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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed the facility's current policy related to seclusion. This affected two (Patients #2 and #12) of 12 patients whose medical records were reviewed including three behavioral health patients. This deficient practice had the potential to affect all patients that required seclusion/restraints, or time outs.

The facility's census at the time of the survey was 286.

Findings include:

1. The medical records of Patient #2, including the patient's six admissions to the Behavioral Unit since May, 2013, was reviewed on 12/30/13 at 10:00 AM. According to the Psychiatric Physician's History and Physical documentation, the patient had a long standing history of explosive behavioral disorder, bipolar disorder, intellectual disability (baseline was that of an 8 year old level), seizure disorder, severe depression, suicidal and homicidal ideations, past suicide attempts, and gastroesophageal reflux disease.

The patient was admitted on 11/13/13 at 11:48 AM. A Nursing Note from the emergency department for this admission, noted the patient was discharged yesterday and his/her mother reported that when the patient got home the patient became very agitated, throwing things and hit the caregiver. The caregiver called 911 and the patient was taken to another hospital where the patient spent the night and was discharged the morning of 11/13/13.

The caregiver brought the patient directly back to this facility's emergency department. The emergency department note indicated the patient became aggressive in the emergency department when it was decided that he/she didn't meet the criteria for admission. The patient hit the caregiver with his/her fist, attempted to bite a social worker, and threw a chair in the hall, just missing people passing by. The patient was given medication intramuscularly and transferred to the Behavioral Unit for an involuntary 72 hour hold. Suicide precautions were ordered and initiated.

Documentation of the 15 minute checks, required on all patients admitted to the Behavioral Unit, were reviewed on 01/02/14 at approximately 11:30 AM. The 15 minute checks were noted on a form entitled "Inpatient Observation Flow Record". The form lists separate columns for the time, the patient's location, the patient's activity, and behavior. The patient was noted to be in the "quiet room" for one hour on 11/11/13 from 8:30 AM. until 9:30 AM. A Nursing Note for that same date indicated the patient became agitated after he/she was told that he/she wouldn't be discharged that day but discharge would occur the next day. The note indicated the patient requested to take a "timeout."

Staff B was interviewed on 01/02/14 at 11:45 AM. When asked what the quiet room was Staff B reported the quiet room was the same as the seclusion room but clarified that the patient was not in seclusion but was in open seclusion.

Staff J was interviewed on 01/03/14 at 12:00 PM. When asked what open seclusion was, Staff J stated, "There is no such thing as open seclusion."

The facility policy entitled "Violent/Self Destructive Restraint Management" was reviewed on 12/31/13 at 1:40 PM. According to the policy, seclusion is used "only after less restrictive alternatives have been used and failed." The policy lists 11 alternatives, including instituting time out. The policy indicated that time out is "limited to no more than 30 minutes."

A Nursing Note, dated 11/14/13, noted the patient to be in the "quiet room" again on 11/14/13 from 10:45 AM to 5:30 PM. The Nursing Note indicated the patient, without provocation, became agitated and aggressive toward the staff, twice throwing a chair and attempting to punch one staff member. The Nursing Note stated the patient was "confronted about being hospitalized 6 times in the past 6 weeks" and was informed of probable discharge the next day. The documentation stated that informing the patient of the probable discharge "may have triggered" the patient's aggression and agitation. The documentation stated the patient "remains in seclusion room at present" and stated, "behaviors to come out of seclusion room reviewed with patient."

Staff F was interviewed on 01/03/14 at 12:00 PM. Staff F stated, "I didn't realize our policy said time out was limited to 30 minutes." Staff F confirmed the phrase "behaviors to come out of seclusion room reviewed with patient" denoted the patient had been involuntarily placed in the seclusion room and therefore required a physician's order. The medical record lacked documentation of a physician's order for the patient to be placed in seclusion.

A Nursing Note, dated on 11/15/13, at 9:00 AM, reported the patient was threatening nurses and was "escorted" to the unlocked seclusion room.

Review of the Medication Administration Record revealed the patient was medicated with Zyprexa 15 mg tablet at 8:26 AM. The 15 minute check form indicated the patient remained in the seclusion room for 2 and 1/2 hours, until 11:30 AM., when the form documented that the patient walked with a registered nurse to his/her room.

