HospitalInspections.org

Based on record review and interview, the Governing Body failed to:

I. provide a safe physical environment for suicidal and self- harm patients on the Latency and Adolescent units as evidenced by: A. bedroom risks, such as: sharp edges on metal window frames in six of 16 adolescent bedrooms, removable plastic mattress covers on 26 of 50 mattresses, and large drawers under 50 of 50 beds. B. bathroom risk, such as: metal expansion shower rods in seven of nine showers, and eleven of eleven residential lifting toilet seats in patient bathrooms.
C. therapy and service areas risks, such as: two patient accessible hand sanitizer wall dispensers, accessible pencils without a monitoring inventory processes in three of three activity rooms, 28 of 28 light weight desks and chairs in three activity rooms, accessibility behind one of two nursing stations. (Refer to Tag A-144)

II. ensure a separation was maintained for operational and quality matters, such as Governing Board meeting minutes, quality data and initiatives to include, but limited to: restraint and seclusion management, infection control data and program initiatives between the two facilities owned by the company: an acute facility and a PRTF (Psychiatric Residential Treatment Facilities) with separate CMS provider numbers. (Refer to finding below).

III. ensure policies were approved and appropriate for the specific services and functions provided by the hospital for a sample of three of three policies reviewed. (Refer to finding below).

IV. ensure the Quality Improvement Program included measurable quality indicators for high risk, problem prone areas, monitored effectiveness and safety,Governing Body approved data frequency and collection details, data was tracked and analyzed, preventative actions implemented, lessons learned communicated, and annual improvement projects developed in areas such as staffing and turnover rates, environmental sanitation, incidents and grievance report evaluation, restraint / seclusion /timeout evaluation and infection control, aggressive patients and safety concerns. (Refer to Tag A-0263).

V. ensure a policy was implemented that required direct formal consultations to be conducted with the Governing Body (or their designee) and the director of the Medical Staff (or staff responsible for the organization and conduct of the medical staff) on topics including, but not limited to: scope and complexity of hospital services, patient population serviced, identified issues with patient safety, such as patient aggression and restaint and seclusion and quality that required participation and input of the Medical Staff at minimum biannually, and conduct consultative sessions per policy. (Refer to Tag A-0053).

VI. ensure the hospital had a transfer agreement with a facility to provide services not available at the hospital and seven of seven clinical contracts were evaluated for adherence to standard of care, safety and effectiveness and expiration. (Refer to tag A-0083 and Tag A-0084).

VII. appoint a qualified Infection Control Preventionist, who provided oversight for an effective Infection Control Program which included surveillance, reporting of findings and quality improvement initiative in accordance to acceptable standards of practice to improve health outcomes in the areas such as environmental sanitation, patients lying on the floor, patients laundering personal clothing, skin infections, and wound management. (See Tag: A-0747).

VIII. ensure policies and procedures were specific to services provided for the immediate assessment of emergency conditions, initial treatment, transfer and qualified/competent RNs capable of initial triage and assessment of patients experiencing a medical emergency. (Refer to Tag A-0093)

IX. to maintain oversight of grievances and designate a Grievance Committee in writing responsible for implementing and maintaining an effective grievance process. (Refer to Tag A-0119)

These failed practices:

I. resulted in an Immediate Jeopardy to patients' health and safety, resulted in a sample of 34 incidents that involved hazardous physical environmental items, and had the likelihood to result in increased risk of strangulation, suffocation, crushing injuries, other physical injuries for the 20 adolescent patients and four latency patient currently being monitored for suicidal and self- harm behavior.

II. had the likelihood to provide services that were incongruent with the 2017 CMS communication which stated PRTFs:
* are never a hospital or a part of a hospital. Some are owned by hospital entities, but they are never a part of the hospital. A hospital entity may own a separately certified PRTF.
* a co-located PRTF must be a separate distinct entity.
* a PRTF co-located with a hospital, or psychiatric hospital must never behave as a unit of the hospital.

III. had the likelihood for the staff not implementing the standards of practice expectations of the Governing Body for the services the hospital provided.

IV. had the likelihood for improvement opportunities not to be identified, analyzed for causes, and the implementation of preventative measures to improve patient outcomes.

V. resulted in the lack of action plans being developed regarding the scope and complexity of hospital services, patient populations serviced, the identification of patient safety and quality issues, and had the potential for other issues that required Medical Staff input to go unrecognized, unpursued, and result in missed quality opportunities to improve patient outcomes.

VI. resulted in the omission of one essential contract and seven contracts that were not evaluated as part of the hospital's quality improvement program, and had the likelihood of other contracts not to be evaluated for effectiveness and adherence to national standards of practice.

VII. had the likelihood for the Infection Control Program to lack effectiveness in areas, such as: development, surveillance, investigation of issues, implementation of preventative and control measures for the approximately 47 latency and adolescent patients who receive care daily.

VIII. had the likelihood to increased risk to patient safety and adverse health outcomes to all patients who were in need of emergent medical care at the psychiatric facility.

IX. had the likelihood for grievances not to be evaluated comprehensively and the Governing Body to be unaware of patient care issues and hospital performance concerns.

Findings:

II. Separation of Acute Facility and a PRTF

On 06/08/18 at 11:14 am, Staff A stated the owner of the acute hospital (being surveyed) also owned a residential treatment facility (PRTF) at a nearly location. Staff A stated each facility had separate CMS provider numbers, and operated under the same Governing Body.

A review of CMS guidelines titled, "PRTF vs Hospital, Psychiatric hospital, CAH programs (date 05/31/17)" documented PRTFs are never a hospital or a part of a hospital. Some are owned by hospital entities, but they are never a part of the hospital. A hospital entity may own a separately certified PRTF. A co-located PRTF must be a separate distinct entity. A PRTF co-located with a hospital, or psychiatric hospital must never behave as a unit of the hospital.

A review of two of two Board Meeting Minutes from 03/17 to 06/18 and four of four Leadership Meeting Minutes from 07/17 to 06/18 showed Quality Assurance- Performance Improvement (QAPI) discussions, such as staffing and turnover rates, environmental sanitation, incidents and grievance report evaluation, restraint / seclusion /timeout evaluation and infection control, aggressive patients and safety concerns. The data and discussions combined quality information from the PTRF and the Acute care Unit.

On 06/21/18 at 9:08 am, Staff B stated the data for the Quality information and Infection Control Report was based on the combined information from the acute hospital and residential facility, which did not function under the acute hospital's CMS provider number.

III. Policies

Review of hospital policy titled "Patient Supervision, dated 11/01/12" showed the policy included a header "Willow Crest Hospital, Inc./Moccasin Bend Ranch. The policy failed to provide evidence the policy was specific to the acute care psychiatric hospital and was approved by the Governing Body.

Review of hospital policy titled "Competency of Clinical Staff, dated 03/02/10" showed the policy included a header "Willow Crest Hospital, Inc./Moccasin Bend Ranch and stated "the governing policy of Willow Crest Hospital/Moccasin Bend Ranch ..." The policy failed to provide evidence the policy was specific to the acute care psychiatric hospital and was approved by the Governing Body.

Review of hospital policy titled "Orientation, dated 02/01/17" showed the policy included a header "Willow Crest Hospital, Inc./Moccasin Bend Ranch and stated "all employees of Willow Crest Hospital/Moccasin Bend Ranch ..." The policy failed to provide evidence the policy was specific to the acute care psychiatric hospital and was approved by the Governing Body.

On 06/21/18 at 9:08 am, Staff B stated policies were not specific to the acute care psychiatric hospital or approved by the Governing Body.

Based on interviews and observations, the hospital failed to:

I. provide a safe physical environment for suicidal and self- harm patients on the Latency and Adolescent units as evidenced by: A. bedroom risks, such as: sharp edges on metal window frames in six of 16 adolescent bedrooms, removable plastic mattress covers on 26 of 50 mattresses, and large drawers under 50 of 50 beds. B. bathroom risk, such as: metal expansion shower rods in seven of nine showers, and eleven of eleven residential lifting toilet seats in patient bathrooms.
C. therapy and service areas risk, such as: two patient accessible hand sanitizer wall dispensers, accessible pencils without a monitoring inventory processes in three of three activity rooms, 28 of 28 light weight desk and chairs in three activity rooms, accessibility to behind one of two nursing stations. (Refer to Tag: A-0144)

These failed practices posed an Immediate Jeopardy to patients' health and safety, resulted in 34 incidents (random sampling) involved hazardous physical environmental items, and had the likelihood to result in increased risk of strangulation, suffocation, crushing injuries, other physical injuries for the 20 adolescent patients and four latency patient currently being monitored for suicidal and self- harm behavior.

On 06/20/18 at 12:26 pm, the CEO and members of the hospital leadership team were notified of the Immediate Jeopardy conditions identified in Latency and Adolescent units, therapy, and service areas.

On 06/29/18 at 12:30 am, the hospital submitted written plan of removal consisting of the following:
* replacement of all mattresses that had loose plastic coverings with new mattresses with fitted washable covers.
* removal of all shower curtains and rods (all bathrooms were private and designed as wet rooms) and new anti-ligature shower rods were purchased.
* hinged toilet seats were modified and adhered to toilet base.
* 50 drawers under 50 beds were removed and the space under the bed was enclosed.
* sharp edges on the windows were smoothed and wood frames were installed to cover edges.
* light-weight chairs were removed from the Craft Room
* light-weight desk and chairs were replaced with heavy-weight tables with attached seating in the Latency and Adolescent classrooms.
* hand sanitizers were removed from the halls and a process was developed for alternatives to comply with proper hand hygiene.
* locked doors were placed to enclose the adolescent nursing station.
* pencils were counted, logged, and monitored.

The Governing Body approved the hospital's Plan of Removal which included the physical changes listed and also designated specific staff to monitor the elements of the plan at defined times and instructed staff as to how to communicate findings. The plan included a 90 day formal reassessment of changes and new processes.

06/29/18 at 12:30 pm, the surveyors accepted the Plan of Removal.

On 06/29/18 at 12:55 am, the surveyors verified the hospital's Plan of Removal of the immediacy by:
A. Observation
* observed the replacement of all mattresses that had loose plastic coverings with new mattresses with washable covers.
* observed the removal of all shower curtains and rods (all bathrooms were private and designed as wet rooms) and new anti-ligature shower rods purchased.
* observed the hinged toilet seats were modified and adhered to toilet base.
* observed drawers under beds were removed and the space under the bed was enclosed.
* observed sharp edges on the windows were smoothed and wood frames were installed to cover edges.
* observed the light-weight chairs were removed from the Craft Room
* observed the light-weight desk and chairs were replaced with heavy-weight tables with attached seating in the Latency and Adolescent classrooms.
* observed hand sanitizers were removed from the halls and a process was developed for alternatives to comply with proper hand hygiene.
* observed locked doors were placed to enclose the adolescent nursing station.
* observed the log sheet for pencils to be counted, logged, and monitored.
* observed adolescent laundry room locked.

B. Interview with leadership stated the following monitoring and reporting plan:
* Nursing staff to check mattresses and under bed enclosure weekly to ensure mattresses were risk free and report identified risks to the Director of Plant Operations. The Director of Plant Operations to perform monthly inspection to evaluate mattresses and under bed enclosure risks.
* Housekeeping staff to inspect showers for risks at each cleaning and will train to identify risk. Director of Plant Operations will perform monthly inspections for shower risks.
*Housekeeping staff to inspect toilet for potential risks at each cleaning. Director of Plant Operations will perform monthly inspections for toilet risks.
* Administration with monitor all area at minimum three times a day for potential throwing risks.
* Nursing will dispense hand sanitizer and administration with monitor all area at minimum three times a day for compliance and self-harm risks.
* Charge Nurses trained to keep nursing station doors locked at all times, and administration with monitor all area at minimum three times a day for compliance and self-harm risks.
* Medication nurse will verify pencil counts were being performed at end of each shift.

II. ensure oversight of grievances and appointment of the Grievance Committee by the Governing Body, promptly initiate investigation grievances that alleged abuse for three (Patient #21 and 22 [02/07/18, 02/10/18]) of three grievances, and provide written responses of the investigational process, results of the investion, date(s) of completion and name of hospital contact to the minor patient's parent(s) or guardian for a sample of 23 of 23 grievances reviewed.

These failed practice resulted in the likelihood for two (Patient #21 and 22 [02/07/18, 02/10/18]) patients to remain in a situation that increased emotional distress and the potential for adverse health outcomes, and 23 patients' parent(s) or guardians who did not receive written notification of the hospital's investigation, results, and date(s) of completion, of the minor patient's grievance.

E. ensure when chemical restraints, physical managment and/or seclusion where used:

I. the patient's plan of care was revised for a sample of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 10, 12, 14, 15, 17, 18, and 20) of 14 patients.
II. nursing staff notified the physician as soon as possible for an order for physical management, chemical restraint and/or seclusion for four (Patient #1, 6, 17 and 18) of 14 adolescent patients.
III. a qualified RN completed the one hour face-to-face evaluation for a sample of five (Patient #3, 4, 6, 15, and 18) of 14 patients.
IV. a comprehensive physical/medical condition and behavioral asssessment per CMS regulations was performed and documented for 26 26 (Patient #1, 4, 5, 7, 17, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40) of 26 patients
V. nursing staff documented the description of patients behavior requiring restraint/seclusion, and response to the intervention for one (Patient #4) of a sample of 14 patients.

This failed practice had the likelihood to result:

I. increased risk for emotion distress and injury for 14 (Patient #1, 2, 3, 4, 5, 6, 7, 10, 12, 14, 15, 17, 18, and 20) patients when chemical restraint, seclusion and/or physical management were utilized, and the potential for increased risk to patient safety and emotional distress for all pediatric psychiatric patients admitted to the hospital when chemical restraint, seclusion and/or physical management were used.

II. in the misuse of seclusion for four (Patient #1, 6 17, and 18) adolescent patients and increased the risk of emotional distress and potential adverse health outcomes.

