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Based on concerns identified during the complaint survey conducted 2/11/16 and 2/17 through 2/19/16, the Governing Body failed to ensure oversight was provided regarding services provided by the facility including:

482.12(e) Contracted Services A0083
482.12(f)(1) Emergency Services A0093
482.13(c)(2) Patient Rights Care in a safe setting A0144
482.13(d)(1) Patient Rights Confidentiality of Records A0147
482.13(e)(3) Patient Rights Restraints A0165
482.13(3)(4)(i) Patient Rights Restraints A0166
482.13(e)(5) Patient Rights Restraints A0168
482.13(e)(6) Patient Rights Restraints A0169
482.13(e)(10) Patient Rights Restraints A0175
482.13(f)(1) Patient Rights Restraints A0196
482.13(f)(2) Patient Rights Restraints A0199
482.24(b) Form and Retention Medical Records A0438
482.24(c) Content of Record A0449
482.24(c)(1) Medical Records Services A0450
482.55(a)(3) Emergency Services A1104
482.55(b)(2) Qualified Emergency Services Personnel A1112


Please refer to the specific citations for further details.

Based on staff interview and during the course of a complaint investigation, the facility staff/Governing Body failed to ensure contracted staff were appropriately credentialed.

The findings included:

During the personnel and credentialing review for hospital employees and contracted staff, the facility stated the CSB (Community Services Board) staff who provided mental health evaluations and pre-screening services to patients in the ED (Emergency Department) and PEC (Psychiatric Emergency Care) area were not required to be credentialed by the facility.

On 2/19/16 at 8:35 a.m., Staff #5 stated no credentialing was done on the CSB employees who come into the facility.

On 2/19/16 at 10:50 a.m., Staff # 22 stated, I do not have the CSB employee files. (Name) the director of emergency services with (CSB) is going to send the CSB files, but it may take them awhile to get them together."

The facility Staff #24 stated on 2/19/16 at 2:40 p.m. that the CSB employees are given an "access badge" and that the facility requires them to provide proof of identification and social security number, however, no information is obtained in regards to the CSB personnel's education, certification or training.

Complaint Deficiency

Based on staff interview, facility document review and during the course of a complaint investigation, it was determined the Governing Body failed to ensure the facility Emergency Department (ED) policies and procedures included the Psychiatric Emergency Care (PEC) area which was identified as an extension of the ED.

The findings included:

During a review of the facility policies and procedures the survey team was unable to identify any policies and procedures that specifically identified the PEC area of the ED.

On 2/9/16 at 10:25 a.m., the surveyors toured the PEC area located in the Dillard Building. The area was in a building directly across from the ED ambulatory entrance (approximately 50 feet or less). The unit could only be accessed with a badge carried by staff and the entrance consisted of the locked door, a small area and another locked door which opened into the PEC area. The second door could not be opened until the first door had shut completely and locked. The area consisted of four rooms, a nurses station, a security area, a back office and "provider area" with computers and desk space, a locked medication and storage room, and a bathroom with a shower. Each room, as well as the area of the nurses station contained video monitoring cameras and the central monitor at the security desk. There was a small nourishment center adjacent to the nurses station with a refrigerator. The rooms had the capability of being locked and had a large plexi (safety)-glass-type window.

The survey team was provided with a document "Psychiatric Emergency Center Process Review" which documented, "The Psychiatric Emergency Center (PEC) exists to: serve mental health patients seeking evaluation and treatment within Centra Health emergency departments, provide consultation services to the medical units, and review mental health inpatient referrals from external facilities. The greatest expectation is that all processes are manifested in a way that respect every patients' privacy, dignity, rights, and preferences allowing for a person-centered holistic, recovery oriented approach to providing excellent patient care. Processes that are in place can be changed as the unit grows in their practice, expertise, resourcefulness, and creativity." The document outlines the processes that were to take place for : I. Patient to the Emergency Department-Voluntary, II, Patient to the Emergency Department- Emergency Custody Order, III. Patient to Emergency Department-Voluntary needing Disposition, IV. Patient to PEC-Admission, V. PEC Patient- Voluntary needing to be ECO'd (Preauthorization), VI. PEC Patient to Centra Inpatient Facility-Transfer, VII. PEC Patient to Non-Centra Facility-Discharge, VIII. PEC Patient to HOME-Discharge, IX. Emergency Planning-CODES and Resources/Responders, X. Care of the Patient-General Rules and Guidelines for PEC, XI. Care in the PEC -Interventions and Documentation. The title page also listed: Xii. Intake Services, XIII. Consultation Services, XIV. Staffing and XV. Riskmaster, however these areas were not included in the document provided to the surveyor.

Items 1. through VIII contained a table that listed the process for each of the areas when a patient was received onto the PEC such as how to enter, who to notify, obtaining a bed, and entering patients into the facility computer system as well as who would accompany the patient, security clearance and consultation activities.

Staff #5 stated the "PEC was an extension of the ED and was under the policies and procedures for the ED" on 2/8/16 at 1:10 p.m. The survey team was unable to locate any mention of the PEC area in the ED policies and procedures that were reviewed.

Complaint Deficiency

Based on clinical record review, staff interview, and review of facility documents, the facility staff failed to ensure the rights of each patient was protected and promoted in regards to safety and the use of restraints.

The findings included:

During the complaint survey conducted 2/11/16 and 2/17/16 through 2/19/16, the survey team identified concerns regarding patient right for the following:

Patient Rights Care in a safe setting A0144
Patient Rights Restraints A0165
Patient Rights Restraints A0166
Patient Rights Restraints A0168
Patient Rights Restraints A0169
Patient Rights Restraints A0175
Patient Rights Restraints A0196


Please refer to the individual citations above for further information.

Based on staff interview, clinical record review, review of facility documents and during the course of a complaint investigation, it was determined the facility staff failed to ensure each patient received care in a safe setting. This involved Patient #12 who sustained gunshot wounds on 1/11/16 in the Psychiatric Emergency Care (PEC) area.

The findings included:

Review of the clinical record
for Patient #12 revealed the patient presented at the Emergency Department (ED) of the hospital on 1/10/16 at 21:32 (9:32 p.m.) with a family member who requested a "Mental Health Evaluation". The family member provided information, according to the clinical record, that the patient "needs his/her medications adjusted- loss of appetite, can't sleep, denies suicidal or homicidal, meds adjusted a couple of weeks ago."

Further review of the ED record revealed the following, in part:
Mental Status: The patient is awake, sometimes will not answer questions.
Affect: The patient is calm.
Orientation: The patient is oriented to person, place and time.
Speech: The patient is speaking coherently.
PRIMARY TRIAGE FORM:
Onset of symptoms, last known well; Approximately Thursday, January 7, 2016. The patient exhibits the following symptoms: and no signs symptoms requiring a swallowing screen were noted. The suicidal/homicidal screening was completed. Patient denies having any suicidal thoughts. Patient denies having any homicidal thoughts. SAD Persons (Suicide Risk Assessment). Fall risk assessment form completed. Domestic violence screening completed. The patient denies feeling afraid or threatened. The patient denies being hurt by someone. According to the Emergency Severity Index Version 4 (four) Algorithm, the ESI Level =2. (ESI Level 2 indicated the patient was in a "high risk situation- (c)ESI Triage Research Team, 2004)...MEDICAL HISTORY: Schizophrenia, Bipolar Disease, Schizo affective, Hypertension...SOCIAL HISTORY: Uses tobacco products on occasion, Drinks alcohol on occasion, denies use of illicit drugs...."

The "Nursing Notes" documented the following:
1/10/16 21:39 (9:39 p.m.) Patient assigned to Bay 2.
1/10/16 21:52 (9:52 p.m.) (The following assessment was documented in the clinical record at the same time as previously noted 9:52 p.m.) ABC's: The airway is open and patent. Respirations are spontaneous and non-labored. Breath sounds: clear equal bilaterally. All pulses is/are strong. Level of consciousness: The patient is awake, staring off, selectively engaging with this nurse (Staff # 11) with an affect that is inaccessible. The patient is oriented x3 (times three) and speaking coherently. Skin color, temperature, moisture: The patients color is normal for age and race. The skin is warm and dry. Skin Turgor is good. Risk history entered. The patient uses alcohol. Alcohol use, amount, length of time: "Sometimes". The patient denies the use of drugs. The patient is a smoker. Posture, motor activity, gait: The patients posture is normal. The patient has normal motor activity. The patient has a normal gait. Grooming, personal hygiene: The patients clothing is appropriate. The patient is clean, hair, nails, skin. Odors of breath: The patient has normal-smelling breath. Description of behavior: The patient's mood is flat and inaccessible. Patient is in no apparent physical distress. Patient denies pain. Nursing Assessment Note: Pt (patient) presents to ED from home with his/her family. The pt's [sibling] (name) is at the bedside on assessment and indicated that the patient has been experiencing increased anxiety for approximately the past two weeks. He/She has had a decreased appetite and "hasn't slept for 4 days. We really just want to get him/her in to (name of psychiatric hospital) so that he/she can get his/her medications regulated. He/she has been to (name of state facility) a couple of times in the past, but we don't want him/her to go back there. We really just want him/her at (name of psychiatric facility)". Pt (patient) denies SI/HI (suicidal ideations/homicidal ideations). Pt selectively answers my questions but [sibling] gives full report on the pt and when asked if everything the [sibling] was reporting is accurate, he/she refuses to answer...