A Nursing Note, dated 11/15/13, at 12:00 PM., documented the patient was "allowed" to return to his/her room. Staff J, at 12:00 PM., on 01/03/14, confirmed the phrase "allowed to return" to his/her room denoted the patient had been involuntarily placed in the seclusion room, which would have required a physician order. Staff J also confirmed that the medical record lacked documentation of a physician order for seclusion.

2. Review of the medical record, Patient #12 was admitted to the Behavioral Unit on 12/02/13, with complaints of suicidal ideations. A Nursing Note dated 12/27/13 at 12:52 AM., indicated the patient was found sitting in the patient's room looking out of window admitting to hearing voices telling him/her to hurt him/herself. The patient was medicated with Zyprexa and was assisted to the quiet room for "closer observation." The patient remained in the quiet room until 5:05 AM on the same day, a 5 hour time period.

On 01/03/14 at 12:00 PM., Staff F confirmed there was no physician's order for seclusion and if the patient was placed in the seclusion room for a "time out", the time period Patient #12 had remained in the seclusion room had exceeded the 30 minute time limit permitted for use of the seclusion room for a "time out", as stated in the facility policy.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed the facility's current policy related to seclusion. This affected two (Patients #2 and #12), and has the potential to affect all patients that required seclusion/restraints, or time out. (A167).

The facility failed to ensure staff conducted suicide risk assessments, as required by the facility's policy on patients presenting with suicidal ideations. This affected one (Patient #2). (A395).

The facility failed to ensure established nursing care plans and planned interventions were utilized to ensure the least restrictive measures were implemented; the care plans included appropriate, specific, and measurable interventions based on the patient's behavioral health needs as indicated by documentation of evaluations and revisions of the care plans. This affected three (Patients #2, #11, and #12) of three medical records reviewed for patients admitted to the facility's behavioral health unit (A396).

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff conducted suicide risk assessments, as required by the facility's policy, for patients presenting with suicidal ideations. This affected one (Patient #2) of 12 patients whose medical records were reviewed, and included three patients who were admitted to the behavioral health unit. The facility's census was 286 at the time of the survey.

Findings include:

The medical record of the Patient #2, including the patient's six admissions to the Behavioral Unit since May, 2013, was reviewed on 12/30/13 at 10:00 AM. According to the documentation contained on the Psychiatric Physician's History and Physical form, the patient had a longstanding history of explosive behavioral disorder, bipolar disorder, intellectual disability (the patient's baseline was that of an 8 year old level), seizure disorder, severe depression, suicidal and homicidal ideations, past suicide attempts, and gastroesophageal reflux disease.

Patient #2 first presented to the Emergency Department on 05/11/13 at 7:40 PM., with reports of feeling suicidal for several days. The patient reported being told by the mother of the patient's significant other of five years that the relationship was over. It was documented the patient stated that the significant other's mother had always been nice until this time and the patient believed the mother intentionally tried to hurt his/her feelings. Although the patient denied a specific plan to commit suicide, the patient reported the feeling to commit suicide was getting stronger over the last several days.

Documentation of the Suicide Risk Assessment was noted on 05/11/13 at 7:41 PM. The risk assessment included a SAD PERSONS scale which is an acronym developed as a clinical assessment tool to determine a patient's risk of suicide. The score is calculated from ten yes/no questions with points given for affirmative answers. The questions include: "S" for male sex, "A" for age less than 19 or greater than 45, "D" for depression or hopelessness, "P" for previous suicide attempts or psychiatric care, "E" for excessive ethanol or drug use, "R" for rational thinking loss, "S" for single, widowed, divorced, "O" for organized or serious attempt, "N" for no social support, "S" for stated future intent (determined to repeat). A score of less than or equal to five indicates a low suicide risk. A score of six or greater indicates a potentially significant suicide risk. The patient's score was seven at 7:41 PM. The patient was admitted to the Behavioral Unit at 12:00 AM and suicide precautions were ordered and initiated.

Staff B was interviewed, on 12/31/13 at 11:00 AM., and was asked how often the suicide risk assessments are performed on suicidal patients. Staff B stated that the assessments are performed every shift or change in caregiver.

