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Based on review of documents, medical records and staff interview, it was determined the facility failed to protect and promote each patient's rights. The facility failed to ensure the use of restraints was in accordance with a written modification to the plan of care (see tag A-0166). The facility failed to ensure the use of restraints was in accordance with an order from a physician (see tag A-0168). The facility failed to ensure the condition of the patient was monitored by certified staff (see tag A-0175). The facility failed to ensure physicians had a working knowledge of policies regarding the use of restraints (see tag A-0176). The facility failed to ensure the patient had safe implementation of restraints by trained staff (see tag A-0194). The facility failed to ensure staff was trained on a periodic basis according to hospital policy (see tag A-0196). The facility failed to ensure all appropriate staff were re-certified in the use of cardiopulmonary resuscitation (see tag A-0206).

Based on review of medical records and staff interview it was determined the facility failed to ensure a written modification to the care plan was completed for each patient placed in restraints in ten (10) of ten (10) medical records reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This has the potential to negatively affect all patients by leaving them with incomplete documentation of a process that includes assessment, intervention, and evaluation when restraints are used.

Findings include:

1. Patient #1 was admitted to the hospital on 10/11/11. Physical restraints were used on 12/28/11 without a written modification to the Care Plan.

2. Patient #2 was admitted to the hospital on 11/22/11. Physical restraints were used on 11/28/11 without a written modification to the Care Plan.

3. Patient #3 was admitted to the hospital on 9/30/10. Physical restraints were used on 11/5/11 and 11/24/11 without a written modification to the Care Plan.

4. Patient #4 was admitted to the hospital on 10/20/11. Physical restraints were used on 11/4/11 without a written modification to the Care Plan.

5. Patient #5 was admitted to the hospital on 5/7/10. Physical restraints were used on 11/8/11 and 11/9/11 without a written modification to the Care Plan.

6. Patient #6 was admitted to the hospital on 7/28/11. Physical restraints were used on 11/8/11 without a written modification to the Care Plan.

7. Patient #7 was admitted to the hospital on 11/19/11. Physical restraints were used on 11/21/11 without a written modification to the Care Plan.

8. Patient #8 was admitted to the hospital on 10/4/11. Physical restraints were used on 10/5/11 and 10/8/11 without a written modification to the Care Plan.

9. Patient #9 was admitted to the hospital on 3/31/10. Physical restraints were used on 10/1/11, 10/4/11, 10/14/11, 10/18/11, 10/20/11, 10/21/11, 10/23/11 and 10/25/11 without a written modification to the Care Plan.

10. Patient #10 was admitted to the hospital on 10/12/11. Physical restraints were used on 10/18/11, 10/19/11, 10/21/11 and 10/22/11 without a written modification to the Care Plan.

11. These medical records were discussed with the Clinical Nurse Manager #2 at 10:50 a.m. on 1/25/12 and she revealed restraints are not added to the Care Plan/Treatment Plan. She stated restraints are an intervention, not a problem.

Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure the staff received an order from the physician for restraints in ten (10) of ten (10) medical records reviewed for orders (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This has the potential to negatively affect all patients, by restraints being used inappropriately.

Findings include:

1. Hospital policy titled Guidelines for: Seclusion/Restraint, last reviewed 5/20/10 states in part: "Physical Restraint (Last Resort): A method of physically restricting, using only human touch, a person's freedom of movement, physical activity, or normal access to his/her body without the person's permission. Order up to one (1) hour...A brief physical restraint is used for restricting a person's voluntary movement by physical force for any length of time up to five (5) minutes and requires physician notification. (Does not require a physician order).

2. Patient #1 was placed in physical restraint without a physician order on 12/28/11.

3. Patient #2 was placed in physical restraint without a physician order on 11/28/11.

4. Patient #3 was placed in physical restraint without a physician order on 11/5/11.

5. Patient #4 was placed in physical restraint without a physician order on 11/4/11 and 11/9/11.

6. Patient #5 was placed in physical restraint without a physician order on 11/8/11 and 11/9/11.

7. Patient #6 was placed in physical restraint without a physician order on 11/8/11.

8. Patient #7 was placed in physical restraint without a physician order on 11/21/11.

9. Patient #8 was placed in physical restraint without a physician order on 10/4/11, 10/5/11 and 10/8/11.

10. Patient #9 was placed in physical restraint without a physician order on 10/1/11, 10/4/11, 10/14/11, 10/18/11, 10/20/11, 10/21/11, 10/23/11, 10/25/11 and 11/5/11.

