HospitalInspections.org

Based on observation, interview, and document review, the hospital's Governing Body failed to meet the requirements at 42 CFR 482.12 Condition of Participation for Governing Body due to the following failures:

Findings:

Surveyors notified hospital administrators that a state of immediate jeopardy existed due to the following:

The Governing Body failed to effectively manage the functioning of the hospital to protect patients and staff from harm as evidenced by the (6) six immediate jeopardy conditions identified on 10/29/2015, 11/2/2015, 11/4/2015 and 11/5/2015 in the following areas:

1. Failure to ensure that the hospital developed and implemented a hospital-wide Quality Assessment and Performance Improvement program that developed effective and timely action plans when problems were identified.

2. Failure to provide sufficient numbers of trained and competent patient care staff members;

3. Failure to develop and implement an effective infection control program that ensured systems for infection surveillance and minimizing infection risks were developed and implemented;

4. Failure to provide a "Culture of Safety" in the patient care environment, as defined by the establishment of a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment; collaboration across all ranks and disciplines to seek solutions to patient safety problems; and organizational commitment of resources to address safety concerns.

5. Failure to ensure the hospital used restraints on patients, only as needed to ensure the physical safety of patients and staff members.

The Governing Body's failure to identify and correct the deficiencies described above, resulted in a healthcare environment that was unsafe for patients and staff members.

Due to the scope and severity of deficiencies detailed under 42 CFR 482.13 Condition of Participation for Patient Rights; 42 CFR 482.21 Condition of Participation for Quality Assessment and Performance Improvement; 42 CFR 482.23 Condition of Participation for Nursing Services; and 42 CFR 482.42 Condition of Participation for Infection Control, the Condition of Participation for Governing Body was NOT MET.

Cross-Reference: Tags A0083; A0115; A0263; A0385; A0747
.

.
Based on observation, interview, document review, the hospital failed to ensure that the hospital provided patients with care in a safe setting and protected them from immediate harm.

Failure to protect and promote each patient's rights risked the patient's loss of personal freedom, dignity, physical and psychological harm. The cumulative effects of these systemic problems resulted in the hospital's inability to provide for patient and staff safety, resulting in the surveyors' declaration of multiple immediate jeopardy situations.

Findings:
.
On 10/29/2015 at 12:00 and 2:00 PM, the surveyors notified hospital administrators that multiple immediate jeopardy situations existed due to the following:

Insufficient numbers of trained and competent patient care staff, a root cause identified by the facility during internal investigations of problems related to assaults;

Failure to provide a "Culture of Safety" in the patient care environment, as defined by the establishment of a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment; collaboration across all ranks and disciplines to seek solutions to patient safety problems; and organizational commitment of resources to address safety concerns.


Failure to take immediate, effective action for known patient safety concerns;

High rates of patient-to-patient and patient to staff assaults;

Ineffective communication between administration and physicians and direct care staff;

Not selecting the least restrictive alternative to restraint use;

Ordering restraints on an "as needed" basis;

Failure to monitor the patient as directed by hospital policies and procedures;

Failure to release the patient from restraints at the earliest possible time;

Failure to develop and implement a plan for reduction of restraint use for individual patients;

Failure to address gaps in documentation and use of restraints, after multiple deficiencies cited by various agencies during surveys and investigations conducted between 2013 and 2015.

Due to the scope and severity of deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET.

Cross Reference: Tags A0118, A0143, A0154, A0164, A0169 A0174, A0175, A0194, A0392, A0396, A0397
.

Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop and implement a hospital-wide quality assessment and performance improvement (QAPI) plan.

Failure to systematically collect and analyze hospital-wide performance data and to develop action plans to improve performance based on that data resulted in sub-standard clinical care and poor patient outcomes. The cumulative effects of these systemic problems resulted in the hospital's inability to provide for patient and staff safety, resulting in immediate jeopardy.

Findings:

On 11/2/2015 at 4:00 PM, the surveyors notified hospital administrators that a state of immediate jeopardy existed due to the following:

Failure to analyze Adverse Occurrence and Incident Reports regarding patient to patient and patient to staff assaults for contributing factors; such as when patients assaulted other patients and staff while on 1:1 observation status;

Failure to collect and analyze data regarding "near miss" events, such as patient pre-assaultive behaviors and medication errors that did not meet a narrow definition developed by the hospital;

Failure to develop and implement action plans in response to data collected from the Culture of Safety survey in April 2015, which indicated serious concerns regarding the hospital's work environment;

Failure to develop performance improvement plans and projects related to data analysis performed in August 2015 related to patient to patient and patient to staff assaults;

Failure to develop performance improvement plans and projects related to goals that were approved by the hospital's Governing Body in August 2015:

Due to the scope and severity of deficiencies cited under 42 CFR 482.21, the Condition of Participation for Quality Assurance and Performance Improvement was NOT MET.

Cross Reference: Tags A0286, A0297, A0308, A0309

.

.
Based on observation, interview, and document review, the hospital failed to ensure the hospital had at all times, a sufficient number of trained registered nurses, licensed practical nurses, and mental health technicians to deliver safe and effective care to patients.

Failure to ensure the hospital provided enough staff to meet patient needs resulted in sub-standard care and risk of delayed treatment.

The cumulative effects of these systemic problems resulted in the hospital's inability to provide for patient and staff safety, resulting in immediate jeopardy.

Findings:

On 11/14/2015 at 1:45 PM, the surveyors notified hospital administrators that a state of immediate jeopardy existed due to the following:

The hospital failed to develop and implement an action plan to provide sufficient numbers of trained and competent patient care staff, a root cause that was identified by the hospital during internal investigations of problems;

Failure to ensure that all staff members assigned to patient care units are familiar with and know the needs of the patient on that unit prior to beginning their shift;

Failure to ensure that the number of assigned personnel allows for treatment planning and delivery, as ordered by the treatment team;

Failure to ensure that all personnel assigned to patient care have been trained and demonstrate competencies for care delivered, such as conducting suicide and assault risk assessments, and implementation of therapeutic engagement and restraint and seclusion protocols;

Failure to ensure that a registered nurse makes patient care assignments;

Failure to ensure that staff are used according to their professional qualifications, such as assigning registered nurses to transport patients to and monitor patients at the treatment mall; to perform 15 minute ward checks; to dish up food and serve it to the patients; and to perform unit cleaning tasks.

Due to the scope and severity of deficiencies cited under 42 CFR 482.23, the Condition of Participation for Nursing Services was NOT MET.

Cross Reference: Tags A0175, A0192, A0392, A0396, A0397


.

.
Based on observation, interview, record review, and review of the hospital's infection control program, the hospital failed to develop and implement an effective infection prevention and control program.

Failure to systematically perform surveillance, prevent the spread of infections, and control infections risks transmission of infections between patients.

Findings:

On 11/5/2015 at 3:00 PM, the surveyors notified hospital administrators that a state of immediate jeopardy existed due to the following:

The hospital failed to develop and implement infection control policies and procedures based on current Centers for Disease Control (CDC) guidelines;

The hospital failed to ensure that patient-care staff members were knowledgeable of and utilized transmission-based precautions according to hospital policies and CDC guidelines.

The hospital failed to develop an effective infection surveillance system to track and trend incidence and prevalence of infections, such as multi-drug resistant organisms; and to determine whether healthcare acquired infections were the result of poor infection control practices

The hospital failed to implement a program for fit-testing N95 masks for all staff who may be involved in airborne infectious disease outbreaks, such as tuberculosis.

Due to the scope and severity of deficiencies cited under 42 CFR 482.42, the Condition of Participation for Infection Control was NOT MET.

Cross Reference: A0749
.

.
Based on observation and interview, the hospital failed to post the nurse staffing plan in a public area on each patient care unit for 2 of 2 clinical units observed.

Failure to post nurse staffing plans creates a risk that patients and other members of the public and hospital staff are not aware of nurse staffing levels, which may contribute to quality of care issues.

Reference: RCW 70.41.420 Nurse staffing committee
(7) Each hospital shall post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for that shift on that unit, as well as the relevant clinical staffing for that shift. The staffing plan and current staffing levels must also be made available to patients and visitors upon request.
.
Findings:


1. On 10/27/2015 at 8:50 AM, Surveyor #2 noted no nurse staffing plan for clinical unit F-1 posted for the public.

2. On 10/27/2015 at 10:25 AM, Surveyor #2 noted no nurse staffing plan for clinical unit F-2 posted for the public.

3. On 11/3/2015 at 1:30 PM, Surveyor #2 interviewed a registered nurse (Staff Member #54) about where the hospital posted the nurse staffing plan and nurse time schedule. S/he stated the nurse time schedule was located in the staff break room. S/he was unable to locate a nurse staffing plan for the current shift and was unfamiliar with that term. Staff Member #54 indicated the patient care assignment sheet was posted on each shift at the nurse's station.
.

.
Based on interview, the hospital failed to develop and implement a process for evaluation of the quality of care provided by hospital patient-care contractors.

Failure to determine whether patient care contractors meet all Medicare Conditions of Participation and standards risks provision of ineffective and unsafe healthcare to patients.