III. in a delay in recognition of changes in the patient's physical and behavioral condition and increased risk of restraint, seclusion and physical management misuse for five (Patient #3, 4, 6, 15 and 18) patients, and the potential for restraint misuse and adverse health outcomes for all pediatric and adolescent psychiatric patients requiring the use of restraints, seclusion and/or physical management.

IV. in contributing factors to patient's violent or self-destructive behavior to go unrecognized and treated and result in adverse health outcomes for 26 (Patient #1, 4, 5, 7, 17, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, AND 40) of 26 chemical restraint, seclusion and/or physical management patient records reviewed.

V. in misuse and adverse health outcomes for one (Patient #4) patient for whom chemical restraints, seclusion and/or physical management interventions were utilized.

Based on record review and interview, the hospital failed to ensure the Quality Improvement Program (QAPI) was effective and data driven with no evidence of QAPI discussions in two of two Board Meeting Minutes from 03/17 to 06/18 and four of four Leadership Meeting Minutes from 07/17 to 06/18.

This failed practices had the likelihood for improvement opportunities not be identified, causes analyzed, no implementation of preventative measures to improve patient outcomes in areas such as staffing and turnover rates, environmental sanitation, incidents and grievance report evaluation, restraint/seclusion /timeout/physical management evaluation and infection control, aggressive patients and safety concerns.

Findings:

I. Separation of acute facility and a PRTF

A review of two of two Board Meeting Minutes from 03/17 to 06/18 and four of four Leadership Meeting Minutes from 07/17 to 06/18 showed QAPI data for staffing, morale, incidents, grievances, and infection control surveillance which included both information from the the acute hospital and the company's PTRF.

On 06/21/18 at 9:08 am, Staff B stated the data for the Quality information and Infection Control Report was based on the combined information from the acute hospital and residential facility, which did not function under the acute hospital's CMS provider number.

II. Quality Program

On 06/18/18 at 2:30 pm, surveyors requested the hospital quality improvement plan for 2018, and the document titled, "Leadership Management (no date)" was provided. The document showed that annual performance improvement review should be completed and incorporated in the budget package. The document showed "The Leadership Committee (Management Team)" functions included assessing and monitoring services, establishing performance improvement priorities, overseeing the implementation of plan, a written plan should be formulated, and systems should be evaluated for effectiveness. The document showed the Governing Body was responsible for supervising and "respond[ing]" to the process. The surveyors found no evidence the hospital fulfilled the expectations for quality improvement as outlined in the "Leadership Management" document.

A review of a document titled, "Vizion Health Oklahoma LLC-Board Meeting Minutes dated 03/20/17 and 06/01/17" (no meeting minutes provided for 2018) showed broad discussions regarding staffing and turnover rates, restraints, and seclusion, but there was no documentation of improvement initiatives were developed, measured, monitored, tracked, and analyzed.

A review of documents titled, "[Leadership] Meeting Minutes dated 05/17/18, 03/15/18, 10/26/17, and 07/27/17" showed minimal monitoring of data and broad discussions without evidence of analyses and the development of goals and action plans regarding staffing and turnover rates, infection control, environmental sanitation, incidents reports, aggressive patients and safety concerns.

On 06/18/18 at 11:14 am, Staff B stated quality matters were discussed in the Leadership meetings. Staff B and Staff A stated the Governing Body did not participate in the Leadership meetings, but stated there was a meeting conducted at 9:30 am each weekday via telephone in which the Governing Body was represented. When the surveyor requested meeting minutes for this meeting, Staff A stated no formal minutes were taken. Staff A provided informal noted from 06/11/18 to 06/27/18. The notes documented "discussed projects", and "discuss progress on policies", and the information was insufficient enough to determine the Governing Body's participation in the hospital's quality efforts.

On 06/27/18 at 2:02 pm, Staff A stated he/she reviewed incident reports and staff complaints about double charting (documenting in the medical record and on the incident report). Staff A stated the documentation of incident follow-up required improvement.

On 06/27/18 at 11:40 am, Staff B stated the hospital had conducted no formal quality improvement projects, but had initiatives to improve the physical environment.

Based on interviews and observations, the hospital failed to:
I. provide safety features in the bedrooms, bathrooms, therapy, and service areas for the psychiatric latency and adolescent patient as evidenced by:
* bedroom risks, such as: sharp edges on metal window frames in six of 16 adolescent bedrooms, removable plastic mattress covers on 26 of 50 mattresses, and large drawers under 50 of 50 beds. * bathroom risk, such as: metal expansion shower rods in seven of nine showers, and eleven of eleven residential lifting toilet seats in patient bathrooms..
* therapy and service areas risk, such as: two patient accessible hand sanitizer wall dispensers, accessible pencils without a monitoring inventory processes in three of three activity rooms, 28 of 28 light weight desk and chairs in three activity rooms. (Refer to Tag A-0144 and A-0701)

II. restrict the adolescent patients from the hazards associated with laundering their own clothing, and adolescent patients having access to behind the nursing station with risks associated with office supplies. (A-0701)

These failed practices posed an Immediate Jeopardy to patients' health and safety, resulted in 34 incidents (random sampling) involved hazardous physical environmental items, and had the likelihood to result in increased risk of strangulation, suffocation, crushing injuries, other physical injuries for the 20 adolescent patients and four latency patient currently being monitored for suicidal and self- harm behavior.

Based on record review, interview, and observation, the hospital failed to:

I. appoint a qualified Infection Control Preventionist to develop and implement initiatives for an effective Infection control Program. (Refer to Tag: A-0748)

II. develop, implement, and maintain, an infection control program and report the effectiveness of initiatives for infection control risks including, but not limited to, environmental sanitation, patients lying on floor, patient personal clothing laundering, lice management, and skin infection and wound management with no evidence of infection control- quality assurance performance improvement (QAPI) discussions in two of two Board Meeting Minutes from 03/17 to 06/18 and four of four Leadership meeting minutes from 07/17 to 06/18. (Refer to Tag A-0749)

These failed practices had the likelihood for the Infection Control Program to lack effectiveness in areas, such as: development, surveillance, investigation of issues, implementation of preventative and control measures for the approximately 47 latency and adolescent patients who receive care daily.

Based on record review and interview, the hospital failed to:
I. ensure an organ, tissue, and eye procurement policy was developed and addressed the facility's responsibilities to include, but not limited to timely notification within one hour of the patient's death, definition of imminent death per CMS requirements, and the organ procurement agreement and staff training requirements. (Refer to Tag A-0885)

II. ensure five (Staff H, M, V, BB, and CC) of five RN staff had organ, tissue, and eye procurement training which included the required CMS curriculum. (Refer to Tag A-0891).

These failed practices had the likelihood for procurement opportunities to be missed for any patients who expired due to the lack of established processes and staff training.

1.Based on record review, document review, and interviews, the facility failed to provide ongoing physician assessment, evaluation, and treatment to ensure that three (3) of eight (8) active sample patients could achieve their optimal level of function (Patients A4, A6, and A8). Specifically, the facility followed a policy that specified the psychiatrist would see patients once weekly when moved to Acute 2 status. The facility failed to take into account the acuity of the patient or their individualized needs for psychiatric treatment. Failure to provide psychiatric evaluation and treatment on an ongoing basis can delay recovery of acutely ill patients. (Refer to B125)

2. Based on record review, policy review, and interview the facility failed to provide social work assessments that met professional social work standards, including conclusions and recommendations that described anticipated social work roles in treatment and discharge planning. (Refer to B108)

3. Based on medical record review, document review, and interview, the facility failed to provide treatment plans that identified patient-related, short-term and long-term goals documented in observable, measurable, behavioral terms (Refer to B121)

Based on record review and interview, the Governing Body failed to ensure:

I. a policy was implemented that required formal consultations to be conducted with the Governing Body (or their designee) and the director of the Medical Staff (or staff responsibile for the organization and conduct of the medical staff) on topics including, but not limited to: scope and complexity of hospital services, patient population serviced, identified issues with patient safety and quality that required participation and input of the Medical Staff at minimum biannually.

II. consultative sessions were conducted between the Governing Body (or their designee) and the director of Medical Staff as per policy.

These failed practices resulted in the lack of action plans being developed regarding the scope and complexity of hospital services, patient populations serviced, the identification of patient safety and quality issues, and had the likelihood for other issues that required Medical Staff input to go unrecognized, unpursued, and result in missed quality opportunities to improve patient outcomes.

Findings:

I. Policy

On 06/18/18 at 11:45 am, the surveyors requested a policy that designated the requirements of formal consultations between the Governing Body and the director of Medical Staff, topics to include, but not limited to: scope and complexity of hospital services, patient population serviced, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff, and none was provided.

A review of the " Medical Staff By-laws (dated 08/17)" showed the duties and responsibilities of the Director of the Medical Staff did not include formal consultative sessions with the Governing Body at minimum biannually.

On 06/20/18 at 10:20 am, Staff A stated the hospital had no documentation of formal consultative sessions between the Governing Body and the director of the Medical Staff.

II. Consultative Sessions

A review of a document titled, "Vizion Health Oklahoma LLC-Board Meeting Minutes dated 03/20/17 and 06/01/17" showed no documentation regarding formal consultative sessions between the Board and the director of Medical Staff regarding scope and complexity of hospital services, patient population serviced, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff.

On 06/12/18 at 11:45 am, Staff A, (CEO) stated the President of Medical Staff met informally in his/her office regarding quality matters. The surveyors requested the documentation of these informal meetings or evidence of quality initiatives; none was provided.

Based on record review and interview, the Governing Body failed to ensure:

I. the hospital had a transfer agreement with a facility to provide services not available at the hospital.

II. seven of seven clinical contracts were evaluated in accordance with standards of practice and two of seven contracts were up-to date.

These failed practices resulted in the omission one essential contract and seven contracts that were not evaluated as part of the hospital's quality improvement program, and had the likelihood of other contracts to not be evaluated for effectiveness and adherence to national standard of practice.

Findings:

I. Transfer Agreement

On 06/18/18 at 11:45 am, the surveyors requested the "Transfer Agreement" with another facility that provided services unavailable at their hospital, such as those of a higher level of service. No agreement was provided.

A review of a document titled, "Willow Crest Hospital, Inc. Vendor/Contract Services 2017" showed "Integris Baptist- Medical Services" , but failed to indicate the type of services provided.

On 06/20/18 at 10:20 am, Staff A stated although "Integris Baptist- Medical Services" was listed on the contract list, the hospital had no formal transfer agreement with another facility.

II. Current Clinical Contracts

A review of a document titled, "Vizion Health Oklahoma LLC-Board Meeting Minutes dated 03/20/17 and 06/01/17", showed no discussions regarding the evaluation of contracted services.

A review of documents titled, "[Leadership] Meeting Minutes dated 05/17/18, 03/15/18, 10/26/17, and 07/27/17" showed the attachment of "Willow Crest Hospital, Inc. Vendor/Contract Services 2017". Only 03/15/18 minutes contained information regarding clinical contracts, and documented "vendor list discussed", but no evidence contracted services were evaluated for effectiveness.

A review of a document titled, "Willow Crest Hospital, Inc. Vendor/Contract Services 2017" listed the name of the companies and service type. The document failed to list the current linen vendor (Superior Linen), and listed an expired contract of DLO (Diagnostic Laboratory of Oklahoma) (expired 08/07).

On 06/27/18 at 10:50 am, Staff E stated contracts were discussed, but not formally evaluated in Leadership Meetings.

On 06/18/18 at 11:14 am, Staff B stated linen service had changed from Healthcare Linen Specialist to Superior Linens.

Based on record review and interview, the Governing Body failed to assess services under contracts and ensure the hospital had a transfer agreement with a facility to provide services not available at the hospital, seven of seven clinical contracts were evaluated for safety, and effectiveness and two of seven contracts were up-to-date.

These failed practices resulted in the omission of one essential contract and seven contracts that were not evaluated as part of the hospital's quality improvement program, and had the likelihood of other contracts not to be evaluated for effectiveness and adherence to national standards of practice.

Findings:

A review of a document titled, "Vizion Health Oklahoma LLC-Board Meeting Minutes dated 03/20/17 and 06/01/17", showed no discussions regarding contracted services.

A review of documents titled, "[Leadership] Meeting Minutes dated 05/17/18, 03/15/18, 10/26/17, and 07/27/17" showed the attachment of "Willow Crest Hospital, Inc. Vendor/Contract Services 2017". Only the 03/15/18 minutes contained information regarding clinical contracts and documented "vendor list discussed", but no evidence of the evaluation of contracted services.

A review of a document titled, "Willow Crest Hospital, Inc. Vendor/Contract Services 2017" listed the name of the companies and service type. The document failed to list the current linen vendor (Superior Linen), and listed an expired contract of DLO (Diagnostic Laboratory of Oklahoma) (expired 08/07).

On 06/18/18 at 11:14 am, Staff E stated contracts were discussed in Leadership Meetings, but many contracts had not been evaluated for safety and effectiveness.

On 06/18/18 at 11:14 am, Staff B stated linen service had changed from Healthcare Linen Specialist to Superior Linens, and Staff BB stated the Infection Control Preventionist had not toured and evaluated the current linen service.

Based on record review and interview the Governing Body failed to ensure policies and procedures were specific to services provided for the immediate assessment of emergency conditions, initial treatment and referral or transfer from the psychiatric facility with no dedicated emergency services, including, but not limited to: medical and nursing qualifications, competency, responsibilities, and the availability of necessary equipment/

These failed practices had the likelihood to increase the risk to patient safety and adverse health outcomes to all patients who were in need of emergent medical care at the psychiatric facility.

Findings:

Review of hospital document titled "Physical Health Emergencies, dated 07/25/16" failed to include but not limited to the following:
*identify steps and responsibilities for medical and nursing staff which included initial triage and assessment for patients, staff and/or visitors who experienced a medical emergency.
*identify the qualifications, training and competency requirements for RNs to perform the initial appraisal and referral or transfer of patients.
*identify equipment necessary for response to a potential medical emergency.

