisions as the patient's aggressive behavior manifested. The hospital also failed to implement measures to ensure the patient who was admitted under PEC (physician emergency certificate) remained in the hospital for treatment by implementing interventions to redirect these behaviors. Instead, the hospital called the local sheriff's office/department in order "to control the patient as the staff were having difficulty controlling her aggressive behaviors"; this information was obtained from an interview, 10/24/12 at 11:15 AM, with S3 DON.

2. Review of the closed medical record for patient #7 revealed she was admitted to the hospital under PEC. Review of Patient #7's Master Treatment Plan revealed the patient's diagnoses were: Axis I: Schizophrenia undifferentiated chronic in partial remission and Axis II: Borderline Intellectual Functioning. Problem #1: Aggressive; Problem #2: Impulse Control; and Problem #3: Anxious Mood. Short Term Goals were listed as "No aggression or anxious behaviors in the next 5 days." Further review of the treatment plan revealed 2 (two) pre-printed pages with the first identified as:
I) Psychosis: (Specify): (area left blank).
Short Term Goals:
1) "Patient will demonstrate trust and a decrease in paranoia by 8/11. AEB (As Evidenced By) Increase in interactions with peers and staff. Attend 100% of recreational and therapy groups by 8/12/12, Participate in discussion with therapist on family therapy." Interventions: "Provide opportunity to develop 1:1 therapeutic relationship (Social Worker), Provide daily therapy groups (Social Worker), Provide individual therapy 3 times per week (Social Worker), and Provide exercise and recreational groups daily (Recreational Therapist), and "Patient will comply with medication regimen and report side-effects to staff by 8/12/12."
2) Short Term Goals: "Patient will have 6-8 hours of uninterrupted sleep for 3 consecutive nights by 8/12/12."
3) Short Term Goals: "Patient will perform ADLs (Activities of Daily Living) independently by 8/12/12." Interventions: Assist in preparation of environment before time of ADL activity (Nursing).
4) Short Term Goals: "Patient will comply with medication regimen and report side effects to staff by 8/12/12." Interventions: Educate on importance of medications and potential side effects (Nursing).

II) Bipolar: Manic (the second pre-printed Treatment Plan)
1) Short Term Goals: Patient will have 3 consecutive nights sleep by 8/12/12. Interventions: Staff will encourage medication compliance (Nursing)
2) Short Term Goals: Patient will have "0" episodes of disrupted behaviors by 8/12/12. Interventions: Medication as prescribed to control anxiety. Redirect as needed (Nursing).
3) Short Term Goals: Patient will exhibit increased control of motor and verbal behavior by 8/12/12. Interventions: Medication as ordered by Physician. Administered and monitored by nursing (Nursing).
4) Short Term Goals: Patient will verbalize less preoccupation with delusional thoughts and maintain reality based conversations. Interventions: Redirect patient to reality based topics. Encourage participation in program activities (All Staff).

The treatment plan failed to identify appropriate short term goals and interventions related to the patient's aggressive and violent behaviors that were exhibited on 08/11/12.

The hospital also failed to implement measures to ensure the patient who was admitted under PEC (physician emergency certificate) remained in the hospital for treatment by implementing interventions to redirect these behaviors. Instead, the hospital called the local sheriff's office/department in order to "take the patient to jail" as identified by review of the patient's medical record. There failed to be documented evidence Patient #7's Treatment Plan was updated to reflect the aggressive/violent behaviors the patient exhibited on 08/11/12 as confirmed by interview on 10/24/12 at 11:15 AM with S3 DON.

Review of the Apollo Behavioral Health Hospital, LLC Rights and Responsibilities form revealed in part: #12. A patient's rights include being informed of his or her health status, being involved in care planning and treatment and being able to request or refuse treatment.

Based on review of patient closed medical records (patient #1 and 7), Hospital Patient Rights and Responsibilities form and interview, the hospital failed to ensure each patient's right to be involved with the planning of care that includes requesting or refusing treatment.

Findings:

Review of the closed medical record for Patient #1 revealed she was admitted 10/16/12 under PEC (physician's emergency certificate). Review of the Master Treatment Plan revealed the diagnoses were: Axis I: Schizoaffective Paranoid, acute exacerbation versus Schizoaffective disorder Bipolar.
Problem #1 was identified as "Psychosis" with the Short Term Goal (STG) "Patient will have decrease hallucinations and disorganized thoughts" and Long Term Goal "Patient will achieve optimal level of functioning relative to patient capabilities". Review of pre-printed Treatment Plan revealed "Psychosis" was listed as the problem with the following STGs and interventions:
1) STG: "Patient will have decrease in hallucinations and disorganized thinking. AEB (As Evidenced By): Less attention to internal stimuli. Intervention: Evaluate prescribed meds as needed. Administer meds as ordered, monitor response. Encourage reality orientation. Staff: Nursing and All staff."
2) STG: "Patient will demonstrate increased trust and a decrease in paranoia by 10/22/12. AEB: Increase in interactions with peers and staff. Attend 50% of recreational and therapy groups by 10/23/12. Participate in discussion with therapist on family therapy. Interventions: Provide opportunity to develop 1:1 therapeutic relationship. Provide daily therapy groups. Provide individual therapy PRN (as needed) times a week. Provide exercise and recreational groups daily."
3) STG: "Patient will have 6-8 uninterrupted sleep for 5 nights by 10/22/12." Intervention: "Monitor/record sleep hours."
4) STG: "Patient will comply with medication regimen and report side effects to staff by 10/22/12." Interventions: "Educate on importance of medications and potential side effects."

Review of the medical record revealed documentation on 10/19/12 that Patient #1 exhibited aggressive and violent behaviors. Patient #1 went out to the smoking area (10/19/12), where she used her fist to hit S8 MHT about the head and left ear. Interview on 10/25/12 at 10:15 AM with S8 MHT revealed patient #1 had exhibited destructive behaviors earlier that day.

The hospital also failed to implement measures to ensure the patient who was admitted under PEC (physician emergency certificate) remained in the hospital for treatment by implementing interventions to redirect these behaviors. Instead, the hospital called the local sheriff's office/department in order "to control the patient as the staff were having difficulty controlling her aggressive behaviors"; this information was obtained from an interview, 10/24/12 at 11:15 AM, with S3 DON.