1/10/16 22:16 (10:16 p.m.) ED provider at bedside (name of Staff # 9).
1/10/16 23:17 (11:17 p.m.) Nursing Note: Patients family has gone home. Several contact names and numbers have been listed on the patients chart. Pts [parent] (name) reports he/she is the patients "guardian" His/her number is (number listed). Patient also has a case manager (name) no number listed.

1/10/16 23:20 (11:20 p.m.) Patient refuses consent for blood work because "I don't feel comfortable with it. I will probably just leave in the morning anyway." I explained that we are unable to obtain any medications levels without blood work and advised him/her that it is not likely that we will be able to get him/her hospitalized without blood work, and still he/she insists that no blood will be drawn.
1/10/16 23:24 (11:24 p.m.) The patient was searched for potentially harmful items by the security officer. Per (name of officer) "He/She has a can of dip and a wallet, but there is nothing dangerous in the wallet, I also searched that."
1/10/16 23:39 (11:39 p.m.) Speciality contact: Physician paged. Speciality: Psychiatry
1/10/16 23:40 (11:40 p.m.) Speciality Contact: Spoke to Physician Speciality: Psychiatry.

1/11/16 00:04 (12:04 a.m.) Nursing Note: I have reminded the patient 3 times to attempt to give us a urine sample. He/She continues to say, "I will do it". But when I return, he/she still has not given a urine sample. I asked if he/she needs someone to come and assist him/her, he/she declines.
1/11/16 00:10 (12:10 a.m.) Patient resting quietly. When I inquired about the patient's pain he/she reports, "I'm just mentally disturbed." I inquired as to whether he/she was having SI or HI, pt denies both. Pt also denies visual and auditory hallucinations. He/She refuses to elaborate on his/her comment. Comfort measures provided. Pain reassessment performed. VS (vital signs) rechecked (see VS grid).

1/11/16 00:49 (12:49 a.m.) Community Services Board consultant in to see patient.
1/11/16 01:25 (1:25 a.m.) Nursing Note: Patient up in the hallway pacing around. He/She was redirected back to his/her room.
1/11/16 02:12 (2:12 a.m.) Nursing Note: I spent a considerable amount of time talking with patient about his/her medication, Remeron (an antidepressant medication - www.drugs.com). He/She had questions about what it's good for and expressed that he/she wasn't sure that he/she "needed it". I printed off CareNotes about the medication and reviewed them with the pt. Still he/she states: "I don't know yet if I want to take it". I advised him/her that I would give him/her time to think about it and return in a few minutes to inquire again.

1/11/16 03:06 (3:06 a.m.) Lab Specimens: blood obtained, specimen drawn by nurse from the right antecubital via butterfly needle the specimen was sent to the lab as this RN (Registered Nurse) was drawing blood pt states "I just want to keep it safe".
1/11/16 03:08 (3:08 a.m.) Nursing-Nursing Assessment Note: Pt approaches this RN and states, "I don't want anyone having my blood".
1/11/16 03:45 (3:45 a.m.) Items found upon search; (initial of hospital Security Officer) (name) advises that he/she saw the pt in the room doing push-ups and while he/she was on the floor, a knife fell out of his/her shirt pocket. Per (name of officer) the pt told him/her that he/she had placed the knife under his/her pillow when (officer) searched him/her previously. Knife was confiscated by (Security).

PT PLACEMENT COORDINATOR/ADM UNIT:
PEC (Psychiatric Emergency Center) bed/chair request received and is being processed.- PEC Bed/Chair assignment: Bed/Chair is ready: 4. 1/11/16 03:18 (3:18 a.m.)

FLOWSHEETS: Medication Administration: Mirtazapine (Remeron) ORAL 15mg (fifteen milligrams) Route: PO (by mouth) NOW (ordered at 00:37) GIVEN PO 15mg (name of Staff #11)1/11/16 03:00 (3:00 a.m.).

HISTORY OF PRESENT ILLNESS: Time Provider with Patient: Sunday January 10, 2016 22:21 (10:21 p.m.)
Vital Signs per nurses notes.
Historian: Patient, other family member
The patient presents with a complaint of abnormal behavior hallucinations. The episode was witnessed by: [parent], sibling(s). The onset was sudden. The symptoms have been occurring for 4 day(s). The episode was precipitated by: Unknown. Associated symptoms: (+)(positive) depression, (+) difficulty sleeping, (+) paranoia, Prior related problems: (+) schizophrenia. Pt with a hx (history) of schizophrenia with 4 days of pacing, insomnia, hallucinations and paranoia. Pt (patient) with recent alcohol intake.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: All negative
NEURO: All negative
CARDIOVASCULAR: All negative
ENT: All negative
RESPIRATORY: All negative
MUSCULOSKELETAL: All negative
INTEGUMENTARY: All negative
ALLERGIC?IMMUN: All negative
HEME/Lymph: All negative
ENDOCRINE: All negative

EXAM:
CONSTITUTIONAL: Distress NAD (No apparent/acute distress) Patient appears WDWN (well developed, well nourished). Patient is alert. NEURO: Oriented x3. Cranial Nerves II-XII within normal limits. No motor or sensory deficits. PSYCH: Oriented x3, depressed, very flat affect. No homicidal ideations. No previous suicidal attempt. No previous suicidal ideation. No previous suicidal plans. Pt with paranoia about my questions. CARDIOVASCULAR: Regular rate and rhythm, heart sounds normal, no gallops, rubs or murmurs, no edema present. GI/ABDOMEN: Soft, non tender, no organomegley, no pulsatile mass. Normal bowel sounds. MUSCULOSKELETAL/Extremities: Non-tender, normal ROM (range of motion), no pedal edema or calf tenderness. NVT intact. NECK: The neck is supple no JVD (jugular vein distention), thyromegaly (enlargement of the thyroid), or lymphadenopathy (palpable enlargement of the lymph nodes). RESPIRATORY: Breath sounds clear, no distress present, no wheezing rales, rhonci, or tachypnea. Normal rate and effort. INTEGUMENTARY: Color normal for race, warm dry, no rash. EYES: PERRL (pupils equal round reactive to light) lids and conjunctivae are normal on exam, no acute pathological process. ENT: External inspection normal, TM's (tympanic membrane) clear, pharynx normal, teeth normal...

Further documentation revealed physician's orders for:
Mirtazipine (Remeron) ORAL 15MG; Route PO; Now - 1/11/16 00:37 (12:37 a.m.)
Laboratory: 1/10/16 22:25 (10:20 p.m.), Hemogram, Comprehensive Metabolic Panel (chem 12) Alcohol Serum Level, TSH Reflex to FT4, Urinalysis, Urine Drug Screen, Lithium Level.

Behavioral Health Consult: Type of referral consult/referral: Psychiatric consult for admission 1/10/16 22:25 (10:25 p.m.)

The clinical record documents the receipt of the following lab results on 1/11/16 at 3:12 a.m.:
Hemogram
At 3:18 a.m. Platelet count
3:35 a.m.- Chem 12
Alcohol Serum- 3:35 a.m.
TSH Reflex to FT4- 3:50 a.m.
Lithium Level- 4:02 a.m.

The ED physician further documented: Spoke with consulting physician 1/11/16 00:37.
Diagnosis: Schizophrenia, paranoid, chronic with acute exacerbation.

Physician: Patient to be placed in the Psychiatric Emergency Center. The patients condition is stable. (1/11/16 2:49 a.m.)

DISPOSITION:
Nursing: Psychiatric Emergency Center ( note-PEC which was described as an extension of the emergency department for observation of psychiatric patients). Time of ED Departure: Monday January 11, 2016 04:15 a.m.

Attempted to call report to PEC. (Name of Staff #12), nurse at PEC advised he/she will review the paperwork and print out the chart. We are waiting for Lithium levels and an evaluation of the elevated liver enzymes prior to his/her (Patient #12) admission to PEC. 1/11/16 4:05 a.m.

According to the clinical record, Patient #12 departed the ED for the PEC area at 4:15 a.m. on 1/11/16.

