HospitalInspections.org

Based of review of facility documentation and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to enforce the Patient's Bill of Rights in the investigation and documentation of one of one behavioral health complaint/grievance (PT1MR1).

Findings include:

Review of policy and procedure, on November 4, 2015, revealed, "LECOM Health Millcreek Community Hospital Patient Rights ... The hospital has in place a process for prompt resolution of the patient grievance, regardless of whether or not the hospital complaint procedures are used, complaints can also be addressed to: Pennsylvania Department of Health Division of Acute and Ambulatory Care Room 532 Health and Welfare building Harrisburg PA 17120 1-800-254-5164 ... Rev. [revised] 10/2015."

Review, at approximately 9:01 AM on November 5, 2015, of Behavioral Care Policy G-1, "Grievance Procedure," effective March 1, 2015, revealed, "... Procedure: 1. Grievance Procedure: a) Any patient, or those helping him/her, may initiate a complaint orally or in writing, concerning the exercise of these rights or the quality or services and treatment at the facility. The complaint shall be presented as soon as possible to the unit leader or other appropriate person. ... c) The unit leader, administrative supervisor, or their designees receiving the complaint shall investigate the complaint and make every effort to resolve it. Based upon this investigation, a decision shall be rendered in writing as soon as possible but within 48 hours after the filling [sic] of the complaint. Complaints shall be decided by persons not directly involved in the circumstances leading to the grievance. d) The patient shall be given a copy of the complaint and final decision and a copy shall be filed in the patient's record. ..."

1. Review of, "Archived Notes," from the patient's medical record (MR1), revealed, "... 12/26/14 2219 ... Pt refused [his/her] PM med. Doctor order [sic] IM if [he/she] refused it [medication]. It takes 4 [staff] to hold [him/her] down and gave IM. Pt came out and start [sic] threatening and try [sic] to assault staff. Code 9 was called. It took 15 [staff] to bring [him/her] in to seclusion. ..."

Review of, "Doctors' Progress Record," from MR1, revealed, "... 12/31/14 815 [AM] Psychiatry OMS [Osteopathy Medical Student] III Pt seen. Pt wanted to have all names of staff on this floor. ..."

Review of, "BH Mental Status Flowsheet," documentation from MR1, revealed, "... 12/31/14 1320 ... Patient told staff that [he/she] has a "schedule for a grievance" because [he/she] was choked in [his/her] room. ..."

Review of MR1 did not reveal a copy of the patient's complaint, or the decision of the investigation into the complaint.

2. Review of the facility Complaints/Grievance Report documentation for the period of December 2014 to November 2015 revealed no complaints/grievances associated with the patient (PT1).

3. On November 5, 2015, at 11:40 AM, EMP5 provided a typed document, dated January 16, 2015. Review of the document revealed that EMP5 had met with the patient (PT1) regarding concerns that [he/she] had been placed in a choke hold during a restraint and that [he/she] was administered medication that [he/she] was allergic to. When asked if there was an investigation into the patient's concerns, EMP5 stated, "I looked at it as a patient who claimed [he/she] was man-handled during a Code 9."

4. On November 5, 2015, at 11:50 AM, EMP9 confirmed that the investigation into the concerns expressed by the patient did not go beyond the document presented by EMP5.


Cross reference with:
§482.13(e)(1)(ii)
§482.13(e)(4)(i)
§482.13(e)(5)

Based on observation, review of facility documentation and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that the requirements for the use of seclusion were afforded to patients confined to a geographically secluded area for two of two patients (PT1/MR1, and PT2/MR2).