On 06/18/18 at 2:43 pm, Staff B stated the hospital did not have policies and procedures for management of patients or visitors who may experience an emergent medical condition. Staff B stated the hospital did not have a room that was used to triage a patient experiencing an emergent medical condition. Staff B stated there was no medical equipment for potential medical emergencies except for the defibrillator that was maintained in the medication room.

Based on record review and interview the Governing Body failed to maintain oversight of grievances and designate a Grievance Committee in writing responsible for implementing and maintaining an effective grievance process.

This failed practice had the likelihood for grievances not to be evaluated comprehensively and the Governing Body to be unaware of patient care issues and hospital performance concerns.

Findings:

Review of hospital policy titled "Grievance, dated 10/16/14" showed the Grievance Committee included the Director of Patient Care Services and the Director of Clinical Services or their designee. The policy failed to show the policy and the Grievance Committee had been approved by the Governing Body.

On 06/18/18 at 11:17 am, Grievance Committee Meeting Minutes were requested by surveyors. None were provided.

On 06/26/18 at 11:47 am, Staff B stated the Grievance Committee included the Director of Nursing, Director of Clinical Services, CEO, and Director of Quality. Staff B stated the committee had not be approved or designated in writing by the Governing Body. Staff B stated the Grievance Committee was not a regular committee that met to discuss grievances and minutes were not taken.

Based on record review and interview the hospital failed to promptly initiate a review and investigation for grievances that alleged abuse for three (Patient #21 and 22 [2/07/18, 02/10/18]) of three patient grievances.

This failed practice resulted in the likelihood for three (Patient #21 and 22 [02/07/18, 02/10/18]) of three patients to remain in a situation that increased emotional distress, and the potential for physical and emotional injury and adverse health outcomes.

Findings:

Review of hospital policy titled "Grievance, dated 10/16/14" showed grievances were reviewed utilizing a three level process. Allegations of physical or emotional mistreatment would bypass the grievance process and be immediately reported by a staff member.

Review of Patient #21's Grievance form showed the event occurred on 08/16/17 on the latency unit when Patient #21 hit a staff member with his/her jacket and the staff member "shoved patient against the wall". Grievance was filed on 08/17/17 and was reviewed by the charge nurse (name illegible). Grievance not reviewed until 08/21/17 (five days later). Investigation included review of video, interview of "staff, patient and witnesses", "spoke to patient at length about incident" and "spoke to administration and human resources". Actions taken included, "reviewed principles of ProACT with employee and handled per human resources policy" and "additional retraining completed with staff". There was no evidence of the following:
*Date, time name, title and content of staff interviewed.
*Date, time, name, title and content of witnesses interviewed.
*Date, time, and content of patient interviewed.
*Date, time, name, title and content of administrative staff interviewed.
*Date, time, name, title and content of human resource staff interviewed.
*Date, time, and what actions were taken per human resources policy.
*Identification of additional training provided, staff who were required to attend, date and time training was completed.

Review of Patient #22's Grievance form showed the event occurred on 02/07/18 on the adolescent unit. Patient #22 stated he/she "did not feel safe here because peers were bullying him/her ...not able to do treatment ...staff tolerating it." Reviewed by Staff HH (Adolescent Unit Charge Nurse) who talked to the patient and forwarded grievance to the Director of Nursing. Grievance was reviewed by Staff C (DON) who spoke to patient "about her feelings of not being safe" and "discussed coping techniques and to discuss feelings with staff at the time they occur". There was no evidence of the following:
*Date and time patient was interviewed.
*Date, time, name, title and content of staff interviewed.
*Date, time, name, and content of any witnesses interviewed.
*Date, time and actions taken to protect patient from other patients and provide a therapeutic environment for treatment.
*Date, time, and identification of specific coping techniques discussed with patient.

Review of Patient #22's Grievance form showed the event occurred on 02/10/18 on the adolescent unit. Patient #22 stated another peer touched him/her inappropriately and made him/her uncomfortable. Grievance was filed on 02/12/18 and was sent to a Grievance Coordinator Staff EE who spoke to the patient. Patient #22 stated the peer touched him/her in their private area under the table during group. Staff EE "encouraged patient to notify staff immediately if this ever happened again so it could be handled appropriately." Staff EE notified staff to "ensure this does not occur again". There was no evidence of actions taken to ensure the patient's safety, and the date/time and identification of staff who were notified of this event.

On 06/27/18 at 10:30 am, Staff B stated grievances that may be related to allegations of abuse should be directed to administration. Staff B stated he/she agreed there was no way to identify from the documentation on Patient #21's grievance form that the patient was shoved or not. Staff B stated grievances are not signed until the grievance investigation had been completed. Staff B agreed there was no way to identify when the grievance was received by administration and investigation initiated for Patient #21 and Patient #22.

Based on record review and interview the hospital failed to provide written responses of the investigational process, results of the investigation, date(s) of completion, and name of hospital contact person to the minor patient's parent or guardian for a sample of 23 of 23 patient grievances reviewed.

This failed practice resulted in 23 patients' parent(s) or guardians not being notified and receiving written notification of the hospital's investigation, results, and date(s) of completion, of the grievance, and the likelihood for all parent(s) or guardians of minor patients who filed grievances to receive no evidence of investigation and resolution.

Findings:

Review of hospital policy titled "Grievance, dated 10/16/14" showed grievances were reviewed utilizing a three level process. First level review would include the Charge Nurse meeting with the patient in an effort to resolve the patient's concerns. For grievances that were not able to be resolved by the Charge Nurse a second level review would be initiated and investigated by the Grievance Coordinator within three days of receipt of the grievance. For grievances that were not able to be resolved at the second level the Grievance Coordinator would forward to the Grievance Committee for a third level review. The Grievance Committee should complete their investigation and meet with the patient within four days to address their concerns. At each level if the grievance was resolved a copy of the grievance form should be provided to the patient with the resolution. The policy failed to define a grievance and identify the elements of the written response for all grievances. The policy showed no evidence for notification of the parent or guardian when a grievance is made by a minor, and provision of a written response.

Review of hospital documents titled "Adolescent Patient Handbook, undated" and "Latency Patient Handbook, undated" showed patients would be provided a copy of the grievance form they completed with a resolution for all requested second and third level reviews. If investigation not completed prior to discharge a copy would be mailed to the patient.

Review of 23 minor patient grievances showed grievances including but not limited to bullying by staff and other peers, alleged staff abuse of an animal, staff yelling and acting inappropriately to patients, and staff not responding to alleged injuries appropriately. Grievances showed each grievance was discussed with the patient by either a charge nurse, grievance coordinator or DON. Grievances involving staff included interviews with those staff members. Once the hospital determined the investigation was completed (resolved) the minor patient would be asked to sign the grievance form, and a copy provided. There was no evidence the minor patient's parent(s) or guardians were notified or written response provided that included the allegations, investigative process, results of the investigation, date completed, and name of hospital contact person.

On 06/27/18 at 10:30 am, Staff B stated the hospital does not notify the parent or guardian when the patient files a grievance and they do not send a written response to them once the investigation was completed.

Based on interviews and observations, the hospital failed to:
I. provide a safe physical environment for suicidal and self- harm patients on the Latency and Adolescent units as evidenced by: * bedroom risks, such as: sharp edges on metal window frames in six of 16 adolescent bedrooms, removable plastic mattress covers on 26 of 50 mattresses, and large drawers under 50 of 50 beds. * bathroom risk, such as: metal expansion shower rods in seven of nine showers, and eleven of eleven residential lifting lifting toilet seats in patient bathrooms.
* therapy and service areas risk, such as: two patient accessible hand sanitizer wall dispensers, accessible pencils without a monitoring inventory processes in three of three activity rooms, 28 of 28 light weight desk and chairs in three activity rooms, accessibility to behind one of two nursing stations.

These failed practices posed an Immediate Jeopardy to patients' health and safety, resulted in a sample of 34 incidents that involved hazardous physical environmental items, and had the likelihood to result in increased risk of strangulation, suffocation, crushing injuries, other physical injuries for the 20 adolescent patients and four latency patient currently being monitored for suicidal and self- harm behavior.

Findings:

I. Safe Physical Environment

A review of a random sample of incident reports from 01/01/18 to 06/28/18 showed 34 incidents involved patient's behavior and physical environmental hazards. These incident reports documented multiple patients throwing or flipping three tables, throwing 13 chairs, throwing three desks, removing one hand sanitizer from hall, three injuries with pencils, and six events of patients going behind the nursing desk of the adolescent unit, all of which resulted in an unsafe environment for staff and patients. (The incident reports failed to consistently identify the location of the incidents and age of patient.)

A review of the document titled, "Leadership Meeting Minutes 07/27/17", the medical director's review showed "difficult and patients appear to be causing a chaotic and sometimes dangerous environment for the hospital."

On 06/18/18 at 11:45 am, the surveyors observed the following:
* Metal expansion shower rods, which posed a strangulation risk used to hold plastic shower curtain which posed a suffocation risk: two were in the Adolescent Unit and five in the Latency Unit. * Household toilet seats, which lifted and posed a strangulation risk, or could be removed and used as a weapon.: six were in the Adolescent Unit and five were in Latency Unit.
* Bed drawers which consisted of two large sliding drawers under the beds that pull out about 1 1/2 foot and could be used to inflict crushing injuries, posed a strangulation risk, and at risk for a small child to be placed in drawer: 64 were in the Adolescent Unit and 44 were in the Latency Unit.
* Twin mattress that were zipped into loose protective plastic covers which could easily be removed and become a suffocation risk: 14 were in the Adolescent Unit and nine in the Latency Unit.
* Bedrooms had external windows with a secondary plexi-glass covering that was secured with metal framing with multiple sharp areas which posed a risk for cutting and self harm: six in the Adolescent Unit.

On 06/20/18 at 10:20 am, the surveyors observed pencils being used in the classrooms, and 14 light weight desk and chairs in the latency classroom, and 14 lightweight desks with attached seating in the adolescent classroom.

On 06/28/18 at 1:58 pm, Staff S stated patients sometimes throw chairs.

On 06/28/18 at 1:00 pm, Staff R stated a patient had thrown a desk and hit her/him.

Based on record review and interview the hospital failed to ensure the patient's plan of care reflected a process of assessment, intervention and evaluation each time a chemical restraint, physical management and/or seclusion was utilized for a sample of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 10, 12, 14, 15, 17, 18, and 20) of 14 patients who required the use of chemical restraint, physical management and/or seclusion.


This failed practice had the likelihood to increase the risk for emotional distress and injury for 14 (Patient #1, 2, 3, 4, 5, 6, 7, 10, 12, 14, 15, 17, 18, and 20) of 14 patients, and the potential for increased risk to patient safety and emotional distress for all pediatric psychiatric patients admitted to the hospital when chemical restraint, seclusion and/or physical management were used.

Findings:

Review of hospital policy titled "Patient Management, dated 01/23/15" failed to show after the use of physical or chemical restraints, seclusion and/or physical hold, nursing staff were required to modify the patient's plan of care to include an assessment, intervention and evaluation for the use of the restraint, seclusion and/or physical hold.

Review of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 10, 12, 14, 15, 17, 18, and 20) patient medical records who required the use of chemical restraints, physical management and/or seclusion showed no evidence of a revision or update to the patient's treatment plan or plan of care that included an assessment, intervention utilized and evaluation each time a chemical restraint, physical management and/or seclusion was determined to be necessary.


On 06/29/18 at 8:05 am, Staff T stated nursing staff did not have a process for modifying the patient's treatment plan each time a restraint, seclusion or physical hold was used. Staff T stated he/she would write "continue treatment plan".

Based on record review and interview the hospital failed to ensure nursing staff notified the physician or licensed independent practitioner as soon as possible and received an order for physical management, chemical restraint and/or seclusion for four (Patient #1 6, 17 and 18) of 14 adolescent patients with severe anger, aggression, and self-harming behaviors who required restraints, physical management or seclusion.

This failed practice resulted in the misuse of seclusion for four (Patient #1, 6 17, and 18) adolescent patients and increased the risk of emotional distress and potential adverse health outcomes.

Findings:

Review of hospital policy titled "Patient Management, dated 01/23/15" showed in emergent situations seclusion may be initiated prior to an order being obtained. The RN should notify the physician as soon as possible to obtain the order for seclusion.

Patient #1 was a 10 year old female who was "hitting, kicking ...and displayed physical aggression towards staff and peers, refused to take time-out". Review of the medical record showed:
*Patient placed in seclusion from 10:00 am to 10:46 am.
*At 10:00 am, a telephone order read back (TORB) for "1:1 time-out room for up to 2 hours for physical aggression" was obtained by Staff II (RN).
*Patient was placed in the time-out room with door closed and locked.
*There was no evidence the physician was notified the patient refused the time-out, and was subsequently placed in seclusion for 46 minutes. No order was obtained to maintain the patient in seclusion.

Patient #6 was a 15 year old male who was "being defiant, threatening staff and self-harming". Review of the medical record showed:
*Staff M (RN) notified Staff X (physician) at 7:00 pm, and order was received to physically manage the patient from 7:00 pm to 7:20 pm, and give Zyprexa 10mg IM and Benadryl 50 mg IM for severe anger/agitation and self-harming.
*Patient was physically managed using a two person prone (lying on stomach) containment for 20 minutes (7:00 pm to 7:20 pm).
*Zyprexa 10mg intramuscular (IM) and Benadryl 50mg IM (chemical restraint) was administered, and patient was released by staff when calm.
*Patient threatened staff again and was placed in seclusion in the time-out room from 7:30 pm to 8:30 pm, with the door closed and locked.
*There was no evidence Staff M notified Staff X the patient behavior warranted seclusion and received an order to maintain the patient in seclusion.

