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Based on interview, record review, video recording review, and policy review the facility failed to:
- Ensure staff appropriately followed Crisis Prevention Institute (CPI, a type of training whereby staff use physical hold which restrict a person's movement) training, which resulted in the physical injury of one discharged patient of (#1) of one discharged patient reviewed. (Refer to A-0144)
- Use techniques to prevent escalation during necessary but non-consensual medication administration to one discharged patient (#1) of one discharged patient reviewed. (Refer to A-0144)
- Provide a safe environment for patients, staff and visitors, when security officers did not remove their firearms prior to being in close proximity to one escalated discharged patient (#1) of one discharged patient reviewed. (Refer to A-0144)
- Immediately remove two security officers (Staff N and MM) from patient care pending an investigation after an altercation with a patient. (Refer to A-0144)
- Provide immediate re-education to all CPI trained staff, including security. (Refer to A-0144)
- Recognize and appropriately investigate the use of inappropriate CPI techniques. (Refer to A-0145)
- Ensure that the least restrictive form of restraint was utilized for three discharged patients (#44, #46, and #47) of three discharged patients reviewed for chest restraints (five point, a restraint used in addition to four-point restraints [medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others] to restrict the patient from sitting up). (Refer to A-0165)
- Ensure Advanced Practice Nurses did not write restraint orders. (Refer to A-168)
- Ensure that the Important Message from Medicare (IM, information about a patient's rights to appeal discharge) was given within the appropriate time frame and were thoroughly completed for four current patients (#5, #18, #42 and #43) of 10 current Medicare patient records reviewed for the IM. (Refer to A-0117).

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The facility census was 222.

The severity of 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 11/20/19, 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 all patients.

As of 11/21/19, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Three involved security officers were removed from patient care duties by the Security Director.
- The Chief Medical Officer (CMO) debriefed the Chief Executive Officer (CEO), Chief Operating Officer (COO) and the Chairman and Vice-Chair Board of Trustees regarding the IJ status and expansion of survey into the Governing Body.
- Immediate re-education of the three involved security officers regarding appropriate CPI techniques which does not include securing a patient by the upper chest, neck or head area for transport/escort as this could result in significant patient harm. Appropriate techniques were demonstrated by the RN Educator/CPI Coordinator with successful return demonstrations by the security officers. This re-education was complete by the RN Educator/CPI Coordinator.
- Re-education of Emergency Department (ED) clinical caregivers, security officers and Behavioral Emergency Response Team ("BERT") nursing staff in developing plan as a team prior to engaging with patient, clinician is directing plan, escort techniques (Principles of Holding - Standing Position), holding patient around upper chest, neck or head area are not appropriate techniques, allowing patient to de-escalate if patient not an immediate danger to self or others. Education started 11/20/19 for all applicable present staff and all applicable staff to be re-educated prior to next shift. Patient care will not be provided until after staff is re-educated.
- Securing patient by upper chest, neck or head area for transport/escort as this could result in significant patient harm will be included in CPI curriculum. RN Educator/CPI Coordinator will update curriculum prior to next scheduled sessions.
- Security Officers educated to make every attempt to secure Taser/firearm in lockbox when physical restraint is part of clinician directed plan.
- Rounding by ED leadership will be conducted to validate caregiver understanding of abuse/neglect, CPI techniques, clinician/nursing role as primary responsibility when security involved, allowing patient to de-escalate if patient not an immediate danger to self or others and provide any just in time training/clarification. This rounding will be conducted daily for two weeks, then weekly for four weeks then monthly for three months. Vice President Clinical Operations/Emergency Department Leadership/Security Leadership/Quality and Regulatory Leadership will review results of rounding to identify any further organizational interventions on a weekly basis.
- Immediate corrective action plan initiated with ED clinical caregivers and security officers re-educated on topics outlined in action plan.
- Re-education of core investigation team members regarding following Abuse, Neglect or Exploitation of patient by caregivers, other patients or visitors, investigation process where CPI techniques were not followed or were exceeded.