Upon further review of the clinical record, the Behavioral Health Assessment/Evaluation was not present in the chart for Patient #12. The surveyor requested the facility obtain the evaluation from the Community Services Board. The document was received by the surveyor and revealed the following:
"Virginia Pre-Admission Screening Report- Community Services Board (Name of CSB)
Date of Pre-screening: 1/11/16 Time pre-screening began- 1:00 a.m. Time PreScreening ended: 4:30 a.m....Assessment: (sic) The client is a (age) year old single (race) (gender) who presented at (name of ED) for suicidal ideation. The client was voluntary and was dropped off by family. The client was sitting on the edge of the bed appropriately dressed, clean clothes, no odor and looking at the floor. Upon entering the client made eye contact and said hi. The writer introduced him/herself and explained why he/she was in the room. The writer stated the client was going to be under an ECO (Emergency Custody Order) and asked the client if he/she knew what an eco was. The client stated, "emergency custody order" and stated he/she knew that he/she could not leave. The writer explained it was his/her job to evaluate for a TDO and asked the client if he/she know what a TDO was and the client stated, "yes, a temporary detaining order". The client then stated he/she was on a TDO when he/she went to (another hospital). The writer asked the client how he/she was feeling and the client stated fine. The writer spent two hours total with the client but split the time into several interviews to monitor the client, It should be noted that the writer also monitored the client at the nurses station in the pod. The writer observed the client interacting with female staff appropriately. The client was able to articulate the date, being in the hospital, brought in by his/her (family member), at the hospital because he/she was not taking his/her medications for the last couple of days. The writer asked the client if he/she was feeling suicidal or homicidal and the client stated "no" as he/she looked at the writer. The client was asked if he/she saw or heard things. The client stared at the writer but did not respond. The writer asked if the client saw things that were not there. The client stated no more than normal. The client would not expand on this. The writer asked the client of he/she heard voices, sounds, whispers or static noises. The client stated me (sic) and when the client was asked stated it was his/her thoughts. The client denied any command voices or desires to hurt anyone. The client was adamant about wanting to go to the PEC for overnight and evaluation in the morning. The client was very insightful. The writer discussed with the client the steps it would take to go to the PEC. The client stated that he/she understood he/she had to take his/her Remeron in order to go. The client stated his/her other medications to be Lithium (Client called it Lithium salts) and Saphris. The writer spoke to the client about his/her medications. The client stated he/she stopped taking them because he/she felt they were not working. The writer discussed the importance of medications. The client stated he/she understood he/she needs to continue to take them. The client stated he/she was willing to take the Remeron and spend the night at the care center and be evaluated in the morning. The writer reiterated his/her request and asked the client if he/she would take his/her medication and the client said yes. At this time the writer spoke with the nurse and informed him/her of the clients decision. The writer observed the client taking his/her Remeron without incident. It should be noted at this point, the client did not demonstrate any behaviors that would have him/her meet criteria for a TDO (Temporary Detaining Order). The client was alert and orientated (sic) knew his/her situation and was aware of the impact his/her medication has on his/her symptoms. The client did not demonstrate any behaviors to indicate he/she was agitated, anxious or a harm to self or others. At this time, the writer was standing outside when approached by security staff who asked what the status of the ECO (Emergency Custody Order) and whether it was issued or lifted or voided. The writer stated that the status of the ECO was on the staff. The writer explained that the client did not meet TDO criteria due to his/her willing to volunteer and following directions. The supervisor went in to the room and spoke with the client in which the writer observed. The client spoke with the supervisor appropriately and appeared to responded (sic) well. The supervisor stated that (Name of local Law enforcement) dispatch states there is a 24 hour window to service the ECO. The writer stated if that was the case then the course of the plan would be to have the client go to the PEC and if the client acted up in any way then initiate the ECO for the TDO eval. The writer informed medical staff and coworker of this plan and it was agreed upon. The writer went into the room and discussed with the client the request of blood work. The writer explained how a blood level was needed to measure the Lithium level. The writer explained the purpose to prevent any harm and to ensure the proper dosage was administered. The client asked how much, and the writer stated only enough to get the level done. The client consented. The nurse went in to obtain blood and came out of the treatment room stating the client would not consent to his/her blood being drawn. The writer went in to the room with the nurse and reexplained the reason why the blood was needed. The client consented and gave blood. The client then got up and left his/her room. When asked why, the client stated he/she was going to the PEC to sleep. The writer and staff easily redirected the client back to his/her room and explained they were waiting for results. The client was observed by the writer for a few moments longer and the client did not demonstrate any behaviors to change the voluntary status. The writer did inform security and staff that if anything changed to let the writer know quickly to evaluate the change. The staff and security confirmed. The writer completed the case at this point. Moments later, the writer was asked by the clients nurse to speak to the PEC about the client hot having a blood urine test. The writer called and spoke with the nurse (Name) and explained the decision between (name of psychiatrist and ED physician). He/she stated okay and approved the client to go over. It should be noted that upon entering the case the writer was informed the client was being placed under an ECO by the medical doctor due to the client not willing to take his/her medication. There was thought the client might have issues will tall men due to his interacting with women so well. The agreement of the client going to the PEC under voluntary status as long as the client took his/her night time medication and willing to stay the night and be evaluated in the morning was done prior to the writer taking the case and between the medical provider (name) and (name of psychiatrist)." The document was signed by the Community Services Board (CSB) worker and co-signed by "supervisor" of the CSB worker.

Review of documents provided by the facility, revealed the patient arrived to the PEC area on 1/11/15 (verified date error- should have been 1/11/16) at 4:15 a.m.(sic):
According to a handwritten document completed by Staff #12, "Pt (patient) came from ED to our unit at 0415 a.m.- agitated, pacing, running hands through hair. Tried to talk to him/her asking if wanted food, drink. Told he/she would be safe - would see MD (physician) in am to determine next phase in treatment. Asked to tell me how he/she was feeling, what he/she was thinking. Asked to talk to us. Pt asked to see security officer (Name of Staff # 13) (Staff #13 and name of other security) brought to unit at 4:15 a.m. Called (Security) at 0420. At 0422, (Staff #13- security) was over here at unit. Ask that he/she stay so I could put meds in and give pt prior to his/her leaving. Staff #13 agreed. Pt. asked to make phone call, this was done. Called pharmacy at 0430, asked they put in Haldol, Ativan, and cogentin ASAP, it was imperative. 0435 told Staff #27 to call pharmacy back and tell them if meds (O with a line through it indicating not) in w/i (within) 5 five min (minutes) we were going to have a code Atlas ( violent, aggressive behavior). Staff #27 was told to call admissions to have him/her (Patient #12) transferred to PEC. I kept trying in Accudose to get pts name to come up, but still (O with a line through it indicating not) in Accudose. At approximately 437 heard scuffle, came out to see patient, (name of Staff #10) and (document says "over" to continue this portion of event) (name of Staff # 13) in a scuffle near the security desk. (name of Staff #13) pulled tazer but patient took from him/her. Tried to taze them both (Staff #10 and Staff #13). (Name of Staff #10) went towards room 4 and patient was running towards him/her and rounded refrigerator area. (Name of Staff #10) tazed in left shoulder area. (Name of Staff #27) and I ran. I went to the med room and (Name of Staff #27 went into the back. Within minutes, heard gun shots...heard 3 shots but states 4 were fired... 450 called (Name of police department)... " The document continues on the front side with the following information "ECO (emergency custody order) obtained at 1:18 a.m., discussed with ED and CSB (Community Services Board) about ECO's (not) coming to our unit. Was told (Patient #12) voluntary by both...Was told by ED and (Name of psychiatrist) that plan was to get him/her (Patient #12) to our unit, settle down for night and take meds. Any trouble and they would TDO (Temporary detaining order) him/her."

Further review of the clinical record did not reveal any other documentation regarding the events that occurred on the PEC unit after Patient #12 arrived. The information concerning the event was obtained through interviews and documents provided by the facility staff that had not been entered into the clinical record. After the event occurred on the PEC, the clinical record documented the following (in part) in regards to the condition, care and treatment for Patient #12: (Not all information contained on the triage/treatment record is contained in the following by the surveyor)
CHIEF COMPLAINT: GSW (gun shot wounds)
TRIAGE: CHIEF COMPLAINT QUOTE: Patient found at PEC with multiple GSW's.
ARRIVAL: The patient arrived in a stretcher pushed to ED from the PEC from within the hospital.
The patient was accompanied by: ED staff.
AIRWAY: The airway is open and patent.
BREATHING: Agonal Breath sounds are diminished bilaterally entire lobes.
CIRCULATION: Bilateral femoral pulse is strong.
MENTAL STATUS: The patient responds to verbal commands.
SPEECH: The patient is speaking incoherently.
SKIN COLOR: The patient's skin appears dusky.
TEMPERATURE: The skin feels cool.
CONDITION: The patient's skin is diaphoretic.
MEDICAL CARE DISCUSSION: Unable to obtain permission due to patient's condition.
PRIMARY TRIAGE FORM: Onset of symptoms, last known well: Approximately Monday, January 11, 2016 04:45 (a.m.)
PATIENT ALLERGIES: No known allergies.
MEDICAL HISTORY: Schizophrenia, Bipolar Disease, Schizo affective, hypertension
SOCIAL HISTORY: Uses tobacco products on occasion, Drinks alcohol on occasion, Denies use of illicit drugs.
NURSING NOTES:
1/11/16 04:51 TRAUMA FLOWSHEET Trauma alert Level 1 was called. Alert activated prior to arrival. Alert was called by the Communication Technician. The time the alert was called: 04:51. A Trauma Level 1 Alert was called according to guidelines using the following criteria: significant penetrating trauma to head, neck or torso (torso is above the inguinal ligaments, including genitalia).
1/11/16 04:51 The patient arrived to the ED Trauma Bay at: 04:51 Time ED physician at bedside: (name of physician) in room but (name of physician) met the patient at the PEC with this RN and nursing supervisor (name).
1/11/16 04:51 Mechanism of injury: assault handgun- See security note regarding incident patient belongings given to (local law enforcement initials) officer.
1/11/16 04:51 C Spine immobilization- Not immobilized on arrival and no backboard in place on arrival....
1/11/16 04:51 Gross blood loss: The patient's total blood loss is a heavy amount. Currently the patient is bleeding a heavy amount. The blood is bright red...
1/11/16 04:51 General Injuries- chest: There is a/an 1 gunshot wound(s) and located on the upper chest and 1 gunshot wound(s) left upper ribs...
1/11/16 04:51 Abdominal/pelvis: There is a/an 1 gunshot wound(s) to the left of the umbilicus...
1/11/16 04:51 There is a/an 2 gunshot wound(s) to left upper arm
1/11/16 04:51 There is a/am 2 gunshot wound(s) to the right upper leg...
1/11/16 05:01 Trauma surgeon at the bedside (name) 05:01
1/11/16 05:03 Patient log rolled to assess for posterior injuries.
1/11/16 05:03 General Injuries back: There is a/an 1 gunshot wound(s) to the left scapula with a large amount of blood pooled on stretcher. The wound and bleeding were noted after the patient sat up and started grabbing staff and yelling "Jesus"...

