40710 Based on interview, record review, policy review, and video review the facility failed to provide a safe environment and protect one patient (#10) of 28 patients reviewed for abuse or neglect when the facility failed to implement immediate measures to remove a staff member (Staff W) from patient care after allegations of abuse were reported. The facility also failed to follow physician orders of placing one patient (#10) on one-on-one (1:1, a continuous visual contact with close physical proximity) monitoring, and failed to appropriately assess the need to place one aggressive and physically violent patient (#11) on 1:1 monitoring, to ensure the safety of other patients and staff. These deficient practices resulted in the facility's non-compliance with specific requirements found under 42 CFR 482.13 Condition of Participation: Patient's Rights. The facility census was 282 patients with 58 of those patients admitted for behavioral health related care. After the Centers for Medicare & Medicaid Services (CMS) reviewed the details of the survey, it was determined that the severity of these practices had the potential to place all patients at risk for their safety, also known as Immediate Jeopardy (IJ). On 05/16/19, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients. As of 05/16/19, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following: - Education on the revised 1:1 monitoring policy included the immediate placement of a designated person, without any other duties assigned, with any patient that had been placed on 1:1 monitoring. - Education on the revised 1:1 monitoring policy began immediately to all clinical leaders and House Supervisors, and they began education to all staff regarding the policy. - All clinical employees on site and all reporting for the next shift were educated. - All clinical employees, including as needed (PRN) employees, were educated before their next shift. - Clinical employees throughout the building would randomly, on each shift, be asked about the appropriate response if a patient was placed on 1:1 monitoring. If less than 100% compliance to these questions then re-education would be given. - The revised 1:1 monitoring training was added to the new employee orientation and annual training. - Clinical employees would be provided a questionnaire to demonstrate compliance at new hire orientation and annual training to demonstrate understanding. This information would be kept in the employees personnel file. - All current patients with assessed needs for and/or orders for 1:1 monitoring were placed on 1:1 monitoring by a designated person that did not have any additional responsibilities. - Any future patients who expressed behaviors that threatened the safety of self or others would be placed on 1:1 monitoring, and an immediate assessment by a qualified staff member would be completed. - Qualified staff members who completed the assessments could place patients on 1:1 monitoring immediately and then consult with the provider for written orders. - Clinical leaders completed audits of any patients who were on 1:1 monitoring to ensure compliance.

18018 Based on interviews, record review and policy review the facility failed to: - Protect one discharged patient (#23) on the Rehabilitation Unit from physical abuse and continued abuse by a staff member. - Follow the facility's internal policy and procedure related to abuse and neglect and to report incidents/events to proper facility administration in a timely manner when allegations of abuse are suspected and/or witnessed. - Complete a physical examination and notify the physician after the alleged physical assault/abuse from staff had taken place with a discharged patient (#23). - Ensure staff was competent and trained to prevent, recognize and respond to all forms of abuse by co-workers. - Ensure staff was immediately educated/re-educated about abuse, to include steps to take if staff witnessed abuse, after the substantiated allegation of staff to patient abuse occurred between staff and a discharged patient (#23). - Report to the appropriate State Agency staff abuse towards Patient #23, when staff physically assaulted the patient. Refer to A-0145 for additional information. - To obtain either verbal and/or written consent of discharged Patient #7's legal guardian, (a legal relationship created when a person or institution is assigned by a court to take care of minor children or incompetent adults), when informed consent was required for a care decision, when the facility allowed Patient #7 to sign herself out of inpatient hospital care Against Medical Advice (AMA) without prior authorization from her legal guardian. - Immediately remove staff from patient care after an allegation of abuse was identified/witnessed by two co-workers. Refer to A-0144 for additional information. These failures created an unsafe environment and had the potential to place all patients admitted to the facility at an increased risk for their safety. The facility census was 285. The severity and cumulative effect of these failed systematic practices resulted in the overall non-compliance with 42 CFR 482.23 Condition of Participation: Patient's Rights that resulted in a condition of Immediate Jeopardy (IJ). As of 08/30/18, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following: Abuse/Neglect: - Action Item #1: Immediate action to be taken on Wednesday, 08/29/18 - Re-educate all clinical and non-clinical personnel prior to the start of their next shift (current day shift staff on 08/29/18 prior to them leaving shift) on the following: - Timely reporting of alleged and/or confirmed patient, staff and/or visitor abuse or neglect; and - Abuse and Neglect Policy (reporting process and signs of abuse). - Action Item #2: As of 08/29/18 Human Resources (HR) to report all allegations, disciplinary actions and terminations involving alleged or confirmed abuse/neglect of patient, co-worker, and/or visitors to Risk Department. - Action Item #3: Alleged abuse substantiated by PCT (Patient Care Technician) admission during termination investigation. Termination date 04/03/18 by Director Clinical Operations. On 8/29/18, immediate action taken - The two Registered Nurses (RNs) neglecting to report suspected/witnessed abuse received a written warning in compliance with HR disciplinary policy. Durable Power Of Attorney DPOA (A type of advance medical directive in which legal documents provide the power of attorney to another person in the case of an incapacitating medical condition) and Guardianship: - Action Item #1: Immediate action to be taken on Wednesday, 08/29/18 - Re-educate all clinical personnel prior to the start of their next shift (current day shift staff on 08/29/18 prior to them leaving shift) on the following: - DPOA/Guardianship; - AMA Policy; and - Arrival/Admission Assessment of DPOA/Guardianship. - Action Item #2: Immediate action to be taken on Wednesday, 08/29/18 - All Nursing Unit Leaders received Transferring Patient Report Form. As of 08/29/18 form is to be utilized for all patients transferring to our facility from an outside facility to ensure referring facility provides guardianship status/documentation during report to Charge Nurse. - Action Item #3: AMA Policy updated 08/29/18 to require confirmed guardianship during AMA process. - Action Item #4: Added DPOA/Guardianship education to New Employee Orientation (NEO). Next facility NEO scheduled for 08/31/18.

32280 Based on interview, record review, and policy review the facility failed to follow physician orders for a 1:1 sitter (continual observation for safety) for one discharged patient (#3) of one patient reviewed with a 1:1 sitter order, that allowed her to successfully elope (escape) from the facility and to provide nursing oversight to ensure that the proper elopement precautions were in place to prevent the elopement. These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Nursing Services. The facility census was 337. The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On 01/10/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect all patients. As of 01/10/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following: - Action Item #1: Immediate action to be taken on Wednesday 01/10/18 was to conduct an assessment for all inpatients that are currently on elopement precautions and/or 1:1 sitter to ensure elopement precautions are in place appropriately and according to policy, and sitter is knowledgeable of this policy and patient's current condition. This will be completed at all three campuses. Daily audits will be conducted in real time every shift. Patient's current condition and sitter verbalization of understanding has been added to the daily audit spreadsheet. Audit process already includes patient with self-harm, suicide and safety issues. Address any issues in real time and follow -up with appropriate manager. Compliance will be reviewed weekly with the Chief Nursing Officer (CNO) and rounding log maintained by Nursing Operations. - Action Item #2: Reeducate all staff prior to the start of their next shift (current day shift staff on 01/10/18 prior to them leaving shift) on the following: Elopement Risk Policy; Observation Policy; Elopement scenarios; Code Purple. This will be completed at all three campuses. Annual Patient Safety will be provided to all staff, including new hires to include the above elements. Leaders responsible to facilitate education include senior leadership from all three campuses. - Action Item #3: Implement revised huddle template to include constant observation and safety risk to include suicide/psychiatric and elopement risk. This is to be utilized on all inpatient nursing units as the pre-shift huddle reports. All huddle sheets will be submitted to the CNO for review following huddle, and reviewed and reconciled with the rounding logs in Action #1. - Action Item #4: Immediate action to be taken on 01/10/18 PM shift (allowing for education to be provided to current and oncoming shifts). Mock Code Purple drills will be conducted at a minimum daily every shift for two weeks and if 100% compliance is achieved then mock Code Purple Drills will be conducted daily, alternating shifts until survey team returns for revisit. Evaluation form is to be filled out and reviewed in tandem with Quality and Security departments. Real time education and feedback will be provided to involved unit/department leader.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32280 Based on interview, record review, policy review, and review of the facility's Digital Video Disc (DVD) recording, the facility failed to ensure: - Nursing staff assessed, monitored and observed one (#1) of one patient who successfully committed suicide when he placed a paper towel down his throat that completely blocked off his airway while a patient on the Senior Adult ([AGE] years of age or older) Behavioral Health Unit (BHU a unit for care of patients with mental health issues). (Refer to A-0395) - An appropriate suicide risk assessment and interventions for the appropriate level of observation were initiated for one (#1) of one patient who successfully committed suicide while a patient on the Senior Adult Unit; (Refer to A-0395) - Patient Observation Flow Sheets (flow sheets that recorded every 15 minute checks to ensure patient safety) were performed and documented in real time for one deceased patient (#1) and 12 current patients (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17) of 13 patient Observation Flow Sheets reviewed on the BHU; (Refer to A-0395) and - Immediate Cardiopulmonary Resuscitation (CPR, Basic Life Support [BLS] lifesaving technique used in emergencies where breathing and heartbeat has stopped) was immediately initiated when unresponsiveness and lack of pulse (heartbeat) and breathing was assessed for one of one patient (#1) that was found unresponsive on the Senior Adult BHU. (Refer to A-0395) Patient #1 was last observed on [DATE] at 2:33 AM by Staff T, Safety Coordinator. He was found to be unresponsive at 2:40 AM by Staff V, Mental Health Technician (MHT). The code cart (cart on wheels that contains emergency resuscitative equipment and supplies used for CPR but does not contain emergency drugs) arrived at 2:44 AM followed by Emergency Medical Services (EMS, paramedics) at 2:49 AM. The patient was taken to the Emergency Department (ED) at 3:07 AM. The patient was pronounced dead at 3:20 AM, 12 hours after the patient's admission to the facility. The facility failures resulted in a patient's death and placed all patients within the BHU at risk for their safety. The BHU census was 64. The Senior Adult Unit census was 13. The facility census was 263. The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On [DATE], after the survey team informed the facility of the IJ, facility staff created educational tools and began educating staff and put into place interventions to protect patients within the entire facility. As of [DATE], at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following: - Conducted a suicide risk assessment for all current inpatients who had been admitted with suicidal ideations to ensure the risk assessment was conducted correctly and interventions were in place according to policy. - Education began to all BHU Nursing Personnel regarding completion of the suicide risk assessment and associated interventions based on the outcome of the assessment, staggering of rounds, BLS refresher including silent choking, Rapid Response Team (RRT, a team of health care providers that respond to patients with early signs of clinical deterioration to prevent respiratory or cardiac arrest) process that included the use of a panic button and documentation requirements and educational materials of suicide and the elderly population. - Education began to all BHU MHT's regarding staggering of rounds and if they were unable to complete the round that they were to delegate to another MHT or Registered Nurse (RN), the RRT process that included a panic button and documentation requirements and educational materials of suicide and the elderly population. - All education was given prior to the start of the staff members' next shift. - BHU assignment sheet was changed to include which staff was assigned to what patient room, who received report and patient risk assessment status. - Scheduled pastoral care to meet with unit staff to debrief around event. - Mock RRT drills on each shift that assessed if staff followed the process as outlined in the policy. - Conduct a 30 minute competency revalidation to all BLS certified staff on the BHU that included review of the event. - Each Charge RN to monitor every Behavioral Health patient (house wide) every shift to ensure a suicide risk assessment was completed and interventions were outlined per policy. - All new employee orientation and yearly education was reassessed and updated for evaluation on what information needed to be added or changed to reflect the above training/changes. - The BHU House Supervisor or BHU Assistant Chief Nursing Officer were to evaluate immediately after a RRT event that the associated RRT event paperwork was complete. - All nursing staff not working on a BHU received education of suicide assessments and interventions. - All BHU's were to conduct video validations (visual review of video recording of patient rounding on the units) of 15 minute rounding. This was to be conducted by a member of the leadership team. - Employee found not to have done patient rounding prior to the event was suspended on [DATE] and was terminated on [DATE]. The additional staff member that was assigned to the patient was also suspended until a full investigation was completed. - All action items were to be tracked daily to ensure that compliance was met. A daily report was to be provided to the Chief Executive Officer and monthly to the Board until all action plans were completed. - All BHU Nursing personnel were to have a competency revalidation that 15 minute rounds were completed according to policy. - On all BHU's the nurse and the MHT were to round together each hour to validate that the MHT rounded every 15 minutes. The nurse was to validate the round on the observation flow sheet and the charge nurse was to actively validate once a shift by visualizing each nurse and MHT completing this process.

27029 Based on observation, interview, record review, and policy review the facility failed to: - Adequately protect one patient (#10) of 11 patients on the Intensive Treatment Unit (ITU - a psychiatric unit for patients with aggressive or behavioral issues) from physical and verbal abuse. (Refer to A-0145) - Follow their internal policies on Code White; Restraint/Seclusion and Patient Abuse and Neglect. (Refer to A-0145) - Protect one of one patient (#10) from an Alleged Perpetrator (AP), following an abuse event. (Refer to A-0145) - Conduct a timely investigation following an abuse event which resulted in the failure to implement corrective action to prevent any future abuse. (Refer to A-0145) - Protect two current patients (#2 and #11) from neglect and verbal abuse and one discharged patient (#9) from verbal abuse or threats which were punitive in nature. (Refer to A-0145) These failures had the potential to affect all patients at risk of abuse in the facility. The facility census was 339 of which 73 patients were considered at risk for abuse in the psychiatric units. The cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On 09/17/14, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect patients. As of 09/18/14, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following: - Staff HH, RN, charge nurse, who choked the patient was terminated on 09/17/14. - Staff MM, RN, House Supervisor, who failed to intervene on the patient's behalf or report the event was terminated on 09/17/14. - The police department was notified by the facility and responded on 09/18/14. - All psychiatric nursing staff were re-educated on the expectations of mandated reporting of abuse before resuming the care of patients on the psychiatric units. - All House Supervisors were educated on their role expectations to include identifying abuse, oversight of Code White (a multi-disciplinary team response to evaluate and intervene when a patient, family member or visitor is exhibiting a behavioral crisis, or potentially disruptive, inappropriate or threatening action(s) that compromises the safety and well-being of themselves and/or others) and restraint episodes, to lead and direct the employees, to remain at the event and manage the situation, and immediately report events to the administrator on call. - All psychiatric Senior Leadership Administration, Leadership of Security and Emergency Services were re-educated on the Patient Abuse and Neglect Policy, Mandated Reporting Policies and CPI (Crisis Prevention Institute) techniques. - Additional training and education was provided to all staff on psychiatric units on the use of patient privileges used punitively for disciplinary action. - Additional training and education was provided to nursing staff on patient assessments while in restraints, documentation in restraints and event reporting. - Concentrated training was provided to all psychiatric staff on NVCI(Non-violent Crisis Intervention)/CPI de-escalation techniques with a certified CPI Trainer. -The facility revised multiple policies including the Code White Policy and procedures and terminated employee badge access procedures. - Unannounced mock Code White drills were implemented on an ongoing basis to include all shifts. -The facility created, approved and posted a new safety tech (technician) role for the Adult/ITU and will hire for the position by 09/24/14. The role is designed for the behavioral health (psychiatric) units to manage the milieu (a physical or social setting), continually round on patients and be the team lead for Code White. - An external Peer Review will be completed for Staff U, Psychiatrist, attending physician, and his participation in the event. - Senior Leadership and psychiatric unit's management will round on current patients multiple times daily to ensure continued safety, address patient concerns and encourage feedback on care. - All Code Whites will be reviewed by Senior Leadership by the next business day to ensure the policy and NVCI/CPI techniques have been utilized correctly. The review will include review of the documentation and videotapes on the psychiatric units. All Code Whites will be tracked and trended on an ongoing basis for occurrence and appropriate documentation. This will be reported to the Quality Committee monthly. 18018 12450

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29047 Based on record review and staff interview, an immediate jeopardy situation was found to exist when the hospital failed to provide stabilizing treatment within its capacity and capability to five (#1, 2, 4, 5, and 20) of 20 patients who presented to the hospital emergency department seeking care for an emergency psychiatric condition, out of a sample selected from November through [DATE]. Findings included: 1. Review of hospital policy titled, Admission to 7W - Criteria and Process dated [DATE], showed that capability of the inpatient psychiatric unit located on the 7th floor included patients who are/ or have: -Age 18 to [AGE] years with psychiatric problems; -Patients with suicidal ideation or attempt; -Patients with physically aggressive threats or actions due to a treatable primary psychiatric condition; -Patients with inability to care for self due to primary treatable psychiatric condition; -Patients with significant impairment in social, familial, or occupational relations. 2. Review of the on call list revealed a psychiatrist was on call to the emergency department every day during the month of November and December when Patients # 1, 2, 4, 5 and 20 presented to the ED seeking care for a psychiatric emergency. 3. During an interview on [DATE] at 12:57 PM, the Nursing Director of the Intake Center located inside Hospital B stated that placement determination (patient admission ) is made by the call center staff and that they arrange admissions for all the Missouri hospitals in their corporate health system including Research Medical Center. The Director stated that patients aged 55 or older are transferred to Hospital B's senior unit and when questioned regarding the 18 - 65 age limit for the psychiatric unit on 7 West stated probably the oldest patient they've had (referring to 7 W) was [AGE] years of age. When re-questioned regarding capability of the psychiatric unit on 7 West, the Director stated anyone outside the age of 18 - 65, otherwise there is no one that cannot be managed on 7 West. 4. Review of a closed medical record reported by Quality Risk Manager (QRM) B revealed Patient # 1 presented with family to the emergency department (ED) on [DATE] at 11:43 AM after threatening self harm. At 1:11 PM, ED nurse O documented that while in the radiology department for a CT scan (a special type of x-ray), Patient # 1 jumped off the table, ran down the hallway saying staff want to kill me. ED nurse O documented she notified ED physician N regarding the situation Staff J, a Licensed Professional Counselor (LPC) examined Patient # 1 (time unknown) and documented at 4:02 PM that Patient # 1 appeared confused, obsessively checking own sense of reality, had difficulty distinguishing between what was real and what was a dream, cooperated with the exam on behalf of the spouse but then claimed the spouse was not really my spouse. Further documentation revealed Patient # 1's spouse found a letter saying I'd kill myself, but I am too chicken and that the patient had attempted suicide [AGE] years ago. Staff J documented arrangements to transfer Patient # 1 to Hospital B. Review of the transfer form revealed ED physician N documented at 3:45 PM that Patient # 1's transfer was medically indicated to obtain Inpt (inpatient) psych (psychiatric) services unavailable (at Research Medical Center) and that transport would be provided by the local Fire Department emergency service. Review of the ED physician's progress note confirmed that Patient # 1 had been accepted by Hospital B but that the mode of transport changed and Patient # 1's spouse would provide the transportation. ED nurse N documented Patient # 1 left the ED with the spouse at 6:16 PM. The medical record did not contain evidence that Patient # 1's psychiatric emergency was stable in the ED, that on call psychiatrist R was contacted, or that arrangements were made to admit Patient # 1 to any of 10 beds available on the 30 bed psychiatric unit located on 7 W (7th floor, West). Documentation provided by Research Medical Center (RMC) during the EMTALA investigation revealed instead of going to Hospital B, the spouse took Patient # 1 home, and that Patient # 1 was agitated and ran out into traffic and was killed. During an interview on [DATE] at 4:10 PM, LPC J stated that when she evaluated Patient #1 in the ED, the patient was anxious, confused, didn't recognize the spouse and was very depressed. I really didn't trust the patient. I felt the patient needed to be admitted . LPC J confirmed she did not attempt to arrange admission to the hospital's psych unit on 7 W because of Patient # 1's age (Patient # 1 met the age criteria for admission to 7 W). LPC J stated she requested admission to Hospital B's Senior Unit and the patient was accepted. LPC J stated she was informed later that night (by Hospital B), that the patient never showed up for admission. LPC J stated she found out the following day that Patient # 1 had died after jumping out of a car. During an interview on [DATE] at 1:11 PM, ED Physician N stated he was concerned about Patient # 1's depression and felt the patient was a danger to self, but was unsure why the patient was admitted the Senior Unit at Hospital B. ED Physician N stated that patients admitted to Hospital B's Senior Unit usually have dementia, and Patient # 1 didn't have dementia. During an interview on [DATE] at 11:00 AM, ED Physician G confirmed that he took over Patient # 1's care after ED Physician N went off duty. According to ED Physician G, LPC J reported to him that Patient # 1 was willing to be transported to Hospital B if the spouse could provide transportation. ED Physician G stated that when he changed the mode of transportation from ambulance to family (private vehicle), no one voiced any concerns. I don't know how long it was after I changed the mode of transportation until the patient left. I didn't discuss where the patient was going because the off going ED physician (physician N) said the mental health professional was making arrangements. They determine where the patient will go, but I don't know how that whole process works, you would have to ask the mental health staff. ED Physician G confirmed that he did not see or evaluate Patient # 1. During an interview on [DATE] at 12:57 PM, Staff D, Intake Director stated the call center staff consisted of Masters prepared Social Workers, Masters prepared Counselors, and Registered Nurses. During an interview on [DATE] at 2:30 PM, Staff F, Call Center Staff member stated, We (Call Center staff) do all placements for all patients (inpatient and outpatient) for all (Missouri Hospitals within our health system). We are required to find placement for every patient called into us (Call Center) who meet admission criteria. 5. Review of the closed medical record revealed Patient # 2 presented to RMC ED escorted by law enforcement on [DATE] at 11:52 AM. A report provided to the hospital by law enforcement indicated Patient # 2's family stated he suffered from schizoid effective disorder and psychosis, that he was not taking his medications, had been drinking alcohol, hadn't slept in 2 or 3 days, was not making sense and was having paranoid delusions. Two affidavits included in the medical record attested that the patient believed he was hearing secret coded messages in music, was injuring himself, and drinking excessively because he feared going to sleep. The ED nurse documented Patient # 2 was placed in four-point restraints (all 4 extremities restrained) after becoming physically aggressive, violent, combative, and destructive. While restrained, Patient # 2 continued to be agitated, clenching his fists and banging his head on the bed side rail while attempting to remove his restraints, later becoming confused and disoriented. At 2:36 PM, Patient # 2 became subdued and the ED nurse removed the restraints from the patient's left wrist and right ankle, and at 3:34 PM the remaining two restraints were removed. At 4:20 PM, an ED nurse documented that the patient began to pace, closed the room door, punched the door, and turned off the lights. Security was notified as well as the ED physician, who ordered the patient to be placed in four-point restraints and medicated with a sedative Benadryl (100 mg IM), an anti-anxiety Ativan (4 mg IM), and an anti-psychotic Haldol (10 mg IM). The transfer record, signed by the ED Physician, indicated that the patient was unstable and was to be transferred to Hospital B for inpatient psychiatric services. At 4:55 PM, Kansas City Fire Department (KCFD) was in the ED and assisted in moving Patient # 2 to a cot, and KCFD and RMC security escorted the patient to Hospital B by ambulance at 7:02 PM. The medical record did not contain evidence that Patient # 2's psychiatric emergency was stable in the ED, that on call psychiatrist T was contacted, or that arrangements were made to admit Patient # 2 to any of 16 beds available on the 30 bed psychiatric unit located on 7 W. 6. Review of a closed medical record revealed Patient # 4 presented to the ED on [DATE] at 3:14 PM, complaining of homicidal and suicidal ideations. ED nursing documentation at 4:09 PM, indicated that the patient had thoughts of suicide, thoughts of homicide, was experiencing auditory hallucinations, and had attempted suicide in the past. Review of the transfer form showed documentation in the physician section indicating the reason for the transfer was medically indicated to obtain a service (psychiatric) that was unavailable (at Research Medical Center). The patient was transferred to Hospital B at 6:24 PM. The medical record did not contain evidence that Patient # 4's psychiatric emergency was stable in the ED, that on call psychiatrist S was contacted, or that arrangements were made to admit Patient # 4 to any of 22 beds available on the 30 bed psychiatric unit located on 7 W. During an interview on [DATE] at 1:00 PM, QRM B stated that based on medical record review and the call center log summary, the call center did not contact 7 W to determine capability and capacity for admitting Patient # 4. During an interview on [DATE] at 2:05 PM, QRM B stated that after review of the 7 W inpatient census for [DATE], the facility had the capacity and capability to provide Patient # 4's inpatient psychiatric care. 7. Review of a closed medical record revealed Patient # 5 presented to the ED by ambulance on [DATE] at 12:03 AM, complaining of intoxication, depression, and wanting to die. At 12:06 AM, the ED physician examined the patient and documented the patient had a history of schizoaffective disorder, was depressed, having suicidal ideations, and planned to overdose on her medication. At 2:45 AM, the patient was evaluated by a mental health professional who documented that the patient had a significant history of suicide attempts, poor impulse control and coping skills, and was a threat to herself. At 6:02 AM, KCFD was contacted to transport the patient to Hospital B for inpatient psychiatric services and the patient was transferred at 7:20 AM. The medical record did not contain evidence that Patient # 5's psychiatric emergency was stable in the ED, that on call psychiatrist R was contacted, or that arrangements were made to admit Patient # 5 to any of 16 beds on the 30 bed psychiatric unit located on 7 W. During an interview on [DATE] at 1:40 PM, QRM B stated that Patient # 5 was transferred to Hospital B because the patient had previously been admitted there. During an interview on [DATE] at 2:05 PM, QRM B stated that after review of the 7 W inpatient census for [DATE], the facility had the capacity and capability to provide Patient # 5's inpatient psychiatric care. 8. Review of a closed medical record revealed Patient # 20 presented with law enforcement to the ED on [DATE] at 10:32 AM, after the patient was found yelling in the street and experiencing hallucinations. The ED nurse documented that patient # 20 was anxious, walking in the streets yelling and felt like terrorists had abducted him and were tearing his insides up, that he was continuously rambling and had a history of substance abuse. Documentation in the Emergency Physician Record indicated patient # 20 was agitated, hostile, experiencing auditory hallucinations, had prior thoughts of suicide, was schizophrenic and had not taken his anti-psychotic medication Zyprexa for two days. The medical record contained 16 handwritten pages in which patient # 20 expressed the belief that his body was occupied by terrorists and people close to him were being raped and abused. Documentation by Call Center staff U at 12:09 PM, indicated arrangements were made to transfer Patient # 20 to Hospital B. Review of the transfer form revealed Staff V documented at 12:30 PM that patient # 20 required transfer to obtain a service (psychiatric) unavailable at (Research Medical Center). Review of the Physician Certification Statement specifying the reason for ambulance transportation to Hospital B revealed the Pt (patient) is schizophrenic and is a flight risk. The medical record did not contain evidence that patient # 20 received treatment for his psychosis while in the ED, that his emergency medical condition was stable, that on call psychiatrist O had been contacted, or that arrangements were made to admit him to any of the 14 beds available on 7 W. 9. During an interview on [DATE] at 10:32 AM, QRM B stated that based on staff interviews and record reviews during the EMTALA investigation, it was unclear how the hospital staff determined capacity and capability before transferring patients to another facility.

39147 Based on interview, record review, video review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening exam (MSE) for one patient (#6). The hospital also failed to maintain an accurate central log for patients presenting to the emergency department (ED) for care. They failed to accurately document the disposition of six patients (#6, #7, #9, #15, #17, #24, and #25) and to maintain an ED log for the period of 04/07/22 through 06/15/22, in regards to six patients (#20, #26, #27, #28, #29, and #30) selected, of 31 ED records reviewed from February 2022 through August 2022. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's combined average monthly ED census over the past six months was 5,529. Findings included: Review of the hospital's policy titled, Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an EMC) Definitions and General Requirements, dated 09/01/19, showed that a MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists; screening is to be conducted to the extent necessary, by physicians and/or other qualified medical profession (QMP) to determine whether an EMC exists; and with respect to an individual with behavioral symptoms, a MSE consists of both a medical and behavioral health screening. Although requested, a policy regarding the maintenance and required documentation of a Central ED Log was not provided. Although requested, the hospital was unable to produce a Central ED Log for the dates of 04/07/22 through 06/15/22. The hospital provided an unlabeled report, pulled from financial data, with minimal patient information for that time frame. All patients were listed by account numbers only, and all dispositions for this time frame were documented as home. The patient selection pulled from the unlabeled report consisted of a total of six patients (#20, #26, #27, #28, #29, and #30). Review of Patient #6's medical record showed that she presented to the ED on 08/09/22 at 1:02 PM with a stated complaint of suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideantion (HI, thoughts or attempts to cause another's death) and off her medications. Triage (process of determining a priority of a patient's treatment based on the severity of their condition) note showed the patient was escorted out by KCPD and medications were not given. Medication orders were documented for Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder) and Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure). There was no MSE documented. Patient #6 was discharged at 1:16 PM. Please refer to 2405 and 2406 for further details.

