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Based on observation, staff interview, medical record review, risk assessment review, and policy review; it was determined the facility failed to provide a safe environment for psychiatric patients and staff (A144), failed to ensure the type of restraint or seclusion matched the physician's order (A168), failed to follow their policy for the reassessment by nursing at least every two hours for patients in restraint or seclusion for violent or self destructive behavior (A175), failed to ensure a face to face evaluation was completed within one hour of initiating or changing restraints and/or seclusion and all elements of the face to face evaluation were documented (A179), and failed to ensure all staff were trained prior to providing monitoring for restrained and secluded patients (A196). The systemic effect of these practices resulted in the facility's inability to ensure the safety of the patients. The facility had a census of 20 patients in the psychiatric unit.

Based on observation, risk assessment review, and staff interview; the facility failed to provide a safe environment for psychiatric patients. This had the potential to affect all patients admitted to the inpatient psychiatric unit. The active psychiatric census was 20 at the time of the survey.

Findings include:

Tour of the inpatient psychiatric unit (6B) was completed on 10/06/15 and 10/08/15, which revealed furniture on the unit not bolted down. The moveable furniture (chairs and nightstands) could potentially be used as a weapon towards other patients posing a safety risk.

Review of the Behavioral Health Risk Assessment completed by the facility in November 2014 had identified unbolted furniture that could be used as a weapon. The action plan was to request appropriate furniture with the construction of a new facility. It was unknown when a new facility would be built at that time.

Staff B stated in an interview prior to exit on 10/09/15 at 3:01 PM, administrative staff spoke with the Facilities Director and Nurse Manager of the unit whom both state they had no plans to remove the bedside tables/ moveable furniture. In the event a patient's behavior escalates, the nurse can use judgement to immediately break down the room to ensure the safety of all patients.

Staff O stated in an interview on 10/09/15 at 3:01 PM the unit had a guide of how to breakdown a room to ensure the safety of other patients on the unit. Staff O stated "this is a hospital and not a prison."

Based on policy review, medical record review, and staff interview; the facility failed to ensure the type of restraint or seclusion matched the physician's order. This affected two of eight patients restrained or secluded (Patients #1 and #9). The facility census was 458.

Findings include:

1. Review of "The Use of Restraint and Seclusion" policy revealed the physician or Licensed Independent Provider must order the restraint or seclusion. The order for restraint or seclusion for violent or self destructive behavior would remain in effect until the patient's behavior or situation no longer required the use of restraint or seclusion, but no longer than four hours. The physician or Licensed Independent Provider would order the type of limb restraint (e.g. wrist or ankle restraints in leather or soft). The Registered Nurse uses clinical judgement to determine the least restrictive number of limbs to restrain.

2. Review of the medical record for Patient #1 revealed the patient was admitted on 09/03/15 with a diagnosis of Bipolar Disorder and Schizoaffective Disorder. The medical record contained documentation the patient was in seclusion and/or restraints from 7:28 PM on 09/10/15 through discharge on 09/23/15. The medical record contained an order for seclusion on 09/10/15 at 7:28 PM. The nursing documentation on the Restraint Flowsheet documented the patient was placed in seclusion on 09/10/15 at 7:28 PM and was then placed in four point leather restraints at 8:25 PM due to attempts to break the camera in the seclusion room. An order for bedrails times four was added on 09/10/15 at 8:25 PM, but the nursing restraint flowsheet lacked documentation of bedrails, instead listed four point leather restraints. At 8:56 AM on 09/10/15, leather restraints were ordered, but lacked direction on how many limbs to restrain.

The Restraint Flowsheet documented the patient was in three or four point restraints from 8:25 AM on 09/10/15 through 8:00 AM on 09/17/15 without discontinuation or removal. The restraint order on 09/11/15 at 4:14 AM for leather restraints specified the order was valid for four hours. The next order for restraints or seclusion was written at 8:30 AM, four hours and 16 minutes later, and ordered seclusion. The medical record lacked an order for leather restraints from 8:14 AM to 12:37 AM, although the Restraint Flowsheet documented the patient was in four point leather restraints for that time period, and lacked documentation of seclusion. The medical record contained orders for seclusion in addition to leather restraints on 09/11/15 from 8:21 PM through 09/12/15 at 8:00 PM, however the Restraint Flowsheet lacked documentation of seclusion during this time frame.