2. Review of the closed medical record for patient #7 revealed she was admitted to the hospital under PEC. Review of Patient #7's Master Treatment Plan revealed the patient's diagnoses were: Axis I: Schizophrenia undifferentiated chronic in partial remission and Axis II: Borderline Intellectual Functioning. Problem #1: Aggressive; Problem #2: Impulse Control; and Problem #3: Anxious Mood. Short Term Goals were listed as "No aggression or anxious behaviors in the next 5 days." Further review of the treatment plan revealed 2 (two) pre-printed pages with the first identified as:
I) Psychosis: (Specify): (area left blank).
Short Term Goals:
1) "Patient will demonstrate trust and a decrease in paranoia by 8/11. AEB (As Evidenced By) Increase in interactions with peers and staff. Attend 100% of recreational and therapy groups by 8/12/12, Participate in discussion with therapist on family therapy." Interventions: "Provide opportunity to develop 1:1 therapeutic relationship (Social Worker), Provide daily therapy groups (Social Worker), Provide individual therapy 3 times per week (Social Worker), and Provide exercise and recreational groups daily (Recreational Therapist), and "Patient will comply with medication regimen and report side-effects to staff by 8/12/12."
2) Short Term Goals: "Patient will have 6-8 hours of uninterrupted sleep for 3 consecutive nights by 8/12/12."
3) Short Term Goals: "Patient will perform ADLs (Activities of Daily Living) independently by 8/12/12." Interventions: Assist in preparation of environment before time of ADL activity (Nursing).
4) Short Term Goals: "Patient will comply with medication regimen and report side effects to staff by 8/12/12." Interventions: Educate on importance of medications and potential side effects (Nursing).

II) Bipolar: Manic (the second pre-printed Treatment Plan)
1) Short Term Goals: Patient will have 3 consecutive nights sleep by 8/12/12. Interventions: Staff will encourage medication compliance (Nursing)
2) Short Term Goals: Patient will have "0" episodes of disrupted behaviors by 8/12/12. Interventions: Medication as prescribed to control anxiety. Redirect as needed (Nursing).
3) Short Term Goals: Patient will exhibit increased control of motor and verbal behavior by 8/12/12. Interventions: Medication as ordered by Physician. Administered and monitored by nursing (Nursing).
4) Short Term Goals: Patient will verbalize less preoccupation with delusional thoughts and maintain reality based conversations. Interventions: Redirect patient to reality based topics. Encourage participation in program activities (All Staff).

The treatment plan failed to identify appropriate short term goals and interventions related to the patient's aggressive and violent behaviors that were exhibited on 08/11/12.

The hospital also failed to implement measures to ensure the patient who was admitted under PEC (physician emergency certificate) remained in the hospital for treatment by implementing interventions to redirect these behaviors. Instead, the hospital called the local sheriff's office/department in order to "take the patient to jail" as identified by review of the patient's medical record and confirmed by interview on 10/24/12 at 11:15 AM with S3 DON.

Review of the Apollo Behavioral Health Hospital, LLC Rights and Responsibilities form revealed in part: #12. A patient's rights include being informed of his or her health status, being involved in care planning and treatment and being able to request or refuse treatment.

Based upon review of policies and procedures, 2 of 12 medical records (#1, #7) and staff interviews, hospital staff failed to implement interventions when patients #1 and #7 exhibited aggressive and violent behaviors that were not controlled by redirection and the administration of anti-psychotic/sedative/hypnotic medications that were ordered by the Psychiatrist. When patient #1's and patient #7's behaviors escalated, which included attacking staff and destroying hospital property, local law enforcement officials were called and the patients were placed in handcuffs, removed from the hospital, and taken to a local acute care hospital for further care of their violent and aggressive behaviors. Findings:

Patient #7:
Review of patient #7's medical record revealed the patient was admitted to the hospital on 08/07/12 under a Physician Emergency Certificate (PEC, dated 08/06/12, timed 6:50 PM). On 08/08/12, a Coroner's Emergency Certificate (CEC) was completed (timed 7:12 AM). According to the CEC, the "History of Present Illness" included "Per PEC, 26 yo (year old) BF (Black Female) presented on an OPC (Order of Protective Custody) that she has been violent and aggressive. Patient reports that she broke out windows in her trailer. Very impulsive behaviors and has multiple hospitalizations. Recently in jail for violent behavior". The CEC further identified the patient was gravely disabled and unable to seek voluntary admission.

Review of the Multidisciplinary Progress Notes revealed from the time of admission on 08/06/12, 1:00 PM to 08/11/12, 8:00 AM, revealed no violent or aggressive behaviors were identified. Further review of the Multidisciplinary Progress Notes revealed the following RN documentation:
08/11/12, 8:35 AM: "Patient in her room screaming and angry because staff will not let her change beds. Patient wants to sleep in another bed because she does not like her bed anymore. Patient began punching the walls and threatened to break windows when staff not compliant with her requests. She began pulling the mattress off her bed and then began to punch window and broke window."
08/11/12, 8:35 AM: "Ativan 2 mg (milligrams)/Haldol 5 mg dose administered for anxiety at 8:30 AM"
08/11/12, 8:50 AM: "Pt (Patient) in day room screaming and threatening staff. Threatening to break TV. Pt. threw chairs around and broke AC (Air Conditioner) cover. States that she rather go to jail than to sleep in that bed."
08/11/12, 8:52 AM: "3 Deputies arrived to make report on the damages made by pt."
08/11/12, 9:15 AM: "Pt. continues to display aggressive bx (behaviors) in front of Deputies. Deputies stated that they will take Pt."
08/11/12, 9:34 AM: "Received a call from (Nurse) at (Hospital A) ER stating that Pt. was brought here. She stated that she has no records. Explained to her that I did not send any records being that I was not transferring Pt. to any facility. As far as I understood, Deputies were taking her to jail."
08/11/12, 11:45 AM: "Patient arrived in handcuffs with Deputy from (Hospital A). Patient is calm and pleasant and apologized to staff for previous behaviors. Patient is no longer aggressive..." The Multidisciplinary Progress Notes failed to identify who contacted, or who instructed the hospital staff to contact, the local sheriff's department.

Further review of patient #7's medical record revealed a form titled "Daily Nurse Flow Sheet Note" dated 08/11/12, Shift: 7A-7P. The RN identified by check mark the interventions provided included "Relaxation techniques; Redirect patient towards appropriate behavior"; however, the RN failed to identify the relaxation and redirection techniques used. Further review of the Multidisciplinary Progress Notes revealed there was a seventeen minute lapse in time from when the patient began exhibiting violent/aggressive behaviors and required the administration of IM anti-psychotic/anti-anxiety medications (8:35 AM) to when sheriff Deputies were present in the hospital (8:52 AM) and allowed to intervene and "take the patient" even though the patient was still under a Coroner's Emergency Certificate. S4 Psychiatrist was notified by telephone the patient was exhibiting aggressive/violent behaviors and anti-psychotic/anti-anxiety medications were ordered; however, there failed to be documentation the Psychiatrist was notified the medications were ineffective prior to the patient being taken by the Sheriff Deputies.