39147 Based on interview, record review and policy review the hospital failed to maintain an accurate central log for patients presenting to the emergency department (ED) for care. They failed to accurately document the disposition of six patients (#6, #7, #9, #15, #17, #24, and #25) and to maintain an ED log for the period of 04/07/22 through 06/15/22, in regards to six patients (#20, #26, #27, #28, #29, and #30) selected, of 31 ED records reviewed. The hospital's combined average monthly ED census over the past six months was 5,529. Findings included: Review of hospital's policy titled, Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an emergency medical condition) Definitions and General Requirements, dated 09/01/19, showed that all individuals that arrive at the ED seeking emergency treatment should be placed on a Central ED Log. The purpose of the log would be to track whether the individual refused treatment, was refused treatment, whether they were admitted and treated, stabilized and transferred, or discharged . Although requested, a policy regarding the maintenance and required documentation of a Central ED Log was not provided. During an interview on 08/16/22 at 10:45 AM, Staff D, Chief Nursing Officer (CNO), stated that they were unaware that there were missing portions of the Central ED Logs until requested by the survey team. They identified that April, May, and half of June were missing. The ED Director was out on maternity leave and there had not been an interim ED Director put in place until June 2022. Review of the ED log dated 08/09/22 showed that Patient #6 presented to the ED on 08/09/22 at 1:02 PM with no disposition listed. Review of Patient #6's medical record showed that she presented to the ED on 08/09/22 at 1:02 PM with a chief complaint of suicidal ideation (SI, thoughts of causing one's own death), homicidal ideations (HI, thoughts or attempts at causing another's death) and off her medications. She was discharged to home. Review of the ED log dated 08/09/22 showed that Patient #7 presented to the ED on 08/09/22 at 2:16 PM with no disposition listed. Review of Patient #7's medical record showed that she presented to the ED on 08/09/22 at 2:16 PM with blockages in her legs and left without being seen (LWBS) after triage (process of determining the priority of a patient's treatment based on the severity of their condition). Review of the ED log dated 08/06/22 showed that Patient #9 presented to the ED on 08/06/22 at 5:06 PM with no disposition listed. Review of Patient #9's medical record showed that she presented to the ED on 08/06/22 at 5:06 PM with ingestion of methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) and LWBS after triage. Review of the ED log dated 07/16/22 showed that Patient #15 presented to the ED on 07/16/22 at 6:56 PM with no disposition listed. Review of Patient #15's medical record showed that she presented to the ED on 07/16/22 at 6:56 PM with SI, HI, and assault. She left prior to receiving a medical screening exam (LPMSE). Review of the ED log dated 06/27/22 showed that Patient #17 presented to the ED on 06/27/22 at 3:51 PM with no disposition listed. Review of Patient #17's medical record showed that she presented to the ED on 06/27/22 at 3:51 PM with a complaint of inability to stay awake. She was discharged to home at 6:44 PM. Review of the ED log dated 03/06/22 showed that Patient #24 presented to the ED on 03/06/22 at 11:20 AM with no disposition listed. Review of Patient #24's medical record showed that she presented to the ED on 03/06/22 at 11:20 AM with burns to her hands. She had been place on the ED log under a different name. The medical record documentation was under another name, her correct name. She was discharged to home. Review of the ED log dated 03/18/22 showed that Patient #25 presented to the ED on 03/18/22 at 5:56 AM with no disposition listed. Review of Patient #25's medical record showed that he presented to the ED on 03/18/22 at 5:56 AM with muscle aches, but LPMSE. Although requested, the hospital was unable to produce a Central ED Log for the dates of 04/07/22 through 06/15/22. The hospital provided an unlabeled report, pulled from financial data, with minimal patient information for that time frame. All patients were listed by account numbers only, and all dispositions for this time frame were documented as home. The patient selection pulled from the unlabeled report consisted of a total of six patients (#20, #26, #27, #28, #29, and #30). Review of the hospital's untitled report dated 04/30/22 showed that Patient #20 presented to the ED on 04/30/22 at 9:17 PM with home listed under disposition. Review of Patient #20's medical record showed that he presented to the ED on 04/30/22 at 9:17 PM with SI and agitation (a state of feeling irritated or restless). He was discharged to home. Review of the hospital's untitled report dated 05/02/22 showed that Patient #26 presented to the ED on 05/02/22 at 10:38 PM with home listed under disposition. Review of Patient #26's medical record showed that he presented to the ED on 05/02/22 at 10:38 PM with an opiate overdose. He was discharged to home. Review of the hospital's untitled report dated 04/07/22 showed that Patient #27 presented to the ED on 04/07/22 at 8:34 PM with home listed under disposition. Review of Patient #27's medical record showed that she presented to the ED on 04/07/22 at 8:34 PM with a request for medication refill and food. She was discharged to home. Review of the hospital's untitled report dated 04/12/22 showed that Patient #28 presented to the ED on 04/12/22 at 6:08 PM with disposition to home. Review of Patient #28's medical record showed that he presented to the ED on 04/12/22 at 6:08 PM with SI. He was admitted to the psychiatric center. Review of the hospital's untitled report dated 05/26/22 showed that Patient #29 presented to the ED on 05/26/22 at 4:23 PM, no diagnosis listed, with disposition to home. Review of Patient #29's medical record showed that he presented to the ED on 05/26/22 at 4:23 PM with an intentional overdose, over the counter cold medication, five boxes with 16 tablets each, a total of 80 tablets. He was held in the ED pending psychiatric placement and ultimately discharged to home on 05/28/22 at 5:30 PM. Review of the hospital's untitled report dated 05/31/22 showed that Patient #30 presented to the ED on 05/31/22 at 7:17 AM, no diagnosis listed, with disposition to home. Review of Patient #30's medical record showed that he presented to the ED on 05/31/22 at 7:17 AM with SI. He was transferred to an inpatient psychiatric hospital. 39840

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40189 Based on interview, record review, policy review and video review, the hospital failed to provide within its capability and capacity, an appropriate medical screening exam (MSE) for one patient (#6) out of 31 Emergency Department (ED) records reviewed from February 2022 through August 2022. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's average monthly ED census over the past six months was 5529. Findings included: Review of the hospital's policy titled, Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment, and transfers of individuals with an EMC) Definitions and General Requirements, dated 09/01/19, showed that a MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists; screening is to be conducted to the extent necessary, by physicians and/or other qualified medical profession (QMP) to determine whether an EMC exists; and with respect to an individual with behavioral symptoms, a MSE consists of both a medical and behavioral health screening. Review of Kansas City Police Department's (KCPD) document titled, Mental Health /Crisis Intervention Team (CIT) Report, dated 08/09/22, showed that Staff T, Police Officer (PO), was called to Patient #6's home where he found a neighbor that reported the patient was threatening to harm others, was a danger to herself, had an edged weapon, was using alcohol, had a mental health diagnosis of bipolar (characterized by clear changes in mood, energy, and activity levels with periods of extremely energized behavior) and schizophrenia (a serious mental disorder that affects a person's ability to think, feel, and behave clearly). The report showed that the patient was on medications but was noncompliant and was currently in services with an outpatient mental health clinic. Review of KCPD's document titled, Narrative, dated 08/09/22, showed that Staff T, PO, first responded to Patient #6's home address where it was reported by a neighbor that the patient was making statements that she believed some neighbors were going to shoot her and another neighbor; people were trying to kill her. She began threatening people with a [NAME] like object. The patient was not found at the first location. Staff T responded to a second location after he saw a woman that fit the description of the patient and where Staff S, PO, responded on a separate call. It was a liquor store where the patient was found drinking alcohol inside and had not paid. No charges were being brought against the patient. Patient #6 was released to Staff T who called Emergency Medical Services (EMS, ambulance), to transport the patient to the hospital for a mental health evaluation. The patient stated to Staff T, that she was followed and threatened by neighbors who she could not identify. The patient stated she heard the neighbors who talked about shooting her and a neighbor. The patient stated she, might have to kill them before they kill her. Once the patient arrived to the ED, the patient began to panic stating she did not want to go to the alien room. She stated she was scared of the aliens and then tried to hide in a corner. The patient was crying and appeared terrified. A female provider asked why Patient #6 was there. Staff T explained the circumstances that led to the mental health evaluation. The provider responded, I'm the provider, I'm clearing her medically, just take her to jail. He advised her that there were no charges being brought against her and it was purely a mental health service. The provider responded, I'm medically clearing her, just get her out of my hospital. The patient was discharged from the hospital at that time without being seen or treated. Review of the Kansas City Fire Department (KCFD) EMS document titled, Patient Care Record, Incident #: 22-105470, dated 08/09/22, showed that Patient #6 was a [AGE] year old woman that had a Primary Impression of Behavioral/psychiatric episode, Chief Complaint was, Needs meds. Signs and Symptoms were, Behavior/Emotional State, strange and inexplicable behavior, Mental Status, Event oriented, hallucinations, person oriented, place oriented, time oriented. Patient stated she was off her medications and wanted to get back on them. The patient displayed strange behavior and hallucinations. The patient denied suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideations (HI, thoughts or attempts at causing another's death). The patient was transported to the hospital with Staff S, PO, who sat in the back with the patient. Patient #6 was transported without incident. Report was given and patient care was transferred to the Registered Nurse (RN) at the receiving hospital. Review of KCPD's Body Cam Video, tkj00771_20220809171707e0_20220809172705_01_001w.mp4, verified by KCPD as dated 08/09/22, showed that the first response by police was at the patient's home address. Patient #6's neighbor stated the patient had a weapon that was like some sort of pick ax or something, screaming and shit. The neighbor reported that earlier the patient had thrown her clothes and things out of her house, as she pointed to the front yard. The neighbor reported that the patient was picked up by an ambulance earlier that day and she returned at about 11:30 AM that morning. The patient was first calm and then began talking about how she wanted to die and wanted to kill herself. As the patient sat and waited for an ambulance the neighbor had called, she became more paranoid (excessive suspiciousness without adequate cause); she picked up the next door neighbor's weed eater and stated she needed a weapon. The patient insisted someone was there to kill her neighbor, although no one was around. The patient reportedly had put her shoes on and ran up the street. The officer was unable to locate the patient. Review of KCPD's Body Cam Video, tjk00771_20220809173706e0_20220809173636_01_000w.mp4, verified by KCPD as dated 08/09/22, showed that the second response by police was to a liquor store where the patient was found drinking alcohol and had not paid for it. The patient was sitting on a curb, handcuffed and was giving the officer identifying information. The liquor store decided to not press charges against the patient. The patient verified her address where the police had first responded. The patient stated to the police officer, I don't want my neighbor to die. She requested the police go check on her neighbor's safety. She stated, I just want to protect my neighbor from somebody shooting her. She reported that two neighbors were going to shoot her and her neighbor. She stated she felt like her neighbors were watching her. The patient admitted to hearing voices and stated she was schizophrenic and bipolar. The patient stated she was off her medications for a couple days and felt like things had gotten worse. The patient stated she wanted to get back on her medications. The police officer stated he had called an ambulance and the patient agreed to go to the hospital for help. The officer was heard stating he had enough information for a Crisis Intervention Team (CIT) report. The patient remained calm and appeared drowsy sitting on the curb. The patient had the handcuffs removed and began to walk off. The police were able to redirect the patient into the ambulance. A police officer got into the back of the ambulance and accompanied the patient to the hospital for safety of the EMS staff. Review of the hospital's ED video, verified by the hospital as dated 08/09/22, showed that Patient #6 walked into the ED and was escorted by KCPD and EMS. The paramedic and EMT left the ED. Within minutes, the patient was seen leaving the ED and was escorted by hospital security and KCPD. Once the patient was outside, she was seen walking across the parking lot alone until out of the camera's view. Review of Patient #6's medical record showed that she presented to the ED on 08/09/22 at 1:02 PM with a stated complaint of SI and HI and off her medications. Triage (process of determining a priority of a patient's treatment based on the severity of their condition) note showed the patient was escorted out by KCPD and medications were not given. Medication orders were documented for Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder) and Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure). There was no MSE documented. Patient #6 was discharged at 1:16 PM. Review of the ED log dated 08/09/22 showed that Patient #6 presented to the ED on 08/09/22 at 1:02 PM with the chief complaint of SI and HI and off her medications. The patient's disposition was logged as home. Review of the hospital's document titled, Research Medical Center On Call Schedule, dated 08/09/22, showed that two psychiatrists were on call at the time of Patient #6's ED visit. During an interview on 08/15/22 at 3:40 PM, Staff F, RN, stated that she had not recalled caring for Patient #6. Medication could have been ordered by the provider and not given if the patient had calmed herself down. If a patient retracted saying they had SI or HI, the patient could have been discharged . During an interview on 08/15/22 at 4:32 PM, Staff H, Advanced Practice Provider (APP), stated that Patient #6 was well known to the ED for substance abuse and psychosis. The police told her that the patient was found at a liquor store drinking alcohol and acting erratically; the police were called and they picked the patient up and brought her to the ED. Patient #6 refused to go into a psychiatric (relating to mental illness) room; the patient lost her mind, collapsed to the floor crying out that she would rather have gone to jail than into one of those rooms. EMS told her the police were arresting the patient. Staff N, Security Guard, was there with the patient but had not touched her; the patient was not aggressive. The patient denied SI or HI. The patient was de-escalated and then was assessed. She performed a MSE but had not documented it. The police officers never said anything about a 96-hour hold (court ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) or an affidavit (a written statement confirmed by oath, for use as evidence in court). During an interview on 08/16/22 at 11:09 AM, Staff I, RN, stated that the APP only talked to the patient, but no physical assessment was performed. Security and two police officers walked the patient out of the ED; the patient was calm and not handcuffed. There were mental health providers on call every day for assessment of patients. During an interview on 08/16/22 at 12:15, Staff O, ED Charge Nurse (CN), stated that the patient came in calmly and escorted by police. Patient #6 cried that she would rather go to jail than to one of the rooms (referring to the psychiatric rooms). The patient was cleared medically by Staff H, APP. The police officers never mentioned a 96-hour hold or an affidavit needed because she was a notary and would have been the one who signed the paperwork. During an interview on 08/16/22 at 12:25 PM, Staff N, Security Guard, stated that he saw Patient #6 sitting in a corner crying and said she would rather have gone to jail than to have gone into one of the rooms. Staff H, APP, stated that if the patient had nothing medically wrong, she was cleared to leave the ED. He had to escort them out to unlock the doors. During an interview on 08/18/22 at 4:50 PM, Staff S, PO, stated the patient did not have a weapon when found at the liquor store. He accompanied the patient in the ambulance to the hospital. Staff T, PO, stated that he was filling out a CIT and affidavit. The patient was calm until she was by the psychiatric rooms where she became emotional and appeared frightened. She stated she would have rather gone to jail than into one of those rooms. Staff H, APP, stated that the patient was medically cleared and was no longer needed there. The patient was allowed to leave the hospital alone because she was not under arrest. During an interview on 08/19/22 at 12:56 PM, Staff T, PO, stated that he first responded to a mental health call at Patient #6's home address. The patient was not there but he had spoken to the neighbor that made the 911 call. The neighbor reported that the patient had a [NAME] like weapon and thought other neighbors were going to shoot them; the patient became increasingly paranoid. He never saw a weapon at the scene. The neighbor thought the patient was seen earlier at the hospital. He responded to a second location, a liquor store, where the patient was found drinking alcohol and had not paid. The liquor store had not charged the patient, therefore Staff S, PO, released the patient to him and she was then taken to the hospital for a mental health examination. The patient was calm and cooperative. The patient stated that she would kill the others before they could kill her. Upon arrival to the hospital, the patient cried and appeared scared of the psychiatric rooms. She stated she would have rather gone to jail than go into one of those rooms. The provider yelled back and forth with the patient; there was a lot of commotion. He told the provider about the 96-hour hold, but she may not have heard him. He was given an affidavit by the hospital staff, but he had no time to fill it out because she was discharged so quickly. Staff H, APP, stated that the patient was medically cleared and to take her out of the hospital; security escorted the patient out of the hospital. The patient was allowed to walk off hospital grounds because she had not been charged with any crime. During an interview on 08/22/22 at 10:22 AM, Staff U, Paramedic, stated that they were called by police to transport a patient for a behavioral health episode. The patient was picked up at a liquor store. She was the one that took care of the patient in back of the ambulance. The patient was calm and cooperative. Patient #6 told her that she needed to get back on her medications. The patient denied any SI or HI. The patient exhibited strange behavior, talking to the wall of the ambulance and did not make any sense. Upon arrival to the ED, the patient's demeanor changed and she had become more paranoid about going back to the psychiatric rooms. The police stated they planned to do a CIT and an affidavit, which was the purpose of the visit. Report was given to the hospital staff upon arrival. She saw the patient on the street alone after leaving the hospital grounds. During an interview on 08/22/22 at 10:35 AM, Staff V, Emergency Medical Technician (EMT), stated that she was the driver of the ambulance and did not have much interaction with the patient; the patient exhibited strange behavior like she was anxious and paranoid. During an interview on 08/15/22at 3:50 PM, Staff G, ED Physician, stated that he did not see Patient #6 when she arrived. He initially signed up to care for the patient, but Staff H, Advanced Practice Provider (APP), saw the patient first. Staff H informed him she assessed Patient #6 and completed a MSE; the patient was cleared medically and was discharged . He expected a MSE to have been documented in the medical record if it was performed. All patients who presented to the ED should have a MSE documented. During an interview on 08/17/22 at 4:21 PM, Staff R, ED Medical Director, stated that he would have expected a MSE to have been performed and documented on every patient that came through the ED doors. It depended on how the patient presented to the ED if a psychiatric evaluation was performed; this patient was calm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40710 Based on interview, record review, policy review and review of video surveillance, the facility staff failed to immediately remove one staff member (Staff W) from patient care after allegations of abuse, of one staff member reviewed for abuse allegations. This had the potential to allow for continued abuse by staff, and could affect all patients. The facility census was 282. Findings included: 1. Review of the facility's policy titled, Abuse and Neglect revised 09/2018, showed that upon witnessing or receiving an allegation of abuse or neglect, facility staff should place any staff suspected to have committed an act of abuse or neglect on administrative leave until a determination of the allegation can be made. Review of Patient #10's medical record dated 03/19/19 through 04/08/19, showed he was a [AGE] year old male who was admitted to the psychiatric center. Review of Patient #11's medical record dated 04/01/19 through 04/07/19, showed he was an [AGE] year old male who was admitted to the psychiatric center. He had poor impulse control, and was non-compliant with requests to leave Patient #10 alone. Review of a facility investigation dated 04/07/19, showed that on the morning of 04/07/19 at approximately 11:30 AM, Patients #10 and #11 were in a physical altercation with each other. A code white (code used to prompt help with altercations) was called and Staff W, Mental Health Technician (MHT), responded. Staff W came up behind Patient #10 to remove him, and in the process both Staff W and Patient #10 fell to the ground, hitting the wall first. Patient #10 received a facial laceration and a bloody nose. Review of the facility's video surveillance dated 04/07/19, from 11:34 AM to 11:36 AM, showed that during the altercation, Staff W came up behind Patient #10 and grabbed him with what appeared to be a bear hug and with forward motion, they both fell to the ground, hitting the wall prior to the fall. Staff W landed on top of Patient #10 and approximately 59 seconds after the fall, got up and released Patient #10. During an interview on 05/01/19 at 10:00 AM, Staff U, Registered Nurse (RN), stated that on 04/07/19 at approximately 11:30 AM, she saw Staff W have a hold on Patient #10 from behind, with his arms around the patient's waist, and then hit the wall as they fell to the floor. After the physical altercation, Staff W was moved to the other half of the adult male unit, but was allowed to continue working. She felt the approach that Staff W used to separate the two patients was not appropriate and did not follow crisis prevention institute (CPI, training for health care professionals to to provide non-violent interventions while caring for emotionally distraught, disruptive or violent people) guidelines. During an interview on 05/07/19 at 9:00 AM, Staff W, MHT, stated that: - After the incident, he was moved to B hall, which is in the same unit but on a different hall. - He finished his shift on 04/07/19, and left around 7:30 PM. - He returned to work on the next day, 04/08/19, and worked until around 2:00 PM. - On 04/08/19 at 2:00 PM, he was told to leave because of an investigation related to the events on 04/07/19. During an interview on 05/01/19 at 11:30 AM, Staff Y, RN, stated that: - She felt Staff W was frustrated during the altercation between Patient #10 and Patient #11, and she had instructed Staff W to back off and get up off of Patient #10. - After the event, Staff W was not sent home, but was moved to work another hall on the unit. - Staff W had attempted to return to the same hallway after being removed, but she redirected him. During an interview on 04/30/19 at 12:00 PM, Staff Q, Human Resource Director, stated that as a result of the initial event occurrence on 04/07/19 at 11:30 AM, Staff W was suspended, he had put in his notice after his suspension, but was terminated during his two week notice period on 04/18/19. During an interview on 04/30/19 at 11:30 AM, Staff E, Interim Chief Nursing Officer (CNO) of the psychiatric center, stated that he did not feel Staff W followed the proper CPI techniques with Patient #10 and was terminated. During an interview on 05/01/19 at 11:00 AM, Staff J, Risk Management Director and Staff I, Quality [NAME] President, stated that after review of the video surveillance of the incident, neither of them felt that Staff W had utilized proper CPI techniques, and that they expected the employee should have been immediately removed from the hospital pending investigation. They were under the impression that Staff W had been removed from the hospital after this event, and shared that they were not aware that he had been allowed to continue working on another unit the remainder of his shift, and again on the following day. The facility failed to implement immediate measures to remove a Staff W from patient care after alleged abuse, and allowed him to continue to work with patients, which could have resulted in the abuse of other patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40710 Based on interview, record review, policy review and review of video surveillance, the facility failed to implement protective measures to protect one patient (#10) of 28 patients reviewed for abuse or neglect, after the patient was repeatedly attacked by another patient. This had the potential to lead to unnecessary fear or injury of patients and had the potential to affect all patients in the facility. The facility census was 282. Findings included: 1. Review of the facility's policy titled, Abuse and Neglect revised 09/2018, showed that upon witnessing or receiving an allegation of abuse or neglect, facility staff should ensure immediate protection of the patient. Review of the facility's policy titled, Levels of Observation revised 03/2018, showed: -One-on-one (1:1, continuous visual contact with close physical proximity) observation is ordered when a patient is at immediate risk of harm to self and/or others; -The staff member will remain within arm's reach of the patient at all times while on 1:1; and -The patient will be reassessed each shift for continued need; Review of Patient #10's medical record dated 03/19/19 through 04/08/19, showed: - He was a [AGE] year old male that presented to the Emergency Department (ED) by law enforcement for evaluation and a 21 day hold (court order to remain under psychiatric care for 21 days) for increased aggression and homicidal (thoughts to harm another person) threats after he had brandished (to wave around as a threat) a knife and threatening to harm other people at his nursing home. - He had a history of paranoid schizophrenia (a mental illness that involves mistaken beliefs that one or more people are plotting against them or their loved ones), with recent exacerbations (increase in symptoms). - Upon admission to the psychiatric center, the patient was placed on the geriatric psychiatric unit but was quickly moved to the transitions unit (adult male only unit) due to his behaviors. - During the course of treatment, the patient had frequent verbal outbursts and/or threats to others. - He was described as verbally antagonistic (showing hostility toward someone), disruptive, verbally sexually inappropriate, intrusive (enter into an area, group or conversation where one is not welcome), and often agitated. - The treatment team had to redirect him often and use de-escalation (reduction of the intensity of a conflict or potentially violent situation) techniques with the patient which included placing him in reduced stimuli (something which causes a response) environments. - They had to reinforce healthy communication boundaries with the patient frequently. - That he was receptive but often did not comply with boundaries. Review of Patient #11's medical record dated 04/01/19 through 04/07/19, showed: - He was an [AGE] year old male that presented to the ED by law enforcement for evaluation and treatment due to erratic, bizarre, and aggressive behavior with his father at home and for suicidal ideation (SI, thoughts of causing one's own death). - He had a history of psychosis (a disorder characterized by false ideas about what is taking place or who one is) daily drug use, and depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed). - Upon admission to the psychiatric center, Patient #11 was placed on the transitions unit. - During the course of his treatment, the patient verbalized that he was angry, he had a recent break up with his girlfriend, and that he was depressed and felt paranoid (excessive suspiciousness without adequate cause) that someone was out to harm him. - The treatment team worked to avoid seeming suspicious and maintained a calm attitude with patient, using simple and brief messages and low stimuli. - He was often non-compliant (did not follow the recommendations) with care, refused to speak to staff or answer any of their questions, and was hesitant to participate in group therapies. - He was described as antagonistic, particularly with other patients, and was fixated on Patient #10 in particular. - He had poor impulse control, and was non-compliant with requests to leave Patient #10 alone. Review of a facility investigation dated 04/07/19, showed that on the morning of 04/07/19 at approximately 11:30 AM, Patients #10 and #11 were in a physical altercation with each other. A code white (code used to prompt help with altercations) was called, and during attempts to separate the patients, Patient #10 fell to the ground, hitting the wall first, and sustained a facial laceration and a bloody nose. During an interview on 05/01/19 at 10:00 AM, Staff U, Registered Nurse (RN), stated Patient #11 had previously hit Patient #10 in the head, that both patients had aggravated each other all shift and that Patient #11 was the main instigator. He would get in Patient #10's face, follow him, enter his room without permission and antagonize him. Staff interventions were to redirect the two men. After the physical altercation at 11:30 AM, Patient #10 was placed on one-on-one (1:1, continuous visual contact with close physical proximity), but Patient #11 was not. During an interview on 05/01/19 at 11:30 AM, Staff Y, RN, stated that: - She had witnessed antagonism between Patients #10 and #11, both on 04/07/19 and on prior shifts. - Patient #10 was hyper verbal and hyper aggressive at his baseline. - Patient #11 was younger and angry, and was not going to take it. - She had noticed Patient #11 put a strong focus on Patient #10, and it had caused her great concern. - She felt something bad would happen between the two patients. - She had contacted the physician (unsure of his name) for direction after their 04/07/19 altercation at 11:30 AM, and was given orders to place Patient #10 on 1:1. - Frequently, if orders were received for 1:1 during the middle of the shift, they would not be able to place the patient on the 1:1 until the next shift, because they would not have enough staff to do so. - On 04/07/19, she and another nurse attempted to trade off and cover the 1:1 for Patient #10 for the remainder of their shift. - She was not sure why Patient #10 was the only patient placed on 1:1. During an interview on 04/30/19 at 11:30 AM, Staff E, Interim Chief Nursing Officer (CNO) of the psychiatric center, stated that Patient #10 was placed on 1:1, but Patient #11 was not. Patient #11 had an obsessive focus on Patient #10 and they felt that having Patient #10 on 1:1 was enough to keep Patient #10 protected. During an interview on 05/07/19 at 9:00 AM, Staff W, Mental Health Technician (MHT) stated that: - Patient #10 had been verbal and hostile all day on 04/07/19 towards Patient #11 and staff attempted to redirect him, but it did not work. - Patient #11 was walking down the hallway when Patient #10 punched him and caused a fight between the two patients. - Neither Patient #10 nor Patient #11 were put on 1:1 during the remainder of his shift on 04/07/19 because they didn't have enough staff to do so. Review of a facility investigation dated 04/07/19, showed that on the evening on 04/07/19 at approximately 10:00 PM, Patients #10 and #11 had a second physical altercation. Staff #11 entered the day room covered in a blanket and jumped on Staff X, MHT, to get to Patient #10. During that event, Patient #10 was knocked down to the ground, and later complained of pain, guarded his right leg and was non weight bearing. He was transported to the ED where he was admitted with a diagnosis of a right femoral head fracture (a type of hip fracture). During an interview on 05/01/19 at 10:20 AM, Staff V, RN, stated that at approximately 10:00 PM on 04/07/19 she heard a loud commotion in the day room area. Patient #11 ran towards Patient #10. A staff member in the room tried to prevent the attack, but was unable, and Patient #10 ended up on floor, after he fell backwards. Patient #10 complained of pain and was sent out to the ED. Security had called 911, and police came and took Patient #11 away after he had also attempted to attack security and police. The facility failed to implement protective measures to protect Patient #10 from Patient #11, who was repeatedly aggressive and physically violent toward the patient.

19172 Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. The facility census was 312. 1. Observation on 11/27/18, during the facility tour, showed the following; -designated surgical ICU exit requires patients, staff and visitors to walk 100 feet to a hard surface. Sixteen feet of path to hardpath consists of grass and a steep hill. - designated east stair A exit requires patients, staff and visitors to walk into a courtyard where the hardpath is blocked by a gate. Observation showed patients, staff and visitors would have to manually lift up the gate to exit to the public way. Record review of the facility layout showed the exit discharge areas designated for resident use. During an interview on 11/27/18 at 1:20 P.M., the Division Director of Construction Management confirmed the observations. The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states: // 7.7 Discharge from Exits. 7.7.1* Exit Termination. Exits shall terminate directly, at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.

19172 Based on observation and facility staff interview, the facility staff failed to provide and maintain one of one kitchen range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition requirements. The facility census was 312. 1. Observation on 11/27/18, during the facility tour, showed the range hood did not have a an enclosed metal container to collect grease from the drip tray. During an interview on 11/27/18 at 1:30 A.M., The Division Director of Construction Management confirmed the observation. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 6.2.4.1 states: Grease filters shall be equipped with a grease drip-tray beneath their lower edges.