The medical record lacked an order for leather restraints from 8:11 AM to 8:27 AM on 09/12/15, from 10:44 AM to 11:04 AM on 09/13/15, from 10:33 AM to 10:49 AM and 2:49 PM to 2:56 PM on 09/14/15, from 12:47 AM to 7:41 AM on 09/16/15, from 10:35 PM on 09/16/15 to 12:25 AM on 09/17/15, from 1:35 PM to 1:53 PM on 09/17/15, from 4:08 PM to 4:50 PM on 09/18/15, from 6:58 PM to 10:24 PM on 09/19/15, and from 2:47 AM to 3:06 AM on 09/22/15; however the Restraint Flowsheet documented leather restraints were in place. The medical record contained orders for seclusion in addition to the leather restraints from 10:46 AM on 09/13/15 through 2:49 PM on 09/14/15, however seclusion was not listed on the Restraint Flowsheet during this time frame. The Restraint Flowsheet listed four point leather restraints and seclusion on 09/14/15 at 2:56 PM, but the medical record lacked an order for seclusion at that time. The medical record contained an order at 9:44 AM on 09/15/15 for leather restraints and seclusion with an order for bedrails times four added at 10:56 AM and an order for leather restraints, seclusion and bedrails times four at 1:27 PM; however, the Restraint Flowsheet lacked documentation of the seclusion and bedrails during this time frame. The Restraint Flowsheet documented left upper extremity and bilateral lower extremity restraints at 5:27 PM and 8:00 PM on 09/15/15, but lacked documentation as to the type of restraint (soft, leather, etc.).

The medical record contained orders for seclusion in addition to leather restraints from 1:27 PM on 09/15/15 through 7:28 PM on 09/16/15; however the Restraint Flowsheet lacked documentation of seclusion during this time frame except at 3:30 PM on 09/16/15. On 09/17/15, the Restraint Flowsheet documented soft wrist restraints times four at 8:00 AM, seclusion at 10:00 AM, soft wrist restraints times four at 12:00 PM, and soft wrist restraints times four and four point leather restraints at 2:00 PM, however leather restraints were ordered at these times. On 09/19/15 at 7:45 AM, the Restraint Flowsheet listed seclusion only; however the order for that time was for seclusion, leather restraints and bed rails times four. The Restraint Flowsheet for 09/21/15 at 5:30 PM documented waist (wheelchair) restraint, bedrails times four and four point leather restraints, however the order at that time was for seclusion, leather restraints, and bed rails times four. All restraint orders for leather restraints lacked direction on how many limbs to be restrained.

This was verified by Staff E on 10/09/15 at 2:00 PM.


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3. Review of the medical record for Patient #9 revealed the patient was admitted to the facility on 09/15/15 for diagnoses to include toxic metabolic encephalopathy secondary to alcohol withdrawal. The medical record confirmed the patient had an altered mental status and was exhibiting symptoms of restlessness/ agitation thus requiring intubation after a rapid decline in respiratory status on 09/19/15. Arterial blood gases noted respiratory acidosis with metabolic compensation and metabolic alkalosis. The patient was noted to be in bilateral soft wrist/ankle restraints to ensure safety.

Review of the nursing restraint flowsheets revealed the patient was in four point leather restraints on 09/20/15 at 7:00 AM. The medical record lacked evidence of a physician's order for four point leather restraints on 09/20/15. Staff B confirmed this finding on 10/09/15 at 1:32 PM.

On 10/09/15 at 2:02 PM, electronic documentation was provided by the nurse stating on 09/20/15 the nurse inadvertently charted the patient was in leather restraints, the patient was not in leather restraints.

Based on policy review, medical record review, and staff interview; the facility failed to follow their policy for the reassessment by nursing at least every two hours for patients in restraint or seclusion for violent or self destructive behavior. This affected one of six medical records reviewed for restraint or seclusion for violent or self destructive behavior (Patient #1). A total of 10 medical records were reviewed, and active psychiatric census was 20 at the time of the survey.