Based on interview, record review and policy review, the facility failed to ensure inpatient Medicare beneficiaries and/or their representative received the Important Message from Medicare (IM, information about a patient's right to appeal discharge) and ensure that it was signed, dated and placed in the patient's medical record upon admission within two days of admission for four current patients (#5, #18, #42 and #43) of 10 current Medicare patient records reviewed for the IM. This had the potential to affect all Medicare beneficiary patients admitted to the facility. The facility census was 222.

Findings included:

1. Review of the facility's policy titled, "An Important message from Medicare," dated 10/27/14, showed the direction for staff:
- To provide an IM from Medicare to Medicare inpatients or representative within two calendar days of an unscheduled admission.
- To obtain signatures from inpatients or representatives within two days of admission.
- To provide the IM to all acute inpatients.
- To obtain signature from the patient or the patient's representative, date and time on the IM from Medicare about your rights.
- To obtain signature from the patient's representative in person or by phone if the patient was unable to sign or understand the notification.
- To complete the IM to reflect the way in which the signature was obtained (patient, representative or other) and place in the patient's chart.

Review on 11/21/19 in current Patient #5's medical record, showed documentation of verbal consent on the IM, without verification of the staff who documented the verbal consent, or if the patient's representative was informed.

Review on 11/21/19 in current Patient #18's medical record, showed documentation of verbal consent on the IM, without verification of the staff who documented the verbal consent, or if the patient's representative was informed.

Review on 11/21/19 in current Patient #42's medical record, showed that the patient was admitted on 11/18/19 and their IM from Medicare wasn't signed until 11/21/19.

Review on 11/21/19 in current Patient #43's medical record, showed that the patient was admitted on 11/18/19 and their IM from Medicare wasn't signed until 11/21/19.

During an interview on 11/21/19 at 12:55 PM, Staff B, Operation Vice President, stated that the staff had experienced problems with completing the IMs.

Based on interview, record review, video recording review, and policy review, the facility failed to:
- Ensure staff appropriately followed Crisis Prevention Institute (CPI, a type of training whereby staff use physical hold which restrict a person's movement) training, which resulted in the physical injury of one discharged patient of (#1) of one discharged patient reviewed.
- Use techniques to prevent escalation during necessary but non-consensual medication administration to one discharged patient (#1) of one discharged patient reviewed.
- Provide a safe environment for patients, staff and visitors, when security officers did not remove their firearms prior to being in close proximity to one escalated discharged patient (#1) of one discharged patient reviewed.
- Immediately remove two security officers (Staff N and MM) from patient care pending an investigation after an altercation with a patient.
- Provide immediate re-education to all CPI trained staff including security.
These failures created an unsafe environment and had the potential to affect all patients in the facility. The facility census was 222.

Findings included:

1. Review of facility document titled, "Crisis Prevention Institute Unit 9: Physical Interventions - Holding Skills," showed the learning goal for a higher level hold in a standing position was to physically hold the individual in crisis in a reasonable and proportionate manner based on their actions or risk behavior.

Review of facility policy titled, "Patient Abuse, Neglect or Exploitation by Workforce, Other Patients or Visitors (Zero Tolerance Policy)," dated 06/27/19, showed that the organization will prevent further potential abuse while the investigation is in progress as any caregiver/volunteer alleged to be involved in suspected abuse will be removed immediately from direct care until completion of the investigation.

Review of the video recording dated 11/05/19, showed that:
- Patient #1 was seated in the recliner in Emergency Department (ED) room 1523.
- Patient #1 stood up and walked behind the recliner, further into the ED room and out of the camera's view.
- Staff N and Staff MM, Security Officers, walked down the hallway towards the camera and stopped at the patient's room.
- Staff N entered the patient's room and appeared to be talking to the patient out of the camera's view.
- Staff V, Registered Nurse (RN), Mental Health Nurse, Staff OO, RN, Primary Nurse, and Staff W, Physician, were all positioned in front of the doorway to ED room 1523. Patient #1 and Staff N remained inside the room out of the camera's view.
- Staff II, Security Officer entered room and appeared to struggle with patient while Staff MM, Security Officer grasped the back of Patient #1's neck.
- Patient #1 leaned forward, parallel to the wall, with his head down toward the floor.
- Staff OO, RN entered the room with the medication syringe in hand.
- Staff N and Staff MM, Security Officers, escorted the patient out of the room into the hallway when the patient tried to free himself by lowering his body towards the floor. Staff N positioned himself behind Patient #1 and placed his right arm around the patient's upper body with the bend of his elbow in close proximity to Patient #1's neck while Staff MM was at the patient's right side.
- Staff N and Patient #1 walked backwards while Staff N's right arm remained around the patient's neck to ED room 1539 and out of the camera's view.

