STADTER CENTER: Plan of Action Approved: New Violations Reported As Psychiatric Center Works on Fixing Previous Problems

By Elisa L. Rineheart, Grand Forks Herald, N.D.

Jun. 3–Two months after undergoing a state and federal investigation, the Richard P. Stadter Psychiatric Center is under the microscope again for additional regulation violations.

The 34-bed Grand Forks mental health facility was the subject of simultaneous state and federal investigations in mid-March, which resulted in dozens of citations. But after the center implemented a plan to rectify the violations, the North Dakota Department of Health and Human Services removed the citations.

The investigations were brought on by complaints about staffing and quality of care deficiencies, said Bruce Pritschet, director of the state’s Division of Health Facilities.

And those complaints were legitimate, according to a 111-page report that was released recently to the Herald by the department.

The hospital was cited for more than 50 different issues, including fire safety violations and failure to provide adequate supervision to violent and suicidal patients, the document said.

Psychiatric with that many irregularities are placed under periodical state and federal monitoring, Pritschet said.

State health authorities issued three additional citations to the Stadter Center after a follow-up visit in mid-May.

New plan

As a result of the investigations, the Stadter Center is implementing a state-required plan of correction that exceeds mental health standards, said Bonnie Rice, Stadter’s chief operating officer.

“The state gave us resources that we were not aware of, and that helped us move forward,” Rice said.

Investigators determined that nursing staff failed to provide care in a safe setting. They cited the cases of six patients interviewed who had attempted suicide while in the hospital. Of those, four injured themselves with bathroom accessories such as shower bars. Three other patients escaped from the hospital and later were found. Five patients displayed needle stick injuries and four others displayed signs of self-injury, the report said.

Rice said the industry is more aggressively moving into a suicide-free environment. Items such as bathroom curtains that were deemed safe by the health department in a previous certification inspections weren’t approved this time around, she said.

Lack of staff, supervision

Stadter’s management team turned the incident into a positive experience and used it as catalyst for developing and implementing a more effective patient care system, Rice said.

The center now has a quality improvement and a risk management program that ensure policies and procedures are carried out effectively and hold staff accountable for medical mistakes, Rice said.

Some of the procedures nursing staff failed to follow in the past include failure to prevent abuse and harassment among patients and against medical staff.

Lack of an infection control plan also was a concern, the report said.

In 2005, 48 cases of infections were reported in the center. Of those, 14 involved patients with skin infections. Four others had eye infections.

In one instance, a 12-year-old patient was verbally abused by an older patient who doctors had deemed violent.

Also, a different patient bit a nurse, but investigators found no evidence of injury treatment. Neither the staff, nor the patient were checked for HIV or hepatitis, as required by the hospital’s bylaws anytime human teeth break the skin.

Investigators also found issues involving unrestrained violent behavior of school-age patients. Most of those cases ended up as minor injuries. The incidents weren’t investigated or recorded, the report said.

State and federal investigators said they couldn’t comment on how significant the violations were.

New citations

Three additional citations have been issued by the state since the first investigation concluded.

According to a report released Wednesday to the Herald, a patient received an antidepressant in an amount that far exceeded doctor’s orders and a tranquilizer not prescribed by the physician.

The nurse didn’t check the patient’s vital signs for nine hours after the incorrect dose was administered. Nursing staff didn’t notify the patient of the mistake, and failed to record the error, which impeded the staff’s ability to track and prevent medication irregularities, the report said.

Rice said she couldn’t comment on the specifics of the citations that stemmed from either one of the investigations, but said that medication errors aren’t uncommon in most hospitals.

“What was different in this situation was that we didn’t have a risk management program in place,” Rice said.

The nursing department is under a different supervisor and the hospital has implemented a quality management program, she said. Cynthia Tredwell, the hospital’s vice president of operations, resigned shortly after the investigation.

Rice also said that most of the incidents mentioned in the first report had to do with nursing processes not being followed, and with contractors, who were hired to perform patient care services, violating regulations.

“Now there’s a system in place to prevent that,” she said.

Asked why the hospital hired nurses and health-care technicians without adequate psychiatric background, Rice said, “we don’t get applicants with psychiatric experience.”

Since the end of March, each member of the nursing team has received about 30 hours of patient care training. An individualized professional development program designed to detect individual deficiencies and prevent medical errors was put into practice. And a voluntary training program to improve knowledge of medication dosage and interaction now is offered to nurses, Rice said.

“We took the ball and ran with it,” she said. “We’ve done in one year what most hospitals do in two.”

The Stadter Center is in the process of completing a $20 million expansion that will increase the number of beds in the inpatient psychiatric hospital from 34 to 70.

State citations issued in mid-May should be cleared after a follow-up survey, Weidner said.

Rineheart reports on business and military affairs. Reach her at (701) 780-1269; (800) 477-6572, ext. 269; or [email protected]


Copyright (c) 2006, Grand Forks Herald, N.D.

Distributed by Knight Ridder/Tribune Business News.

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