19172 Based on observation and interview the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems in all areas of the facility. This deficient practice affects all patients in the facility. The facility census 312. 1. Observation on 11/27/18, during the facility tour, showed standard sprinkler heads mixed with quick response sprinkler heads in the operating room smoke compartment. 2. During an interview on 11/27/18 at 12:20 P.M., the Division Director of Construction Management confirmed the observation. Section 8.3.3.2 of the National Fire Protection Association (NFPA 13) states: Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39840 Based on observation, interview, record review and policy review, the facility failed to provide accurate and complete information to patients with regards to patient rights and the required contact information to file a grievance. This failure had the potential to affect all patients in the facility who may have needed to file a grievance related to their care. The facility census was 285. Findings included: Review of the facility's policy titled, Guidelines for the Management of Patient Complaints and Grievances, dated 11/2015 directed staff to inform the patient in writing that he/she may lodge a grievance with the State of Missouri, Department of Health and Senior Services, 1617 Southridge Drive, PO Box 570, [NAME] City, MO 65102 regardless of whether he/she had first used the hospital's grievance process. The facility failed to provide the correct address. During an interview on 08/27/18 at 3:36 PM, Patient #1 stated that he did not know if he received information on how to contact the state agency if he had concerns. He stated that he would report his concerns to Staff Q, Director of Patient Safety and Risk Management, however, he did not know what her job was or what she did. During an interview on 08/27/18 at 3:55 PM, Patient #2 stated he did not know if he received information on how to file a complaint or grievance with the facility or how to contact the state agency if he had concerns. He stated he did not know who to contact at the facility with concerns. During an interview on 08/28/18 at 10:42 AM, Staff Q, Director of Patient Safety and Risk Management, stated that patients are given the brochure and leaders round to check with the patients to see if they have any questions. Record review of the patient brochure showed that the following was listed on the back of the brochure: Missouri Department of Health (not the Missouri Department of Health and Senior Serivces) Complaint Hotline: [PHONE NUMBER] or [PHONE NUMBER]. The facility failed to list an address. Observation on 08/27/18 through 08/29/18 showed varied versions of Patient's Rights signage posted throughout the facility. None of the signage contained the contact information for the Missouri Department of Health and Senior Services. The facility failed to provide accurate and consistent information for patients with regard to filing a complaint or grievance. 18018 39841

39841 Based on interview, record review and policy review, facility staff failed to ensure a safe environment for two discharged patients (#7 and #23) of two patients reviewed when: - Proper documentation of legal guardianship (someone legally responsible for a person who is unable to care for and make appropriate decision for self) was not completed. - The patient was allowed to leave against medical advice (AMA) without notification to the guardian. - The patient was provided transportation by cab without notification to the guardian. - Immediately remove staff from patient care after an allegation of abuse was identified/witnessed by two co-workers. These failures had the potential to lead to deterioration, injury, or death when policies and procedures to protect patients were not utilized, and could affect all patients in the facility with guardianship status. The facility census was 285. Findings included: 1. During an interview on 08/29/18 at 1:45 PM, Staff AA, Regulatory Manager, stated the facility did not have a policy or procedure for notification of patients' family or representative upon admission. Review of a History & Physical (H&P) dated 07/21/18 at 8:51 AM, showed Patient #7 was transferred by ambulance from the nursing home in which she resided, with a medical history of Chronic Obstructive Pulmonary Disease (COPD, lung disease that makes it difficult to breath) and schizoaffective disorder (mental health disorder that makes someone feel extremely excited and then extremely sad). Patient #7 was admitted to the hospital at 10:14 AM, and the patient's guardian was not notified. Review of nursing home documentation provided to the Emergency Department (ED) on 07/21/18, showed the name of the patient's guardian, relationship, and home telephone number. Included in the paperwork, was a Psychiatric Inpatient Note that documented the court granted Patient #7 a temporary guardian on 05/22/18, for a six month period (valid through 11/22/18). During a telephone interview on 08/28/18 at 7:48 PM, Staff CC, Registered Nurse (RN), stated she was not aware Patient #7 had a guardian, and did not review the nursing home paperwork that was transferred with the patient. During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), stated that when a patient was admitted from the ED, the transfer paperwork from the nursing home was placed in the paper medical record, and it stayed with the patient when they went to the inpatient floor. The admission nurse entered patient information (such as guardianship) from the transfer paperwork, into the patient's electronic medical record (EMR) during the patient's admission, in the admission assessment. During an interview on 08/28/18 at 9:40 AM, Staff K, Health Information Management Director, stated if a patient had a guardian, and the guardian's information was entered into the patient's EMR, it was visible to staff every time a patient was admitted , and added that there was no documentation of a guardian for Patient #7. The facility failed to ensure staff were aware of the patient's legal guardianship, and failed to ensure staff appropriately documented guardianship in the EMR. 2. Review of the facility's policy titled, AMA - Leaving Against Medical Advice, dated 02/2018, showed the facility failed to have a procedure in place that required confirmation of patient guardianship status for patients that wished to leave AMA. Review of Discharge Summary Report dated 07/24/18 at 7:32 AM, showed Staff PP, Physician, documented that Patient #7 discharged from the facility AMA on 07/23/18. Review of a form titled, Refusal of Transfer, Left Without Being Seen, or Leaving AMA, dated 07/23/18, showed Patient #7 left AMA, refused to sign the completed form, and showed no documentation that the patient's guardian was contacted. The document was witnessed by Staff FF, RN, Charge Nurse. 3. Review of a Case Management Report by Staff OO, Caseworker, dated 07/23/18 at 10:20 AM, showed that Patient #7 required a cab voucher for transportation at discharge. The facility failed to consult or notify the guardian when Patient #7 requested to discharge AMA, and failed to consult or notify the guardian when the patient, with a history of psychiatric illness, was provided cab fare when she left. 3. Review of the facility's policy titled, Patient Abuse and Neglect, revised 08/2016, showed directives for staff to place on administrative leave, any staff that was suspected to have committed an act of abuse or neglect until a determination was made. This allows time to conduct an investigation, while keeping in mind the protection of the patient, the facility and staff involved. Review of Patient #23's discharged electronic medical record (EMR) showed that he was admitted to the facility's Rehabilitation Unit on 12/28/17 for rehabilitative care and treatment following a motor vehicle collision (MVC) and status post-traumatic brain injury (TBI - a disruption in the normal function of the head that can be caused by a bump, blow, or a jolt to the head, or penetrating head injury). Review of the facility's list of staff that was terminated from employment over the past six months showed Staff NN, Patient Care Technician (PCT), was terminated on 04/03/18. Review of Staff NN, PCT's personnel file showed that a Disciplinary/Corrective Action Form dated 04/03/18 was given to Staff NN, PCT, and showed: - Category of Disciplinary Action: - Conduct/behavior; - Performance; - Ethics; and - Patient safety. - Level of Disciplinary Action: Termination. Detailed Summary of Offense(s) Leading To This Action: - Staff NN, PCT, allegedly abused Patient #23 on 01/22/2018. Staff NN, PCT, was assisting the patient back to his room and he was complaining that she was hurting him and began to yell. Staff MM, Registered Nurse (RN), came out into the hall when she heard the commotion and witnessed Staff NN, PCT, hitting the patient on the back of his head. Staff LL, RN, also witnessed Staff NN, PCT, hitting the patient. Staff LL, RN, screamed at Staff NN, PCT, to move away from the patient. Staff NN, PCT, moved away from the patient while Staff LL, RN, and Staff MM, RN, took the patient back to his room. Staff LL, RN, went to get the patient's medications and Staff MM, RN, left the patient's room to attend to another patient. Staff NN, PCT, re-entered the patient's room, pushed him to the floor, and got on top of him. Staff MM, RN, told Staff LL, RN, to call security. Security came to the room and witnessed the patient on the floor. Staff MM, RN, and Staff LL, RN, helped the patient up off the floor. Security questioned the patient if he was alright and he stated that his chin was sore but otherwise alright (the patient had a fractured left leg that resulted from the MVC). - On 03/21/2018, Staff NN, PCT, was questioned (by Staff DD, RN, Director of Nursing Operations) about the alleged abuse towards Patient #23 on 01/22/2018. Staff NN, PCT, admitted to hitting the patient in the back of his head on multiple occasions and demonstrated how she hit him by hitting one hand into the other. Staff NN, PCT, also stated that she wrestled the patient to the ground. - Staff NN, PCT, did not follow Code White (a code called when staff needed assistance to handle an out of control/disruptive and/or violent behavior by a person) policy. - Staff NN, PCT, did not de-escalate (reduce the intensity of a conflict or potentially violent situation) the situation or call for assistance. - Staff NN, PCT, violated I-CARE Values of Integrity, Compassion and Respect by hitting the patient and pushing him to the ground. - Staff NN, PCT, was suspended on 02/16/18, the date Staff DD first became aware of the incident. - Termination was recommended. Review of Staff NN, PCT's Time Sheet showed that: - She was allowed to finish her scheduled 12-hour night shift on 01/22/18 after the alleged physical assault/abuse of Patient #23 had occurred. - She was allowed to work 13 additional scheduled 12-hour night shifts from 01/22/18 to 02/16/18. The facility failed to remove Staff NN, PCT, from patient care after allegations of physical assault/abuse occurred to Patient #23 on 01/22/18 and she was allowed to work and provide patient care for 13 additional scheduled 12-hour night shifts which placed all patients she cared for at increased risk for abuse. During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), acknowledged that Staff NN, PCT, was allowed to continue working until the end of her scheduled 12-hour night shift on 01/22/18 after the alleged physical assault/abuse to Patient #23. Staff DD acknowledged that Staff NN, PCT, was allowed to work 13 additional scheduled 12-hour night shifts from 01/22/18 to 02/16/18. During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that: - She worked a 12-hour night shift on the Rehabilitation Unit on 01/22/18. - Staff NN, PCT, pushed Patient #23 to the floor in his room and was standing over him and was hitting him in the back of his head. - She told Staff NN, PCT, to get off the patient and she (Staff MM) assisted him up off the floor. - Staff NN, PCT, reported that the patient had punched her, so she hit him back and she admitted that she had pushed the patient onto the floor. - She requested the patient's primary assigned nurse (Staff LL, RN) to call for security to come to the unit because of the altercation between Staff NN, PCT, and Patient #23. - She did not know what the facility's policy and procedure instructed staff to do for witnessed staff to patient abuse, but since she had security called she thought that was all she needed to do. - Staff NN, PCT, was not allowed to care for Patient #23 after the incident but was allowed to finish working until the end of her scheduled 12-hour night shift on 01/22/18. During a telephone interview on 09/05/18 at 10:49 AM, Staff NN, PCT, stated that: - Patient #23 hit her in the chest, so she restrained him and put him on the floor. - Denied she ever punched or hit the patient in the back of his head multiple times. - She continued to work after the altercation with Patient #23 and finished her scheduled 12-hour night shift on 01/22/18 but did not care for the patient after the altercation. During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that: - She was working a 12-hour night shift on 01/22/18. - She was newly hired and had only worked at the facility for approximately two weeks when the incident occurred between Staff NN, PCT, and Patient #23. - She recalled the events that transpired between Staff NN, PCT and Patient #23 on 01/22/18. - She was Patient #23's primary assigned nurse for the 12-hour night shift on 01/22/18. - Staff NN, PCT, was walking with the patient and had the back of his pants balled up in her hand and was pulling his pants up and she (Staff NN, PCT) refused to release her hold on the back of his pants even after the patient informed her she (Staff NN, PCT) was hurting him. - The patient had a cast on his right arm and swung it at Staff NN, PCT, when she (Staff NN, PCT) would not let go of the back of his pants. He tried to get Staff NN, PCT, to let go of his pants because it was hurting him the way she (Staff NN, PCT) held onto him but she (Staff NN, PCT) refused to let go. - When the patient swung his casted arm towards Staff NN, PCT, she pushed the patient to the floor and stood over him and hit him multiple times in the back of his head. - She visually observed Staff NN, PCT, hit the patient on his head between three to four times. - She yelled at Staff NN, PCT, to get off the patient and Staff MM, RN, responded and had to pull Staff NN, PCT, off the patient. - She called the facility's security to come to the floor to assist with the altercation and physical assault from Staff NN, PCT, toward the patient. - She did not notify the House Supervisor because she thought Staff MM, RN, had notified them of the incident. - Security arrived and asked how the patient got on the floor and she informed him that Staff NN, PCT, had put him on the floor and was hitting him. - Staff NN, PCT was removed from caring for Patient #23 but was allowed to finish her 12-hour scheduled night shift on 01/22/18. - She did not recall any abuse/neglect education/training when she started and she had a lot of policies and other information to complete during orientation but did not recall the abuse/neglect information. The facility failed to: - Protect Patient #23 from physical assault and abuse by Staff NN, PCT. - Staff NN, PCT, was allowed to continue to abuse Patient #23 when she was allowed to hurt him while walking with him, then when she wrestled him to the floor and began to hit him multiple times in the head. - Staff NN, PCT, was allowed to not only finish her scheduled 12-hour night shift on 01/22/18 but was allowed to work 13 additional scheduled 12-hour night shifts between 01/22/18 and 02/16/18. 18018