Findings:

1. On 10/28/2015 between 9:00 AM and 11:15 AM, Surveyor #5 interviewed the hospital's Director of Quality (Staff Member #2) who indicated that there is currently no process for ensuring that the quality program evaluates the performance of patient care contractors who were not granted privileges through the hospital's medical staff credentialing process to assess their compliance with all Medicare Conditions of Participation. These patient care contractors provide services that include radiology services and sex offender treatment and counseling.

2. On 10/282015 at 2:45 PM, Surveyor #5 confirmed this finding during an interview with the Contract Manager (Staff Member #30) for Consolidated Business Services, Incorporated (CIBS).

Cross Reference: Tag A0308
.
.

.
Based on observation, interview, and review of hospital policy and procedure, the hospital failed to resolve patient complaints in a timely manner.

Failure to promptly address patient grievances risks patient safety and delayed treatment for unmet care needs.

Findings:

1. The hospital policy and procedure titled "GRIEVANCE/COMPLAINT RESOLUTION AND RESPONSE" (Revised 8/26/2013) read in part: "WSH will provide timely response to patient complaints, including allegations of patient rights violations, ensuring the patient receives fair and courteous treatment. If the grievance cannot resolve within 7 days, a letter of acknowledgement must be sent and will include the anticipated date when the resolution/response will be completed."

2. On 10/27/2015 at 10:00 AM, Surveyor #6 and Surveyor #10 observed Patient #35 at the nurse's station asking about when his/her glasses could be "fixed". Surveyor #6 noted that the patient's eyeglasses had damage in multiple places. Patient #35 spoke with the surveyors indicating s/he uses glasses for activities of daily living. Hospital staff informed the patient that his/her name had been posted to the white board communicating it "was to get done" and an escort would come and take the patient to get the glasses repaired once they could arrange for the service.

3. On 10/28/15 at 1:30 PM, Surveyors #6 and #10 followed up with Staff Member #62 regarding the repair status for the glasses. Staff Member #62 told them that the patient's glasses remained broken. Staff Member #62 reported s/he would make out a "ticket" which would then initiate an escort to take the patient to vision services.

4. On 11/2/2015 at 10:00 AM on Ward C-6, Surveyor #6 noted the patient walking in the hallway toward the lunchroom with the unrepaired glasses resting on the bridge of the nose and the left side secured to the left ear. The surveyor observed the right ear piece was missing from the frame.

5. On 11/2/2015 at 2:00 PM, Surveyor #6 interviewed Staff Member #5 who reported that on 11/3/2015, s/he had received an email with the status of the glasses, which stated:

"I took (Patient #35)'s glasses over to be fixed and they did not have the right bands, screws or otherwise. Now (s/he) must be put on the wait list which is still full for pts (sic) from March of this year (2015)."

Based on the date of the email, the wait list was at least seven months long.


6. At the time of exit conference on 11/5/2015, Patient #35 was still using his/her broken frame glasses.

.

.
Based on observation and review of hospital policies and procedures, the hospital failed to protect the patients' right to personal privacy for 3 of 3 clinical units (87 beds total).

Failure to provide physical privacy risks patients' loss of personal dignity and freedom while performing personal hygiene and dressing activities.

Findings:

1. The hospital's patient handbook (dated 2013-2014) under "Basic Rights" read in part: "You have the right to: 1. Be treated with dignity and respect, consistent with the principles of recovery."
The hospital form WSH 1-29 (Revised 04/15) titled "PATIENT RIGHTS" under the section "The Right to Privacy" read in part: " You have the right to: 2. Be protected from invasion of privacy."

2. During a tour of clinical unit F-1 on 10/27/2015 at 8:50 AM, Surveyor #2 observed that patient room doors had no window coverings, allowing any staff member or patient to observe inside the room, which included the toilet/commode and hand washing sink areas. There was no place patients could change their clothes in a private place.


3. During a tour of clinical unit F-2 on 10/27/2015 at 10:25 AM, Surveyor #2 observed a patient room door with a white cloth taped over the window insert. The surveyor observed that the white cloth could be moved, allowing any staff or patient to observe inside the room, which included the toilet/commode and hand washing sink areas.

4. During a tour of clinical unit F-5 on 10/27/2015 at 11:45 AM, Surveyor #2 observed patient room doors with red cloth window coverings located on the outside of the door. The window covering could be moved, allowing any staff or patient to observe any activity inside the room.
.

.
Item #1: Safe from Self-Harm

Based on interview, observation and document review,the hospital failed to ensure patients' right to receive care in a safe setting by providing a sufficient number of properly trained and competent staff.

The hospital's failure to have patient care staff members who were trained in recognition of suicidal ideation and intervention, and failure to properly communicate patients' risk of suicide to unit staff members, placed patients at risk of injury and death due to self-harm.

Findings:

1. Western State Hospital Patient Handbook, 2013-2014, "Basic Rights for Patients" stated in part: " You have the right to: 2. Live in a humane environment that affords protection from harm. "

2. On 11/5/2015, Surveyor #4 reviewed the medical record and hospital incident report for patient #4, which included the following information:

a. The patient's record documented s/he was admitted to the hospital 1/16/2015 after a suicide attempt and at that time the patient was distraught about going to prison for assault. There was no information in the record indicating the facility assessed the patient for risk of suicide or provided interventions to monitor the patient for suicidal thoughts.

b. On 8/27/2015, the patient stated to several staff members that s/he was going to jail. Staff members caring for the patient did not recognize that the delusion about going to jail could potentially be related to suicidal thoughts and as a result, the hospital did not develop or implement a treatment plan for care that included interventions to address the issue.

c. On 8/29/2015 at 4:03 pm, a Licensed Practical Nurse (LPN) opened the bathroom door looking for Patient #4. When the door opened, the patient fell to the floor unconscious. The patient had a sheet tied around his/her neck. The other end of the sheet was held in place (until the door was opened) by the top of the closed bathroom door. Cardiopulmonary Resuscitation was performed without success and the patient died at 4:23 P.M.

d. On 8/29/2015 [time not identified] an entry in Patient #4's record indicated s/he was "Pleasant and cooperative. "

e. Review of hospital documentation indicated several staff members working on the unit on 8/29/2015 were not offered suicide training during new employee orientation. In addition, surveyor #4 noted that on-call staff had limited knowledge related to suicide training. On the day of the patient's suicide, 5 of 11 staff members were on-call staff.

f. At the time of the incident, the unit had 4 of 30 patients on 1:1 monitoring. Patient #4 was not on 1:1 monitoring.

g. The unit was equipped with two safety rooms for suicidal patients. Hospital staff did not provide Patient #4 with access to the "safety room" because they did not know that these rooms were used for this purpose. Staff members referred to the rooms as "observation rooms."

Item #2- Safe Environment

Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to provide a safe and secure environment for patients and/or staff.

Failure to maintain a safe and secure environment risked serious injury or death for patients, staff, and visitors in the hospital.

Findings:

1. Between 11/3/2015 and 11/5/2015, Surveyor #4 reviewed the medical record and hospital incident reports for patient #23, which included the following information:

Patient #23 was admitted to the hospital in 1990 with diagnoses of mood disorder and developmental delay. Review of the hospital- recorded incidents revealed that Patient #23 had assaulted other patients 17 times between 4/10/2015 and 10/27/2015:

a. On 4/10/2015, the patient punched another patient in the face, causing bruising.

b. On 4/15/2015, the patient was in an altercation with several other patients resulting in injuries to another patient. Hospital staff placed the patient in restraints.

c. On 5/12/2015, the patient struck another patient in the head resulting in injury to the other patient. Hospital staff placed patient #23 in restraints.

d. On 6/14/2015, the patient struck another patient in the head, resulting in injuries to the other patient. Hospital staff placed Patient #23 in seclusion.

e. On 7/11/2015, the patient struck another patient in the head, resulting in injuries to the other patient, which required a hospital visit. An entry in the report stated, "Treatment team needs to come up with a plan to protect physically vulnerable patients."

f. On 7/17/2015, the patient was in an altercation with several other patients. The record noted no injuries. The patient was secluded in his/her room with an open door.

g. On 7/27/2015, the patient struck another patient in the head, resulting in a superficial injury.

h. On 8/2/2015, the patient struck another patient in the face resulting in substantial injury with bleeding to the mouth and nose.

i. On 9/9/2015, the patient struck another patient with his fists. No injuries were sustained.

j. On 9/12/2015, the patient punched another patient in the face with his fists, causing njury with bleeding at the bridge of the nose. An entry in the report stated, "We may need new TX [treatment] plan, existing plan seems not working. May need help from MSW, Psychology involved for better plan."

k. On 9/16/2015, the patient punched at a staff member with his fists. Hospital staff placed the patient in restraints.

l. On 9/20/2015, the patient struck another patient with his fists. Neither patient sustained an injury. An entry in the report indicated the patient was on 1:1 monitoring at the time of the incident, the patient "was on T.E. [therapeutic engagement] 1:1 at the time of event and remains on a T.E. currently."

m. On 9/28/2015, the patient struck another patient with his fists, resulting in injury to the other patient. Hospital staff placed the patient in restraints.

n. On 10/12/2015 at 9:15 PM, the patient assaulted Patient #14. The hospital transferred Patient #23 to another secured Unit, F-1. Hospital staff placed the patient in restraints and medicated him/her at 9:25 PM. Hospital staff released the patient from restraints the following day at 8:11 PM. The patient was in restraints for 22.77 hours. On 10/13/2015, hospital staff placed him/her on Therapeutic 1:1 monitoring.


o. On 10/14/2015 at 10:45 AM, hospital staff placed the patient into restraints for destructive behaviors. On 10/15/2015 at 10:45 AM, hospital staff released him/her from restraints. The patient was in restraints for 24 hours.

p. On 10/16/2015 at 10:15 AM, Patient #23 punched Patient #26 in the face and sustained a laceration. An entry in the incident report titled, "Administrative Report of Incident (AROI); section 12. Reporter's Immediate Supervisor Review/Actions: Supervisory Actions Taken for Patient(s) and Staff" included "1:1 monitoring" for Patient #26 and "Consulted with MD [Medical Doctor] R/T [related to] the possibility of 2:1 [monitoring] in the evening."

