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Based on observation, staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure the rights of each patient is protected.

Findings include:

1. The facility failed to ensure a copy of patient rights is provided to each patient. (Refer to Tag A 117)

2. The facility failed to ensure that an appropriate pain assessment is provided to each patient. (Refer to Tag A 129)

3. The facility failed to ensure that personal privacy is provided to each patient. (Refer to Tag A 143)

4. The facility failed to ensure that patients receive care in a safe setting. (Refer to Tag A 144)

5. The facility failed to ensure that patients who are in restraints are restrained in accordance with the patient's written care plan. (Refer to Tag A 166)

6. The facility failed to ensure that patients in restraints are restrained in accordance with the order of a physician or licensed independent practitioner. (Refer to Tag A 168)

7. The facility failed to ensure that patient restraints are ordered in accordance with facility policy. (Refer to Tag A 173)

8. The facility failed to ensure that patient restraints are discontinued at the earliest possible time. (Refer to Tag A 174)

9. The facility failed to ensure that the condition of patients in restraints are monitored according to facility policy. (Refer to Tag A 175)

10. The facility failed to ensure that the physician and other licensed practitioner training requirements are specified in the hospital policy. (Refer to Tag A 176)

Stratford Campus

A. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure a copy of the patient's rights is provided to each patient.

Findings include:

Reference: Facility policy, Patient Rights & Responsibilities, states, "Purpose To ensure communication to the patient, and when appropriate, the healthcare representative to promote and support his/her rights when receiving care, treatment ... A copy of these rights and responsibilities are given to the patient and when appropriate, the healthcare representative ... at the time of admission to our organization. These rights are provided and explained in a manner that the patient (or healthcare representative) can understand. ..."

1. Upon review of Medical Record #5 on 10/18/19, the following was noted:

a. The patient was admitted to the hospital on 10/14/19. The patient has a history of dementia and was confused.

b. According to the patient's History and Physical dated 10/14/19, " ... Family at bedside ..."

c. The form titled, "An Important Message from Medicare About Your Rights" was not signed.

i. "Pt (patient) unable to sign due to mental status, no NOK (next of kin) to call" was hand written under the signature line.

d. Contact information for next of kin was not in the patient's medical record.

e. The above findings were confirmed with Staff #3, Staff #11, and Staff #12.



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2. During a tour of the Emergency Department (ED) on 10/18/19, the following was noted:

a. Upon interview at 10:30 AM, Staff #8 (ED Registrar) stated that the patients read their Patient Rights during the registration process. If the patient would like a copy of his/her Patient Rights, a copy is provided for them.

i. Upon interview, Patient #1 stated he/she was not offered or provided a copy of his/her Patient Rights during the ED registration/admission process.

ii. Upon interview, Patient #2 stated he/she was not offered or provided a copy of his/her Patient Rights during the ED registration/admission process.

3. During a tour of unit 2 East on 10/18/19, the following was noted:

a. Upon interview, Patient #3 stated he/she was not offered or provided a copy of his/her Patient Rights during the ED registration/admission process.

4. The above findings were confirmed by Staff #1 and Staff #2.



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Cherry Hill Campus

B. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure a copy of the patient's rights is provided to each patient.

Findings include:

Reference: Facility policy, Patient Rights & Responsibilities, states, "Purpose To ensure communication to the patient, and when appropriate, the healthcare representative to promote and support his/her rights when receiving care, treatment ... A copy of these rights and responsibilities are given to the patient and when appropriate, the healthcare representative ... at the time of admission to our organization. These rights are provided and explained in a manner that the patient (or healthcare representative) can understand. ..."

1. On 10/21/19, review of Medical Records #1, #2, #3, #4, and #10, lacked evidence of a signed copy of a Patient Rights form, indicating the patients were made aware of their patient rights.

2. Upon interview on 10/21/19, Staff #1 stated that the facility has a new electronic medical record (EMR) system in place since September 2019. He/she confirmed that from September 2019 to October 18, 2019, patients were not given a copy of their patient rights due to an oversight with the new EMR system.

3. Staff #1, Staff #2, and Staff #5 confirmed the above finding.

Stratford Campus

Based on staff interview, medical record review, and review of facility policies and procedures, it was determined that the facility failed to ensure that all patients have appropriate assessment and management of pain.

Findings include:

Reference #1: Facility policy, Patient Rights & Responsibilities, states: "... Hospital Patient Rights ... Medical Care ... The right to receive pain relief. The right to an appropriate assessment and management of your pain. ..."

