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Based on review of 13 medical records, policies and procedures, and other pertinent documentation, unit observations, and staff interviews, it was determined that the hospital was out of compliance with the Condition of Participation of Patient Rights, as evident by multiple standard level violations listed below:

1. The hospital failed to uphold the rights of 1 patient to make informed decisions and agree to or refuse procedures and treatment. Cross-reference tag A-0131.
2. The hospital failed to provide a safe environment of care to the patients on its Behavioral Health Unit, as evidenced by presence of ligature points in patient rooms. Cross-reference tag A-0144.
3. The hospital failed to ensure that seclusion intervention was only used for management of violent or self-destructive behaviors for 1 of 6 behavioral patients reviewed. Cross-reference tag A-0162.
4. The hospital failed to obtain a valid physician order for a restraint episode of a patient. Cross -reference tag A-0168.
5. The hospital failed to ensure that restraint orders were never written as standing orders. Cross-reference tag A-0169.
6. The hospital failed to complete a face-to-face assessment of 1 patient who was placed in seclusion. Cross-reference tag A-078.
7. The hospital failed to document all of the required components of a face-to-face assessment for 1 patient who was placed in seclusion. Cross-reference tag A-0179.

The cumulative effect of these failures created an unsafe environment of care that did not protect or promote the rights of patients in the hospital.

Based on the review of 13 medical records, hospital policies, and other pertinent documents, it was determined that the hospital failed to uphold the patient right to make informed decisions about care and treatment for 1 of 13 patients reviewed. Specifically, the hospital staff failed to assess whether a patient (Patient #3) lacked decision-making capacity or certify an incapacity prior to obtaining consents from a surrogate decision maker.

The findings include:

The surveyor reviewed the hospital's policy titled "Consent for Treatment (Informed Consent)," revised March 26, 2019. The policy stated in part:

Patients will be given the information needed, in terms they can understand, in order to make an informed decision and authorize consent for treatment and/or invasive procedures.....Substituted consent for medical treatment shall be obtained prior to providing a nonemergency service to an individual who lacks sufficient understanding or capacity to make or communicate a responsible decision on health care for himself...Prior to obtaining substituted consent, two physicians must certify in writing that the patient is incapable of making an informed decision regarding treatment.

Patient #3 (P3) was an 80+ year old who presented to the hospital via the emergency department for treatment of an acute respiratory issue. P3 had two inpatient admissions, less than one week apart, both with similar complaints.

During P3's first admission, there was a general consent for treatment seen in the medical record that was signed by P3's family member. On day 2 of this admission, P3 required a blood product transfusion. P3's family member signed the consent form for this blood transfusion. In addition, P3's family member signed the discharge summary for this admission, which was an acknowledgement of receipt for any follow-up care or recommendations.

During P3's second admission, P3's family member again signed the general consent for treatment. Included with the general consent was an acknowledgement of the notice of privacy practices, telehealth care services, and liability for patient valuables.

There was no documentation found in the medical record for both admissions that P3 had a condition which would preclude them from signing the consent forms or if the patient was certified by two physicians to lack capacity. The medical record documented P3's discussion with several providers regarding his/her medical history and treatment plan. Furthermore, nursing assessments of P3's level of consciousness and orientation, identified P3 as alert, appropriate, awake, following commands, and oriented to person, place, time, and situation. P3 maintained similar neurological assessments throughout his/her admissions. The surveyor was not able to determine if P3 received all of the necessary information regarding his/her treatment and discharge planning during the 2 hospitalization episodes.

Based on observation of the environment of care on the Behavioral Health Unit (BHU), it was determined that the hospital failed to provide a safe care setting to its behavioral health patients.

On day one of the survey at approximately 10:00 am, the surveyor completed observations of the BHU, including an unoccupied patient room. During this observation, the surveyor noted that there were lights above the patient bed. These lights were not completely flush with the wall, leaving a gap that created a potential ligature risk.