Findings include:

Review of policy and procedure, on November 4, 2015, revealed, "LECOM Health Millcreek Community Hospital Patient Rights ... The exercise of patient rights provides for the right to receive care in a safe setting. ... A patient has the right to exercise his/her rights while receiving care or treatment in the facility without coercion, discrimination, or retaliation. ... The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of the Millcreek Community Hospital Behavioral Care Policy R-1, "Restraint Devices-Behavioral Health," effective May 11, 2015, revealed, "SUBJECT: CONTROL MEASURES: To define, for staff, the appropriate response when a patient's behavior begins to get out of control. PROCEDURE: 1. The least restrictive measure of control is always used to de-escalate a patient's acting out behavior. ... More restrictive measures should only be used when a less restrictive method has been tried and failed, or has been determined to be inappropriate. 2. It will be the responsibility of the Charge Nurse to direct the implementation of control measures and direct the facilitation of the control measures to be used. 3. The possible control measures are verbal prompting, time out, therapeutic hold, seclusion and restraint. (refer to the individual policies on SECLUSION and RESTRAINT for specific procedures on these two control measures. 4. Specific procedures for Time Out: a. Time Out is always a voluntary control measure offered to the patient with appropriate clinical encouragement. b. Time Out occurs in a quiet, safe area that is designed to reduce external stimuli so the patient can regain behavioral control. c. Staff should remain near the patient and may stand in the doorway of the room where the patient is in Time Out, but may not prohibit the patient from leaving the room in any way that could be construed as restraint. d. There is no upper limit placed on Time Out, however, the shortest length of time required is desirable." Further review of the policy revealed no information related to, "Geographic Seclusion."

Review of policy and procedure, on November 4, 2015, revealed, "Behavioral Care Policy S-1 ... effective date 5-11-15 ... Millcreek Community Hospital ... Seclusion of patients ... Definition of seclusion: Seclusion is involuntary confinement of a patient age 12 years or older alone in a room where the patient is physically prevented from leaving. ... During the course of inpatient psychiatric treatment a patient's behavior may be so severely aggressive, destructive or dangerous that the patient may need to be physically secluded for his own protection, for the protection of others and/or for the protection of the environment. Because of the restrictive nature of this treatment option, it is only employed in an emergency and when all other less restrictive alternatives have been either tried without success or rejected for clinically justifiable reasons. ... For purpose of this policy, an emergency is defined as an instance in which there is an imminent risk of patient harming self or others; when non-physical interventions are not viable; and safety issues require an immediate physical response. The use of seclusion is not by protocol. It is always as result of a physician's order. ... Each time seclusion is used the least restrictive method for behavioral control must be attempted before a decision is made to seclude a patient. The measures attempted must be documented on the seclusion flow sheet. ... The RN secures a physician's order for seclusion which includes: ... A description of the behavior for which the patient is being secluded. A time limit with regard to length of time the patient may be secluded according to the patient age. Specific parameters with regard to frequency of the RN's reassessment of the patient's condition and need for continued seclusion according to the patient age. If the order cannot be immediately secured, and the situation is of an emergency nature, the charge RN is permitted to authorize the seclusion of a patient. However, in these instances, the physician's order and physician face to face must be completed within one (1) hour of the initiation of seclusion. The RN must contact the attending psychiatrist or physician delegate to secure an order for seclusion and physician face to face within one hour of seclusion initiation and every subsequent order. ... Documentation requirements include completing all required areas on the seclusion documentation flow sheet and completing a treatment plan with the specific goal of discontinuing seclusion as soon as clinically feasible."

1. Tour of the Unit 4 Adult Behavioral Health Unit, on November 4, 2015, at approximately 10:05 AM, revealed PT2 to be located in an area isolated from the remainder of the unit by locked doors at each end of that section of hallway. The area included a hallway; approximately 8' x 26' with access to two patient rooms, Room 410 and 411.

2. On November 4, 2015, at 10:08 AM, when asked why PT2 was located away from the rest of the unit by locked doors, EMP7 stated, "It is a geographically limited area. It's not seclusion." When asked to confirm that the locked doors of the hallway prevented PT2's access to other patients, the community room and other common areas of the unit, EMP7 stated, "Yes."

3. Review of MR2 revealed the patient was placed in seclusion on admission to the behavior health unit. Further review revealed multiple entries of PT2 being in the geographically limited/seclusion area between October 29, 2015, and November 1, 2015.