Reference #2: Facility policy, Pain Management, states: "... Comprehensive Pain Assessment (CPA) ... upon the identification of each new pain source. ... If such assessment identifies a positive pain response, the RN will document in the electronic medical record the assigned pain score and conduct a more detailed assessment of the pain characteristics ... also known as a CPA ... body location ... pain rating ...interventions ... comfort/acceptable pain level ... pain radiation ... quality ... frequency ... pain onset/duration ... Post-Intervention Assessment ... for oral pharmacological ... the RN will conduct a post-intervention pain assessment within 2 hours of administration. ..."

1. Upon review of Medical Record #2, the following was noted:

a. Patient #2 was admitted to the ED on 10/18/19.

b. The patient complained of a headache at 9:20, with an initial pain level of four (4).

i. The RN did not document a detailed assessment of the pain interventions, comfort/acceptable pain level, radiation, quality, and frequency of the pain.

c. The patient was medicated at 10:47 with Tylenol 650 mg (milligrams).

i. A post intervention pain assessment was not documented within 2 hours of the oral medication administration.

2. Upon review of Medical Record #3, the following was noted:

a. Patient #3 was admitted to the facility on 10/16/19.

b. The patient complained of pain in his/her right leg at 13:54, with a pain level of nine (9).

i. The RN did not document a detailed assessment of the pain interventions, comfort/acceptable pain level, radiation, quality, and frequency of the pain.

3. Upon review of Medical Record #4, the following was noted:

a. Patient #4 was admitted to the facility on 10/15/19.

b. The patient complained of pain on 10/16/19 at 7:30, with a pain level of two (2).

i. The patient was medicated at 9:18 with Tylenol 650 mg.

ii. At 12:40, the patients pain level, in response to the intervention, was assessed.

iii. A post intervention pain assessment was not documented within 2 hours of the oral medication administration.

4. The above findings were confirmed by Staff #1 and Staff #3.

Cherry Hill Campus

A. Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure personal privacy for each patient.

Findings include:

Reference: Facility policy, Patient Privacy & Confidentiality, states, "...Procedure... 5. All patients reports, medical records, daily patient census sheets, daily operating room schedules and/ or computer screens, shall not be left open or unsecured when unattended ..."

1. During a tour of the Emergency Department (ED) on 10/18/19 at 10:15, in the presence of Staff #2, Staff #5 and Staff #22, the following was noted:

a. Two (2) stationary computer monitor screens, used for documenting patient information, were located on both corners of the nurses station. The monitors were facing an outward direction toward the hallway and patient care areas.

b. The computer monitors were visible to patients and visitors.

c. At 11:08 AM, the computer screen was left open, unsecured, and unattended.

d. At 11:18 AM, the computer screen was left open, unsecured, and unattended.

e. The following information was visible on the computer screens that were left open, unsecured, and unattended:

i. Patient's first and last names

ii. Patient's age

iii Patient's complaint

iv. Patient's room number

2. The above findings were confirmed by Staff #2 and Staff #5.



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B. Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that all patients receive personal privacy.

Findings include:

Reference: Facility policy, Patient Rights and Responsibilities, states, "... Privacy and Confidentiality... The right to have both personal and physical privacy during medical treatment... unless you need assistance. The right to be assured of confidentiality about your hospitalization. ... ."

1. During a tour of the Emergency Department (ED) on 10/18/19, the following was noted:

a. At 10:19, in the Behavioral Health Waiting Room, Patient #1 was sitting in a chair next to Staff #4, who was conducting an interview with him/her. Patient #2 was present in the Behavioral Health Waiting Room and was sitting in a chair in close proximity to Patient #1.

b. Staff #4 was heard discussing Patient #1's issues with substance abuse and recovery treatment options with him/her, while Patient #2 was in close proximity.

i. There were no privacy curtains, room dividers, or a designated privacy area present in the waiting area.

c. Upon interview on 10/18/19, Staff #4 stated that he/she is a volunteer recovery coach called in by the facility to discuss treatment options with patients with substance abuse problems.

i. Staff #4 confirmed that he/she conducts patient interviews "out in the open" and stated, "There is never any privacy in this room."

2. Staff #1, Staff #3, and Staff #5 confirmed the above findings.

Washington Township Campus

A. Based on observation, staff interviews, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that patients receive care in a safe environment.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, "..... Procedure: ... 8. While in restraint or seclusion, the condition of the patient is continually assessed, monitored, and re-evaluated by the RN and other members of the health care team to ensure safe management and its discontinuance at the earliest time regardless of the scheduled order expiration. The RN documents all required monitoring components within the medical record depending on the patient restraint type. Any significant changes in the patient's condition are communicated/documented immediately. a. Violent/self-Destructive - every fifteen (15) minutes ..."