The next entry stated, "Short staffing form processed." Hospital staff did not implement the 2:1 monitoring.

q. Patient #23 was involved in patient-to-patient altercations on the following dates and times:
(1) On 10/17/2015 at 3:15 PM

(2) 10/20/2015 at 9:30 AM

(3) 10/24/2015 at 6:05 PM

(4) and 10/27/2015 at 5:55 AM,

r. On 10/27/2015, hospital staff placed the patient on therapeutic 1:1 engagement.

s. On 11/4/2015, Surveyor #4 conducted interviews with Staff members and Psychiatrist #72 caring for Patient #23. They indicated that s/he continued with exhibiting aggressive behaviors. Patient #23 had been placed on Therapeutic Engagement (1:1 monitoring to redirect the patient when exhibiting aggressive/assaultive behaviors). Staff members indicated that Patient #23 was cognitively impaired. Patient #23 was a smoker and exhibited frustration, aggression and assaultive behaviors because s/he was not allowed to smoke when s/he wanted. Observation of patient #23 revealed that s/he remained on F-1, a high security unit and required 1:1 monitoring to keep other patients safe.


2. Between 11/3/2015 and 11/5/2015, Surveyor #4 reviewed the medical record and hospital incident reports for patient #13, which included the following information:

Patient #13 was admitted to the hospital in 2010 with mental health disorders and behavioral problems. The patient had a self-harm/ suicide risk addendum in his Treatment Plan.

a. On 4/7/2015 at 8:30 AM, the patient punched a staff member with closed fists. There were no injuries. Hospital staff placed the patient in seclusion.

b. On 4/7/2015 at 3:25 PM, the patient attacked a staff member, causing an injury. Hospital staff had released the patient from seclusion within the hour and had been monitoring him/her at the time of the incident.

c. On 10/12/2015, the patient punched a staff member. Hospital staff placed the patient in restraints.

d. On 10/13/2015, the patient punched a staff member. The record contained no documentation as to what measures the hospital implemented to prevent future incidents.

e. On 10/16/2015 for 11:00 AM, an entry in the Prescribed Treatment Orders by a physician stated "Patient Continues to be at extremely high risk for reassault [sic] and should not be released from restraints regardless of meeting the standard release criteria. (His/Her) release has to be with my approval."

f. On 10/16/2015, the patient continued in 3 point restraints (3 limbs are restrained). A registered nurse wrote the order and a physician signed it. It stated, "Continue 3 pt (point) restraint as necessary for patient and staff safety."

g. On 10/16/2015 at 10:00 PM, a physician order stated,"Continue with restraint up to 5 point as necessary for pt (patient) and staff safety."

h. On 10/20/2015, an order was written to transfer the patient to another Unit; F-2.

i. On 10/27/2015, the patient punched a staff member. The record contained no documentation as to what measures the hospital implemented to prevent future incidents.

j. On 10/31/2015 at 4:30 PM, the hospital placed the patient on 1:1 Therapeutic Engagement (continuous observation by a staff member).

k. On 10/31/2015 at 6:55 PM, hospital staff placed the patient in seclusion for assaultive behavior. The physician order included, "Seclusion as necessary for patient and staff safety."

l. On 11/1/2015, the patient injured another staff member. An order was written to transfer the patient to another Unit: F-1 a Forensic Unit. The physician's recommendation was to evaluate the patient for appropriate placement within the hospital.


3. Between 11/3/2015 and 11/5/2015, Surveyor #4 reviewed the medical record and hospital incident reports for patient #14, which included the following information:

Patient #14 was admitted to the facility 6/21/2013 with behavioral problems.

a. On 7/18/2015, Patient #14 was in an altercation with Patient #23 on the F-5 Unit. Both patients remained on the F-5 Unit after the incident.

b. On 8/2/2015 at 3:55 PM, a second assault occurred between Patient #14 and Patient #23 on the F-5 Unit. Patient #23 hit Patient #14 multiple times in the face with a closed fist. Patient #14 had no substantial injury from the assault. Both patients remained on the F-5 Unit.

c. The updated Treatment and Recovery Plan Addendum for Patient #14 dated 9/8/2015, included "No threats or assaults on peers." The "Individualized Strategy/Interventions/Support" included "Nursing Staff will notice early when intimidating, targeting and angry around others. Staff will help compose [patient] and maintain harmless behavior. Offer PRNs as ordered and needed to maintain control." This intervention would be offered once a week for 15 weeks and the method of delivery would be accomplished through 1:1 staffing.

The surveyor found no documentation in the record to support that hospital staff implemented, monitored or evaluated this intervention for effectiveness.

d. On 10/12/2015 at 12:50 PM on Unit F-5, a third assault occurred when Patient #23 assaulted Patient #14. Patient #23 struck Patient #14 in the face with a closed fist. The hospital transported Patient #14 to another hospital for evaluation and treatment of a fractured jaw and loss of a tooth. S/he returned to the hospital following treatment.
.

.
Based on record review and review of the hospital policies and procedures, the hospital failed to ensure a patient's right to be free from restraints was protected for 1 of 1 patients reviewed (Patient #27).

Failure to use restraints only as needed to ensure the immediate physical safety of the patient and staff, risks psychological harm, loss of dignity and personal freedom.

Findings:

1. The hospital's policy and procedure titled "MANAGEMENT OF THE PATIENT IN SECLUSION AND RESTRAINT" (Revised October 2015) under the section "SUPPORTIVE DATA" read in part: "Limitations: The use of seclusion or restraint(s) is an emergency intervention of a last resort to manage behaviors that pose imminent risk of harm to the patient, staff, or others. Restraint(s)/Seclusion may be used only after alternative; least restrictive interventions have been determined to be ineffective. Non-physical interventions are to be the first therapeutic intervention employed when possible, unless safety issues demand an immediate physical response. The use of seclusion or restraints may not be used as punishment, an aversive technique of behavior modification program, staff convenience or to discharge individuals from exercising their rights."

2. On 10/27/2015 at 10:00 PM, Surveyor #5 toured clinical unit E7 and reviewed the medical record of Patient #27 who had a history of limited mobility due to quadriplegia and used an electric wheelchair.

During review of the medical record for Patient #27, Surveyor #5 noted the following information:

On 10/13/2015 at 8:05 AM, Patient #27 ran into the back of a staff member's leg with his/her electric wheelchair while the staff member was serving breakfast. The patient's psychiatrist wrote an order to "Hold electric wheelchair for one week - manual wheelchair is being used."

As a result, Patient #27's mobility was significantly impaired, essentially acting as a restraint. There was no evidence in the patient record to indicate that staff members had first attempted a less restrictive alternative. Once the clinical staff implemented the physician's order, they failed to initiate the hospital's restraint protocol. An interview with the center director (Staff Member #57) and a registered nurse supervisor (Staff Member #42) at the time of the record review confirmed these findings.

,.

.
Based on record review and review of the hospital policies and procedures, the hospital failed to ensure that hospital staff members considered and determined less restrictive interventions were ineffective before restraints were applied for 1 of 1 patients reviewed (Patient #36).

Failure to utilize less restrictive alternatives to restraints put patients at risk of loss of personal freedom and dignity without providing additional measures of safety for patients and staff.

Findings:

1. The hospital's policy and procedure titled "MANAGEMENT OF THE PATIENT IN SECLUSION AND RESTRAINT" (Revised October 2015) under the section, "CARE DIRECTIVES" read in part: " 1. RN evaluates the following to determine the need for or use of seclusion or restraint: a. Behavior(s) which pose an imminent risk of harm to self or others. b. Ineffectiveness of less-restrictive interventions. c. Mental status and degree of agitation. D. All available therapeutic modalities have proven ineffective.".

2. On 11/3/2015 at 10:45 AM, Surveyor #5 reviewed the medical record of Patient #36 who was readmitted to clinical unit E7 following an outside hospitalization for treatment of aspiration pneumonia. During the patient's hospitalization, the other hospital inserted a peripherally inserted central catheter (PICC) into the patient's arm for administration of intravenous antibiotics. On 10/15/2015 at 7:20 PM, the medical record indicated that the patient became "anxious" and began to pull on the PICC line. Hospital staff members placed the patient in five point restraints at that time. There was no documentation to indicate that hospital staff members had considered or attempted a less restrictive alternative first, such as application of mitt restraints. The record indicated that the patient remained in restraints until 10/16/2015 at 3:00 PM.