Staff B was interviewed on 12/31/13 at 3:00 PM. and was asked how often suicide risk assessments are performed by staff. Reading aloud from the policy while pointing to words from the policy, Staff B stated, "SAD PERSONS scale should occur daily."

The facility policy entitled Suicide Risk Assessment was reviewed on 12/31/13 at approximately 2:45 PM. According to the policy, reassessments utilizing the SAD PERSONS scale should occur daily at minimum and other times to consider reassessment include change of status, change of diagnosis, and prior to discharge.

The patient was reassessed, on 05/12/13 at 12:23 AM., and, according to the documentation of the SAD PERSONS scale, received a SAD PERSONS score of "13". There were no other suicide risk assessments documented during this five day admission.

A Nursing Note, dated 05/15/13 at 10:42 AM., revealed the patient's affect had been blunted, and the patient's mood documented as "somber/depressed." The patient was discharged on 05/16/13 at 1:37 PM.

Staff E was interviewed on 01/03/14 at 3:19 PM., and was asked to provide documentation of daily suicide risk assessments, as required by facility policy, during the patient's admission from 05/11/13 to 05/16/13. Staff E reported he/she was unable to find any suicide risk assessments other than the two identified in the above paragraphs.

According to the medical record of the patient's admission on 10/02/13, the patient presented to the emergency department, on 10/02/13 at 11:30 AM., with complaints of increased depression, anger, suicidal intent, and aggression. The patient was again admitted to the Behavioral Unit. A note written by a registered nurse, on 10/02/13 at 2:23 PM., revealed the patient's caregiver had called the police after the patient became upset and began throwing things and threatening the caregiver. According to the note, the patient began getting more and more depressed and just wanted to lay in bed. When caregivers attempted to get the patient up, the note explained that the patient became angry and "explosive." The documentation, on the assessment using the SAD PERSONS scale, revealed the patient's score was a seven on this admission. The patient's score remained a seven for each of the daily assessments. The patient was discharged on 10/04/13 at 1:30 PM.

Staff E was interviewed, on 01/03/14 at 9:00 AM., and was asked if it was unusual for there not to be any improvement in a patient's SAD PERSONS scale score. Staff reported no change in the patient's score was not unusual.

According to the medical record of the patient's 10/06/13, admission, the patient presented to the emergency department on 10/06/13 at 6:29 PM., stating: "I'm afraid I'm going to hurt myself." The assessment using the SAD PERSONS scale revealed the patient's score at 6:31 PM., was "10" and at 6:39 PM., was six. The patient's score at 7:00 PM., was noted to be a two, with affirmatives only at "S" for male sex and "N" for no social supports. There was no documentation of an assessments of the "D" for depression or hopelessness or of the "R" for rational thinking loss. The affirmative answer for not having social support was the first time "N" was documented as such. Nursing Notes with each admission had documentation of the patient's parents visiting. A score of "0" was also noted for "P", for previous suicide attempts or psychiatric care.

Staff E was interviewed on 01/03/14 at 2:00 PM., and was asked for clarification of the meaning of the "N" in the acronym SAD PERSONS scale and the "P" for previous suicide attempts or psychiatric care. Staff E explained that any score other than a 0 means that there is a perceived deficit in the patient's support system. Staff E stated, "Previous suicide attempts or psychiatric care means just what it says." Staff E reported not being able to explain why someone would perceive the patient as not having a support system or not having any suicide attempts or psychiatric care. Staff E confirmed that this admission was at least the second admission to the Behavioral Unit which meant there was previous psychiatric care and the Psychiatric Physician's History & Physical form had noted previous suicidal attempts, so the "P" score should have been a two. Staff E confirmed that the "N" went from a "0" for all assessments to a one with no documentation to explain the sudden perceived deficit in the patient's support system.

The medical record revealed the last two suicide risk assessments, using the SAD PERSONS scale, for this admission had occurred on 10/13/13 at 8:45 AM., and at 4:00 PM. Both of these assessments documented the patient had no history of previous suicide attempts or psychiatric care, as the "P" score was a "0". The "N" was noted to be a "0" during these assessments.

Staff E confirmed that these assessments were incorrect on 01/03/14 at 2:30 PM.