Patient #1:
Review of patient #1's medical record revealed the patient was admitted to the hospital on 10/16/12 at 1:00 PM, with the diagnosis of Schizophrenia. The patient was placed on a Physician Emergency Certificate (PEC dated 10/15/12, timed 4:54 PM) and a Coroner's Emergency Certificate (CEC dated 10/16/12, timed 7:10 PM). According to the CEC "History Of Present Illness" it was identified "Per PEC 38 yo (year old) BF (Black Female) presented with a history of violent behavior. Patient is very labile and behaviors is threatening. She is paranoid and delusional." The CEC also identified the patient was gravely disabled and unable to seek voluntary admission.

Review of the Multidisciplinary Progress Notes from 10/16/12 through 10/19/12 revealed documentation by the RN the patient exhibited auditory hallucinations, physical aggression and violent behaviors that included attacking the staff. The patient was administered the anti-psychotic medication Haldol 5 milligrams and the sedative/hypnotic medication Ativan 2 milligrams Intramuscular (IM) on 10/17/12, 12:40 AM and 10/18/12 7:50 AM. On 10/16/12, 6:40 PM; 10/18/12 8:50 AM; 10/19/12, 7:30 AM, Haldol 10 mg and Ativan 2 mg were administered IM. On 10/18/12 at 1:00 PM, Thorazine 50 milligrams was administered IM.

Further review of the Multidisciplinary Progress Notes revealed the following:
10/19/12, 2:00 AM: "Continues with yelling and screaming with delusional and paranoid thoughts. Remains isolated to room with constant redirection towards appropriate behavior. Continue to monitor"
10/19/12, 8:16 AM: "Patient with no sleep hrs (hours) this shift. Remains with psychotic behavior, aggressiveness, agitation and irritability..."
10/19/12, 9:00 AM: "Patient psychotic; fighting staff and peers; screaming on top of her voice; hallucinating; labile. Gave her Ativan 2 mg and Haldol 10 mg IM at 7:30 PM. Hitting staff; pacing the floors; aggressive; hostile. (Local police department) was notified for pt. assaulting staff and pt was escorted by police to (Hospital A) Emergency Room to be PEC." The patient was already under a PEC, initiated on 10/15/12 at 4:54 PM and a CEC that was initiated on 10/16/12 at 7:10 PM. There failed to be documentation by the RN why the patient required another PEC.

Review of the form titled "Daily Nurse Flow Sheet Note" dated 10/19/12, Shift: 7A-7P revealed S10 RN identified "N/A" for "Interventions Provided: Relaxation techniques; Redirect patient towards appropriate behavior; Isolate patient to less stimulated setting; MD contacted; Seclusion order received" and "Meds Refused; PRN Med; Reason; and Other".
Review of the physician orders revealed on 10/19/12 at 8:35 AM, S4 Psychiatrist gave S10 RN verbal orders for "Thorazine 100 milligrams IM stat x (times) 1 dose". At 8:44 AM on 10/19/12 S10 RN documented on the physician orders "Clarification of orders: OK to give Thorazine 100 mg IM stat x 1 dose with Geodon".

Interviews with S12 RN on 10/23/12 at 1:20 PM, S7 MHT on 10/24/12 at 10:40 PM, S11 MHT on 10/24/12 at 3:40 PM, and S8 MHT on 10/25/12 at 10:15 AM, revealed when asked if they had utilized any type of restraint or seclusion at this hospital, all replied "no".

Interview with S19 Licensed Practical Nurse (LPN) on 10/24/12 at 9:00 AM revealed when asked about patient #1's behaviors on 10/19/12, S19 LPN replied the night before (10/18/12) the patient broke the TV and continued with aggressive/violent behaviors on the morning of 10/19/12. The Psychiatrist was called and Thorazine 100 mg IM was ordered by the Physician "stat" (there failed to be documentation in the medical record the patient received the stat dose of Thorazine). When asked about the Sheriff Deputies presenting to the unit, S19 LPN replied the Deputies were already on the patient hall when she was giving her 9:00 AM medications and even though patient #1 was in handcuffs she went ahead and administered the anti-psychotic medication Geodon 10 mgs IM at this time.

Interview with S7 Mental Health Technician (MHT) on 10/24/12 at 10:40 AM, revealed when asked about patient #1, he replied the patient was confused, yelling and screaming, and swinging her arms in an attempt to hit staff. On the night before (10/18/12) the patient broke the TV in the activity room and tore her bed from the wall. On the morning of 10/19/12, patient #1 pushed the door open to the patio where S8 MHT was with other patients who were smoking. According to S7 MHT, the patients came back into the hospital saying someone needs to go outside and help S8 MHT because patient #1 was "beating on her". S7 MHT stated he then went outside, calmed patient #1 down and brought her inside to her room. S7 MHT instructed (S8 MHT) to go get the nurse in order to give the patient a shot. S1, Chief Executive Officer (CEO) was then on the unit, observed what patient #1 had destroyed and S7 MHT stated the next thing he knew, the Sheriff Deputies were coming down the hall. When asked what techniques he used to calm the patient down, S7 MHT replied he would use a stern but calm voice with the patient and she would respond well to the redirection. S7 MHT added patient #1 did not like females and would become physically aggressive and attack them.

Interview with S10 RN on 10/24/12 at 3:30 PM revealed when asked who had called the police department, S10 RN replied she did not know and when she looked up "there they were". When asked about the physician's order dated 10/19/12 for the stat dose of Thorazine, S10 RN replied the medication was not given to the patient because there was no Thorazine in stock. There failed to be further documentation by S10 RN S4 Psychiatrist was notified the medication was not available and alternate medication orders obtained.

Interview with S5 Social Worker on 10/24/12 at 3:40 PM revealed when he walked onto the unit he could hear patient #1 yelling and see that she was agitated. The patient came out of her room and into the hallway, looked at S8 MHT, and then attempted to attack her. S5 SW stated he grabbed patient #1 by the arm and lead her back to her room. When asked who called the sheriff deputies, S5 SW replied S1 CEO instructed him to call the sheriff after the patient had attacked a MHT and damaged hospital property. S5 SW further added patient #1 required a physical take down to the floor on 10/18/12 due to her behaviors; however, review of the patient's medical record revealed there failed to be documentation relative to a physical take down.

Interview with S4 Psychiatrist on 10/24/12 at 2:50 PM revealed when asked what type of patients were admitted to the hospital, he replied "all kinds, patients with Suicidal Ideation, Homicidal Ideation, alcohol, and acute psychosis." When asked why patient #1 could not be taken care of in the hospital, S4 Psychiatrist replied "she was very big, about 250 pounds. I had 5 patients come to me and tell me they were scared of her." When asked if he had evaluated the patient prior to her being taken out of the hospital, S4 replied the nursing staff called him while he was on his way to the hospital and said the patient was getting more violent; however, when he reached the hospital the patient had been removed by the sheriff deputies. When asked about evaluating patient #1's strengths/assets/liabilities, S4 Psychiatrist responded he was unable to assess the patient and he "was scared of her".