18018 Based on interviews, record review and policy review the facility failed to: - Protect one discharged patient (#23) from physical abuse and continued abuse by a staff member, of one patient reviewed for abuse. - Follow the facility's internal policy for abuse and neglect when they failed to report the abuse of one discharged patient (#23) to administration in a timely manner, of one patient reviewed for abuse. - Complete a physical assessment and notify the physician after the alleged abuse for one patient (#23) of one patient reviewed for abuse. - Ensure staff were trained and competent to prevent, recognize and respond to all forms of abuse by co-workers, and failed to ensure staff were immediately re-educated about abuse and reporting, after allegation of staff to patient abuse occurred. - Report allegations of abuse to the appropriate State Agency. These failed practices by the facility placed all patients admitted to the facility at increased risk for their safety. The facility census was 285. Findings included: 1. Review of the facility's policy titled, Patient Abuse and Neglect, revised 08/2016, showed directives for staff: - Patient abuse and neglect by employees shall be grounds for disciplinary action, up to and including termination. -All reports of alleged abuse will be taken seriously, and will be investigated immediately. - It was the responsibility of all employees who may witness, suspect patient abuse or receive report of same from the patient, or other staff, to report this suspected abuse and/or neglect to their supervisor immediately. This can include physical, sexual, emotional, verbal and/or social abuse. - Any witnessed or un-witnessed incident of patient abuse or neglect or exploitation was initially reported to the Department Director or House Supervisor immediately. - Any health care provider who knowingly fails to make an abuse report may be subject to disciplinary action up to, and including, termination. - Upon receipt of an allegation of suspected abuse and/or neglect, it was the responsibility of the Department Director or House Supervisor to initiate investigation of the situation. - Reports of suspected abuse or neglect will be referred to the appropriate agencies within 24-hours of determination. - Verbal report shall be made immediately to the Missouri Department of Human Services Abuse Hotline and/or police. - Staff having reasonable cause to suspect that abuse was committed on the grounds of the facility, shall contact the Chief Nursing Officer (CNO), or Director of Risk Management and security department if needed. Review of Patient #23's discharged electronic medical record (EMR) showed that he was admitted to the facility's Rehabilitation Unit on 12/28/17 for rehabilitative care and treatment after a motor vehicle collision with traumatic brain injury (a disruption in normal brain function caused by injury to the head). Review of the facility's list of terminated staff showed that Staff NN, Patient Care Technician (PCT), was terminated on 04/03/18. Review of Staff NN, PCT's, Disciplinary/Corrective Action Form dated 04/03/18, showed she was terminated on 04/03/18, after Staff MM, Registered Nurse (RN) and Staff LL, RN, witnessed her repeatedly hit Patient #23 on 01/22/18. Later, after she hit the patient, she went to the patient's room and pushed the patient to the floor and got on top of him (the patient had a fractured left leg that resulted from the motor vehicle collision). On 03/21/18, Staff NN admitted that she hit the patient on multiple occasions, as well as wrestled the patient to the ground. During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that: - She worked night shift on the Rehabilitation Unit on 01/22/18. - Staff NN, PCT, pushed Patient #23 to the floor in his room and stood over him and hit him in the back of the head. - She was shocked by Staff NN's behavior and told Staff NN, PCT, to get off the patient, - Staff NN, PCT, reported that the patient had punched her, so she hit him back and admitted that she had pushed the patient onto the floor. - She requested Staff LL, RN to call security to come to the unit because of the altercation. During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that: - She worked night shift on 01/22/18 as Patient #23's primary nurse. - Staff MM, RN, worked as Charge Nurse on 01/22/18. - Staff NN, PCT, walked the patient, had the back of his pants balled up in her hand and pulled his pants up. - The patient stated she was hurting him, but she refused to release her hold on his pants. - The patient swung his casted arm at Staff NN, PCT. - She observed Staff NN, PCT, push the patient to the floor, stood over him, and hit him three to four times in the back of his head. - She yelled at Staff NN, PCT, to get off the patient and Staff MM, RN, responded and pulled Staff NN, PCT, off the patient. - She called security to come to the floor to assist with the altercation. - Security arrived and she informed security that Staff NN, PCT put the patient on the floor and hit him. - She did not know if the patient's physician was notified after the physical assault/abuse. During a telephone interview on 09/05/18 at 10:49 AM, Staff NN, PCT, stated that: - Patient #23 hit her in the chest, so she restrained him and put him on the floor. - She denied that she punched or hit the patient in the back of his head multiple times. - She was terminated because she was accused of attacking the patient. This showed that the facility failed to protect Patient #23 from repeated physical abuse by Staff NN. 2. During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), stated that: - Staff LL, RN, and Staff MM, RN, came to her with concerns they had while working with Staff NN, PCT (believed to be on or around 02/16/18, more than 20 days after the alleged abuse). - On 02/16/18, she called Staff NN, PCT, Staff LL, RN, and Staff MM, RN, in for a meeting. - Staff LL, RN, reported that Staff NN, PCT, had hit a patient and put him down on the floor and was on top of him. - Staff LL, RN, and Staff MM, RN, reported to her that they had called security on 01/22/18 because of Staff NN, PCT's behavior towards Patient #23. - This was the first time staff had reported to leadership, that Staff NN, PCT, had hit a patient. - Risk Management informed her not to contact the State Agency regarding the allegation of alleged staff to patient abuse. During an interview on 08/29/18 at 12:30 PM, Staff GG, Security Officer (SO), Safety Coordinator, stated that when he responded to a request for help on 01/22/18 on the Rehabilitation Unit, Staff GG found Patient #23 on the floor. Staff LL and Staff MM, RNs, reported that Staff NN, PCT, was aggressive with Patient #23, and so Staff GG completed an incident report and gave it to his supervisor. During an interview on 08/29/18 at 12:30 PM, Staff HH, Security Director (not the Security Director/Supervisor on 01/22/18), stated that when a SO filled out a report, it was the Security Director's responsibility to send the report with allegations of abuse and/or neglect to the Risk Manager and Nursing Director of the Unit involved, and the Nursing Director would forward the report accordingly to appropriate leadership as needed. During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that she did not notify the House Supervisor or complete an incident report for the abuse of Patient #23. During an interview on 08/30/18 at 9:25 AM, Staff II, RN, Director of Nursing (DON), Rehabilitation Unit, stated that Staff LL, RN, admitted that she did not report Patient #23's abuse immediately. During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that she did not recall if she reported the abuse to the charge nurse, did not know what the policy instructed her to do, but since security was called, she thought that was all she needed to do. During a telephone interview on 09/05/18 at 8:55 AM, Staff QQ, Interim Director, Rehabilitation Unit, stated that Staff LL, RN, and Staff MM, RN, did not immediately report the altercation between Staff NN, PCT, and Patient #23 to leadership, and when the incident was disclosed to her, way after the incident had occurred, Staff DD, RN, DNO, informed her that she was taking care of the situation. This showed that the facility failed to immediately report the abuse of Patient #23 to leadership. 3. Review of Nurses Notes dated 01/22/18 and 01/23/18, showed no notes of the incident that occurred on 01/22/18 between Patient #23 and Staff NN, PCT, no physical examination of the patient after the abuse and no documentation of notification to the physician. During an interview on 08/29/18 at 4:16 PM, Staff G, RN, Informatics Director, stated that Patient #23's EMR: - Did not contain Nurse's Notes related to Staff NN, PCT's, altercation and physical assault/abuse toward the patient. - Did not contain any documented nursing assessment of the patient after the altercation/physical assault/abuse from Staff NN, PCT. - Did not contain any documentation that the patient's physician was notified of the physical assault/abuse of the patient by Staff NN, PCT. During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that she did not know if Patient #23's physician was notified after the abuse. During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that she did not know if the patient's physician was contacted after the event. During an interview on 08/30/18 at 9:28 AM, Staff JJ, Physician, Rehabilitation Unit Medical Director, stated that he did not recall receiving notification of the altercation and alleged physical abuse by Staff NN, PCT, towards Patient #23. This showed that the facility failed to assess and immediately notify the physician after the abuse of Patient #23. 4. During an interview on 08/30/18 at 10:29 AM, Staff Z, [NAME] President of Quality, stated that Staff NN, PCT, did not receive any abuse/neglect training in 2016 or in 2018. During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), stated that she did not formally provide staff with abuse and neglect education after she learned of the alleged abuse, and after staff failed to immediately notify leadership of the abuse. During an interview on 08/29/18 at 12:30 PM, Staff GG, SO, Safety Coordinator, stated he did not recall any abuse education/training after the alleged patient abuse that occurred on 01/22/18. This showed that the facility failed to ensure staff were adequately educated in abuse, and that the facility failed to immediately re-educate staff about abuse, after staff to patient abuse had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39147 Based on observation, interview, record review, and policy review the facility failed to follow physician orders for 1:1 sitter (continuous observation of patient by a staff member) for one discharged patient (#3) of one discharged patient reviewed with an order for 1:1 sitter. Facility staff also failed to recognize the elopement risk of the patient that resulted in her elopement (escape) from the facility. The facility census was 337. Findings included: 1. Record review of Patient #3's History & Physical (H&P) showed: -She was admitted on [DATE] through the Obstetrics service in the Women's Services Emergency Area; -Her primary complaint at admission was heavy vaginal bleeding for one hour, she was 36 weeks, six days gestational (the carrying of an embryo or fetus inside the uterus) age via ultrasound; -She admitted to having had limited prenatal care (preventative healthcare, regular check ups during pregnancy to prevent any potential health care issues or problems) during this pregnancy; -She reported two previous pregnancies that both resulted in cesarean sections (C-section, a surgical intervention to deliver an infant when a vaginal delivery would put the mother or infant at risk), one of them for placental detachment (a serious complication during pregnancy where the placenta detaches or tears away from the uterus which is what supplies the infant with food and oxygen); -Her past medical history included depression and anxiety; -She denied any alcohol or drug use, admitted to smoking one pack of cigarettes a week; -She underwent an emergency C-section for heavy vaginal bleeding and possible placental abruption on 12/14/17 at 10:43 PM with delivery of a male infant at 11:07 PM. 2. Review of the Facility's policy titled, Behavioral Health: Levels of Observation, revised 08/2016, showed the directive for a 1:1 Observation as being ordered for a patient that is at immediate risk of harm to self and/or others, should have an assigned and dedicated staff member for the patient. Staff member should remain within arm's reach of the patient. No patient is to be left unattended while on 1:1 status. 3. Review of the Facility's policy titled, Code Purple-Patient Elopement (Precautions, Patient Safety, and Reporting), revised 11/2016, directed staff members to implement the following interventions to reduce the risk of patients wandering or leaving the facility: signage on the door and chart, removal of shoes, issuance of blue paper scrubs, bed alarm, and/or use of 1:1 sitter. 4. Review of Patient #3's medical record showed that there was a physician order for 1:1 observation, ordered on 12/15/17 at 12:48 PM, and to be continued on transfer to Four West due to acute psychiatric break (a harsh and abrupt disconnect or break from reality or episode of psychosis). Patient #3 had been involved in a Code White (overhead page alerting all available personnel and security to respond and aide in assisting fell ow staff with a violent patient) on 12/15/17 while on the post-partum (following childbirth or birth of young) unit when she became acutely agitated with staff and threw an entire tray of food at them, pulled out her own urinary catheter, and became verbally abusive towards staff. Patient #3 was transferred from post-partum unit to Four West on 12/15/17 at approximately 5:30 PM. Medical record review of Consultation Note, dated 12/15/17, from Patient #3's medical record showed: - She was admitted and delivered an infant via C-section (12/14/17 at 11:07 PM), her third child; - Consult was initiated by her behavior the morning after her C-section, she became acutely agitated with staff and threw an entire tray of food at them, pulled out her own urinary catheter, became verbally abusive towards staff, and remained loud and threatening, patient verbalized that she felt that she was being attacked when staff responded to the Code White; -She had been previously hospitalized in the Psychiatric Center for a few days during this pregnancy; -Most recent admission for psychiatric issues was related to feeling harassed whenever she was on public transportation; she was treated for depression and only provided with an antidepressant medication; -She had also been hospitalized at another psychiatric facility during this same pregnancy for depression and trouble with her temper; -She denied having had any previous hallucinations or delusions, but exhibited suspicious thinking, over valued ideas, with insight and judgement impairment; -Multiple psychiatric admissions during the last year in multiple facilities exhibited a chronic psychiatric illness history; -Recommendations made by Psychiatry included: 1:1 sitter, moving to a medical-surgical floor (off Post-partum unit), move to psych unit when post-operative day #3, patient not be allowed to leave Against Medical Advice (AMA, when a patient leaves the hospital against the advice of their doctor), and staff to fill out affidavit to hold the patient. Review of Patient #3's medical record showed: - An Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours dated 12/15/17, and signed by the patient's physician; - The Affidavit noted that she had been yelling at hallucinations (an experience involving the apparent perception of something not present) of people in her room whom were spraying her; - She had been talking about devil worshipers, and throwing objects endangering herself and staff members; - Family members reported that she had a history of Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly, a disconnect from reality) and a previous history of use of psychiatric medications. Review of the facility's document titled, The Frequent Monitoring Flowsheet, dated 12/15/17 showed: - That the first documentation of Patient #3's behavior was noted at 7:00 PM; - The observation level marked on the form directed staff that Patient #3 was Safety and Dignity (the need for a safety sitter to prevent injury to the patient); - There was no notation for the 1:1 status. 5. Review of the facility's document titled, The Frequent Monitoring Flowsheet, dated 12/16/17, had no observation level marked to direct staff and no notation for the 1:1 status. 6. During an interview on 01/09/18 at 1:32 PM, Staff II, Chief Nursing Officer, stated that the expectation is that staff members/nurses, are to follow doctor's orders. That the physician's order, for Patient #3, directed for patient to be 1:1 with a sitter and that she had actually been assigned as a 2:1, with the sitter sitting in the doorway between both rooms. During an interview on 01/09/18 at 10:00 AM, Staff K, RN, Four West Manager, stated that it was expected that all elopement risk patients and 1:1 patients be identified during shift huddles (brief staff meetings that are held daily on each shift and unit, to communicate patient issues). She stated that on the day of the elopement, it was passed on in huddle that the patient was a 2:1 patient (or patient requiring a sitter for safety). Staff K also stated that all staff are educated yearly through Healthstream (computer education) regarding elopement risks and proper use of safety sitters. During an interview on 01/10/18 at 9:06 AM, Staff KK, Patient Care Technician (PCT) stated: - On the day that Patient #3 eloped, she was the sitter assigned to her, in addition to one other patient; - That she was positioned in the hallway facing both rooms (4124, Patient #3's room, 4123, second patient's room), and that both beds were in her line of site; - That when she was given her assignment from the night shift PCT, she was told that she was to be a 2:1 sitter (a staff member assigned to watch and keep safe two patients; prevent them from falling or injuring self); - Patient #3 was on a psych hold (an involuntary confinement to hospital for suspected mental disorder in which a person is a danger to themselves, a danger to others, or gravely disabled) due to her behavior on Post partum ward; - The second patient was an Alzheimer's (senile dementia, a progressive disease that destroys memory and other important mental functions) patient; - They did tell her that the Alzheimer's patient was impulsive, and up and down frequently, either to the bedside commode or to the door, setting off the bed alarm each time; - Patient #3's behavior was appropriate, and she had been calm and cooperative, until the Division of Family Services (DFS) worker had gone in to see her; - She could hear Patient #3 crying, she was upset because DFS wanted her to be cleared by a Psychiatrist prior to any contact with her newborn child; - When Staff MM, Registered Nurse (RN) entered the room, she removed the DFS worker to the hallway, trying to diffuse the situation; - At that time, the Alzheimer's patient, began getting out of bed, and could not be directed from the hallway, so Staff KK had to go into the room at the bedside; - Staff KK stated that there had been other staff members present, and that Patient #3 had been sitting on her bed; - When she returned to the hallway, approximately 6 minutes later, she checked the room of Patient #3, and was not able to locate her; - She immediately called the Charge Nurse, Staff LL, whom hit the panic button and called a Code Purple (overhead announcement to let all staff know that a patient has eloped/escaped from a unit); - When asked how Patient #3 was dressed, Staff KK stated that she had a hospital gown on, and that Staff MM, RN, had provided the patient with pajama bottoms and slipper socks; - Staff KK also stated that it was impossible to watch Patient #3 in her room, at the same time she was assisting the second patient in her room. Observation on 01/09/18 at 09:15 AM showed that the room that Patient #3 had occupied was located at the entrance to the Four West unit. The room was approximately five feet from the double fire doors, 10 feet from the nurses' station, and less than 20 feet from the visitor elevators to the lobby. During a telephone interview on 01/10/18 at 1:50 PM, Staff LL, RN, stated that when she came on shift that morning, it was relayed to her by the Night Charge Nurse, that the patients in rooms [ROOM NUMBERS], were being monitored by a 2:1 sitter. Patient #3 was described to her as being subdued, she was told that the patient had been medicated prior to transferring to the unit, and had slept all night. The second patient in room [ROOM NUMBER], was described as being more of a Fall Risk, and confused at times. Staff LL stated that Staff KK, PCT, was positioned in the hallway, straddling both rooms. Staff LL stated that it was never relayed to her that Patient #3 was an Elopement Risk. During an interview on 01/10/18 at 2:05 PM, Staff MM, RN, stated that: - She was assigned to Patient #3 on the day that she eloped from the facility; - That she was never informed that Patient #3 was an Elopement Risk, she was told that she was 2:1 with a sitter for her behavior on Post Partum; - Patient #3 had initially been cooperative with the assessment, and any care provided that morning; - Staff MM stated that she received a phone call from Patient #3 requesting that she come to the room to assist her; - Staff MM stated that when she entered, the DFS worker was at the bedside, along with the physician, and they were attempting to explain options for temporary placement of Patient #3's newborn; - Patient #3 became increasingly upset, and that she asked the DFS worker to leave the room; - She was under the impression that her sister was the person that called the DFS hotline, and that if her newborn could not be placed with the uncle she lived with, they could just put him up for adoption; - She was adamant that her sister not be allowed temporary custody ; - Staff MM stated that had she known that Patient #3 was an Elopement Risk, she would not have supplied her with the pajama bottoms or the slipper socks; - Patient #3 did not have shoes with her or in the room, she was not sure about a personal cell phone, but she didn't think she had one; she had witnessed her using the hospital phone in the room. Patient #3 was assessed as an elopement risk but was not on elopement precautions which included 1:1 observation and successfully eloped from the facility 33 hours after she had undergone and emergency C-section for the delivery of her infant. This placed her at a higher risk of post-surgical complications and risk for her safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32280 Based on interview, record review, policy review, and review of the facility's Digital Video Disc (DVD) recording the facility failed to ensure: - Nursing staff assessed, monitored, and observed one (#1) of one patient who successfully committed suicide while a patient on the Senior Adult ([AGE] years of age or older) Behavioral Health Unit (BHU, a unit for care of patients with mental health issues); - Patient rounding (every 15 minute patient safety checks) was performed and documented in real time on the Observation Flow Sheets for one deceased patient (#1) and 12 current patients (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17) of 13 patient Observation Flow Sheets reviewed; and - Immediate Cardiopulmonary Resuscitation (CPR, Basic Life Support [BLS] lifesaving technique used in emergencies where breathing and heartbeat has stopped) was immediately initiated when unresponsiveness and lack of pulse (heartbeat) and breathing was assessed for one patient (#1) of one patient that was found unresponsive on the Senior Adult BHU. Patient #1 was last observed on [DATE] at 2:33 AM by Staff T, Safety Coordinator that had entered the unit and stopped at Patient #1's door to see if he needed anything. Patient rounding by Staff V, Mental Health Technician, (MHT), was performed at 2:07 AM and was not performed again until 2:40 AM, and at that time the patient was found to be unresponsive. The code cart (cart on wheels that contains emergency resuscitative equipment and supplies used for CPR but does not contain emergency drugs) arrived at 2:44 AM followed by Emergency Medical Services (EMS, paramedics) at 2:49 AM. The patient was transported from the Senior Adult BHU to the Emergency Department (ED) at 3:07 AM. The patient was pronounced dead at 3:20 AM, 12 hours after his admission. Patient rounding was not performed on Patient #1 for a total of 33 minutes but was falsely documented on the Observation Flow Sheets that rounding had been done within that 33 minute time frame. These failures resulted in a patient's death and placed all patients within the BHU at risk for their safety. The BHU census was 64. The Senior Adult BHU census was 13. The facility census was 263. Findings included: 1. Record review of the facility's policy titled, Behavioral Health: Levels of Observation, dated ,d+[DATE] showed: - Purpose was to delineate the levels of patient observation and associated procedures specific to each of the BHU's at the facility; - The BHU's were committed to the care and improvement of human life and in recognition of this commitment the facility strived to promote a safe and secure environment for all patients. - On admission, all patients were to be placed on a minimum of 15 minute safety checks unless otherwise ordered by physician due to increased risk to self or others or indicated by medical status. - 1:1 Observation was ordered on a patient who was at immediate risk or harm to self and/or others (unable to contract for safety and actively seeking ways to harm self or others). - The physician initiated the order for 1:1 observation and any change in assessment was to be reported by staff to the physician. - For the protection of the patient or others, the Registered Nurse, (RN), could initiate 1:1 observation and the attending physician had to be called within one hour to communicate the behavior and status of the patient and an order was to be obtained at that time. - 15 minute safety checks were to be conducted in a random manner on all patients to maintain a secure and safe environment unless more intensive monitoring was ordered; - The staff member was to observe the patient within every delineated 15 minute increment of time and document their location and activity on the Observation Flow Sheet throughout their hospitalization . - The staff member assigned to 15 minute patient safety checks was not to leave the unit or divert from their assignment in any matter without first securing another staff person to assume responsibility of assignment. - The team Charge Nurse or Nurse Manager was to be notified in the event of rounding interruptions so that the 15 minute safety checks could be reassigned and continued. Record review of the facility's policy titled, BH-002 Assessment - Reassessment of the BHU Patients, dated ,d+[DATE] showed: - The purpose was to delineate the assessment processes and associated timeframes for assessment of patients on the BHU's. - The policy was to provide a Medical Screening Exam (MSE), and a comprehensive psychiatric screening examination for all persons who presented for assessment in order to determine the need for care and if so the most appropriate level and to access any needed medical, psychiatric or other services for those clients at the most appropriate level of care. - During the assessment process, the need for care considerations and for further assessment should be determined based on an analysis of the patient's diagnosis; the care they were seeking; the present level of care; the patient's response to previous care; and high risk screens that included the patient's nutritional and functional status. - Additional screening assessments could include suicide risk assessments. - The RN or RN House Supervisor was to use the information obtained to communicate the assessment of the patient to the on-call or referring psychiatrist for treatment, care and service decisions. - For direct admissions the nursing staff was responsible for patient assessment. - This assessment included harm assessment with nursing unit staff responsible for additional information regarding high risk screens for suicide risk. - The suicide risk assessment assessed the patient's plan for self-harm, the likelihood of self-harm attempt including while in the facility and if so what would they use, access to means, triggers, current level of safety and education provided with regard to new coping skills. - Suicide risk of low indicated time frame for completion during regular shift reassessment; - Suicide risk of medium indicated reassessment with suicide risk monitoring every 24 hours; and - Suicide risk of high indicated reassessment with suicide risk monitoring every shift. 2. Record review of Patient #1's admission questionnaire dated [DATE] at 12:00 PM, showed that he had not recently been seen by a psychiatrist or therapist for his depression and that he had current thoughts of ways to harm himself. Record review of Patient #1's Behavioral Health assessment dated [DATE] at 2:12 PM, showed Staff Z, Mental Health RN, Intake Assessor documented that: - The patient said he was there, voluntarily, because he could not make decisions that included what to wear; - The patient had asked his sister to speak for him; - On [DATE] the patient informed his sister that he was so low that he had made a plan for suicide and his plan was specific but he had not proceeded with it due to his consideration for others; - The patient admitted to suicidal thoughts and had purchased chemicals and was going to leave his sister a note. The patient didn't want his sister to come into the apartment and find him because he was worried he would vomit and chemicals would then get onto her; - The patient had also planned to use knives to slit his wrists in a vacant lot next door to his apartment but was afraid it would affect the flow of surrounding businesses. - The patient had active thoughts with plans; - The patient had the potential for self-harm; and - The patient was placed on 15 minute level of monitoring. Record review of Patient #1's Admission assessment dated [DATE] at 2:09 PM by Staff BB, RN, showed: - Self-harm potential; - The patient had specific plans for suicide; - Patient stated he sought treatment because he wasn't able to function properly; - Patient felt as if he was on a [NAME] totter; - Patient had slow but appropriate thinking; - Suicide assessment of active thoughts with plan; - Precautions for suicide; - Level of monitoring every 15 minutes; Record review of Patient #1's Nurse Admit Assessment Summary dated [DATE] at 6:49 PM by Staff BB, RN, showed that the patient was admitted from home and was alert and oriented x4 (orientation of a person that showed they were aware of who they were, where they were, date and time and recent events). He was very depressed with poor eye contact. The patient was suicidal with a plan to drink a chemical that was used in a car. The patient stated that he made a mistake and it's just more than being depressed and when asked for clarification the patient just shook his head. He was placed on 15 minute checks to ensure safety. There was no History & Physical or Psychiatric Evaluation completed for Patient #1 as the patient had been admitted 12 hours prior to his death and had not had these two assessments completed. 3. Review of the facility's DVD recording titled, Senior B, dated [DATE], showed the camera view of hallway B on the Senior Adult BHU. At the beginning of the hallway was the patient/shower room, then three patient rooms with Patient #1's room at the end of the hallway just before the door to enter and exit the unit. The review showed: - 2:07:16 AM Staff V, Mental Health Technician, (MHT), was at the doorway of Patient #1's room; - 2:08:23 AM Staff V walked towards the camera and out of the camera's view; - 2:09:07 AM Staff V back into camera view with a female patient in the hallway by the patient shower/bathroom; - 2:09:34 AM Staff V walked towards the camera and out of camera view; - 2:20:36 AM Staff V back into camera view walked half way down hallway and obtained her drink from a table and walked back towards camera and out of view. - 2:28:11 AM Staff V back into camera view with a female patient in the hallway by the shower/bathroom door then out of camera view; - 2:33:31 AM unit door opened and Staff T, Safety Coordinator walked onto the unit; - 2:33:34 AM Staff T stopped at Patient #1's doorway and appeared to be talking with patient; - 2:33:36 AM Staff T walked away from Patient #1's door towards the camera; - 2:33:34 AM Staff V, MHT back into camera view and took a female patient into the bathroom; - 2:39:38 AM Staff V out of bathroom with female patient; - 2:40:28 AM Staff V entered Patient #1's room; - 2:40:52 AM Staff V exited Patient #1's room and walked (at a normal pace) down the hallway towards the camera with her right arm pointing back towards Patient #1's room. She appeared to be talking in the direction of the nurses' station. She continued to walk up and down the hallway at a normal pace talking in the direction of the nurses' station; - 2:41:29 AM Staff V walked back down the hallway and entered Patient #1's room by herself. No other staff had come into the camera's view; - 2:41:35 AM Staff W, MHT walked down hallway towards Patient #1's room; - 2:41:44 AM Staff W entered Patient #1's room; - 2:42:44 AM Staff V, MHT exited Patient #1's room and walked down the hallway towards the nurses' station. Staff V stopped halfway down the hallway at a table and chair and picked up a pair of shoes (Staff V was wearing a pair of patient yellow non-skid socks with no shoes) then continued to walk toward the camera; - 2:42:55 AM Staff X, RN Charge Nurse into camera view and walked towards Patient #1's room; - 2:42:58 AM Staff Y, RN into camera view with blood pressure machine and followed Staff X down the hallway toward Patient #1's room. Staff V, MHT walked out of camera view at this time. - 2:43:04 AM Staff Y, RN ran down the remainder of the hallway and entered Patient #1's room with Staff X, RN; - 2:43:12 AM Staff V, MHT back into camera view and walked towards Patient #1's room; - 2:43:16 AM Staff T, Safety Coordinator entered Patient #1's room; - 2:43:35 AM Unit door opens and Staff D, RN, House Supervisor walked onto the unit; - 2:43:49 AM Staff Y, RN exited Patient #1's room; - 2:43:54 AM Staff X, RN Charge Nurse exited the patients room and walked then ran towards the nurses' station and out of camera view; - 2:44:09 AM Staff Y, RN continued to walk toward nurses' station and out of camera view; - 2:44:41 AM Staff EE entered patients room with the code cart and Staff Y, RN followed behind; - 2:44:42 AM Staff X, RN Charge Nurse into camera view and ran down hallway towards patients' room; - 2:44:55 AM Staff V, MHT exited Patient #1's room with blood pressure machine; - 2:46:02 AM Staff V walked to a table and picked up what appeared to be a clipboard and stopped in front of patient room two doors down from Patient #1 and appeared to make patient rounds from the hallway; - 2:49:06 AM Unit door opened and EMS staff member onto the unit; - 2:49:32 AM Second EMS staff member onto unit and entered Patient #1's room; - 2:49:46 AM EMS stretcher onto the unit outside Patient #1's room; - 2:51:12 AM Staff X, RN, Charge Nurse exited patients room and then walked towards the camera and out of view; - 2:51:24 AM Staff W, MHT exited Patient #1's room and walked down the hallways towards the camera and out of view; - 2:52:08 AM Staff W back into camera view and walked back down hallway towards Patient #1's room; - 3:03:56 AM EMS staff pushed stretcher into Patient #1's room; - 3:06:52 AM stretcher out of patients room and out into hallway; and - 3:07:01 AM EMS exited the BHU with Patient #1 on the stretcher. Staff V, MHT assigned to do patient safety rounds on Patient #1, was visualized by DVD recording review to have made rounds at 2:07:56 AM and 2:40:28 AM on Patient #1 and only at 2:07:56 for Patients #7 and #10. Staff V did not complete her patient rounding for a total of 33 minutes and 12 seconds. Staff V left Patient #1 alone after she discovered him to be unresponsive for a total of one minute 17 seconds. She did not activate any type of alarm to alert staff that there was an emergency and she did not begin CPR. 4. Record review of the Senior Adult BHU Observation Flow Sheets dated [DATE] showed Staff V, MHT documented that three patients (#1, #7, and #10) had been seen on [DATE] at 2:07 AM, 2:22 AM, and at 2:37 AM in their bed and/or room. One additional time of 2:52 AM had been written in on Patient #1's Observation Flow Sheet but was not completed for his location or activity and was initialed by Staff V. Per DVD review Staff V, MHT did not round on these three patients at the times she documented on the Observation Flow Sheets. During an interview on [DATE] at 10:05 AM Staff V, MHT stated that: - She was aware that she did wrong and missed some rounds then filled the times in later because she was with another patient; - Observation Flow Sheets were to be handed off to another MHT or a nurse when she wasn't able to make the rounds; - She had set the clipboard with the observation sheets on a table in the hallway and told Staff X, RN Charge Nurse, and Staff Y, RN that she was with another patient (that wasn't assigned to her); - She had been on her feet all night and she was tired but knew she had done wrong; - When she rounded on Patient #1 at 2:07 AM he was the only patient in that room and he was on his knees beside the bed with this hands folded together under his chin. The patient told her he was praying and hurried her out of the room. He told her that she had to give him his time to pray and that she had to leave. - When she made her next round on Patient #1 at 2:40 AM she found the patient on the floor on his side; - She turned the light on; checked for a pulse; there was none and he wasn't breathing. - She went out into the hallway and yelled at the nurses at the desk to call 911. - The first staff member to come to Patient #1's room was Staff W and he turned the patient over and started doing chest compressions. - She panicked when she felt the patient had no pulse and did not want to move him for fear of a neck injury; - She saw a small amount of blood on the patients nose so she thought he had fallen and this was why she didn't want to move him; - She had been trained on CPR and knew what to do in the event a patient was unresponsive; - If a patient had fallen then the staff was to use the call button inside the patient's room. - Patients were unable to reach the call lights so it was unusual when a call light was activated; - She was unaware of how to activate the strobe light ligature alarm (an alarm installed at the top of the patient doorways that caused a beam of light from one side of the door to the other and when that beam was interrupted a loud alarm sounded with a strobe light visible in the hallway that indicated a patient may have attempted to hang themselves) at the top of the patient's doorways; - Looking back at the event she knew she should have stayed with the patient after she found him unresponsive; - Staff W, MHT did chest compressions until the code cart was brought into the room. Then the bag (Ambu-bag, a hand held manual resuscitator that provides breathing to patients) was used; - During report at the start of her shift she remembered the day shift nurse reported that she was unsure of Patient #1's situation; that she had not admitted him; - She knew he was depressed and that he had been admitted voluntarily but she was unsure of his actual level of observation (precautions); - The MHT's were responsible for completing the observation sheets and circled the precautions at the top of the sheet that pertained to the patient; and - Level of observations was either close observation which was within sight at all times or 1:1, which was that staff stayed with the patient all the times. Staff V, MHT did not perform patient rounding every 15 minutes per policy to ensure patient safety. She falsified documentation that indicated she did perform the rounding. Staff V did not activate the call light button or the ligature alarm for Patient #1 that would have alerted staff of the emergency and enabled Staff V to remain with the patient and begin CPR. Record review of Staff V's training transcript showed the following training: - Heart Code BLS part 1 on [DATE]; - Suicidal Tendencies: Screening for Risk of Self-harm on [DATE]; - Heart Code BLS parts 2 and 3 on [DATE]; - Observation Rounds on [DATE]; and - Patient Safety Education on [DATE]. During a telephone interview on [DATE] at 1:45 PM, Staff W, MHT stated that: - He heard Staff V, MHT yell out to call 911 that a patient had fallen and there was blood on the floor; - Staff V did not inform the staff that the patient was unresponsive with no pulse or breathing, just stated that the patient had fallen and to call 911; - When he entered Patient #1's room (per DVD review 2:41:44 AM) the patient was lying on the floor between the two beds with his head up close to the wall; - He stepped over the patient and saw blood on the floor and blood on the patient's nose; - He pulled the patient away from the wall by his ankles and saw that his mouth was half way opened with his tongue sticking out; - It appeared to him that the patient had agonal breathing (abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing accompanied by strange vocalizations and noises). It appeared that a breath came out of his mouth when he moved the patient; - He then proceeded to tear off the patient's shirt to start CPR but was unable to remove it; - Staff T, Safety Coordinator entered the room (per DVD review 2:43:16 AM) and gave him scissors to cut off the patient's shirt; - He then started chest compressions immediately after the shirt was removed; - The code cart arrived (per DVD review 2:44:41 AM) and Staff T began to do the breathing using the Ambu-bag while he continued chest compressions; - Staff X, RN, Charge Nurse re-positioned the patient's head because the chest did not rise and fall with the Ambu-bag ventilations; - He and Staff T continued CPR with chest compressions and ventilations until the EMS staff arrived and took over CPR. During a telephone interview on [DATE] at 3:45 PM, Staff X, RN Charge Nurse, stated that: - During report from day shift Staff AA, RN informed the staff that Patient #1 had been admitted that day and that he had wanted to jump in front of a car. - Patient #1 had stood at the nurses' station most of the evening and had talked about his whole life. - She did not have any concerns that he wanted to hurt himself or end his life. - She was at the desk working on an admission when Staff V came out of a patient room yelling that a patient had fallen. - Staff V was screaming to call 911 that the patient was down and without a pulse. - She immediately called 911 and told Staff Y, RN to get the code cart. - The 911 dispatcher asked her to get an assessment of the patient and that she would hold on while she went to the patient's room. - When she got to the room Staff W, MHT was performing chest compressions and informed her that the patient had no pulse so she did not assess the patient herself; - She returned to the 911 phone call and told them the patient had no pulse and to send EMS as soon as possible. - She returned to Patient #1's room and repositioned his head and Staff T, Safety Coordinator was bagging the patient and Staff W was performing chest compressions. - The code cart arrived to the room and the AED was placed on the patient and instructed, No shock continue CPR. - The patients hands were cold; she checked the carotid (artery located on each side of the neck) pulse and he had no pulse; there was no rise and fall of the chest and his stomach was distended. - EMS arrived at this time so she left the room. - She returned to the nurses' station and called the patients daughter then called the patients doctor and informed both of the event. - As an RN it was her responsibility to have done the patients assessment but she did not because Staff W, MHT was already there and had determined the patient had no pulse and was not breathing. - Nurses were to monitor the MHT's and what they do and what they were supposed to do and that the nurses were to do patient rounding once per hour and document that rounding in real time on the observation sheet. - If nursing staff were concerned regarding a patient's safety they would initiate close observation (line of sight) and then call the physician for the order. - She would know if a patient had suicidal ideations on their mind if they would have told the nursing staff. During an interview on [DATE] at 3:15 PM, Staff D, RN House Supervisor, stated that: - She was House Supervisor on the night the event occurred. - She heard the Rapid Response on the overhead speaker and responded to the Senior Unit. - She called the administrator on call. - Prior to the event there was no actual Rapid Response Team designated that any staff that was available was to respond. - When she arrived to Patient #1's room he was on the floor between the beds and staff members were shaking him calling out his name and checking for a pulse. - Someone called out to get the code cart and that 911 had already been called by the Charge Nurse. - She remembered Staff T, Safety Coordinator, Staff W, MHT and a couple of other nurses from other units were in the patients' room all assessing him. Chest compressions were began shortly after she entered the room, prior to the code cart arriving. - There was no rise and fall of the patient's chest with bagging during CPR so she asked for his head to be repositioned,which it was but still no rise and fall of the chest was seen. - She viewed the DVD recording with Senior Leadership after the event. During an interview on [DATE] at 9:25 AM, Staff T, Safety Coordinator stated that: - He responded to all Rapid Responses primarily to help de-escalate the situation. - At approximately 2:30 AM he entered the Senior Adult BHU and stopped at Patient #1's doorway because he saw him knelt down at the side of the bed and wanted to make sure he was okay. - He asked the patient if he was praying and the patient replied yes so he thought he would let him finish and he walked away from the patients doorway. - He later heard the Rapid Response call and he responded. - When he arrived to the Senior Unit he entered Patient #1's room and saw the patient on the floor in-between two beds. - He remembered that there was a MHT there and he was opening up the patient's shirt but was having difficulty so he gave him his scissors to cut the shirt off. - The patient was unresponsive, staff was checking his vital signs (pulse rate, respirations and blood pressure). - Once the patients' shirt was removed the MHT started doing chest compressions and once the code cart arrived he gave the patient breaths with the Ambu-bag. - The patient did not have a pulse. - The AED was connected and instructed not to shock just to continue CPR. - While he was bagging the patient he noticed that there was no rise and fall with his chest so the patients head was repositioned and they did look into the patient's throat but were unable to see anything, so he continued with bagging but never saw rise and fall of his chest. - They did about three to four cycles of 30 compressions to two breaths until EMS arrived and took over. - When EMS arrived they placed an apparatus in the patient's mouth to open his mouth and they removed what appeared to be a paper towel. During a telephone interview on [DATE] at 11:35 AM, Staff Y, RN stated that: - He was seated at the nurses' station when Staff V, MHT came out of Patient #1's room and yelled down the hall for someone to call 911. - Staff X instructed him to call a Rapid Response. - When he arrived to Patient #1's room Staff W, MHT was already doing chest compressions so he looked out into the hallway for the code cart but didn't see it so he started down the hall and heard someone was going to get the cart. - Staff X was on the floor assessing Patient #1; - He went back to the nurses' station and prepared the patient's paperwork to send with EMS. - He didn't remember any information that was told in the shift report from the day staff that would have indicated that Patient #1 was at risk for self-harm. He just remembered that he was admitted for major depression and that he had made statements to his family prior to admission regarding suicidal ideations (thoughts of suicide). - If a patient verbalized to him that they currently had suicidal thoughts then he would call the doctor for a higher level of observation like 1:1 or close observation. During a telephone interview on [DATE] at 2:40 PM, Staff Z, RN Mental Health Nurse, Intake Assessor stated that: - She worked as an intake assessor and part of the assessment for a potential admission was a suicide risk assessment. - Mid morning she had received a call from Physician Staff FF, asking her to call Staff DD, Psychiatrist and ask if he would accept admission for Patient #1; that he was being directly admitted to the BHU; - Staff DD accepted the patient; - Patient #1 arrived at the facility at approximately 12:00 Noon; - Prior to admission the patient had purchased items (chemicals) to drink and had planned to slit his wrists to commit suicide; - She was not concerned with the potential for self-harm as an inpatient since he did not have access to the items that were in his previous suicide plan and just had a gut feeling that his safety was not a concern; - She felt the 15 minute safety checks were an appropriate level of observation for Patient #1. - If she would have felt Patient #1 or any other patient was at risk for self harm she would have called the physician and obtained an order for higher level of observation. During a telephone interview on [DATE] at 3:10 PM, Staff BB, RN, stated that: - He completed the admission assessment for Patient #1 on the Senior Adult BHU; - Patient spoke in depth regarding his plans for suicide explaining that he had purchased a chemical to drink; - Patient stated that there was more to thisand sometimes didn't fully answer questions; - He had received a quick run-down on the patient's suicidal ideations from the intake assessor Staff Z, RN; - The patient stood at the nurses' desk for the admission and for the remainder of the day shift. - The patient was talkative with the staff. - He felt better after talking with the patient for a few hours in regards to his safety. - The patient was not placed on close observation only on 15 minute safety checks; - If during an assessment he was ever concerned about a patient's safety he called the physician and asked for an order for close observation. - His practice was to do rounding once per hour and to make sure rounding sheets were being completed. - In the past he had seen Observation Flow Sheets that were blank and when he asked the MHT why he was told that they would get them caught up. During a telephone interview on [DATE] at 1:30 PM, Staff

36474 Based on interview, record review of Emergency Department (ED) Logs, 72 Hour Return Logs, Medical Records, Staffing and Physician On-Call Schedules, the facility failed to appropriately complete a medical screening exam (MSE) within its capacity and capability for one Patient (#28) of 28 patient's records reviewed, when the facility failed to notify the patient's guardian of his imminent discharge, and allowed the patient to leave unattended after information was obtained that the patient was an elopement risk. The emergency department average daily census was 137. The facility census was 330. The facility had the capability and capacity to complete an appropriate MSE to determine whether the patient had a guardian, and that he required supervision prior to discharge due to a significant history of mental illness and traumatic brain injury (a brain dysfunction caused by a mechanical force), and who also resided in a locked unit at a skilled nursing facility. Please refer to A2406 for details.

36474 Based on interview, record review, and policy review the facility failed to provide an appropriate medical screening exam (MSE) sufficient to determine whether a patient had a guardian, or that he required supervision and was an elopement risk for one Patient (#28) of 28 patient records reviewed. Patient #28's guardian was not notified prior to, or at the time of discharge, from the Emergency Department (ED). Facility nursing staff was made aware prior to discharge that the patient posed a significant elopement risk. Before being transported back to the skilled nursing facility where he resided, the patient independently left the ED without staff knowledge. Approximately three days later the local police found Patient #28 in front of a hotel and transported him back to this facility for treatment, and the patient was subsequently admitted . The facility's failure to provide a complete examination within its capabilities and capacity had the potential to increase the risk for a negative outcome for all individuals seeking treatment within the ED. The emergency department average daily census was 137. The facility census was 330. 1. Record review of the facility's policy titled, EMTALA (Emergency Medical Treatment and Labor Act) MSE Policy, dated 02/01/16, showed the following: -An MSE shall be provided to determine whether or not the individual is experiencing an Emergency Medical Condition (EMC) or a pregnant woman is in labor. -The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. -The extent of the MSE is an ongoing process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. -The responsibility of the MSE remains with the ED physician until the individual's private physician or an on-call specialist assumes that responsibility, or the individual is discharged . -If an individual leaves the facility without notifying facility personnel, this must be documented upon discovery. 2. Review of Patient #28's ED record showed: -The patient arrived at the facility per Emergency Medical Services (EMS) on 07/23/16 at 3:49 AM. -The physician's notes showed that the patient's chief complaint was chest pain. -Demographic sheet from the patient's skilled nursing facility, received by the ED upon arrival of the patient and scanned into the ED record, showed that the patient had a Public Administrator, who served as his guardian. -The physician had contact with the patient at 4:20 AM. She noted the patient was cooperative, oriented, and that speech was within normal limits. She also noted his mood and affect were within normal limits and he was not suicidal. -Past medical history included: -Schizophrenia (a long-term mental disorder that is a break down in the relation between thought, emotion, and behavior which leads to faulty perception, inappropriate actions and feelings, and withdrawal from reality); -Traumatic Brain Injury (a brain dysfunction caused by a mechanical force); -Chronic Renal Failure (a slow progressive loss of kidney function over a period of several years); -Hypertension (chronic elevated blood pressure); -Hyperlipidemia (chronic elevated cholesterol levels); -Dementia (a chronic mental disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning); -Diabetes (a disease in which the body's inability to produce any or enough insulin causes elevated levels of glucose (sugar) in the blood); -Angina (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart); and -Hypothyroidism (abnormally low activity of the thyroid gland). -The patient had an electrocardiogram (a machine that measures electrical activity all over the heart), laboratory blood tests, oxygen, cardiac monitoring, chest x-ray, and medication administration of a Gastrointestinal Cocktail (generic term for a mixture of three liquid medications primarily used to treat acid reflux, which is a condition in which acid travels up from the stomach to the esophagus causing a burning sensation or pain). -There were no notations in the record by the physician or nursing that the patient had a guardian or was an elopement risk, and no evidence of any contact made with the guardian. -There was no documentation that the patient eloped from the facility. -The physician documented a disposition decision and discharge to home at 6:02 AM on 07/23/16. There is no further documentation from this physician regarding any events after 6:02 AM. -Nursing note recorded on 07/23/16 at 6:25 AM showed the following,Patient found smoking in the room, patient educated on hospital policy and risk of possible injury with oxygen in the room. -Nursing note recorded on 07/23/16 at 6:30 AM showed the following,Report called to the skilled nursing facility, Logisticare (a company that transported patients from the ED to their home or other facility and utilized cab drivers or ambulances dependent on the patient and circumstances of transfer) notified for transport. -No further notes from nursing staff. Disposition indicated that the patient was discharged , and the time noted in the chart by nursing was 7:30 AM on 7/23/16. During an interview on 08/03/16 at 2:15 PM, Staff O, ED Registered Nurse (RN), stated that: -She met Patient #28 in the ED when he arrived via Emergency Medical Services. -Her role was to triage the patient, but that was her only contact with him. -They did not receive any report that he had a guardian or that he was an elopement risk, nor did she ask the patient. -The normal practice is to review the paperwork sent from the skilled care or nursing facility, but she did not recall if she reviewed the paperwork for this patient. -There is no prompt in their electronic medical record that required nursing to document whether patient had a guardian or durable power of attorney. During a telephone interview on 08/02/16 at 4:15 PM, Staff F, ED RN, stated that: -She was the primary nurse for Patient #28 after he was triaged. -The patient never attempted to leave the department, or gave any indication he would be an elopement risk. He also never mentioned he had a guardian. -She contacted the skilled nursing facility once the physician indicated he would be discharged , and had planned to send him back in a cab. The skilled nursing facility informed her that he was not able to come back by cab because he was a high elopement risk and had come from a locked unit. -After she received that information, she ordered an ambulance to transport the patient through Logisticare. She did not implement any action to prevent the patient from leaving the ED prior to transport arriving. -Staff F stated, I didn't have any issues with him, so I didn't expect he would leave, and we are a locked unit so someone would have had to let him out. During a telephone interview on 08/02/16 at 2:10 PM, Staff E, ED RN, stated that: -She took report from Staff F at 7:00 AM on Patient #28. -Staff F relayed to her that she had ordered transport for the patient due to the skilled nursing facility's report that the patient was an elopement risk and resided on a locked unit. -She did not put any interventions in place to prevent the patient from eloping prior to transport. -At approximately 7:30 AM she noticed the patient was no longer in his room. She immediately searched the department for the patient. She called Security and gave them a description of the patient and they were asked to watch out for him (the security office was a glassed area that had full view of the ED waiting room and triage area, as well as the main ED entrance). She made the Charge Nurse aware of the situation, and no further action was taken. -Staff E stated,I had three other patients so I went back to caring for them. -She did not document any of the situation in the patient's medical record. -She was not aware the patient had a guardian until later in the day, and after he had eloped. During an interview on 08/02/16 at 10:15 AM, Staff J, Team Lead Registration, stated that she collected information from patients and their families regarding durable power of attorney (DPOA) or guardians, and they would then contact the guardian or DPOA and obtain consent. She noted that if the patient had a guardian, the guardian would normally ask to be transferred to the nurse to be updated on the medical condition of the patient. She stated that the situations which would prompt her to ask whether the patient had a guardian or DPOA, would be if they are older or from a nursing home. Record review of the facility's policy titled, Advance Directive Administrative Process-The Patient Determination Act, dated 08/2013, showed no directive for staff to obtain information regarding guardianship for patient's admitted to the ED. During an interview on 08/03/16 at 3:15 PM, Staff D, Assistant Director of the ED, stated that: -The facility did have a policy titled,Code Purple, that directed staff throughout the hospital how to respond when a patient eloped. -Staff D stated, We don't usually call Code Purple's in the ED because our unit is secure and we usually are able to find them. -She confirmed that if a Code Purple had been called when Patient #28 eloped, the staff would have had heightened awareness and they would have probably caught him prior to leaving the ED. -There was no documentation prompt in the electronic medical record for staff to ask about a guardian or DPOA. -Since the event with Patient #28, staff had been educated in the ED Daily Huddles (meetings done at the beginning of each shift where updates are given verbally to staff) that all patients who are an elopement risk but be a one to one ([1:1] an intervention where a staff member remains with the patient at all times), and that this included patients from nursing homes that had locked units. -She reported that she had ordered new forms from the print shop that will prompt staff when taking report from another facility, to ask if the patient had a guardian or was from a locked unit. The forms would be ready in the next week and staff would be educated on their use. -There is no prompt in the nursing assessment to inquire about a guardian or DPOA. During a telephone interview on 08/04/16 at 9:30 AM, Staff N, ED Physician, stated that she had been the physician for Patient #28. She was not aware he had a guardian, nor that he was an elopement risk and had come from a locked unit. During an interview on 08/03/16 at 10:55 AM, Staff M, ED Medical Director, stated that he had been made aware of the situation with Patient #28. He felt that the physician's at the facility did not take chances if there was a risk of elopement. He stated that in regards to whether or not a patient had a guardian, the physicians were often the last to know. He stated that his expectation was that if a guardian or DPOA was established for the patient, the physician would communicate with them and find out their expectations for care. Review of a 2nd medical record showed that patient # 28 presented to the ED by ambulance on 7/26/16 at 2:20 AM, approximately 72 hours after eloping on 7/23/16. The ED physician documented the patient had been missing for three days until he was found tonight. Further documentation showed the patient was under legal guardianship and resided in a locked psychiatric unit at a nursing home due to his mental illness, dementia, and previous traumatic brain injury. Lab tests revealed patient # 28 had an elevated blood glucose of 289 (normal is 70 - 99 mg/dl) and a creatine kinase (CK) elevated at 2,965 units/liter (CK is an enzyme that is released when skeletal muscles are damaged, normal level is 26 - 308 units/liter). Patient # 28 was subsequently admitted to Research Medical Center for treatment of Rhabdomyolysis (a serious syndrome in which damaged skeletal muscle breaks down and an enzyme harmful to the kidneys is released into the blood stream).