During an interview on 11/20/19 at 3:00 PM, Staff N, Security Officer stated that:
- Security had been called to respond to the ED room 1523, to assist with medication administration to a patient.
- The physician had ordered a physical hold.
- He entered the patient's room and told him to calm down and cooperate for the medication injection.
- Upon entrance into the room the patient was yelling, cursing and kicked the chair that was located in the back of the room.
- The physician came to the doorway and told the patient the need for the medication injection.
- Staff OO, RN, administered the medication injection while he and Staff MM, Security Officer held the patient.
- After the injection, the patient sat in a chair and continued to scream at the staff but did not attempt to fight them.
- They were asked to move the patient, so he grabbed the patient's arm and Staff MM, Security Officer grabbed the other one, to escort the patient to ED room 1539.
- Once they cleared the doorway, the patient broke their grasp and lowered his body towards the floor. When the patient did this maneuver, the best way he (Staff N) could control the patient was to put his arm in a high chest hold and leaned the patient's weight against his own chest and walked the patient backwards down the hallway.
- CPI did not teach the hold that he performed on the patient.

Review of Patient #1's medical record showed that:
- He presented to the ED on 11/05/19 at 11:02 AM, with chief complaint of thoughts of self-harm.
- The patient had a history of methamphetamine (a drug with more rapid and lasting effects than amphetamine, [an addictive mood altering drug] used illegally as a stimulant) abuse.
- The patient reported that he was suicidal (thoughts to harm self) and was hearing voices.
- The urine drug screen was positive for amphetamines.
- Staff HH, Registered Nurse, (RN), Psychiatric Emergency Clinician, recommended an injection due to patient agitation, prior to admission to the Mental Health Unit (MHU).
- The patient declined the medication injection and a physical hold order was obtained.
- The patient became uncooperative and was given a medication injection. The physical hold failed, an altercation resulted with security, and the patient attempted to grab the security officer's gun.
- The patient was subdued and placed in a psychiatric safe room and he was found to have a dislocated shoulder.
- The radiology report showed a right anterior (front side) shoulder dislocation.
- The right shoulder dislocation was corrected by Staff W, ED Physician with a closed reduction (manipulation of the bone without surgical intervention).
- The patient was monitored and later admitted to the MHU.

During an interview on 11/20/19 at 2:50 PM, Staff W, ED Physician stated that after the security officers escorted the patient to the psychiatric safe room, the patient voiced discomfort with his arm, and an X-ray showed a dislocation of his shoulder. Staff W was able to do a closed reduction to put the shoulder back into place.

2. During an interview on 11/21/19 at 10:10 AM, Staff HH, RN, Psychiatric Emergency Clinician, stated that he had performed the psychiatric screening on Patient #1. He stated that the patient was very agitated, distracted, angry, and irritable, appeared to be impaired, initially wanted admission and voiced thoughts of self-harm. Staff HH spoke with the psychiatrist, and an involuntary hold was initiated. He stated that he spoke to the providers regarding a medication injection to calm the patient prior to taking him to the MHU.

During an interview on 11/19/19 at 2:30 PM, Staff E, Advanced Practice Registered Nurse, (APRN), stated that she verbally informed Staff W, Physician, that Patient #1 needed an order for a physical hold for nursing to administer an injection. She stated that she did not explain to the patient that he was going to receive medication by injection.

During an interview on 11/21/19 at 12:35 PM, Staff GG, RN, ED Charge Nurse stated that it was the process for nursing staff to discuss medication administration with the patient, not security.