4. On November 4, 2015, at 10:46 AM, when asked if there was a policy specific to geographic seclusion,. EMP10 stated, "It [policy] is not specific to geographic seclusion."

5. On November 4, 2015, at approximately 11:00 AM, EMP5 confirmed there was no policy for geographic seclusion stating, "We use it as a step-down from when a patient gets out of seclusion." EMP5 further confirmed that the withholding of privileges and also the use of the geographic seclusion area without proper orders and care plans had been identified recently stating, "... We didn't develop the policy for geographic seclusion area yet. ... We identified it, but didn't put it in the forefront. ..."

6. Review of Census documentation, including patient room assignments, revealed that PT1 was assigned to Room 410, within the geographically limited area, from December 27, 2014, time unknown, through January 7, 2015, time unknown.

Further review of MR1 revealed, "Archived Notes ... 12/27/14 0631 ... Seclusion Termination Pt's seclusion order has been terminated, patient is [sic] resting quietly for quite some time. Patient is still bizarre and restless but at this time posses [sic] no threat to [himself/herself] or others [sic] safety. ..."

Additional review of MR1 revealed, "Doctors' Progress Record ... 12/30/14 1150 [Psych] Progress Note Patient seen and examined in swing area. ... 01/01/14 0750 [psych] note ... patient has not been a problem and well-behaved ... 1/4/15 1330 [psych] attend ... Remains in swing. ..."

Review of PT1's, "BH Physiological Assessment," documentation revealed, "... 12/26/14 2323 ... became more agitated after IM & was taken to swing area, & secluded; ... 12/27/14 1420 ... pt remains geographically restricted in unit swing area. ... 12/30/14 1359 ... Remains in geographical limitation. ... 12/31/14 1913 ... Pt. was standing in the SA [swing area] looking in the nurses station with a towel on [his/her] head for most of the evening. ... 01/01/15 1345 ... remains in swing area ... 01/02/15 1432 ... Summary Pt remains in geographically limited area. ... 01/03/15 1324 ... Observation every 5 minitues [sic] in Step Down area. ... Pt is isolative and remains in step down area. ... 01/03/15 2230 ... Pt still remains in swing area. ... 01/04/15 1313 ... pt remains in the limited area ... 01/05/15 1220 ... pt was isolative the majority of the shift remains in swing area ... 01/05/15 2043 ... Pt remains in the swing area to monitor for impulsive behaviors and disorientation. ... 01/06/15 1453 ... remains in swing area ... 01/06/15 2225 ... Pt. spent most of the evening in [his/her] room but did come out once in a while in the swing area. ... 01/07/15 1845 ... Observations every 5 minutes in step down area ..."

Review of MR1 did not reveal a physician's order for geographically limited seclusion.




Cross reference with:
§482.13(a)(2)
§482.13(e)(4)(i)
§482.13(e)(5)

Based on review of facility documentation and medical records (MR), and employee interviews (EMP), it was determined that modifications were not made to patient care plans for two of two behavioral health patients placed in geographic seclusion (PT1/MR1 and PT2/MR2).


Findings include:

Review of policy and procedure, on November 4, 2015, revealed, "Behavioral Care Policy S-1 ... effective date 5-11-15 ... Millcreek Community Hospital ... Seclusion of patients ... Definition of seclusion: Seclusion is involuntary confinement of a patient age 12 years or older alone in a room where the patient is physically prevented from leaving. ... Documentation requirements include completing all required areas on the seclusion documentation flow sheet and completing a treatment plan with the specific goal of discontinuing seclusion as soon as clinically feasible."

1. Tour of the Unit 4 Adult Behavioral Health Unit, on November 4, 2015, at approximately 10:05 AM, revealed PT2 to be located in an area isolated from the remainder of the unit by locked doors at each end of that section of hallway. The area included a hallway; approximately 8' x 26' with access to two patient rooms, Room 410 and 411.