Findings include:

Review of "The Use of Restraint and Seclusion" policy revealed an assessment would be completed by the registered nurse and reassessments would be completed at least every two hours. The assessment would include the appropriateness of the restraint, the level of distress/agitation, mental status, cognitive function, hydration, skin integrity, range of motion, nutrition, and elimination needs of the patient.

Review of the medical record for Patient #1 revealed the patient was placed in seclusion and restraints on 09/10/15 at 7:28 PM through discharge on 09/23/15. The medical record lacked documentation of nursing reassessment every two hours on 09/11/15 from 10:00 PM to 09/12/15 at 12:25 AM, on 09/12/15 from 6:11 AM to 8:30 AM, on 09/13/15 from 3:32 AM to 5:45 AM, on 09/15/15 from 10:00 PM to 09/16/15 at 12:09 AM, on 09/16/15 from 7:00 PM to 10:00 PM, on 09/18/15 from 6:00 AM to 8:18 AM, on 09/21/15 from 7:06 PM to 9:16 PM, and on 09/22/15 from 12:47 AM to 3:06 AM.

This was verified by Staff E on 10/09/15 at 2:00 PM.

Based on policy review, medical record review, and staff interview; the facility failed to ensure a face to face evaluation was completed within one hour of initiating or changing restraints and/or seclusion and that all elements of the face to face evaluation were documented. This affected two of four medical records reviewed for restraint or seclusion for violent or self destructive behaviors (Patient #1 and #6). The census of the psychiatric unit was 20.

Findings include:

1. Review of "The Use of Restraint and Seclusion" policy revealed following the initiation of restraints or seclusion for violent or self destructive behavior the physician or Licensed Independent Provider must perform a face to face evaluation of the patient to validate the appropriateness of the restraint or seclusion and write an order. The evaluation should include 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.

2. Interview with Staff O and Staff P on 10/09/15 at 10:20 AM, revealed the comments section of the order was the face to face documentation. The physician or resident was required to assess the patient in person prior to ordering or renewing any restraint or seclusion order for violent or self destructive behavior.

3. Review of the medical record for Patient #1 revealed the patient was placed in seclusion on 09/06/15 at 2:35 PM. The patient was placed in seclusion on 09/10/15 at 7:28 PM, and the restraint/seclusion continued through discharge on 09/23/15. The comment section of the orders for seclusion, on 09/06/15 at 2:35 PM and on 09/10/15 at 7:28 PM, lacked documentation of the patient's immediate situation and the patient's reaction to interventions. The restraint and/or seclusion orders were modified to add additional types of restraint and/or seclusion (i.e. leather restraints, bed rails times four, seclusion, etc.) at the following dates and times: 09/10/15 at 8:25 PM, 09/10/15 at 8:56 PM, 09/11/15 at 8:30 AM, 09/11/15 at 12:37 PM, 09/11/15 at 8:21 PM, 09/12/15 at 8:13 AM, 09/12/15 at 8:27 AM, 09/13/15 at 10:46 AM, 09/15/15 at 9:44 AM, 09/15/15 at 10:56 AM, 09/15/15 at 1:27 PM, 09/16/15 at 7:41 AM, 09/16/15 at 9:09 AM, 09/16/15 at 10:35 AM, 09/17/15 at 12:25 AM, 09/17/15 at 9:35 AM, 09/18/15 at 8:18 AM, 09/18/15 at 8:28 PM, 09/19/15 at 10:24 PM, 09/21/15 at 8:22 AM, 09/22/15 at 3:06 AM , 09/22/15 at 9:32 PM, 09/23/15 at 8:51 AM, 09/23/15 at 12:10 PM, and 09/23/15 at 12:12 PM. These orders lacked documentation of the patient's immediate situation and the patient's reaction to interventions.



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4. Review of the medical record for Patient # 6 revealed the patient was admitted to the adult psychiatric unit on 09/18/15 with a diagnosis of schizophrenia. The medical record confirmed the patient had decompensated due to non-compliance with prescribed medications. The nursing flowsheet documentation described the patient as agitated/restlessness whom could not demonstrate safe behaviors towards self/others.