1. Upon review of Medical Record #1, the following was noted:

a. A "Restraints violent or self-destructive adult order," dated 10/7/19 at 21:19, for bilateral wrist restraints. The order was time-limited to 4 hours. The type of wrist restraints was not included in the order.

b. A "Restraints Non-Violent or Non-Self [sic] Destructive order," dated 10/8/19 at 3:03, for bilateral wrist restraints was entered by Staff #24. The order was time-limited to 24 hours.

c. A "Restraints Violent or Self-Destructive Adult order," dated 10/8/19 at 3:39, for "Secure Padded Locked Bilateral Wrists-Psych/ED" and "Secure Padded Locked Bilateral Ankles-Psych/ED." The order was time-limited to 4 hours.

d. A restraint flowsheet indicated that the first documented 15-minute entry was entered at 21:20 on 10/7/19.

i. The next two entries were at 23:20 on 10/7/19 and at 3:30 on 10/8/19 .

e. There was no documented evidence that the patient was assessed, monitored, and reevaluated for behavior management every 15 minutes while in restraints.

f. Staff #8 (Administrator) agreed with the above findings.

2. During a tour of the Emergency Department (ED) on 10/18/19 at 10:15, in the presence of Staff #2 and Staff #23, the following was noted:

a. A request was made to see where the physical restraints used for behavior management were stored. A wall cabinet in a hallway was found to contain approximately 12-14 locking, nylon wrist and ankle cuffs attached to nylon straps. The interior surface of one of the wrist cuffs was visibly soiled with a dried brown substance.

b. Staff #5, a registered nurse, stated that when restraints for behavior management are required they are taken from the wall cabinet in the hallway and when they are discontinued from patient use they are returned to the same cabinet. He/she stated that there are not separate areas within the cabinet for clean restraints and for restraints that have been used.

c. Staff #7, an ED Supply Equipment Technician, stated that he/she takes all the physical restraints out of the wall cabinet every Monday and washes them. He/she then returns the restraints to the wall cabinet.

d. Staff #8 (Administrator) agreed with the findings.

3. During a tour of Unit MS4, a medical surgical unit, on 10/18/19, in the presence of Staff #2 and Staff #25, the following was noted:

a. The temperature of the hot water from the handwashing sink at the nurse's station, was 126° F (Fahrenheit).

b. The temperature of the hot water from the handwashing sink in Patient Room #401, was 124° F.

c. Staff #25 agreed with the findings.


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Cherry Hill Campus

B. Based on observation, staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure that all at risk patients receive the necessary care in a safe setting.

Findings include:

Reference #1: Facility policy, Suicide Risk Assessment and Prevention, states, "... All patients within the ED setting or admitted to the hospital will be assessed for suicide risk at the time of admission utilizing the Columbia Suicide Assessment Rating Scale (CSSR)... All individuals that are screened as moderate risk or high risk will be placed on Suicide Precautions per LIP order. ... Question 3: Suicidal thoughts with Method, Without Specific Plan or Intent to Act. ... Question 6: Suicidal Behavior Question - 'Have you ever done anything, started to do anything, or prepared to do anything to end your life?' If yes - 'How long ago did you do any of these?' ... After initial screen - if patient responds YES to items 3 & 6- Patient is considered a Moderate Risk requiring further intervention. ... If Patient screens YES to question 4-5-6 (thoughts of suicide in the last 3 months) Patient is considered High Risk. ... Moderate Risk Interventions: Suicide Precautions and 1:1 (one to one) observations will be initiated immediately... Order must be obtained to determine level of 1:1 supervision... Staff will keep patient in direct visualization and continuous supervision at all times, including when the patient is using the bathroom, has visitors... 1:1 will remain in place until LIP (licensed independent practitioner) assessment is completed and further interventions are ordered... Documentation will be completed every 15 minutes. ... ."

Reference #2: Facility policy, Therapeutic Sitter (1:1) Observation states, "... d. Therapeutic Sitter One-to-one (1:1) Sitter: Continuous 1:1 monitoring by a qualified staff member for a patient who presents an immediate or actual threat of harm to themselves and/or others. The patient remains within direct visualization and continuous supervision at all times. ... a. Implementing a Therapeutic Sitter requires a physician order by the LIP. ... 2. Documentation Requirements include: a. The Therapeutic Sitter is responsible for documenting on the 'Non Behavioral 1:1 Safety/Suicide Prevention' flowsheet... Every 15 minutes. ... ."