2. On November 4, 2015, at 10:08 AM, when asked why PT2 was located away from the rest of the unit by locked doors, EMP7 stated, "It is a geographically limited area. It's not seclusion." When asked to confirm that the locked doors of the hallway prevented PT2's access to other patients, the community room and other common areas of the unit, EMP7 stated, "Yes."

3. Review of MR2 revealed multiple entries of PT2 being in the geographically limited/seclusion area between October 29, 2015, and November 1, 2015.

4. Review of rounding documentation for PT2 for the period of October 30, 2015, to November 4, 2015, revealed no documentation that PT2 had been observed, on rounding, outside the area for geographic seclusion. At 10:45 AM, when asked if it was possible to tell by the rounding documentation if the doors to the area had been locked or open, EMP7 stated, "You can't. We don't just put anyone back here."

5. On November 4, 2015, at 10:10 AM, EMP7 confirmed that geographic seclusion was not listed on the initial or updated care plan for MR2.

6. On November 4, 2015, at approximately 11:00 AM, EMP5 confirmed there was no policy for geographic seclusion stating, "We use it as a step-down from when a patient gets out of seclusion." EMP5 further confirmed that the withholding of privileges and also the use of the geographic seclusion area without proper orders and care plans had been identified recently stating, "... We didn't develop the policy for geographic seclusion area yet. ... We identified it, but didn't put it in the forefront. ..."

7. Review of Census documentation, including patient room assignments, revealed that PT1 was assigned to Room 410, within the geographically limited area, from December 27, 2014, time unknown, through January 7, 2015, time unknown.

8. Review of MR1 revealed that PT1's ordered seclusion episodes, were discontinued at approximately 3:20 AM on December 27, 2014.

Further review of MR1 revealed, "Archived Notes ... 12/27/14 0631 ... Seclusion Termination Pt's seclusion order has been terminated, patient is [sic] resting quietly for quite some time. Patient is still bizarre and restless but at this time posses [sic] no threat to [himself/herself] or others [sic] safety. ..."

Additional review of MR1 revealed, "Doctors' Progress Record ... 12/30/14 1150 [Psych] Progress Note Patient seen and examined in swing area. ... 01/01/14 0750 [psych] note ... patient has not been a problem and well-behaved ... 1/4/15 1330 [psych] attend ... Remains in swing. ..."

Review of PT1's, "BH Physiological Assessment," documentation revealed, "... 12/26/14 2323 ... became more agitated after IM & was taken to swing area, & secluded; ... 12/27/14 1420 ... pt remains geographically restricted in unit swing area. ... 12/30/14 1359 ... Remains in geographical limitation. ... 12/31/14 1913 ... Pt. was standing in the SA [swing area] looking in the nurses station with a towel on [his/her] head for most of the evening. ... 01/01/15 1345 ... remains in swing area ... 01/02/15 1432 ... Pt remains in geographically limited area. ... 01/03/15 1324 ... Observation every 5 minitues [sic] in Step Down area. ... Pt is isolative and remains in step down area. ... 01/03/15 2230 ... Pt still remains in swing area. ... 01/04/15 1313 ... pt remains in the limited area ... 01/05/15 1220 ... pt was isolative the majority of the shift remains in swing area ... 01/05/15 2043 ... Pt remains in the swing area to monitor for impulsive behaviors and disorientation. ... 01/06/15 1453 ... remains in swing area ... 01/06/15 2225 ... Pt. spent most of the evening in [his/her] room but did come out once in a while in the swing area. ... 01/07/15 1845 ... Observations every 5 minutes in step down area ..."

Review of MR1 did not reveal an update to the patient's plan of care for the use of the geographically limited area.


Cross reference with:
§482.13(a)(2)
§482.13(e)(1)(ii)
§482.13(e)(5)

Based on observation, review of facility documentation and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that the use of seclusion was used only in accordance with physician orders for two of two patients (PT1/MR1, and PT2/MR2).