Documentation continues with multiple entries concerning the initiation of intravenous catheters, fluids, oral intubation, type and cross match and administration of blood products, insertion of chest tube, x rays, central line placement, medications administered, and assessments.

Further documentation revealed:
"HISTORY OF PRESENT ILLNESS:
Time provider with patient: Approximately Monday January 11, 2016 05:00 HPI text: We were called for gunshot wounds at the psychiatric emergency Center.
I ran to the psychiatric emergency Center with the nursing supervisor after a call was made for shots fired with a patient down. Upon arrival the patient was lying on the floor supine with security guards holding pressure on (his/her) thoracic and extremity ballistic injuries. Patient was agonal. I immediately asked the nursing supervisor to activate a level 1 trauma to alert the on call surgeon and operating room. We loaded the patient onto the stretcher and ran (him/her) back to the resuscitation bay in the emergency department. I directed the trauma resuscitation: (He/She) was put on a non-rebreather mask while (he/she) was still breathing spontaneously and IV access was obtained...Patient had suffered multiple ballistic injury's to left chest, left upper extremity and right lower extremity. As resuscitation went on (his/her) vital signs improved and so did (his/her) mental status and (he/she) became combative and trying to pull off (his/her) mask, pulling with (his/her) arms at staff and sitting up in the bed for a brief period of time. (He/She) was paralyzed and intubated...(He/She) left the department in critical but stable condition. At no time did the patient moved (his/her) lower extremities..."

The clinical record contained a document "History and Physical" dated 1/11/16, which evidenced, in part: "(name) is a (age) (gender) with a long history of erratic behavior. (He/She) is apparently schizophrenic and tonight came to the emergency room in a temporary detaining order(sic) apparently was obtained. (He/She) apparently went berserk in the psych emergency room resulting in a fight in which security tried to subdue the (gender). (He/She) apparently seized various weapons and ultimately was brought down with multiple gunshots....EXAMINATION: ...There is an entry gunshot wound just at the sternum which seems to exit from the left side of the chest and then go through the left upper arm. There is a gunshot wound over the right anterior thigh. There is a single entry wound at the mid abdomen just to the left. There is also an entry wound to the back...PLAN: 1. Massive transfusion protocol. 2. IV resuscitation 3. Broad spectrum antibiotics 4. Patient will be taken to the operating room immediately..."

The "Operative Report" contained in the clinical record dated 1/11/16 which revealed, in part:
"...INDICATIONS FOR PROCEDURE: (name) is a (age/gender) admitted through the emergency room with multiple gunshot wounds to the right leg, abdomen, chest, left arm and back...PROCEDURE IN DETAIL: ...The chest wound is now briefly explored. This actually seems to track subcutaneously. The posterior wound tracks more to the posterior ,midline. There is a fractured rib easily palpable below the skin margin. The left arm injury seems superficial, and the radial pulse in the left arm is good....There is an entry wound in the mid abdomen to the left of the midline. The injury in the right thigh appears superficial....there is a suspected thoracic injury because of the lack of movement in the lower extremities..."

A "Consultation" note dated 1/11/16 from neurology evidenced: "...IMPRESSION/PLAN: Spinal Cord injury secondary to bullet fragment at T7. Anticipate the patient will have paralysis below this level...can have aggressive spinal cord rehabilitation. At this level of paralysis, the patient can learn to be independent with ADLs and toileting..."

According to further documentation in the clinical record, Patient #12 was transferred to another acute care facility per request of the patients family on 1/13/16.

On 2/9/16 at 9:40 a.m., the surveyor spoke with Staff # 19, staff # 18, Staff # 6, Staff #2, and Staff # 5 regarding the PEC- Psychiatric Emergency Center. Staff # 19 (Vice President of Mental Health) stated, "About one and a half to two years ago, we began evaluating the way we were working with patients in the ED, those who were in a psychiatric crisis. At that time we did not have specialized facilities designed for those psych patients in the ED, we didn't have the hardware to make those patients safe in the ED. We looked at how we could create in the ED a safe area for the evaluation and care of those patients and we determined we could use the Dillard Building which is across the street for that purpose. Our partners at (name of a CSB) and the Crisis Intervention team received a training grant and it also partners with the Sheriffs office for non serious and non violent patients to get psychiatric help rather than taking those patients to jail. They needed a place and we were evaluating a different system, so we determined the Dillard Building could be that space. It is designed for the assessment, treatment and observation of psychiatric patients that come to the emergency room for help. There are 4 rooms, and it is staffed with nurses, an on-call psychiatrist, mental health staff ,Nurse Practitioner and Professional Providers..." Staff #5 (Director of Emergency Services) stated, "We started taking patients there November first..." Staff # 18 (Director of Adult Mental Health) stated, "It also houses an Intake Center for phone calls and a consultation service for hospitalizations from our Nurse Practitioner and Psychiatrist for patients with dual diagnoses and mental health..." Staff # 19 continued, "We made a determination a year ago that if patients, after receiving a medical clearance first, needed a quieter safer area, that the ED was not best place for them to remain for observation..." Staff # 6 (Emergency Department Medical Director) stated, "If the patient came in and were violent or highly decompensated, needed medical management or were very psychotic, they would remain in the emergency department to obtain treatment and disposition and would not go to the PEC. All patients that come in to the ED must have a screening and medical clearance before any determination of disposition is made..." Staff #19 continued, "Patients who were on ECO (Emergency Custody Order) were the patients that the grant was specifically set up for and it would allow the local law enforcement to be able to hand off the patient to a specially trained Crisis Intervention Officer and then return to their duties on the street..." Staff # 6 stated, " When we first began the PEC we could send the ECO patients, however staffing became an issue and because we did not have the availability of a provider on site 24/7 we pulled the ECO's back to the main emergency department...it was used for those who may have severe depression or anxiety in order to continue to observe the patient for a period of time and allow them to receive treatment and counseling until a determination could be made whether the patient required hospi

Based on interview and document review, it was determined the facility staff failed to ensure the least restrictive restraint was ordered for one (1) of eleven (11) restrained patients included in the survey sample (Patient #41).

The findings included:

Review of Patient #41's electronic medical record (EMR) indicated the patient was admitted to the facility on 12/07/2015 at 11:43 a.m., for mental health crisis. Patient #41's EMR included a "Doctor Order Sheet" "Seclusion / Restraint Order Form" dated "12/7/15"and timed at "2340 (11:40 p.m.)." Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" listed the "Type of Restraint" as "Type II-Vest or Jacket Restraint"; "Type III-Soft" restraints for bilateral legs; and "Type IV-leather/twice as tough" restraints for Patient #41's bilateral wrist and legs. Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" indicated it was for both "4 hours (Violent >18)" and "24 hours (Non-Violent)." The "Doctor Order Sheet" "Seclusion / Restraint Order Form" had been signed by the physician on "12/8/15" at "0930 (9:30 a.m.)." Review of restraint monitoring documentation revealed Patient #41 had been placed in bilateral "leather" wrist restraints and bilateral "soft" leg restraints. Patient #41's EMR did not contain documentation for the reason "Type III soft" were used bilaterally as leg restraints and "Type IV leather/twice as tough" were used as bilateral wrist restraints.

An interview was conducted on 02/17/2016 at 2:35 p.m., with Staff # 5 and Staff #33. Staff #33 verified Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" listed the facility staff could use any of three (3) categories of restraints. Staff #33 confirmed Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" should have specified the least restrictive means of restraining Patient #41. Staff #33 verified the facility staff failed to obtain a specific physician's order to utilize a combination of "leather" and "soft" restraints.

A review of the facility's policy titled "Patient Care Services - Patient Restraint and Seclusion" approved "07/29/2014" was conducted on 02/11/2016. The policy read in part: "III. Philosophy ... B. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm."

Based on interview and document review,it was determined facility staff failed to modify the care plans for two (2) of eleven (11) restrained patients included in the survey sample (Patients #40, #42).

The findings included:

1. Review of Patient #40's electronic medical record (EMR) revealed the patient was admitted to the facility at 8:43 p.m. on 02/15/2016 for respiratory failure. Patient #40's EMR indicated the patient had been intubated by emergency medical transport (EMT) personnel en route to the facility. Review of Patient #40's EMR documented Patient #40 was placed in restraints on 02/15/2016 and remained in restraints through 2:30 a.m. on 02/16/2016. Review of Patient #40's EMR did not reveal a modification to his/her care plan related to restraints.

An interview was conducted on 02/17/2016 at 11:40 a.m., with Staff #54. Staff #54 reviewed Patient #40's EMR. Staff #54 verified Patient #40 had been restrained and his/her care plan had not been modified to reflect the utilization of restraints.

2. Review of Patient #42's EMR revealed the patient had been admitted to the facility on 06/12/2015 at 2:46 a.m. for Bipolar disorder. Patient #42's EMR documented the patient had been placed in a restraint chair on 06/12/2015 at 3:00 p.m. and continued to be restrained until 6:20 p.m. on 06/12/2015. The care plan in Patient #42's EMR had not been modified to reflect that Patient #42 had been restrained.

An interview was conducted on 02/17/2016 at 3:11 p.m., with Staff #22. Staff #22 reviewed Patient #42's EMR. Staff #22 verified Patient #42's EMR did not have a modified plan of care to include restraints.