A ligature risk, such as gapping of fixtures, on a behavioral health unit created an unsafe environment of care for all patients on the unit.

Based on the review of medical records of 6 behavioral health patients, hospital policy, and other pertinent documents, it was determined that, on two occasions, hospital staff secluded a patient in the absence of violent or self-destructive behaviors. This was evident in 1 out of 6 patient records reviewed.

The findings include:

The surveyor reviewed the policy titled "Restraints and Seclusion." The policy defines seclusion as, "The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior and is only implemented on the Behavioral Health Unit. Seclusion is generally less restrictive than physical restraint."

Patient # 6 (P6) was a 30 + year old patient who was brought to a local Emergency Department (ED) by police for an emergency psychiatric evaluation due to displaying dangerous behaviors towards others. He/she was transferred to this hospital as an involuntary admission for further treatment and medication management.

The following information was obtained during the review of the patient's medical record.

Approximately 12 hours after P6's admission to the hospital, he/she was making sexually inappropriate comments to staff. Staff attempted redirection, targeted staff left the unit, security was notified for support, and the patient was administered as needed oral medication. The patient later grabbed a peer's hand and caressed it, then rubbed the nurse's shoulders. The provider spoke with the patient. When that conversation ended, the patient blew kisses at staff and yelled out. Following this interaction, the patient was placed in seclusion for approximately 1 hour.

Approximately 24 hours after P6's admission to the hospital, hospital staff witnessed P6 and a peer in the doorway entrance of the peer's bedroom. The peer was observed lifting their own shirt. Both patients were observed kissing and embracing one another. Hospital staff responded to the area and the patients disengaged and returned to their respective rooms. A Behavioral Health Specialist's note related to this incident stated, "The patient [P6] in room [number] became verbally combative. I was able to deescalate the patient verbally but was unsuccessful. I then placed the patient [P6] in a therapeutic hold and began to escort [him/her] to the seclusion room. While escorting [P6] to the seclusion room, I asked the patient what happened. The patient responded, '[He/She] wanted me to make love to [him/her], but I just kissed [him/her].' The patient was successfully placed in the seclusion room, where [they] increasingly became more agitated. Security was notified by [unit] staff and agitation protocol was given by mouth." The patient remained in seclusion for approximately 50 minutes.

The surveyor did not find any documented evidence of P6 displaying violent or self-destructive behaviors that would warrant the use of seclusion leading up to the two seclusion episodes described above.

Based on the review of medical records of 6 behavioral health patients, hospital policy, telephone interview with hospital staff, and other pertinent documents, it was determined that the facility failed to obtain a valid physician order for a "therapeutic hold", a type of physical restraints.

The findings include:

The surveyor reviewed the hospital policy titled "Restraints and Seclusion." Under section the "Physical Hold," the policy stated, "Physical hold means when one or more members of staff holding the person, moving the person, or blocking their movement to stop them from leaving. Physical hold shall be considered a manual method of restraints. This is different than a therapeutic hold typically used in behavior health areas and would only be used in an emergency situation ...Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint. Therefore, a physician order and a face-to-face evaluation with 1 hour would still apply."

Review of the medical record for Patient #6 determined the following:

Patient # 6 (P6) was a 30 + year old patient who was brought to a local Emergency Department (ED) by police for an emergency psychiatric evaluation due to displaying dangerous behaviors towards others. He/she was transferred to this hospital as an involuntary admission for further treatment and medication management.

The following information was obtained during the review of P6's medical record.

Approximately 24 hours after P6's admission to the hospital, hospital staff witnessed P6 and a peer in the doorway entrance of the peer's bedroom. The peer was observed lifting their own shirt. Both patients were observed kissing and embracing one another. Hospital staff responded to the area and the patients disengaged and returned to their respective rooms. A Behavioral Health Specialist's note related to this incident stated, "The patient [P6] in room [number] became verbally combative. I was able to deescalate the patient verbally but was unsuccessful. I then placed the patient [P6] in a therapeutic hold and began to escort [him/her] to the seclusion room. While escorting [P6] to the seclusion room, I asked the patient what happened. The patient responded, '[He/She] wanted me to make love to [him/her], but I just kissed [him/her].' The patient was successfully placed in the seclusion room, where [they] increasingly became more agitated. Security was notified by [unit] staff and agitation protocol was given by mouth." The patient remained in seclusion for approximately 50 minutes.