11. Patient #10 was placed in physical restraint without a physician order on 10/18/11, 10/19/11, 10/21/11 and 10/22/11.

12. During an interview with the Director of Nursing (DON) on 1/26/12 at 0900, she stated there will not be physician orders found in any medical record for physical restraints. She stated there is no requirement for a physician order if the physical restraint is five (5) minutes or less.

A. Based on review of documents and staff interview it was determined the facility failed to ensure staff had completed the job requirements for annual re-certification of Non Violent Crisis Prevention Intervention (NVCPI) in thirty four (34) of forty seven (47) employees (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 and 34. This has the potential to negatively affect all patients requiring NVCPI by inappropriate restraint methods being used by untrained staff.

Findings include:

1. Hospital policy titled Non Violent Physical Crisis Intervention, last reviewed 9/10/08 states in part: "Clinical, direct care, security and Admissions staff shall be trained and certified annually in NVCPI."

2. Employee #21's NVCPI expired 3/27/09.

3. Employee #11's NVCPI expired 2/26/11.

4. Employee's #12 and #32 NVCPI expired 5/21/10.

5. Employee #16 NVCPI expired 7/1/10.

6. Employee #4 NVCPI expired 7/7/10.

7. Employee #3 NVCPI expired 8/27/10.

8. Employee #14 NVCPI expired 9/21/10.

9. Employee's #17 and #23 NVCPI expired 10/17/10.

10. Employee #27 NVCPI expired 10/15/10.

11. Employee's #8, #9 and #26 NVCPI expired 11/3/10.

12. Employee's #18 and #20 NVCPI expired 11/10/10.

13. Employee's #33 and #34 NVCPI expired 1/14/11.

14. Employee's #10, #15, #22, #24, #25, #29, #30 and #31 NVCPI expired 1/19/11.

15. Employee #1, #6, #7, #13, #19 and #28 NVCPI expired 1/25/11.

16. Employee #2 NVCPI expired 11/23/11.

17. Employee #5 NVCPI expired 12/22/11.

18. During an interview at 1000 on 1/27/12 with the Director of Nursing, she revealed these employee's had not renewed their NVCPI re-certification as per hospital policy.

B. Based on review of documents and staff interview it was determined the facility failed to ensure staff had completed the job requirements for re-certification of cardiopulmonary resuscitation (CPR) in five (5) of thirty six (36) employee records reviewed (#9, 19, 26, 35 and 36). This has the potential to negatively affect all patients requiring CPR by inappropriate resuscitative methods being used by un-certified staff.

Findings include:

1. Review of the job description for employee's of the facility revealed CPR is a job requirement and must be renewed every two (2) years.

2. Employee #9 CPR expired 9/24/09 and was not renewed at that time.

3. Employee #26 CPR expired 2/12/10 and was not renewed at that time.

4. Employee's #19 and #35 CPR expired 2/18/10 and was not renewed at that time.

5. Employee #36 CPR expired 2/19/10 and was not renewed at that time.

6. During an interview with the Director of Nursing (DON) on 1/27/11 at 1000, she revealed these employee's were delinquent in the re-certification of CPR.

Based on review of documents and staff interview it was determined the facility failed to ensure physicians had a working knowledge of hospital policy/Federal Regulations regarding the use of restraints. This has the potential to negatively affect all patients by incomplete orders/no orders being written for the use of restraints.

Findings include:

1. Federal Regulations at tag A-0168 state: The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law." (There is no time limit on the use of restraints prior to initiating an order.)

2. During an interview conducted on 1/26/12 with the clinical Director of psychologists (Medical Director) at 1345, he stated physical restraints can be used without a physician order if they last less than five (5) minutes. He also stated physical restraints can be used when a patient is being verbally aggressive.

Based on review of video recordings and staff interview, it was determined the facility failed to ensure the safe implementation of a restraint in one (1) of one (1) medical records reviewed for death in restraints (Patient #1). This has the potential to negatively affect all patients requiring restraints by causing un-necessary harm or death.

Findings include:

1. Review of a video recording of a physical restraint on 1/23/12 at 1520 with the Director of Safety/Security showed the video recording of the physical restraint used on patient #1. During the recording, the HSW #3 was seen laying on, then straddling the patient.

2. During an interview with the Director of QA/PI/Staff Education on 1/23/12 at 1235, she revealed during training of the staff for Non Violent Crisis Prevention Intervention (NVCPI), they are taught to never lay on, sit on or straddle a patient during a physical hold.

Based on review of documents and staff interview it was determined the facility failed to ensure staff had completed the job requirements for annual re-certification of Non Violent Crisis Prevention Intervention (NVCPI) in thirty four (34) of forty seven (47) employees (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 and 34. This has the potential to negatively affect all patients requiring NVCPI by inappropriate restraint methods being used by untrained staff.