A review of the facility's policy titled "Patient Care Services - Patient Restraint and Seclusion" approved "07/29/2014" was conducted on 02/11/2016. The policy read in part: "III. Philosophy ... C. The use of restraint or seclusion must be- 1. In accordance with a written modification to the patient's plan of care ..."

Based on observation, interview and document review, it was determined the facility staff failed to obtain appropriate physician's orders to restrain three (3) of eleven (11) restrained patients included in the survey sample (Patients #40, #41 and #43).

The findings included:

An interview was conducted on 02/11/2016 at approximately 2:00 p.m., with Staff #22. Staff #22 reported the facility's "Doctor Order Sheet" "Seclusion / Restraint Order Form" were for a "calendar day." Staff #22 reported each calendar day would require a new restraint order if the patient continued in restraints for non-violent patients and every four hours for patients exhibiting violent behaviors.

1. Review of Patient #40's electronic medical record (EMR) revealed the patient was admitted to the facility at 8:43 p.m. on 02/15/2016 for respiratory failure. Patient #40's EMR indicated the patient had been intubated by emergency medical transport (EMT) personnel en route to the facility. Staff #54 and the surveyor reviewed Patient #40's EMR. Patient #40"s EMR documented the patient was placed in restraints on 02/15/2016 and remained in restraints through 2:30 a.m. on 02/16/2016. Patient #40's EMR did not contain a "Doctor Order Sheet" "Seclusion / Restraint Order Form" dated for 02/15/2016. The surveyor asked if Patient's 40's EMR and paper medical record was complete. Staff #54 stated, "The record is complete. If a patient transfers to a different unit the entire paper record is sent with the patient and the electronic record flows, it is all one electronic system." Staff #54 verified Patient #40's EMR and paper medical record did not contain a physician's order for restraints used on 02/15/2016.


2. Review of Patient #41's electronic medical record (EMR) indicated the patient was admitted to the facility on 12/07/2015 at 11:43 a.m., for mental health crisis. Patient #41's EMR included a "Doctor Order Sheet" dated 12/7/2015 at 6:20 p.m. which read: "Four point leather restraints, PRN." The "Doctor Order Sheet" had been stamped as "Electronically Authenticated by [the physician's name] On 12/10/2015 0617 PM EST." The order did not specify if the four point leather restraints were for violent or non-violent behaviors. [As cited in A-0169 facility staff cannot order restraints on an as needed or PRN basis.]

Patient #41's EMR included an additional "Doctor Order Sheet" "Seclusion / Restraint Order Form" dated "12/7/15"and timed at "2340" (11:40 p.m.). Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" listed the "Type of Restraint" as "Type II-Vest or Jacket Restraint"; "Type III-Soft" restraints for bilateral legs; and "Type IV-leather/twice as tough" restraints for Patient #41's bilateral wrist and legs. The "Doctor Order Sheet" "Seclusion / Restraint Order Form" had not been checked to indicate whether the restraint order was for non-violent or violent behavior. A section on the form for description of behaviors "Behavior Requiring Use of Seclusion / Restraint" documented the following behaviors: "Danger to self/others," "Serious disruption of environment," "Agitation," "Combative," and "High risk for falls."

Review of Patient #41's EMR nursing documentation indicated the restraints were employed related to the patient's violent and self-destructive behaviors. Review of unit monitoring documentation revealed Patient #41 was placed in a restraint chair at 11:00 p.m. on 12/7/2015 and staff employed bilateral "leather" wrist restraints and bilateral "soft" leg restraints. The last reassessment documentation indicated Patient #41 remained in restraints until 5:00 a.m. on 12/8/2015. Restraint orders for violent adult patient have the maximum duration of four (4) hours. Patient #41 remained in restraints per the facility's documentation for six (6) hours. Patient #41 was restrained from 3:00 a.m. to 5:00 a.m. on 12/8/2016 without a physician's order for restraints.

An interview was conducted on 02/17/2016 at 2:35 p.m., with Staff # 5 and Staff #33. Staff #33 verified Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" listed the facility staff could use any of three (3) categories of restraints. Staff #33 confirmed Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" should have specified the least restrictive means of restraining Patient #41. Staff #33 verified the facility staff failed to obtain a specific physician's order to utilize the combination of "leather" and "soft" restraints. The surveyor asked if leather or "twice as tough" restraints were utilized with non-violent patients; Staff #33 stated, "You wouldn't think so, but I'm not sure." Staff #33 acknowledged nursing documentation indicated Patient #41 exhibited violent behaviors. Staff #3 and the surveyor reviewed the facility's policy "Patient Care Services - Patient Restraint and Seclusion" approved "07/29/2014."

The policy read in part: "IV. Orders: A. Restraint and seclusion require a physician/NP [Nurse Practitioner]/PA [Physician Assistant] order ... D. Restraint and Seclusion Orders 1. Violent or self-destructive patient (harm to self or others) 1.1 Maximum Duration of the restraint or seclusion order for the management of violent or self-destructive behavior is: 4 hours for adults 18 years of age and older: ..."

3. Patient #43 an active patient was admitted to the facility on 02/03/2016 at 1:24 p.m., for acute respiratory failure. An observation and interview was conducted on 02/17/2016 at 11:49 a.m., with Patient #43. The observation conducted in Patient #43's room revealed a vest-type restraint laying on the couch next to the patient, who was sitting up in a chair. The surveyor asked Patient #43 about the restraint. Patient #43 stated, "They used that to tie me down. I don't know why they did that to me. I'm not holding a grudge, but no one should be treated like that in this day and age. One day I urinated on myself. I was tied down it was embarrassing. I'm happy it's off." Patient #43 reported that they had removed the vest restraint on 02/16/2016.

Patient #43's EMR was reviewed with Staff #54. Nursing documentation revealed Patient #43 was restrained for non-violent behaviors. Staff #54 reviewed Patient #43's paper medical record for restraint orders. The review revealed the restraint order for 02/13/2016 had not been signed by a physician. Patient #43's paper medical record did not have a restraint order for 02/10/2016 and 02/16/2016. Review of Patient #43's EMR revealed the patient was in restraints on 02/10/2016 and 02/16/2016 without a physician's order for restraints. The surveyor asked Staff #54 if the paper physician orders could be waiting to be filed. Staff #54 stated, "No, they should be on the chart. There is no physician order for February 10th or 16th." The surveyor asked Staff #54 regarding the time frame for physician's to sign restraint orders. Staff #54 deferred to the on-line policy.

The facility's policy titled "Patient Care Services - Patient Restraint and Seclusion" did not specifically reflect when the physician should sign the restraint order. The policy in part read "2.1 Restraint orders for the management of non-violent or non-destructive behavior must be renewed every calendar day." Staff #54 acknowledged Patient #43 had been restrained without physician orders for restraints on 02/10/2016, 02/13/2016, and 02/16/2016.

Based on interview and document review, it was determined the facility staff failed to ensure a restraint was not ordered on an as needed (PRN) basis for one (1) of eleven (11) restrained patients included in the survey sample (Patient #41).

The findings included:

Review of Patient #41's electronic medical record (EMR) indicated the patient was admitted to the facility on 12/07/2015 at 11:43 a.m., for mental health crisis. Patient #41's EMR included a "Doctor Order Sheet" dated 12/7/2015 at 6:20 p.m. which read: "Four point leather restraints, PRN." The "Doctor Order Sheet" had been stamped as "Electronically Authenticated by [the physician's name] On 12/10/2015 0617 PM EST."

Patient #41's EMR included an additional "Doctor Order Sheet" "Seclusion / Restraint Order Form" dated "12/7/15"and timed at "2340" (11:40 p.m.). Patient #41's "Doctor Order Sheet" "Seclusion / Restraint Order Form" listed the "Type of Restraint" as "Type II-Vest or Jacket Restraint"; "Type III-Soft" restraints for bilateral legs; and "Type IV-leather/twice as tough" restraints for Patient #41's bilateral wrist and legs.

Review of the restraint monitoring documentation indicated Patient #41 had been placed in bilateral "leather" wrist restraints and bilateral "soft" leg restraints.

An interview was conducted on 02/17/2016 at 2:35 p.m., with Staff # 5 and Staff #33. Staff #33 verified Patient #41's EMR contained a "Doctor Order Sheet" ordering as needed (PRN) bilateral wrist and leg leather restraints as well as a "Doctor Order Sheet" "Seclusion / Restraint Order Form" that listed multiple types of restraints that could be used to restrain Patient #41. Staff #33 reported restraint orders could not be written as PRN or as needed.

A review of the facility's policy titled "Patient Care Services - Patient Restraint and Seclusion" approved "07/29/2014" was conducted on 02/11/2016. The policy read in part: "IV. Orders: ... B. Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).

Based on observation, interview and document review, it was determined the facility staff failed to monitor patients placed in restraint in accordance with the facility's policy for four (4) of eleven (11) restrained patients included in the survey sample (Patients #5, #41 and #42 and #45).

The findings included:

1. Review of Patient #5's electronic medical record (EMR) indicated the patient was brought to the facility's emergency department (ED) on 11/29/2015 by emergency medical transport. Patient #5's EMR documented the patient was admitted with a diagnosis of "Overdose." The nursing assessment for Patient #5 utilized a form titled "SAD PERSONS Suicide Risk Assessment," which list factors that calculate the patient's risk and level of monitoring. Patient #5 scored a "5" on the "SAD PERSONS" assessment. The form documented Patient #5's level of risk and monitoring: "Moderate Risk ** Patient monitoring every 30 minutes and document in medical record**."

