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Based upon record review and interview, the facility failed to ensure that seclusion was terminated when release behaviors were demonstrated by 1 of 5 (#5) patients reviewed.

Review of policy #1200.315 titled "Seclusion and Restraints, Discontinuation of Restraint/Seclusion" revealed the following: "Although the restraint/seclusion order is written for a maximum time period, the goal is to discontinue restraint or seclusion as soon as the patient meets the criteria for release. As soon as possible in the restraint/seclusion process, the patient is made aware of the rationale for the restraints or seclusion, and the behavior necessary for it's discontinuation. Discontinuation of restraint/seclusion is determined by the physician or RN only, and is documented in the medical record after a re-evaluation of the patient. The use of restraint/seclusion is discontinued once the unsafe situation ends. If the patient is released from restraint or seclusion, and the patients behavior again becomes dangerous to themselves or others, a new order must be obtained. Behavioral criteria for discontinuation of restraint or seclusion may include 1.) absence of self injurious behavior; and 2.) absence of aggressive/violent/threatening behavior. Staff shall assist the patient to meet the behavioral criteria for release. Use of restraint/seclusion shall be terminated as soon as criteria for release have been met, as evaluated by the RN or physician".

Review of the patient's medical record revealed nurse's notes dated 9/14/11@11:50 am that states "Patient kicking walls and hitting walls. Threatening peers, verbally abusive. Agressive towards staff. Agitated. Not responding to verbal de-escalation. Escorted back to seclusion room by staff. Placed in seclusion."

Review of the form titled "Physician's Orders for Seclusion/Restraint" revealed orders for patient to be restrained/secluded for up to 2 hours. Purpose for behavioral restraint seclusion: high risk of injury to self, high risk of injury to others. Behavioral restraint/seclusion order: Physical Hold, Seclusion Room, Emergency Medication. Behavioral restraint/seclusion start time: 11:50 am. Specific Measures for safety, health and well-being: Linen removed from seclusion room, staff monitoring patient. Criteria for Release from Behavioral Restraint/Seclusion: Not threatening to hurt self/others, Contracting with staff not to hurt self/others, responding to verbal re-direction, No demonstration of other aggressive acts.

Review of RN Progress Notes for monitoring patient during seclusion were as follows:
11:15 am - Patient escorted back to quiet room. She was kicking the wall in the hallway. Door locked.
11:30 am - Patient pacing the floor, in No Acute Distress.
11:45 am - Patient pacing the floor, in No Acute Distress.
12:00 pm - Patient sitting on bed, in No Acute Distress.
12:15 pm - Patient sitting on bed, in No Acute Distress.
12:30 pm - Patient sitting on bed, in No Acute Distress.
12:45 pm - Patient sitting on floor, in No Acute Distress.
1:00 pm - Patient kicking doors. Kicking walls. Yelling.
1:15 pm - Patient received PRN medication for agitation.
1:30 pm - Patient standing in quiet room, in No Acute Distress.
1:45 pm - Patient removed from quiet room. Explained to patient requirements for release. Patient calm and coopertive. Responding to re-direction. Verbalized understanding of need to report to staff when agitated and use of coping skills.

Further review of form titled "Restraint/Seclusion Checklist" (an observation flow sheet) dated 9/14/11 revealed the following:
11:15 am - walking
11:30 am - walking
11:45 am - walking
12:00 pm - walking
12:15 pm - Standing Still
12:30 pm - Quiet
12:45 pm - Quiet
1:00 pm - Kicking, Combative
1:15 pm - Lying Down
1:30 pm - Standing Still
1:45 pm - Standing Still
Review of these monitoring documents when patient was in seclusion reveals patient was in seclusion from 11:15 pm - 1:45 pm which is 2.5 hours. The order for restraint/seclusion was for up to 2 hours.
Further review of the monitoring documentation revealed patient was not exhibiting aggressive behavior from 11:15 am -1:00 pm. and from 1:15 pm - 1:45 pm. There also was no documentation of re-evaluation by the RNof readiness for discontinuation of restraint or seclusion.

An interview was conducted on 11/29/11 at 10:30 am with the Risk Manager and the Nursing House Supervisor. The medical record and specifically the restraint documentation were reviewed. The Risk Manager and Nursing House Supervisor both confirmed the restraint lasted 2.5 hours according to the monitoring documentation, monitoring documentation revealed only 15 minute time frame during that 2.5 hour time that patient was aggressive, and no documentation of evaluation of readiness for release.

Based upon record review and interview, the facility failed to ensure that seclusion was terminated when release behaviors were demonstrated by 1 of 5 (#5) patients reviewed.

REFER TO TAG A-171