On 09/18/15 at 3:07 PM, the medical record confirmed the patient was placed in seclusion. The medical record failed to document a licensed independent provider conducted the one hour face to face evaluation to validate the appropriateness of the restraint or seclusion.

5. Staff P stated in an interview on 10/07/15 at 4:00 PM the face to face should occur one hour after the patient is placed in restraint and/or seclusion.

Based on policy review, medical record review, personnel file review, and staff interview; the facility failed to ensure all staff were trained prior to providing monitoring for restrained and secluded patients. This affected Patient #1 and Staff S. A total of ten medical records were reviewed. The census on the psychiatric unit was 20.

Findings include:

Review of "The Use of Restraint and Seclusion" policy revealed only trained staff can monitor the patient in restraint or seclusion. Behavioral Observers, Behavioral Health Techs, and Customer Support Partners may only monitor patients in restraint or seclusion. Staff will have training at orientation, before participating in the use of restraint or seclusion, and every two years thereafter. Staff who monitor patients in restraints will be trained in the recognition of signs of physical and psychological distress, including signs of asphyxia.

Review of the medical record for Patient #1 revealed Staff S was assigned to watch the video monitor and document every 15 minutes for the continuous monitoring of Patient #1 while restrained and in seclusion on 09/22/15.

Review of the personnel file for Staff S revealed a hire date of 10/20/97. Staff S was a Customer Support Partner. The personnel file lacked documentation of restraint or seclusion training.

On 10/09/15 at 4:00 PM, Staff A verified the facility was unable to provide electronic or paper evidence of restraint or seclusion training for Staff S.

Based on medical record review and staff interview, it was determined nursing staff failed to document daily weights as ordered by the physician. This affected one (Patient #4) of ten medical records reviewed. The active census was 458.

Findings include:

Review of the medical record for Patient #4 revealed the patient was admitted to the facility on 09/03/15 for chest pain and acute respiratory failure. Further, the medical record confirmed the patient had a history of congestive heart failure. The medical record documented the patient was prescribed Lasix (diuretic). Physician's orders upon admission included to weigh the patient daily. The medical record lacked evidence the patient was weighed daily.

This finding was confirmed with Staff D on 10/07/15 at 2:33 PM.

Based on medical record review, policy review, and staff interview, it was determined nursing failed to developed a plan of care utilizing the nursing process. This affected two (Patients #3 and #4) of ten medical records reviewed. The active census was 458.

Findings include:

Review of the care planning policy (ELEMENT IX) states the registered nurse develops an individualized plan of care utilizing the nursing process. The plan of care is revised as the patient condition warrants, and is used to provide a basis of continuity, consistency, documentation, evaluation and discharge planning. The plan is a collaborative effort between the members of the multidisciplinary team. In some areas an interdisciplinary plan of care is used together with the nursing plan of care.

1. Review of the medical record for Patient #3 revealed the patient presented to the emergency department on 09/01/15 with complaints of coffee/black color emesis. The patient was admitted for a gastrointestinal bleed and septic shock. Upon admission, a stage two pressure ulcer of the coccyx was identified. Physician's order included to cleanse/irrigate with normal saline and apply a small amount of hydrogel to the wound (floor stock). Cover with mepilex sacral border and change daily. Continue use of spencos, offload heels, use of incontinence pH balanced cleanser, reposition every two hours, patient of a stryker bed with isogel low air loss mattress. The medical record lacked evidence of a nursing care plan that identified the alteration in skin integrity.

2. Review of the medical record for Patient #4 revealed the patient was admitted to the facility on 09/03/15 for chest pain and acute respiratory failure. The medical record documented the patient was prescribed Lasix (diuretic) and had a twenty year history of chronic diarrhea. The laboratory confirmed the patient was positive for clostridium difficile. The medical lacked evidence a nursing care plan that identified the altered elimination and/or to monitor for fluid volume deficit.

These findings was confirmed with Staff D on 10/07/15 at 2:33 PM.