The provider telephone order obtained by the Registered Nurse for this episode was documented as "Restraints - Seclusion" and did not specify which intervention was supposed to be used. The corresponding face-to-face assessment clarified that the intervention used was seclusion. There was no additional order found for the "therapeutic hold", as was documented in the Behavioral Health Specialist's note.

Based on the review of medical records of 6 behavioral health patients, hospital policies, and other pertinent documents, it was determined that the hospital staff documented orders for chemical restraints as standing or as needed (PRN). This was evident in the records of 4 out of 6 behavioral patients reviewed.

The findings include:

While onsite, the surveyors reviewed a total of 6 behavioral health patient records and the following was noted:

A. Patient # 4 (P4) was a 20 + year old patient who was seen in a local Emergency Department (ED) for behavioral health services following an Emergency Petition (EP) for danger to self. He/she was transferred and voluntarily admitted to this hospital's Behavioral Health Unit (BHU) for further treatment and medication management.

B. Patient #5 (P5) was a 30 + year old patient who presented to the Emergency Department (ED) for behavioral health services. He/she was voluntarily admitted to the Behavioral Health Unit (BHU) for further treatment and medication management.

C. Patient # 6 (P6) was a 30 + year old patient who presented to a local Emergency Department (ED) for behavioral health services following an Emergency Petition (EP) for danger to others. He/she was transferred to this hospital on an involuntary admission for further treatment and medication management.

D. Patient #13 (P13) was an 18+ year old patient who was brought to the emergency department (ED) by their parent/guardian for statements of wanting to self-harm and hearing voices telling him/her to harm others. He/she was transferred to the inpatient psychiatric unit as a voluntary admission for further treatment and medication management.

Medical record of P4, P5, P6 and P13's contained a "Behavioral Health Admission" 5-page order set. On page 3 of the order set, the following boxes were checked, in addition to others:

Sedative-Hypnotics:

- Diphenhydramine HCl 50 mg orally every 4 hours as needed For severe agitation & anxiety To be given along with Ativan 1 mg PO (by mouth) and Haldol 5 mg PO

- Diphenhydramine HCl 50 mg intramuscularly every 4 hours as needed For severe agitation & anxiety Give IM (intramuscular) if patient is refusing PO administration To be given along with Ativan 1 mg IM and Haldol 5 mg IM

Antipsychotics:

- Haloperidol 5 mg orally every 4 hours as needed For severe agitation & anxiety not to exceed 20 mg in 24 hours To be given along with Ativan 1 mg PO and Benadryl 50 mg PO

- Haloperidol lactate 5 mg intramuscularly every 4 hours as needed For severe agitation & anxiety not to exceed 20 mg in 24 hours Give IM if patient is refusing PO administration To be given along with Ativan 1 mg IM and Benadryl 50 mg IM

Anti-Anxiety Agents:

- Lorazepam 1 mg orally every 4 hours as needed For severe agitation & anxiety To be given along with Haldol 5 mg PO and Benadryl 50 mg PO

- Lorazepam 1 mg intramuscularly every 4 hours as needed For severe agitation & anxiety Give IM if patient is refusing PO administration To be given along with Haldol 5 mg IM and Benadryl 50 mg IM.

Review of the electronic medical records determined that the above orders were also transcribed in the patients' electronic Medication Administration Record (MAR) by nursing staff.

Based on the review of restraints/seclusion documentation in the medical records of 6 behavioral health patients, hospital policy, and other pertinent documents, it was determined that the facility failed to complete a face-to-face assessment of 1 patient who was placed in seclusion.