1. During a tour of the Emergency Department (ED) on 10/18/19, the ED Behavioral Health Waiting Room and Hallway Beds #1-10 lacked call bells, or a system for patients to call for assistance if needed.

2. During a tour of the ED Behavioral Health Waiting Room on 10/18/19, Patient #1 was observed sitting in the waiting room accompanied by a family member. At 10:42, Patient #1 was observed exiting the Behavioral Health Waiting Room unaccompanied.

a. Upon interview at 10:25, Staff #3 stated that behavioral health patients who are not suicidal, homicidal, or who do not display violent or aggressive behaviors, are placed in the ED Behavioral Health Waiting Room to await treatment. A request was made for the facility policy regarding the ED Behavioral Health Waiting Room. Staff #3 stated that there was no specific policy addressing the ED Behavioral Health Waiting Room.

b. Upon interview at 10:42, Staff #7 stated that he/she was assigned to the patients in the Behavioral Health Waiting Room. He/She stated that Patient #1 was admitted to the ED "the night before" and was not on one-to-one observation. Staff #7 stated that Patient #1 was permitted to go to the bathroom unaccompanied and would "come to the nurses' station if he/she needed something."

3. Upon review of Medical Record #1 on 10/21/19, the following was noted:

a. The patient arrived at the ED on 10/17/19 at 18:50 with complaints of suicidal thoughts and alcohol abuse.

b. The ED provider notes dated 10/17/19 at 18:50 states, "... Reports suicidal ideation. Reports plan is to shoot himself or hang himself. Patient does have a gun, but he gave it to a friend to hold. Patient has a plan on how to hang himself and reports he has extensive construction experience and would know how to do it. ... Patient with SI (suicidal ideation) and plan, requires crisis eval [evaluation] for further treatment. ..."

c. Review of the patient's Columbia Suicide Severity Rating Scale dated 10/17/19 at 19:16 indicated that for Question #3, Suicidal thoughts with Method, Without Specific Plan or Intent to Act, the nurse documented "no." For Question #5, Suicide Intent with Specific Plan, the nurse documented "no."

(i) The nurses' documentation on the CSSR-S did not indicate that the patient had suicidal thoughts and/or a plan.

d. Upon interview, Staff #1 was asked why the nurse's suicide assessment of the patient, twenty-six (26) minutes after the physician's assessment, did not indicate that the patient had suicidal thoughts with a plan.

(i) Staff #1 stated, "I do not have an answer for that."

e. There was no evidence that the ED physician ordered 1:1 supervision for the patient, in accordance with the facility's policy and procedure for suicide risk assessments.

f. There was no evidence that the patient received a crisis evaluation, as indicated in the ED provider notes.

4. Review of Medical Record #3 on 10/21/19 revealed the following:

a. The patient arrived at the ED for evaluation on 10/17/19 at 13:41 with complaints of aggressive behavior.

b. Review of the physician's orders indicated that on 10/18/19 at 14:56, 1:1 Observation (Therapeutic Sitter) was ordered for the patient. The order states, "Patient presents as an imminent danger to others by reason of a behavioral health issue." The order for 1:1 observation was discontinued on 10/18/19 at 19:16.

c. The Therapeutic Sitter documented safety checks on the Safety/Suicide Prevention flowsheet at 15:00, 15:15, and 15:30. There was no evidence of safety checks documented every fifteen (15) minutes from 15:30 to 19:15.

5. During a tour of the Child and Adolescent Psychiatric Unit (CAPU) on 10/18/19, the following was noted:

a. At 13:46, the door to the Community Room was locked. No patients or staff members were present inside the Community Room. A request was made to Staff #18 to unlock the door to tour the Community Room.

b. In the Community Room, a wall mounted landline telephone with a coiled, rubber cord was present and accessible to patients and staff.

c. Upon interview, Staff #18 indicated that the Community Room is used daily at different times throughout the day. Staff #18 stated that patients are always supervised by staff when they are in the Community Room. Staff #18 stated that staff supervise small groups of three (3) to five (5) patients in the Community Room, and that the number of patients depends on the level of supervision that each child needs.

d. Staff #18 directed facility staff to immediately remove the wall mounted landline telephone from the Community Room.

6. Staff #1, Staff #2, and Staff #3 confirmed the above findings.

Stratford Campus

A. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that the use of restraints is in accordance with a written modification to the patient's plan of care.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, " ... The RN (Registered Nurse) modifies the interdisciplinary care plan to incorporate restraint or seclusion as a patient problem within the medical record. ..."