Interview with S8 MHT on 10/25/12 at 10:15 AM, revealed a general statement "instead of handling the behaviors, the staff (not identified) threatened patients that the police would be called if they don't settle down." When asked about patient #1 attacking her, S8 MHT replied she doesn't think the situation was handled right and added "The nurses seemed to want to get (patient #1) out of the hospital" and "they didn't try to put her in the seclusion room or anything; gave her a shot and then the deputies were here and took her away." There failed to be further documentation in the medical record of attempts to intervene through the use of restraint and/or seclusion when patient #1's aggressive/violent behaviors were not controlled with the administration of anti-psychotic/anti-anxiety medications.

Review of patient #1's ED record from Hospital A documented by the RN revealed "10/19/12, 10:00 AM "Brought in by (Sheriff Department) to bed isolation. Pt. (patient) is in handcuffs with head down in w/c (wheel chair) from Apollo Mental Health Hospital. Reports from (Sheriff Deputy) are that pt became violent with staff." "10:02 AM: To bed - handcuffs removed. Pt is very calm and sleepy. Easily aroused...". At 12:20 PM the RN documented "Hollers, Redirected easily".

Review of policy #3.7 titled "Seclusion & Restraint for Behavior Management" revealed "...Use of restraints, as identified below. will be clinically justified and employed only to prevent a patient from injuring self or others." "Seclusion or Restraint can only be used in emergency situations if needed to ensure the patient's physical safety and less restrictive interventions have been determined to be ineffective. The use of restraint or seclusion must be selected only when less restrictive measures have been found to be ineffective to protect the patient or others from harm.

Review of hospital policy #1.7, titled "Admission Criteria" revealed the following: "PURPOSE Criteria for appropriate admission to...Hospital and the types of admission...relating to psychiatric care of the patients. PROCEDURE 1. The Director of Nursing or Administrator will administratively screen patients for evidence of acceptable conditions of admission...3. Patients who show evidence of symptoms of acute psychiatric disorders will be accepted for admission if they are medically cleared and who are over 18 years of age. Such conditions include but are not limited to: a. Suicide attempt or risk, b. Homicide ideation, intent, or risk of violent/assaultive behavior as a result of a psychiatric disorder...j. Has demonstrated a serious attempt to harm self, other, property within 72 hours prior to admission..."

Interview with S1 CEO on 10/24/12 at 11:16 AM revealed he arrived to the hospital on 10/19/12 between 7:30 AM and 8:00 AM. The staff was calling S3, RN/DON for assistance and when he got to the floor, the sheriff deputies were already on the unit. According to S1 CEO, the sheriff asked him and S8 MHT if he they wanted to press charges against patient #1 and both replied "no". When the sheriff deputies observed the patient trying to hit S8 MHT, the patient was handcuffed and removed from the hospital. Further interview with S1 CEO on 10/24/12 at 11:35 AM revealed when asked why patient #1 was not readmitted back to the hospital, his reply was "well we have to use common sense with the type of patients we take...we have to take into consideration the safety of other patients and staff" and further added "we don't have a bouncy room" When asked about the "bouncy room", S1 CEO replied the padding on the walls and floor. Interview with S3 RN/DON on 10/25/12 at 11:40 AM revealed when asked why patient #1 was not readmitted, S3 RN/DON response was the patient required long term psychiatric care and added "I felt like (patient #1) had a better chance of getting into a state long term facility if she was in another state hospital."

Based upon review of 1 of 12 medical records (#1), incident/accident reports, and staff interviews, the hospital failed to ensure the medical record for patient #1 described the patients behaviors that resulted in a physical "take down" and the patient being secluded in her room on 10/19/12 by three staff members. Findings:

Interview with S5, Social Worker on 10/24/12 at 3:40 PM, revealed a physical "take down" was implemented on patient #1 due to her aggressive/violent behaviors.

Review of the medical record of patient #1 revealed the patient was admitted to the hospital on 10/16/12 at 1:00 PM with the diagnosis of Schizophrenia. A Physician Emergency Certificate (PEC dated 10/15/12, timed 4:54 PM) and a Coroner's Emergency Certificate (CEC dated 10/16/12, timed 7:10 PM) were implemented due to the patient's "recently increasing violent behavior" (PEC) and "...is very labile and behavior is threatening. She is paranoid and delusional..." (CEC).

Review of the Multidisciplinary Progress Notes from 10/16/12, 1:00 PM through 10/19/12, 9:00 AM revealed documentation by the Registered Nurse the patient exhibited auditory hallucinations, physical aggression and violent behaviors and received the anti-psychotic medication Haldol along with the sedative/hypnotic medication Ativan, intramuscular (IM). In addition to these medications, on 10/18/12, the psychiatrist also ordered another anti-psychotic medication, Thorazine 50 milligrams that was administered at 1:00 PM by the RN with documentation "Patients remains psychotic and anxious". On 10/18/12 at 8:17 PM, the RN documented "Continues with psychotic behavior to include damages to building and attempting to exit back door. Continue with redirecting and less stimulating environment for patient, continue to monitor". On 10/19/12 at 9:00 AM, S10 RN documented "Patient psychotic, fighting staff and peers, screaming on top of her voice, hallucinating, labile. Gave her Ativan 2 mg and Haldol 10 mg IM at 7:30 AM. Hitting staff, pacing the floors, aggressive, hostile. (Local Police Department was notified for patient assaulting staff and patient was escorted by police to (Hospital A) emergency room for PEC."

There failed to be further documentation in patient #1's medical record the interventions implemented to control the patient's violent/aggressive behaviors to include the patient required a physical take down.

Review of the incident/accident reports for October 2012 revealed there failed to be documented evidence a report was completed on patient #1 when, according to S5 SW, a physical take down was implemented on 10/18/12.

Based upon reviews of personnel files for 4 of 6 Mental Health Technicians (MHTs--S#s 6, 8, 11, 15), 4 of 4 Registered Nurses (RNs--#s S10, 12, 13, 14), policy/procedures, Job Description for MHT, staff and Administrative interviews the hospital failed to ensure all staff received documented training and evaluation of their competencies relative to de-escalation of aggressive/violent behaviors prior to providing direct patient care as evidenced by a lack of documented evidence they had received training and had their competencies evaluated for de-escalation of aggressive/violent patient behaviors which could place all patients, themselves and other staff members in dangerous situations. Findings:

Review of S6, S8, S11 and S15's (MHTs) personnel files revealed they had not received training relative to dealing with aggressive/violent patients and methods to be employed to de-escalate the patients behaviors prior to providing direct patient care. There also lacked documented evidence their competencies for these methods were evaluated and documented.

Review of S10, S12, S13, and S14's (RNs) personnel files revealed a lack of documented current training and competencies relative to aggressive/violent patients and the methods to be employed to de-escalate those negative behaviors prior to providing direct patient care.