.
Based on record review and review of hospital policies and procedures, the hospital failed to ensure that hospital staff members wrote orders for restraints which were specific to the type and number of restraints required and not on an "as needed" basis.

Failure to have physician orders for restraints specific as to type and number, placed patients at risk for not having appropriate physician re-evaluations based on their changing conditions.

Findings:

1. The hospital's policy and procedure titled "MANAGEMENT OF THE PATIENT IN SECLUSION AND RESTRAINT" (Revised October 2015) under the section, "CARE DIRECTIVES" read in part: "8. RN obtains order from the attending psychiatrist or O.D. as soon as possible and within one hour following the emergency intervention. . .10. RN communicates to staff members the type of restraint (to chair, to bed, ambulatory) and the number of points of restraint 1 point, 2 point etc."

2. On 11/3/2015 at 10:45 AM, Surveyor #5 reviewed the medical record of Patient #36 who was readmitted to clinical unit E7 on 10/15/2015 at 5:20 PM following an outside hospitalization for treatment of pneumonia. During the hospitalization, the treating facility put a peripherally inserted central catheter (PICC) into the patient's arm for administration of intravenous antibiotics.

The medical record review indicated that on 10/15/2015 at 7:20 PM, the patient became "anxious" and began to pull on the PICC line. The physician wrote an order for restraints for the following dates and times:

a. 10/15/2015 at 7:25 PM as "Restraint(s) up to 5 points, up to 4 hour(s) until able to meet release criteria."

b.10/15/2015 at 11:20 PM as "up to 3 points."

c. 10/16/2015 at 3:20 AM as "up to 3 points."

d.10/16/2015 at 7:30 AM as "up to 4 points ."

e.10/16/2015 at 11:35 AM as "up to 4 points."

As the physician orders for restraints were not specific as to type and number, this constituted an "as needed" order.
.

.
Based on record review and review of hospital policies and procedures, the hospital failed to ensure that patients were removed from restraints at the earliest possible time for 1 of 5 patients reviewed (Patient #36).

Failure to remove patients from restraints at the earliest possible time put patients at risk from physical harm, loss of dignity and personal freedom.

Findings:

1. The hospital's policy and procedure titled "MANAGEMENT OF THE PATIENT IN SCLUSION AND RESTRAINT" (Revised October 2015) under the section "CARE DIRECTIVES" , read in part: "25. Release from seclusion or restraint when behavior that necessitated seclusion or restraint is no longer in evidence and the release criteria stated in MD order is attained."

2. On 11/3/2015 at 10:45 AM on clinical unit E7, Surveyor #5 reviewed the medical record of Patient #36, a patient that had a peripherally insertered central catheter (PICC) line, and noted the following:

The medical record indicated that on 10/15/2015 at 7:20 PM, the patient became "anxious" and began to pull on his/her (PICC) line. Hospital staff members placed the patient in five-point restraints at that time. The release criteria identified on the orders stated, "No longer exhibits behavior that jeopardized the immediate physical health and or safety of self or others." Instructions on the restraint flow sheet read "Notify RN when release criteria are met, or if patient is quiet/sleeping more than one 15-minute segment."

Documentation on the restraint flow sheet indicated that the patient was sleeping in restraints during the following periods:

a. From 10/15/2015 at 10:30 PM until 10/26/2015 at 3:00 PM, a period of 4.5 hours

b. From 10/16/2015 at 4:45 AM until 5:15 AM, a period of 30 minutes

c. From 10/16/2015 at 5:30 AM until 6:15 AM, a period of 45 minutes

d. From 10/16/2015 at 7:00 AM until 7:30 AM, a period of 30 minutes

e. From 10/16/2015 at 8:00 AM until 8:30 AM, a period of 30 minutes

f. From 10/16/2015 at 9:00 AM until 11:45 AM, a period of 2 hours and 45 minutes

g. From 10/16/2015 at 12:30 PM until 1:00 PM, a period of 30 minutes

h. From 10/16/2015 at 1:15 PM until 3:00 PM, a period of 1 hour and 45 minutes at which time hospital staff members released the patient from restraints.

Overall, the medical record indicated that the patient was sleeping for 11 hours and 45 minutes out of the 19 hours and 40 minutes the patient spent in restraints. There was no documentation on the restraint flowsheet to indicate that the hospital staff members had considered releasing the patient form restraints at the times listed above.
.

.
Based on record review and review of hospital policies and procedures, the hospital failed to ensure hospital staff monitored patients placed in restraints or seclusion according to hospital policy for 3 of 5 patients reviewed (Patient #36, #32, #23).

Failure to monitor patients who are restrained or secluded put them at risk of injury or decline in status.

Findings:

1. The hospital's policy and procedure titled "MANAGEMENT OF THE PATIENT IN SECLUSION AND RESTRAINT" (Revised October 2015) under the section "Monitor physical, emotional, and safety needs" read in part: "15. Assign staff member to perform care interventions, assess needs, and document behavioral response to seclusion or restraints at least every 15 minutes. a. Check breathing (ensure proper position of the head and neck), skin color, circulation. b. Proper positioning of restraint device(s) to prevent restriction of circulation. c. Take vital signs if patient condition indicates. d. Address nutrition/hydration needs. e. Assess circulation, reposition and perform ROM at least every two hours. f. Address personal hygiene and elimination needs. g. Monitor physical and psychological status and comfort."

2. On 10/29/2015, Surveyor #2 reviewed the medical record of Patient #23, who staff placed in restraints on 10/14/2015 at 10:45 AM and released from restraints on 10/15/2015 at 10:45 AM. The monitoring flowsheet directed staff to "Every 15 minutes, document interventions offered, if not accepted, check refused." There was no documentation on the seclusion/restraint assessment flowsheet to indicate that staff members assessed the patient's circulation for the following periods:

a. From 10/14/2015 at 12:45 PM to 3:45 PM, a period of 3 hours

b. From 10/14/2015 at 4:00 AM until 7:30 PM, a period of 3 hours and 30 minutes

c. From 10/14/2015 at 7:45 PM until 10/15/2015 at 3:00 AM, a period of 7 hours and 15 minutes

d. From 6:30 AM to 10:00 AM, a period of 3 hours and 30 minutes

3. On 10/29/2015 and 10/30/2015, Surveyor #4 and Surveyor #6 reviewed the seclusion/restraint flowsheet for Patient #32 for the period 10/25/2015 at 11:00 PM to 10/29/2015 at 1:45 AM. There was no documentation in the flowsheet to indicate that staff members assessed the patient's circulation for the following periods:
a. From 10/25/2015 at 11:15 PM to 2:30 AM, a period of 3 hours and 15 minutes

b. From 10/26/2015 at 6:15 AM to 5:00 PM, a period of 10 hours and 45 minutes

c. From 10/26/2015 at 9:00 PM to 10/27/2015 at 00:45 AM, a period of 3 hours and 45 minutes

d. From 10/27/2015 at 3:30 AM to 7:45 AM, a period of 4 hours and 15 minutes

e. From 11:15 AM to 1:45 PM, a period of 2 hours and 30 minutes

f. From 2:30 PM to 5:00 PM, a period of 2 hours and 30 minutes

g. From 5:45 PM to 9:00 PM, a period of 3 hours and 15 minutes

h. From 10/28/2015 at 3:15 AM to 6:00 AM, a period of 2 hours and 45 minutes

i. From 6:15 AM to 10:30 AM, a period of 4 hours and 15 minutes

j. From 10:45 AM to 2:00 PM, a period of 3 hours and 15 minutes

4. On 11/3/2015 at 10:45 AM, Surveyor #5 reviewed the medical record of Patient #36 who was placed in restraints on 10/15/2015 at 7:20 PM and released from restraints on 10/16/2015 at 3:00 PM. The monitoring flowsheet directed staff to "Every 15 minutes, document interventions offered, if not accepted, check refused." There was no documentation on the seclusion/restraint assessment flowsheet to indicate the staff checked for the patient's circulation, signs of injury and skin integrity for the following periods:
a. From 10/16/2015 at 7:30 PM to 10:30 PM, a period of 3 hours

b. From 10/16/2015 at 4:00 AM until 7:30 AM, a period of 3.5 hours

c. From 10/16/2015 at 7:30 AM until 12:00 PM, a period of 4.5 hours
.

.
Based on document review, interviews, and review of hospital policy and procedure, the hospital failed to ensure staff members received training on management of patients in seclusion or restraints.

Failure to follow policies and procedures for caring for secluded or restrained patients, risked physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure titled "MANAGEMENT OF THE PATIENT IN SECLUSION AND RESTRAINT" (Revised October 2015) under the section "Desired outcomes for nursing" read: "Patient rights, therapeutic milieu and Treatment goals are maintained. Safe therapeutic implementation by competent trained staff. Accurate and timely documentation. Safe Application, maintenance and removal of restraint device(s) by competent, trained staff."