Findings include:

1. Hospital policy titled NonViolent Physical Crisis Intervention, last reviewed 9/10/08 states in part: "Clinical, direct care, security and Admissions staff shall be trained and certified annually in NVCPI."

2. Employee #21's NVCPI expired 3/27/09.

3. Employee #11's NVCPI expired 2/26/11.

4. Employee's #12 and #32 NVCPI expired 5/21/10.

5. Employee #16 NVCPI expired 7/1/10.

6. Employee #4 NVCPI expired 7/7/10.

7. Employee #3 NVCPI expired 8/27/10.

8. Employee #14 NVCPI expired 9/21/10.

9. Employee's #17 and #23 NVCPI expired 10/17/10.

10. Employee #27 NVCPI expired 10/15/10.

11. Employee's #8, #9 and #26 NVCPI expired 11/3/10.

12. Employee's #18 and #20 NVCPI expired 11/10/10.

13. Employee's #33 and #34 NVCPI expired 1/14/11.

14. Employee's #10, #15, #22, #24, #25, #29, #30 and #31 NVCPI expired 1/19/11.

15. Employee #1, #6, #7, #13, #19 and #28 NVCPI expired 1/25/11.

16. Employee #2 NVCPI expired 11/23/11.

17. Employee #5 NVCPI expired 12/22/11.

18. During an interview at 1000 on 1/27/12 with the Director of Nursing, she revealed these employee's had not renewed their NVCPI re-certification as per hospital policy.

Based on review of documents and staff interview it was determined the facility failed to ensure staff had completed the job requirements for re-certification of cardiopulmonary resuscitation (CPR) in five (5) of thirty six (36) employee records reviewed (#9, 19, 26, 35 and 36). This has the potential to negatively affect all patients requiring CPR by inappropriate resuscitative methods being used by un-certified staff.

Findings include:

1. Review of the job description for employee's of the facility revealed CPR is a job requirement and must be renewed every two (2) years.

2. Employee #9 CPR expired 9/24/09 and was not renewed at that time.

3. Employee #26 CPR expired 2/12/10 and was not renewed at that time.

4. Employee's #19 and #35 CPR expired 2/18/10 and was not renewed at that time.

5. Employee #36 CPR expired 2/19/10 and was not renewed at that time.

6. During an interview with the Director of Nursing (DON) on 1/27/11 at 1000, she revealed these employee's were delinquent in the re-certification of CPR.

Based on review of documents, medical records, employee records and staff interview it was determined the facility failed to ensure nursing services were supervised by a registered nurse. The facility failed to ensure nursing supervised and evaluated the care of the patient (see tag A-0395). The facility failed to ensure nursing developed and kept current a nursing care plan for each patient (see tag A-0396). The facility failed to ensure a registered nurse assigned the care of each patient to other personnel in accordance with the patients needs, specialized qualifications and competence of the staff available (see tag A-0397).

Based on review of video recordings and staff interview, it was determined the facility failed to ensure the registered nurse supervised and evaluated the nursing care for each patient in one (1) of one (1) medical records reviewed for inappropriate restraint use (patient #1 on identifier list). This has the potential to negatively affect all patients by not having a registered nurse as an advocate to ensure safety of restraints at all times.

Findings include:

1. Upon review of a video showing the use of a physical restraint in the common area of the unit (A-2) it was noted the registered nurse (RN) did not supervise the care of a patient having a physical restraint applied. The registered nurse walked away from the patient while the restraint was being done and did not tell the Health Service Worker #3 (HSW) to get off the patient. The HSW #3 was using an inappropriate restraint. The HSW was laying across the patients upper body.

2. During an interview with the Director of QA/PI/Staff Education on 1/23/12 at 1520, she noted the RN was the leader of the unit and should have supervised the staff by telling the HSW #3 to get off the patient-he was using an inappropriate physical restraint.

3. During interview with the Interim Administrator on 1/25/12 at 0845, she stated the expectation is that the RN would stay with the patient during the Non Violent Crisis Prevention Intervention (NVCPI).

Based on review of medical records and staff interview it was determined the facility failed to ensure nursing developed and kept current a nursing care plan for each patient (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This has the potential to negatively affect all patients by nursing not completing ongoing assessments of the patient needs and the patient's response to the interventions.

Findings include:

1. Patient #1 was admitted to the hospital on 10/11/11. Physical restraints were used on 12/28/11 without a written modification to the Care Plan.

2. Patient #2 was admitted to the hospital on 11/22/11. Physical restraints were used on 11/28/11 without a written modification to the Care Plan.