Review of hospital policy #4.1 titled "Staff Orientation" revealed the following: "POLICY It is the policy of the Hospital that all staff be fully and properly oriented to the Hosptial operations prior to assuming full work responsibilities...PROCEDURE ...2. The employee's direct supervisor will assume responsibility for orientation activities (i.e.: Director of Nursing; Administrator). 3. Orientation of all full-time...not be limited to items outlined on the 'Education Checklist'...4. Each new hire will be assigned a staff person or designee in their specific area before being allowed to work solo with patient..."

Review of a Job Description titled "Mental Health Technician" revealed: "Job Purpose or Mission: ...Maintains a safe and therapeutic environment and assists in control of patients who exhibit unacceptable behavior...ESSENTIAL JOB FUNCTIONS AND DUTIES include but are not limited to the following: ...2. ASSISTS in provision of maintaining a safe and therapeutic milieu by monitoring compliance with hospital rules, providing assistance with security and supportive man-power by assisting in control of patients who exhibit unacceptable behavior..."

Interview, on 10/25/12 at 10:15am, with S8 MHT revealed when she was questioned as to what type of training she had received prior to working with psychiatric patients, she stated she had not received any type of training to protect herself or other patients from an aggressive/violent patient. S8 further stated she did not receive an orientation; only worked one day with another MHT before taking her own assignments. Continued interview with S8 revealed she had taken patients out for their smoke break on 10/19/12 and was the only MHT present outside. S8 stated Patient #1 rushed out the door and began hitting her (S8 MHT) about the left side of her head and left ear. S8 stated she sustained about 9 to 10 blows to the head and left ear when Patient #1 used her (#1) fist to hit her (S8). Further interview with S8 revealed another MHT was alerted by the patients (who were outside smoking) that S8 needed help because patient #1 was beating S8. S8 stated she did not know how to stop patient #1 from beating her.

Interview, on 10/24/12 at 3:40pm, with S11 MHT revealed she had been attacked twice by Patient #1. S11 thought the attacks took place on 10/18/12 but was not certain. The surveyor questioned S11 MHT what type of training she had received in regard to de-escalation of aggressive/violent patients; she stated the only training she had received was when she worked at a prison and that was Defensive Techniques that she was to use on prisoners.

Interview, on 10/25/12 at 11:05am, with S3 Director of Nursing (DON) confirmed MHTs and RNs had not received training dealing with aggressive/violent patients prior to working with patients. S3 DON agreed by not having all staff members trained in de-escalation techniques this could place all patients and staff in dangerous situations.

Based upon reviews of 2 of 12 (Patient #s 1,6) Psychiatric Evaluations, and staff interview, the psychiatrist failed to evaluate and document patient's assets as evidenced by a lack of documentation. Findings:

Review of patient #s 1 and 6's Psychiatric Evaluations, documented by S4 Psychiatrist on 10/16/12 and 10/15/12 respectively, revealed there failed to be documented evidence S4 evaluated and documented the patient's assets.

Interview with S4 Psychiatrist, on 10/24/12 at 2:50pm, revealed he was unable to assess patient #1's assets because he was scared of her. No explanation as to why patient #6 not evaluated.

Based upon review of 12 of 12 (#s 1-12) patient psychiatric treatment plans/interventions, and staff interviews, the hospital failed to ensure each patient (#s 1-12) received an individualized comprehensive treatment plan as evidenced by the use of pre-printed treatment plans and interventions that were not individualized. Findings:

A) Review of Patient #1's Master Treatment Plan revealed the diagnoses were: Axis I: Schizoaffective Paranoid, acute exacerbation versus Schizoaffective disorder Bipolar.
Problem #1 was identified as "Psychosis" with the Short Term Goal (STG) "Patient will have decrease hallucinations and disorganized thoughts" and Long Term Goal "Patient will achieve optimal level of functioning relative to patient capabilities". Review of pre-printed Treatment Plan revealed "Psychosis" was listed as the problem with the following STGs and interventions:
1) STG: "Patient will have decrease in hallucinations and disorganized thinking. AEB (As Evidenced By): Less attention to internal stimuli. Intervention: Evaluate prescribed meds as needed. Administer meds as ordered, monitor response. Encourage reality orientation. Staff: Nursing and All staff."
2) STG: "Patient will demonstrate increased trust and a decrease in paranoia by 10/22/12. AEB: Increase in interactions with peers and staff. Attend 50% of recreational and therapy groups by 10/23/12. Participate in discussion with therapist on family therapy. Interventions: Provide opportunity to develop 1:1 therapeutic relationship. Provide daily therapy groups. Provide individual therapy PRN (as needed) times a week. Provide exercise and recreational groups daily."
3) STG: "Patient will have 6-8 uninterrupted sleep for 5 nights by 10/22/12." Intervention: "Monitor/record sleep hours."
4) STG: "Patient will comply with medication regimen and report side effects to staff by 10/22/12." Interventions: "Educate on importance of medications and potential side effects."

On 10/19/12, Patient #1 exhibited aggressive and violent behaviors. Patient #1 went out to the smoking area (10/19/12), where she used her fist to hit S8 MHT about the head and left ear.

The treatment plan failed to identify appropriate short term goals and interventions related to the patient's aggressive and violent behaviors that were exhibited on 10/18/12 and 10/19/12. Instead of implementing interventions to redirect these behaviors, the hospital called the local sheriff's office/department in order "to control the patient as the staff were having difficulty controlling her aggressive behaviors"; this information was obtained from an interview, 10/24/12 at 11:15am, with S3 DON.

B) Review of Patient #2's Master Treatment Plan revealed the patient's diagnosis was: Axis I: Bipolar d/o (disorder) type I, Manic. Problem #1: Manic
1) Short Term Goal: "Pt (patient) will have 5 consecutive nights sleep by 10/22/12." Intervention: "Staff will encourage medication compliance"
2) STG: "Pt will have '0' episodes of disrupted behavior by 10/22/12". Intervention: Medication as prescribed to control anxiety. Redirect as needed."
3) STG: "Pt will have decrease in mood disturbance by 10/22/12." Intervention: "Provide daily therapy groups. Provide recreation groups daily and provide exercise at (left blank) level daily."
4) STG: "Pt will exhibit increased control of motor and verbal behavior by 10/22/12." Intervention: "Medication as ordered by physician Administered and monitored by nursing".
5) STG: "Pt will verbalize less preoccupation with delusional thoughts and maintain reality based conversations." Interventions: "Redirect patient to reality based topics. Encourage participation in program activities."

Review of Patient #2's Treatment Plan Review and Update, dated 10/18/12, revealed nursing staff, social services, and AT (activity) service had documented the patient continued to "exhibit symptoms of manic behaviors"; however, there failed to be documentation relative to the interventions for the "manic behaviors".

