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Based on staff interviews, review of policies and procedures, and medical records, it was determined that the hospital used seclusion for patient #8 when staff zoned the patient to an area of the unit and when she did not comply with the zoning was placed in seclusion. Patient #7 was placed in seclusion for extended period of time without renewal orders.

As indicated in A0154, during medical record reviews it was discovered that on 2/4/14 and 2/8/14, patient #8 was secluded for refusing to remain in a zoned area of the unit. On both days although the patient was refusing to follow staff instructions to remain in the zoned area (which is a form of seclusion) the medical record description of the patient ' s behavior did not reveal behavior that was imminent risk to patient or others. In addition, the security staff performed manual hold when they carried the patient to the seclusion room and placed the patient in seclusion. In addition, the staff interviews revealed that the hospital was using a "Behavioral Health Restraint Continuation Order Form" to renew restraint order for patient #7. The form has a line that states "I have assessed the patient and judge that restraints should be continued or discontinued as noted below, with staff circling " behavior present continued the RN signature and the physician signature. The hospital's form for renewal of order does not provide the type of restraint, time-limited order, behavior, and criteria for release therefore it does not meet regulatory standards.

Based on medical record reviews, policy and procedure reviews , and staff interviews, it was determined that 1 out of 14 medical record reviews (patient #8) was being forced to remain in a zoned area of the unit and when she refused to stay in the area was secluded without any behavioral justification. In addition, the patient was physically restrained via manual hold and received chemical restraint without adequate justification.

Based on the medical records , Patient #8 was zoned to a specific area on the behavioral health unit and when she exited the zoned area, the patient was medicated and secluded on 2/4/14 10:30 AM-12:00 Noon and 2/8/14 10:30 AM-1:00 PM. The initial order form was incomplete for 2/4/14 because the time-limited order for adult was not checked off. In both cases the documentation regarding patient #8's behavior was not descriptive of behaviors that would warrant restraint or seclusion and therefore did not justify the need for seclusion. Further the patient was actually already secluded when she was zoned to an area and not allowed to leave the area. The hospital violated patient's #8 rights when it used seclusion for reasons other than for assaultive or violent behaviors.


On 2/4/14 at 10:30 AM the patient walked out of the zoned area and laid under a cubby area in the hallway. She refused an offer for her morning medications. Security was called and the patient refused to stand-up and had refused to comply with the zoning. The patient was given IM (intramuscular) medication and security staff carried the patient to the seclusion room. There is no documentation that the patient's behavior was violent or assaultive to self or others.


At 11:15 AM the patient got off the mat and asked to use the restroom, she voided x1. The criteria for release was discussed with the patient and she seem reluctant to agree to zoning. At 11:15 AM on the monitoring form, staff documented "She remains unpredictable and impulsive. She is unable and unwilling to discuss safety with staff. She does not meet criteria for release at this time. Seclusion continued." The patient remained in seclusion until 12:30 when the staff documented that patient #8 agreed to cooperate and take her medications. The patient understood she needed to return to zoning. The patient was placed in a regular gown, took some of her morning meds, and then went to dayroom to eat lunch. Restricting the patient through the use of zoning is a form of seclusion. In addition, the staff did not obtain a restraint order for the physical hold when security carried the patient to seclusion.


On 2/8/14 at 10:30 AM the patient had been on zoning but was irritable, refused, meals, refused staff efforts to provide comfort and meals. Per the records , she "Refused to answer staff about her issues, was informed that she would be assisted to shower after group. She stated she wasn't going group, she just wanted a shower. Patient ran back to a hall to her room and sat in shower. Patient refused to leave, she became combative, security was called and patient removed to seclusion given medication IM." While the documentation indicates that the patient was defiant and combative , it did not provide an indication that she was danger to herself or others. There was also no indication of the least restrictive intervention and continued seclusion of the patient through zoning.


The hospital failed to meet this regulation as evident by : 1) seclusion and restraint of a patient without documented behavioral justification, 2) continuing the seclusion when the patient was able to return to the milieu from a behavioral standpoint, 3) using zoning of patients which can be another form of seclusion, and 4) medicating patient because they will not comply with accepting medications or remaining in zoned areas. This pattern of staff placing patients into seclusion without sufficient behavioral justification, zoning patients to a specific area of the unit and medicating and secluding the patient if they refuse to stay in a particular area without behavioral justification and without consideration of less restrictive measures is a violation of the patient's rights.

Based on medical record review, policy and procedure, and staff interviews, it was determined that 1 out of 14 medical record reviews (patient #8) was being forced to remain in a zoned area of the unit and when she refused to stay in the area was secluded without any behavioral justification.

Patient #8 was zoned to a specific area on the behavioral health unit and when she exited the zoned area, the patient was medicated and secluded on 2/4/14 10:30 AM-12:00 Noon. As referenced to A0154 patient # 8 was first zoned to an area of the inpatient psychiatric unit and when she refused to remain in the area was taken to seclusion by security and medicated. The patient was physically prevented from leaving a designated area of the unit and secluded for behavior that did not pose imminent risk to the patient or others as described in the medical record. The staff use of zoning in this case functioned as a form of seclusion since the patient was not free to exit the area and eventually secluded for doing so.

