HospitalInspections.org

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Based on record review, interview, video review, facility document and policy review, the facility failed to ensure physician's orders for seclusion and restraint were obtained immediately for 2 patients (#2 and #7) out of 8 sampled patients. Specifically, 1) 50 minutes passed before obtaining a seclusion order for patient #7 and 2) physician orders were not obtained until the conclusion of seclusion for patient #5. This failed practice placed the patients at risk for unnecessary or extended seclusion time without immediate physician orders and input. Findings:

Patient #5

Record review on 9/30-10/2/19 revealed Patient #5 was admitted to the facility with diagnoses that included intermittent explosive disorder (repeated, sudden episodes of impulsive, aggressive, violent behavior or angry outbursts disproportionate to the situation), attention deficit hyperactivity disorder and borderline intellectual functioning.

Review of "Restraint/Seclusion Order/Record," dated 9/21/19, revealed Patient #5 was escorted into the seclusion room for pulling the fire alarm and being assaultive. The seclusion start time was at 11:40 am and the end time was at 1:00 pm.

Further review revealed the physician's order for the seclusion was not obtained until 12:30 pm.

During an interview on 10/2/19 at 11:10 am, the Medical Director stated the physician should be notified right away if a patient was placed in seclusion or restraint. The Medical Director was shown Patient #5's "Restraint/Seclusion Order/Record," dated 9/21/19, and stated that was a long time for a seclusion before the physician was notified.

Patient #7

Record review on 9/30-10/2/19 revealed Patient #7 was admitted to the facility with diagnoses that included major depressive disorder and post-traumatic stress disorder (PTSD).

Review of "Restraint/Seclusion Order/Record," dated 8/24/19 revealed the Patient was placed in a physical restraint for attacking his/her peer at 7:00 pm that ended at 7:02 pm, followed by seclusion, which began at 7:02 pm and ended at 7:30 pm.

Review of the 8/24/19 incident on video on 10/1/19 at 2:45 pm with the Administrator #2, revealed Patient #7 was placed in a physical hold and then walked into the seclusion room. Once in the seclusion room, the patient immediately sat down in the corner of the room and remained seated there for the duration of the event.

Further review of "Restraint/Seclusion Order/Record," dated 8/24/19, revealed the physician's order for the seclusion was not obtained until the seclusion ended at 7:30 pm.

During an interview on 10/1/19 at 12:30 pm, Licensed Nurse (LN) #1 stated he/she would call the physician within 5 minutes of restraining or secluding a patient.

During a joint video review and interview on 10/1/19 at 2:02 pm, the Assistant Director of Nursing (ADON) stated the physician would be called immediately for orders once a patient was placed in seclusion or restraint.

Review of the facility's "New Employee Orientation" binder under "Identifying and Managing Risk Factors Associated with Seclusion and Restraint," dated 7/19, revealed " ...the RN [LN] is required to notify the ...MD immediately after the hold/seclusion takes place."

Review of the facility's policy "Seclusion and Physical Restraint," revised 10/18, revealed "The physician must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated."
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Based on record review, video review, interview, facility document and policy review, the facility failed to ensure a seclusion event was discontinued at the earliest possible time for 1 patient (#7) out of 8 sampled patients. Specifically, the patient was not being continuously monitored by staff and remained in seclusion with calm behaviors. This failed practice placed the patient at risk for excessive seclusion time and potential for psychosocial instability. Findings:

Record review on 9/30-10/2/19 revealed Patient #7 was admitted to the facility with diagnoses that included major depressive disorder and post-traumatic stress disorder (PTSD).

Review of "Restraint/Seclusion Order/Record," dated 8/24/19 revealed the Patient was placed in a physical hold for attacking his/her peer at 7:00 pm that ended at 7:02 pm, followed by seclusion, which began at 7:02 pm and ended at 7:30 pm. The "Criteria for release: [was] MAINTAIN SAFE BX'S [behaviors]."