During an interview on 11/20/19 at 2:50 PM, Staff W, ED Physician stated that it was the process for nursing or physicians to explain to the patient the need for medication/injections and that he did not speak to the patient prior to the time that security entered the room for the medication administration.

During an interview on 11/19/19 at 3:51 PM Staff B, Operational Vice President, stated that nursing typically informed patients regarding impending medications, especially those that would be injections, but it was not done in this case.

The failure to attempt to de-escalate Patient #1 and the failure to have clinical staff present prior to security officers entering the patient's room, resulted in the patient's increased agitation and uncooperative behavior. Staff MM's grasping the back of Patient #1's neck and Staff N's right arm around Patient #1's neck were inappropriate CPI techniques that had the potential to negatively affect the health and safety of the patient.

3. During an interview on 11/26/19 at 11:35 AM, Staff MM, Security Officer stated that:
- He remained in the hallway outside of the ED room 1523 while Staff N, Security Officer entered the room and talked to the patient.
- The patient appeared to be agitated, yelled and cursed at them.
- Typically nursing staff explained to the patient the reasoning for medication/injections and this was an unusual situation as nursing wasn't in the room.
- Unsure if the patient attempted to obtain his gun from his holster, but his ammunition pack fell from his belt onto the floor while they were holding the patient for the injection.
- The CPI techniques used by both he and Staff N were inappropriate in relation to how they were trained but with just two of them it was the "proper" way to control the situation.
- The patient was leaned back onto Staff N when they walked backwards to the ED room 1539, and the patient talked and yelled the entire time.

During an interview on 11/21/19 at 9:54 AM, Staff II, Security Officer stated that:
- When she arrived outside the doorway of the ED room 1523 the patient was in the back left corner of the room with Staff N, Security Officer on the patient's left side with Staff MM, Security Officer on the patient's right side.
- She stated the patient was loud, cursed and showed increased agitation and postured (positioning of body in an aggressive manor) towards Staff N and Staff MM.
- The nurse came in to administer the medication injection while Staff N and Staff MM held the patient in a physical hold.
- She witnessed the patient's left arm/hand swipe across Staff MM's gun holster and she positioned herself closer and held the patient's left hand.
- After the injection she overheard someone say that the patient needed to be moved to ED room 1539.
- The appropriate response would have been to take the patient to the ground but this did not happen and Staff N, Security Officer, placed his arm around the patient's upper chest/neck area and walked backwards to room 1539.
- The patient continued to yell and was very loud during the transport.

During an interview on 11/20/19 at 10:15 AM, Staff O, Chief Medical Officer (CMO), stated that he had viewed the video recording and that Staff N, Security Officer had used appropriate CPI technique when he transferred Patient #1 down the hallway to the psychiatric safe room. He was aware of the "history" and that the patient had reached for the security officer's gun and knocked his ammunition pouch off in the process.

Although the facility leadership viewed the video recording they failed to recognize the safety issue when security placed themselves in close proximity to patients who were at risk for harm to themselves or others while they were armed with a firearm.

4. Review of the facility document titled, "Investigation Summary ED Patient Injury Event," dated 11/05/19 showed:
- A medical record review for Patient #1 that noted the dislocated right shoulder after patient was moved from ED room 1523 to ED room 1539.
- Caregiver interviews that included Staff MM, Security Officer, Staff N, Security Officer, Staff II, Security Officer, Staff OO, RN, ED, Agency Nurse, and Staff GG, RN, ED Charge Nurse.
- A review of the video recording.
- An evaluation by Staff G, RN, Clinical Development Specialist (Education Department CPI Coordinator), which included that CPI did not teach participants to grab a person in crisis around the upper chest.
- A summary from review of the video, that did not identify the inappropriate CPI used by the security officers.

During an interview on 11/20/19 at 8:42 AM, Staff G, RN, Clinical Development Specialist stated that:
- She was the facility educator for Advanced CPI training.
- She had viewed the video recording of the event with Patient #1 during the investigation process.
- The situation may have been different if nursing staff would have approached the patient prior to security.
- CPI "does not teach those moves" that the security officers performed.