1. Upon review of Medical Record #8 on 10/21/19, the following was noted:

a. The patient was placed in restraints on 10/11/19.

i. The patient's care plan was not modified to incorporate restraints.

2. Upon review of Medical Record #9 on 10/21/19, the following was noted:

a. The patient was placed in restraints on 3/5/19.

i. The patient's care plan was not modified to incorporate restraints.

3. Upon review of Medical Record #10 on 10/21/19, the following was noted:

a. The patient was placed in restraints on 7/30/19.

i. The patient's care plan was not modified to incorporate restraints.

4. The above findings were confirmed with Staff #3.



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Washington Township Campus

B. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that the use of restraints is in accordance with a written modification to the patient's plan of care.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, " ... The RN (Registered Nurse) modifies the interdisciplinary care plan to incorporate restraint or seclusion as a patient problem within the medical record. ..."

1. Upon review of Medical Record #3 on 10/18/19, the following was noted:

a. The patient was placed in restraints on 10/17/19 at 15:00 and 10/21/19 at 02:45.

b. The Care Plan states, "Intervention ... assess restraints every 15 minutes for adverse effects ..."

i. There was no documented evidence that the patient was assessed every 15 minutes.

c. The Care Plan states, "Intervention ... Protect Skin and Joint Integrity ... Release and replace at regular intervals per facility protocol, Assist with frequent joint range of motion activity."

i. There was no documented evidence that ROM (range of motion) was performed on 10/21/19.

b. These findings were confirmed with Staff #3.

Washington Township Campus

Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure the use of restraints is in accordance with the order of a physician or other licensed independent practitioner.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, "..... Procedure: ... 3. If the patient's behavior cannot be abated by alternative measures, the RN notifies the licensed provider (LP) for a written order. ... 4. The LP conducts a comprehensive individual patient assessment. If agreed, the LP documents all required order components in the medical record including the type of restraint device to be used, location, patient restraint type, reason for restraint, order duration, patient's mental status, and date, time, and provider signature. a. Maximum order duration is outlined below; however restraints or seclusion can be discontinued at any earlier time. * Violent/Self-Destructive- four (4) hours age 18 or older; two (2) hours (age 9-17); and one (1) hour (age 8 or younger). ... 7. Regardless of patient type, continuing the use of restraint or seclusion requires a renewal order which must be obtained ..."

1. Upon review of Medical Record #1, the following was noted:

a. A "Restraints violent or self-destructive adult order" dated 10/7/19 at 21:19 for bilateral wrist restraints. The order was time-limited to 4 hours. The type of wrist restraints was not included in the order.

b. A "Restraints Non-Violent or Non-Self [sic] Destructive order" dated 10/8/19 at 3:03 for bilateral wrist restraints was entered by Staff #24. The order was time-limited to 24 hours.

c. A "Restraints Violent or Self-Destructive Adult order" dated 10/8/19 at 3:39 for "Secure Padded Locked Bilateral Wrists-Psych/ED" and "Secure Padded Locked Bilateral Ankles-Psych/ED." The order was time-limited to 4 hours.

d. A "Restraints Violent or Self-Destructive Child order" dated 10/8/19 at 10:11 for "Secure Padded-All Extremities." The order was time-limited to 1 hour.

e. A "Restraints Violent or Self-Destructive Adult order" dated 10/8/19 at 11:02 for "Secure Padded-All Extremities." The order was time-limited to 4 hours."

f. The Restraint flowsheet indicated that the patient was in physical restraints between 21:20 and and 23:20 on 10/7/19 and between 3:30 and 12:15 on 10/8/19. There were no flowsheet entries indicating that the patient was being monitored continuously between 23:20 on 1/7/19 and 3:30 on 10/8/19. There was no documentation in the medical record indicating that restraints were discontinued during this time frame.

i. There was no evidence in the medical record of a physician order for restraints between 1:20 and 3:02 on 10/8/19 (1 hour and 42 minutes). The patient was in bilateral wrist restraints.

ii. There was no evidence in the medical record of a physician order for restraints between 7:40 and 10:11 on 10/8/19 (3 hours and 31 minutes). The patient was in bilateral wrist and ankle restraints.

2. Administrators #3 and #8 agreed with the findings.

Stratford Campus

Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that each order for restraints is renewed according to hospital policy.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, "... Continuing the use of restraint or seclusion requires a renewal order which must be obtained at least every twenty-four (24) hours based on an examination of the patient by the LP (Licensed Provider), a face-to-face reassessment of the patient's needs. ..."