2. On 10/26/2015 at 2:20 PM, Surveyor #6 interviewed a charge nurse (Staff Member #57) who indicated that no restraint or seclusion training had been done by him/her or other ward staff for a couple of years due to inadequate staffing.

3. On10/26/2015 at 3:20 PM, Surveyor #2 interviewed a registered nurse (Staff Member #54) whose primary duty was to "float" or go to wards with acute nursing shortages. S/he indicated that they had not received any new training on restraints or seclusion for the last two weeks.

4. On 10/27/2015 at 3:50 PM, Surveyor #2 interviewed a registered nurse supervisor (Staff Member #56) who indicated that the new training on management of aggressive/assaultive behavior and restraints and seclusion had been released in "bits and pieces" over the past week. As a supervisor, s/he is responsible for ensuring training occurs on the ward but acknowledged that it is difficult to ensure it happens when having to work as a floor nurse to cover shortages or provide clinical supervision for more than one floor.

5. On 11/5/2015 at 9:00 AM, Surveyor #2 reviewed a document that displayed the current completion statistics for the mandated on-line training for the hospital staff on the revised Nursing Protocol 302 - Management of the Patient in Seclusion and Restraint; Nursing Protocol 301 - Management of Aggressive/Assaultive Behavior; and DSHS BHSIA WSH Behavior Observational Record. Surveyor #2 noted that 535 personnel out of 1050 assigned personnel or 50.9% had completed Nursing Protocol 302; 553 personnel out of 1050 assigned personnel or 52.6% had completed Nursing Protocol 301; and 553 personnel out of 1050 assigned personnel or 50.8% had completed the new behavior observational record training.
.

.
Based on interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to develop and implement effective performance improvement plans and projects to address patient safety.

Failure to develop and implement performance improvement plans and projects that increase patient safety resulted in an unsafe healthcare environment.

Findings:

ITEM #1 - ANALYSIS OF NEAR-MISS EVENTS

1. The Behavioral Health Service Integration Administration (BHSIA) policy titled "Adverse Patient Safety Events" (Policy No. 1.5; Effective March 2015), defined a "Close Call" as a "near miss" or "good catch"; a patient safety event that did not reach the patient, but could have resulted in harm. The policy indicated that each hospital under BHSIA, including Western State Hospital, could have "a mechanism to track no-harm events, close calls, and hazardous conditions." The policy stated "The results of the tracking are used to identify opportunities to prevent harm."

2. The hospital's policy titled "Review of Sentinel Events and Near Miss Events" (Policy No. 2.6.6; Revised 9/24/2013) defined a "Near Miss Event" (NME) as "An event not resulting in death or permanent major loss of function for which the Medical Director deems an intensive assessment is in order to minimize the risk of recurrence."

3. During an interview with Surveyor #5 on 10/28/2015 from 9:00 to 11:15 AM, the Management Analyst from the hospital's Clinical Risk Management department (Staff Member #33) indicated that the hospital analyzed NME's individually and not in aggregate, which could determine if there were common factors present between events. The interview revealed that the hospital tracked and analyzed only NME's that required an "intensive assessment". The hospital did not track, analyze, and trend all "no-harm" events that could potentially harm patients.

4. During an interview with Surveyor #5 on 10/30/2015 at 10:10 AM, the hospital's pharmacy director (Staff Member #31) and a clinical pharmacist (Staff Member #32) stated that hospital policy does not require potential medication errors to be reported as "near miss" events to the hospital's pharmacy department.


ITEM #2 - ANALYSIS OF ADVERSE EVENTS

1. Review of the root cause analysis (RCA) for a patient suicide which occurred at the hospital in August 2015, included a subsequent recommendation to perform an in-depth suicide risk assessment for all patients on admission to the hospital and when they transferred from one ward to another within the hospital. During an interview with Surveyor #1 on 11/4/2015 at 10:00 AM, the hospital's Chief of Staff (Staff Member #8) indicated that the hospital had not yet implemented plans to perform suicide risk assessments of patients.

2. A Review of four RCA's completed for adverse events occurring at the hospital in 2015, revealed that all four RCA's identified problems with staffing shortages and hospital staff members' lack of familiarity with patients and their histories. There was no evidence that the hospital had developed and implemented performance improvement projects to address these problems.


ITEM #3 - CULTURE OF SAFETY

1. A review of quality program data revealed that the hospital conducted a "Culture of Safety" survey in April 2015. Analysis of the survey responses completed in May 2015 revealed that less than 50% of respondents agreed that Western State Hospital (WSH) leadership provided a work climate that promoted a Culture of Safety. Less than 50% of respondents agreed that leadership is actively doing things to improve the Culture of Safety. Less than 50% of respondents agreed that WSH leadership's interest in and focus on the Culture of Safety seems to be consistent over time. Fifty-five percent of respondents disagreed that their unit had adequate staffing levels to keep safe.

There was no evidence that the hospital had developed and implemented performance improvement projects to address findings from the survey and improve the hospital's Culture of Safety.

2. Review of data regarding numbers of nursing department personnel hired between April and October 2015 revealed that of 149 staff members hired, 66 had resigned (44%). There was no evidence that the hospital had conducted an analysis of the reasons behind the attrition rate.

3. During an interview with Surveyor #5 on 10/30/2015 at 9:15 AM, a member of the hospital's workplace safety department (Staff Member #34) indicated that the hospital provided an "anonymous hotline" telephone number for hospital staff members to report concerns about hospital safety.

On 10/30/2015 at 10:00 AM, Surveyor #8 called the safety hotline and stated s/he wanted to report a safety concern. The staff member who answered the call asked for the surveyor's name. The surveyor did not give his/her name and terminated the call. At the time of the call, Surveyor #4 overheard two staff members discussing the call. An office assistant (Staff Member #35) informed a registered nurse supervisor (Staff Member #36) that someone had called the complaint hotline but had not left a name. Staff Member #36 stated, "Well, you know how I feel about anonymous complaints."

4. Staff interviews conducted by survey team members throughout the survey reflected that the hospital administration had not promoted a Culture of Safety. Those interviewed indicated there was ineffective communication between administration and physicians as well as between administration and direct care staff. Staff members feared punishment and retaliation for their actions and felt excluded from the quality improvement process.

a. On 9/2/2015, during an investigation of a patient-to- patient assault that occurred on 8/15/2015, Surveyor #4 interviewed a mental health technician (Staff Member #41). The technician indicated that on the date of the assault, s/he had been assigned to a unit that s/he had not worked on for several months. The technician indicated that unfamiliarity with the patient who committed the assault had contributed to the incident.

The technician indicated that when the assault happened, she and another staff member activated their "panic buttons", emergency devices that signaled activation of a "Code Green" to summon staff for assistance. The technician indicated that there was a 20 to 30 second lag between the time staff members activated their devices and the hospital switchboard announced a "Code Green". Because of this delay, the technician stated s/he intervened in the assault. The technician indicated the hospital terminated him/her from their position effective 9/4/2015 and believed that the termination was due to the fact s/he had intervened instead of waiting for assistance.

b. On 10/28/2015 beginning at 9:45 AM, Surveyors #1 and #9 interviewed a physician (Staff Member #40). The physician indicated s/he had expressed concerns to hospital administration regarding a planned increase in the number of hospital beds. The physician indicated that s/he had expressed these concerns due to staffing problems and the increased numbers of assaults at the hospital. The physician indicated that the hospital threatened members of the medical staff with punitive action if they continued to resist the expansion.

c. The physician also indicated s/he had expressed concerns to hospital administration about the increasing number of assaults at the hospital after implementation of the Psychiatric Emergency Response Team (PERT). The physician noted that prior to expressing this concern; s/he had full access to hospital's assault data. After expressing this concern, the physician observed that the hospital no longer allowed him/her access to the data and the hospital administration informed him/her that they would direct how s/he would be able to use the data in the future.

d. The physician also indicated that s/he believed that patients transferred to the Forensics units were not getting active treatment, and that hospital administration was not concerned about the increasing number of assaults.

5. On 10/27/2015 at 11:15 AM, Surveyor #5 interviewed a registered Nurse (Staff Member #42). The nurse indicated that the hospital had contracted with a staffing consultant group in 2015 to analyze staffing at the hospital. The nurse noted that s/he had not heard results of this analysis and believed that the hospital had suppressed the report results. The nurse indicated that staffing shortages had resulted in discontinuance of staff competency assessments for seclusion and restraints. The nurse reported that if hospital staff members suffered an injury while attempting to prevent patient injury during an assault, then the hospital administration would deny their Labor and Industries (workers compensation) claim.

6. On 10/28/2015 at 1:45 PM, Surveyor #2 interviewed a registered nurse (Staff Member #39) about staffing, restraint and seclusion usage, and the organizational climate. The nurse indicated that the hospital did not base unit staffing on patient acuity. The nurse also indicated that the hospital did not increase staffing over the base level until there are two or more patients on a unit that required 1:1 staff- to- patient monitoring. When asked about the organizational climate, Staff Member #39 reported that the chief executive officer (Staff Member #1) met with the hospital staff last year about the need to reduce restraint use. Some staff members felt threatened when the hospital administration indicated that the hospital would not be responsible for liability in regards to restraint use if staff members did not follow the policy.
.