During an interview on 11/20/19 at 10:30 AM Staff P, Regulatory Director, stated that per Staff G's video recording review, when the security officer's attempted to place the patient in the higher level hold, it was unsuccessful, and that's how the patient's arm became dislocated. Staff P stated that Staff G reported that the security officer did an inappropriate CPI technique when he transported the patient to the other room and the "general" consensus was that the type of hold the security officer performed had to be done in order to move the patient.

During an interview on 11/19/19 at 3:01 PM Staff F, Security Director, stated that he had viewed the video during an investigation process, and that Staff N, Security Officer performed advanced CPI when he placed his arm on the "upper chest" of Patient #1 and that the technique was correct and it was "all he could do" to hold the patient.

During an interview on 11/19/19 at 3:51 PM Staff B, Operational Vice President, stated that she had viewed the video and the only concern the facility leadership had, was that Patient #1 had suffered a dislocated shoulder as a result of an altercation with security. She added that Staff MM, Security Officer was temporarily removed from patient care and then returned, but Staff N, Security Officer was not, and returned for his next regularly scheduled shift three days later. She stated that the facility's internal investigation was reported to the state agency, and was considered completed when the facility received confirmation that the state agency accepted their investigation.

The state agency had not accepted the facility's investigation which resulted in an on-site investigation by the state agency, therefore the investigation was not completed, and the security officers involved were allowed to work. This failure placed all patients within the facility at continued risk for their safety.

5. Review of the facility document showed that no re-education of appropriate CPI techniques was provided to staff immediately following the event.

Based on interview, record review, video recording review, and policy review, the facility failed to recognize the use of inappropriate Crisis Prevention Institute (CPI, a type of training whereby staff use physical hold which restrict a person's movement) techniques when security officers used inappropriate CPI techniques for one patient (#1) of one patient reviewed that resulted in an incomplete investigation.
This failure had the potential to place all patients that required CPI, at risk for their health and safety. The facility census was 222.

Findings included:

1. Review of the facility document titled, "Crisis Prevention Institute Unit 9: Physical Interventions - Holding Skills," showed the learning goal for a higher level hold in a standing position was to physically hold the individual in crisis in a reasonable and proportionate manner based on their actions or risk behavior.

Review of Patient #1's medical record showed:
- He presented to the Emergency Department (ED) on 11/05/19 at 11:02 AM with chief complaint of thoughts of self-harm.
- The patient had history of methamphetamine (a drug with more rapid and lasting effects than amphetamine, [an addictive mood altering drug] used illegally as a stimulant) abuse.
- The urine drug screen was positive for amphetamines.
- Staff HH, Registered Nurse, (RN), Psychiatric Emergency Clinician, recommended an injection due to patient agitation prior to admission to the Mental Health Unit (MHU).
- The patient declined the medication injection and a physical hold order was obtained.
- The patient was subdued and placed in a psychiatric safe room and he was found to have a dislocated shoulder.
- The radiology report showed a right, anterior (front side) shoulder dislocation.

Review of the video recording dated 11/05/19 showed that:
- Patient #1 was seated in the recliner in the ED room 1523.
- Patient #1 stood up and walked behind the recliner, further into the room and out of the camera's view.
- Staff N and Staff MM, Security Officers walked down the hallway towards the camera and stopped at the patient's room.
- Staff N entered ED room 1523 and appeared to be talking to the patient out of the camera's view.
- Staff V, RN, Mental Health Nurse, Staff OO, RN, Primary Nurse, and Staff W, Physician, were all positioned in front of the doorway to ED room 1523.
- Staff MM, Security Officer, entered the room and walked towards the back of the room out of camera view.
- Staff II, Security Officer, entered the room and appeared to struggle with patient while Staff MM, Security Officer, grasped the back of Patient #1's neck.
- Patient #1 leaned forward parallel to the wall with his head down toward the floor.
- Staff OO, RN entered the room with the medication syringe in hand.
- Staff N and Staff MM escorted the patient out of the room into the hallway when the patient tried to free himself by lowering his body toward the floor. Staff N, Security Officer positioned himself behind Patient #1 and placed his right arm around the patient's upper body with the bend of his elbow in close proximity to Patient #1's neck while Staff MM, Security Officer was at the patient's right side.
- Staff N and Patient #1 walked backwards while Staff N's right arm remained around the patient's neck to ED room 1539 and out of the camera's view.