Based on record review, staff interview, and policy and procedure review, the facility failed to ensure the established nursing care plans and interventions utilized were the least restrictive measures. The nursing care plans failed to include appropriate, specific, and measurable interventions with documentation of the evaluations of the effectiveness and revisions based on the patient's behavioral health needs. This affected three (Patient #2, #11, and #12) of three patients who were admitted on the behavioral health unit, whose medical records were reviewed

During an interview, on 12/31/13 at 1:05 PM., Staff E, the Behavioral Health Unit Education Nurse, identified expectations for behavioral health care plans included identifying the patient's problem and selecting specific goals and interventions from a pre-established computerized software list.

1. On 01/02/14 the closed record for Patient #2 was reviewed. Patient #2 was admitted on 11/13/13 at 11:57 AM., with a diagnosis from the emergency room of agitation and suicidal ideation. The medical record documented four specific care plans including: (1) behavioral health discharge planning needs; (2) behavioral health risk for harm to self; (3) behavioral health ineffective coping; and (4) behavioral health risk for harm to others. Each of the four care plans lacked documentation of specific goals and interventions.

During an interview on 01/02/14 at 11:10 AM., Staff E stated the goals and interventions were grouped together under the heading entitled "Behavioral Health Treatment Plan: and were applicable to each of the care plans individually.

Six goals listed under the "Behavioral Health Treatment Plan" for Patient #2 included: Patient will be able to maintain appropriate social boundaries; Patient will be able to eliminate impulsive behavior; Patient/family will be able to participate in treatment and discharge plans; Patient will be able to have clear/adequate disposition/follow up; Patient will be able to notify staff when experiencing harmful thoughts toward self; and Patient will be able to eliminate self harming behaviors.

Eight interventions listed under the "Behavioral Health Treatment Plan" for Patient #2 included: redirect inappropriate behavior; assess disposition needs and needed referrals; determine suicidal intent and available means; assess concentration and thinking in groups; one to one education about illness; one to one education about medication; evaluate medication effectiveness and side effects; and provide therapeutic environment. The interventions lacked any specific methods to be used to redirect inappropriate behaviors or measures to be utilized to provide a therapeutic environment.

During an interview on 01/02/14 at 11:10 AM., Staff E indicated it was up to each nurse to utilize redirecting techniques as they felt were appropriate to the situation. Staff E also offered "open seclusion" as an option to a therapeutic environment.

A care plan note, initiated by a staff registered nurse, dated 11/14/13 at 11:00 AM., documented, " GOAL: Patient will be able to eliminate impulsive behavior. DATA: Patient initially calm and in control of his behaviors. Without provocation, patient became agitated and aggressive toward writer and other staff. Threw chair from his room twice at staff. Also attempted to punch writer. Patient escorted to seclusion room for decreased stimulation. PRN (as needed) medication given. Earlier patient denied suicidal ideation/homicidal ideation or hallucinations. Verbally contracted for safety with writer. No harm to self noted patient on suicide precaution. ACTION: Patient monitored every 15 minutes per suicidal precaution protocol. Patient medicated at this time with Geodon 20 mg (milligram) IM (IntraMuscular) and Ativan 2 mg IM in right deltoid muscle for agitation and aggression. Scheduled medications offered. One to one with patient. Milieu participation encouraged. Behaviors to come out of seclusion room reviewed with patient. Support and reassurance given. Patient seen in Treatment Team. Patient confronted about being hospitalized six time in the past six weeks. Patient unable to identify the source of his aggression and agitation. Patient informed he will probably be discharged tomorrow which may have triggered his aggression and agitation. RESPONSE: Patient compliant with scheduled medications. Appears free of medication side effects. Remains in seclusion room at present." The care plan note lacked documentation of any non-pharmalogical interventions attempted, any least restrictive measure taken, or of any of the eight care planned interventions attempted prior to "Patient escorted to seclusion room...and PRN medications given."