Patient #17 was a 10 year old female who was physically aggressive and harming other peers by hitting and kicking. Review of the medical record showed:
*06/20/18 at 8:22 am, patient was causing physical harm to others by hitting and kicking. Staff placed the patient in a two man prone containment from 8:22 am to 8:24 am.
*Staff II notified Staff AA and received a TORB for the physical management from 8:22 am to 8:24 am and a 1:1 time-out with staff for continued physical aggression.
*Patient was placed in seclusion from 8:24 am to 9:00 am, in the time-out room. The medical record documentation showed from 8:22 am to 8:45 am, the patient was in "containment (physical hold)", 8:45 am to 9:00 am, the door was locked and at 9:00 am the patient was released.
*There was no evidence Staff II notified Staff X of the patient's continued behavior that warranted a second physical management from 8:24 am to 8:45 am, and seclusion from 8:24 am to 9:00 am. No order was received from the physician for the continued physical management or seclusion.

Patient #18 was a 13 year old male who was physically aggressive and self-harming. Review of the medical record showed:
*06/06/18 at 2:40 pm, patient was "running around unit ...self-harming, banging head." Patient was placed in a two man prone containment and escorted to a time-out room by staff. Physical management of the patient was initiated at 2:40 pm, and patient was released at 3:10 pm. Patient was placed in seclusion from 3:10 pm to 3:25 pm. Staff II notified Staff AA at 2:40 pm. There was no evidence of an order for the physical management or seclusion.
*06/12/18 at 1:20 pm, patient was in time-out and began banging his head "forcefully" against the time-out door. The patient was placed in seclusion and a 2 man prone containment from 1:20 pm to 1:23 pm. Staff K (RN) notified Staff AA at 1:25 pm. There was no evidence of an order for the physical management or seclusion.
*06/14/18 at (no time documented), patient was acting out and self-harming. Patient was taken to time-out room and given Zyprexa 5mg PO/Benadryl 50mg at 3:20 pm. Staff H (RN) notified Staff X at 3:20 pm. There was no evidence of an order for the chemical restraint.
*06/15/18 at 1:02 pm, patient was "banging head, punching staff numerous times, choking self with hands making face red." The patient was placed in a two man prone containment from 1:02 pm to 1:09 pm and administered Haldol 2.5mg IM. Staff H notified Staff AA at 1:15 pm. There was no evidence of an order for the physical management or the chemical restraint.

On 06/28/18 at 1:26 pm, Staff H stated nursing staff were required to notify the physician and obtain an order for patients receiving a chemical restraint, physical management or placed in seclusion.

Based on record review and interview the hospital failed to ensure the qualified RN:

I. performed and documented a complete face-to-face evaluation within one hour for a sample of five (Patient #3, 4, 6 15, and 18) of 14 violent or self-destructive patients who required the use of a chemical restraint, seclusion and/or physical management.

II. performed and documented a comprehensive physical/medical condition and behavioral assessment per CMS regulations for 26 (Patient #1, 4, 5, 7, 17, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, AND 40) of 26 chemical restraint, seclusion and/or physical management patient records reviewed.

These failed practices had the likelihood:

I. to result in a delay in recognition of changes in the patient's physical and behavioral condition and increased risk of restraint, seclusion and physical management misuse for five (Patient #3, 4, 6, 15 and 18) patients, and the potential for restraint misuse and adverse health outcomes for all pediatric and adolescent psychiatric patients who required the use of restraints, seclusion and/or physical management.

II. for contributing factors to patient's violent or self-destructive behaviors to go unrecognized and treated and result in adverse health outcomes for 26 (Patient #1, 4, 5, 7, 17, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, AND 40) of 26 chemical restraint, seclusion and/or physical management patient records reviewed.

Findings:

Review of hospital policy titled "Patient Management, dated 01/23/15" showed a one hour assessment by the RN would be determined by the physician and would be included in the physician's order. When ordered the RN should report patient's orientation, justification if patient remained in restraint or seclusion, mental status when patient released, and any physical injuries incurred. The policy lacked the following elements per CMS regulations:
*RN evaluation and documention of the patient's reaction to chemical restraint, seclusion and/or physical management
*Comprehensive physical/medical and behavioral assessment following the use of a chemical restraint, physical management and/or seclusion, and
*Determination for continuation or termination of chemical restraint, seclusion and/or physical management.

Review of hospital document titled "Therapeutic Hold/Seclusion Restraint Form, revised 02/15" showed no evidence of a physical/medical or behavioral assessment to determine any contributing factors to the patient's behavior including but not limited review of systems, physical/mental assessment, medications, vital signs, and laboratory results (if any). The section titled "LIP Assessment (within 1 hour)" consisted of the following "Yes/No" questions:
*"Does a need exist to continue the restraint?"
*"Does a need exist to continue the seclusion?"
*What environmental triggers contributed to escalation?"
Section titled "Medical Assessment" consisted of three additional "Yes/No" questions:
*"Was patient oriented to person/place/time?"
*"Upon questioning, does patient report any injuries?"
*"Upon physical examination, where there any observable injuries"

I. Completion of One Hour Face-to-Face Evaluation

Patient #3 was an 11 year old female who was admitted to the hospital for disruptive mood disorder, PTSD (post-traumatic stress disorder) and attention deficit hyperactive disorder (ADHD). Patient had a history of hallucinations, physical aggression, nightmares, flashbacks and physical abuse. Patient had a medical history of asthma. Review of the patient's medical record showed:
*06/18/18 at 4:10 pm, patient "kicked, punched staff, throwing desks/chairs at peers". Staff M (RN) obtained a verbal order read back (VORB) for physical management from 4:10pm to 4:16 pm, administration of Zyprexa 10mg IM/Benadryl 50mg IM one time for aggression and seclusion up to two hours. RN was to complete assessment and report to physician.
* No face-to-face evaluation performed and documented in the patient's medical record within one hour, including assessment and documentation of the patient's behaviors that resulted in the use of chemical restraints and time out, assessment and documentation of the patient's physical and behavioral response to chemical restraint and time-out, and termination or continued need for restraint and/or time-out.


Patient #4 was a 16 year old male who was admitted to the hospital for disruptive mood disorder and ADHD. Patient had a history of physical and sexual abuse. Review of the patient's medical record showed:
*06/14/18 at 3:20 pm, Staff II (RN) obtained a VORB from Staff X (physician) for Zyprexa 5mg by mouth (PO) sublingual (SL)/Benadryl 50mg PO (chemical restraint) one time for self-harm with 1:1 time-out for up to two hours.
*06/18/18 at 1:15 pm, Staff II obtained a TORB from Staff AA (physician) for 1:1 time-out for up to two hours, Zyprexa 5mg PO SL/Benadryl 50mg PO for continued self-harm and RN to complete assessment and report to physician.
*06/24/18 at 8:40 am, Staff II obtained a TORB for Zyprexa 5mg PO/Benadryl 50mg PO, 1:1 time out up to two hours and RN to complete assessment and report to physician.
*No face-to-face evaluations were performed and documented in the patient's medical record within one hour, including assessment and documentation of the patient's behaviors that resulted in the use of chemical restraints and time out, assessment and documentation of the patient's physical and behavioral response to chemical restraint and time-out and, and termination or continued need for restraint and/or time-out.

Patient #6 was a 15 year old male who was admitted to the hospital for suicidal ideations and self-harm behaviors. Patient had a history of aggressive behavior and alcohol abuse. Review of the patient's medical record showed:
*06/22/18 at 7:00 pm, Staff M (RN) obtained a TORB from Staff X for physical management from 7:00 pm to 7:20 pm, and Zyprexa 10mg IM/Benadryl 50mg IM for severe anger/agitation and self-harming.
*06/22/18 at 7:30 pm, patient was placed in seclusion due to threatening staff, and released at 8:30 pm.
*No face-to-face evaluation was performed and documented in the patient's medical record within one hour for the physical management and chemical restraint or the seclusion episodes, including assessment and documentation of the patient's behaviors that resulted in the use of chemical restraints, physical management and seclusion, assessment and documentation of the patient's physical and behavioral response to each intervention, and termination or continued need for each intervention.

Patient #15 was a 12 year old male who was admitted to the hospital for suicidal ideations and depression. Patient had a history of violence. Review of the patient's medical record showed:
*06/23/18 at 10:15 am, patient attacked another peer punching her in the face multiple times. Patient was placed in two man prone containment from 10:15 am to 10:30 am.
* No face-to-face evaluation was performed and documented in the patient's medical record within one hour for the physical management episode, including assessment and documentation of the patient's behaviors that resulted in the use of the physical management, assessment and documentation of the patient's physical and behavioral response, and termination or continued need for an intervention.


Patient #18 was a 13 year old male who was admitted to the hospital for suicidal ideations and physically aggressive behaviors. Patient had a history of aggressive behavior and suicide attempt by hanging and overdose. Review of the patient's medical record showed:
*06/05/18 at 1:34 pm, Staff II (RN) obtained a TORB from Staff AA (physician) for physical management from 1:34 pm to 2:10 pm (36 minutes), 1:1 time-out for up to two hours and RN assessment and report to physician.
*06/06/18 at 2:14 pm, Staff II obtained a TORB from Staff AA for Zyprexa 10 mg PO SL/Benadryl 50mg PO one time for agitation.
* No face-to-face evaluations were performed and documented in the patient's medical record within one hour for the physical management or chemical restraint episodes, including assessment and documentation of the patient's behaviors that resulted in the use of chemical restraints and physical management, assessment and documentation of the patient's physical and behavioral response to each intervention, and termination or continued need for each intervention.


On 06/29/18 at 8:05 am, Staff T stated the RN did not perform a full physical assessment of the patient after a restraint or seclusion. Staff T stated the RN would "make sure the patient was alert and breathing okay", ask "if the patient had any injuries" and "observe for any injuries". Staff T stated he/she would usually perform the face-to-face evaluation when the patient had calmed down and he/she was able to "reason with them". Staff T stated the assessment was documented either on the restraint form or in the progress notes.


II. Comprehensive Physical/Medical and Behavioral Assessment


Review of 26 (Patient #1, 3, 4, 5, 7, 17, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, AND 40) of 26 chemical restraint, seclusion and/or physical management patient records showed no evidence of an assessment of the patient's physical/medical and behavioral conditions to determine any contributing factors for the violent and/or self-destructive behavior.

On 06/29/18 at 8:05 am, Staff T stated the RN did not perform a full physical assessment of the patient after a restraint or seclusion. Staff T stated the RN would "make sure the patient was alert and breathing okay", ask "if the patient had any injuries" and "observe for any injuries". Staff T stated he/she would usually perform the face-to-face evaluation when the patient had calmed down and he/she was able to "reason with them".

Based on record review and interview the hospital failed to ensure the nursing staff documented the patient's behavior, chemical restraint, seclusion, physical management, and the time of initiation and discontinuation of restraint, seclusion and/or physical management for one (Patient #4) of a sample of 14 patients who required the use of chemical restraint, seclusion and/or physical management patient records reviewed.

This failed practice had the likelihood to result in misuse and adverse health outcomes for one (Patient #4) patient for whom chemical restraints, seclusion and/or physical management interventions were utilized.

Findings:

Review of hospital policy titled "Patient Management, dated 01/23/15" showed the following:
*RN should document "a description of events and patient behaviors leading to the need for physical management."
*When seclusion was required the RN should document "a description of the events, patient behavior leading to the need for seclusion ...purpose for seclusion and length of time patient was in seclusion."
*The policy failed show evidence for documentation of the patient's behavior for patient's requiring chemical restraints and 1:1 time-out.

Review of hospital document titled "Therapeutic Hold/Seclusion Restraint Form, revised 02/15" provided a blank line for documentation of the following elements:
*"Time restraint initiated"
*"Time restraint discontinued"
*"Time seclusion initiated"
*"Time seclusion discontinued"
*The form lacked a place to document initiation and discontinuation of 1:1 time-out for management of violent and/or self-destructive behaviors.

Patient #4 was a 16 year old male who was admitted to the hospital for disruptive mood disorder and ADHD. Patient had a history of physical and sexual abuse. Review of the patient's medical record showed:
*06/14/18 at 3:20 pm, Staff II (RN) obtained a VORB from Staff X (physician) for Zyprexa 5mg PO SL/Benadryl 50mg PO one time for self-harm with 1:1 time-out for up to two hours.
*06/18/18 at 1:15 pm, Staff II obtained a TORB from Staff AA (physician) for 1:1 time-out for up to two hours, Zyprexa 5mg PO SL/Benadryl 50mg PO for continued self-harm and RN to complete assessment and report to physician.
*No documentation by the RN of the patient's behavior that lead to the initiation of chemical restraint.
*No documentation by nursing staff for the time the 1:1 time-out was initiated and discontinued.

On 06/29/18 at 8:05 am, Staff T stated he/she would usually perform the face-to-face evaluation when the patient had calmed down and he/she was able to "reason with them". Staff T stated documentation was done using the restraint form.

Based on record review and interview the hospital failed to ensure nursing staff assessed and documented the patient's response to the use of a chemical restraint, seclusion and/or physical management for one (Patient #4) of a sample of 14 patients who required the use of chemical restraint, seclusion and/or physical management patient records reviewed.

This failed practice had the likelihood to result in a delay in recognition of changes in the patient's physical and behavioral condition and increased risk of restraint, seclusion and physical management misuse for one (Patient #4 ) of 14 patients.

Findings:

Review of hospital policy titled "Patient Management, dated 01/23/15" showed the following:
*Nursing staff were responsible for documentation in the patient's medical record the patient's response to time-out.
*RN was responsible for documentation of "the patient's response to initial (physical) management".
*The policy failed to show evidence nursing staff were required to assess and document the patient's response for chemical restraints and seclusion.
*There was no evidence in the policy nursing staff were required to document a reason for continued use of a restraint, seclusion or physical management intervention.

Review of hospital document titled "Therapeutic Hold/Seclusion Restraint Form, revised 02/15" showed no evidence for nursing staff to document the patient's response to chemical restraint, seclusion or physical management interventions.