C) Review of Patient #3's Master Treatment Plan revealed the diagnosis of Depression. Problem #1: Suicidal ideation
1) STG: "Pt will acknowledge presence/absence of suicidal ideation. Interventions: Suicide Precaution as ordered by Physician, Evaluate, prescribe medications, Medications as prescribed to control depression."
2) STG: "Pt will not exhibit any harm to self for (left blank) consecutive days. Interventions: Administer and monitor meds. Staff will encourage medication compliance. Redirect as needed..."
Problem #1: Depression
1) STG: "Pt will have '5' consecutive nights sleep by 10/22/12. Interventions: Evaluate, prescibe medications as needed, and monitor. Administer medications as ordered and monitor response. Educate patient/family regarding medications."
2) STG: "Pt will have increase in energy level by 10/22/12 AEB: Increase in appetite, Increase in group attendance. Interventions: Staff will encourage healthy nutrition and monitor document intake. Provide daily exercise groups."
3) STG: "Pt will participate in 95% of therapy groups by 10/19 to identify coping strategies. Interventions: Provide daily therapy groups, Individual therapy (left blank) x per week."
4) STG: "Pt will hove decrease in mood disturbance by (left blank) AEB (left blank) Interventions: Administer medications as ordered and monitor response. Staff will provide opportunity for 1:1 to develop therapeutic relationship."
5) STG: "Pt will participate in 100% of recreational groups by 10/25/12. Interventions: Provide daily recreational groups, encourage participation and group interactions. Provide exercise at 3 level 5 x per week."
6) STG: "Pt will participate in discussion with therapist regarding family therapy. Interventions: Provide opportunity for family sessions."

D) Review of Patient #4's Master Treatment Plan revealed a diagnosis of Major Depression (Axis I). Short Term Goals and Interventions were the same as for Patient #3 (see above).

E) Review of Patient #5's Master Treatment Plan revealed a diagnosis of Schizophrenia, Paranoid-chronic with acute exacerbation (Axis I). Problem #1 was identified as "Psychosis" (Specify)--left blank .
1) STG: "Pt will have decrease in hallucinations and disorganized thinking. AEB: less attention to internal stimuli. Interventions: Evaluate prescribe meds as needed, Administer meds as ordered, monitor response, Encourage reality orientation."
2) STG: "Pt will demonstrate increased trust and a decrease in paranoia by (left blank). AEB: Increased interactions with peers and staff. Attend 80% of recreational and therapy groups by 10/10/12. Participate in discussion with therapist on family therapy. Interventions: Provide opportunity to develop 1:1 therapeutic relationship. Provide daily therapy groups. Provide individual therapy 'prn' times per week. Provide family therapy 'prn' times per week. Provide exercise and recreational groups daily."

Continued review of patient #5's treatment plan revealed it was the same as patient #1's.

F) Review of Patient #6's Master Treatment Plan revealed the diagnosis was listed as Opiate Abuse along with Benzodiazepine (Axis I). Problem #1: Suicidal Ideation Long Term Goal: "To be free of suicidal ideation and identify strategies for coping when feeling suicidal."
1) STG: "Pt will not exhibit harm to self for 5 consecutive days--10/20/12."
2) STG: "Pt will acknowledge presence/absence of suicidal ideation by 10/20/12. Interventions: Suicide Precautions as ordered by Physician, Evaluate, prescribe medications, Medication prescribe to control depression..." Continued review of Patient #6's treatment plan revealed the remainder was the same as Patient #3's. (see above Patient #3)

G) Review of Patient #7's Master Treatment Plan revealed the patient's diagnoses were: Axis I: Schizophrenia undifferentiated chronic in partial remission and Axis II: Borderline Intellectual Functioning. Problem #1: Aggressive; Problem #2: Impulse Control; and Problem #3: Anxious Mood. Short Term Goals were listed as "No aggression or anxious behaviors in the next 5 days." Further review of the treatment plan revealed 2 (two) pre-printed pages with the first identified as:
I) Psychosis: (Specify): (area left blank).
Short Term Goals:
1) "Patient will demonstrate trust and a decrease in paranoia by 8/11. AEB (As Evidenced By) Increase in interactions with peers and staff. Attend 100% of recreational and therapy groups by 8/12/12, Participate in discussion with therapist on family therapy." Interventions: "Provide opportunity to develop 1:1 therapeutic relationship (Social Worker), Provide daily therapy groups (Social Worker), Provide individual therapy 3 times per week (Social Worker), and Provide exercise and recreational groups daily (Recreational Therapist), and "Patient will comply with medication regimen and report side-effects to staff by 8/12/12."
2) Short Term Goals: "Patient will have 6-8 hours of uninterrupted sleep for 3 consecutive nights by 8/12/12."
3) Short Term Goals: "Patient will perform ADLs (Activities of Daily Living) independently by 8/12/12." Interventions: Assist in preparation of environment before time of ADL activity (Nursing).
4) Short Term Goals: "Patient will comply with medication regimen and report side effects to staff by 8/12/12." Interventions: Educate on importance of medications and potential side effects (Nursing).

II) Bipolar: Manic (the second pre-printed Treatment Plan)
1) Short Term Goals: Patient will have 3 consecutive nights sleep by 8/12/12. Interventions: Staff will encourage medication compliance (Nursing)
2) Short Term Goals: Patient will have "0" episodes of disrupted behaviors by 8/12/12. Interventions: Medication as prescribed to control anxiety. Redirect as needed (Nursing).
3) Short Term Goals: Patient will exhibit increased control of motor and verbal behavior by 8/12/12. Interventions: Medication as ordered by Physician. Administered and monitored by nursing (Nursing).
4) Short Term Goals: Patient will verbalize less preoccupation with delusional thoughts and maintain reality based conversations. Interventions: Redirect patient to reality based topics. Encourage participation in program activities (All Staff).

The treatment plan failed to identify appropriate short term goals and interventions related to the patient's aggressive and violent behaviors that were exhibited on 08/11/12. Instead of implementing interventions to redirect these behaviors, the hospital called the local sheriff's office/department in order to "take the patient to jail" as identified by review of the patient's medical record.

There failed to be documented evidence Patient #7's Treatment Plan was updated to reflect the aggressive/violent behaviors the patient exhibited on 08/11/12.

H) Review of Patient #8's Master Treatment Plan revealed a diagnosis of "Chronic Paranoid Schizophrenia" (CPS). Problem #1: Depression. The Short Term Goals and Interventions were the same as for patient #s 3 and 4.

I) Review of Patient #9's Master Treatment Plan revealed a diagnosis of "Bipolar Disorder, Polysubstance Abuse" and Problem #1 was identified as "Psychosis". Patient #9's treatment plan was the same as patient #s 1, 5 and 7.

J) Review of Patient #10's Master Treatment Plan revealed diagnoses of "Bipolar, Chronic Paranoid Schizophrenic" and the Problems were listed as #1 Depression, #2 Suicidal, and #3 Psychosis. Patient #10's treatment plan was the same as patient #s 1, 2, 3, 4, 5, 6, 7, 8, and 9.