29117 Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and standards for patient care when staff failed to: - Appropriately clean an implanted port (a device placed just under the skin on the upper part of the chest wall to deliver medication, chemotherapy or fluids). (A749) - Appropriately wear required Personal Protective Equipment (PPE),when caring for patients in Contact Isolation (CI, special precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases), and clean a computer on wheels after it was removed from a CI room in the Intensive Care Unit (ICU). (A749) - Clean a blood glucose monitor (the device used to measure the blood glucose) and supply case used for three of three patients who had a blood glucose test (a procedure to check the amount of sugar in their blood). (A749) - Perform indwelling urinary catheter (a tube placed in the bladder to drain urine) care (cleansing of the catheter, genitals and anus) without cross contamination. (A749) - Ensure catheter bags (bag to collect urine that drained from the bladder) were not in contact with the floor. (A749) - Perform hand hygiene (clean hands with sanitizer or soap and water) before and after glove use, after touching inanimate objects, and failed to change gloves between patient tasks. (A749) - Perform hand hygiene after glove use while cleaning a colonoscope (instrument used to look at the distal part of the small bowel). (A749) These failed practices had the potential to expose all patients to cross contamination and increase the potential to spread infection to all patients, staff and visitors. The facility census was 256. As a result of this survey, the complaint was substantiated and the Condition of Participation: Infection Control, was found to be out of compliance. Please see the 2567. 27727 32280

29117 Based on observation, interview, record review and policy review the facility failed to ensure staff followed infection control policies for patient care when staff failed to: - Appropriately clean an implanted port (a device placed just under the skin on the upper part of the chest wall to deliver medication, chemotherapy or fluids) for one patient (#30) of one patient observed. - Appropriately wear required Personal Protective Equipment (PPE, a gown) when caring for one patient (#9), failed to put on a PPE gown for one patient (#13) and failed to clean a computer on wheels (COW) after it was removed from a Contact Isolation (CI, special precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases) room for one patient (#26) of three patients observed in the Intensive Care Unit (ICU). - Clean a blood glucose monitor (device used to measure the blood sugar) and supply case used for three of three patients (#34, #35, and #36) who had a blood glucose test. - Perform indwelling urinary catheter (tube placed in the bladder to drain urine) care (cleansing of the catheter, genitals and anus) without cross contamination for one of one patient (#2) observed. - Ensure catheter bags (bag to collect urine that drained from the bladder) were not in contact with the floor for two of two patients (#2 and #4) observed. - Perform hand hygiene (clean hands with sanitizer or soap and water) before and after glove use, after touching inanimate objects, and failed to change gloves between patient tasks for five patients (#26, #22, #37, #29, #30) of 19 patients observed. - Perform hand hygiene after glove use while cleaning a colonoscope (instrument used to look at the distal part of the small bowel) by one of one staff (GG). These failed practices had the potential to expose all patients to cross contamination and increase the potential to spread infection to patients, staff and visitors. The facility census was 256. Findings included: 1. Record review of the facility's policy titled, Intravenous Access Management Policy, dated 10/2011, showed that two percent chlorhexidine (topical antiseptic) based preparation was to be used for cleaning of the site for accessing of an implanted port. During an interview on 03/23/16 at 3:30 PM, Staff E, [NAME] President, (VP) of Quality, stated that the facility used Lippincott's Nursing Procedures (a book of detailed descriptions of procedures used as a reference for nursing staff) as the reference for nursing procedures. 2. Record review of facility provided document titled, Lippincott Procedures, Implanted port accessing, revised 04/03/15, showed: - Vascular catheter associated infections were reasonably prevented using various infection prevention techniques such as hand hygiene, properly preparing the access site and maintaining sterile technique. - Clean the implanted port access site with an antiseptic solution. - For Chlorhexidine, apply with an applicator using a back and forth scrubbing motion for at least 30 seconds and allow the area to dry. 3. Observation on 03/22/16 at 3:05 PM on four North showed Staff UU, Registered Nurse (RN) in Patient #30's room and prepared to de-access and re-access the patients implanted port. Staff UU used a Chlorhexidine cleansing swab and with a circular motion she cleaned the area beginning at the insertion site and worked her way outwards. She placed her left fingers on the device at the insertion site then swabbed over that area again with the cleansing swab. She then proceeded to insert the needle into the port. The circular motion for cleaning that Staff UU used was in contradiction to the facility policy in regards to the use of Chlorhexidine and when she touched the insertion site after the initial cleaning she contaminated the site. During an interview on 03/22/16 at 3:15 PM, Staff UU, RN, stated that she used a Chlorhexidine swab to clean the site and it was her personal preference to feel for the device and the insertion site prior to inserting the needle and that since she had felt it with her fingers she always cleaned it again with the swab prior to accessing it. Staff UU stated that the facility policy and procedure was to clean in a circular motion and move the circle outwards. 4. Record review of the facility policy titled, Isolation Precautions dated 05/2015 showed direction to staff to immediately put on and wear gowns when entering the room of a patient in Contact Isolation (CI). 5. Observation on 03/22/16 at 9:16 AM in the ICU showed Staff LLL, Infectious Disease Physician, in Patient #9's room who was in a CI room with Methicillin Resistant Staphylococcus Aureus (MRSA), an infection which is resistant to many antibiotics. The gown, which is part of the required PPE's was below his nipple line and untied at his neck and waist which exposed his clothes to the MRSA and then had the potential to be transferred to other patients, staff and visitors. During an interview on 03/22/16 at 9:21 AM, Staff LLL stated that he did not have his gown on properly because he was distracted when he walked in the room because someone from Your team asked me who I was. The physician had been observed for two minutes or so before he was asked his name by the facility administration. 6. Observation on 03/21/16 at 2:30 PM in the ICU showed Staff Q, RN, in Patient #13's CI room with Clostridium Difficile (C-Diff), a bacteria which can cause diarrhea to life threatening inflammation of the colon. Staff Q did not have the required PPE gown on which had the potential to contaminate her clothes and to potentially spread germs to other patients, staff and visitors. During an interview on 03/22/16 at 2:40 PM, Staff Q stated, I didn't have a gown on; I'm too busy. I'm stressed. I need more help . 7. Record review of the facility's policy titled, Guidelines for Cleaning, Disinfecting, and Sterilization, dated 10/2014, showed facility directive to staff to clean equipment between each patient use. 8. Observation with concurrent interview in the ICU on 03/22/16 at 2:30 PM showed: - Staff JJ, Respiratory Therapist (RT), used a COW in Patient #26's room, who was on contact isolation. - He touched the patient, the patient's linen, and the COW. - Staff JJ then left the room and walked across the ICU with the contaminated COW and failed to clean the COW. - Staff JJ later returned to Patient #26's room with a different COW, and the COW arm (attached the computer to the wheels on the bottom) touched the patient's linens. Staff JJ touched the patient and the COW keyboard and scanner. He left again without cleaning the COW. - Staff JJ stated that when he cleaned the COW, he only cleaned the monitor and keyboard and not the entire COW. - He took the COW across the ICU to a room for RT and completed the cleaning of the COW in the room. - He would clean the COW if going directly into another patient's room. Taking a dirty COW throughout the ICU greatly increased the risk for transmission of infectious bacteria to other patients, staff, and visitors in the ICU. 9. Record review of Patient #26's lab showed on 03/14/16 MRSA, of his sputum (a mixture of saliva and mucous coughed up from the lungs and respiratory passages). During an interview on 03/22/16 at 3:00 PM Staff KK, Director of RT, stated that a COW should not be used in the isolation room. 10. Record review of facility provided document titled, Lippincott Procedures, Blood Glucose Monitoring, revised 04/03/15, showed facility directive for staff to clean and disinfect the blood glucose monitor because contaminated equipment increases the risk of infection. 11. Observation on 03/22/16 between 11:05 AM and 11:30 AM showed: - On the sixth floor, Staff KKK, Registered Nurses (RN), performed a blood glucose test on Patient #34, - On the sixth floor,Staff GGG, RN performed a blood glucose test on Patient #35. - On three North, Staff HHH, RN, performed a blood glucose test on Patient #36. - Each RN failed to clean the blood glucose monitor and the supply case used when they left the patient's room. During an interview on 03/22/16 at 11:10 AM, Staff KKK, RN, stated that it would make sense to clean the blood glucose monitor and the case after she left the patient's room, but typically she did not. During an interview on 03/22/16 at 11:25 AM, Staff GGG, RN, stated that she was nervous and failed to clean the blood glucose monitor and the case. During an interview on 03/22/16 at 11:35 AM, Staff HHH, RN, stated that she should have cleaned the blood glucose monitor and case after she left the patient's room. During an interview on 03/22/16 at 11:40 AM, Staff QQ, Assistant Chief Nursing Officer (CNO), stated that she expected the blood glucose monitor and supply case to be cleansed after each patient use. 12. Record review of facility provided document titled, Lippincott Procedures, Indwelling Urinary Catheter Care and Management, revised 10/02/15, showed facility directive for staff to avoid contamination, to always clean by wiping away from the urinary meatus (external opening where urine exits the body). The urinary catheter bag should not be in contact with the floor to reduce the risk of contamination and a subsequent patient infection. 13. Observation with concurrent interview on five East, on 03/21/16 at 2:45 PM showed Patient #2's urinary catheter bag in contact with the floor (increased risk for the patient to acquire a urinary tract infection). Staff F, RN, performed catheter care for Patient #2. She cleaned the catheter tube by starting approximately three inches from the urinary meatus and washed toward the meatus. She rinsed her cloth in water and cleansed the meatus and then worked back up the tube over what she had just cleaned. Staff F stated that she should not have cleaned from the meatus up the tube because she contaminated what she just cleaned. 14. Observation with concurrent interview on four West, on 03/21/16 at 4:10 PM showed Patient #4's urinary catheter bag in contact with the floor. Staff G, RN, stated that the urinary catheter bag should not have been on the floor. 15. Record review of the facility's policy titled, Hand Hygiene, dated 10/2015, showed facility directive for staff: - That gloves were to be used for hand-contaminating activities; - That gloves should be changed during the care of a single patient when moving from one procedure to another; - Hand hygiene must be performed: - Before and after patient contact; - After contact with a source of microorganisms; - After removal of gloves; - When moving from a contaminated body site to a clean body site during patient care; and - After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Record review of the facility's document titled, Isolation Precautions, dated 05/2015, showed facility directive for staff that gloves shall be changed between tasks and procedures on the same patient. 16. Observation with concurrent interview in the ICU on 03/22/16 at 2:40 PM showed Staff JJ, RT, with gloved hands suctioned Patient #26's tracheostomy (incision in the windpipe made to remove an obstruction for breathing). With the same gloves in place he preceded to administer a medication per aerosol (an enclosed substance placed under pressure which allows release in a fine mist) route. Staff JJ stated that he should have removed his gloves, performed hand hygiene, and put on new gloves before the medication administration. 17. Observation with concurrent interview in Operating Room (OR) #14 with Patient #22, on 03/22/16 at 9:25 AM showed Staff Y, RN, was wearing gloves and was carrying bed pads, which he placed on a cart. He removed his gloves and failed to perform hand hygiene. He stated that he typically sanitizes with foam between glove changes and just forgot. 18. Observation with concurrent interview in the Emergency Department (ED) on 03/22/16 at 3:15 PM showed Staff LL, Physician, in Patient #37's room. He removed his gloves, left the patient's room and walked to the nurse's station. Staff LL failed to perform hand hygiene after he removed his gloves. Staff LL stated that he should have performed hand hygiene after he removed his gloves. 19. Observation on four East on 03/22/16 at 2:55 PM showed Staff TT, RN, entered Patient #29's room and immediately put on a pair of gloves and failed to perform hand hygiene. After he emptied the urinary catheter bag he removed his gloves, touched many inanimate objects, opened the door, exited the room and did not wash his hands until he got to the nurses' station. He failed to perform hand hygiene after his glove removal. During an interview on 03/22/16 at 3:02 PM, Staff TT, RN, stated that he guessed he didn't perform hand hygiene when he entered the room because he had just exited the same room after he obtained a urine sample and washed his hands when he had finished. He stated that he should have washed his hands immediately after he removed his gloves and shouldn't have waited until he got to the nurses station. 20. Observation on four North on 03/22/16 at 3:05 PM showed Staff UU, RN, in Patient #30's room. Staff UU touched many inanimate objects then put on gloves to assist another nurse to reposition the patient in bed. Staff UU failed to perform hand hygiene after touching the inanimate objects and prior to putting on gloves. During an interview on 03/22/16 at 3:15 PM, Staff UU, RN, stated that she had performed hand hygiene upon entering the patients' room but didn't think about doing it again prior to putting on gloves but realized now that she should have. She stated that the facility policy directed staff to do hand hygiene before and after glove use. 21. Observation with concurrent interview in the Endoscopy (procedure that looks at the interior of a hollow organ or cavity) Lab scope (instrument used in the Endoscopy procedure) cleaning room, on 03/22/16 at 1:30 PM, Staff GG, Gastrointestinal (GI) Technician, placed a clean scope (not disinfected) into a tub, removed her gloves, and put on new gloves and failed to perform hand hygiene. She took the tub into the adjoining room to prepare the scope for the disinfection process. Staff GG stated that typically, she did not perform hand hygiene when she removed her gloves at that point in her cleaning process. During an interview on 03/23/16 at 2:00 PM and 3:10 PM, Staff EEE, RN, Infection Prevention/Employee Health, stated that: - An implanted port site should not be touched after the initial cleaning. - The staff should wear gown and gloves in contact isolation patient rooms. - She expected staff to clean and /or disinfect the COW and the blood glucose monitor between patients and if it touched any area of the patient care area. - Staff should ensure urinary catheter bags were not on the floor and during catheter care staff were expected to start cleaning at the urinary meatus and work outward. - She expected staff to perform hand hygiene after removal of gloves, after touching the patient and patient environment, and after emptying a urinary catheter bag. She expected staff to change gloves and perform hand hygiene between patient care tasks. 27727 32280

29047 Based on observation, interview and policy review, the facility failed to ensure patients were educated and offered privacy from video monitoring during personal care and toileting for three patients (#43, #44 and #45) of four patients reviewed for privacy. Approximately 250 of the facility's patient beds had video monitoring capability, on seven units. The facility census was 328. Findings included: 1. Record review of the facility's policy titled, Patient Monitoring, dated 04/2015, showed that the primary nurse was responsible for providing patient and family education regarding the monitoring system. The policy also gave direction for staff to activate the Nurse Privacy button when providing direct patient care. Activation of the privacy button will block the (patient monitored) image from viewing for 15 minutes. If the staff needs more than 15 minutes, they can press the privacy button another time. 2. Observation on 01/06/16 at 10:50 AM, showed Staff VVV, Registered Nurse (RN) uncovered Patient #43, to change a colostomy (a surgically created opening in the abdominal wall through which digested food passes) bag. During the patient's care, the patient's breast and abdomen were exposed. Staff VVV did not activate the patient's privacy button, and the care was observable on a monitor in the nurses' station. Observation of the 5th floor nurses' station video monitor, and concurrent interview with Staff UUU, Nurse Manager, on 01/06/16 at approximately 11:20 AM, showed 24 patients were monitored by camera on the 5th floor Nephrology/Metabolic (kidney disorder/bodily chemical process) Unit. Staff UUU, Nurse Manager, stated that nurses were responsible for educating patients about the video monitoring and were expected to stop the video surveillance of patients when they provided patient care or during toileting and baths. Observation on 01/07/16 at 9:07 AM, showed Staff YYY, RN, changed Patient #44's dressing, which was located around her tailbone. During the dressing change, the patient's perineal area (the genitals) was exposed. Staff YYY did not activate the patient's privacy button, and the care was observable on a monitor in the nurses' station. Observation on 01/07/16 at approximately 10:00 AM, showed Patient #45 on the video monitor at the 3 North nurses' station. The patient was seen sitting on a commode in the patient's room. During an interview on 01/07/16 at 10:20 AM, Patient #45 stated that she was not aware she was being monitored by video while on the commode, and when asked if it bothered her, stated that she liked her privacy. During an interview on 01/07/16 at approximately 10:30 AM, Staff XXX, RN, stated that patients were able to opt out of video monitoring if they chose. Staff XXX stated that she placed Patient #45 on the commode and did not shut off the video monitoring, but was unable to give a reason why.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12450 Based on observation, interview, record review and policy review, the facility: - Failed to ensure nursing staff consistently and accurately assessed, supervised and evaluated nursing care for wounds and/or pressure sores/ulcers (injury to the skin and/or underlying tissue usually over a bony prominence) for three current patients (#8 and #34, and #44) of 11 current patients reviewed, and one discharged patient (#15) of one discharged patient reviewed. - Failed to provide skin care consults per facility policy for three current patients (#8, #34 and #44) of 11 current patients reviewed, and one discharged patient (#15) of one discharged patient reviewed. - Failed to follow wound care treatment orders for two current patients (#8 and #34) of 11 current patient wound/pressure sores reviewed. - Failed to obtain wound care treatment orders for two current patients (#34 and #44) of 11 current patients and one discharged patient (#15) of one discharged patient wound/pressure sores reviewed. - Failed to auscultate vascular access (listen, with the aid of a stethoscope, sounds in the blood vessel) to assure the vessel was not blocked before starting dialysis (the clinical purification of the blood by dialysis, as a substitute for the normal function of the kidney) for one patient (#41) of one patient observed during dialysis. - Failed to label a Mediport (a small medical appliance that is installed beneath the skin in the chest region and connects the port to a vein, and is used administer medications and draw blood) access dressing for one patient (#5) of one patient observed with a Mediport dressing. - Failed to label intravenous (IV, in the vein) catheter (flexible tubing used to withdraw or administer fluids or medication) sites and/or tubing for nine patients (#1, #3, #20, #21, #22, #23, #27, #30, and #34) of 19 patients' IV's observed. These failures had the potential to cause harm to all patients with skin care issues, and had the potential to lead to IV site or bloodstream infections, if IV sites or tubing were not changed according to facility policy. The facility census was 328. Findings included: 1. Record review of the facility's policy titled, Pressure Ulcers: Management and Treatment of the Patient at risk for and with existing Pressure Ulcers, revised on 03/2014, showed the following: - All patients will be assessed utilizing a pressure ulcer risk screening tool called the Braden Scale, on admission and every shift thereafter. Lower scores indicate greater risk (10-12 High, 13-14 Moderate, 15-18 Mild). - Any patient with a Braden (score) of 13 or less will require a skin care clinician consult. - The nurse will document location, type, drainage (amount, color, odor), size and color of wound bed. - The nurse will obtain treatment orders for pressure ulcers. - The nurse will measure and document those measurements on admission, upon initial identification, on each Wednesday, or with dressing changes. - Multiple wounds are numbered to correspond with the wound number (a diagram of an anatomical man) in the computer system. 2. Record review of current Patient #34's History and Physical (H&P) dated 01/06/16, showed the patient was admitted on [DATE] with poor circulation and multiple ulcers on his right lower leg. The patient had a history of diabetes (can contribute to poor circulation) and a left above-knee amputation related to poor circulation. Record review of a podiatry consult (foot care doctor) dated 01/05/16, showed the patient had the following: - An area of eschar (dead tissue) on the right big toe measuring 1.0 centimeters (cm-a unit of measure) by 1.5 cm. - An area of discoloration on the right second toe. - A full thickness ulceration on the posterior (back) calf measuring 3.0 cm by 4.0 cm, with a small amount of eschar. - A blistered lesion on the front of the calf measuring 7.0 cm by 7.0 cm. Record review of a podiatry consult dated 01/06/16, showed the following: - The right big toe eschar measured 2.0 cm by 2.0 cm. - The right second toe discoloration measured 1.0 cm by 2.0 cm, with eschar. - The anterior and posterior calf ulceration measurements remained the same. - The type/cause of the ulcers showed Pressure, Arterial, Stage II (partial thickness skin loss, usually presenting as an abrasion, blister, or shallow crater.) Record review of an Adult Admission Systems assessment dated [DATE] at 5:27 PM, showed the following: - A Braden score of 16; - Several blistered areas to the left lower leg (should be right leg), labeled as Blister, Wound #1. - No other wounds were identified, documented, and/or measured per the facility policy on admission. Record review of an Adult Shift assessment dated [DATE] at 9:35 PM, showed the following: - A yellow sore on the upper right leg measuring 1.0 cm by 1.0 cm, labeled as Skin tear, Wound #1 (even though Wound #1 was on the lower leg on the previous assessment). - Several blisters to the right lower leg, labeled as Blister, Wound #2. - Foot ulcers on the right big two toes, 100% black, measuring 1.0 cm by 1.0 cm, labeled as foot ulcer, Wound #3 (even though this involved two toes, there was only one measurement and description). - An open area on the right upper knee with a yellow sore. Staff failed to measure and label this area. Record review of an Adult Shift assessment dated [DATE] at 8:00 AM, showed the Braden score was lowered to 12, the dressing was changed on the right lower leg, the toes were blackened and there was a yellow sore on the right upper knee. The assessment showed no further description and/or measurement of these wounds. Even though requested, the facility could not provide evidence of a skin care consult for this patient. Record review of physician's orders dated 01/05/16, showed staff were to treat the front of the right lower leg with a Vaseline gauze, ABD (thick gauze pad) and Mepilex (an absorbent, but padded dressing). Staff were to treat the back of the right lower leg with Vaseline gauze and Mepilex, both sites twice daily. Even though requested, the facility failed to provide an order for treatment to the right knee. 3. Observation on 01/06/16 at 10:17 AM, on the 3rd floor, showed current Patient #34 had the following: - A large area (approximately 20 cm) of darkened, taut, weeping skin, on the right lower calf, from the ankle to about two inches from the knee, completely surrounding the calf. There was a large blister, partially filled, on the front, outer calf region, and some small open areas throughout. - A black circular area of eschar on the tip of the right big toe measuring approximately 2.0 cm by 2.0 cm. - An elongated, oval shaped black area on tip of the right second toe measuring approximately 1.0 cm by 1.5 cm. - A blackened circular area on the right knee measuring approximately 1.0 cm by 0.8 cm. - Staff PP, Registered Nurse (RN), placed ABD pads on the entire circumference of the patient's calf wounds, front and back, contrary to the orders. - Staff PP also placed a small dressing on the right knee. 4. Record review of an Adult Shift assessment dated [DATE] at 10:49 PM, showed the same wounds as labeled on the 01/05/16 9:35 PM assessment. The two toes were still not separately described and/or measured, as well as not for the right knee. 5. Record review of current Patient #8's H&P dated 12/30/15, showed the patient was admitted to the geriatric psychiatric unit on 12/29/15 with a diagnosis of major depressive disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed). The patient had a history of bowel and bladder incontinence (lack of control), persistent diarrhea, and was wheelchair bound (all can contribute to skin breakdown), and some Stage II pressure sores on her buttock (no sizing information provided). The physician recommended a wound care consult. Record review of the patient's Braden scores showed 13, from admission through 01/02/16, which would require a skin care consult per policy. Even though requested on 01/05/16, the facility failed to provide evidence of a skin care consult. Record review of the admission Nurse assessment dated [DATE], showed the patient had pressure sores on the left buttock as Wound #1, and a pressure sore on the right buttock as Wound #2. Staff failed to stage, describe, or measure the pressure sores. Record review of wound/incision care orders dated 12/29/15, showed staff were treat the patients skin breakdown with Triamcinolone cream (an anti-inflammatory cream) topically, twice daily. Record review of wound/incision care orders dated 12/30/15, showed staff were to treat the patient's skin breakdown with skin barrier cream twice daily. Record review of skin treatment records from 12/29/15 through 01/06/16 showed staff failed to document treatment 14 of 17 times. During an interview on 01/06/16 at 9:57 AM, Staff III, Assistant Chief Nursing Officer and [NAME] President of Operations for the Behavioral Health Units, stated that she expected staff to document treatments as performed per the physician's orders. Staff III confirmed there was no documentation of measurements. 6. Observation on 01/04/16 at 2:17 PM, on the geriatric psychiatric unit, showed Patient #8 had an elongated Stage II pressure sore on the left upper hip that measured approximately 0.25 cm by 0.50 cm. There was a large area of excoriation (reddened, rash type area) surrounding the pressure sore. Even though requested, the facility failed to provide evidence of staging, description or measurement of this pressure sore. 7. Record review of current Patient #44's H&P dated 01/05/16, showed the patient was admitted on [DATE] with a decubitus ulcer (wound) on her sacrum (tailbone) and one on her lower left buttock. The patient had a history of cerebral palsy (disorder of movement, muscle tone, or posture), was wheel chair bound, and with multiple decubitus ulcers (pressure ulcers). The plan (not written as a physician's order) for the patient included wound care with wet-to-dry dressings twice daily. Record review of an adult admission assessment dated [DATE] at 8:30 PM, showed: - A Braden Score of 13; - Wound 1, A Stage II pressure ulcer to the left buttock which measured 3 cm long by 3 cm wide, by 0.2 cm deep; - The wound was cleansed with saline (salt water solution) and a wet to dry dressing was placed on the wound, and; - No other wounds were identified, documented, and/or measured per the facility policy on admission. Record review of a shift assessment dated [DATE] at 8:00 AM, showed: - A Braden Score of 13; - Wound 1 measured 4 cm long by 3 cm wide, by 1 cm deep; - The wound was cleansed with a wound cleanser and a Hydrocolloid dressing (a clear dressing which contains gelatin and other ingredients used to heal wounds) was applied, and; - No other wounds were identified, documented, and/or measured per the facility policy on assessment. Record review of a shift assessment dated [DATE] at 8:25 PM, showed: - A Braden Score of 13; - Wound 1 was not measured; - The wound was cleansed with a wound cleanser, and a wet to dry dressing was applied, and; - No other wounds were identified, documented, and/or measured per the facility policy on assessment. Even though requested, the facility could not provide evidence of a skin care consult, or a physician's wound care order for the Stage II pressure ulcer for this patient. 8. Record review of discharged Patient #15's H&P dated 10/31/15, showed that the patient was admitted on [DATE] with: - A gangrenous (death of tissue cause by inadequate blood supply) second digit (toe) on the right foot; - Multiple left foot wound ulcers, which were draining, with concerns for osteomyelitis (infection in the phone); - Cellulitis (infection on the skin) of the left leg; - Blister on the back and outside of the left leg; - A left foot wound, Stage IV (with bone showing); - A Stage I (reddened area on the skin which is not open) wound to the top of the left foot; - Stage II ulcers to both the left and right buttock, which were healing; - No other wounds; and - A history of a partial amputation of the left metatarsal (foot). Record review of an adult admission assessment dated [DATE], showed only three wounds documented: - Wound 1 location - right buttock; - Wound 2 location - left buttock; and - Wound 3 location - left foot. There was no length, width or depth of the wounds documented, no description of the wounds documented, no description of the drainage documented or dressings documented. The patient's Braden score was 12. Record review of nurse Wound 1 assessment documentation showed: - The wound was located on the right buttock from 10/31/15 through 11/11/15; - The wound was located on the coccyx (tailbone) from 11/12/15 through 11/17/15; - The wound length was documented as 12 cm on 11/12/15, 4 cm on 11/13/15 and 12 cm on 11/14/15; - The wound width was documented as 12 cm on 11/12/15, 4 cm on 11/13/15 and 12 cm on 11/14/15; and - The wound was documented as intact (together, healed or closed) from 11/04/15 through 11/13/15. Record review of nurse Wound 2 documentation showed: - The wound was located on the left buttock from 10/31/15 through 11/12/15; - The wound was located on bilateral buttocks on 11/13/15; - The wound was located on right back from 11/14/15 through 11/17/15; - The wound measured 2 cm long by 2 cm wide on 10/31/15; and - The wound was not measured during the remainder of the patient's stay. Record review of nurse documented Wound 3 showed: - The wound was located on the left foot from 10/31/15 through 11/05/15; - The wound was located on the left lower leg from 11/06/15 through 11/11/15; - The wound was located on the right buttock on 11/12/15; and - The wound was located on the left buttock from 11/13/15 through 11/17/15. Record review of physician orders, showed there was no wound care orders by a physician until 11/12/15, 13 days after the patient was admitted . Record review of Braden score documentation showed that the patient scored between 7 and 16 during her stay from 10/31/15 through 11/17/15. Even though requested, the facility could not provide evidence of a skin care consult for this patient. 9. Observation with concurrent interview on 01/07/16 at 9:07 AM, showed Staff YYY, RN, provide wound care to Patient #44. The patient had a foam dressing on her coccyx and on the patient's left lower buttock. The coccyx wound was healed except for sloughing skin, and the left buttock wound measured approximately 8 cm long by 3 cm wide, with no depth. The measurement was verified by a second surveyor. The nurse reported that the wound measured 2.8 cm long by 1 cm wide, with no depth. During an interview on 01/06/16 at 2:12 PM, Staff QQQ, RN and Director of Clinical Excellence, and Staff RRR, RN, and Intensive Care Unit Educator, stated the following: - The facility's skin care consultant retired in 2014 and they had not re-filled the position. - Because there was no skin care consultant, when physician's requested a skin care consult, it did not happen. - Any stageable wound should have a specific wound care order written by a physician. - Wounds (all) should be assessed on admission, to include site, stage, description, and measure. Wounds should be assigned a number and that number should remain with that specific wound throughout the hospitalization . - Wounds should be re-measured with each dressing change. - All orders for treatment were to be followed and documented. -Their current wound care policy did not reflect the current process expectations for wound. 10. Record review of the facility's policy titled, Assessment and Preparation of Internal Access for Needle Placement for Dialysis, dated 01/28/15, showed directives for staff to auscultate vascular access by listening to the entire length of the access for changes in the sound of the bruit (noise of the blood flow). A low pitched bruit should be present and if no sound is present, assume the access is thrombosed (blocked), do not attempt cannulation (needle with tube insertion), and contact the attending physician. 11. Observation on 01/06/16 at 9:40 AM in the inpatient Dialysis Treatment Area showed Staff KKK, Certified Clinical Hemodialysis Technician (CCHT), in the room with Patient #41 to administer a dialysis treatment. Staff KKK inserted a needle into the patient's blood vessel and connected the dialysis tubing (filled with the patient's blood) to the dialysis machine without auscultating (listening with the aid of a stethoscope) to the patient's blood vessel. During an interview on 01/06/16 at 11:00 AM, Staff KKK, CCHT, stated that she did not auscultate the patient's blood vessel and she did not know if the RN auscultated the patient's blood vessel prior to the needle insertion and administrating dialysis. During an interview on 01/06/16 at 11:05 AM, Staff JJJ, RN, stated auscultated the patient's blood vessel after the needle insertion and not before the insertion. She stated that she did not know until questioned, that Staff KKK had not performed auscultation and she should have done so. During an interview and concurrent policy review on 01/06/16, Staff LLL, Dialysis Patient Services Manager, stated that the nurse usually auscultates the patient's blood vessel before needle insertion; and currently there was no process to assure that either a nurse or CCHT auscultated the patient's blood vessel before inserting the needle and initiating dialysis. 12. Record review of the facility's policy titled, Intravenous Access Management Policy, dated 02/2015, showed that IV sites are labeled with the date and time of insertion or date and time of last dressing change, and IV tubing is labeled with the date and time to be changed. 13. Observation on 01/04/16 at 2:15 PM showed Patient #5 with an unlabeled Mediport dressing. During an interview and concurrent review of Patient #5's record on 01/04/16 at 2:55 PM, Staff DD, RN Unit Director, stated that according to policy, the dressing should have been labeled when the port was accessed in the emergency department. 14. Observations from 01/04/16 to 01/06/16 showed patients (#1, #3, #20, #21, #22, #23, #30) with medication infusing through unlabeled IV tubing and patients (#27 and #34) with an undated IV catheter dressings. During an interview on 01/06/16 at 1:30 PM, Staff KK, Chief Nursing Officer (CNO), stated that staff were expected follow policies and procedures and label all dressings and Dialysis staff were expected to follow Dialysis policies and procedures. 29047 31891