1. Upon review of Medical Record #8 on 10/21/19, the following was noted:

a. The patient was placed in restraints on 10/11/19 at 23:59.

b. The order for restraints was renewed on 10/12/19.

c. There is no evidence of an examination by the LP documenting a face-to-face reassessment of the patient's needs.

2. Upon review of Medical Record #10 on 10/21/19, the following was noted:

a. The patient was placed in restraints on 7/30/19 at 13:20.

b. The order for restraints was renewed on 7/31/19, 8/1/19, 8/2/19, and 8/3/19.

c. There is no evidence of an examination by the LP documenting a face-to-face reassessment of the patient's needs.

3. The above findings were confirmed with Staff #3.

Washington Township Campus

Based on observation, review of facility policies and procedures, and medical record review, it was determined that the facility failed to ensure that the use of restraints is discontinued at the earliest possible time.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, "... Policy: ... 4. Restraints or seclusion will only be used as a temporary measure to prevent injury or harm to patients, staff, or others and must be discontinued at the earliest possible time based upon patient assessment. ... Procedure: ... 4. The LP (Licensed Provider) conducts a comprehensive individual patient assessment. If agreed, the LP documents all required order components in the medical record including the type of restraint device to be used, location, patient restraint type, reason for the restraint, order duration, patient's mental status, and date, time, and provider signature. a. Maximum order duration is outlined below; however restraints or seclusion can be discontinued at any earlier time. * Violent/Self-Destructive- four (4) hours age 18 or older; two (2) hours (age 9-17); and one (1) hour (age 8 or younger). ... 8. While in restraints or seclusion the condition of the patient is continually assessed, monitored, and re-evaluated by the RN and other members of the health care team to ensure safe management and its discontinuance at the earliest time regardless of the scheduled order expiration. ... 11. The RN and LP will evaluate the patient for the earliest possible time to discontinue and remove the restraint or seclusion using the following criteria: *Reduction in or resolution of behaviors due to improvement in medical condition or discontinuance of specific therapeutic interventions ...

1. During a tour of the Unit ICU3 on 10/18/19 at 10:30 AM, the following was noted:

a. Patient #2 was in bilateral soft wrist restraints, which were initiated on 10/17/19 at 22:00.

i. The clinical justification documented on the flowsheet states, "prevent dislodging of tubes or lines."

ii. The discontinuation criteria documented on the flowsheet states, "absence of activity."

iii. The patient was observed in bed with his/her eyes closed, in a supine position, lying still.

iv. At 10:30 Staff #19 stated, "The patient has been sedated since 07:30. ... The last time the patient touched the tubing was at 7:30."

v. The flow sheet indicated that the patient was calm at 02:00, 04:00, 06:00, 07:00 and 09:00.


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2. Upon review of Medical Record #1, the following was noted:

a. The patient was in physical restraints continuously for behavior management between 21:19 on 10/7/19 and at least 12:15 on 10/8/19.

b. A "Restraints Violent or Self-Destructive Child order" dated 10/8/19 at 10:11 for "Secure Padded-All Extremities." The order was time-limited to 1 hour. The "Reason for restraint use" section of the order stated: "Demonstrating aggressive behavior to self" and "Demonstrating aggressive behavior to others."

c. A "Restraints Violent or Self-Destructive Adult order" dated 10/8/19 at 11:02 for "Secure Padded-All Extremities." The order was time-limited to 4 hours." The "Reason for restraint use" section of the order stated: "Demonstrating aggressive behavior to self."

d. A restraint flowsheet in the medical record indicated that at 10:30, 10:45, 11:00, 11:15, 11:30, 11:45, 12:00, and 12:45 on 7/9/19 that the patient was "Asleep."

e. The patient remained in restraints for at least 1 hour and 45 minutes after it was documented he/she was asleep.

Washington Township Campus

A. Based on a staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure the condition of patients, who are physically restrained, are monitored by a physician, other licensed independent practitioner, or trained staff at an interval determined by hospital policy.

Findings include:

Reference: Policy and procedure, Restraints and Seclusion, states: "A. Responsibility: The overall responsibility of restraint or seclusion processes is delineated to the licensed provider and assigned clinical nurse. ... Policy: ... 4. Restraints or seclusion will only be used as a temporary measure to prevent injury or harm to patients, staff, or others and must be discontinued at the earliest possible time based upon individual patient assessment. ... Procedure ... 8. While in restraint or seclusion, the condition of the patient is continually assessed, monitored, and re-evaluated by the RN and other team members of the health care team to ensure safe management and its discontinuance at the earliest time regardless of the scheduled order expiration. The RN documents all required monitoring components within the medical record depending on the patient restraint type. Any significant changes in the patient's condition are communicated/documented immediately. a. Violent/Self-Destructive - every fifteen (15) minutes ... 11. The RN and LIP will evaluate the patient for the earliest possible time to discontinue and remove the restraint or seclusion using the following criteria: * Reduction in or resolution of behaviors due to improvement in medical condition or discontinuance of specific therapeutic interventions ..."