Patient #4 was a 16 year old male who was admitted to the hospital for disruptive mood disorder and attention deficit hyperactive disorder (ADHD). Patient had a history of physical and sexual abuse. Review of the patient's medical record showed:
*06/14/18 at 3:20 pm, Staff II (RN) obtained a VORB from Staff X (physician) for Zyprexa 5mg PO SL/Benadryl 50mg PO one time for self-harm with 1:1 time-out for up to two hours.
*06/18/18 at 1:15 pm, Staff II obtained a TORB from Staff AA (physician) for 1:1 time-out for up to two hours, Zyprexa 5mg PO SL/Benadryl 50mg PO for continued self-harm and RN to complete assessment and report to physician.
*06/24/18 at 8:40 am, Staff II obtained a TORB for Zyprexa 5mg PO and Benadryl 50mg PO, 1:1 time out up to two hours and RN to complete assessment and report to physician.
*No evidence of an assessment and documentation by nursing staff of the patient's physical and behavioral response to chemical restraint and time-out.

On 06/29/18 at 8:05 am, Staff T stated he/she would usually perform the face-to-face evaluation when the patient had calmed down and he/she was able to "reason with them". Staff T stated documentation was done using the restraint form.

Based on record review and interview, the hospital failed the ensure nursing services were provided by a qualified registered nurse who was highly experienced in the delivery of psychiatric services.

The failed practice had the likelihood for psychiatric nursing care not to be carried out and for patient needs to go unrecognized.

Finding:

A review of the personnel file for the Director of Nursing showed he/she was hired 12/04/17, and the resume' showed no prior experience in the delivery of psychiatric care and limited experience in the delivery of nursing care for adolescence and children.

On 06/27/18 at 2:02 pm, Staff A stated the current Director of Nursing was going to "step down" and the hospital was trying to hire a qualified replacement.

Based of record review, interview, and observations, the hospital failed to ensure the nursing units had adequate number of qualified staff to meet the needs of the patients as evidenced by twenty of fifty-three 11 pm to 7 am shifts from 04/30/18 to 06/15/18 had staff patterns below requirements, pulled mattresses on floor in the corridor at night for direct line of sight supervision and other shifts, monitored patients in front of the adolescent nursing station and no seating available with frequent observations of patients lying on floor.

These failed practices had the likelihood to have contributed to a sample of 34 incidents which involved chaotic patient behavior and violence which involved hazardous physical environmental items, 134 physical managements and 34 seclusions for 11/17, and staff turnover of 32% for 2017, all of which had the likelihood to negatively impact the approximately 47 latency and adolescent patients who received care daily.

Findings:

I. Staffing Patterns

A review of the job description titled, "Infection Control Nurse/ Staff Coordinator (05/18)" documented duties to include, but not limited to "assure" adequate/safe staffing levels on each nursing unit per the standards of patient to staff ratio.

A review of the policy titled, "Nursing Service Staffing Plan (date 08/25/15) showed at least one RN would be assigned to care and provide active treatment for every 15 patients on each shift for each unit. The policy documented when the unit census exceeded 15 patient, but did not exceed 20 patients, an RN or LPN would be added, and two RNs would be assigned for census exceeding 20 patients.

A review of the 11 pm to 7 am "Daily Assignment Sheet" from 04/28/18 to 06/20/18 showed that staffing patterns for the Adolescent and Latency Unit, but did not include patient acuity such as 1:1 or direct line of sight patient needs. The staffing level deficiencies were as follows:

Adolescent Unit
04/30/18 had 30 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 10.
05/11/18 had 29 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 9.
05/13/18 had 29 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 9.
05/23/18 had 30 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 10.
05/24/18 had 30 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 10.
05/28/18 had 27 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 7.
05/29/18 had 29 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 9.
06/11/18 had 27 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 7
06/12/18 had 28 patients with 1 RN and 1 LPN providing care which exceeded maximum patients per nurse by 8.
[Note: the schedule listed Staff CC as an RN; however, a review of Staff CC's personnel file showed he/she was a LPN].

Latency Unit
04/30/18 had 17 patients with 1 RN providing care which exceeded maximum patients per nurse by 2.
05/11/18 had 19 patients with 1 RN providing care which exceeded maximum patients per nurse by 4.
05/12/18 had 19 patients with 1 RN providing care which exceeded maximum patients per nurse by 4.
05/13/18 had 19 patients with 1 RN providing care which exceeded maximum patients per nurse by 4.
05/23/18 had 20 patients with 1 RN providing care which exceeded maximum patients per nurse by 5.
05/24/18 had 18 patients with 1 RN providing care which exceeded maximum patients per nurse by 3.
05/28/18 had 18 patients with 1 RN providing care which exceeded maximum patients per nurse by 3.
05/29/18 had 19 patients with 1 RN providing care which exceeded maximum patients per nurse by 4.
06/11/18 had 19 patients with 1 LPN providing care which exceeded maximum patients per nurse by 15.
06/12/18 had 19 patients with 1 LPN providing care which exceeded maximum patients per nurse by 15.
06/15/18 had 17 patients with 1 RN providing care which exceeded maximum patients per nurse by 2.
[Note: the schedule listed Staff CC as an RN; however, a review of Staff CC's personnel file showed he/she was a LPN].

On 06/28/18 at 12:48 pm, Staff R stated the hospital could use more staff, especially mental health technicians (MHT) for 3:00pm to 11:00 pm shift. Staff R stated sometimes there was only one MHT in the classroom and disruptive patients had to be escorted back to their unit with only one staff, and stated there was no intercom in the school, craft room, or group rooms.

II. Staff Turnover

A review of document titled "Leaderhip Meeting Meetings 03/15/18" showed 2017 staff turnover was 32% turnover with 89 hires and 72 terminations.

On 06/28/18 at 1:30 pm, Staff U stated there was a high turnover rate at the hospital, and more staff was needed due to the behavior of the patients.

II. Patient Behavior and Supervision

A review of the document titled, "Leadership Meeting Minutes 07/27/17", the medical director's review showed "difficult and patients appear to be causing a chaotic and sometimes dangerous environment for the hospital."

A review of the document titled, Leadership Meeting Meeting 03/15/18" showed 11/17 had 134 physical managements and 34 seclusions for 11/17.

A review of the policy titled, "Patient Supervision (date 11/12)" documented the Charge Nurse may keep the door open to between the units (Adolescent and Latency) during the night shift. The policy documented patient bedrooms were to locked during waking hours and patients were to remain outside their bedrooms.

On 06/28/18 at 12:48 pm, Staff R stated at night, mattresses would be pulled into the corridor for 1:1 or line of sight patients or for patients who sexually act out, and currently the adolescent unit had one patient sleeping out.

On 06/28/18 at 1:15 pm, Staff T stated at night, some patients would sleep out in the hall on a mattress so the staff could watch them.

On 06/18/18 at 2:55 pm, Patient #9 stated patients often have to "sleep out" in the hall on a mattress for patients "who were bad" or had trouble falling asleep.

On 06/29/18 at 10:30 am, Staff B stated patient bedrooms were locked during day, because there was not enough staff to monitor the patients if the doors were left open. Staff B stated the adolescent patients, who were standing at the nursing desk or lying or sitting on the floor in front of the nursing desk tended to be the patients who did not want to go to school or attend an activity.

On 06/27/18 at 2:30 pm, surveyors reviewed the video taping from unit camera and 06/26/18 at 10:15 pm, observed patient lying on mattresses in the corridor of the Adolescent Unit.

On 06/18/18 at 2:36 am and 06/21/18 at 10:11am and multiple other times during random tours, surveyors observed patients lying on bare floor in the adolescent corridor floor in front of nursing station and in the seclusion room.

Based on record review, interview and observation the Registered Nurse (RN) failed to ensure nursing staff communicated and interacted with patients to maintain acceptable behavior, and promote a therapeutic and safe environment.

This failed practice had the likelihood to result in increased risk for a disruptive milieu leading to emotional distress and physical injury due to lack of communication and interaction of the nursing staff with the patient.

Findings:

Review of hospital policy titled "Patient Supervision, dated 11/01/12" showed nursing staff were responsible for patients at all times except while in therapy. Nursing staff were expected to be interacting with patients and not sitting at the desk except to document in the patient's chart and conduct telephone business.

Review of hospital policy titled "Standards of Care and Practice for Nursing Process, dated 11/01/12" showed nursing interventions should address patients' "physical, psychological, and social symptoms and behaviors" ...the goal of interventions by nursing staff were to "promote behaviors and responses to improve patient's adjustment and adaptability to his/her life and environment"....Nursing staff should utilize individualized interventions that included but were not limited to communication and interactions with patients and assist patients to "modify or eliminate maladaptive behaviors" by reinforcement of constructive patient behaviors.

On 06/27/18 at 11:32 am, on the adolescent unit surveyors observed patients leaning on the nurses' station, several patients wandering up and down the hallways and one patient running on a freshly mopped floor without shoes while nursing staff were seated at the nursing station talking.

On 06/27/18 at 11:40 am, on the adolescent unit surveyors observed Patient #18 wandering around the nurses' station while one mental health specialist and two RNs were sitting at the desk talking. At 11:43 am, Patient #18 entered the doctor's consultation area unobserved by nursing staff and started asking questions of the surveyors.

On 06/28/18 at 2:00 pm, Staff T stated nursing staff should ensure patient safety and provide a good therapeutic atmosphere to help patients with their behavior. Staff T stated staff talk with them and spend time with them to distract them from bad behaviors and try to de-escalate situations.

Based on record review and interview the hospital failed to ensure nursing staff and mental health specialists were adequately oriented, trained and demonstrated competencies to provide specialized care to meet the needs of the patients.

This failed practice had the likelihood to result in increased risk for adverse patient outcomes and emotional distress for pediatric and adolescent psychiatric patients secondary to staff having no demonstrated competencies or knowledge in how to manage this population of patients.

Findings:

Review of hospital policy titled "Competency of Clinical Staff, dated 03/02/10" failed to show evidence of orientation, training or competencies for the hospital's specialized patient population which included pediatric psychiatric conditions and management. The policy stated clinical staff were to complete Crisis Prevention Intervention training and updates.

Review of hospital policy titled "Skill Assessment - Initial, dated 11/01/12" showed staff competence to perform duties included but were not limited to: consideration of clinical knowledge and skills in pediatric and adolescent psychiatric care based on Psychiatric and Mental Health nursing standards, and staff's previous clinical experience in mental health facilities.

Review of seven (Staff H, I, J, K, M, V, GG) of seven staff files showed no evidence of pediatric and/or adolescent psychiatric clinical conditions, management and skills per hospital policy and procedure.

On 06/29/18 at 8:05 am, Staff T stated the hospital did not provide any regular training on pediatric or adolescent psychiatric clinical conditions. Staff T stated that this training "would be helpful" for the mental health specialists and nursing staff.

Based on record review and interview the hospital failed to ensure the "Special Precautions Flowsheet" was completed for eleven (Patient #1, 2, 3, 4, 5, 6, 14, 15, 17, 18 and 20) of 26 patient medical records reviewed per hospital policy and procedure.

This failed practice had the likelihood for increased risk for patient injury and adverse health outcomes for eleven (Patient #1, 2, 3, 4, 5, 6, 14, 15, 17, 18 and 20) of 26 patient records reviewed, and the potential for increased risk for injury and adverse health outcomes for all patients with special precautions ordered.

Findings:

Review of hospital document titled "Special Precautions Flowsheet" showed precautions including but limited to close observations, suicide, self-harm, AWOL (absent without leave), and assault. Staff should "check-mark" each precaution the patient was being monitored for. The flowsheet was divided into 15 minute increments with columns for patient location, patient behavior and staff initials. The flowsheet was for a 24 hour period.

Eleven (Patient #1, 2, 3, 4, 5, 6, 14, 15, 17, 18 and 20) of 26 patient medical records reviewed showed periods of no documentation of 15 minute observations. The Special Precautions Flowsheet was marked with a green tab or had evidence of a tab copied into the paper medical record.

On 06/19/18 at 3:25 pm, Staff E stated the green tab on a medical record notified staff that they needed to go back and complete their documentation.

On 06/28/18 at 2:25 pm, Staff U stated patients on precautions have a separate sheet the mental health specialists (MHS) document (Special Precautions Flowsheet) on. Staff U stated the MHS should be physically with the patient and filling the document out every 15 minutes.

Based on interviews and observations, the hospital failed to:
I. provide safety features in the bedrooms, bathrooms, therapy, and service areas for the psychiatric latency and adolescent patient as evidenced by:
* bedroom risks, such as: sharp edges on metal window frames in six of 16 adolescent bedrooms, removable plastic mattress covers on 26 of 50 mattresses, and large drawers under 50 of 50 beds. * bathroom risk, such as: metal expansion shower rods in seven of nine showers, and eleven of eleven residential lifting toilet seats in patient bathrooms.
* therapy and service areas risk, such as: two patient accessible hand sanitizer wall dispensers, accessible pencils without a monitoring inventory processes in three of three activity rooms, 28 of 28 light weight desk and chairs in three activity rooms.

II. restrict the adolescent patients from the hazards associated with laundering their own clothing, and adolescent patients having access to behind the nursing station with risks associated with office supplies.

These failed practices posed an Immediate Jeopardy to patients' health and safety, resulted in 34 incidents (random sampling) involved hazardous physical environmental items, and had the likelihood to result in increased risk of strangulation, suffocation, crushing injuries, other physical injuries for the 20 adolescent patients and four latency patient currently being monitored for suicidal and self- harm behavior.


Findings
I. Safety Features
A review of a random sample of incident reports from 01/01/18 to 06/28/18 showed 34 incidents involved patient's behavior and physical environmental hazards. These incidents report documented multiple patients throwing or flipping three tables, throwing 13 chairs, throwing three desks, removing one hand sanitizer from hall, and three injuries with pencils all of which resulted in an unsafe environment for staff and patients. (The incident reports failed to consistently identify the location of the incidents and age of patient.)