Findings include:

Review of policy and procedure, on November 4, 2015, revealed, "LECOM Health Millcreek Community Hospital Patient Rights ... The exercise of patient rights provides for the right to receive care in a safe setting. ... A patient has the right to exercise his/her rights while receiving care or treatment in the facility without coercion, discrimination, or retaliation. ... The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of the Millcreek Community Hospital Behavioral Care Policy R-1, "Restraint Devices-Behavioral Health," effective May 11, 2015, revealed, "SUBJECT: CONTROL MEASURES: To define, for staff, the appropriate response when a patient's behavior begins to get out of control. PROCEDURE: 1. The least restrictive measure of control is always used to de-escalate a patient's acting out behavior. ... More restrictive measures should only be used when a less restrictive method has been tried and failed, or has been determined to be inappropriate. 2. It will be the responsibility of the Charge Nurse to direct the implementation of control measures and direct the facilitation of the control measures to be used. 3. The possible control measures are verbal prompting, time out, therapeutic hold, seclusion and restraint. (refer to the individual policies on SECLUSION and RESTRAINT for specific procedures on these two control measures. 4. Specific procedures for Time Out: a. Time Out is always a voluntary control measure offered to the patient with appropriate clinical encouragement. b. Time Out occurs in a quiet, safe area that is designed to reduce external stimuli so the patient can regain behavioral control. c. Staff should remain near the patient and may stand in the doorway of the room where the patient is in Time Out, but may not prohibit the patient from leaving the room in any way that could be construed as restraint. d. There is no upper limit placed on Time Out, however, the shortest length of time required is desirable." Further review of the policy revealed no information related to, "Geographic Seclusion."

Review of policy and procedure, on November 4, 2015, revealed, "Behavioral Care Policy S-1 ... effective date 5-11-15 ... Millcreek Community Hospital ... Seclusion of patients ... Definition of seclusion: Seclusion is involuntary confinement of a patient age 12 years or older alone in a room where the patient is physically prevented from leaving. ... During the course of inpatient psychiatric treatment a patient's behavior may be so severely aggressive, destructive or dangerous that the patient may need to be physically secluded for his own protection, for the protection of others and/or for the protection of the environment. Because of the restrictive nature of this treatment option, it is only employed in an emergency and when all other less restrictive alternatives have been either tried without success or rejected for clinically justifiable reasons. ... For purpose of this policy, an emergency is defined as an instance in which there is an imminent risk of patient harming self or others; when non-physical interventions are not viable; and safety issues require an immediate physical response. The use of seclusion is not by protocol. It is always as result of a physician's order. ... Each time seclusion is used the least restrictive method for behavioral control must be attempted before a decision is made to seclude a patient. The measures attempted must be documented on the seclusion flow sheet. ... The RN secures a physician's order for seclusion which includes: ... A description of the behavior for which the patient is being secluded. A time limit with regard to length of time the patient may be secluded according to the patient age. Specific parameters with regard to frequency of the RN's reassessment of the patient's condition and need for continued seclusion according to the patient age. If the order cannot be immediately secured, and the situation is of an emergency nature, the charge RN is permitted to authorize the seclusion of a patient. However, in these instances, the physician's order and physician face to face must be completed within one (1) hour of the initiation of seclusion. The RN must contact the attending psychiatrist or physician delegate to secure an order for seclusion and physician face to face within one hour of seclusion initiation and every subsequent order. ... Documentation requirements include completing all required areas on the seclusion documentation flow sheet and completing a treatment plan with the specific goal of discontinuing seclusion as soon as clinically feasible."

1. Tour of the Unit 4 Adult Behavioral Health Unit, on November 4, 2015, at approximately 10:05 AM, revealed PT2 to be located in an area isolated from the remainder of the unit by locked doors at each end of that section of hallway. The area included a hallway; approximately 8' x 26' with access to two patient rooms, Room 410 and 411.

2. On November 4, 2015, at 10:08 AM, when asked why PT2 was located away from the rest of the unit by locked doors, EMP7 stated, "It is a geographically limited area. It's not seclusion." When asked to confirm that the locked doors of the hallway prevented PT2's access to other patients, the community room and other common areas of the unit, EMP7 stated, "Yes."