.
Based on interview and review of the hospital's quality program and quality documents, the hospital failed to develop and implement effective performance improvement plans and projects related to data analysis and goals that the hospital's Governing Body approved in August 2015.

Failure to develop and implement performance improvement plans and projects based on identified areas of concern revealed in quality data, resulted in an unsafe healthcare environment.

Findings:

1. On 10/28/2015, a review of data analysis performed by the hospital's quality management department and presented to the hospital's Quality Council on July 15, 2015 regarding patient-to-patient and patient-to-staff assaults that occurred between January 2013 and June 2015 revealed increasing numbers of patient-to-patient assaults, and increasing numbers of patient-to-staff assault-related injuries.

2. A review of the Governing Body meeting minutes for August 2015 revealed that the Governing Body approved development of performance improvement projects that addressed the following goals:

a. Decrease the number of patient to staff assault claims filed

b. Decrease the quarterly rates of patient seclusion hours

c. Decrease the quarterly rates of restraint use

d. Increase the rates of active treatment hours

e. Decrease the quarterly rates of patient- on- patient violence

3. On 10/28/2015 from 9:00 AM to 11:15 AM, during an interview with Surveyor #5, the hospital's Director of Quality Management (Staff Member #2) indicated that the hospital did not have any current performance improvement projects related to these goals.
.

Based on interview and review of the hospital's quality program and quality documents, the hospital failed to develop and implement a hospital-wide plan to monitor, evaluate, and improve the quality of patient care services through data collection and analysis.

Failure to monitor quality of care and the care environment in all hospital services and departments limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

During the survey, surveyors interviewed hospital staff members and reviewed the hospital's governing body by-laws, medical staff by-laws, and portions of the 2015 meeting minutes for the Quality Council, Medical Staff Executive Committee, Governing Body Committee, and Patient Care Committee. The interviews and document review revealed the following:

1. On 10/28/2015 from 9:00 AM to 11:15 AM, during an interview with Surveyor #5, the hospital's Director of Quality (Staff Member #2) indicated there is currently no process for ensuring that the hospital's quality program evaluates the performance of patient care contractors who were not privileged through the hospital's medical staff credentialing process. These patient care contractors provide services that include radiology services and sex offender treatment and counseling. On 10/28/2015 at 2:45 PM, Surveyor #5 confirmed this finding during an interview with the Contract Manager (Staff Member #30) for Consolidated Business Services, Incorporated (CIBS).

Cross Reference: Tag A0083


2. On 10/30/2015 at 10:10 AM, during an interview with Surveyor #5, the hospital's pharmacy director (Staff Member #31) and a clinical pharmacist (Staff Member #32) indicated that they investigated medication errors individually, in aggregate and by category. The Medication Variance Team discussed the findings during their meetings, but they did not report them to the hospital's Quality Assessment Performance Improvement (QAPI) program.

3. On 11/4/2015 at 1:00 PM, during an interview with Surveyor #5, a member of the Medical Staff (Staff Member #37) ,who prepared quarterly reports regarding patient mortality and morbidity, indicated that the mortality and morbidity reports went to the Medical Executive Committee but were not reported to the hospital's QAPI program.

4. On 11/5/2015 at 9:35 AM, Surveyor #1 interviewed a Utilization Review (UR) department staff member (Staff Member #38) about data collected through UR, regarding hospital readmissions. The staff member indicated that the hospital did not relay the data to the discharge planning team for analysis and development of performance improvement action plans. The hospital only shared readmission data with the Office of Financial Recovery. The information was not included in the hospital's QAPI Program.

Cross Reference: A0843

.
Based on interview and review of the hospital's quality plan, the hospital's Governing Body failed to develop and implement a quality assessment and performance improvement (QAPI) plan.

Failure to develop and implement a QAPI plan limited the hospital's ability to identify problems and formulate action plans. This resulted in sub-standard clinical care and patient outcomes.

Findings:

On 10/26/2015 at 1:30 PM, Surveyor #5 requested a copy of the hospital's QAPI plan. Review of this plan and along with an interview with the hospital's Director of Quality (Staff Member #2) on 10/28/2015 from 9:00 AM to 11:15 AM revealed the following:

1. The hospital failed to finalize the draft QAPI plan and failed to obtain the Governing Body's approval of the plan.

2. The plan included goals for improvement but did not identify specific performance improvement projects.

3. The plan stated that individual hospital departments would develop performance benchmarks but did not identify how each department would establish those benchmarks.

4. The hospital reviewed data regarding the incidence of patient-to-staff and patient- to- patient assaults but failed to develop any action plans to reduce assault occurrences.

5. The hospital had no systematic reporting structure to convey information regarding hospital-wide quality measures and action plans to the quality management department.
.

.
Based on document review and interviews, the hospital failed to ensure the facility was staffed with sufficient number of nursing personnel to provide safe effective care to patients.

Failure to provide an adequate number of trained registered nurses, licensed practical nurses, and mental health technicians risked patient safety and delayed treatment.

Findings:

1. On 1/29/2015, the Joint Nurse Staffing Committee submitted a 2015 nurse-staffing proposal to the hospital Chief Executive Officer (Staff Member #1). The Joint Nurse Staffing Committee is responsible for developing and overseeing implementation of the annual nurse-staffing plan and responding to staffing concerns presented to the committee. It consists of direct client care Registered Nurses appointed by the local union and an equal number or less of appointees by the psychiatric nurse executive. The hospital failed to adopt any of the specific recommendations contained in the proposal. A letter dated February 17, 2015 from Staff Member #1 in reply to the Joint Nurse Staffing Proposal stated, " I concur with assigning the right number of RNs, LPNs, and treatment. Our challenge at this time is doing so within existing allocation of resources."

2. A review of the verified "Nurse Time Scheduler" report for a fifteen-day period (10/11/2015 - 10/26/2015) showed 35 out of 45 shifts did not have the required minimum registered nurse coverage for the hospital. During that same period, utilizing the daily staffing report, the documentation indicated that on average, 31 nursing personnel called in sick daily and 101 nursing personnel either were called in to work or worked overtime daily, (64 nursing personnel worked on call, and 37 nursing personnel worked overtime) creating turbulence in the patient care environment.

On 10/28/2015 at 9:00 AM, Surveyor #2 interviewed a nursing supervisor (Staff Member #72) regarding which documents and spreadsheets the hospital used to track nurse staffing. S/he confirmed the verified nurse time scheduler was the most accurate of the documents used to track nurse staffing.

3. On 10/27/2015 at 11:15 AM on clinical unit E7, during an interview with Surveyor #5, a registered nurse (Staff Member #42) indicated that "Environmental Safety Rounds" (ward checks), which include 15-minute visual checks of all patients on the unit, now takes one staff member working full time to complete. S/he also stated that because of a shortage of food service workers, registered nurses and licensed practical nurses prepare and serve trays of food to patients. S/he stated between the three meals per day, this takes one staff member approximately six hours of time to complete, time that could be used to provide active treatment.

4. On 10/27/2015 at 2:20 PM on clinical unit E5, during an interview with Surveyor #5, a registered nurse (Staff Member #53) stated, "I don't have time to get my work done." S/he indicated this was because s/he had been assigned to perform ward checks on all patients on the unit. The ward check consists of visually observing and verifying that all patients were present on the ward at 15-minute intervals, and recording this information on a checklist.

5. On 10/28/2015 at 2:00 PM, Surveyor #4 interviewed a social worker (Staff Member #28) who worked at the treatment mall. When the surveyor asked why there were registered nurses monitoring the hallways during classes, Staff Member #28 indicated there were no nurses assigned to the treatment malls and that registered nurses came from other floors and went back to their clinical areas when their patient population completed their classes.

6. On 10/28/2015 at 2:20 PM, Surveyor #4 interviewed a therapy supervisor (Staff Member #25) who acknowledged that nurses accompany patients from their unit to the treatment mall and sit in the halls to monitor patients until their class is over.

7. On 10/29/2015 and 10/30/2015, Surveyor #4 and Surveyor #6 reviewed the medical record of Patient #32. A review of the patient's record noted on 10/14/2015 at 10:15 AM, a physician order for 2:1 behavioral observational monitoring for safety concerns related to danger to others and self. A review of the behavioral observational monitoring record for the period 10/14/2015 at 10:15 AM to 10/16/2015 at 2:45 PM revealed that only 32 hours of the 53-hour period had the correct number of required staff assigned to monitor the patient.

On 11/4/2015 at 2:20 PM, Surveyor #6 interviewed a registered nurse supervisor (Staff Member #59) about the gap in coverage for monitoring Patient #32. S/he acknowledged directing staff to do 1:1 monitoring, as staff members were needed to fill another area.