Review of Patient #5's monitoring revealed three missed opportunities for every thirty (30) minute checks. Patient #5's EMR revealed staff did not document monitoring every thirty (30) minutes between 5:05 a.m. and 6:05 a.m.; 6:05 a.m. and 7:00 a.m. also between 8:30 a.m. and 9:28 a.m.

An interview was conducted on 02/11/2016 at 11:30 a.m., with Staff #20. Staff #20 and the surveyor reviewed Patient #5's EMR. Staff #20 verified staff had not performed as required every thirty (30) minute monitoring of Patient #5 on 11/29/2015.

2. Review of Patient #41's electronic medical record (EMR) indicated the patient was admitted to the facility on 12/07/2015 at 11:43 a.m., for mental health crisis. Patient #41's EMR documented the patient was placed in a restraint chair in the emergency department (ED) at 1:26 p.m. on 12/07/2015. The physician's order indicated the the restraint was for violent behavior. Accordingly restraints for violent behavior required every fifteen (15) minutes monitoring. Review of Patient #41's EMR revealed every fifteen minute restraint monitoring until "1445 (2:45 p.m.)." Patient #41's EMR contained a physician's order to discontinue use of the restraint chair at "1552 (3:52 p.m.)." Review of nursing documentation did not reveal Patient #41 had been released prior to the 3:52 p.m. order to discontinue the restraint chair.

Patient #41's EMR did not have every fifteen (15) minute monitoring from the last entry at 2:45 p.m., until the physician order to discontinue. Facility staff failed to perform monitoring at least four separate fifteen (15) minute intervals prior to the order to discontinue the restraint chair.

An interview was conducted on 2/17'2016 at 2:35 p.m., with Staff #5. Staff #5 reviewed Patient #41's emergency department EMR. Staff #5 reported there was no other documentation related to Patient #41's every fifteen minute monitoring between "1445 (2:45 p.m.) and 1552 (3:52 p.m.)."

3. Review of Patient #42's EMR revealed the patient had been admitted to the facility on 06/12/2015 at 2:46 a.m. for Bipolar disorder. Patient #42's EMR documented the patient had been placed in a restraint chair on 06/12/2015 at 3:00 p.m. and continued to be restrained until 6:20 p.m. on 06/12/2015. Review of Patient #42's EMR did not reveal that every fifteen (15) minute monitoring was documented from 4:04 p.m. through 6:20 p.m. on 06/12/2015. Review of facility's staff documentation of Patient #42's vital signs did not include monitoring the patient's vital signs from 1604 (4:04 p.m.) through 2247 (8:47 p.m.) on 06/12/2016.

An interview was conducted on 02/17/2016 at 3:11 p.m. with Staff #22. Staff #22 reviewed Patient #42's EMR. Staff #22 verified the above findings and reported staff failed to document they had performed restraint monitoring every fifteen (15) minutes as required per facility policy.

A review of the facility's policy titled "Patient Care Services - Patient Restraint and Seclusion" approved "07/29/2014" was conducted on 02/11/2016 and 02/17/2016. The policy read in part: "X. Reassessment and Monitoring Guidelines ... by § RN [Registered Nurse]/LPN [Licensed Practical Nurse] (Nursing); § RN/LPN/MHC (Behavioral Health)" for "Violent Behavior - Frequency of Activity at least: Respirations (Violent Behavior) Q [Every] 15 min [minute] & [and] PRN [as needed]; Proper position of restraint/signs of injury Q 15 min. & PRN; Circulation check Q 15 min. & PRN; Least restrictive measure tried Q 15 min. & PRN; Mental status and emotional well-being Q 15 min. & PRN; Rights, dignity and safety Q 15 min. & PRN; Level of distress or agitation Q 15 min. & PRN; Evaluation for removal Q 15 min. & PRN ..."


34756

4. The survey team was provided a list of currently restrained hospitalized patients by facility staff on 2/17/2016. While in the CCU, observation of Patient #45 at 12:10 PM on 2/17/2016 confirmed that the patient was in soft wrist restraints. A review of Patient #45's record revealed that the patient was admitted to the facility on 2/14/2016, and had restraint orders in his/her record which were signed and dated by the physician for 2/15/2016. At 12:10 PM on 2/17/2016, two surveyors observed paper copies of restraint orders dated 2/16/2016, and 2/17/2016 in Patient #45's record, neither had been signed by the physician. During an interview with Staff #57, the RN caring for Patient #45, stated "(Patient's name) has been restrained since admission". There was documentation in the electronic record of every 2 hour monitoring and assessment of Patient #45's restraints between 0000 hours (midnight) on 2/15/2016 through 2/16/2016 at 0924 hours (9:24 AM). From 0924 hours on 2/16/2016 until 1530 hours (3:30 PM) on 2/16/2016, the record lacked documentation of restraint assessment and monitoring. Between 1530 hours on 2/16/2016 and 12:00 PM 2/17/2016, when Patient #45 was observed by the surveyors to be in restraints, every 2 hour restraint assessment and monitoring was documented.

On 2/17/2016 at 12:25 PM during an interview with Staff #57 regarding the facility restraint policy, he/she stated "restraint orders are renewed every 24 hours, patients are assessed for what restraints are needed, and least restrictive ones are used; non-violent restraints are documented every 2 hours, and the paper form in the record is the primary source to check for the order". Staff #29, the CCU nurse manager was present during the interview of Staff #57 and was in agreement with Staff #57's statement.

The facility's Patient Restraint and Seclusion policy states the following under the heading reassessment and monitoring guidelines: for non-violent behavior, monitor VS (vital signs) every 4 hours and lists the following 13 activities to be performed every 2 hours and PRN (as needed) by an RN (registered nurse) or an LPN (licensed practical nurse):
proper position of restraint/signs of injury
circulation check
least restrictive measure tried
mental status and emotional well being
rights, dignity, and safety
level of distress or agitation
evaluation for removal
nutrition/hydration
loosen and perform ROM
hygiene
elimination/I&O
turn/reposition/ambulate
skin integrity under restraint

Staff #33, an RN, assisted the surveyor with the EMR (electronic medical record) when looking for documentation of the every 2 hour restraint monitoring and assessment for
Patient #45, and at 2:50 PM on 2/17/2016, he/she stated "I think it's (the assessment) is just not there".

The findings were discussed with Staff #57 and #29 on 2/17/2016 at 12:30 PM.

Based on staff interview and an audit of six (6) PEC (psychiatric emergency center) employee records, it was determined the facility staff failed to ensure that two (2) of six (6) direct care staff received restraint training and demonstrated competency in the application of restraints, implementation of seclusion, and the monitoring, assessment, and provision of care for a patient in restraint or seclusion prior to performing any of those actions.

Findings include:

1. A review of the employee record for Staff #12 (who was present on the PEC unit when Patient #12 showed aggressive behavior on 1/11/2016) revealed that he/she was hired on 10/5/2015 to work as an RN (registered nurse) on the PEC unit. On 2/19/2016, an interview with Staff #22, the PEC unit manager, he/she stated that "Staff #12 worked in the PEC unit between 11/1/2015 and 1/11/2016 while it was open". There is no documentation that Staff #22 received unit specific orientation or BLS (basic life support) after hired, and he/she did not become MANDT certified until training on 12/28 and 12/29/2015, more than 2 months after he/she began working on the PEC unit. MANDT training is "a comprehensive integrated approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others" (www.mandtsystem.com).

As of 2/19/2016 at approximately 11:00 AM, when Staff #22 pulled up training information on the computer, there was no documentation that Staff #12 was certified in CPR (cardio-pulmonary resuscitation). The facility's Professional Nursing Development, Nursing Orientation 2015 states that all new hires must have AHA (American Heart Association) CPR certification within 30 days of employment".

2. A review of the employee record for Staff #58, an AMHP (approved mental health provider), revealed that he/she was hired on 10/19/2015. The record lacked documentation of a unit specific orientation for the PEC, and there was no documentation that he/she had completed BLS or MANDT training as of 2/19/2016 when the employee record was reviewed. When asked if Staff #22 had been working on the PEC unit, Staff #22, the PEC unit manager stated "yes".

Staff #22 provided the surveyor with a blank skills check off list for an RN working in the PEC unit and a skills check of list for an AMHP working in the PEC in order to share the training expectation for staff working in the PEC. The skills checkoff list for an RN included "..19. Therapeutic Interventions; 20. Therapeutic Escort and HOLD-Order, MANDT, Documentation; 21. Restraints, Seclusion-Order, Time, Face to Face, Documentation". The skills checkoff list for the PEC-AMHP included "...7. Therapeutic Interventions; 8. Therapeutic HOLD-MANDT, Documentation; 9. Restraints, Seclusion-Time, Documentation".

The job description for a Mental Health Professional states the following under "Required Certification and Licensure Requirements: "Certified in Mandt Training within four months of hire. Current BLS within four months of hire". Regulations requires that all staff designated by the hospital as having direct patient care responsibilities, including contract or agency personnel, must demonstrate competencies in the application of restraints, implementation of seclusion, monitoring, assessment, or care of a patient in restraint or seclusion initially as part of orientation, before performing any of the above actions.