3. On November 4, 2015, at 10:10 AM, when asked if there was an order for PT2 to be, "geographically secluded," EMP7 stated, "One was put in just now." When further asked if there were prior orders for, "geographic seclusion," EMP7 stated, I don't see any. [He/She] was put right in seclusion when [he/she] came up [admission to the behavioral health unit]."

4. Review of MR2 revealed multiple entries of PT2 being in the geographically limited/seclusion area between October 29, 2015, and November 1, 2015.

5. Review of rounding documentation for PT2 for the period of October 30, 2015, to November 4, 2015, revealed no documentation that PT2 had been observed, on rounding, outside the area for geographic seclusion. At 10:45 AM, when asked if it was possible to tell by the rounding documentation if the doors to the area had been locked or open, EMP7 stated, "You can't. We don't just put anyone back here."

6. On November 4, 2015, at 10:46 AM, when asked if there was a policy specific to geographic seclusion,. EMP10 stated, "It [policy] is not specific to geographic seclusion."

7. On November 4, 2015, at approximately 11:00 AM, EMP5 confirmed there was no policy for geographic seclusion stating, "We use it as a step-down from when a patient gets out of seclusion." EMP5 further confirmed that the withholding of privileges and also the use of the geographic seclusion area without proper orders and care plans had been identified recently stating, "... We didn't develop the policy for geographic seclusion area yet. ... We identified it, but didn't put it in the forefront. ..."

8. Review of Census documentation, including patient room assignments, revealed that PT1 was assigned to Room 410, within the geographically limited area, from December 27, 2014, time unknown, through January 7, 2015, time unknown.

9. Review of MR1 revealed that PT1's ordered seclusion episodes, were discontinued at approximately 3:20 AM on December 27, 2014.

Further review of MR1 revealed, "Archived Notes ... 12/27/14 0631 ... Seclusion Termination Pt's seclusion order has been terminated, patient is [sic] resting quietly for quite some time. Patient is still bizarre and restless but at this time posses [sic] no threat to [himself/herself] or others [sic] safety. ..."

Additional review of MR1 revealed, "Doctors' Progress Record ... 12/30/14 1150 [Psych] Progress Note Patient seen and examined in swing area. ... 01/01/14 0750 [psych] note ... patient has not been a problem and well-behaved ... 1/4/15 1330 [psych] attend ... Remains in swing. ..."

Review of PT1's, "BH Physiological Assessment," documentation revealed, "... 12/26/14 2323 ... became more agitated after IM & was taken to swing area, & secluded; ... 12/27/14 1420 ... pt remains geographically restricted in unit swing area. ... 12/30/14 1359 ... Remains in geographical limitation. ... 12/31/14 1913 ... Pt. was standing in the SA [swing area] looking in the nurses station with a towel on [his/her] head for most of the evening. ... 01/01/15 1345 ... remains in swing area ... 01/02/15 1432 ... Summary Pt remains in geographically limited area. ... 01/03/15 1324 ... Observation every 5 minitues [sic] in Step Down area. ... Pt is isolative and remains in step down area. ... 01/03/15 2230 ... Pt still remains in swing area. ... 01/04/15 1313 ... pt remains in the limited area ... 01/05/15 1220 ... pt was isolative the majority of the shift remains in swing area ... 01/05/15 2043 ... Pt remains in the swing area to monitor for impulsive behaviors and disorientation. ... 01/06/15 1453 ... remains in swing area ... 01/06/15 2225 ... Pt. spent most of the evening in [his/her] room but did come out once in a while in the swing area. ... 01/07/15 1845 ... Observations every 5 minutes in step down area ..."

Review of MR1 did not reveal a physician's order for geographically limited seclusion.


Cross reference with:
§482.13(a)(2)
§482.13(e)(1)(ii)
§482.13(e)(4)(i)