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Based on observation, policy/procedure review, document review, and staff interviews, the hospital's administrative staff failed to implement systems to ensure a safe environment, including a ligature free environment, to minimize risks for patients with psychiatric diagnoses. The presence of ligature risks in the psychiatric unit are points available to psychiatric patients to attach items for the purpose of hanging or strangulation. The acute psychiatric unit census was 16 inpatients (12 patients had suicidal thoughts) and 230 hospital inpatients at the time of the complaint investigation. The following examples confirm this determination.

The hospital administrative staff failed to identify and remove or replace all non-ligature proof hardware from all areas in the inpatient psychiatric unit including patient and hallway doors, and faucets. (Refer to A-144)

The hospital administrative staff failed to maintain a safe environment for suicidal patients by failing to minimize risk factors available in psychiatric bedrooms and throughout the acute psychiatric inpatient unit. (Refer to A-144)

The psychiatric unit staff failed to ensure that staff watched, by means of a monitored camera, unattended patients with suicidal ideation, occupying rooms with non-ligature proof hardware including handles, exposed hinges, non-tamperproof screws, non-tear resistant patient clothing as well as safety risk hazards throughout the inpatient unit. (Refer to A-144)

Failure of the nursing staff to choose the least restrictive intervention during restraint application may cause a patient to experience unneeded additional psychological distress and potential abuse or physical injury including death from a staff member applying a towel over a patients mouth. (Refer to A-145)

Failure of nursing staff to update the Plan of Care for patients with restraint orders could potentially result in nursing staff being unaware of a patient condition or interventions that had been used to control self-destructive behaviors during the patient's stay. (Refer to A-166)

The hospital department staff failed to ensure that time limited violent restraints were removed every four hours according to the physician's order and in conjunction with the hospital policy for adult patients. (Refer to A-171)

Failure of nursing staff to perform assessments on patients in restraints could potentially result in unfavorable physical or psychological effects. (Refer to A-175)

The hospital staff failed to ensure face to face assessment for violent restraints occurred as directed by the hospital policy. (Refer to A-178)

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the safe care and monitoring of psychiatric patients and patients in the hospital.

On 8/2/18 the hospital implemented the following corrective action plan to remove the IJ noncompliance:

On 8/1/18, immediate Behavioral Health risk assessment were completed including those items of ligature concerns.

Effective immediately to ensure patient safety from hallway ligature risks, the Patient Services Vice (VP) President designated 2 additional staff members to monitor all hallways on 2 north. The responsible party, Manager Behavior Health identified this was completed on 8/3/18.
Staff were instructed to continuously monitor to ensure patient safety with the following expectations:
Two (2) dedicated staff members will have visualization of hallways.
Staff #1, per shift, will be placed in section 1 to actively visualize and monitor exterior rooms and hallways of Rooms 2611 - 2620.
Staff #2, per shift, will be placed in section 2 to actively visualize and monitor exterior rooms and hallways of Rooms 2601 - 2610.
This will continue until all ligature risks have been removed on 9/18/18.

The facility began education on 8/2/18 to address the following:
2 North showers will not be utilized until all ligature risks have removed.
Linen carts and bags were removed and placed in locked areas.
Shower doors are locked at all times.
Behavioral Health staff are immediately available to hand out linens and collect soiled linens.
No carts or linen bags are allowed on the unit unless staff is present to collect soiled linens.
Linen cart will then be immediately returned to locked area.

In addition, the Mandatory Education was initiated on 8/2/18, staff will be educated on the following:
Review staff visualization plan.
Review and perform walk through of ligature risks on unit and internal risk assessment.
A floor map was attached to mark the designated hall monitoring with sections to observe continuously.
All staff signed attestation form prior to their next scheduled shift.
The facility would ensure mandatory education was completed on 8/6/18 or the next scheduled shift.

Staff was re-educated on 8/6/18 or by next shift by reviewing Observation Levels Policy.
All staff will sign attestation form prior to next scheduled shift.
Rooms 2611, 2612 and 2615 were identified to have ligature risks within 2 North Behavioral Health Unit Patient Rooms. Patients have been immediately re-assigned to other rooms.

Inpatient Risk Assessment were completed by 8/6/18 on standard medical/surgical room, and ED Risk Assessment completed as well.

On 8/2/18 collaboration with contractors and Executive Director, Construction and Design VP Patient Services developed a plan to immediately mitigate ligature risks on 2 north.

On 8/3/18, facility to ensure patients will be escorted to ligature free showers within the Behavioral Health department, until ligature risks have been removed.

On 8/3/18, the Executive Director, Construction and Design VP Patient Services completed an action plan for when materials (not limited to the following: exit signs, thermostat guards, shower handles, double hung doors and patient hinges) had been ordered, dates when will be received, and dates of replacement.