1. Upon review of Medical Record #4, the following was noted:

a. A "Restraints Violent or Self-Destructive Child order" dated 10/8/19 at 10:11 for bilateral wrist restraints was entered by Staff #15, a physician. The order was time-limited to 1 hour.

i. The patient's age at the time that the order was placed was 78 years-old.

ii. The type of wrist restraints was not included in the order.

b. A "Restraints Non-Violent or Non-Self [sic] Destructive order" dated 10/8/19 at 3:03 for bilateral wrist restraints was entered by Staff #24. The order was time-limited to 24 hours.

i. The type of wrist restraints was not included in the order.

c. A "Restraints Violent or Self-Destructive Adult order" dated 10/8/19 at 11:02 for "Secure Padded -All Extremities" restraints. The order was time-limited to 4 hours. The "Provider Face to Face Evaluation Comments" section of the order stated: "Patient is agitated." The "Reason for restraint use" section of the order stated: "Demonstrating aggressive behavior to self. A restraint flowsheet in the medical record indicated that at 10:30, 10:45, 11:00, 11:15, 11:30, 11:45, 12:00, and 12:45 that the patient was "Asleep."

i. The patient was ordered to be continued in 4-point restraints for behavior management even though it was documented he/she had been asleep for 28 minutes prior to, and 1 hour and 16 minutes after, the order was entered.



33802

Stratford Campus

B. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure the use of restraints are in accordance with facility policy.

Findings include:

Reference: Facility Policy, Restraints and Seclusion, states, "...While in restraint or seclusion, the condition of the patient is continually assessed, monitored, and re-evaluated by the RN ... Non-Violent/Non-Self-Destructive - Every two (2) hours ..."

1. Upon review of Medical Record #7 on 10/21/19, the following was noted:

a. The patient was in Non-Violent/Non-Self-Destructive restraints.

b. On 10/17/19, the patient was re-evaluated by the RN at 21:15.

i. The next time the patient was re-evaluated by the RN was on 10/18/19 at 7:00.

ii. The patient was not re-evaluated by the RN for nine (9) hours and forty-five (45) minutes.

2. Upon review of Medical Record #10 on 10/21/19, the following was noted:

a. The patient was in Non-Violent/Non-Self-Destructive restraints.

b. On 7/31/19, the patient was re-evaluated by the RN at 3:00.

i. The next time the patient was re-evaluated by the RN was on 7/31/19 at 7:00.

ii. The patient was not re-evaluated by the RN for four (4) hours.

c. On 7/31/19, the patient was re-evaluated by the RN at 13:00.

i. The next time the patient was re-evaluated by the RN was on 7/31/19 at 20:00.

ii. The patient was not re-evaluated by the RN for seven (7) hours.

3. The above findings were confirmed with Staff #3.


36492


Cherry Hill Campus

C. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that patients on one to one observation are monitored according to facility policy.

Findings include:

Reference: Facility policy, Therapeutic Sitter (1:1) Observation, states: "... Policy: ... 2. Documentation Requirements include: a. The Therapeutic Sitter is responsible for documenting on the "Non Behavioral 1:1 Safety/Suicide Prevention" flowsheet in the CIS (Clinical Information Systems) every 15 minutes. ..."

1. Upon review of Medical Record #9 on 10/21/19, the following was noted:

a. A physician order dated 10/3/19 at 14:36 states, "Orders Modified 1:1 Observation (Therapeutic Sitter) Patient presents as an imminent danger to self by reason of a behavioral health issue (Comment: Modified from 1:1 Observation (Therapeutic Sitter) Patient presents as an imminent danger to self by reason of a behavioral health issue)."

b. The Non Behavioral 1:1 Safety Suicide Prevention (Non Behavioral) note states, "Details, 1:1 Safety Suicide Prevention ... Type initiated Behavioral Observation Emotional State/ Behavior Observed/ Psychological Status: Asleep; Calm... Safe Room Environment Actions Implemented: Dangerous items removed from patient ... Keep patient in direct sight at all times."

c. The Non Behavioral 1:1 Safety Suicide Prevention (Non Behavioral) note dated 10/3/19 states, "Details, 1:1 Safety Suicide Prevention ... the patient had continuous in person observation ... every 15 minutes from 14:36 until 23:15."

i. There was no documented evidence that the patient had continuous in person observation every 15 minutes from 23:30 on 10/3/19 until 01:14 on 10/4/19.

ii. There was no documented evidence that the patient had continuous in person observation every 15 minutes from 03:45 until 07:00 on 10/4/19.

d. The above findings were confirmed with Staff #3 and Staff #22.