On 06/18/18 at 11:45 pm, the surveyors observed the following:
* Metal expansion shower rods, which posed a strangulation risk used to hold plastic shower curtain which posed a suffocation risk: two were in the Adolescent Unit and five in the Latency Unit. * Household toilet seats, which lifted and posed a strangulation risk, or could be removed and used as a weapon.: six were in the Adolescent Unit and five were in Latency Unit.
* Bed drawers which consisted of two large sliding drawers under the beds that pull out about 1 1/2 foot and could be used to inflict crushing injuries, posed a strangulation risk, and at risk for a small child to be placed in drawer: 64 were in the Adolescent Unit and 44 were in the Latency Unit.
* Twin mattress that were zipped into loose protective plastic covers which could easily be removed and become a suffocation risk: 14 were in the Adolescent Unit and nine in the Latency Unit.
* Bedrooms had external windows with a secondary plexi-glass covering that was secured with metal framing with multiple sharp areas which posed a risk for cutting and self harm: six in the Adolescent Unit.

On 06/20/18 at 10:20 am, the surveyors observed pencils being used in the classrooms, and 14 desk and chairs in the latency classroom, and 14 desks with attached seating in the adolescent classroom.

On 06/28/18 at 1:58 pm, Staff S stated patients sometimes throw chairs.

On 06/28/18 at 1:00 pm, Staff R stated a patient had thrown a desk and hit her/him.

II. Access to Hazardous Areas
A. Personal Laundry
A review of policy titled, "Laundry Policy Procedures (date 11/12)" documented personnel clothing of each patient was to be laundered by that patient using a washer and dryer provided in the hospital. The policy documented the detergent would be provided by the hospital which would be measured by the patient. The policy documented if clothing was soiled with stool, the nursing staff would clean the clothing in a washer tub in hot water and adding one cup of bleach. The policy failed to protect the adolescent patients from the risk of exposure to chemical and mechanical hazards, and the risk of the required water temperature.

On 06/21/18 at 9:29 am, surveyors observed four large plastic tubs on the floor of the adolescent laundry room. The bins were not labeled with current patient names. Clothing was spilling from one tub to another. The tubs showed visible dirt on the rims.

On 06/19/18 at 11:25 am, surveyor asked Patient #18 if he/she was responsible for washing his/her personal clothing. In response, Patient # 18, who was standing in the corridor in front of the adolescent nursing station, walked into the adolescent laundry room without staff supervision, opening a cabinet to obtain liquid detergent, poured the detergent into the washer, and started a wash cycle. (The door to the laundry room was unlocked by maintenance for Life Safety Surveyor).

B. Access behind Nursing Station
A review of a random sample of incident reports from 01/01/18 to 06/28/18 showed 34 incidents involved patient's behavior and physical environmental hazards which included six events of patients going behind the nursing desk of the adolescent unit.

On 06/18/18 at 11:45 pm, the surveyors observed the nursing station for the adolescent unit consisted of a bar like counter with no doors on either end of the counter to restrict the access of patients coming into the nursing work area. The nursing work area contained office supplies which could be used for weapons or self harm. The surveyors observed a water container and cups within the nursing work area and saw multiple patients serve themselves.

Based on record review, interview, and observation, the hospital failed to appoint a qualified Infection Control Preventionist to develop and implement initiatives for an effective Infection control Program.

This failed practices had the likelihood for the Infection Control Program to lack effectiveness in areas, such as: development, surveillance, investigation of issues, implementation of preventative and control measures for the approximately 47 latency and adolescent patients who receive care daily.

Findings:

On 06/18/18 at 11:14 am, Staff B stated the Infection Control Preventiontist (ICP) position was recently filled by Staff BB, RN. Staff B stated Staff BB had been in the position for two weeks, but had been on vacation for one of the two weeks. Staff B stated the position had been held by Staff CC, LPN, and he/she was training Staff BB.

A review of the job description titled, "Infection Control Nurse/ Staff Coordinator (05/18)" documented the role was under the general direction of the Director of Nursing and provided advanced, specialized infection control knowledge to facilitate an effective Infection Control Program, and be responsible for JCAHO and CDC standards. The document showed the duties of the ICP role included, but not limited to: surveillance for possible sources of infection and report finding to DON, assured antibiotic therapy was ordered and monitored, monitors infection patients reports, documents percentages of nosocomial infection.
*The job description failed to document what aspect of antibiotic therapy was being monitored, what reports were being monitored and why, and did not describe any actions to be taken once the percentages of nosocomial infection were documented.
* The job description documented a licensed practical nurse would meet the basic job qualification and be expected to facilitate an effective program; however, The Oklahoma Board of Nursing (OBN) differentiates between the responsibilities of a RN and LPN in OBN Nursing Practice Act. The Nurse Practice Act outlined the RN Scope of Practice, regarding nursing care, using verbs such as assessing, analyzing, establishing goals, planning strategies, establishing priorities, and implement strategies. The Scope of Practice for the LPN, regarding nursing care, included verbs such as contributing to assessment, participating in the development, implementing appropriate aspects, and participating in evaluation, which was not compatible with leading an Infection Control Program. The job description documented the LPN was under the direction of the Director of Nursing.

A review of the personnel file for Staff CC showed Association for Professionals in Infection Control and Epideminology (APIC) Training 101 in 11/12 and no other documented Infection Control Preventitionist education.

A review of the personnel file for the Director of Nursing showed no infection control preventionist training.

A review of the personnel file for Staff BB showed no infection control preventionist training.

On 06/28/18 at 8:15 am, Staff A stated Staff BB, the current ICP, had not been formally approved by the Governing Body as the Infection Control Preventionist.

Based on record review, interview, and observation, the hospital failed to develop, implement, and maintain, an infection control program and report the effectiveness of initiatives for infection control risks including, but not limited to, environmental sanitation, patients lying on floor, patient personal clothing laundering, lice management, and skin infection and wound management with no evidence of infection control- quality assurance performance improvement (QAPI) discussions in two of two Board Meeting Minutes from 03/17 to 06/18 and four of four Leadership meeting minutes from 07/17 to 06/18.

This failed practices had the likelihood for the Infection Control Program to lack effectiveness in areas, such as: development, surveillance, investigation of issues, implementation of preventative and control measures for the approximately 47 latency and adolescent patients who receive care daily.

Findings:

I. Separation of acute facility and a Psychiatric Residential treatment Facility (PRTF)

A review of two of two Board Meeting Minutes from 03/17 to 06/18 and four of four Leadership Meeting Minutes from 07/17 to 06/18 showed infection control surveillance such as hand hygiene, lice infestation, skin infections, and employee illnesses without evidence of corrective initiatives, which included both information from the the acute hospital and the company's PTRF.

On 06/21/18 at 9:08 am, Staff B stated the data for the Quality information and Infection Control Report was based on the combined information from the acute hospital and residential facility, which did not function under the acute hospital's CMS provider number.

II. Program
A review of the documented titled, "Infection Control Plan 2018" showed prioritized risk/strategies, overall goals, and specific goals for hand hygiene, influenza vaccination, and skin infection. There no evidence that Infection Control Plan 2018 had been approved by the governing body and that initiatives reflected the complexity and significant issues such an environmental sanitation and lice infestation. There was no evidence the Governing Body had approved the data collection design and frequency.

A review of the document titled, "Infection Control Annual Risk Assessment 2018" ranked lice infestation as having a high risk potential for occurrence and this risk was not included on the hospital's Infection Control Plan 2018. Improper environmental cleaning was ranked as a low risk and not on the Infection Control Plan; however, surveyor observations identified significant sanitation issues.

A review of the policy titled, "Infection Control Program (date11/12)" documented the Infection Control Preventionist received reports, provided the surveillance, and reported findings to the Leadership Committee.

A review of the policy titled, "Infection Control Committee (date 11/12)" documented the policy manual would be revised and updated as necessary, but at least on an annual basis".

On 06/28/18 at 3:14 pm, Staff BB stated infection control policies had not been reviewed annually.

On On 06/18/18 at 11:14 am, Staff B stated infection control matters were discussed in the Leadership meetings. Staff B and Staff A stated the Governing Body did not participate in the Leadership meetings, but stated there was a meeting conducted at 9:30 am each weekday via telephone in which the Governing Body was represented. When the surveyor requested meeting minutes for this meeting, Staff A stated no formal minutes were taken. Staff A provided informal noted from 06/11/18 to 06/27/18. The notes documented "discussed projects", and "discuss progress on policies", and the information was insufficient enough to determine the Governing Body's participation in the hospital's quality efforts.

III. Surveillance

A review of the policy titled, "Surveillance and Reporting Mechanism (11/12)" documented the hospital was to have a "total house surveillance" for the systematic, active, ongoing observation of the events or conditions that increase or decrease the risk of such occurrences. The policy documented the surveillance included the regular analysis of observational data which would be disseminated to individuals who need to know in order to take appropriate remedial action. The policy documented the data collected was compiled to identify hospital acquired infections, but failed to include an another purpose of surveillance which was to validate adherence to policies and procedures and ensure patient care was provided in accordance with standards of infection control practices which may not have resulted in a hospital acquired infection. The policy failed to describe the specific observations to be performed or reporting responsibilities to the Governing Body.

A review of the document titled, "Infection Control Report- 3rd quarter 2017, 4th quarter 2017, 1st quarter 2018, and 2nd quarter 2018" showed number of patient cases provided for skin infections, lice infestations, strep throat infection, documented environmental monitoring system "continued", hand hygiene "improved" for all quarters. The report did not identify hospital acquired infections. All four reports included the same "recommendations", word for word copied to each quarter. The recommendations included general nonspecific plans to include, but not limited to "practice good hygiene, use of hand sanitizer, do not share drinking cups, and clean door handles and objects that patients touch." The report failed to document specific initiatives in which the data was analyzed, action plans implementation and evaluated for effectiveness.

On 06/21/18 at 9:08 am, Staff B stated the data for the Infection Control Report was based on the combined information from the acute hospital and residential facility, which did not function under the acute hospital's CMS provider number.

A review of the 1st quarter "2018 Infection Control Plan Goal" for hand hygiene surveillance showed 90% with no data for 2018 and no explanation of the number of required observations or locations to be evaluated. A review of the hand hygiene surveillance for 3rd quarter 2017 and 2nd quarter 2017 showed 80% achievement and no initiatives for improvement and no context of observations. The surveyor requested the raw data for hand hygiene surveillance for the 2nd and 3rd quarter of 1017, and none was provided.

Although nursing employee absentees rates due to infections and patient infection rates were documented monthly, the ICP made no type of correlation assessment that might relate the two groups. The employee gastrointestinal infections were monitored, but there was no evidence of gastrointestinal infections were monitored in patients, and no evidence of investigations for improvement opportunities. A review of the employee absentee rates for 01/18, 02/18, and 03/18 showed 22 employee abesences for gastrointestinal issues.

IV. Environmental Sanitation
A. General Sanitation
A review of policy titled, "Environment of Care (date 05/13)" documented the Plant Operations Manager would conduct monthly survey of the environment to identify items which included cleanliness. The policy documented the Plant Operation Manager would keep logs of surveys that would be presented quarterly at the leadership meetings. A review of four of four Leadership meeting minutes from 07/17 to 06/18 showed no environmental care log information.

A review of the document titled, "Housekeeping Department- Daily Work Schedule (date 1014)" showed patient bedrooms and bathrooms, group therapy rooms, seclusion room, and showers would be cleaned daily. The laundry room and cleaning showers in between patients or when contaminated were not addressed and "cleaning" was not defined.

A review of the document titled, "Deep Cleaning Procedures (11/12)" showed a deep cleaning including, but not limited to: walls, furniture, sinks, bathrooms would be done every three months and corridors would be done every six months in which areas/items would be "thoroughly and disinfected" using "friction".

On 06/28/18 at 11:00 am, Staff D stated a deep cleaning program had begun on 06/25/18.

On 06/14/18 at 8:18 am, Patient #9 stated the floor in the time out/seclusion room were dirty and "gross".

On 06/18/18 at 11:54 am, Staff U stated the facility had been "short staffed' in housekeeping for a couple of weeks.

On 06/28/18 at 1:13 pm, Staff H stated he/she "had not seen housekeeping around lately", and stated housekeeping services "used to be better."

On 06/18/18 at 11:45 am and 06/21/18 9:08 am, surveyors observed a large amount of patient activity papers, patients' drawings, and trash on the floor in the closet within the Big Group Room. Staff B stated that patients slide the items in the gap under the door.

On 06/18/18 at 2:36 am and 06/21/18 at 10:11am, Patient #5 was observed lying on the floor in the corridor, with and without a blanket. Staff B stated patients on the floor in the corridor in front of nursing station were patients who refused to go treatment and were being monitored.

On 06/28 8:30 am, in the presence of the Director of Quality, the surveyor used a saniwipe to gently wipe the perimeter of traffic areas in the following rooms and made these observations:
* Adolescent bedroom #16 showed a moderate amount lint, dirt, hair, food
* Toilet room floor by medication room showed a small amount of lint, dirt and hair
* Adolescent bedroom # 8, under mattress on bed frame showed a small amount of lint
* Adolescent seclusion room showed a large amount of peeled paint chips, lint, dirt, hair and brown stained 4x4 dressing (Surveyors observed patients lying on bare floor on 06/18/18 at 2:36 am and 06/21/18 at 10:11am and multiple other times during random tours).
* Adolescent laundry room showed a moderate amount of lint, dirt, hair
* Adolescent's Big Group Room showed a large amount of lint, dirt, hair, food, paper, crayon peeled paint, wrapper and a used bandaid.
* Adolescent corridor floor in front of nursing station showed a moderate amount of lint, dirt, hair (This was the same area that surveyors observed patients lying on bare floor on 06/18/18 at 2:36 am and 06/21/18 at 10:11am and multiple other times during random tours). On 06/27/18 at 11:47 am, Housekeeping was observed mopping around patients lying on the floor.

On 06/28/18 at 3:14 pm, upon looking at the dirty floor surveillance wipes, Staff BB stated that there were issues with cleaning.