The findings include:

The surveyor reviewed the policy titled "Restraint and Seclusion." The Procedures section of the policy stated, "X. Assessment and Monitoring. Face-to-Face Evaluation. As soon as possible within 1 hour of initiation of restraints." This information was located in a chart within the policy titled "Ordering LIP (Licensed Independent Practitioners) Responsibilities" under "Violent/Self-Destructive Restraints or Seclusion and any Physical Hold."

Patient # 6 (P6) was a 30 + year old patient who was brought to a local Emergency Department (ED) by police for an emergency psychiatric evaluation due to displaying dangerous behaviors towards others. He/she was transferred to this hospital as an involuntary admission for further treatment and medication management.

The surveyor noted the following information during the review of P6's medical record.

Approximately 24 hours after P6's admission to the hospital, hospital staff witnessed P6 and a peer in the doorway entrance of the peer's bedroom. The peer was observed lifting their own shirt. Both patients were observed kissing and embracing one another. Hospital staff responded to the area and the patients disengaged and returned to their respective rooms. A Behavioral Health Specialist's note related to this incident stated, "The patient [P6] in room [number] became verbally combative. I was able to deescalate the patient verbally but was unsuccessful. I then placed the patient [P6] in a therapeutic hold and began to escort [him/her] to the seclusion room. While escorting [P6] to the seclusion room, I asked the patient what happened. The patient responded, '[He/She] wanted me to make love to [him/her], but I just kissed [him/her].' The patient was successfully placed in the seclusion room, where [they] increasingly became more agitated. Security was notified by [unit] staff and agitation protocol was given by mouth." The patient remained in seclusion for approximately 50 minutes.

The provider face-to-face evaluation for this seclusion episode was completed approximately 1 hour 50 minutes after the seclusion episode began.

Based on the review of restraint/seclusion records of 6 behavioral health patients, hospital policy, and other pertinent documents, it was determined that the hospital failed to document the following components of a face-to-face assessment for 1 of 6 patients reviewed: the patient's immediate situation, the patient's reaction to the intervention, the patient's medical condition, or the need to continue or terminate the restraint.

The findings include:

The surveyor reviewed the policy titled "Restraint and Seclusion." Section IV. Of the Procedures section of the policy stated, "Required face to face elements for restraints, seclusion, and physical holds: A. Behavior/rationale requiring restraint. B. Whether less restrictive approaches have been considered and deemed inappropriate or ineffective. C. Type of restraint(s) to be used. D. Rationale for continued use of restraints."

The policy did not address the following elements that are required by this regulation to be included into the face-to-face assessment:

- The patient's reaction to the intervention;
- The patient's medical and behavioral condition.

Review of the medical record for Patient #6 determined the following:

Patient # 6 (P6) was a 30 + year old patient who was brought to a local Emergency Department (ED) by police for an emergency psychiatric evaluation due to displaying dangerous behaviors towards others. He/she was transferred to this hospital as an involuntary admission for further treatment and medication management.

The surveyor noted the following information in the patient's medical record.

Approximately 12 hours after P6's admission to the hospital, he/she was making sexually inappropriate comments to staff. Staff attempted redirection, targeted staff left the unit, security was notified for support, and the patient was administered PO (by mouth) as needed medication. The patient later grabbed a peer's hand and caressed it, then rubbed the nurse's shoulders. The provider spoke with the patient. When that conversation ended, the patient blew kisses at staff and yelled out. Following this interaction, the patient was placed in seclusion for approximately 1 hour.

The 1-hour face-to-face assessment for this seclusion episode documented the following information: "Restraint Phase: Initial Application, Rationale for Violent Patient Restraints/Seclusion: Danger To Others, Violent Restraint Type: Seclusion, Behavior: Belligerent, Combative/Hostile, Impulsive/Intrusive, Inappropriate for Situation, Uncooperative, Patient's Response to Alternative/Less Restrictive Measure: Ineffective, Escalating."