Care plan nursing notes for Patient #2 document: 11/14/13 at 11:00 AM., seclusion and PRN medications, 11/14/13 at 2:51 PM., "sleeping in restraint room since receiving PRN medications", 11/14/13 at 4:04 PM., "resting in restraint room, eyes shut", 11/14/13 at 5:03 PM., "is requesting to go back to Behavior Intensive Care Unit (Patient #2's private room), patient instructed to eat dinner in seclusion room". 11/15/13 at 8:26 AM., "Patient threw a chair in room. Patient will not state why upset. Patient offered support and reassurance. Patient given (PRN) 15 mg Zyprexia Zydis by mouth." 11/15/13 at 9:00 AM., "Patient escorted to seclusion. Patient resting in unlocked seclusion." 11/15/13 at 10:00 AM., "Patient resting quietly in unlocked seclusion." 11/15/13 at 12:00 PM., " Patient allowed to return to room." These notes indicated Patient #2 was given PRN medications and/or confined to seclusion/restraint room/unlocked seclusion on 11/14/13 from 11:00 AM., until at least 5:03 PM., and on 11/15/13 from 8:26 AM., until 12:00 PM,.

2. On 01/02/14 the medical record for Patient #11 was reviewed. Patient #11 was admitted on 12/23/13 at 8:18 PM., from a facility provider located in Southern Ohio. Patient #11 had care plans that included (1) behavioral health altered thought processes, (2) behavioral health discharge planning needs, and (3) behavioral health sensory perceptual alteration. The care plan documented ten goals and 15 interventions including redirect inappropriate behaviors, provide behavioral intervention as needed, and provide therapeutic environment.

During an interview on 01/03/14 at 11:55 AM., Registered Nurse, Staff G, indicated Patient #11 had been given PRN medications and placed in "open seclusion" on 01/01/14, to control behaviors. Review of the nursing care plan note dated 01/01/14 at 2:20 PM., documented Patient #11 experienced increased agitation. Non-pharmalogical interventions were attempted unsuccessfully. Patient #11 was escorted to the "de-escalation room" and given PRN medications.

3. On 01/02/14 the open record for Patient #12 was reviewed. Patient #12 was admitted on 12/18/13 at 10:28 PM., through the emergency room with diagnoses including psychosis. Patient #12 was admitted to the geriatric psychiatric unit and had care plans including (1) fall risk, (2) skin integrity, (3) behavioral health alteration in mood, (4) behavioral health altered health processes, and (5) behavioral health discharge planning needs. The care plan documented ten goals and 11 interventions under Behavioral Health Treatment Plan including redirect inappropriate behaviors.

During an interview on 01/03/14 at 12:10 PM., Registered Nurse, Staff H, indicated Patient #12 had been given PRN medications on 01/01/14, to control behaviors. Review of the nursing care plan note dated 01/01/14, at 10:14 AM., documented Patient #12 was given a PRN medication for anxiety.

The nursing care plans reviewed lacked documentation of reassessments of goals or interventions, or of care plan revisions to include PRN medications or the use of seclusion, restraint room, unlocked seclusion, or de-escalation room.

On 01/02/13 at 12:00 PM an interview was conducted with a Psychiatric Physician, Staff I. Staff I indicated the behavioral care plans were computer formatted and needed to be more individualized for the behavioral care patient. Staff I stated more specific, measurable interventions needed to be added to the software program or the ability for nurses to add items to the existing format and that they needed to be routinely evaluated and revised to reflect the patients' current needs.

On 01/03/14, the facility's policy and procedures for care plans was reviewed. Policy 1.5.102 Documentation of the Nursing Process including Patient Assessment and Care Planning, revised 07/2012 and referenced by Joint Commission: Comprehensive Accreditation Manual for Hospitals: 2006, documented, "A multidisciplinary care plan will be developed to provide for continuity and individualized care with patient needs identified." "Patient problems are documented in the Care Plan and Interdisciplinary Notes where progress towards resolution of issues is documented." "Interventions and outcomes will be documented in the patient care plan, patient education activity, and Interdisciplinary Notes." "Information outside the scope of the care plan will be documented in the Interdisciplinary Notes using the DAR (Data, Action, Response) format." A copy of the policy reference, Joint Commission: Comprehensive Accreditation Manual for Hospitals: 2006 was requested for review. Hospital administration, Staff C, indicated the referenced manual was not available for review.

During an interview on 01/03/14 at 11:00 AM.,, Hospital administration, Staff D, provided an additional Care Plan reference entitled Nursing Diagnoses in Psychiatric Nursing, Care Plans and Psychotropic Medications, sixth edition, by Mary C. Townsend. This reference documented care plans should include nursing interventions and outcome criteria along with a date for evaluating and documenting the success of the nursing interventions in achieving the goals of care and modifying the plan as required.