On 06/19/18 at 11:27 am, Patient #17 was observed walking around in barefeet.

B. Cleaning Showers

A review of the policy titled, "Housekeeping Department--Patient Bath Areas (11/12)" described the cleaning/ disinfection process for bathrooms, but failed to address the cleaning/ disinfection requirements between patients.

On 06/14/18 at 8:18 am, Patient #9 stated if a patient "poops" in the shower, the staff spray the shower and watch the patient clean the shower stall.

On 06/21/18 at 10:16 am, Patient #2 stated the showers not cleaned between patients.

III. Patients' Personal Laundry

A review of Center for Disease Control and Protection (CDC) article titled, "Guidelines for Environmental Infection Control in Health-Care Facilities 6/03" documented extensive, detailed guidelines for laundering in a healthcare facility. "Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient apparel...The laundry facility in a health-care setting should be designed for efficiency in providing hygienically clean textiles, fabrics, and apparel for patients and staff..." The article specified the laundering processes including mechanical, thermal from 135 -160 degrees, and chemical factors that would render textiles hygienically clean. The article documented current control measures should be continued to minimize the contribution of contaminated laundry to the incidence of health-care-associated infections. The control measures described in the guidelines were based on principles of hygiene, common sense, and consensus guidance, and pertain to laundry services utilized by health-care facilities, either in-house or contract, rather than to laundry done in the home.

A review of policy titled, "Laundry Policy Procedures (date 11/12)" documented personal clothing of each patient was to be laundered by that patient using a washer and dryer provided in the hospital. The policy documented detergent would be provided by the hospital which would be measured by the patient. The policy documented if clothing was soiled with stool, the nursing staff would clean the clothing in a washer tub in hot water and adding one cup of bleach. The policy failed to protect the adolescent patients from the risk of exposure to chemical and mechanical hazards, and the risk of the required water temperature.

A review of policy titled, "Water Temperature (date 11/12)" documented water temperature should not exceed 110 degrees at the tap in all patient care areas. The policy showed the nursing staff would be responsible for checking the water temperature once each shift.

On 06/18/18 at 12:15 am, Staff D stated he/she did not know the water temperatures for the adolescent washing machine. Staff D stated no log of water temperature were measured and documented.

On 06/28/18 at 9:38 am, Staff DD stated stool soiled clothing washed in water and soap.

On 06/28/18 at 10:00 am, Staff U stated stool soiled clothing was precleaned in Odoban and water before laundered.

On 06/21/18 at 9:29 am, surveyors observed four large plastic tubes on the floor of the adolescent laundry room. The bins were not labeled with current patient names. Clothing was spilling from one tube to another. The tubs showed visible dirt on the rims.

On 06/19/18 at 11:25 am, surveyor asked Patient #18 if he/she was responsible for washing his/her personal clothing. In response, Patient # 18, who was standing in the corridor in front of the adolescent nursing station, walked into the adolescent laundry room without staff supervision, opening a cabinet to obtain liquid detergent, poured the detergent into the washer, and started a wash cycle. (The door to the laundry room was unlocked by maintenance for Life Safety Surveyor).

V. Lice Management
A review of document titled, "Infection Control Report 2017-2018" showed: 1st quarter of 2018= 5 lice cases, 2nd quarter of 2017= 8 lice cases, 4th quarter of 2017= 5 lice cases, and 3rd quarter of 2017= 9 lice cases. For all quarters, the report documented the ICP made the exact same recommendations regarding lice. The recommendation was to emphasize teaching patients and employees the importance of early detection and proper treatment; and limiting the sharing of clothing and hair brushes/ties, and stress the significance of cleaning/treating the environment and not only treating patient's hair. The recommendation shows no specific plan to teach staff and patients, evaluate policies, and no specific plan to observe practices.

A review of the policy titled, "Control of Lice (date 11/12)" documented all patients will be examined for the presence of head lice by a nurse upon admission and before being assigned to a room. The policy showed in the event that lice were found, all of the patient's clothing would be washed in hot, soapy water, and all linens would be removed with double bag method.

On 06/28/18 at 3:14 pm, Staff BB stated all patients have an admitting nursing assessment and sometimes the patients' clothing were piled in the room behind the adolescent nursing and not put in a bag before examined for lice.

On 06/21/18 at 9:29 am, surveyor observed multiple patients' belonging including, but not limited to a backpack and clothing piled on the floor in a room behind the nursing station. Staff C stated the belongings were those of newly admitted adolescent patients and needed to be inventoried.

VI. Skin Infection Management

A review of document titled, "Infection Control Report 2017-2018" showed: 1st quarter of 2018= 5 skin infections, 2nd quarter of 2017= 6 skin infections, 4th quarter of 2017= 8 skin infections, and 3rd quarter of 2017= 9 skin infections. For all quarters, the report documented the ICP made the exact same recommendations regarding skin infections that an emphasis should be placed on teaching patients and employees the importance of hand hygiene, proper treatment of infections, and cleaning / disinfection of environment. The recommendation shows no specific plan to teach staff and patients, evaluate policies, and no specific plan to observe practices.

A review of the document attached to the 03/15/18 Leadership Meeting Minutes titled "Infecion Cortrol Report 2017" showed 29 skin infections for 2017.

A review of a document titled, "Infection Control 2017 Evaluation" showed skin infections were "high risk priority" with most from self harm or wounds/ lesion. The evaluation's goal was that staff would receive education on steps to properly treat patient and environment.

A review of the medical record for Patient #5 documented the patient's action of self harm resulted in bleeding under his/her shirt.

On 06/21/18 at 10:11 am, surveyor observed Patient #4's left arm was scratched and bloody and was not covered by clothing or bandages..

On 06/28 8:30 am, the surveyor observed on the floors of the Adolescent's Big Group Room showed a large amount of lint, dirt, hair, food, paper, crayon peeled paint, wrapper and a used bandaid and in the Adolescent seclusion room showed a large amount of peeled paint chips, lint, dirt, hair and brown stained 4x4 dressing.

Based on record review and interview, the hospital failed to ensure an organ, tissue, and eye procurement policy was developed and addressed the facility's responsibilities to include, but not limited to timely notification within one hour of the patient's death, definition of imminent death per CMS requirements and the organ procurement agreement, and staff training requirements.

These failed practices had the likelihood for procurement opportunities to be missed for any patients who expired due to the lack of established processes and staff training.

Findings:

On 06/18/18 at 11:14 am, the surveyors requested the policies and procedures governing organ, tissue, and eye procurement. Staff B provided a policy titled, "Organ and Tissue Donation (date 12/12)" documented the hospital was "not capable of facilitating organ and tissues donations to organ procurement institutions" and failed to address the hospital's responsibilities for organ, tissue, and eye procurement.

On 06/19/18 at 8:48 am, Staff B stated the hospital had no other organ, tissue, and eye procurement policies than the one provided.

Based on record review and interview, the hospital failed to ensure five (Staff H, M, V, BB, and CC) of five RN staff had organ, tissue, and eye procurement training which included the required CMS curriculum.

This failed practices had the likelihood for procurement opportunities to be missed for any patients who expired due to the lack of established processes and staff training.

Findings:

A review of the documents titled, "Competency / Skill Checklist- Registered Nurse", "Competency / Skill Checklist-Licensed Practical Nurse", and "In-service Summary Sheet" showed no evidence of organ, tissue, and eye procurement (OPO) training as part of the hospital's orientation and annual staff training.

A review of the five (Staff H, M, V, BB, and CC) of five RN staff personnel files failed to contain evidence of OPO training.

On 06/20/18 at 10:20 am, Staff A stated the hospital staff did not have OPO training.

Based on record review, policy review, and interview the facility failed to provide Social Work Assessments that met professional social work standards, including conclusions and recommendations that described anticipated social work roles in treatment and discharge planning. This resulted in a lack of professional social work treatment services and/or lack of input to the treatment team for eight (8) active sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8.)

Findings Include:

A. Medical Record Review

1. Patient A1's Integrated Biopsychosocial Assessment, dated 5/3/18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

2. Patient A2's Integrated Biopsychosocial Assessment, dated 5/23/18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

3. Patient A3's Integrated Biopsychosocial Assessment, dated 6/6/18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

4. Patient A4's Integrated Biopsychosocial Assessment, dated 6/8/18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

5. Patient A5's Integrated Biopsychosocial Assessment, dated 6/8/18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

6. Patient A6's Integrated Biopsychosocial Assessment, dated 4/26/18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

7. Patient A7's Integrated Biopsychosocial Assessment, dated 6/6 /18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

8. Patient A8's Integrated Biopsychosocial Assessment, dated 5/26/18, failed to document an assessment or conclusions or the role of the social service staff in discharge planning based on the data obtained in the biopsychosocial assessment.

B. Policy Review

Hospital Policy Number CS-002, last revised 10/26/12, titled, "Inpatient Sub-Acute Clinical Policy and Procedure Subject Psychosocial Evaluation," Section 3, states the following requirement for a Psychosocial Evaluation ... "Recommendations describing anticipated social work roles in treatment," and does not require conclusions based upon the data obtained.

C. Interview

1. In an interview on 6/19/18 at 1:30 p.m., the Director of Clinical Services concurred with the findings regarding Biopsychosocial Assessments.

Based on medical record review, document review, and interview, the facility failed to provide treatment plans that identified patient-related, short-term and long-term goals, documented in observable, measurable, behavioral terms for seven (7) of eight (8) active sample patients (Patients A1, A2, A3, A5, A6, A7 and A8). In addition, the goals for the active sample patients on the latency unit (Patients A5, A6, A7 and A8) were not age appropriate. This deficiency has the potential to result in a document that fails to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients.

Findings Include:

A. Medical Record Review

1. Patient A1 had a Master Treatment Plan (MTP) dated 5/31/18. For the problem, "Risk of harm to self and others," the non-measurable short-term goal was, " [Patient] will identify triggers to [his/her] suicidal ideation, self-harm, and aggression, and implement positive cognitive processing patterns that maintain a realistic and hopeful perspective on a daily basis before stepping down to Acute Level 2."

2. Patient A2 had an MTP dated 5/22/18. For the problem, "Mood Disturbance," the non-measurable short-term goal was, "[Patient] will identify and communicate thoughts, feelings and needs to adults, and peers in an assertive, honest manner as opposed to resorting to defiant behaviors or threats (punching objects, aggression to others) 4 of 7 days weekly as evidenced by staff documentation by 6/22/18."

3. Patient A3 had an MTP dated 6/7/18. For the problem, "Risk of Harm to Self," the non-measurable short-term goal was, "Patient] will state the strength of the suicidal feelings, the frequency of the thoughts, and the detail of the plans on a daily basis before stepping down to acute level 2 status. S/he will also work on implementing, appropriate coping skills in order to reduce feelings of depression instead of thinking [he/she] needs to kill [himself/herself}."

4. Patient A5 (five years old) had an MTP dated 6/8/18. For the problem, "Past Trauma/Abuse," the non-measurable, non-age appropriate short-term goal was, "[Patient] will learn and implement personal self-management skills to manage emotional reactions related to trauma and other stressors 3 of 7 days by 07/0/2018."

5. Patient A6 (eight years old) had an MTP dated 4/26/18. For the problem, "Risk of harm to self and others," the non-measurable, non-age appropriate short-term goal was, "[Patient] will identify triggers to his/her suicidal ideation, self-harm, such as banging his/her head, and aggression, and implement positive cognitive processing patterns that maintain a realistic and hopeful perspective on a daily basis before stepping down to Acute Level 2."

6. Patient A7 (eight years old) had an MTP dated 6/6/18. For the problem, "Mood Disturbance," the non-measurable, non-age appropriate short-term goal was, "[Patient] will identify and communicate thoughts, feelings and needs to adults, family, and peers in a controlled, honest and mutually respected manner as opposed to resorting to aggressive behaviors or self harm designed to manipulate others as evidence by staff documentation 5 out of 7 days by 7/6/18."

7. Patient A8 (eight years old) had an MTP dated 5/24/18. For the problem, "Past Trauma/Abuse," the non-measurable, non-age appropriate short-term goal was, "[Patient] will identify, challenge, and replace fearful self-talk with reality-based, positive self-talk 3 of 7 days by 06/28/2018."

B. Policy Review

Review of policy titled, "Treatment Planning," number CS-011, revised 10/26/12, stated, "This Objective [short-term goal] will be a measurable, behavior specific, and time-limited statement of what the patient is expected to accomplish during the course of hospitalization."

C. Interview

In interview on 6/20/18 at 9:00 a.m., the Clinical Director agreed that the short-term goals were not measurable.

Based on record review, document review, and interviews, the facility failed to provide ongoing physician assessment, evaluation, and treatment to ensure that three (3) of eight (8) active sample patients could achieve their optimal level of function (Patients A4, A6, and A8). Specifically, the facility followed a policy that specified that the psychiatrist would see patients once weekly when moved to Acute 2 status. The facility failed to take into account the acuity of the patient or their individualized needs for psychiatric treatment. Failure to provide psychiatric evaluation and treatment on an ongoing basis can delay recovery of acutely ill patients.

Findings Include:

A. Medical Records

1. Patient A4

Patient A4, a 13-year-old, was admitted on 4/23 /18. The admission Psychiatric Evaluation dated 4/23/18 listed diagnoses of "Major Depressive Disorder, recurrent, Severe; Attention Deficit Hyperactivity Disorder, combined presentation, and Oppositional Defiant Disorder." He/she stated on admission "I just want to kill myself right now." Past psychiatric history revealed, "The patient has reportedly attempted to hang [him/herself] with a charger cord in the past." This patient had a history of multiple hospitalizations including three during 2018. On 4/28/18 the patient was moved from level Acute 1 (3 physician visits per week) to level Acute 2 (one physician visit per week).