During an interview on 11/20/19 at 3:00 PM, Staff N, Security Officer stated that:
- They were asked to move the patient so he grabbed the patient's arm and Staff MM, Security Officer grabbed the other one to escort the patient to ED room 1539.
- Once they cleared the doorway the patient broke their grasp and lowered his body toward the floor. When the patient did this maneuver the best way he (Staff N) could control the patient was to put his arm in a "high chest hold" and leaned the patient's weight against his own chest and walked the patient backwards down the hallway.
- CPI did not teach the hold that he performed on the patient.

During an interview on 11/26/19 at 11:35 AM, Staff MM, Security Officer, stated that the CPI techniques used by both he and Staff N were inappropriate in relation to how they were trained.

During an interview on 11/19/19 at 3:01 PM, Staff F, Security Director, stated that he had viewed the video during the investigation process and that Staff N, Security Officer performed advanced CPI when he placed his arm on the "upper chest" of Patient #1, that the technique was correct and it was "all he could do" to hold the patient.

During an interview on 11/19/19 at 3:51 PM Staff B, Operational Vice President stated that she had viewed the video and the only concern the facility leadership had was that Patient #1 suffered an injury as a result of an altercation with security. Staff B stated that if the patient had not suffered an injury the facility would not have investigated or reported the event to the State Agency.

If Patient #1 would not have suffered an injury the facility would not have investigated the event as they failed to recognize the inappropriate CPI techniques therefore the risk of continued use of inappropriate CPI techniques remained.

During an interview on 11/20/19 at 8:42 AM, Staff G, RN, Clinical Development Specialist stated that:
- She was the facility educator for Advanced CPI training.
- She had viewed the video recording of the event with Patient #1 during the investigation process.
- CPI "does not teach those moves" that the security officers performed and she had informed facility leadership staff that Staff N did not perform appropriate CPI when his arm was around the patient's neck.

During an interview on 11/20/19 at 10:30 AM Staff P, Regulatory Director, stated that the facility has a "built-in step" with their investigation process of Staff G, RN, Clinical Development Specialist, (CPI Educator) who critiqued video recordings of events. She stated that per Staff G's video recording review when the security officer's attempted to place the patient in the higher level hold it was unsuccessful and that's how the patient's arm became dislocated. Staff P stated that Staff G reported that the security officer did an inappropriate CPI technique when he transported the patient to the other room and the "general" consensus was that the type of hold the security officer performed had to be done in order to move the patient.

During an interview on 11/20/19 at 10:15 AM, Staff O, Chief Medical Officer (CMO) stated that he had viewed the video recording and that Staff N, Security Officer had used appropriate CPI technique when he transferred Patient #1 down the hallway to the psychiatric safe room.

The facility failed to recognize the inappropriate CPI techniques by the security officers, even though Staff G informed leadership staff of the inappropriate techniques used during the investigation process. This resulted in an incomplete investigation that placed all patients at risk for their health and safety.

Based on interview, record review and policy review, the facility failed to provide evidence they utilized the least restrictive restraint/seclusion (any involuntary physical or confinement of a patient alone in a room where he/she was physically prevented from leaving) for three discharged patients (#44, #46 and #47) of three discharged patients reviewed for chest restraints (five-point, a restraint used in addition to four-point restraints [medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others] to restrict the patient from sitting up). This had the potential to affect all restraint patients, causing them undue stress and/or harm by restricting their movement any more than necessary. The facility census was 222.