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27029 Based on observation, interview, record review and policy review the facility failed to protect one patient (#10) of 11 patients in the Intensive Treatment Unit (ITU - a psychiatric unit for patients with aggressive or behavioral issues) from abuse by strangulation using a Rear Naked Choke (a submission hold used in mixed [NAME] arts that cuts off the flow of blood to the brain. If applied correctly, it will force the opponent to submit. If they do not submit, they will pass out within a matter of seconds), verbal abuse and protection from an Alleged Perpetrator (AP), Staff HH, Registered Nurse (RN). The facility also failed to protect two current patients (#2 and #11) and one discharged patient (#9) from neglect (the failure to maintain reasonable care and treatment of an individual to the extent well-being is injured) and/or verbal abuse (use of threats or harsh words). These failures put all patients at risk for abuse and violation of their basic patient rights. The facility census was 339 and the census on the psychiatric units was 73. Findings included: 1. Record review of the facility's policy titled, Patient Abuse and Neglect, revised 03/14, showed the following direction to staff: - To inform all employees of the policies and procedures of the facility regarding the rules, regulations and consequences pertaining to alleged patient abuse and immediate actions to be taken subsequent to a report or suspicion related to patient abuse. - Patient abuse, neglect, or exploitation by employees, affiliates, and agents of the facility is prohibited, and shall be grounds for disciplinary action up to and including termination. - It is the responsibility of all employees and health care providers employed by or affiliated with the facility who may witness, suspect patient abuse or to receive report of same from the patient, their family or other staff to report this suspected abuse and/or neglect to their supervisor immediately. This can include physical, sexual, emotional, verbal and/or social abuse. - Any health care provider whom knowingly fails to make an abuse report may have criminal liability. - Upon receipt of an allegation of suspected abuse and/or neglect, it is the responsibility of the Department Director or House Supervisor to initiate investigation of the situation and place on administrative leave, any staff that are suspected to have committed an act of abuse or neglect until a determination is made. This allows time to conduct an investigation, while keeping in mind the protection of the patient, the facility and staff involved and initiate the patient grievance process. - Abuse is the intentional infliction of injury (i.e., punching, slapping, biting, pushing, kicking, attempted strangulation), verbal abuse, sexual abuse, unreasonable confinement, fiduciary [person to whom property or power is entrusted for the benefit of another] abuse, intimidation, cruel punishment, omission or deprivation by a caretaker or another person of goods, services which are necessary to avoid physical or mental harm or illness. - Verbal Abuse is language used to manipulate, control, ridicule, insult, humiliate, belittle, vilify, and show disrespect and disdain to another which hurts the listener and is not accidental. - The Department Director/House Supervisor has the independent authority to immediately place the employee on administrative leave pending resolution, and results of the abuse investigation. - The Department Director/House supervisor will immediately notify the Administrator on Call and Security of the allegation for further assistance and guidance as needed. - Reports of suspected abuse or neglect will be referred to the appropriate agencies within 24 hours of determination. Record review of the facility's Policy titled, Code White, revised 03/14, gave the following direction to staff: - To provide a multi-disciplinary team approach to evaluate and intervene when a patient, family member or visitor is exhibiting a behavioral crisis, or potentially disruptive, inappropriate or threatening action(s) that compromises the safety and well-being of themselves and/or others. - Behavioral management of the crisis situation will be conducted in a manner that utilizes the least restrictive environment possible to provide care, welfare, safety and security of all those involved in the crisis situation. - Patient Care Services with current competency training in non-violent crisis intervention shall respond to all crisis situations which will be called Code White campus wide. The Security staff will respond per campus specific practices. - Employees with direct responsibility for therapeutically managing crisis situations, shall be certified in NVCI [Non Violent Crisis Intervention] at the start of employment and biannually. - Purpose of the Code White Team [a multidisciplinary response team with current competency training in non-violent crisis intervention that responds to and has the authority to de-escalate behavioral situations involving disruptive, inappropriate or threatening behaviors that compromise the safety and well-being of others] is to assist a patient, family member or visitor to regain control of behaviors that place them or others at risk and to provide safety for the patient, family member, visitor, staff or other patients. To this purpose the team will provide staff backup; escort the patient, family member, visitor or employee to a safe area, using the least restrictive means; use seclusion when necessary for the safety of patients and others; apply restraints to provide safety for the patient and others; assists in the administration of emergency medications. - Debriefing: Following the Code White the responders and involved staff are required to hold a debriefing event with the patient and with the team and involved clinical staff. - Notifications: Following the Code White intervention and debriefing event the team lead will initiate a MediTech [name of computer software form] Notification and copy of the following individuals: Director and immediate supervisor of area; Medical team; Quality and Risk Manager; CNO [Chief Nursing Officer] or Administrator; Administrator on Call; Patient representative - Patient Safety; Social Services; Spiritual Care. - Documentation and review of Code White events: Initial Responders: Team Lead will complete the Code White Event form following the event. This form will be maintained in a log book in Nursing administration. Primary caregiver: Will document the summary of events leading up to the event including behavioral triggers for the Code White in the patient's medical record. Secondary responders: Will document their interdisciplinary assessment, interventions and recommendations in the patient's medical record. Debriefing and recovery will occur immediately following the intervention. Written observations will be documented in the form. Record review of the facility's policy/procedure guideline titled, Alternatives to Restraints, revised on 04/14, gave the following direction to staff on Physical Holds: Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint. This includes holds that some members of the medical community may term therapeutic holds. Many deaths have occurred while employing these practices. Physically holding a patient during a forced psychotropic medication procedure is considered a restraint. If the patient is in a physical hold, a second staff person is assigned to observe the patient to ensure safety and the patient's airway is not compromised. 2. Record review of the facility's undated document titled, Restraint/Seclusion, gave the following direction to staff on documentation for patients placed in restraints: - Complete restraint documentation screens in MediTech for clinical justification; type of restraint; second tier review; monitor; least restrictive measures/alternatives/ notifications of family guardian; criteria for release; safety/dignity check. - Change of condition note in MediTech - describe behaviors and least restrictive measures attempted; - Debrief; - Complete a notification in MediTech; - Notify administrator and nurse manager on call for all restraint/seclusion events. 3. Record review of Patient #10's history and physical dated 09/05/14 showed he was a [AGE] year old male with a past history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels), borderline personality disorder (a mental illness marked by unstable moods, behavior, and relationships), polysubstance dependence (addiction to more than one drug), self-harm (the practice of cutting or otherwise wounding oneself, usually considered as indicating psychological disturbance), and multiple suicide attempts (serious gestures of self-harm without the result of death). 4. During an interview on 09/16/14 at 9:55 AM Staff P, Chief Executive Officer of the Psychiatric Units, stated that an abuse event occurred on 09/07/14 but the administration did not learn of the event until 09/10/14 because it was not reported by Staff MM, HS, as required by policy and procedure. She stated that the AP, Staff HH, RN; Staff MM, House Supervisor (HS), were telephoned and put on administrative leave pending position termination and Staff NN, RN, was telephoned but resigned her position at that time. Staff P stated that a Root Cause Analysis and Action Plan were completed by Leadership Management on 09/15/14. 5. Record review of the facility's undated document titled, Root Cause Analysis and Action Plan Framework Template, showed that the following events were precipitated by the removal of patio privileges (e.g. smoking privileges) as a result of a patient's poor behavior. These patient privileges were used in a punitive manner that caused Patient #10 to escalate (increase) his behaviors and began hitting the wall with his fist. 6. Observation on 09/16/14 at 10:10 AM showed a videotape (video) of the event on ITU on 09/07/14 at 5:26 PM with Staff HH, AP, RN, Charge Nurse; Patient #10; Staff Y, Mental Health Technician (MHT) and Staff NN, RN, Patient #10's primary Nurse. The video showed the patient going down the hall away from the camera and punching the wall with his right hand approximately 16-17 times. The three staff members were then seen walking side by side down the hall toward Patient #10. They moved in a line toward the patient backing him up to the wall. The patient broke through the line and started walking toward the camera when Staff HH jumped on the patient from behind and proceeded to get his right arm around the patient's neck and they hit the wall and then fell to the floor. Staff NN jumped over the patient and held the patient's right arm to the floor. Other staff responded to the Code White one at a time. Security did not respond to this event (and there were conflicting accounts if they were ever called to respond). Staff U, Psychiatrist, and Staff MM, RN, HS, were both seen in the videotape standing directly in front of the patient's head while Staff HH had the patient in a choke hold. Patients on the unit were seen walking up to and around the patient and staff without being redirected or moved to a safe area. The episode lasted approximately 13 minutes with the patient being held to the floor for approximately 12 minutes. Observation on 09/16/14 at 10:30 AM of a second video dated 09/04/14 at approximately 5:57 PM showed another event occurred when Patient #10 jumped on top of the nurses' station counter and onto the floor inside the nurses' station. Staff HH then jumped onto the same counter and onto Patient #10's back with his right arm around the patient's neck, knocked over an intravenous (in the vein) pole and hit a medication cart before falling to the floor. The patient did not move at this point and other staff began to respond to the Code White and eventually Staff MM, HS, and Staff W, Security Specialist (Officer), responded. Other staff identified in the video were Staff Q, Plant Operations; Staff OO, RN; Staff PP, RN, and Staff Y, MHT. 7. Record review of the medical record for Patient #10 and the nurses' notes documented by Staff NN, RN, Patient #10's primary nurse, did not provide the required documentation for restraints. 8. During an interview on 09/16/14 at 10:30 AM, Staff R, Nurse Manager of ITU, stated that he had watched the video and was bothered that no one [staff] helped the patient. He stated that several staff and physicians had been injured in these kinds of events and they were just now getting started to change the milieu (social environment) of the ITU. Staff R stated that Staff HH was viewed by the female staff as their [NAME] and cowboy and kept them safe. He stated that Staff HH, Staff MM and Staff NN were on administrative leave but were still employees of the facility. He stated that Staff HH called him at the facility on 09/08/14 and came in to talk with him about, Some take downs that didn't go too well over the weekend. Staff R stated that they viewed the video of the event together and after the first event Staff HH stated, If you think that is something, wait until you see the next one. Staff HH told Staff R the name of the choke hold on the patient and stated that, He knew what he was doing and occluded both of the patient's carotid arteries which caused him to pass out. Staff HH told Staff R that he then relaxed his grip on the patient until he began to regain consciousness and then applied the hold again to keep the patient down awaiting medication. Staff HH had an appointment with administration on 09/17/14. Staff NN was interviewed over the telephone about the event and resigned her position at that time. 9. Record review of Patient #10's undated verbal statement given to Staff R stated that the patient was asked to talk about the events that occurred on 09/07/14. I don't agree with everything that happened, but I don't want to get anyone in trouble either. He [Staff HH] choked me out. I think he was scared. He came up a couple of times this week to see me. I told him I wouldn't report it. He was cussing at me. He said, Go to sleep fucker and he choked me out. I don't want him to get in trouble though. I think he did what he did because he was scared. My vision went black and I could see these colored dots flashing. I didn't know if he was going to kill me or what. 10. During an interview on 09/16/14 at 3:40 PM, Staff R stated that he was not aware that the AP, Staff HH, had visited Patient #10 after the event until Patient #10 told him. It must have been after we watched the video together. 11. During an interview on 09/16/14 at 3:32 PM, Patient #10 stated that he liked the nurse that hurt him and that he had been there two times to talk to him since the event. Patient #10 stated that he remembered what happened to him and that he thought the nurse [Staff HH] was afraid and wanted to protect the girls, I wouldn't hurt a girl, they haven't done anything to me that I haven't done to myself. Patient #10 stated that he was put in four point leather restraints after the event and that he broke the bed that held the leather straps holding his ankles and freed his legs. He stated that he was able to bite his hand removing the skin so he would be taken to the emergency room (ED). 12. Observation of Patient #10 on 09/16/14 at 3:32 PM showed a large five inch square bandage on his left hand. 13. Record review of the facility's emergency provider report dated 09/07/14 at 8:43 PM showed the patient presented to the ED with head pain, back pain and bilateral hand pain. The report showed: - Patient transferred here from [the psychiatric unit] after biting skin off of his left hand and eating it. He then was tackled over a desk and stated he hurt his back during that time. He was then medicated and transferred to the ED. - Head/eyes: Frontal hematoma [a collection of blood on the surface of the brain]; - Skin: Left hand with a five by five cm [centimeters] square laceration. There is no skin or the patient removed it. There is also a small one cm flap [of skin] with frayed edges. There is viable tissue present. - Indication: Assault, hypoxia [reduction of oxygen supply to a tissue]. - Reason for exam: tackled at [psychiatric unit]. 14. During an interview on 09/17/14 at 2:00 PM, Staff MM, RN, HS, watched the video of the events and stated, I think he's [Staff HH] talking to him [the patient], isn't he? Staff MM denied that she saw Staff HH's arm around Patient #10's neck during either encounter when she was present. She stated she didn't do a MediTech report (incident report of the event) because she didn't see anything wrong with the take down. Staff MM stated that she didn't know the patient was in a choke hold because she couldn't see his face. Staff MM stated that it didn't look like CPI was used by staff in the video. She stated that she called and talked with administration three times on the evening of 09/07/14 after the events but didn't report abuse of the patient or put Staff HH on administrative leave because she didn't know it was abuse until now. 15. During an interview on 09/17/14 at 1:05 PM, Staff HH, RN, stated that: - Patient #10 had been denied a smoke break because he received a Geodon (antipsychotic medication used to treat schizophrenia and depression) injection prior to his smoke break causing his gait to be unsteady and staff was afraid he would fall. - Patient #10 became upset because he could not have his smoke break and stated that it was his right and began to yell at staff. - Patient #10 did not calm down after staff tried to calm him. - Patient #10 walked down the hall and began punching the wall with his fists. - Two female staff accompanied Staff HH down the hall where Patient #10 punched the wall with his fists. - He called a Code White but facility security did not show up to help with the first incident when Patient #10 was taken down. - He used a rear carotid restraint or also referred to as a rear naked choke (sleeper hold) that he had looked up and used for the first time on Patient #10 during the second take down when he became violent. - He did not have permission from facility staff to use the rear carotid restraint on patients. - During the second incident Patient #10 became very violent by picking up chairs and tables and throwing them. - He did not feel what he did was abuse because of the behavior, violence and threats displayed by Patient #10 towards female staff. - Patient #10 did experience approximately an eight second period loss of consciousness while in the rear carotid restraint. - He never received debriefing from staff after a patient had been taken down or restrained to see what worked or what did not work during the incident. - Staff never told him what needed to be improved or changed during a take down or use of restraints. - He was not sure what the facility's policy and procedure was related to restraints. - Staff HH, stated, How do you expect someone like me to take him down? (On admission to the facility the patient measured 6 feet tall and weighed 319 pounds.) 16. During an interview on 09/24/14 at 1:38 PM, Staff NN, RN, stated that she was the primary nurse for Patient #10 on 09/07/14. She stated that the patient had three different outbursts that evening and had verbally threatened staff and peers. She stated that she had watched the video of the incident where Staff HH held Patient #10 down. She stated that she did not see Staff HH choke the patient but he was rougher with him than usual. She stated that those events happened a lot and it took security 20 plus minutes to respond to her calls that evening. She stated that she resigned her employment because the staff are constantly put in very unsafe situations and the facility never fixed the problem. During an interview on 09/17/14 at 2:35 PM, Staff V, Environmental Services, stated that: - He responded to the Code White for Patient #10 on 09/07/14. - He saw the arm of Staff HH around the patient's neck but did not intervene on the patient's behalf. - What he observed was not the appropriate way to take down a patient. - He would not take down a patient the way Staff HH did and the hold he had on the patient was inappropriate. - He has had no education regarding the events. During an interview on 09/17/14 at 2:50 PM, Staff W, Security Specialist, stated that: - He did not get a call to respond until the second event on the evening of 09/07/14 and Patient #10 was already on the floor in the nurses' station when he arrived. - He stated the patient was talking but the RN's arm was around his neck and I encouraged him to let him up and I backed away from the situation. - He asked staff on the unit what needed to be done and staff informed him that Patient #10 needed to be moved to the quiet room. - The hold on the patient was not a typical way to hold or restrain a patient. - He had not seen staff use that kind of hold on a patient before and he would not have used the same technique that Staff HH used. - He would never use a choke hold because he is not trained in that technique or type of hold. - It would not be his expectation to see staff with their arm around a patient's neck. - He would report anything related to abuse and neglect to his supervisor and he would notify the local police department. During an interview on 09/18/14 at 9:15 AM, Staff BB, MHT, stated that she responded to the second Code White for Patient #10 on 09/07/14. She stated that Staff HH was lying on top of the patient when she arrived and she knelt down to take the patient's hand when he stated to her, He [Staff HH] is making me mad, get him off of me. During an interview on 09/18/14 at 10:00 AM, Staff U, Psychiatrist, stated that he was present at the first event but not at the second event. He stated that he did not see Staff HH's hands at the time but gave verbal orders for medications. Staff U stated that he was paged after the second event at 5:58 PM with Patient #10 and never saw or witnessed the event. He stated that he gave a telephone order for restraints because the medication was not de-escalating (to decrease or diminish the intensity of the episode) the patient and he was out of options. He stated that he did a face-to-face assessment while the patient was in restraints and assessed the injury to his hand and called 911 to transfer the patient to the ED for treatment. During an interview on 09/17/14 at 2:20 PM, Staff X, RN, stated that: - Several codes were called that day that included Patient #10. - She observed Patient #10 down on the floor at the nurses' station. - If she had seen staff using a choke hold on a patient it would be inappropriate and she would not think it was a proper way to handle a patient's behavior. - She did not feel like that kind of force is ever needed and she would never personally take a patient down physically but would seek help from other staff. During an interview on 09/17/14 at 3:30 PM, Staff Y, MHT, stated that: - She knew Patient #10 and had provided 1:1 (one staff member provides constant observation) observation for him in the past. - She held Patient #10's arm during both holds. - Patient #10 had became very upset when staff would not let him have his smoke break because he had received medications earlier and Patient #10 had reported to staff he had fallen. - Patient #10 became very threatening to both staff and peers. - Staff HH was yelling profanity at Patient #10 while he had him in a choke hold. - She used the proper CPI hold on Patient #10 but did not feel like Staff HH used proper hold techniques. - She rubbed Staff HH's arm a couple of times and asked him to calm down and he did relax his hold on the patient's head slightly. - She did not report the incident of Staff HH's improper hold because the house supervisor, charge nurse and Patient #10's physician were present during both take downs. - She was instructed by staff not to document the two incidents with Patient #10. - She tried to encourage Staff HH to calm down because Staff HH and Patient #10 were both verbally going at each other. - No one followed up with her and to her knowledge there was no debriefing after the two incidents with Patient #10. During an interview on 09/17/14 at 1:15 PM, Staff O, Medical Director, stated that: - He was aware of the event that occurred on 09/07/14 and had watched the video recording. - He understood that Staff HH, RN, had requested additional medication to be given, or for an increase to the dosage of the medication injection used for Patient #10. - All of the available oral medications and as needed medication injections had been utilized for the patient. - Patient #10 needed to be talked to, he was escalating. - He was concerned related to the force utilized by Staff HH. - Communication regarding escalating patients needed to improve. - Any number of staff present at the time of the incident should have asked Patient #10 be restrained in a different way. - If the staff were involved in this event again they would have Staff HH remove his arms from around Patient #10's neck. During an interview on 09/17/14 at 1:28 PM, Staff Q, Plant Operations, stated that: - He responded to the Code White on the ITU on 09/07/14. - Staff Q had not had de-escalating technique training (CPI) for approximately four years, and he routinely assisted with patients who were escalating. - He observed Staff HH, RN, have his arm around the upper part of Patient #10's body (neck/shoulder area). - The patient verbalized to Staff HH to let him go. - Staff HH responded not until he calmed down. - This was not usual procedure for take downs. Usually staff held patient's extremities down, not the upper part of the patient's body (neck/shoulder area). During an interview on 09/17/14 at 2:15 PM, Staff Z, RN, stated that: - She was working on the Adolescent unit on the day of the event and that she responded to the Code White on the ITU. - She observed staff and Patient #10 on the floor. - Patient #10 had yelled and cursed at the staff. - The physician was there and gave an order for a medication. - She obtained necessary papers from the computer for the House Supervisor. - She had heard staff tell patients they could not go out and smoke as a punitive measure on the Adult unit. - The patients on the ITU were not allowed to go out and smoke. 17. Record review of the facility's policy titled, Patient Abuse and Neglect, revised 03/14, showed the following: - The use of verbal or other communication to curse, vilify, or degrade a patient; threatening by words or actions with physical harm, or intent to inflict physical injury is considered a Class III abuse. - Examples of verbal abuse include yelling, threatening, swearing. - This can be any oral presentation that is offensive to a patient, visitor or others. 18. Record review of Patient #2's Behavioral Health Assessment, dated 09/10/14, showed the patient was admitted to an adult psychiatric unit on 7 West, on that date with suicidal ideations (thoughts of self-harm) and alcoholism. 19. During an interview on 09/16/14 at 11:05 AM, current Patient #2 stated that: - The facility failed to consistently follow their policies. - Patients were treated like animals. She was left in the Emergency Department (ED) on 09/10/14, on the floor, with vomitus all over her for an extended period of time (this can be a form of neglect). - On the evening of 09/16/14, staff failed to supervise a male patient allowing him to wander up and down the halls of the female patient corridor. All female patients were fearful and did not get any sleep that night (this can be a form of neglect). During an interview on 09/22/14 at 10:36 AM, current Patient #2's spouse stated that on 09/10/14 staff left Patient #2 in the ED, on the floor, for over an hour with vomitus all over her. He had to seek, and insist on assistance to get her in a gown and off the floor (this is a form of neglect). 20. During an interview on 09/18/14 at 9:08 AM, current Patient #11 stated that Staff QQ, RN, threatened to send him outside without a coat, or to the ITU side if he did not behave (this could be considered Class III verbal abuse). 21. Record review of discharged Patient #9's initial psychiatric assessment dated [DATE], showed the patient was admitted to the ITU on 09/08/14 with SI. Patient #9 was discharged on [DATE] and assessed as alert and oriented at that time. 22. During an interview on 09/17/14 at 12:40 PM prior to the patient leaving the facility, discharged Patient #9 stated that: - During her hospitalization , she had witnessed three patients being taken down by about six staff members each time. Each time, staff were rough and sat on the patient (not considered to be appropriate technique). - Her smoking privileges were revoked when she became loud with her voice (a type of punishment). - Staff threatened patients with a B52 injection (unknown what was in it and used to calm/control the patients if they did not comply with staff direction.) 18018 32280 12450 [CARRIAGE RE

18018 Based on document reviews and interviews, the facility failed to ensure that one patient (#1) out of 23 emergency department (ED) records reviewed received a complete medical screening exam (MSE), in order to determine whether or not an emergency medical/psychiatric condition (EMC) existed. The facility failed to ensure compliance with 42 CFR 489.24. Refer to citation at A-02406 for examples. 32281