40041

Washington Campus

D. Based on medical record review and review of facility policy and procedure, it was determined that the facility failed to ensure the restraint and the seclusion policy is implemented.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, "... Responsibility: The overall responsibility of restraint or seclusion processes is delineated to the licensed provider and assigned clinical nurse. Individual responsibilities include:...Registered nurse (RN) is the assigned nurse and is responsible for ongoing assessment and monitoring of the patient's condition to ensure that the patient is safe. He or she is also responsible for performing an assessment of the patient's safety risk factors: implementing alternatives to restraint: and conducting patient monitoring Documentation requirements include the patient's behavior necessitating restraint, change in his/her clinical condition, interdisciplinary plan of care modification, and the time of restraint application and discontinued. ..."

1. Upon review of Medical Record #2 on 10/19/19, the following was noted:

a. The patient was placed in Non Violent/Non-Self Destructive restraints on 10/17/19 at 22:00.

b. There is no documented evidence that the following areas were addressed from 10/17/19 at 22:00 through 10/18/19 at 06:59:

i. Assessment

ii. Justification for restraints

iii. Interventions every two (2) hours

c. The patient was not re-evaluated for eight (8) hours.

2. Upon review of Medical Record #5 on 10/21/19, the following was noted:

a. Patient #5 was placed in Non-Violent/Non-Self Destructive restraints on 10/12/19 at 13:00.

b. There is no documented evidence that the following areas were addressed from 10/12/19 at 13:01 through 18:59:

i. Assessment

ii. Justification for restraint

iii. Interventions every two (2) hours.

iv. The patient was not re-evaluated for six (6) hours.

3. Upon review of Medical Record #3 on 10/21/19, the following was noted:

a. Patient #3 was placed in Non-Violent/Non-Self Destructive restraints on 10/21/19 at 02:45.

b. There is no documented evidence that the following areas were addressed from 10/21/19 at 05:46 through 8:59:

i. Assessment at 09:00

ii. Education at 04:45 and 05:45

iii. Interventions every two (2) hours at 07:45, 05:45, 04:45, and 02:45

Stratford Campus

A. Based on staff interview and document review, it was determined that the facility failed to ensure that a policy is in place that addresses restraint/seclusion training requirements for the physician and other licensed independent practitioners.

Findings include:

1. On 10/21/19, Staff #1 could not provide a policy that addresses restraint and seclusion training requirements for physicians and other licensed independent practicioners.

B. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that all physicians had a working knowledge of hospital policy regarding the use of restraints.

Findings include:

Reference: Facility policy, Restraints and Seclusion, states, "Procedure ...4. The LP (Licensed Provider) conducts a comprehensive individual patient assessment. If agreed, the LP documents all required order components in the medical record including the type of restraint device to be used, location, patient restraint type, reason for the restraint, order duration, patient's mental status, and date, time, and provider signature. a. Maximum order duration is outlined below; however restraints or seclusion can be discontinued at any earlier time. * Violent/Self-Destructive- four (4) hours age 18 or older; two (2) hours (age 9-17); and one (1) hour (age 8 or younger). ... 7. Regardless of patient type, continuing the use of restraint or seclusion requires a renewal order which must be obtained at least every twenty-four (24) hours based on an examination of the patient by the LP, a face-to-face reassessment of the patient's needs."

1. Upon review of Medical Record #8 on 10/21/19, the following was noted:

a. The patient was placed in restraints on 10/11/19 at 23:59.

b. The order for restraints was renewed on 10/12/19.

c. There is no evidence of an examination by the LP documenting a face-to-face reassessment of the patient's needs.

d. The above findings were confirmed with Staff #3.

2. Upon review of Medical Record #10 on 10/21/19, the following was noted:

a. The patient was placed in restraints on 7/30/19 at 13:20.

b. The order for restraints was renewed on 7/31/19, 8/1/19, 8/2/19, and 8/3/19.

c. There is no evidence of an examination by the LP documenting a face-to-face reassessment of the patient's needs.

d. The above findings were confirmed with Staff #3.