Review of the 8/24/19 seclusion event on video on 10/1/19 at 2:45 pm with Administrator #2, revealed Patient #7 was placed in a physical hold and then walked into the seclusion room. Once in the seclusion room, the patient calmly sat down in the corner of the room and remained seated there for the duration of the event.

Further video review revealed the Mental Health Specialist (MHS) #1, who was assigned to continually monitor Patient #7 in seclusion, was pacing back and forth in the ante-room outside the seclusion room, and not seen monitoring the Patient. MHS #1 had his/her back turned to the seclusion room window at times and also sat down on the floor. The window of the seclusion room for viewing the patient could not be seen while in the sitting position on the floor.

During an interview and video review on 10/1/19 at 2:45 pm, Administrator #2 stated MHS #1 was not following protocol. Administrator #2 further stated the MHS #1 should have been looking into the seclusion room continuously, and will need to be trained on seclusion.

During an interview on 10/2/19 at 9:25 am, Patient #7 stated he/she tried to fight his/her peer and then walked with staff upstairs and into the seclusion room. The Patient further stated he/she did what he/she needed to do (take a time out) because he/she was upset.
Further review of "Restraint/Seclusion Order/Record," dated 8/24/19, on the "Seclusion/Physical Restraint Flow Sheet," revealed:

At 7:02 pm, the behavior documented was standing still and quiet;
At 7:10 pm, the behavior documented was standing still;
At 7:20 pm, the behavior documented was lying/sitting;
At 7:30 pm, the behavior documented was lying/sitting.

During an interview on 10/1/19 at 12:15 pm, Therapist #1 stated that a patient should not be in seclusion unless they were assaultive.

During an interview on 10/1/19 at 12:30 pm, Licensed Nurse (LN) #1 stated a patient would be secluded for an imminent risk for danger, or creating an unsafe environment. LN #1 stated that a patient should be monitored continuously while in the seclusion room. LN #1 further stated behaviors to exit seclusion would include being cool, calm and compliant.

Review of the facility's "New Employee Orientation" binder under "Identifying and Managing Risk Factors Associated with Seclusion and Restraint," dated 07/2019, revealed "the Nurse and staff ensures continuous, un-interrupted, in-person observation of the patient, by an assigned staff member, at all times. If in seclusion you must continuously observe through the window of the seclusion room door." Further review under "Processing Clients Out of Seclusion and/or Restraint" revealed "When a client no longer represents an immediate danger to self or others, the processing should begin."

Review of the facility's policy "Seclusion and Physical Restraint," revised 10/2018, revealed it is "each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others ...Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room ...The use of restraint/seclusion is discontinued once the unsafe situation ends ..."
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Based on record review, video review, interview, facility document and policy review, the facility failed to ensure 1 patient (#7) out of 8 sampled patients was continuously monitored during a seclusion event in accordance with facility policy. This failed practice placed the patient at risk for inadequate monitoring and evaluation during a seclusion event. Findings:

Record review on 9/30/19-10/2/19 revealed Patient #7 was admitted to the facility with diagnoses that included major depressive disorder and post-traumatic stress disorder (PTSD).

Review of "Restraint/Seclusion Order/Record," dated 8/24/19 revealed the Patient was placed in a physical hold for attacking his/her peer at 7:00 pm that ended at 7:02 pm, followed by seclusion, which began at 7:02 pm and ended at 7:30 pm. The "Criteria for release: [was] MAINTAIN SAFE BX'S [behaviors]."

Review of the 8/24/19 seclusion event on video on 10/1/19 at 2:45 pm revealed the Mental Health Specialist (MHS) #1, who was assigned to continually monitor Patient #7 in seclusion, was pacing back and forth in the ante-room outside the seclusion room, and not seen continuously monitoring the Patient. MHS #1 had his/her back turned to the seclusion room window at times and also sat down on the floor. The window of the seclusion room for viewing the patient could not be seen while in the sitting position on the floor.