3. Patient #3 was admitted to the hospital on 9/30/10. Physical restraints were used on 11/5/11 and 11/24/11 without a written modification to the Care Plan.

4. Patient #4 was admitted to the hospital on 10/20/11. Physical restraints were used on 11/4/11 without a written modification to the Care Plan.

5. Patient #5 was admitted to the hospital on 5/7/10. Physical restraints were used on 11/8/11 and 11/9/11 without a written modification to the Care Plan.

6. Patient #6 was admitted to the hospital on 7/28/11. Physical restraints were used on 11/8/11 without a written modification to the Care Plan.

7. Patient #7 was admitted to the hospital on 11/19/11. Physical restraints were used on 11/21/11 without a written modification to the Care Plan.

8. Patient #8 was admitted to the hospital on 10/4/11. Physical restraints were used on 10/5/11 and 10/8/11 without a written modification to the Care Plan.

9. Patient #9 was admitted to the hospital on 3/31/10. Physical restraints were used on 10/1/11, 10/4/11, 10/14/11, 10/18/11, 10/20/11, 10/21/11, 10/23/11 and 10/25/11 without a written modification to the Care Plan.

10. Patient #10 was admitted to the hospital on 10/12/11. Physical restraints were used on 10/18/11, 10/19/11, 10/21/11 and 10/22/11 without a written modification to the Care Plan.

11. These medical records were discussed with the Clinical Nurse Manager #2 at 10:50 a.m. on 1/25/12 and she revealed restraints are not added to the Care Plan/Treatment Plan. She stated restraints are an intervention, not a problem. She also revealed the facility uses treatment plans instead of nursing care plans. When the initial treatment plan is complete, it then goes to the treatment team, headed up by a social worker. Once nursing wants or needs to update the treatment plan, it is reviewed by the social worker who determines if the update is appropriate.

A. Based on review of documents, employee records and staff interview, it was determined the facility failed to ensure the Registered Nurse (RN) assigned the nursing care of the patients to other nursing personnel with the qualifications and competencies needed to provide safe care in thirty six (36) of thirty six (36) employee records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36). This has the potential to negatively affect the care given to patients by staff not having the training required to afford safe care.

Findings include:

1. Hospital policy titled NonViolent Physical Crisis Intervention, last reviewed 9/10/08 states in part: "Clinical, direct care, security and Admissions staff shall be trained and certified annually in NVCPI."

2. Employee #21's NVCPI expired 3/27/09.

3. Employee #11's NVCPI expired 2/26/11.

4. Employee's #12 and #32 NVCPI expired 5/21/10.

5. Employee #16 NVCPI expired 7/1/10.

6. Employee #4 NVCPI expired 7/7/10.

7. Employee #3 NVCPI expired 8/27/10.

8. Employee #14 NVCPI expired 9/21/10.

9. Employee's #17 and 23 NVCPI expired 10/17/10.

10. Employee #27 NVCPI expired 10/15/10.

11. Employee's #8, #9 and #26 NVCPI expired 11/3/10.

12. Employee's #18 and #20 NVCPI expired 11/10/10.

13. Employee's #33 and #34 NVCPI expired 1/14/11.

14. Employee's #10, #15, #22, #24, #25, #29, #30 and #31 NVCPI expired 1/19/11.

15. Employee #1, #6, #7, #13, #19, and #28 NVCPI expired 1/25/11.

16. Employee #2 NVCPI expired 11/23/11.

17. Employee #5 NVCPI expired 12/22/11.

18. During an interview at 1000 on 1/27/12 with the Director of Nursing, she revealed these employee's had not renewed their NVCPI re-certification as per hospital policy.

B. Based on review of documents and staff interview it was determined the facility failed to ensure staff had completed the job requirements for re-certification of cardiopulmonary resuscitation (CPR) in five (5) of thirty six (36) employee records reviewed (#9, 19, 26, 35 and 36). This has the potential to negatively affect all patients requiring CPR by inappropriate resuscitative methods being used by un-certified staff.

Findings include:

1. Review of the job description for employee's of the facility revealed CPR is a job requirement and must be renewed every two (2) years.

2. Employee #9 CPR expired 9/24/09 and was not renewed at that time.

3. Employee #26 CPR expired 2/12/10 and was not renewed at that time.

4. Employee's #19 and #35 CPR expired 2/18/10 and was not renewed at that time.

5. Employee #36 CPR expired 2/19/10 and was not renewed at that time.

6. During an interview with the Director of Nurisng (DON) on 1/27/11 at 1000, she revealed these employee's were delinquent in the re-certification of CPR.