Behavioral Health staff were educated beginning on 8/2/18 to review the following:
Patient room 2611 and 2612 as well as storage room 2613 will not be accessible to patients until the ligature risks in all three rooms have been removed. At that point, Corridor 2200B doors will be unlocked.

On 8/3/18, Behavioral Health staff education was initiated on 8/3/18 to:
Staff to escort patients to ligature free showers in 2 South Behavioral Health Unit.
List of ligature risks were reviewed and included in list of education.
Informed rooms 2611, 2612, 2615 will be removed from potential occupancy until all ligature risks have been removed.
On 8/3/18, the Ligature risk in room 2615 had been removed.

All staff (Behavioral Health & Inpatient) were educated starting on 8/6/18 at 4 PM and ongoing as on the definition of ligature risk (point) as defined. Active re-education was reviewed at Managing for Daily Improvement/Safety Huddles daily for two weeks.

The facility removed lined bags and other hazards from patient areas and stored these in locked areas ; and ordered tear resistant cord/sting free scrubs on 8/3/18. All clinical nursing staff will receive electronic education module regarding suicide risk and precautions in a hospital setting. Electronic education will be initiated on 8/3/18 at 3:00 p.m.

The IJ was removed on August 6, 2018.

I. Based on observation, document reviews, and staff interviews, the hospital's administrative staff failed to identify and remove or replace all non-ligature proof hardware and faucets from all areas in the inpatient psychiatric unit including patient rooms, hallway doors, and faucets for 12 of 16 psychiatric patients identified with suicidal ideation upon admission and on suicide precautions. (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12)

Failure to establish and maintain a safe environment including non-ligature proof hardware and faucets for psychiatric patients could potentially provide a point of attachment for a device used for patient strangulation or hanging and result in patient deaths or other life-threatening conditions.

Findings include:

1. Observations on 8/1/18 from 8:40 AM to 10:00 AM and from 12:30 PM to 1:00 PM, with Behavioral Health Nurse Manager and Director of Nursing Operations revealed the following doors identified on the Behavioral Health unit:
- 3 of 3 sets of double doors in the corridors with four exposed hinges on each door that attached to the door frame. The hinges extended approximately 1-inch from the door frame, causing ligature points a patient can attach an item to cause bodily harm or possible strangulation.
- 4 of 4 doors in the Dining/Activity Room with three exposed hinges on each door that attached to the door frame. The hinges extended approximately 1-inch from the door frame, causing ligature points a patient can attach an item to cause bodily harm or possible strangulation.
- 18 of 18 patient room doors opened into the hallway with exposed continuous hinges on the hall side that extended approximately 1-inch from the top of the door, causing ligature points a patient can attach an item to cause bodily harm or possible strangulation. A continuous hinge is a hinge that has a thin pin joint and extends along the full length of the door.

Observations on 8/1/18 from 8:40 AM to 10:00 AM and from 12:30 PM to 1:00 PM, with Behavioral Health Nurse Manager and Director of Nursing Operations revealed the following on the Behavioral Health unit:
- 3 of 3 non-ligature proof door handle levers on non-patient rooms in hallway of Corridor 2200A
- 3 of 4 non-ligatrue proof door handle levers on the inside and outside of patient rooms in Corridor 2200B (Occupied Patient rooms 2611, 2612, 2615)
- 3 of 3 non-ligature proof door handle levers on non-patient rooms in hallway of Corridor 2200B
- 4 of 4 non-ligature proof door handle levers on non-patient rooms in hallway of Corridor 2200C (included 1 of 1 shower room door with non-ligature proof door handle levers on the inside and outside of shower room door)
- 6 of 6 non-ligature proof door handle levers on non-patient rooms in hallway of Corridor 2200D (included 2 of 2 shower room doors and 1 of 1 tub room door with non-ligature proof door handle levers on the inside and outside of tub room)
- 1 of 1 metal door closer mounted on the upper interior surface on each of 6 doors (double doors). Each of the three sets of double doors were in the open position and the metal door closer formed a triangle shape that extended approximately 6 inches into the door opening to the hallway. A door closer is a mechanical device that assists to close a door after it is opened. (Extended closure items cause a ligature point a patient can attach an item to causing a strangulation or hanging hazard).
- The Nurses Station area (an open area from the hallway) - 1 of 1 sink with 1 non-ligature proof faucet, 2 of 2 non-ligature proof faucet handles, and 1 of 1 exposed plumbing under the sink. (The exposed pipes and plumbing presents an area where a patient can potentially attach an item causing strangulation or hanging hazards).
- 3 of 3 shower rooms and 1 of 1 tub room - each room contained non-ligature proof water control knobs.(Knobs that are not ligature proof extend into the room allowing a patient to attach an item causing a strangulation or hanging hazard).
- 1 of 3 shower room (Room 2635) contained a metal linen cart with a yellow laundry bag that contained a cord in the top of the laundry bag long enough to become a ligature risk for a patient.
- 2 of 2 patient rooms with a thermostat cover extending from the wall 3 inches, causing ligature points a patient can attach an item to cause bodily harm or possible strangulation. (Patient rooms 2608 and 2612)
- 2 of 2 Exit signs, shaped like an inverted T, that hung from the ceiling that left a 2 inch gap between the sign and the ceiling that could be a source for hanging.

