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Based on review of policy and procedure, staff/patient interviews, observation and medical record review for one out of 10 open medical records, it was determined that the patient's representatives were not kept informed of the patient's health status, treatment and plan of care after the initial emergency treatment.

Patient #1 was admitted to the hospital after a fall fracturing her wrist and diagnosed with urinary tract infection. In addition, the patient had persistent hypotension and slow heart rate, which did not respond to initial treatment. Patient #1's power of attorney delegated responsibility for health care decisions to two co-agents. Each agent could act independently, without the consent of the other agent. The admission/registration clerks contacted one of patient #1's agents for Emergency consent to treat and bill on 4/7/13 at 9:02 PM. The consent was obtained by phone per hospital policy and procedure. After the initial treatment and stabilization of the patient, it was determined that the patient would require treatment and monitoring that could only be provided in the Critical Care Unit. Beyond the admission clerks contact with the agent no documentation could be found in the medical record regarding follow-up contact with either agent by the Emergency Department physician nor the patient's attending physician regarding the patient's health status, diagnosis, proposed treatment and prognosis.

The patient's health care agent was not informed that the patient was admitted to Critical Care Unit nor the reason for the admission until her visit to see the patient. The hospital failed to comply with the patient's care/treatment directive as evident by failure to keep the agent abreast of the patient's condition, diagnosis, treatment and seek informed consent for patient care/treatment.

Based on policy and procedure, staff interviews and review of one out of 10 open medical records and six closed medical records, it was determined the hospital did not comply with policy in accordance with State law when the hospital failed to obtain a restraint order from a licensed independent practitioner for a physical hold used to administer medication to patient #1.

On 4/15/13 at 1:10 AM the patient was hitting, punching, kicking, and spitting at staff. She tore her monitoring unit off and her IV was leaking. Per the patient's medical record she was given medication intramuscular (IM) in her buttocks with the charge nurse and three staff holding the patient down so she couldn't hit and kick while being given medication. The patient started to calm down and go to sleep. The monitoring was placed back on the patient, she was pulled up in bed and made comfortable. Review of patient #1's medical record revealed no order for the physical hold in order to administer medication.

In addition, based on review of the hospital policy Violent and Destructive Behavior Restraint Policy #093, the hospital failed to address the timely acquisition of the order for restraint or seclusion prior to application of restraint/seclusion or in emergency application situations.

The policy review revealed the only mention of obtaining an order for restraint or seclusion was in regard to the time limit and device specific orders and renewing an order. The hospital policy has not met the regulatory requirements since it does not address the process for an immediate acquisition of restraint or seclusion in the restraint/seclusion policy and procedure.

Based on review of hospital policy and procedure, it was determined that the hospital failed to address the training requirements for the physician and other licensed independent practitioners authorized to order restraint or seclusion.

Review of Policy #093 Violent and Destructive Behavior Restraints revealed that the policy does not address minimum training for physicians and other licensed independent practitioners (LIPs) authorized to order restraint or seclusion. The policy and procedure addresses the staff providing direct care to the patient such as the nurse and nursing assistant. Review of hospital training revealed no training for physicians and other LIPs regarding basic working knowledge of restraints and seclusion nor the requirements for a face-to-face inclusive of the elements: to assess the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.

Based on policy and procedure, staff interviews and review of one out of ten open medical records and six closed medical records, it was determined the hospital did not comply with policy in accordance with State law when the hospital failed to perform a face-to-face within one hour of seclusion of patient #16.

Patient #16 was yelling, banging doors, physically threatening to peers, refused offer of quiet room, medication, one to one direction from staff. The patient escalated to striking out at other and was placed in seclusion on 3/12/12 at 2:40 PM. The Violent Behavior Management Restraint/Seclusion Flow-sheet revealed the physician arrived on the unit to see the patient at 2:50 pm. Since the patient remained aggression he remained in seclusion and the order was written. Review of the medical record of patient #16 revealed that the note written by the physician did not meet the criteria for face-to-face evaluation. The physician note was a restatement of the nursing description of the patient's behavior. There was nothing written regarding the patient's medical and behavioral condition.