Findings included:

1. Review of the facility's policy titled, "Restraints/Seclusion," dated 10/07/19, showed that the following were alternative staff interventions prior to initiating restraints:
- Establish a contract with the patient;
- Allow the patient to vent verbally;
- Ask the patient to stop their behavior;
- Suggest alternative behavior activities;
- Explain consequences if the behavior continues;
- Escort the patient from the situation;
- Counsel the patient;
- Place the patient in a private room;
- Ask others to leave the area;
- Decrease environmental stimulation;
- Provide diversional activities;
- Enhance observation;
- Limit visitors; and
- Relaxation/exercise activities.
If these interventions were not successful, the direction for staff was to initiate the least restrictive restraint and notify the physician to obtain restraint orders.

Review of Patient #44's medical record showed that on 10/25/19 at 3:41 PM, there were ankle, wrist (four-point) and chest (five-point) restraints ordered at the same time.

Review of Patient #46's medical record showed that on 06/15/19 at 9:38 PM, there were ankle, wrist and chest restraints ordered at the same time.

Review of Patient #47's medical record showed that on 09/15/19 at 12:10 AM, there were ankle, wrist and chest restraints ordered at the same time and the nursing documentation failed to show the alternative interventions attempted prior to the restraint orders.

The facility failed to order the least restrictive restraint first and then order additional restraints when needed. Also, the Registered Nurses (RN) should have contacted the physician for an additional order instead of ordering them at the same time.

During an interview on 11/21/19 at 2:40 PM, Staff JJ, RN, stated that when she received a physician order for restraints, the order screen in the computer provided boxes to mark the choice of restraints available and that the chest restraint option had its own box separate from the four-point restraints.

During an interview on 11/21/19 at 2:13 PM, Staff LL, Director of the Mental Health Unit, stated that the chest restraint was not the least restrictive restraint to initiate, and that she was unaware that the physicians were ordering five-point restraints to begin with.

During an interview on 11/21/19 at 2:20 PM, Staff KK, Psychiatrist, stated that he started with verbal de-escalation, then medication, then seclusion, then four-point restraints and finally chest restraint. He also stated that he didn't specify when giving a verbal/telephone order to staff whether the order was for four-point or chest and that he expected the nurses to contact him again for an order for chest restraints.

Based on interview, record review, and policy review the facility failed to ensure that Advanced Practice Registered Nurses (APRN, also referred to as APN) did not order behavioral, violent restraints for one patient (#1) of one patient reviewed. This failure had the potential to place all patients who required behavioral restraints at risk for their safety. The facility census was 222.

Findings included:

1. Review of the facility's policy titled, "Restraints/Seclusion," dated 10/07/19 showed that:
- Restraints or seclusion may be ordered by physicians.
- APN's may independently order non-violent restraints.
- A physical restraint is any manual method, physical or mechanical device that reduces the ability of a patient to freely move their arms, legs, body or head.
- Physical holding for forced medications must have a physician's order prior to the application of the restraint.
- Philosophy on restraints: restraints should be used only with a physician/APRN order.

The facility policy did not give clear, concise direction for staff regarding who had the ability to order restraints.

Review of the facility document titled, "New Provider Orientation," dated 07/01/14 for Staff E, APRN Emergency Department, (ED) showed multiple categories of information/departments for the orientation. Information regarding restraints and seclusion was not listed for the orientation to Staff E, APRN.

Review of the undated facility document titled, "Violent/Self Destructive/Behavioral Restraint," showed that staff were to notify a physician as soon as possible and obtain order as APRN's cannot order.

Record review and concurrent interview of Patient #1's physical hold (to physically hold someone to purposefully restrict the movements of their arms, legs, head, etc.) order showed an order dated 11/05/19 at 1:20 PM with the ordering physician Staff E, APRN. Staff E stated that she could not order restraints. She stated that she had verbally informed Staff W, ED Physician that Patient #1 needed a restraint order for a physical hold for medication administration. Staff E stated that she wasn't sure if she had the authority to order restraints or not after review of the restraint order for Patient #1 that showed she was the provider who had ordered the restraint.

During an interview on 11/20/19 at 2:50 PM Staff W, ED Physician stated that he wasn't certain if APRN's could order restraints or not.