Observation on 8/1/18 at approximately 9:20 AM, with Behavioral Health Nurse Manager, revealed Patient #12 entered shower room 2635 unattended and locked the shower door once the patient entered the shower room. Shower room 2635 contained the metal cart and laundry bag with a cord closure long enough to be used as a ligature or strangulation/hanging risk.

The door hinges, door handle levers, shower/tub fixtures, and faucet listed may be utilized as ligature points and sufficient areas for attachment of a hanging device that a patient could use to hang themselves and resulted in an unsafe physical environment.

2. Review of Patient #12 medical record revealed the patient was admitted with diagnoses of worsening depression and suicidal behavior with plans to hang himself.

3. Review of policy titled "Patient Rights and Responsibilities/Non-Discrimination", dated reviewed/revised 2/15/18, revealed in part, ". . . The following rights and responsibilities will be communicated to patients and families. Patient Rights - While you are a patient, you and your legally designated representative have the right to: . . . Receive care in a safe environment. . . ."

Review of hospital document titled "Patient Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights, revealed in part, ". . . While you are a patient in the hospital, you have the right to...receive care in a safe environment. . . ."

Review of policy titled "Suicide Assessment and Prevention", dated reviewed/revised 8/16, revealed in part, "It is the policy of the Genesis Behavioral Health Program to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors. Patients at risk for suicide require intensive support, close observation and frequent re-assessment of their emotional and physical well-being. . . Suicide Precautions: Staff are to maintain a safe and therapeutic environment for all patients. See Behavioral Department policies "General Safety" and Environmental Safety Checks. . . It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. . . ."

Review of Behavioral Health policy titled "General Safety", reviewed/revised 10/16, revealed in part, ". . . Purpose: To ensure a safe environment for patients, staff, and visitors. . . Daily documented safety inspections of all patient care areas are required. . . ."

Review of Behavioral Health policy titled "Environmental Safety Checks", reviewed/revised 6/17, revealed in part, "Policy: Environmental safety checks will be completed and documented at least once each day by the designated staff member. A pro-active environmental risk assessment will be conducted at least annually by program leadership and communicated to hospital safety officer/plant operations. . . Purpose: To ensure a safe physical environment for patients, staff, and visitors. . . Practice/Procedure: . . . Environmental safety checks will be initiated and documented on round sheet by staff member assigned to room checks. An annual proactive environmental assessment will be conducted with Hospital Safety Officer and environmental safety issues will be communicated to hospital administration for follow-up and correction. . . ."

4. Review of documentation for Behavioral Health daily environmental checks from 7/2/18 to 8/7/18 failed to address any ligature risks including non-ligature proof hardware and faucets.

5. Review of document titled "Behavioral Health Risk Assessment 10-17-16" failed to address all elements of ligature risks for the Behavioral Health 2 North adult psychiatric unit including non-ligature proof hardware and faucets.

6. Review of patient medical records on 8/1/18 at 4:00 PM and 8/2/18 at 7:30 AM, with Staff B, Registered Nurse/Nursing Quality and Standards Specialist revealed Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 were admitted with suicidal ideations and placed on suicide precautions.

7. During an interview 8/1/18 on a tour from 8:40 AM to 10:00 AM, the Behavioral Health Nurse Manager confirmed the door hinges, door handle levers, shower/tub fixtures, and faucet listed may be utilized as ligature points and sufficient areas for attachment of a hanging device that a patient could use to hang themselves and a risk for self harm to patients.

During an interview on 8/1/18 at 9:00 AM, Staff C, Registered Nurse/Charge Nurse, stated all patients on the inpatient psychiatric unit were considered to be on suicide precautions. Staff C verified patients were allowed to shower without staff in attendance.

During an interview on 8/1/18 at 9:07 AM, Staff R, Behavioral Health Registered Nurse, stated they try to have someone sit at the nurse's station at all times unless there is an emergency that the staff have to attend to.