K) Review of Patient #11's Master Treatment Plan revealed a diagnosis of "Schizoaffective Disorder" and Problem #1 was identified as "aggressive behavior as evidenced by (AEB): (decrease) extreme risk of violence by addressing risk factors". Long Term Goal was identified as "identify (illegible word) and symptoms". Short Term Goals: 1) "Pt will experience 5 consecutive days of (decreased) aggressive behavior". Interventions: "Identify issue of anger".; 2) "Decrease extreme risk of violence". Interventions: "(increase) awareness of personal risk factors"; 3) (increase) understanding of risk factors underlying aggression and violence". Interventions: "Link (illegible word) & symptoms of anger c (with) triggers & c ...coping behaviors..."

L) Review of Patient #12's Master Treatment Plan revealed a diagnosis of "Alcohol intox (intoxication)..." Problem #1 was identified as "Depression". The Long Term Goals, Short Term Goals and Interventions were the same as patient #s 3, 4, 8 and 10.

The hospital failed to ensure each patient received an individualized treatment plan for their specific needs. Interview on 10/24/12 at 2:45pm, S3 DON confirmed patients all had pre-printed Master Treatment Plans that were the same for each patient depending upon their diagnosis (i.e. depression: all patients had the same treatment plan, etc).

Based on record review and interview, the hospital failed to meet the Condition of Participation for Special Staff Requirements for Psychiatric Hospitals as evidenced by the failure of the Medical Director and Director of Nursing (DON) to ensure all clinical staff responsible for developing and implementing individualized comprehensive treatment plans and interventions were trained to formulate and implement these plans/interventions. This was evidenced by 12 of 12 patients (#s 1-12, but specifically #s 1,7) with generic plans that failed to include specific focuses and/or needs to customize one intervention from another for the same identified problems. These failures resulted in a lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients improvement and discharge from the hospital. (Refer to B0144 for failures related to the Medical Director; and B0148 for failures related to the DON.)

Based upon reviews of 12 of 12 medical records and interviews, the Medical Director (S4 Psychiatrist) failed to ensure the quality and appropriateness of physician services as evidenced by Master Treatment Plans of 12 of 12 patients identified individualized interventions to address the patients' problems. Findings:

Review of Patients (#s 1-12) Master Treatment Plans revealed pre-printed Master Treatment Plans that were categorized by problems. The plans were placed on individual treatment plan sheets. These plans contained generic and routine functions without specific focuses and/or needs to customize one intervention from another for the same identified problem. These failures resulted in a lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

Interview, 10/24/12 at 2:50pm, with S4 Psychiatrist (Medical Director) revealed when questioned specifically about Patient #1's Master Treatment Plan/Interventions and Psychiatric Evaluation, he replied, he could not complete his assessment of the patient because "she scared me".

On 10/19/12, Patient #1 exhibited aggressive and violent behaviors. Patient #1 went out to the smoking area (10/19/12), where she used her fist to hit S8 MHT about the head and left ear.

The treatment plan failed to identify appropriate short term goals and interventions related to the patient's aggressive and violent behaviors that were exhibited on 10/18/12 and 10/19/12. Instead of implementing interventions to redirect these behaviors, the hospital called the local sheriff's office/department in order "to control the patient as the staff were having difficulty controlling her aggressive behaviors"; this information was obtained from an interview, 10/24/12 at 11:15am, with S3 Director of Nursing.

Patient #1 was handcuffed and transported to Hospital A (a local acute care hospital) by local sheriff's deputies.

Review of Patient #7's medical record revealed she exhibited aggressive/violent behaviors, on 08/13/12, and the staff called the local sheriff's office. Deputies arrived, handcuffed and transported Patient #7 to Hospital A.

Failure of the Medical Director (S4 Psychiatrist) to ensure staff were trained in the development and implementation of individualized treatment/intervention plans contributed to the incidents involving these 2 patients (#1, #7).

Based upon reviews of 12 of 12 medical records (#s 1-12) and interviews, the Director of Nursing (DON) failed to ensure all nursing staff were trained to develop and implement individualized Master Treatment Plans/Interventions as evidenced specifically by patients (#1, #7) who became violent/aggressive and the staff relied upon a local law enforcement agency to control the patients' behaviors by handcuffing and transporting them to a local acute care hospital. Findings:

Review of Patients (#s 1-12) Master Treatment Plans revealed pre-printed Master Treatment Plans that were categorized by problems. The plans were placed on individual treatment plan sheets. These plans contained generic and routine functions without specific focuses and/or needs to customize one intervention from another for the same identified problem. These failures result in a lack of guidance to staff in providing individualized and coordinated treatment, potentially delaying patients' improvement and discharge from the hospital.

On 10/19/12, Patient #1 exhibited aggressive and violent behaviors. Patient #1 went out to the smoking area (10/19/12), where she used her fist to hit S8 MHT about the head and left ear. On the previous night (10/18/12) she (Patient #1) destroyed hospital property by ripping her bed from the wall and breaking the television in the dayroom.

The treatment plan failed to identify appropriate short term goals and interventions related to the patient's aggressive and violent behaviors that were exhibited on 10/18/12 and 10/19/12. Instead of implementing interventions to redirect these behaviors, the hospital called the local sheriff's office/department in order "to control the patient as the staff were having difficulty controlling her aggressive behaviors"; this information was obtained from an interview, 10/24/12 at 11:15am, with S3 Director of Nursing.

Interview, 10/25/12 at 10:30am, with S3 DON revealed when questioned why staff relied on law enforcement individuals to control patient #1 and #7, she had no response. Later, during the same interview, S3 stated she felt patient #1 had a better chance of getting into a State run long-term psychiatric facility if she was in another state hospital (she was referring to a local acute care hospital identified as Hospital A).

Based upon review of policies and procedures, 2 of 12 medical records (#1, #7) and staff interviews, hospital staff failed to implement interventions when patients #1 and #7 exhibited aggressive and violent behaviors that were not controlled by redirection and the administration of anti-psychotic/sedative/hypnotic medications that were ordered by the Psychiatrist. When patient #1's and patient #7's behaviors escalated, which included attacking staff and destroying hospital property, local law enforcement officials were called and the patients were placed in handcuffs, removed from the hospital, and taken to a local acute care hospital for further care of their violent and aggressive behaviors. Findings:

Patient #7:
Review of patient #7's medical record revealed the patient was admitted to the hospital on 08/07/12 under a Physician Emergency Certificate (PEC, dated 08/06/12, timed 6:50 PM). On 08/08/12, a Coroner's Emergency Certificate (CEC) was completed (timed 7:12 AM). According to the CEC, the "History of Present Illness" included "Per PEC, 26 yo (year old) BF (Black Female) presented on an OPC (Order of Protective Custody) that she has been violent and aggressive. Patient reports that she broke out windows in her trailer. Very impulsive behaviors and has multiple hospitalizations. Recently in jail for violent behavior". The CEC further identified the patient was gravely disabled and unable to seek voluntary admission.