During an interview and video review on 10/1/19 at 2:45 pm, Administrator #2 stated MHS #1 was not following protocol. Administrator #2 further stated the MHS #1 should have been looking into the seclusion room continuously, and will need to be trained on seclusion.

During an interview on 10/2/19 at 9:25 am, Patient #7 stated he/she tried to fight his/her peer and then walked with staff upstairs and into the seclusion room. The Patient further stated he/she did what he/she needed to do (take a time out) because he/she was upset.

During an interview on 10/1/19 at 12:30 pm, Licensed Nurse (LN) #1 stated that a patient should be monitored continuously while in the seclusion room.

Review of the facility's "New Employee Orientation" binder under "Identifying and Managing Risk Factors Associated with Seclusion and Restraint," dated 07/2019, revealed "the Nurse and staff ensures continuous, un-interrupted, in-person observation of the patient, by an assigned staff member, at all times. If in seclusion you must continuously observe through the window of the seclusion room door." Further review under "Processing Clients Out of Seclusion and/or Restraint" revealed "When a client no longer represents an immediate danger to self or others, the processing should begin."

Review of the facility's policy "Seclusion and Physical Restraint," revised 10/2018, revealed "Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room ..."

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Based on interview, observation, document review, and policy review the facility failed to ensure there were adequate staff to provide care to all patients as needed. This failed practice had the potential to affect all patients of the facility, based on a census of 47 on the adolescent boys, pre-teen and children's unit, to receive less than optimal care. Findings:

During an interview on 9/29/19 at 5:25 pm, Licensed Nurse (LN) #2 and LN #4 stated that they were sometimes short staffed when staff call out. LN #4 further stated that they had been short recently due to medical leaves and vacations. LN #4 stated that the units were staffed by the core staffing guidelines. LN #4 further stated that staff training was for their primary assignment areas.

During an interview on 9/29/19 at 5:35 pm, Mental Health Specialist #2 stated that sometimes the units are short staffed when staff call out.

During an interview on 9/29/19 at 6:00 pm, LN #5 stated that the availability of licensed nurses was limited and that sometimes the units would go short when there were call outs.

During observations on 9/29/19-10/1/19 at various times, the unit was very busy. Adolescents and children were banging intermittently for the duration of the observation, on windows and doors throughout the unit, one patient was on a 1:1 (order for 1 staff to 1 patient for safety purposes), patients were rough housing with each other, there were medication and other needed items requested, the unit was observed to be very busy and loud.

During an interview on 10/1/19 at 11:00 am, LN #5 stated that the biggest change he/she had seen during his/her duration of employment was that the acuity and need level of the patients had greatly increased. The adolescents and children had a higher need level than when he/she started working there. He/she stated the patients were more mentally ill with complex behavioral challenges such as aggression, poor social functioning, and lack of coping skills.

During an interview on 10/1/19 at 11:15 am, the Assistant Director of Nursing (ADON) stated that units were staff by "core staffing". The ADON stated they try to take acuity into consideration when staffing but acuity often changed. The ADON further stated that the hospital employs FTEs (full time employee positions) for a census of 25 patients out of a 40 bed maximum.

Document review of the unit census provided by management on 10/1/19 at 12:00 pm for the month of September 2019 revealed the census on the adolescent boys and children's units ranged from 22 to 28 patients.

Document review of the unit staffing lists provided by management on 10/1/19 at 12:15 pm revealed the following core staffing based solely on facility identified staffing ratios for safe staffing for the month of September 2019:

On 9/2/19 the preteen unit had a census of 17 with 1 LN and 2 MHS staff on the day shift.
On 9/11/19 the preteen unit had a census of 18 with no LNs scheduled on the night shift though the night RN manager may have filled in and no MHS staff on the night shift.
On 9/18/19 the preteen unit had a census of 22 with no LNs scheduled on the night shift though the night Registered Nurse (RN) manager may have filled in and no MHS staff on the night shift.
On 9/21/19 the adolescent boys unit had a census of 20 with 1 LN and 2 MHS staff on evening shift. The nurse manager may have helped out but he/she was an 8 hour staff which would cause additional shortage on evenings.
On 9/23/19 the adolescent boys unit had a census of 21 with 2 LN staff and 3 MHS staff on the day shift.
On 9/24/19 the adolescent boys unit had a census of 21 with 1 LN staff and 3 MHS staff on the day shift.
On 9/26/19 the adolescent boys unit had a census of 23 with 1 LN staff and 4 MHS staff on the day shift.
On 9/26/19 the adolescent boys unit had a census of 23 with 1 LN staff and 3 MHS staff on the evening shift.
On 9/26/19 the preteen unit had a census of 17 with 1 LN staff and 3 MHS staff on the evening shift.
On 9/29/19 the adolescent boys unit had a census of 22 with 2 LN staff and 3 MHS staff on the day shift.
On 9/29/19 the preteen unit had a census of 18 with no LN staff and 3 MHS staff on the day shift.
On 9/30/19 the adolescent boys unit had a census of 22 with 2 LN staff and 3 MHS staff on the day shift.

During an interview on 10/1/19 at 1:15 pm, LN #3 stated that the unit was often short staffed, both by core staffing numbers and acuity. LN #3 stated that he/she voiced concerns to the scheduler but there was not much the scheduler could do about it. LN #3 reported that they could discuss issues with managers but that there was often no immediate response. LN #1 and LN #3 both stated that they sometimes felt the staffing was so low the unit was unsafe. LN #3 stated that sometimes the short staffing made him/her feel that his/her license was at risk.

During an interview on 10/2/19 at 8:40 am, the Director of Quality Improvement stated the staffing list provided for the survey was actual counts of staff who worked on the units during the reviewed time period.

During an interview on 10/2/19 at 10:00 am, the ADON stated staff were frequently sated concerns about being short staffed. The ADON stated that if acuity was high, additional staff would be scheduled, however, he/she stated "acuity is perceptual". The ADON stated that they sometimes use ancillary staff from housekeeping, recreational therapy, managers, and clinical when units were short. He/she stated that preteens was the highest acuity unit. When asked if these staff were cross trained, the ADON stated that the hospital wide training covers all units/ages, and there was no unit specific training in place at the hospital. The ADON further stated that admissions could occur 24/7 which would require an LN to be off the unit for the admission. There were also unpredictable walk-in assessments that were completed by an LN, which would require the LN to be off the unit.

During an interview on 10/2/19 at 10:55 am, the Scheduler that he/she was responsible for staffing the units. He/she stated some days less people were available to work, especially on weekends and evenings. He/she stated sometimes ancillary staff were pulled to work on the units. He/she stated a recent increase in injuries lowered the pool of available staff. He/she stated that there were times when staffing was under recommended core staffing numbers.

During an interview on 10/2/19 at 9:35 am, Patient #1 stated that he/she had been assaulted by peers a number of times during the current admission. He/she further stated more staff would improve the safety. He/she felt there was not enough staff. He/she stated, "I have gotten into many fights because there's not enough staff, no one is around to watch." Patient #1 stated that he/she noticed increased behavioral issues from peers when staff were not present.

Review of the hospital policy entitled "Nursing Scheduling and Staffing", last reviewed 03/2017 revealed the policy purpose as, "To identify the hospital's core staffing pattern, scheduling system, provisions for unit coverage and floating, guidelines for overstaffing and pool utilization." The Procedure sections revealed, " ...the units have the following minimum staff to patient ratios during the day and evening shifts: Adolescent 1:4; Pre-teen 1:4; Children 1:3.5 ...Night ratios are as follows: All units: 1:10 ... The actual number of staff assigned to each unit is based on the above ratios, census, acuity, special status levels, unit needs, and planned escorts, consults, and/or activities ..."
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