A discussion was held with Staff #5 and #22 on 2/19/2016 at 11:15 AM regarding the AMHP job description requirement that the MANDT training and BLS is not required until 4 months after hire, and Staff #5 responded "that is true they have 4 months to get that training; we will probably be looking at that".

Based on interview, medical record review, and during the course of a complaint investigation, it was determined the facility failed to maintain complete and accurate medical records.

The findings included:

1. The medical records failed to contain information that was complete and accurately documented for 3 (three) of 39 (thirty-nine) patients of the survey sample. (See citation A-0438 for details.)

2. Documentation of behavioral health pre-screening evaluations were not contained on the clinical record for eight (8) of twelve (12) patients and one (1) of eleven (11) patients did not have a care plan developed for the use of restraints. (See 0449 for further details.)

3. General consents for treatment and rights not signed for five (5) of forty-one (41) medical records reviewed. (See citation 0450 for details.)

4. Fifteen minute rounding sheets not dated for two (2) of three (3) patients admitted to the adult behavioral health unit included in the survey sample. (See citation 0450 for details.)

5. Incomplete restraint documentation for one (1) of eleven (11) restrained patients included in the survey sample. (See citation 0450 for details.)

Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation, it was determined the facility staff failed to ensure the medical records contained information that was complete and accurately documented for 3 (three) of 39 (thirty-nine) patients of the survey sample. Patient #1, 2 and 24.

The findings included:

1. The electronic medical record (EMR) for Patient #1 was reviewed on 02/09/16. Patient #1 was admitted to the Emergency Department (ED) on 11/03/15. Patient #1 had a diagnosis of "Depression and suicidal ideation" and was seen in consultation by behavioral health on 11/03/15. On 11/03/15 it was documented in the EMR in the "Disposition" "...to PEC (Psychiatric Emergency Center) patient is stable .... " The surveyor was unable to locate in the clinical record, any documentation of how Patient #1 was transported or escorted to the PEC. On 02/09/16, the surveyor requested further information regarding the method of transportation from the ED to PEC from Staff #20.

The surveyor, along with assistance from facility staff (Staff #5 and #20) who were navigating the EMR, were unable to locate any documentation of the method of transport or escorting to the PEC. On 11/03/15 there was a physician's order for "admission to inpatient psychiatric unit."

On 02/09/16 at 5:00 p.m., the survey team reviewed the concerns with the Administrative Staff #2, #5 and #20.

2. Review of the EMR for Patient #2 revealed the Patient was admitted to the ED on 01/09/16 and transferred to an outside facility on 01/10/16. Patient #2 had a diagnosis of "Self mutilation, major depression and suicidal ideation" and was seen in consultation by behavioral health on 01/10/16. On 01/10/16 it was documented in the EMR in the "Progress Notes" "ECO (Emergency Custody Order) was contacted and completed by magistrate at 1:47." The surveyor was unable to locate any specific orders, or order clarification for the "emergency custody order." The surveyor and Staff #20 were able to locate in the clinical record a TDO (Temporary Detention Order) for Patient #2.

Staff #5 stated he/she was not aware why the medical record has documentation that an ECO was completed by the magistrate for the patient when only a TDO is completed for Patient #2.

On 02/09/16 at 5:00 p.m., the survey team reviewed the concerns of an incomplete medical record with the Administrative Staff #2, #5 and #20.

3. Review of the EMR for Patient #24 on 02/10/16 revealed the Patient was admitted to the facility's ED on 12/10/15 at 10:30 a.m. and discharged home on 12/10/15 at 17:17 p.m. (5:17 p.m.) and then back to the ED on 12/14/15 at 13:51 p.m. (1:51 p.m.) and admitted to the psychiatric inpatient unit on 12/15/15. Patient #24 had a diagnosis of "Opiate addiction and acute opioid withdrawal" on the 12/10/15 ED admission and was seen in consultation by behavioral health on 12/10/15. Patient #24's EMR revealed it was documented on 12/10/15 in "Disposition:" "Discharge home stable follow up with PCP (Primary Care Physician) 3-5 days purpose is to re-eval [re-evaluate] and discussed with another health care provider. "

The EMR for Patient #24's admission to the ED on 12/14/15 revealed a diagnosis of "Mood disorder with psychosis, suicidal ideation and abscess of abdominal wall." The Patient was admitted to the PEC and then psychiatric inpatient unit on 12/15/15. During the surveyor's review of the EMR dated 12/14/15 when Patient #24 was moved from the ED to a psychiatric inpatient bed on 12/15/15, the following was documented in the "Progress Notes:" "Recent discharge from PEC to (name of outside behavioral health facility) services from which he/she signed out AMA (against medical advice) because of auditory and visual hallucinations." The surveyor was unable to locate any specific orders, or order clarification for a "Transfer to an outside facility" during Patient #24's ED visit on 12/10/15.

During an interview with Staff #22 on 02/10/16 at 4:55 p.m. an "EMTALA Transfer form" revealed on 12/11/15 at 14:45 p.m. Patient #24 was transferred to an outside facility from the facility's emergency department.

On 02/10/16 at 5:10 p.m., the surveyor discussed the concerns with the Director of the Emergency Department. The Director of the Emergency Department stated after reviewing Patient #24's EMR he/she really couldn't speak to what happened with this Patient. However, what he/she thinks occurred was, "The physician wrote the disposition for discharge home because he/she couldn't find a bed in an outside facility and the physician was going to send the Patient to the PEC and didn't take the note previously written for discharge out of the disposition."

On 02/10/16 at 5:00 p.m. the survey team discussed the concerns with Staff #2, #5 and #20.

Based on clinical record review, staff interview and during the course of a complaint investigation, it was determined the facility staff failed to ensure the patients medical record contained complete information that would enable the physician and other care providers the ability to make thorough decisions on the provision of care for each patient. This involved 8 of 12 patients who had a community services board (CSB) pre-screening or evaluation ordered by the physician (Patient #12, 14, 18, 39, 40, 41, 42, and 43), and for Patient #44, there was no plan of care developed for the use of restraints.

The findings included:

1. During the review of the clinical records for the patients of the survey sample, the survey team was unable to locate the CSB pre-screening/evaluation for patients who had an order by the physician for a CSB evaluation.

The survey team requested the information from the facility and were informed by Staff # 2 that the documents must be requested from the CSB, that "some of the charts may have them".

Staff # 5 stated on 2/9/16 at 2:14 p.m., "The CSB does not come out necessarily for a voluntary patient...(they) come out for an ECO (emergency custody order) and as a consult they do not leave documentation...we've asked before but all (we) have in in the record..."

For Patient #12, the CSB evaluation done on 1/10/16 was not on the patients record at the time of the review and had to be requested by the surveyor. The document for Patient #12 was received at 3:40 p.m. 2/9/16.

On 2/10/16 at 11:25 a.m., as the survey team reviewed other patient records and made requests of the CSB for documents, the facility staff (Staff #3) was informed by the CSB staff they "were having trouble finding some" of the requested documents.

Patient #18 was seen on 1/21/16 in the ED (two previous admissions). There was a a "medical decision making" statement that documented, "CSB evaluate patient". When the surveyor requested the CSB evaluation, the facility informed the surveyor the CSB had stated the "case manager was in the house, and the patient was upset so the case worker walked in just to say hello because (he/she-patient) was upset". The CSB did provide the surveyor with a note documenting the case worker had spent 40 (forty) minutes on the phone with the patient prior to his/her (Patient #18) arrival in the ER and had called 911 because the patient was threatening to "cut his/her wrist with a dull knife". There was no further documentation regarding any other evaluation for Patient #18.

Patient #14 had a pre-screening on 1/29/16 and 2/4/16 that was not included in the clinical record and had to be requested from the CSB.

Review of other patient records (Patient #39 through 43) also revealed no CSB pre-screening documentation was on the clinical record and had to be requested from the CSB.

The surveyor discussed the concerns with the facility staff regarding the provider not having access to complete information for the care of their patients on 2/10/16 at 4:45 p.m. and further review of the concerns was discussed with the facility staff (#3, 4, 2, and 5) on 2/17/16 at 5:00 p.m.


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2. A review of Patient #44's record on 2/17/2016 revealed that he/she was admitted to the facility on 2/15/2016, and had physician orders for restraints from 2/15/2016 until 2/17/2016. The plan of care for Patient #44 did not include restraints.

This finding was shared with Staff #33, an RN (registered nurse) on 2/17/2016 at 3:00 PM.

Based on interview and medical record review, it was determined the facility failed to maintain complete and accurate medical records:

1. General consents for treatment and rights not signed for five (5) of forty-one (41) medical records reviewed (Patients #6, #8, #26, #29, and #40);

2. Fifteen (15) minute rounding sheets not dated for two (2) of three (3) patients admitted to the adult behavioral health unit included in the survey sample; and

3. Incomplete restraint documentation for one (1) of eleven (11) restrained patients included in the survey sample.

The findings included:

1. Patient #6 was admitted to the facility's emergency department (ED) on 01/14/2016 at 4:18 p.m., for "Depression." Staff #20 and the surveyor reviewed Patient #6's electronic medical record. The general consent for treatment and acknowledgement of receipt of patient rights had been scanned into the EMR and was not signed. Staff #5 was present and stated Patient #6 was under an emergency containment order (ECO). Review of Patient #6's EMR revealed the patient had not been placed on an ECO until "1657 (4:56 p.m.)." Staff #20 reported the consents should have been offered prior to the ECO and registration staff should have documented the patient was "unable or unwilling to sign."