8. On 10/30/2015 at 1:25 PM, Surveyor #2 and Surveyor #10 interviewed the nurse executive (Staff Member #13) about nurse staffing. S/he acknowledged that the current nurse acuity system in use, does not drive or change nurse staffing for the wards. Staffing is primarily adjusted based on the number of patients on each ward who require 1:1 observation monitoring, including those on suicide watch, therapeutic engagement, and behavior monitoring status. Staff Member #13 indicated there was no current quality process for reporting staffing concerns to the hospital quality council. In addition, s/he acknowledged the annual hospital-based nurse skill competency fair changed in February 2015 to a unit-based skill competency model because "we don't have the manpower to do that training because of overtime costs."

9. On 11/3/2015 between 9:00 AM and 12:00 PM, Surveyor #2 interviewed a senior nursing administration leader (Staff Member #12) and the incoming psychiatric nurse executive (Staff Member #55) who reported that the hospital expanded its overall bed capacity by 25 beds within the past five months. During that period, two additional nursing units were open (clinical unit S4 - 10 beds; clinical unit C1 - 15 beds). During this same period, a total of 149 nursing personnel were hired at the facility, however 129 nursing personnel separated from the facility, leaving only a net gain of 20 nursing personnel, which was insufficient to support the expansion of two additional units.

10. On 11/3/2015 at 2:00 PM, Surveyor #2 interviewed the co-chairman of the Joint Nurse Staffing Committee (Staff Member #52) who acknowledged that overall staffing is not sufficient for the vast majority of the units except for a few wards with long-term patients. When asked if licensed nursing personnel serve or "plate" food for patients on the ward, s/he replied that it is "pretty much routine" for the staff to do this task due to manpower shortages. Further, Staff Member #52 stated, "they don't adjust for acuity, the units are all staffed the same " except for when patients require 1:1 monitoring. Staff Member #52 confirmed that one of the five nurse staffing committee's recommendations to the hospital was to change the practice of requiring that the ward use existing staff to absorb the first patient who requires observational monitoring, without obtaining additional staff until at least 2 patients in the ward require observational monitoring.

11. On 11/4/2015 at 8:00 AM, Surveyor #6 reviewed the treatment plan for Patient #35. The plan included a physician order for hospital staff to take vital signs on every shift, beginning on 10/14/2015 with a stop date of 11/14/2015. The plan included an annotation to "NOTIFY M.D. for S/S (signs and symptoms of) INFECTION." The surveyor reviewed the vital signs flowsheet for the past 23 days and noted the following:

a. 6 of 23 days there was no documentation that hospital staff took the patient's vital signs on any shift

b. 16 of 23 days where hospital staff only took the patient's vital signs once a day.

As a result, the patient only received the physician-ordered care for 1 of 23 days. At the time of the review, Staff Member #67 confirmed these findings.

.
Based on interview, observation and record review the hospital failed to ensure the nursing staff developed and kept current, nursing care plans for 5 of 30 current patients (Patient #15, Patient #20, Patient #16, Patient #17 and Patient #35).

Failure to keep accurate and updated plans of care placed patients at risk of harm for not receiving necessary care.

Reference: American Nurses Association (ANA). (In press). Nursing: Scope and standards of practice (3rd edition). Silver Spring, MD: Nursesbooks.org. Under " Outcomes/Planning:
" Based on the Registered Nurses ' patient assessment and diagnosis, measurable and achievable goals are set for the patient. Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it.

Item #1- Therapeutic Monitoring

Findings:

1. The hospital patient handbook for 2013-2014 included information related to "Treatment." On page 29 under the title, "You have the right to: "An individualized treatment plan with scheduled reviews, appropriate revision and a description of services needed. " This section also included, "The nature of recommended treatments and significant adverse (unpleasant) effects, if any: The reasons why particular treatments are considered appropriate, their risk(s) and benefits: Any appropriate and available alternative treatments, services and types of providers of mental health services."

2.Surveyor #4 reviewed the medical records for the following patients whose records indicated a need for 1:1 Therapeutic monitoring:

a. Patient #15 required 1:1 monitoring to prevent him/her from falling. The patient had a recent hip fracture, inability to walk safely and independently, poor safety awareness and poor memory. The hospital implemented 1:1 monitoring to prevent the patient from standing up without supervision and assistance.

b. Patient #20 required 1:1 monitoring for poor safety awareness, poor judgment and behavioral problems. The hospital implemented 1:1 monitoring to keep the patient safe from harm.

c. Patient #16 required 1:1 monitoring for safety purposes. The patient had multiple previous incidents of self-inflicted injuries and continued to be at high risk of self-harm.

d. Patient #17 required 1:1 monitoring for safety purposes. The patient had a history of unsafe behaviors and at risk of self-injury.


3. On 10/26/2015 at 3:20 PM, Surveyor #4 interviewed a Supervisor RN-3 (Staff Member #22) and a Mental Health Technician (MHT) (Staff Member #21). Staff Member #21 indicated that 4 of 30 patients on Unit E-3 were on 1:1 Therapeutic Monitoring. Surveyor #4 asked Staff Member #21 how s/he knew this information. Staff Member #21 indicated s/he learns this information from other staff members but the plans were also in the patients' record documented in the treatment plans. Surveyor #4 asked to see this information. In reviewing the documentation from the "Patient Treatment and Recovery Plan", hospital staff members failed to document the 1:1 Therapeutic monitoring for the following patients: Patient #15, Patient #20, Patient #16 and Patient #17.

On 10/26/2015 at 4:30 PM, during an interview with Surveyor #4, Staff Member #22 confirmed that the "Patient Treatment and Recovery Plan" should have included the 1:1 Therapeutic monitoring intervention.

4. On 10/27/2015, after the surveyor interviewed Staff Member #22, hospital staff members created an addendum in the patients' medical records to include documentation of the 1:1 therapeutic monitoring.

Item #2- Catheter Care

Findings:

1. The hospital policy and procedure titled "Care of indwelling urinary catheter" (Procedure #25, Revised 10-15) read in part: "Routine catheter monitoring 1. Assess two times per day and with any complaints."


2. On 11/4/2015 at 8:00 AM, Surveyor #6 reviewed the medical record of Patient #35 who had a suprapubic catheter. The nursing staff did not identify a problem on the patient's plan of care, for the suprapubic catheter. The record contained no evidence to indicate that hospital staff had performed the twice-daily assessments consistent with hospital policy. At the time of the record review, Surveyor #6 confirmed this finding with a Registered Nurse 3 (Staff Member #67).

.
Based on document review, interviews, and review of hospital policies and procedures, the hospital failed to ensure a registered nurse (RN) was responsible for assigning the nursing care of each patient to other nursing personnel in accordance with hospital policy.

Failure to assign the appropriate nursing personnel to each patient risked patient health and safety.

Findings:

1. The hospital policy and procedure titled "ASSIGNMENT OF PATIENT CARE" read in part: "RN 2 and LPN/PSN: Jointly complete Assignment of Patient Care form at the beginning of the shift, following intershift report. . . C. Registered Nurse 2 or 3: 1. Make appropriate staff-patient assignments, including his/her own assigned duties for the shift. 2. Assign constant or close Suicide Watch. . . 3. Assign Therapeutic Engagement and 1:1 patients. "

2. On 10/27/2015 at 2:25 PM on clinical unit F-5, Surveyor #2 interviewed the oncoming registered nurse 2, (Staff Member #49) who "floated" from another unit, about the "Assignment of Patient Care" worksheet. Staff Member #49 indicated that since s/he did not normally work on the unit, the Psychiatric Security Nurse (PSN) would complete the worksheet, since they are more familiar with the patients. During a review of the evening shift's assignment sheet, the surveyor observed that the patient-care assignments, which included one patient on "1:1 medical observation" monitoring status, had been prepared by the PSN, instead of by the Registered Nurse as required in the hospital's policy.


3. On 10/28/2015 at 9:30 AM on clinical unit F-6, Surveyor #2 interviewed the RN 2 charge nurse (Staff Member #50) about how staff members completed the assignment sheet. Staff Member #50 acknowledged either the registered nurse or licensed practical nurse completed it, whoever arrived on the unit first. A licensed practical nurse (LPN), (Staff Member #51), acknowledged that s/he completed the current shift's patient- care assignment sheet. During a review of the patient-care assignments, the surveyor noted the assignment sheet included one patient on "close suicide watch" monitoring status. According to the hospital's policy, a Registered Nurse should make the assignment for patients under "close suicide watch".

.

Based on interview, record review, review of the hospital's infection log, and review of hospital policies and procedures, the hospital failed to develop and implement an effective system for surveillance and control of communicable diseases.

Failure to develop an active system to prevent and control communicable diseases risked transmission of infections to hospital patients and staff members.


ITEM #1 - INFECTION SURVEILLANCE


Findings:

1. On 10/30/2015 at 11:00 AM, Surveyor #5 interviewed the hospital's infection preventionist (IP) (Staff Member #43) and reviewed the hospital's infection surveillance process. The interview and program review revealed that the IP recorded occurrences of patient infections in an infection log. S/He then counted and categorized infections on a monthly basis. On a quarterly basis, s/he reported the number of infection occurrences to the Infection Prevention and Control Committee and the Patient Care Committee.

a. The IP did not consistently analyze the data to determine the causative organism; whether the organism was sensitive to the antibiotic prescribed and whether there were patterns of infection consistent with patient-to-patient transmission.

b. The IP failed to aggregate (group together) and track incidence and prevalence of infections over time to determine patterns and trends. During the interview, the IP indicated that she had not been educated and trained to analyze, track, and trend infections.