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18018 Based on policy review, record review and interviews, the facility failed to ensure a complete medical screening examination (MSE) within the facility's capacity and capabilities to determine if an Emergency Medical Condition (EMC) existed for one patient (#1) out of 23 Emergency Department (ED) patient records reviewed. The main campus ED sees an average of 135 patients daily and the psychiatric campus sees an average of 20 unscheduled walk-in patients daily. The main campus census was 276 and the psychiatric campus census was 69. Findings included: 1. The facility failed to ensure Patient #1 received a complete medical screening examination and failed to thoroughly assess the patient's homicidal thoughts during the psychiatric assessment to determine whether or not an emergency medical condition existed. 2. Record review of the Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours, not dated, showed the Life Coach documented that the patient became upset when a peer entered his apartment. He asked the other person to leave and told his Life Coach that he was feeling homicidal because that person had been bullying him. He stated that Columbine was about to happen again and that he wanted to torture two of the kids where he lived by shooting one of them repeatedly next to his head so he would lose all of his hearing. He also stated that he wanted to hurt another client with weapons. When asked if he had a gun he said he didn't but that he had plenty of weapons he could use. 3. Review of Patient #1's Behavioral Health Assessment showed the assessment was initiated 06/14/14 at 12:00 AM by Staff J, Mental Health Registered Nurse (MHRN). Patient #1 presented to the facility agitated and in handcuffs, accompanied by a police officer and his Life Coach (involves supporting clients in life skills and decision making) for assessment. Further review for the Behavioral Assessment showed Staff J documented the following: - During the assessment the Patient was very angry, calmed down and then became impatient and the assessor ended that assessment to be completed after the doctor was able to provide orders. -Patient was on medication that he took daily but no notation of how many medications or what they were for. - Unable to assess alcohol history, addictive behaviors or addictions treatment history and whether the patient felt safe where he lived. There was no documentation of vital signs, medical or physical assessment or that the patient was adequately assessed and then reassessed regarding his homicidal behaviors at any time during the encounter. 4. During a telephone interview on 07/02/14 at 9:07 AM, Staff J, MHRN, Intake Assessor for Patient #1, stated that as an intake assessor her responsibility was to assess individuals for threats to themselves or others and the need for in-patient stay. She stated that Patient #1 came in with a police officer and was accompanied by his Life Coach staff member from the group home where he resided. The patient was handcuffed at the time of arrival. After a few minutes the patient seemed to calm down and the police officer left. Staff J stated that she did not have admission criteria for the Psychiatric unit. She stated that once she had assessed the patient her responsibility was to contact the doctor, go over the assessment and the doctor made the decision to admit the patient based on her assessment. During a telephone interview on 07/09/14 at 5:00 PM, Staff J stated that her typical assessment would include a temperature, blood pressure, heart rate, pulse, height and weight. She stated she would ask the patient if they had any medical problems, and past hospitalization s. She stated that typically medications were recorded but they did not make a list of medications unless the patient was admitted . She had no answer for why the vital signs, height and weight were not documented. Staff J stated that the patient was angry and acting out toward his Life Coach, he broke the plastic frame covering a document on the wall in the intake office and threatened to urinate and spit on the floor. Staff J stated that she called for security presence and another staff member to assist with calming the patient. Staff J could not recall the timeframe of events. Staff J stated that her Homicidal assessment of Patient #1 was based on information provided by the Life Coach and from the patient telling her he wanted his roommate out or he was going to kill him. She stated that she asked him if he had access to firearms because it was a question on the assessment but she did not ask him if he had access to other weapons and did not recall he had made a statement that he had access to other weapons. 5. During a telephone interview on 07/02/14 at 9:40 AM, Staff F, Psychiatrist, stated that he was the Psychiatrist on-call the evening of 06/13/14. He stated that based on the psychiatric assessment Patient #1 was socio-pathic (characterized by antisocial behavior) and that the suicidal/homicidal stuff and reference to Columbine and guns spoke to the patient's anger. He stated that the patient had no access to guns and that he backed off the ranting when he calmed down. He stated that the patient lived in a group home with a controlled environment because of his chronic mental condition and socio-pathic behavior. Staff F stated that Staff J's assessment seemed to be accurate of the situation. He stated that at the time of his evaluation the patient had an anti-social disorder. He stated that his rational for not admitting the patient was because acute inpatient treatment was not appropriate for treatment of socio-pathic episodes. During a telephone interview on 07/08/14 at 4:35 PM, Staff F stated that Patient #1 was a healthy [AGE] year old and would not have medical issues. He stated that he would expect vital signs to be checked and a few medical related questions documented in the record but the main focus would have been on the psychiatric issues. He stated that during the interval of time the patient was there he calmed down considerably, an indication the homicidal thoughts were due to his anti-social disorder. Staff F stated that the fact that the patient was in an apartment based independent living situation instead of a group home would not have changed his decision to discharge the patient. He stated that the patient had no AXIS I (describes clinical symptoms that cause significant impairment) illness and did not meet criteria for admission to an acute psychiatric facility. He stated that if the group home could not handle the patient because he had assaulted his roommate then he should have been charged with assault and taken to jail. 6. During an interview on 06/30/14 at 2:15 PM, Staff H, Master of Social Work (MSW), Intake Coordinator, stated that unscheduled patients presenting to the Psychiatric facility should have a basic medical assessment including vital signs by a Registered Nurse (RN) and an RN or Social Worker (SW) assessed the patient's mental status. She stated that when a patient was identified as having a medical problem the House Supervisor was notified and the patient was transferred to the facility's dedicated emergency department to complete the medical screening examination and stabilizing treatment. 32281

15697 Based on employee file review, interview, and Medical Staff Bylaw review, the facility failed to ensure credentialing for two (CC and DD) of two Registered Nurse First Assistants (RNFA, provides aid in exposure, hemostasis [stop bleeding], closure, and other intraoperative [during surgery] technical functions that help the surgeon carry out a safe operation with optimal results for the patient) according to policies and procedures approved by the facility medical staff and governing board and failed to delineate privileges for one (Q) of one Advance Practice Registered Nurse (APRN) working in the Operating Room (OR) and failed to list surgical privileges for both the RNFA and the APRN on the surgical roster available to the OR staff. These deficient practices failed to ensure care was provided by qualified staff and failed to ensure a safe environment for all patients presenting to the facility for surgical care. The facility performs approximately 760 surgical cases per month. The facility census was 253. Findings included: 1. Review of the facility's policies titled, Medical Staff Rules & Regulations dated 11/13, showed: - An application for clinical privileges without a request for Medical Staff membership shall contain the same information as an application for Staff membership. - An applicant for clinical privileges shall be subject to the same obligations as are imposed upon an applicant for Staff appointment, as provided in these Bylaws. - Only those clinical privileges supported by evidence of competence and proof that the applicant meets the criteria for each privilege will be processed through the application process. - Applications and requests for clinical privileges shall be evaluated on the basis of the applicant's education, training, current competence, the ability to perform the clinical privileges requested, professional references, and peer recommendations that include written information about the applicant's medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, professionalism and health status as related to ability to perform the requested privileges, information from the applicant's current or past facility affiliations, professional liability experience and insurance coverage, and other relevant information, including an evaluation by the Chairperson of the Clinical Department in which the privileges have been sought. 2. Record review of the personnel file on 04/22/14 at approximately 2:00 PM for Staff CC, RNFA, showed no evidence of credential or privileging process according to the bylaws and no Quality Assurance (QA) evaluation of clinical practice. Staff CC provided RNFA services for 77 surgical cases for the past six months. 3. Record review of the personnel file on 04/22/14 at approximately 2:30 PM for Staff DD, RNFA, showed no evidence of credential or privileging process according to the bylaws and no QA evaluation of clinical practice. Staff DD provided RNFA services for 89 surgical cases for the past six months. 4. Record review of the personnel file on 04/22/14 at approximately 3:30 PM for Staff Q, APRN, showed no evidence of privileging process for surgical services according to the bylaws and no QA evaluation of clinical practice. Staff Q provided assistance for six surgical cases for the past six months. 5. During an interview on 04/24/14 at 11:30 AM, Staff FF, Director of Medical Staff Services, stated that she did not know why the facility quit credentialing and privileging the RNFAs. Staff FF stated that RNFA files were handled the same as all other hospital employees. Staff FF stated that the credential file available to OR staff on the intranet failed to list privileges for surgery for both the RNFA and the APRN.

31633 Based on observation, interview, record review, and policy review, the facility failed to ensure that staff followed Surgical Services policies and standards. The facility failed to: - Develop policies and procedures to prevent wound vacuum system (wound VAC, negative pressure applied for wound healing) sponges (dressings inserted into the wound) from being retained in the body for one patient (#1) of one patient reviewed; - Ensure staff properly wore surgical attire generally and during preparation for one patient (#16) of two Caesarean section (C-section, delivery of an infant through a surgical opening in the abdominal wall) patients observed; - Ensure staff maintained glove sterility and washed hands after removing gloves during preparation for one patient (#16) of two C-section patients observed; - Ensure staff performed sponge and instrument counts correctly during preparation for two patients (#16 and #17) of two C-section patients observed; - Ensure staff kept linen and waste containers in the Operating Room (OR) until the patient was transferred out of the room for one OR of one OR observed being cleaned; - Ensure staff maintained the correct temperature range for one blanket warming cabinet of four blanket warming cabinets reviewed for temperature readings; - Ensure OR Managers were familiar with Surgical Services policies; and - Develop a policy for outpatient surgery post-operative care planning and coordination, and provisions for follow-up care. These failures increased the risk for patient harm from infection, retained surgical items, and injury, and increased the potential for all surgical patients to receive substandard care. The facility performs approximately 760 surgical cases per month. The facility census was 253. Findings included: 1. Record review of the 2014 Association of Perioperative Registered Nurses (AORN, an organization that promotes safe care of the surgical patient by providing practice support to operative personnel) guideline titled, Recommended Practice for Prevention of Retained Surgical Items, showed retained surgical items (RSI) are considered a preventable occurrence. Further review of the guideline showed that when the patient leaves the OR with wound packing in place, a standardized procedure should be defined and implemented to communicate the location of packing and the plan for eventual removal of items. 2. Record review of the Discharge Summary in Patient #1's medical record showed these procedures performed in the OR: - On 02/16/14, excision of eschar (removal of dead tissue) with drainage of seroma (pocket of fluid) and wound VAC application to right thigh wound; - On 02/19/14, primary closure and drain placement of right thigh wound; - On 03/07/14, removal of sutures and wet-to-dry dressing to right thigh wound; - On 03/11/14, debridement (removal of dead tissue) of right thigh wound; and - On 03/14/14, excision of retained wound VAC sponge to right thigh with placement of wound VAC. 3. Record review of the Operative Reports in Patient #1's medical record showed wound VAC dressing changes to the patient's right thigh on 03/19/14, 03/26/14, 03/29/14, 04/04/14, 04/09/14, and 04/14/14. Further review of the operative reports showed no indication that the number of sponges removed was reconciled with the number of sponges placed at the preceding dressing change. 4. Record review of the Trauma Mortality and Morbidity Committee Meeting and Multidisciplinary Trauma Case Conference minutes showed no surgeon discussion of ways to prevent the recurrence of retained wound VAC sponge until 04/22/14, five weeks after the retained wound VAC sponge was discovered. 5. During an interview on 04/22/14 at approximately 3:00 PM, Staff C, [NAME] President of Quality Assurance (VP-QA), stated that no policies and procedures had been developed to prevent wound VAC sponge retention. 6. Record review of the facility policy, Surgical Attire dated 04/14, showed these directives for staff: - All persons entering semi-restricted (e.g., OR corridors) and restricted (e.g., ORs) areas of the surgical suite must wear surgical attire appropriate for use within the surgical environment. - Hair/head covering will cover head and facial hair, including all side hair and hair at the nape of the neck. - All persons entering the surgical environment where sterile supplies are opened will wear a single surgical mask that covers both nose and mouth. - Masks are to be carefully removed and discarded after use. - Masks are not to be saved by hanging around the neck. - Shoe covers are to be removed before leaving the surgical area. - Hands are to be washed after removing sterile and unsterile gloves. 7. Observation on 04/22/14 at 9:30 AM showed Staff D, OR Manager, and Staff E, OR Educator, wearing surgical shoe covers outside of the OR Department. 8. Observation on 04/22/14 at approximately 10:00 AM showed Staff GG, OR staff member, in the OR corridor wearing a surgical mask hanging at the front of her neck. 9. Observation on 04/22/14 at approximately Noon showed Staff HH, OR staff member, walking by the facility cafeteria wearing surgical shoe covers. 10. Observation on 04/22/14 at approximately Noon showed Staff II, OR staff member, standing at the facility lobby elevator wearing a surgical mask hanging at the front of her neck. 11. During an interview on 04/22/14 at 3:15 PM, Staff D and Staff E stated that they were unaware of the Surgical Services mask or shoe cover policies. 12. Observation on 04/23/14 at Noon showed Staff W, Labor and Delivery (L&D) OR Manager, wearing surgical shoe covers in a corridor outside the L&D Department. 13. Observation on 04/23/14 at approximately 12:15 PM showed Staff AA, Certified Registered Nurse Anesthetist (CRNA), in L&D OR #2 preparing Patient #16 for C-section: - Staff AA's head covering did not cover all her hair, leaving some exposed. - She put on sterile gloves and inserted an epidural catheter (a tube to deliver anesthesia medication) into Patient #16's back. - She removed the soiled gloves and failed to wash her hands before touching the patient and objects in the room. 14. Observation on 04/23/14 at approximately 12:30 PM showed Staff Y, RN, in L&D OR #2 preparing Patient #16 for C-section: She put on sterile gloves and inserted an indwelling urinary catheter (a tube inserted in the bladder to drain urine) in the patient. She removed the soiled gloves and failed to wash her hands before touching the patient and objects in the room. 15. During an interview on 04/23/14 at approximately 3:15 PM, Staff W, L&D OR Manager, stated that she and her staff followed Lippincott (nursing reference manual) for OR policies and procedures. She stated that she was unaware of the facility's Surgical Services policies for her area of responsibility including the shoe cover policy. She stated that she did expect staff members in the OR to have all their hair covered and to wash their hands after removing gloves. 16. Record review of the 2014 AORN guideline titled, Recommended Practice for Prevention of Retained Surgical Items, showed these recommendations for Nurses and Surgery Technicians (STs) when opening sterile instruments and supplies in the OR: - The initial sponge count is performed to determine that all packages of radiopaque (apparent on x-ray) sponges contain the correct number. - Packages containing an incorrect number of radiopaque sponges should be removed from the field. - A count of the instruments at assembly of the instrument set (by sterilization department staff) provides a basic inventory reference for the instrument set but is not considered the initial count before the surgical procedure. 17. Record review of the facility policy titled, Procedure for Surgical Hand Asepsis dated 11/13, showed directive for staff to keep scrubbed hands and arms in view to avoid contamination. 18. Observation on 04/23/14 at approximately Noon showed Staff BB, RN, in L&D OR #2 preparing for Patient #16's C-section: - Staff BB performed sponge and instrument counts with another RN. - She opened several packages of sponges and placed all the sponges together. - She counted the sponges one at a time for a total number of sponges without differentiating among the packages. - She counted the instruments one at a time for a total number of instruments without differentiating among instrument types. - After completing the preparation, she crossed her arms and placed her right sterile gloved hand in her left axilla (arm pit). Observation on 04/23/14 at approximately 3:00 PM showed Staff BB, RN, in L&D OR #2 preparing for Patient #17's C-section: - Staff BB performed sponge and instrument counts with another RN. - She opened several packages of sponges and placed all the sponges together. - She counted the sponges one at a time for a total number of sponges without differentiating among the packages. - She counted the instruments one at a time for a total number of instruments without differentiating among instrument types. 19. During an interview on 04/23/14 at approximately 3:15 PM, Staff W, L&D OR Manager, stated that: - Staff BB did not count the sponges by the package. - Standard practice was that if the sponge package count did not match the expected count per the manufacturer, the package was taken off the sterile field. - Staff BB did not differentiate between instrument types when counting the instruments. - Standard practice was not to differentiate between instrument types when counting instruments. - The instrument inventory sheet provided by the sterilization department would be used to determine the type of any missing instrument by the process of elimination. 20. During an interview on 04/24/14 at 9:25 AM, Staff X, OR RN, stated that there are times when staff performing instrument counts in the OR do not differentiate between instrument types. He also stated that the instrument inventory sheet provided by the sterilization department would be used to determine the type of any missing instrument. 21. During an interview on 04/24/14 at 9:50 AM, Staff MM, Surgical Technician (ST), stated that there are times when staff performing instrument counts in the OR do not differentiate between instrument types. She also stated that the instrument inventory sheet provided by the sterilization department would be used to determine the type of any missing instrument. 22. Record review of the 2014 AORN guideline titled, Recommended Practice for Prevention of Retained Surgical Items, showed the recommendation that linen and waste containers should not be removed from the OR until all counts are completed and reconciled and the patient has been transferred out of the room. 23. Observation on 04/22/14 at approximately 10:00 AM showed OR staff removing linen and waste containers from OR #10 while the patient was still in the room. 24. Record review of the facility's 2014 Medical Equipment Management Plan showed the directive that each employee should know clinical interventions in the event of a medical equipment failure. 25. Record review of the facility policy titled, Warming Cabinets with Blankets and Fluids dated 01/12, showed these directives for staff: - Temperature of warming cabinets will be checked and recorded daily by the perioperative staff. - If the temperature is out of range, the staff member will adjust the temperature, document that the adjustment was made and notify clinical engineering if the temperature is above acceptable temperature or range. - Blanket warming cabinets are not to exceed 130 degrees Fahrenheit (F, a temperature measuring scale). (Blanket warmers store blankets used to cover surgical patients. Blankets with temperatures higher than the accepted range could cause patient burns.) 26. Record review of the facility form titled, Warmer (Fluid/Blanket) Temperature Document Chart, for the blanket warmer between OR #11 and OR #12 showed: - The guideline for an appropriate temperature range for the blanket warmer was 100 to 130 degrees F. - There were handwritten temperature entries from 04/01/14 through 04/22/14. - The temperatures ranged from 135 to 200 degrees F for 20 of the 22 days monitored. 27. During an interview on 04/22/14 at approximately 2:00 PM, Staff D, OR Manager, stated that the temperature for the blanket warmer between OR #11 and OR #12 is checked by night shift staff members. She was unaware of the ongoing high temperature readings and the Biomed Department (clinical engineering that inspects and repairs biomedical equipment used for patient care) should have been notified about the problem when it first occurred. 28. During an interview on 04/23/14 at 10:50 AM, Staff U, Biomed Program Coordinator, stated that his department had not been notified about the high temperature readings for the blanket warmer between OR #11 and OR #12 until 04/22/14. 29. During an interview on 04/24/14 at approximately 2:00 PM, Staff C, VP-QA, stated that OR staff had notified the charge nurse of the high temperature readings for the blanket warmer between OR #11 and OR #12 but no further action was taken. 30. During an interview on 04/24/14 at 9:30 AM, Staff JJ, Director of Outpatient Surgery, stated that she had been in that role for four months and was unaware of the Surgical Services policies for her area of responsibility. 31. Record review of the index of Surgical Services policies showed no policy for outpatient surgery post-operative care planning and coordination, and provisions for follow-up care. 32. During an interview on 04/24/14 at approximately 2:00 PM, Staff C, VP-QA, stated that there was no policy for outpatient surgery post-operative care planning and coordination, and provisions for follow-up care.

27727 Based on interview and record review, the facility failed to follow their policies and procedures and did not provide the necessary stabilizing treatment for an Emergency Medical Condition on one patient (#1), within the facility's capabilities and capacity. This occurred for one patient (#1) out of 30 Emergency Department (ED) patient medical records reviewed from June 2013 to December 2013. The facility census was 223, the average daily ED census over the past six months was 113 and the average monthly ED census over the last six months was 3392. Findings included: Review of the facility policy titled, Management of Psychiatric patients in RMC Emergency Department revised 09/2015 showed the following information: -RMC will assess all patients for problems with substance abuse or dependence, mental disorders or potential for harm to self or others and will provide care and follow-up. -If patient presents with a clear psychiatric condition which requires admission (SI, HI, etc), the ED physician will contact the psychiatrist on call for the Emergency Department for Admission. The ED physician is responsible for providing stabilizing treatment for the patient prior to admission or transfer. -All Patients requiring transfer because the inpatient psychiatric unit does not have the capacity or capability will be transferred to another psychiatric facility via EMS or Security and Hospital personnel. No patient will be transferred via personal vehicle. Review of hospital policy, Admission to 7W - Criteria and process reviewed 05/2013, showed that each patient must be assessed, evaluated and given a diagnosis before he/she may be admitted to the 7 West Behavioral Health Unit (BHU). The Emergency Physician and the 7 West BHU on call psychiatrist or the patient's personal psychiatrist will determine the appropriate course and give the order for admission. The policy described below showed the hospital had the capability to provide stabilizing treatment to patient # 1, who presented to the ED on 12/16/13 at 1:53 PM. A. Inpatient admission criteria include (but are not limited to): 1. Threat to self- requiring 24-hour professional observation a. Suicidal ideation or gesture within 24 hours prior to admission b. Self- mutilation (actual or threatened) within 24 hours prior to admission c. Chronic and continuing self -injurious behavior that poses a significant and/or immediate threat to life, limb, or bodily function. 2. Threat to others requiring 24-hour professional observation: a. Assaultive behavior threatening others within 24 hours prior to admission. b. Significant verbal threat to the safety of others within 24 hours prior to admission. 3. Command hallucinations directing harm to self or others where there is the risk of the patient taking action on them. 4. Acutely disordered/bizarre behavior or psychomotor agitation that interferes with the activities of daily living (ADLs) so that the patient cannot function at a less intensive level of care during evaluation and treatment. 5. Cognitive impairment (disorientation or memory loss) due to an acute Axis I disorder that endangers the welfare of the patient or others. 6. Patients with a dementia disorder who need evaluation or treatment of a psychiatric co-morbidity e.g., risk of suicide, violence, severe depression) warranting inpatient admission. 7. A mental disorder causing major disability in social, interpersonal, occupational, and/or educational functioning that is leading to dangerous or life-threatening functioning, and that can only be addressed in an acute inpatient setting. 8. A mental disorder that causes an inability to maintain adequate nutrition or self-care, for which family/community support cannot provide reliable, essential care, so that the patient cannot function at a less intensive level of care during evaluation and treatment. 9. Failure of outpatient psychiatric treatment so that the patient requires 24-hour professional observation and care. Reasons for the failure of outpatient treatment could include: a. Increasing severity of psychiatric symptoms; b. Noncompliance with medication regimen due to the severity of psychiatric symptoms; c. Inadequate clinical response to psychotropic medications; d. Due to the severity of psychiatric symptoms, the patient is unable to participate in an outpatient psychiatric treatment program. 10. Other conditions may be present: a. A recent weight loss/gain refractory to aggressive outpatient or partial hospitalization therapy; b. Mental Disorder refractory to a thoroughly documented effort at aggressive outpatient or partial hospitalization (e.g. recurrent psychosis not responsive to outpatient treatment, severe depression. Or failing to respond to (21) days of outpatient drug therapy; c. Toxic effects of therapeutic psychotropic drugs; d. Introduction of, withdrawal from or change in dose of psychotherapeutic medication(s), in cases in which there is strong reason to believe that potentially serious side effects are likely to occur( e.g. due to high doses and/or co-concomitant cardiac disease known to be sensitive to the drugs in question). Review of the December 16, 2013 Daily Bed Management sheet for 7 West BHU showed there were 18 occupied beds out of 25, and one confirmed pending discharge and 3 potential discharges. Review of a closed medical record showed Patient # 1 presented to the facility's emergency department (ED) by ambulance on December 16, 2013 at 1:53 PM. Documentation sent from the Nursing Home (NH) where patient # 1 resided included two affidavits to support admission for 96 hours. The affidavits showed patient # 1 had become hostile, assaulted nursing home staff, threatened to elope, would not redirect, and was clearly a danger to himself and potentially other residents. At 2:00 PM the ED nurse documented patient # 1 stated he is being manipulated at the NH. Further documentation revealed patient # 1's past medical history included Schizophrenia (chronic, severe, and disabling mental illness), Bi-polar disorder (a mental illness that causes shifts in mood, energy, and ability to function), Anxiety, and High Blood pressure. At 2:15 PM the ED physician examined patient # 1 and documented the patient had been involved in an altercation prior to arrival, that a family member was the patient's durable power of attorney (DPOA) who arranged commitment to long-term care for his schizoaffective personality disorder, that the patient seemed somewhat tangential (irrelevant responses), and religiously preoccupied, but denied SI/HI (suicidal ideation, homicidal ideation), and that the patient had been discharged from the behavioral health unit on 7 West February 2013. At 2:32 PM the ED nurse documented a sitter was assigned to closely monitor patient # 1 after he attempted to leave the ED and that security was summoned to encourage the patient to remain in his room. Further documentation showedt the ED nurse administered to patient # 1 an intravenous dose of an anti-anxiety medication (Ativan). At 2:35 PM the Licensed Professional Counselor (LPC) interviewed patient # 1 and documented the patient was mildly paranoid with fair insight and judgment. The LPC documented conferring with the on call psychiatrist who determined the patient did not meet clinical criteria for inpatient psychiatric hospitalization . At 4:03 PM the ED nurse documented patient # 1 became increasingly agitated and hostile after being told he would be discharged back to the nursing home and that Patient # 1 screamed at staff and pulled out his intravenous (IV) catheter while verbally and physically assaulting ED staff. The ED nurse completed an affidavit to support admission for 96 hours. The affidavit documentation showed patient # 1 became upset and forcefully pushed his sitter into the corner of the room while screaming get out of my face. At 3:55 PM patient # 1 received an injection of an antipsychotic medication (Geodon). At 5:54 PM the ED physician documented he spoke with the on call psychiatrist who requested patient # 1 be admitted to Hospital B. ED staff documented on the transfer form patient # 1's Medical Condition: Diagnosis: [was] Agitation and that the patient would be transported by ambulance to Hospital B. The space on the transfer form for Support/Treatment during transfer included a blank space for Restraints - Type or Other. The medical record did not contain evidence that the hospital processed an involuntary commitment or stabilized patient # 1's psychiatric emergency medical condition within its capabilities or capacity and did not arrange admission to the psychiatric unit on 7 West. Review of patient # 1's prior 7 West medical record dated February 1 - 28, 2013 (and reviewed by the ED physician on 12/16/13) showed the patient had threatened to kill self and exhibited assaultive behavior towards staff early in his admission. Further documentation in the 7 West February 2013 medical record showed patient # 1 had a long history of psychiatric illness and had been hospitalized multiple times. Review of the December 16, 2013 ambulance report showed patient # 1 left the ED at 7:29 PM and was seated in the ambulance with the seat belt fastened for transport to Hospital B. Further documentation showed the ambulance arrived at Hospital B at 7:33 PM and that an ambulance crew member observed patient # 1 walk out of the front door of Hospital B after refusing to fill out the intake form. During a telephone interview on January 6, 2014 at 3:13 PM, emergency medical technician (EMT) X stated that dispatch sent them a non-emergency transport from Research Medical Center to Hospital B. He stated that the ED nurse did not tell them of the patient ' s prior elopement attempt and he did not remember being told the patient had pushed the ED technician (tech). He stated that he and his partner had walked the patient into Hospital B but his partner then left and went back to the ambulance. He stated that had they known of the elopement attempt and the violence in the ED, they both would have stayed with the patient. During an interview on December 23, 2013 at 4:03 PM, the Director of Risk Management (Staff B) stated Research Medical Center does not have a policy which dictates how a patient was to be transported out of the ED with EMS personnel. During a telephone interview on December 26, 2013 at 10:45 AM, nurse S at Hospital B stated she received report from ED nurse J and that the patient would be transported by ambulance to their hospital. She stated she was told the patient had been agitated at the NH where he lived and had thrown a medication cart. She stated she was told he became a little combative with staff, security had been called, and that the patient had been medicated and was now calm and cooperative. She stated she had not been told he tried to elope or that he had become physically abusive while in the ED.

27727 Based on interview, record review and policy review, the hospital failed to provide stabilizing treatment within its capacity and capability for one patient (#1) out of a sample selected from June through December 2013. The Emergency Departments average daily census is 113 and average monthly census is 3392. Findings included: Review of the facility policy titled, Management of Psychiatric patients in RMC Emergency Department revised 09/2015 showed the following information: -RMC will assess all patients for problems with substance abuse or dependence, mental disorders or potential for harm to self or others and will provide care and follow-up. -If patient presents with a clear psychiatric condition which requires admission (SI, HI, etc), the ED physician will contact the psychiatrist on call for the Emergency Department for Admission. The ED physician is responsible for providing stabilizing treatment for the patient prior to admission or transfer. -All Patients requiring transfer because the inpatient psychiatric unit does not have the capacity or capability will be transferred to another psychiatric facility via EMS or Security and Hospital personnel. No patient will be transferred via personal vehicle. Review of hospital policy, Admission to 7W - Criteria and process reviewed 05/2013, showed that each patient must be assessed, evaluated and given a diagnosis before he/she may be admitted to the 7 West BHU. The Emergency Physician and the 7 West Behavioral Health Unit (BHU) psychiatrist on call or the patient's personal psychiatrist will determine the appropriate course and give the order for admission. The policy described below showed the hospital had the capability to provide stabilizing treatment to patient # 1, who presented to the ED on 12/16/13 at 1:53 PM. A. Inpatient admission criteria include (but are not limited to): 1. Threat to self- requiring 24-hour professional observation a. Suicidal ideation or gesture within 24 hours prior to admission b. Self- mutilation (actual or threatened) within 24 hours prior to admission c. Chronic and continuing self -injurious behavior that poses a significant and/or immediate threat to life, limb, or bodily function. 2. Threat to others requiring 24-hour professional observation: a. Assaultive behavior threatening others within 24 hours prior to admission. b. Significant verbal threat to the safety of others within 24 hours prior to admission. 3. Command hallucinations directing harm to self or others where there is the risk of the patient taking action on them. 4. Acutely disordered/bizarre behavior or psychomotor agitation that interferes with the activities of daily living (ADLs) so that the patient cannot function at a less intensive level of care during evaluation and treatment. 5. Cognitive impairment (disorientation or memory loss) due to an acute Axis I disorder that endangers the welfare of the patient or others. 6. Patients with a dementia disorder who need evaluation or treatment of a psychiatric co-morbidity e.g., risk of suicide, violence, severe depression) warranting inpatient admission. 7. A mental disorder causing major disability in social, interpersonal, occupational, and/or educational functioning that is leading to dangerous or life-threatening functioning, and that can only be addressed in an acute inpatient setting. 8. A mental disorder that causes an inability to maintain adequate nutrition or self-care, for which family/community support cannot provide reliable, essential care, so that the patient cannot function at a less intensive level of care during evaluation and treatment. 9. Failure of outpatient psychiatric treatment so that the patient requires 24-hour professional observation and care. Reasons for the failure of outpatient treatment could include: a. Increasing severity of psychiatric symptoms; b. Noncompliance with medication regimen due to the severity of psychiatric symptoms; c. Inadequate clinical response to psychotropic medications; d. Due to the severity of psychiatric symptoms, the patient is unable to participate in an outpatient psychiatric treatment program. 10. Other conditions may be present: a. A recent weight loss/gain refractory to aggressive outpatient or partial hospitalization therapy; b. Mental Disorder refractory to a thoroughly documented effort at aggressive outpatient or partial hospitalization (e.g. recurrent psychosis not responsive to outpatient treatment, severe depression. Or failing to respond to (21) days of outpatient drug therapy; c. Toxic effects of therapeutic psychotropic drugs; d. Introduction of, withdrawal from or change in dose of psychotherapeutic medication(s), in cases in which there is strong reason to believe that potentially serious side effects are likely to occur( e.g. due to high doses and/or co-concomitant cardiac disease known to be sensitive to the drugs in question). Review of the December 16, 2013 Daily Bed Management sheet for 7 West BHU showed there were 18 occupied beds out of 25, and one confirmed pending discharge and 3 potential discharges. Review of a closed medical record showed Patient # 1 presented to the facility's emergency department (ED) by ambulance on December 16, 2013 at 1:53 PM. Documentation sent from the Nursing Home (NH) where patient # 1 resided included two affidavits to support admission for 96 hours. The affidavits showed patient # 1 had become hostile, assaulted nursing home staff, threatened to elope, would not redirect, and was clearly a danger to himself and potentially other residents. At 2:00 PM the ED nurse documented patient # 1 stated he is being manipulated at the NH. Further documentation revealed patient # 1's past medical history included Schizophrenia (chronic, severe, and disabling mental illness), Bi-polar disorder (a mental illness that causes shifts in mood, energy, and ability to function), Anxiety, and High Blood pressure. At 2:15 PM the ED physician examined patient # 1 and documented the patient had been involved in an altercation prior to arrival, that a family member was the patient's durable power of attorney (DPOA) who arranged commitment to long-term care for his schizoaffective personality disorder, that the patient seemed somewhat tangential (irrelevant responses), and religiously preoccupied, but denied SI/HI (suicidal ideation, homicidal ideation), and that the patient had been discharged from the behavioral health unit on 7 West February 2013. At 2:32 PM the ED nurse documented a sitter was assigned to closely monitor patient # 1 after he attempted to leave the ED and that security was summoned to encourage the patient to remain in his room. Further documentation showedt the ED nurse administered to patient # 1 an intravenous dose of an anti-anxiety medication (Ativan). At 2:35 PM the Licensed Professional Counselor (LPC) interviewed patient # 1 and documented the patient was mildly paranoid with fair insight and judgment. The LPC documented conferring with the on call psychiatrist who determined the patient did not meet clinical criteria for inpatient psychiatric hospitalization . At 4:03 PM the ED nurse documented patient # 1 became increasingly agitated and hostile after being told he would be discharged back to the nursing home and that Patient # 1 screamed at staff and pulled out his intravenous (IV) catheter while verbally and physically assaulting ED staff. The ED nurse completed an affidavit to support admission for 96 hours. The affidavit documentation showed patient # 1 became upset and forcefully pushed his sitter into the corner of the room while screaming get out of my face. At 3:55 PM patient # 1 received an injection of an antipsychotic medication (Geodon). At 5:54 PM the ED physician documented he spoke with the on call psychiatrist who requested patient # 1 be admitted to Hospital B. ED staff documented on the transfer form patient # 1's Medical Condition: Diagnosis: [was] Agitation and that the patient would be transported by ambulance to Hospital B. The space on the transfer form for Support/Treatment during transfer included a blank space for Restraints - Type or Other. The medical record did not contain evidence that the hospital processed an involuntary commitment or stabilized patient # 1's psychiatric emergency medical condition within its capabilities or capacity and did not arrange admission to the psychiatric unit on 7 West. Review of patient # 1's prior 7 West medical record dated February 1 - 28, 2013 (and reviewed by the ED physician on 12/16/13) showed the patient had threatened to kill self and exhibited assaultive behavior towards staff early in his admission. Further documentation in the 7 West February 2013 medical record showed patient # 1 had a long history of psychiatric illness and had been hospitalized multiple times. Review of the December 16, 2013 ambulance report showed patient # 1 left the ED at 7:29 PM and was seated in the ambulance with the seat belt fastened for transport to Hospital B. Further documentation showed the ambulance arrived at Hospital B at 7:33 PM and that an ambulance crew member observed patient # 1 walk out of the front door of Hospital B after refusing to fill out the intake form. During a telephone interview on January 6, 2014 at 3:13 PM, emergency medical technician (EMT) X stated that dispatch sent them a non-emergency transport from Research Medical Center to Hospital B. He stated that the ED nurse did not tell them about the patient's prior elopement attempt and he did not remember being told the patient had pushed the ED tech (technician). He stated that he and his partner had walked the patient into Hospital B but his partner then left and went back to the ambulance. He stated that had they known of the elopement attempt and the violence in the ED, they both would have stayed with the patient. During an interview on December 23, 2013 at 4:03 PM, the Director of Risk Management (Staff B) stated Research Medical Center does not have a policy which dictates how a patient was to be transported out of the ED with EMS personnel. During a telephone interview on December 26, 2013 at 10:45 AM, nurse S at Hospital B stated she received report from ED nurse J and that the patient would be transported by ambulance to their hospital. She stated she was told the patient had been agitated at the NH where he lived and had thrown a medication cart. She stated she was told he became a little combative with staff, security had been called, and that the patient had been medicated and was now calm and cooperative. She stated she had not been told he tried to elope or that he had become physically abusive while in the ED.