Patient #8 was admitted to the facility's ED on 01/13/2016 at 8:58 p.m., for a mental health examination. Staff #20 and the surveyor reviewed Patient #8's electronic medical record. Patient #8 was brought to the emergency department under an ECO escorted by the local police. After the completion of Patient #8's medical and mental health screenings it was determined the patient had "no real intention to harm [him/herself]" and the patient's behavior was the result of an "angry outburst." Patient #8 was discharged home at 11:56 p.m. on 01/13/2016 approximately three (3) hours after admission to the ED. The general consent for treatment and acknowledgement for the receipt of patient rights had been scanned into the EMR and was not signed. Staff #20 reported the registration staff should have documented the patient was "unable or unwilling to sign" the forms.

Patient #26 was admitted to the facility's ED on 01/01/2016 at 2:15 a.m., for a mental health examination. Staff #20 and the surveyor reviewed Patient #26's electronic medical record. Patient #26 was brought to the facility's ED under an ECO escorted by the local police. After the completion of Patient #26's medical and mental health screenings it was determined the patient would transfer to the facility's psychiatric emergency center (PEC) as a voluntary admission. Patient #26's general consent for treatment and acknowledgement of his/her receipt of patient rights had been scanned into the ED EMR, but had not been signed. A review was conducted on 02/11/2016 of Patient #26's PEC EMR with Staff #22. Patient #26's PEC EMR did not contain a signed general consent for treatment and acknowledgement of his/her receipt of patient rights.

Patient #29 was admitted to the facility's ED on 01/12/2016 at 1:36 p.m., for suicidal ideation. Staff #20 and the surveyor reviewed Patient #26's electronic medical record. Patient #29 was brought to the facility's ED under an ECO escorted by the local police. After the completion of Patient #29's medical and mental health screenings it was determined the patient would transfer to the facility's behavioral health unit for treatment. Patient #29's general consent for treatment and acknowledgement of his/her receipt of patient rights had been scanned into the ED EMR unsigned. On 02/11/2016 Staff #5 offered the surveyor a copy of a signed general consent for treatment and acknowledgement of patient rights. The date on the forms was for 01/13/2016 after the patient had been admitted to the behavioral health unit. Staff #5 acknowledged the forms had not been signed for the patient admission to the facility's ED.

Patient #40 was admitted to the facility at 8:43 p.m. on 02/15/2016 for respiratory failure. Patient #40's EMR indicated the patient had been intubated by emergency medical transport (EMT) personnel en route to the facility. Staff #54 and the surveyor reviewed Patient #40's EMR. The surveyor asked if Patient's 40's EMR and paper medical record was complete. Patient #40's general consent for treatment and acknowledgement of his/her receipt of patient rights had been scanned into the EMR unsigned. Staff #54 stated, "The record is complete. If a patient transfers to a different unit the entire paper record is sent with the patient and the electronic record flows, it is all one electronic system." Staff #54 verified Patient #40's EMR did not contain signed consents for treatment and acknowledgement of patient rights.

An interview was conducted on 02/11/2016 at 1:18 p.m., with Staff #5 and Staff #26. Staff #26 stated, "The registrars are directed to make at least two attempts to obtain patient signatures for treatment and patient rights." Staff #26 verified that if the patients are unable to sign or refuses to sign their general consent for treatment and patient rights acknowledgement a notation should be made on the forms.

2. Failure to date "Acute Psychiatry 15 Minute Checks" flow sheet.

Review of Patient #39's EMR revealed the patient had been admitted to the facility on 06/22/2015 at 8:28 p.m. for Bipolar disorder. Patient #39's EMR documented the patient was a direct voluntary admission to the facility's behavioral health unit. Review of Patient 39's EMR revealed an undated "Acute Psychiatry 15 Minute Checks" flow sheet.

Review of Patient #42's EMR revealed the patient had been admitted to the facility on 06/12/2015 at 2:46 a.m. for Bipolar disorder. Patient #42's EMR documented the patient had been placed in a restraint chair on 06/12/2015 at 3:00 p.m. and continued to be restrained until 6:20 p.m. on 06/12/2015. Review of Patient #42's EMR revealed an undated "Acute Psychiatry 15 Minute Checks" flow sheet.

An interview was conducted on 02/17/2016 at 3:11 p.m., with Staff #22. Staff #22 verified the above findings.

3. Review of Patient #41's EMR revealed a "Doctor Order Sheet" "Seclusion / Restraint Order Form" for restraints applied 12/07/2015 failed to document if the order was for "Seclusion," "Restraint: Violent," or "Restraint: Non-Violent."

An interview was conducted on 02/17/2016 at 2:35 p.m., with Staff #5 and Staff #33. Staff #33 verified the staff failed to select the category on the order for Patient #41's restraints.

Based on staff interview, facility document review and during the course of a complaint investigation, it was determined the facility staff failed to ensure policies and procedures were revised to include the Psychiatric Care Unit (PEC) which was considered an extension of the Emergency Department, but specialized in the care of Psychiatric patients only.

The findings included:

During a review of the facility policies and procedures the survey team was unable to identify any policies and procedures that specifically identified the PEC area of the ED.

On 2/9/16 at 10:25 a.m., the surveyors toured the PEC area located in the Dillard Building. The area was in a building directly across from the ED ambulatory entrance (approximately 50 feet or less). The unit could only be accessed with a badge carried by staff and the entrance consisted of the locked door, a small area and another locked door which opened into the PEC area. The second door could not be opened until the first door had shut completely and locked. The area consisted of four rooms, a nurses station, a security area, a back office and "provider area" with computers and desk space, a locked medication and storage room, and a bathroom with a shower. Each room, as well as the area area of the nurses station contained video monitoring cameras and the central monitor at the security desk. There was a small nourishment center adjacent to the nurses station with a refrigerator. The rooms had the capability of being locked and had a large plexi (safety)-glass-type window.

The survey team was provided with a document "Psychiatric Emergency Center Process Review" which documented, "The Psychiatric Emergency Center (PEC) exists to: serve mental health patients seeking evaluation and treatment within Centra Health emergency departments, provide consultation services to the medical units, and review mental health inpatient referrals from external facilities. The greatest expectation is that all processes are manifested in a way that respect every patients' privacy, dignity, rights, and preferences allowing for a person-centered holistic, recovery oriented approach to providing excellent patient care. Processes that are in place can be changed as the unit grows in their practice, expertise, resourcefulness, and creativity." The document outlines the processes that were to take place for : I. Patient to the Emergency Department-Voluntary, II, Patient to the Emergency Department- Emergency Custody Order, III. Patient to Emergency Department-Voluntary needing Disposition, IV. Patient to PEC-Admission, V. PEC Patient- Voluntary needing to be ECO'd (Preauthorization), VI. PEC Patient to Centra Inpatient Facility-Transfer, VII. PEC Patient to Non-Centra Facility-Discharge, VIII. PEC Patient to HOME-Discharge, IX. Emergency Planning-CODES and Resources/Responders, X. Care of the Patient-General Rules and Guidelines for PEC, XI. Care in the PEC -Interventions and Documentation. The title page also listed: Xii. Intake Services, XIII. Consultation Services, XIV. Staffing and XV. Riskmaster, however these areas were not included in the document provided to the surveyor.

Items 1. through VIII contained a table that listed the process for each of the areas when a patient was received onto the PEC such as how to enter, who to notify, obtaining a bed, and entering patients into the facility computer system as well as who would accompany the patient, security clearance and consultation activities.

Staff #5 stated the "PEC was an extension of the ED and was under the policies and procedures for the ED" on 2/8/16 at 1:10 p.m. The survey team was unable to locate any mention of the PEC area in the ED policies and procedures that were reviewed.

Complaint Deficiency

Based on staff interview and the review of six (6) staff records, it was determined the facility staff failed to ensure that five (5) of five (5) direct care staff possessed the skills, orientation, and certifications to meet the written emergency procedures and needs anticipated by the facility, and that six (6) of six (6) staff received unit specific training.

Findings include:

Personnel records for Staff #'s 58, 59, 60, and 63, AMHP's (approved mental health providers), lacked documentation of proof of certification in BLS. The facility's written job description for mental health professional requires certification in BLS (basic life support) and MANDT training within 4 months of hire. Staff #22, the PEC unit manager, looked up training using the computer. It was revealed that there was no documentation that Staff #58, date of hire 10/19/15, had completed MANDT or BLS certification. There was no documentation of BLS training recorded in the computer for Staff #58 and 63, no documentation of BLS for Staff #59, and the personnel record for Staff #62, a registered nurse (RN), lacked documentation of BLS.

During an interview with Staff #22, the PEC (Psychiatric Emergency Center) unit manager, on 2/17/2016 at 2:30 PM he/she stated "I don't have a copy of their CPR (cardio-pulmonary resuscitation) cards. I asked for it, but didn't follow-up to get it. I am not sure if they are current or not".

Records for 6 of 6 PEC unit staff lacked documentation that the employees completed unit specific orientation. Staff #22, the unit manager, stated the following during a discussion of PEC specific orientation on 2/17/2016 at 2:30 PM: "A group orientation was done on 9/28/15, 9/29/15, and 9/30/15, I don't have documentation of who attended. On 10/26/15, 10/27/15, and 10/28/15 there was a PEC process review, but there is no attendance list. In the days before opening, we oriented with a restraint chair from the ED and the nurse educator did mock code blues, but there is no documentation of this training".

These findings were discussed with Staff #22 on 2/17/2016 at 2:30 PM.