Based on medical record review, policy and procedure, and staff interviews, it was determined that 1 out of 14 medical record reviews (patient #8) was being forced to remain in a zoned area of the unit and when she refused to stay in the area was secluded without any behavioral justification. In addition, there is no documentation of less restrictive interventions to manage the patient's behavior.

Patient #8 was zoned to a specific area on the behavioral health unit and when she exited the zoned area, the patient was medicated and secluded on 2/4/14 10:30 AM-12:00 Noon. On 2/4/14 at 10:30 AM the patient walked out of the zoned area and lay under a cubby area in the hallway. She refused offer of her morning medications. Security was called and patient refused to stand-up and had refused to comply with zoning the patient was given IM medication and security staff carried the patient to seclusion. There is no indication that the patient's behavior was violent , assaultive or an imminent risk to herself or others and no indication that less restrictive interventions other than offer of medication was provided for the patient.

Based on medical record review, policy and procedure, and staff interviews, it was determined that in 2 out of 14 medical record reviews (patient #7 and patient #8) were secluded but no modification to their care plans could be found regarding management of behavior with use of seclusion.

The hospital's Restraint and/or Seclusion Use policy and procedure doesn't address written modification to the patient's plan of care. The use of restraint or seclusion constitutes a significant change in the patient's condition therefore the treatment team should address the use of the interventions in the individual's medical record under care planning. The medical record review revealed that the use of seclusion was not addressed in the care plan for patients #7 and patient #8.

Based on review of the hospital policy Restraint and/or Seclusion Use (In Behavioral and Non-Behavioral Health Settings), the hospital failed to address the timely acquisition of the order for restraint and seclusion prior to application of restraint/seclusion or in emergency application situations. In addition, the initial orders for restraint/seclusion include the required elements, if the patient remains in restraint or seclusion the hospital has a continuation form on which the staff circles a " C" and signs the nurse and physician's name. There is no indication of time limit, type of restraint or seclusion etc. The policy and procedure states for both non-violent and violent restraint and seclusion the RN has up to 1 hour after application to obtain the order. Orders for seclusion or restraint must be obtained immediately after the emergency initiation of restraints or seclusion.

Review of the medical record for patient #7 revealed that the patient was placed in seclusion on 3/19/14 at 12:09 AM for behaviors that presented imminent risk to others and where the least restrictive interventions were unsuccessful. The face-face evaluation was performed on time and monitoring performed which included the patient's behaviors and statements. The seclusion was terminated on 3/19/14 at 8:40 AM. The debriefing was performed. As previously noted , the hospital used continuation orders that do not include all the components of a valid order. Patient #7 did not have a valid renewal order for 4:00 AM and 8:00AM instead the hospital used the continuation order as noted in the first paragraph.

Based on medical record review, policy and procedure review , and staff interviews, it was determined that 1 out of 14 medical record reviews revealed that the seclusion for patient #8 was not discontinued at the earliest possible time.


Per the medical records of patient #8, on 2/4/14 at 10:30 AM the patient walked out of the zoned area and lay under a cubby area in the hallway. She refused an offer for her morning medications. Security was called and patient refused to stand-up and had refused to comply with zoning.


The patient was given IM medication and security staff carried the patient to seclusion. There is no indication that the patient's behavior posed an imminent risk to herself or others, assaultive or violent . At 11:15 AM the patient got off the mat and asked to use the restroom, the patient voided x1. The criteria for release was discussed with the patient and she seems reluctant to agree to zoning. At 11:15 AM on the monitoring form, staff documented " She remains unpredictable and impulsive. She is unable and unwilling to discuss safety with staff. She does not meet criteria for release at this time. Seclusion continued. " The patient remained in seclusion until 12:30 when the staff documented that patient #8 agreed to cooperate and take her meds. Patient understood she needed to return to zoning. The patient was placed in a regular gown, took some of her morning medications, and then went to dayroom to eat lunch. Continued zoning is a form of seclusion. In addition, the staff did not obtain a restraint order for the physical hold when security carried the patient to seclusion.



The patient was calm not exhibiting behaviors dangerous to herself or others. She was able to go to the restroom and void but because she was " reluctant to agree to zoning, described as unpredictable and impulsive, and unwilling to discuss safety with staff," it was determined that she did not meet the criteria for release and the patient remained in seclusion from 11:15 AM to 12:30 PM. The reason for seclusion was questionable since there was no real description of behavior and for 1 hour and 15 minutes the patient was kept in seclusion although her behavior was appropriate but she would not agree to zoning or discuss a safety plan. The patient was not released from seclusion at the earliest possible time.

Based on hospital policy and review of patient #8's medical record, it is revealed that no face-to-face evaluation was documented on the records of patient #8 over the course of two seclusions. Patient #8 was zoned on the unit and when she exited the zoned area, the patient was medicated and secluded on 2/4/14 10:30 AM-12:00 Noon and 2/8/14 10:30 AM-1:00 PM. There were no documented face-to-face for either date.