Review of Physician Orders of pharmacologic and behavior management by Nursing Staff from 4/24/18 to 6/19/18 revealed that Patient A4 had multiple psychopharmacological and behavioral interventions but continued to have aggressive, out of control behavior, self-harm behavior and continued to be evaluated by a physician only once weekly. The orders showed the following interventions:

4/24/18- "Start pt [patient] on AWOL [Absent Without Leave], Assault, close obs [observation], suicide, self-harm [with] q [every] 15 minute check precautions."

4/24/18- "Pt placed on 1:1 for suicidal ideations."

4/27/18- "(1) Physically managed Pt in two-man prone containment [manual hold] (1548-1602) for 14 minutes due to physical aggression. (2) give Haldol [antipsychotic]5 mg [milligram] IM [intramuscular] X 1 now."

4/28/18-"stepdown from Acute 1 to Acute 2." [Current facility practice indicated level Acute 1 requires three doctor visits per week and Acute 2 requires only 1 doctor visit per week.]

5/1/18- "Continue precautions of suicide, self-harm, AWOL, Close obs , Assault, SVC [strict visual contact.]"

5/1/18-"physically managed [manual hold] on 5/1/18 on two occasions. Continue Precautions: AWOL, Suicide, Self harm, Close observation. Administer Zyprexa Zydis 5 mg [antipsychotic] po."

5/1/18- "physically manage pt from 1300 to 1333 for severe agitation. When calm give extra dose of Seroquel 100 mg."

5/2/18- "Give extra dose of Benadry [antihistamine] (50 mg) po x 1 now for agitation."

5/16/18- "Continue precautions: suicide, self-harm, close obs, assault, SAD [sic], LOS [line of sight] x 7 days."

5/20/18- "Continue precautions: Suicide, self-harm, close obs, Assault, SAO [sic], LOS x 7 days."

5/25/18- "physically manage from 1450 - 1500. For severe agitation. Give Haldol 5 mg IM now. Release when calm."

5/29/18- "Continue precautions: Suicide, self-harm, close obs, Assault, SAO [sic], LOS [line of sight] x 7 days."

6/5/18- "Continue precautions: Suicide, self-harm, close obs, Assault, SAO [sic], LOS [line of sight] x 7 days."

6/12/18- "continue precautions: suicide, self-harm, close obs, assault x 7 days."

6/12/18- "Physically manage from 1800-1815."

6/13/18- "Physically manage from 1317 to 1318 for agitation; 1:1 TO.[time out] room for up to 2 [hours]."

6/18/18- "Physically manage pt from 1350 - 1400 for self-harm/agitation."

6/19/18- "1:1 time out room c [with] staff" and later "physically manage pt from 1340 to 1347 for self-harm/agitation."


Review of Physician Progress supplied by the facility indicated the following frequency of notes: 4/26/18, 5/1/18, 5/22/18, 5/29/18, 6/5/18, and 6/12/18.

Patient A4 was reviewed at Treatment Team Meeting on 6/19/18 at 10:00 a.m. The following report of the patient's behavior for the week was read by RN 2:

6//12/18- "intrusive, defiant at med [medication] room door refusing to leave making it difficult for peers to get meds [medications.] Tried to unlock T/O [timeout] room door while peer in there."

6/13/18- "walked out of school pm, walking out of group."

6/14/18- "Didn't attend school .... cursing at peers."

6/15/18- "Refusing to get out of bed, throwing things at desk, does as pleases, numerous T/O, ripped up papers on desk, stealing."

6/16/18- "Knocked off phone in dining rm [room]."

6/17/18- "Does as he wants, Bully major-making fun of peers."

6/18/18- "grabbed staff's leg and wouldn't let go."

6/21/18- "SH [self harm] scratching arm with fingernail. Pull paint off the door frame in craft room."

B. Interview

1. In an interview on 6/18/18 at 12:15 p.m., RN2 indicated that Patient A4 was a difficult management problem. During the interview, Patient A4 was intrusive and continued to demand a great deal of RN2's attention.

2. In an interview on 6/18/18 at 1:05 p.m., Patient A4 talked about having been refused entrance into two other facilities. S/he talked about being in three other facilities this year, throwing rocks at "a Kid" and planning on not going to school when s/he left this facility.

3. In an interview on 6/19/18 2:05 p.m., the Medical Director confirmed that usually patients were transferred from Acute 1 to Acute 2 on the fourth day after admission. He also acknowledged some patients could benefit from more individualized attention.

2. Patient A6

Patient A6 was admitted on 4/24/18. The Psychiatric Evaluation dated 4/25/18 revealed that the patient was admitted for stating that s/he was hearing voices to kill her/himself by jumping off a building. The patient had a history of a previous suicide attempt and on admission stated that s/he wanted to die. There was ,also, a history of head banging and throwing self against walls when angry. On 4/28/18 Patient A6 was moved from Acute 1 to Acute 2 and started seeing the physician once per week.

Review of Physician's Order (from 5/2/18- 6/13/18) revealed that Patient A6 continued to have aggressive and self-harm episodes even though s/he remained on Acute 2 and was assessed and evaluated by the physician only once weekly. The orders showed the following interventions:

5/3/18- Seclusion for hitting walls, aggression, and throwing feces.

5/6/18-Manual hold due to aggression and Benadryl (antihistamine) 25mg IM (intermuscular) for severe agitation.

5/7/18-Placed on AWOL (absent without leave) precautions. (runaway risk).

5/8/18-Manual hold for physical aggression with Zyprexa 2.5mg (antipsychotic medication) and Benadryl 25 mg IM.

5/9/18-Order to continue suicidal, AWOL, self-harm, and assault precautions.

5/16/18-Renewal order to continue suicidal, AWOL, self-harm, and assault precautions.

5/17/18-Manual hold due to aggression and self-harm with Zyprexa 2.5mg and Benadryl 25mg IM for severe agitation.

5/21/18-Manual hold for physical aggression with Zyprexa 2.5mg and Benadryl 25mg IM for physical aggression.

5/23/18- Renewal order to continue suicidal, AWOL, self-harm, and assault precautions.

5/23/18- Manual hold for self-harm with Zyprexa 5mg and Benadryl 25mg IM.

5/24/18-Zyprexa Zydis 5mg SL (sublingual-under the tongue) for severe agitation.

5/25/18-Zyprexa Zydis 5mg SL for severe agitation.

5/27/18-Manual hold for self-harm/aggression with Zyprexa Zydis 5mg and Benadryl 25mg po (by mouth) for physical aggression and self-harm.

5/28/18-Zyprexa 5mg po for continued agitation and aggressive behavior.

5/28/18-Manual hold for self-harm with Zyprexa 5mg and Benadryl 25mg IM.

5/29/18- Zyprexa 5mg po for continued agitation and aggressive behavior.

5/29/18-Manual hold for aggression with Zyprexa 5mg and Benadryl 50mg for aggression.

5/30/18- Renewal order to continue suicidal, assault, AWOL and self-harm.

5/30/18-Seclusion order with no behavior listed.

5/31/18- Manual hold for severe aggression with Benadryl 25mg IM.

6/1/18-Seclusion for severe physical aggression.

6/2/18-Seclusion for aggression.

6/2/18- Manual hold for aggression with Zyprexa 2.5mg and Benadryl 25mg IM for severe agitation.

6/3/18-Manual hold for physical aggression with Zyprexa 2.5mg and Benadryl 25mg IM.

6/6/18- Renewal order to continue suicidal, assault AWOL and self-harm precautions.

6/6/18-Manual hold for climbing on desk and aggression with Benadryl 25mg IM.

6/8/18- Seclusion for aggression.

6/9/18- Manual hold for severe aggression and self-harm with Zyprexa 2.5mg and Benadryl 25mg IM.

6/10/18-Seclusion with Zyprexa 2.5mg and Benadryl 25mg IM for severe aggression.

6/11/18- Seclusion for aggression.

6/11/18- Manual hold with Zyprexa 10mg for choking him/herself.

6/12/18- Manual hold with Thorazine 50mg (antipsychotic medication) for physical aggression.

6/13/18- Renewal order to continue suicidal, self-harm, AWOL, and assault precautions.

Review of Physician's Progress Notes from 4/25/18- 6/13/18 revealed notes were written for Patient A6 on 4/25/18, 4/26/18, 5/2/18, 5/9/18, 5/16/18, 5/23/1, 5/30/18, 6/6/18, and 6/13/18. Progress notes from 5/2/18 to 6/13 included:

5/2/18-"Has been quite hyperactive & impulsive. Defecated in shower, smeared feces."

5/9/18- "Patient required seclusion & physical mgmts. [management-manual hold] due to aggressive behavior."

5/16/18-"Patient threw feces at staff member. Urinated when angry. Had angry outbursts."

5/23/18- "Has become more aggressive, requiring physical management x [times] three."

5/30/18-"Patient has had multiple physical mgmts (managements), required extra meds, due to combative behavior."

6/6/18-"Has had multiple seclusions & physical mgmt."

6/13/18-"Pt required physical mgmts, seclusions, extra meds [medications] due to aggression & self harm. Soils [him/herself], disrobes, inserts digits in rectum, smears feces."

B. Interview

1. In interview on 6/19/18 at 12:45 p.m., Therapist 3 stated that Patient A6 "Is not progressing at all." Therapist 3 further stated that Patient A6 was "worse than when [s/he] came in." She acknowledged that she only sees Patient A6 twice weekly because s/he is on Acute 2 and not Acute 1.

2. In an interview on 6/19/18 2:05 p.m., the Medical Director confirmed that usually patients were transferred from Acute 1 to Acute 2 on the fourth day after admission. He, also, acknowledged some patients could benefit from more individualized attention.

3. In interview on 6/20/18 at 10:30 a.m., the Clinical Director stated that even though there was a process to move patients from Acute 2 to Acute 1 where they would receive more physician and therapist time, there was no request made to do so for Patient A6.

3. Patient A8

Patient A8 was admitted on 5/22/18. The Psychiatric Evaluation dated 5/23/18 stated that the patient was admitted for threatening to kill his/her brother and sister. Patient A8 had been hospitalized twice in the two months prior to the current admission for aggression, defiance, and homicidal threats. There was also a history of aggression towards peers at school and aggressive outbursts. On 5/26/18 Patient A6 was moved from Acute 1 to Acute 2 and started seeing the physician once per week.

Review of Physician's Order (from 5/28/18- 6/18/18) revealed that even though Patient A8 continued to be aggressive, he/she remained on Acute 2 and was assessed and evaluated by the physician only once weekly. The orders showed the following interventions:

5/28/18- Order to give extra Seroquel (antipsychotic) 50 mg po for continued agitation/aggression.

5/30/18-Renewal order to continue assault and close observation precautions.

6/2/18- Order to give an extra dosage of Seroquel 50 mg po for continued agitation/severe agitation.

6/6/18-Renewal order to continue assault and close observation precautions.

6/11/18-Manual hold due to self-harm and Zyprexa 2.5 mg and Benadryl 25 mg IM for severe agitation.

6/13/18-Renewal order to continue assault and close observation precautions.

6/17/18- Order for Zyprexa 2.5 mg po for severe agitation.

6/18/18-Order for Zyprexa 2.5 mg and Benadryl 25 mg po for severe agitation.

Review of Physician's Progress Notes from 5/30/18- 6/13/18 revealed notes were written for 5/30/18, 6/6/18 and 6/13/18. The progress notes included:

5/30/18-"Patient is defiant, threatening, tearful, verbally abusive. Had several aggressive incidents. Threatened to choke self. Urinated on floor. Poor behavior in classroom."

6/6/18- "Patient is overactive, aggressive, impulsive, provocative. Requiring physical mgmt. & extra meds."

6/13/18-"Patient is defiant and disruptive. Verbally abusive to peers. Threatens others, has been aggressive & required physical mgmt. Poor behavior in school & groups. Has nocturnal enuresis. Behavior worsens in p.m."

B. Interview

1. In interview on 6/19/18 at 1:30 p.m., Therapist 4 described Patient A8 as "Very angry." She further stated that the patient threatens to kill others and physically acts out, hitting and kicking and requires 24/7 redirection. Therapist 4 acknowledged that she only sees Patient A8 twice weekly because s/he is Acute 2 and not Acute 1.

2. In an interview on 6/19/18 2:05 p.m. the Medical Director confirmed that usually patients were transferred from Acute 1 to Acute 2 on the fourth day after admission. He also acknowledged some patients could benefit from more individualized attention.

B. Document Review

The surveyors were given a copy of a policy from the Oklahoma Health Care Authority (OHCA), titled, "Active Treatment for Children," 317:30-5-95.34. Although the facility has not incorporated this policy into a hospital policy, they were following the OHCA policy. The policy outlines requirements for active treatment for acute care facilities and PRTFs (Psychiatric Residential Treatment Facilities). Based on the facility's understanding of the policy, they could offer two levels of care to acute inpatients (Acute 1 and Acute 2), which would be billed differently. Acute 1 patients received 17 hours of active treatment per week while Acute 2 patients received 14 hours. In addition, Acute 1 patients were scheduled for three (3) sessions per week with the psychiatrist and three sessions with a therapist. Acute 2 patients were scheduled for one (1) session per week with the psychiatrist and two (2) sessions per week with the therapist. Patients are moved from one level to the other with minimal consideration of the patients' clinical status or needs.

Based on record review, document review, and interviews, the Medical Director failed to ensure ongoing physician assessment, evaluation, and treatment to ensure that three (3) of eight (8) active sample patients could achieve their optimal level of function (Patients A4, A6, and A8). Specifically, the facility followed a policy that specified the psychiatrist would see patients once weekly when moved to Acute 2 status. The facility failed to take into account the acuity of the patient or their individualized needs for psychiatric treatment. Failure to provide psychiatric evaluation and treatment on an ongoing basis can delay recovery of acutely ill patients. (Refer to B125)

Interview

In an interview on 6/19/18 at 2:05 p.m., the Medical Director confirmed that usually patients were transferred from Acute 1 to Acute 2 on the fourth day after admission. He also acknowledged some patients could benefit from more individualized attention.