2. A review of the medical records of Patient #27 revealed the patient had a permanent urinary catheter due to loss of bladder function related to quadriplegia. The records indicated that patient had frequent urinary tract infections. During the interview, the IP revealed that s/he had not reviewed the infections, and had not considered that the effectiveness of the patient's urinary catheter care could be a contributing factor to the infection recurrence.


ITEM #2 - PREVENTION AND CONTROL OF METHICILLIN- RESISTANT STAPHYLOCOCCUS AUREUS

Findings:

1. On 10/30/2015 at 11:00 AM, Surveyor #5 interviewed the hospital's IP (Staff Member #43) and reviewed a document titled "Medical Nurse Consultant Update", dated 10/28/2015. The update included a list of patients who had an active infection or were colonized with methicillin-resistant staphylococcus aureus (MRSA). During the interview, the IP indicated that s/he sent this update via electronic mail to a user group that included physicians, Medical Nurse Consultants employed at the hospital, and Registered Nurse (RN) 4 supervisors.

On 11/4/2015 at 3:00 PM, during an interview with Surveyor #6, an RN3 (Staff Member #45) indicated that the afternoon shift's RN4s do not receive the Medical Nurse Consultant Update and do not have access to that information.

2. On 11/4/2015, a review of the medical records of five patients currently receiving treatment in the hospital revealed that the "Medical Nurse Consultant Update" was inaccurate:

a. Patient #24 was listed on the update as having "active" MRSA with an open wound. There was no evidence of the patient having an active MRSA infection in patient's medical record.

b. Patient #30 was listed on the update as having "active" MRSA with an open wound. The patient's wound had healed, and there was no evidence of the patient having an active MRSA infection in the patient's medical record.

c. Patient #18 was listed on the update as "colonized" with MRSA. There was no evidence that the patient was colonized with MRSA in the patient's medical record.

d. Patient #17 was not listed on the update. Review of the patient's medical record indicated patient had active MRSA with an open wound

e. Patient #31 was not listed on update. Review of the September 2015 infection log revealed the patient was listed as having active MRSA.


ITEM #3 - IMPLEMENTATION OF STANDARD AND TRANSMISSION-BASED PRECAUTIONS

Findings:

1. The hospital's infection prevention and control manual, under "Chapter 6 -Hand Hygiene Guidelines" (Approved April 2013), indicated that all healthcare personnel would perform hand hygiene after glove removal. Under "Chapter 8 -Nursing Units Infection Control Policy", part D. "Medical Supplies", the policy indicated that the hospital would store medical supplies in designated "clean" areas.

a. On 10/27/2015 at 9:45 AM, Surveyors #5 and #8 observed a Medical Nurse Consultant provide wound care for Patient #28 on unit E7. During the procedure, the nurse carried clean gloves, adhesive tape, wound antiseptic spray, and scissors in his/her pockets. The nurse did not perform hand hygiene after removing the patient's soiled dressing and did not perform hand hygiene between glove changes.

b. On 11/3/2015 at 9:30 AM, Surveyor #5 observed a Medical Nurse Consultant (Staff Member #46) working on unit E7 while preparing a blood sample for transport to the hospital laboratory. The nurse did not perform hand hygiene after removing his/her gloves.

c. On 11/3/2015 at 11:10 AM, Surveyor #5 observed a licensed practical nurse (LPN) (Staff Member #44) using a glucometer to perform a blood glucose check on Patient #29 in unit #E5. After using a lancet to pierce the patient's finger and obtain a blood sample, the nurse discarded the used lancet into the glucometer case in a section that contained clean lancets. When interviewed at the time of the observation, the LPN did not recognize that s/he had contaminated the clean lancets. After the test's completion, the LPN did not clean the glucometer with disinfectant prior to returning it to its storage cradle at the nurse's station. The nurse did not perform hand hygiene after the procedure.

2. The hospital's infection prevention and control manual, under "Chapter 6 - Isolation Precautions" (Approved March 2013) indicated that hospital staff would employ contact precautions in addition to standard precautions, when a patient had a suspected or confirmed infection with "epidemiologically important microorganisms that can be transmitted by direct or indirect contact with contaminated environmental surfaces", which included staphylococcal disease.

a. On 11/3/2015 at 10:45 AM, during an interview with Surveyor #5, a registered nurse working on unit E7 (Staff Member #47) acknowledged that patients with MRSA were not cared for using contact precautions.

b. On 11/3/2015 at 12:30 PM, during an interview with Surveyor #4, a registered nurse working on unit #E3 (Staff Member #19) acknowledged that patients with MRSA were not cared for using contact precautions.

3. The hospital's infection prevention and control manual, under "Chapter 5 - Isolation Precautions" (Approved March 2013) indicated that hospital staff would employ droplet precautions to reduce the risk of transmission of microorganisms transmitted by droplets (large particle droplets generated by the patient during coughing or the performance of procedures), which included influenza.

On 11/4/2015, at 3:30 PM, Surveyor #6 interviewed a Registered Nurse (RN) (Staff Member #68) The RN did not know that s/he should use droplet precautions when treating patients with influenza .


ITEM #4 - N95 RESPIRATOR FIT TESTING


Reference: 29 CFR 1910.134(a) (2) - Occupational Health and Safety Standards - Personal Protective Equipment. "A respirator shall be provided to each employee when such equipment is necessary to protect the health of such employee. The employer shall provide the respirators which are applicable and suitable for the purpose intended. The employer shall be responsible for the establishment and maintenance of a respiratory protection program, which shall include the requirements outlined in paragraph (c) of this section. The program shall cover each employee required by this section to use a respirator.

Findings:

1. The hospital's policy and procedure titled "Employee Respirator Procedure No. 25.1 - N95 Fit Testing" (Issued 1/14/2010) did not reflect who should be fit tested and how often.

2. On 11/5/2015 at 8:50 AM, Surveyor #5 interviewed the hospital's industrial hygienist (Staff Member #48), the staff member responsible for the hospital's respiratory protection program. During the interview, the staff member confirmed the respiratory protection program should include fit testing of patient- care staff members who wore N95 facemasks when caring for patients with airborne infections. During the interview, the industrial hygienist produced a list indicating that five Medical Nurse Consultants and one Registered Nurse 4 had been fit-tested for N95 facemasks in April 2015. Of the five Medical Nurse Consultants, three were no longer employed at the hospital.
.

.
Based on interviews, record review, and review of hospital forms, policies and procedures, the hospital failed to provide an appropriate discharge plan in the records of 2 of 10 patients (Patient #5 and #6) reviewed, to assess the discharge planning process. There was no documentation to indicate that the hospital developed a discharge plan to include post- hospital care for all patients.

The failure of the hospital to develop and implement policies and procedures to provide direction for appropriate discharge criteria for all patients placed them at risk for unsafe discharge without post- discharge instructions.

Findings:

1. Western State Hospital's Patient Handbook (4.2.6) included discharge planning as a patient right. Review of hospital policy and procedures for discharge planning; (4.3.5) Referrals to Community Service Providers for Follow-up Care, (2.1.7) Community Agency Participation in Western State Hospital Treatment & Discharge Planning and (2.5.14) Civil Discharge Planning indicated documentation would be completed regarding care needs in order to communicate those needs to the next level of care.

2. The hospital policy titled "Civil Discharge Planning" stated in part: "Prior to discharge, the treatment team will collaborate on the development of the "continuity of care" form. Surveyor #4 was unable to locate a "continuity of care" form in the records of Patient #5 and #6. Hospital staff failed to document the patients' identified needs, referrals, medication list and/or additional information to meet the patients' care after discharge.


3. On 11/3/2015, Surveyor #4 reviewed patient records, which revealed a lack of documentation for discharge planning information similar to those that the surveyor had observed in other patient charts. Surveyor #4 requested any additional discharge planning documentation not currently in the records. The Quality Department Administrative Assistant (Staff member #29) indicated that the patients' records were complete and that there was no additional information.

.

.
Based on interview and document review, the hospital failed to use readmission data collected by the Utilization Review staff to evaluate the effectiveness of discharge plans.

Failure to evaluate the effectiveness of discharge plans placed patients at risk of readmission due to ineffective discharge planning.

Findings:

On 11/3/2015 at 10:00 AM, Surveyor #1 interviewed a Registered Nurse (RN) (Staff Member #38), who was a member of the team performing Utilization Review activities for the hospital. During the interview, Staff Member #38 indicated that the Utilization Review team collected data on all readmissions within 90 days. S/he also indicated the collected data was not analyzed.

A follow-up interview on 11/5/2015 at 9:35 AM with Staff Member #38 revealed that the readmission data was entered into a SharePoint database.

An interview with another member of the Utilization Management Committee (Staff Member #71) on 11/5/2015 at 9:45 AM revealed that the only staff with access to the SharePoint data were those in the Office of Financial Recovery. Both the Medical Staff and the Quality Improvement Committee were unable to access the readmission data.