16215 Based on interview and record review the facility failed to ensure restraint training was documented in personnel records of three of three physicians/psychiatrists (Staff Y, Z and AA) as directed by facility policy. The facility census was 241. The average daily census was 20 on the behavioral health unit (BHU) where staff used an average of almost one restraint per month. This deficient practice had the potential to affect all patients who were restrained on the BHU. Findings included: 1. Review of the facility's policy titled, Alternatives to Restraints dated 01/01/11 showed the following: -The scope of the policy included all facility employees, physicians, on-site contractors; all affiliated physician practices, members of the medical staff or credentialed allied health professionals; -The purpose of the policy was to preserve patient rights, safety and dignity; -The policy directed staff to make the correct determination regarding whether the use of a restraint was clinically justified (for violence or a non-violent purpose); -A physical restraint was defined as any manual, physical or mechanical device, material or equipment attached or adjacent to the patient's body that the patient cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move the arms, legs, body, head freely. -Appendix A: Training Requirements: Physicians authorized to order restraint will have a working knowledge of this policy on the use of restraint. 2. Review of the facility's Management Agreement (Provider-Based Program Management) dated 05/23/11 showed the following: -The facility and a local psychiatric facility entered into a contractual agreement for the local psychiatric facility to operate the behavioral health unit (BHU) in a manner to comply with federal, state and local regulations; -The local psychiatric facility agreed to recruit and train professional and support staff for the BHU. 3. During an interview on 04/16/13 at approximately 4:10 PM Staff BB, Director of Medical Service stated the following: -The facility employed three physicians (psychiatrists, Staff Y, Z and AA) on the BHU; -She maintained credentialing files (personnel records) on all of the facility physicians that included their education records; -There was no documentation regarding restraint training provided to the three psychiatrists on the BHU; -There was no specific training regarding restraints in the physician credentialing file. -Physicians were required to abide by the facility policies. -Staff Y's, Z's and AA's credentialing file did not show any evidence of specific restraint training. 4. During an interview on 04/17/13 at 8:45 AM Staff E, [NAME] President of Operations and Staff CC, [NAME] President for Quality Assurance confirmed the following: -The local psychiatric facility provided restraint training for the BHU staff; -The facility did not have any documentation showing Staff Y, Z or AA (BHU physicians/psychiatrists) had any facility provided training regarding restraints. 5, During an interview on 04/17/13 at 9:20 AM, Staff Y, Physician/Psychiatrist stated that he had not received restraint training from the facility. He stated that the other two physician's in his group who practice on the BHU also had not had any training on restraints. 27727

12943 Based on record review, policy review and interviews the facility failed to provide first aid training to staff regarding the use of first aid techniques to patient injuries acquired during the use of restraints in three (Staff B, Staff M and Staff O) of three staff records reviewed. The facility census was 244. Findings included: 1. Record review on 02/29/12 of the facility policy titled, Alternatives to Restraints, policy number: PC-304, new/or revised date: 01/01/11, Appendix A: Training Requirements, showed the following direction: - Direct Care Staff: Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff assist direct care staff, when requested in the application of restraint or seclusion, the security guards or other non-healthcare staff are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion. - Training will occur: 1. Before performing restraint application, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion; 2. As part of orientation, and 3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients; and 4. The results of skills and knowledge assessment, new equipment or Quality Assurance Performance Improvement (QAPI) data may indicate a need for targeted training or more frequent or revised training. The facility policy failed to include the requirement for first aid training related to the use of restraints. 2. Record review of three employee files (Staff B, Mental Health Technician, Staff M, Mental Health Unit Clerk, and Staff O, Mental Health Registered Nurse (RN)), for evidence of restraint first aid training showed no evidence of first aide training related to restraints. 3. During an interview on 02/29/12 at 9:20 AM, Staff N, RN, Director of Risk Management, stated that they were unaware this was a requirement and have not provided first aid training to nursing staff in regard to restraints. During an interview on 02/29/12 at 9:49 AM, Staff Q, Performance Improvement Department Manager, stated that she was not aware of the requirement regarding staff having first aid technique training regarding injuries that may occur when restraints are used. Staff Q confirmed first aid training related to restraints has not been provided to staff. Staff Q is not aware of a facility policy that addresses first aide training related to the use of restraints. 27029

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27029 Based on observation and interviews, the facility failed to provide the necessary oversight to ensure a safe setting for all patients in the Mental Health Unit. The required 15-minute checks on patients conducted by the Mental Health Technicians (MHT's) failed to be random in their implementation. The facility also failed to have more than one staff member on 15-minute rounding for 15 patients during observation. Nursing staff also failed to have a clear understanding for implementing 1:1 (one on one) monitoring of patients which has the potential of affecting all patients requiring this level of care. At the time of survey 10 of 15 patients were on suicidal precautions. The facility census was 244. Findings included: 1. Record review of the facility's policy titled, Observation of the patient through 1:1, close observation and 15-minute checks revised 06/2011, showed the following direction to staff: - On admission, all inpatients will be placed on a minimum of 15-minute checks for safety unless otherwise ordered by physician or indicated by medical status. PROCEDURE: - Fifteen (15) minute checks: Ordered for a patient who verbalizes thoughts of suicide without a plan or immediate threat to self, engaged in non-life threatening/self-damaging behaviors, expresses anger and/or thoughts of harming others without intent to act; - Close Observation: Ordered on patients who present a serious risk of harm to self and/or others (suicidal thoughts but not actively seeking ways to harm self in hospital. Close observation may also be ordered for those with moderate inability to care for themselves, and/or those whose cognitive abilities are insufficient to recognize dangers and follow simple instructions. Staff will maintain visual contact of the patient at all times unless the patient is directly monitored by audio-visual equipment. When the patient is being observed on the monitors, a staff member will be within line of sight of the monitor, and the audio component will remain on and audible; - 1:1 Observation: Ordered on a patient who is at immediate risk of harm to self and/or others (unable to contract for safety and actively seeking ways to harm self). Staff will be in close proximity to the patient, and the patient will be visible to staff at all times. No patient is to be left unattended while on 1:1 status. Record review of the facility's policy titled, Management of patients Displaying hypersexual or sexually inappropriate behavior towards one another dated 01/2012, gave the following direction: Process: Staff needs to be aware that sexual acts between patients can occur in between 15-minute checks. All patients shall be monitored on 15-minute checks or more often, as ordered by their physician. The order of completing the 15-minute checks shall be varied so that patients cannot predict the time of return of staff. 2. During an interview on 02/28/12 at 10:12 AM, Staff B, MHT, stated that he always does the 15-minute rounding by starting in the Dayroom (designated common room for group therapy, dining and relaxation) and working his way down the female hall and back to the Dayroom. During an interview on 02/28/12 at 10:35 AM, Staff C, MHT, stated that he always does the 15-minute rounding the same way starting at room [ROOM NUMBER] and working his way around the unit and back. During an interview on 02/29/12 at 9:00 AM, Staff H, MHT, stated that she always starts the 15-minute rounding at the front first room and works her way to the back. During an interview on 02/28/12 at 10:55 AM, Staff D, RN, Charge Nurse, stated that 15-minute checks should be varied and should never have a pattern because the patients' can plan when the monitors are coming to find them. During an interview on 02/28/12 at 1:33 PM, Staff E, RN, stated that 15-minute checks should never be conducted in the same way because the patients can figure them out and potentially give them more time if they want to plan something. During an interview on 02/28/12 at 1:55 PM, Staff F, RN, stated that 15-minute checks are supposed to be changed around so the patients won't get used to the pattern and be able to avoid the monitors. During an interview on 02/28/12 at 3:40 PM, Staff I, RN, stated that 15-minute checks must not be carried out in the same manner because the patients will recognize that and could plan for 15 or more minutes without supervision. During an interview on 02/29/12 at 9:25 AM, Staff G, RN, Mental Health Nurse Manager, stated that she had just trained the staff on 15-minute rounding and that it should never have a pattern and should always be varied to ensure patient safety. 3. Observation on 02/28/12 at 10:00 AM showed the Mental Health Unit on 7 West designed in an oval shape with the nursing station located at one end and the day room located at the other end. There were two inpatient halls, each hall had patient rooms on either side - one hall houses male patients and the other hall houses female patients. The halls cannot be viewed at the same time and cannot be seen from behind the nurses' station. There were three Registered Nurses (RN's) and two MHT's staffed for 15 current patients. Patient #19 required 1:1 monitoring for safety and Staff B, MHT, was assigned to her room leaving one MHT, Staff C, to conduct the 15-minute checks by himself. During an interview on 02/28/12 at 10:12 AM, Staff B, MHT, stated that it was difficult to conduct the 15-minute checks by himself. He stated that the nurses forget to tell them [MHTs] if a patient has been taken off the unit for some reason like tests and we spend a lot of time looking for them. During an interview on 02/28/12 at 10:35 AM, Staff C, MHT, stated that he was conducting the 15-minute checks by himself today. He stated that the nurses are supposed to help but they don't always have time. Staff C stated that sometimes a patient can't readily be located and the 15-minute checks are late. He stated that they will finally go to the nurses' station to find out that the patient was taken off the unit for some reason but by then we are already late. Staff C stated that they do not get another MHT to help with the 15-minute checks and an MHT has to do it by themselves if there is a patient requiring 1:1 monitoring. During an interview on 02/28/12 at 10:55 AM, Staff D, RN, stated that everyone is responsible to complete the 15-minute checks and nursing is supposed to oversee the process. During an interview on 02/28/12 at 1:33 PM, Staff E, RN, stated that he will occasionally help with the 15-minute checks but they are usually done by the MHTs. 4. Observation on 02/28/12 at 10:00 AM showed Staff B, MHT, sitting in Patient #19's room just inside the door sitting in a chair. Patient #19 was in bed covered up and out of arm's length range from the monitor, approximately six feet. During an interview on 02/28/12 at 10:35 AM, Staff C, MHT, stated that he was not within arm's length of Patient #19 because she was asleep and he didn't want to bother her. He stated that the patient was on 1:1 for safety and if she woke up and needed help he was close enough to reach her in time. During an interview on 02/28/12 at 10:55 AM, Staff D, RN, Charge Nurse, stated that 1:1 monitoring means a patient should be within arm's length. Staff D stated that it really depended upon the reason the patient was on 1:1; if the patient had a sexual problem then I would stand outside the bathroom door while they are showering or toileting, but if they were on 1:1 for suicide precaution then I would keep the door open and maybe even stand inside the bathroom. During an interview on 02/29/12 at 9:25 AM, Staff G, RN, Mental Health Nurse Manager, stated that 1:1 means a patient should be within arm's length of patient and should be able to touch the patient at all times without exception.

05760 Based on interviews, record reviews and policy review, the facility failed to ensure physician's orders for restraints were complete for six patients (#9, #15, #16, #17, #18, #24) and failed to ensure restraint orders were signed by the physician for two patients (#15 and #18) of six restraint records reviewed. The facility census was 244. Findings included: 1. Record review of the facility's policy titled Alternatives to Restraints, Policy #PC-304, revised 01/01/11, showed the following: - The leadership of the facility believes that patients should receive treatment in an environment where health and safety is protected and their dignity, rights and well being are preserved. - An order for restraint must be obtained from a physician who is responsible for the care of the patient prior to the application of restraint. -The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. -An order for restraint may not be written as a standing order, protocol or as needed (PRN) order. -If a telephone order is required, the Registered Nurse (RN) must write down the order while the physician is on the phone and read-back the order to verify accuracy. -When a physician is not available to issue a restraint order, an RN with demonstrated competency may initiate restraint use based upon face-to-face assessment of the patient. -In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint is applied. 2. Record review of Patient #9's History and Physical (H & P) dated 02/14/12, showed the patient was admitted to the facility on that date with a diagnosis of acute respiratory distress, with intubation (placement of a flexible plastic or rubber tube into the trachea, or windpipe, to add or remove fluids or air). The patient also had diagnoses of septic shock, diabetes mellitus and bipolar disorder. Record review of Patient #9's medical record showed the physician ordered a restraint for the patient on 02/24/12, but failed to time the order. The physician ordered the patient to have mitten(s) and soft wrist restraint, but the order did not identify whether the mitten(s) was for the right hand, left hand or bilateral (both). The order also did not reflect whether the soft wrist restraint was for the right wrist, left wrist or bilateral wrist. Record review of the nurses' note dated 02/24/12 at 3:31 AM showed the nurse documented the patient had a non-violent type of restraint and it was a soft bilateral upper extremities (BUE) restraint. Record review of Patient #9's medical record showed the physician ordered a restraint for the patient on 02/26/12, but failed to time the order. The physician ordered the patient to have soft wrist restraint, but the order did not identify whether the soft wrist restraint was for the right wrist, left wrist or bilateral wrists. Record review of the nurses' note dated 02/26/12 at 5:30 AM showed the nurse documented the patient had a non-violent type of restraint and it was a soft bilateral upper extremities (BUE) restraint. Record review of Patient #9's medical record showed the physician ordered a restraint for the patient on 02/27/12 at 7:30 AM. The order did not identify the following: -Reason for Restraint -Type of Restraint -Criteria for Release Record review of the nurses' note dated 02/27/12 at 6:14 AM showed the nurse documented the patient had a non-violent type of restraint and it was a soft bilateral upper extremities (BUE) restraint. During an interview on 02/29/12 at 2:55 PM, Staff K, RN, Nurse Manager, stated that Patient #9 came to the Unit from the Intensive Care Unit (ICU) with restraint orders. She stated that the patient had restraint orders until she returned from surgery on 02/28/12 at 12:30 PM, at which time the order was discontinued. 3. Review of the facility census dated 02/28/12 showed Patient #15 was admitted for Sepsis (a severe illness in which the bloodstream is overwhelmed by bacteria) and renal (kidney) failure. Record review of nursing and physician restraint documentation for Patient #15 showed: -On 02/11/12 the nurse documented a telephone order for restraints, but the time of the order was absent. The portion of the order as to the reason for the restraint was not completed. The order included mitten(s), but it failed to include to which hand the mitten was to be applied or if the mittens should be applied bilaterally (to both hands). The portion of the order that stated that the criteria for release of the restraint was not completed. The physician failed to date and time the order. -On 02/12/12 the physician failed to complete areas on the order for the reason for the restraint and the criteria for release of the restraint. The order included mitten(s), but it failed to include to which hand the mitten was to be applied or if the mittens should be applied bilaterally (to both hands). The physician failed to time the order. -On 02/13/12 the physician order included mitten(s), but it failed to include to which hand the mitten was to be applied or if the mittens should be applied bilaterally (to both hands). The physician failed to sign the order. -Review of nursing documentation showed the patient had bilateral mitten restraints applied on the dates of 02/11/12, 02/12/12 and 02/13/12. 4. Review of the facility census dated 02/28/12 showed Patient #18 was admitted for altered mental status and was on the cardiac (heart) floor. Record review of nursing and physician restraint documentation for Patient #18 showed: -On 02/21/12 and 02/23/12, the physician restraint order failed to state if the left or right hand was to be placed in a mitten restraint or if the restraints were to be applied bilaterally; -The telephone restraint order dated 02/25/12 at 6:00 AM failed to be authenticated with a signature, date, or time by the physician; -Nursing documentation on 02/25/12 at 7:32 PM showed the patient was in a mitten restraint to the left hand. The facility failed to obtain a mitten restraint order for Patient #18's left hand on 02/25/12; -The telephone restraint order dated 02/26/12 at 6:00 AM failed to be authenticated with a date or time of the physician signature; -The telephone restraint order dated 02/27/12 at 6:00 AM failed to be authenticated with a date or time of the physician signature; -Nursing documentation on 02/27/12 at 6:06 AM showed the patient was in a mitten restraint to the left hand. During an interview on 02/28/12 at 3:15 PM, Staff N, Director of Risk Management confirmed the restraint findings for Patient #18. 5. Review of the facility census dated 02/28/12 showed Patient #16 was admitted for Sepsis and was in the Intensive Care Unit (ICU). Record review of nursing and physician restraint documentation for Patient #16 showed: -Physician restraint orders dated 02/24/12 (the time is not legible) for Patient #16 showed an order for soft wrist restraints, but the order failed to state if the restraints were to be applied to the left or right wrist or applied to bilateral wrists. On 02/24/12 at 10:00 AM the nurse documented the patient was in bilateral soft upper extremity restraints; - Physician restraint orders dated 02/26/12 at 8:30 AM for Patient #16 showed an order for soft wrist restraints, but the order failed to state if the restraints were to be applied to the left or right wrist or applied to bilateral wrists. On 02/26/12 at 10:00 AM the nurse documented the patient was in bilateral soft upper extremity restraints; -Physician restraint orders dated 02/27/12 at 6:00 AM for Patient #16 showed an order for all bed rails to be up. On 02/27/12 at 8:00 AM the nurse documented the patient was in bilateral upper extremity soft restraints; The facility failed to obtain bilateral upper extremity soft restraint orders for 02/27/12;and -Physician restraint orders dated 02/28/12 at 5:00 AM for Patient #16 showed an order for all bed rails to be up. On 02/28/12 at 10:00 AM the nurse documented the patient was in bilateral upper extremity soft restraints. The facility failed to obtain bilateral upper extremity soft restraint orders for 02/28/12. 6. Review of the facility census dated 02/28/12 showed Patient #17 was admitted for a pneumothorax (a collection of air or gas in the chest space that causes part or all of a lung to collapse) and was in the ICU. Record review of nursing and physician restraint documentation for Patient #17 showed: -Physician restraint order dated 02/26/12 at 8:10 AM for Patient #17 failed to be completed other than the physician signing, dating and timing a blank order form. On 02/26/12 at 10:00 AM the nurse documented the patient was in soft bilateral upper extremity restraints. The facility failed to obtain bilateral upper extremity soft restraint orders for Patient #17 on 02/26/12. 7. Review of the facility census dated 02/28/12 showed Patient #24 was admitted for pneumonia (a lung infection) and dehydration (excessive loss of water from the body) and was in the ICU. Review review of nursing and physician restraint documentation for Patient #24 showed: -Physician restraint orders dated 02/26/12 at 9:30 PM, included orders for soft wrist restraints, but failed to include if the orders were for the right or left wrist or bilateral wrists. On 02/26/12 at 11:00 PM the nurse documented the patient was in bilateral upper extremity soft restraints. -Physician orders dated 02/27/12 at 7:00 AM, included orders for soft wrist restraints, but failed to include if the orders were for the right or left wrist or bilateral wrists. On 02/27/12 at 10:00 AM the nurse documented the patient was in bilateral upper extremity soft restraints. During an interview on 02/28/12 at 2:00 PM, Staff S, ICU Director, confirmed the survey restraint findings for ICU Patients #16 and #17, and #24, are correct. Staff S stated that the facility improved the restraint order form about two weeks ago and stated that this survey review showed outdated restraint order forms were still in use even after the use had been discontinued. Staff S stated that training has been provided to all nursing staff and failure to get complete restraint orders is not due to a lack of training, but is due to the lack of staff following policy regarding the use of the new restraint order form. 12943

12943 Based on record review and interview, the facility failed to notify the Centers for Medicare & Medicaid (CMS), by telephone, of patient deaths associated with the use of restraints for four patients (#20, #21, #22 and #23) of four restraint related death records reviewed. The facility census was 244. Findings included: 1. Record review on 02/29/12 of the facility policy titled, Alternatives to Restraints, policy number: PC-304, new/or revised date: 01/01/11, Appendix C: Reporting Requirements, stated the following direction: -A report of deaths associated with the use of restraint or seclusion will be submitted to the CMS Regional Office by telephone, no later than close of the next business day following the day in which the hospital knows of the death. 2. Record reviews on 02/29/12, showed the facility notified CMS of patient deaths while in restraints with a faxed form titled, Hospital Restraint/Seclusion Death Report Worksheet, revised July 2008. The facility notified CMS of the following patient deaths via fax: -Patient #20 on 10/03/11 -Patient #21 on 10/10/11; -Patient #22 on 11/14/11; and -Patient #23 on 12/27/11. There is no documentation the facility notified CMS by phone regarding these deaths. During an interview on 02/29/12 at 9:00 AM, Staff N, Director of Risk Management, stated that death reporting of patients while in restraints to CMS is done by fax not by phone. Staff N confirmed the facility policy does require the facility to call CMS to report patient deaths that occurred while in restraints, but the facility used faxes only for CMS notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29047 Based on review of hospital policies and closed patient medical records, the hospital arranged the transfer of five patients (# 1, 2, 4, 5 and 20) prior to providing stabilizing treatment within the capabilities and capacity of its inpatient psychiatric unit and on call psychiatrist out of 20 patients selected for review from November to December 2011. Findings included: 1. Review of hospital policy, EMTALA: Medical Screening Examination and Stabilization Policy dated November 2011, defined a patient as stable when the physician treating the emergency has determined that the EMC that caused the individual to seek care in the ED is resolved. 2. Review of hospital policy, Admission to 7W - Criteria and process dated 06/05/11, specified the capabilities of the inpatient psychiatric unit located on the 7th floor included the following: -Age 18 to [AGE] years with psychiatric problems; -Patients with suicidal ideation or attempt; -Patients with physically aggressive threats or actions due to a treatable primary psychiatric condition; -Patients with inability to care for self due to primary treatable psychiatric condition; -Patients with significant impairment in social, familial, or occupational relations. 3. Review of a closed medical record revealed Patient # 1 presented with family to the emergency department on 11/10/11 at 11:43 AM after threatening self harm. Staff J, a Licensed Professional Counselor examined Patient # 1 (time unknown) and documented at 4:02 PM that Patient # 1 appeared confused, obsessively checking own sense of reality, had difficulty distinguishing between what was real and what was a dream, cooperated with the exam on behalf of the spouse but then claimed the spouse was not really my spouse. Further documentation revealed Patient # 1's spouse found a letter saying I'd kill myself, but I am too chicken and that the patient had attempted suicide [AGE] years ago. Review of the nursing notes revealed arrangements were made to transfer Patient # 1 to Hospital B. ED nurse N documented that Patient # 1 was transported by a family member to Hospital B at 6:16 PM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient #1's psychiatric emergency, or contacted on call psychiatrist R, or made arrangements to admit Patient # 1 to any of 10 beds available on the 30 bed psychiatric unit located on 7 W (7th floor, West). Documentation provided by Research Medical Center during the EMTALA investigation revealed instead of going to Hospital B, the spouse took Patient # 1 home, and that later Patient # 1 was agitated and ran out into traffic and was killed. Refer to Tag A2407 for further details. 4. Review of a closed medical record revealed Patient #2 presented with law enforcement to the emergency department on 11/28/11 at 11:52 AM as a danger to self. The patient had been drinking alcohol for two to three days, without sleep, and hitting things to hurt himself. Documentation showed that Patient #2 was confused, disoriented, physically aggressive and combative to the point that security was contacted and the patient was restrained and later medically sedated. The transfer record, signed by the ED Physician, indicated that the patient was unstable and was to be transferred to Hospital B for inpatient psychiatric services. At 7:02 PM, the patient was transported by ambulance, with security, at 7:02 PM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient #2's psychiatric emergency, or contacted on call psychiatrist T, or made arrangements to admit Patient #2 to any of 16 beds available on the 30 bed psychiatric unit located on 7W. Refer to Tag A2407 for further details. 5. Review of a closed medical record revealed Patient # 4 presented to the ED on 12/09/11 at 3:14 PM, complaining of homicidal and suicidal ideations. Documentation on the Emergency Physician's Record indicated that the patient was depressed and having suicidal thoughts, planned to overdose, and had stopped taking psychiatric medications. Review of the transfer form showed documentation in the physician section indicating the transfer was medically indicated to obtain a service (psychiatric) that was unavailable at (Research Medical Center). The patient was transferred to Hospital B at 6:24 PM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient #2's psychiatric emergency, or contacted on call psychiatrist S, or made arrangements to admit Patient # 4 to any of 22 beds available on the 30 bed psychiatric unit located on 7W. Refer to Tag A2407 for further details. 6. Review of a closed medical record revealed Patient # 5 presented to the ED by ambulance on 11/26/11 at 12:03 AM, complaining of intoxication, depression, and wanting to die. At 12:06 AM, the ED physician examined the patient and documented the patient was depressed and having suicidal ideations, with a plan to overdose on her medication. At 2:45 AM, the patient was evaluated by a mental health professional who documented that the patient had a significant history of suicide attempts, poor impulse control and coping skills, and was a threat to herself. At 6:02 AM, the local fire department emergency service was contacted to transport the patient to Hospital B for inpatient psychiatric services and the patient was transferred at 7:20 AM. The medical record did not contain evidence that the hospital followed its policy and stabilized Patient # 5's psychiatric emergency, or contacted on call psychiatrist R, or made arrangements to admit Patient # 5 to any of 16 beds available on the 30 bed psychiatric unit located on 7W. Refer to Tag A2407 for further details 7. Review of a closed medical record revealed Patient # 20 presented with law enforcement to the ED on 11/30/11 at 10:32 AM, after the patient was found yelling in the street and experiencing hallucinations. The ED nurse documented the patient was anxious, walking in the streets yelling and felt like terrorists had abducted him and were tearing his insides up, that he was continuously rambling and had a history of substance abuse. Documentation in the Emergency Physician Record indicated patient # 20 was agitated, hostile, experiencing auditory hallucinations, had prior thoughts of suicide, was schizophrenic and had not taken his anti-psychotic medication Zyprexa for two days. The medical record contained 16 handwritten pages in which patient # 20 expressed the belief that his body was occupied by terrorists and people close to him were being raped and abused. Documentation by Call Center staff U at 12:09 PM indicated arrangements were made to transfer Patient # 20 to Hospital B. Review of the transfer form revealed Physician Assistant V documented at 12:30 PM that patient # 20 required transfer to obtain a service (psychiatric) unavailable at (Research Medical Center). Review of the Physician Certification Statement specifying the reason for ambulance transportation to Hospital B revealed the Pt (patient) is schizophrenic and is a flight risk. The medical record did not contain evidence that patient # 20 received treatment for his psychosis while in the ED, that his emergency medical condition was stable, that on call psychiatrist O had been contacted, or that arrangements were made to admit him to any of the 14 beds available on 7 W.