Review of the Multidisciplinary Progress Notes revealed from the time of admission on 08/06/12, 1:00 PM to 08/11/12, 8:00 AM, revealed no violent or aggressive behaviors were identified. Further review of the Multidisciplinary Progress Notes revealed the following RN documentation:
08/11/12, 8:35 AM: "Patient in her room screaming and angry because staff will not let her change beds. Patient wants to sleep in another bed because she does not like her bed anymore. Patient began punching the walls and threatened to break windows when staff not compliant with her requests. She began pulling the mattress off her bed and then began to punch window and broke window."
08/11/12, 8:35 AM: "Ativan 2 mg (milligrams)/Haldol 5 mg dose administered for anxiety at 8:30 AM"
08/11/12, 8:50 AM: "Pt (Patient) in day room screaming and threatening staff. Threatening to break TV. Pt. threw chairs around and broke AC (Air Conditioner) cover. States that she rather go to jail than to sleep in that bed."
08/11/12, 8:52 AM: "3 Deputies arrived to make report on the damages made by pt."
08/11/12, 9:15 AM: "Pt. continues to display aggressive bx (behaviors) in front of Deputies. Deputies stated that they will take Pt."
08/11/12, 9:34 AM: "Received a call from (Nurse) at (Hospital A) ER stating that Pt. was brought here. She stated that she has no records. Explained to her that I did not send any records being that I was not transferring Pt. to any facility. As far as I understood, Deputies were taking her to jail."
08/11/12, 11:45 AM: "Patient arrived in handcuffs with Deputy from (Hospital A). Patient is calm and pleasant and apologized to staff for previous behaviors. Patient is no longer aggressive..." The Multidisciplinary Progress Notes failed to identify who contacted, or who instructed the hospital staff to contact, the local sheriff's department.

Further review of patient #7's medical record revealed a form titled "Daily Nurse Flow Sheet Note" dated 08/11/12, Shift: 7A-7P. The RN identified by check mark the interventions provided included "Relaxation techniques; Redirect patient towards appropriate behavior"; however, the RN failed to identify the relaxation and redirection techniques used. Further review of the Multidisciplinary Progress Notes revealed there was a seventeen minute lapse in time from when the patient began exhibiting violent/aggressive behaviors and required the administration of IM anti-psychotic/anti-anxiety medications (8:35 AM) to when sheriff Deputies were present in the hospital (8:52 AM) and allowed to intervene and "take the patient" even though the patient was still under a Coroner's Emergency Certificate. S4 Psychiatrist was notified by telephone the patient was exhibiting aggressive/violent behaviors and anti-psychotic/anti-anxiety medications were ordered; however, there failed to be documentation the Psychiatrist was notified the medications were ineffective prior to the patient being taken by the Sheriff Deputies.

Patient #1:
Review of patient #1's medical record revealed the patient was admitted to the hospital on 10/16/12 at 1:00 PM, with the diagnosis of Schizophrenia. The patient was placed on a Physician Emergency Certificate (PEC dated 10/15/12, timed 4:54 PM) and a Coroner's Emergency Certificate (CEC dated 10/16/12, timed 7:10 PM). According to the CEC "History Of Present Illness" it was identified "Per PEC 38 yo (year old) BF (Black Female) presented with a history of violent behavior. Patient is very labile and behaviors is threatening. She is paranoid and delusional." The CEC also identified the patient was gravely disabled and unable to seek voluntary admission.

Review of the Multidisciplinary Progress Notes from 10/16/12 through 10/19/12 revealed documentation by the RN the patient exhibited auditory hallucinations, physical aggression and violent behaviors that included attacking the staff. The patient was administered the anti-psychotic medication Haldol 5 milligrams and the sedative/hypnotic medication Ativan 2 milligrams Intramuscular (IM) on 10/17/12, 12:40 AM and 10/18/12 7:50 AM. On 10/16/12, 6:40 PM; 10/18/12 8:50 AM; 10/19/12, 7:30 AM, Haldol 10 mg and Ativan 2 mg were administered IM. On 10/18/12 at 1:00 PM, Thorazine 50 milligrams was administered IM.

Further review of the Multidisciplinary Progress Notes revealed the following:
10/19/12, 2:00 AM: "Continues with yelling and screaming with delusional and paranoid thoughts. Remains isolated to room with constant redirection towards appropriate behavior. Continue to monitor"
10/19/12, 8:16 AM: "Patient with no sleep hrs (hours) this shift. Remains with psychotic behavior, aggressiveness, agitation and irritability..."
10/19/12, 9:00 AM: "Patient psychotic; fighting staff and peers; screaming on top of her voice; hallucinating; labile. Gave her Ativan 2 mg and Haldol 10 mg IM at 7:30 PM. Hitting staff; pacing the floors; aggressive; hostile. (Local police department) was notified for pt. assaulting staff and pt was escorted by police to (Hospital A) Emergency Room to be PEC." The patient was already under a PEC, initiated on 10/15/12 at 4:54 PM and a CEC that was initiated on 10/16/12 at 7:10 PM. There failed to be documentation by the RN why the patient required another PEC.

Review of the form titled "Daily Nurse Flow Sheet Note" dated 10/19/12, Shift: 7A-7P revealed S10 RN identified "N/A" for "Interventions Provided: Relaxation techniques; Redirect patient towards appropriate behavior; Isolate patient to less stimulated setting; MD contacted; Seclusion order received" and "Meds Refused; PRN Med; Reason; and Other".
Review of the physician orders revealed on 10/19/12 at 8:35 AM, S4 Psychiatrist gave S10 RN verbal orders for "Thorazine 100 milligrams IM stat x (times) 1 dose". At 8:44 AM on 10/19/12 S10 RN documented on the physician orders "Clarification of orders: OK to give Thorazine 100 mg IM stat x 1 dose with Geodon".

Interviews with S12 RN on 10/23/12 at 1:20 PM, S7 MHT on 10/24/12 at 10:40 PM, S11 MHT on 10/24/12 at 3:40 PM, and S8 MHT on 10/25/12 at 10:15 AM, revealed when asked if they had utilized any type of restraint or seclusion at this hospital, all replied "no".

Interview with S19 Licensed Practical Nurse (LPN) on 10/24/12 at 9:00 AM revealed when asked about patient #1's behaviors on 10/19/12, S19 LPN replied the night before (10/18/12) the patient broke the TV and continued with aggressive/violent behaviors on the morning of 10/19/12. The Psychiatrist was called and Thorazine 100 mg IM was ordered by the Physician "stat" (there failed to be documentation in the medical record the patient received the stat dose of Thorazine). When asked about the Sh