During an interview on 8/8/18 at 11:50 AM, the Executive Director of Construction and Design stated he had been unable to find any Behavioral Health Risk Assessment since the one dated 10-17-16 which he completed. The Executive Director of Construction and Design stated an Environment of Care (EOC) Committee conducted risk assessment rounds that addressed safety issues for clinical areas two times a year but could not recall the last EOC Committee risk assessment round that addressed safety issues in the Behavioral Health Unit.

During an interview on 8/8/18 at 2:10 PM, the Safety and Emergency Preparedness Manager stated he walked around the inpatient psychiatric unit in March 2018 with the Behavioral Health Nurse Manager but did not look specifically for ligature risks throughout the Behavioral Health unit at the time of the walk around. The Safety and Emergency Preparedness Manager stated some ligature risks were identified at the time of the walk around such as a television cord was too long and needed to be shortened, but ligature risks was not the focus of the walk around. The Safety and Emergency Preparedness Manager produced a 36 page document of work orders as a result of the walk around in March 2018 but ligature risks were not identified in the work orders.

II. Based on observations, document review and staff interviews, the hospital's administrative staff failed to identify and remove or replace all potential hazards, including non-tamperproof screws, tear resistant clothing, and clothing with strings, for patients that self harm or may cause harm to others from all areas in the inpatient psychiatric unit including patient rooms and hallways for 13 of 17 psychiatric patients identified with suicidal ideation upon admission and on suicide precautions. (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13)

Failure to establish and maintain a safe environment for psychiatric patients could provide potential hazards including weapons for patient self harm or harm to others and result in patient deaths or other life-threatening conditions.

Findings include:

1. Observations on 8/1/18 from 8:40 AM to 10:00 AM and from 12:30 PM to 1:00 PM, with Behavioral Health Nurse Manager and Director of Nursing Operations revealed the following:
- 3 of 3 sets of double doors in the corridors with 8 non-tamperproof screws in four exposed hinges on each door that attached to the door frame. Each door contained 9 non-tamperproof screws on a metal plate on the edge of the doors. Each door contained 2 metal plates on the flat side of the doors - 1 plate with 6 non-tamperproof screws and 1 plate with 20 non-tamperproof screws. (The presence of non-tamperproof screws provides an opportunity for a patient to remove the screw from the wall to create a ligature point for hanging, potential weapon to harm self or others).
- 17 of 17 patients wearing non-tear resistant clothing - 3 of the 17 patients wearing hospital type gowns with strings attached. (Patients #1, 8, and 13) (Hospital gowns with strings attached and non-tear resistant clothing/scrubs provides patients at risk to fashion a hanging or strangulation device to use for self harm or harm to others).

Observation on 8/2/18 at 8:15 AM, with Staff B, Nursing Quality and Standards Specialist, revealed a locked room outside the locked inpatient psychiatric unit that contained hospital type gowns with 4 strings on each gown - each string approximately 9 - 10 inches long. (The presence of cords or strings attached to hospital gowns provides a patient an opportunity to fashion a hanging or strangulation device to harm self or others).

2. Review of policy titled "Patient Rights and Responsibilities/Non-Discrimination", dated reviewed/revised 2/15/18, revealed in part, ". . . The following rights and responsibilities will be communicated to patients and families. Patient Rights - While you are a patient, you and your legally designated representative have the right to: . . . Receive care in a safe environment. . . ."

Review of hospital document titled "Patient Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights, revealed in part, ". . . While you are a patient in the hospital, you have the right to...receive care in a safe environment. . . ."

Review of policy titled "Suicide Assessment and Prevention", dated reviewed/revised 8/16, revealed in part, "It is the policy of the Genesis Behavioral Health Program to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors. Patients at risk for suicide require intensive support, close observation and frequent re-assessment of their emotional and physical well-being. . . Suicide Precautions: Staff are to maintain a safe and therapeutic environment for all patients. See Behavioral Department policies "General Safety" and Environmental Safety Checks. . . It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. . . ."

Review of Behavioral Health policy titled "General Safety", reviewed/revised 10/16, revealed in part, ". . . Purpose: To ensure a safe environment for patients, staff, and visitors. . . Daily documented safety inspections of all patient care areas are required. . . ."

Review of Behavioral Health policy titled "Environmental Safety Checks", reviewed/revised 6/17, revealed in part, "Policy: Environmental safety checks will be completed and documented at least once each day by the designated staff member. A pro-active environmental risk assessment will be conducted at least annually by program leadership and communicated to hospital safety officer/plant operations. . . Purpose: To ensure a safe physical environment for patients, staff, and visitors. . . Practice/Procedure: . . . Environmental safety checks will be initiated and documented on round sheet by staff member assigned to room checks. An annual proactive environmental assessment will be conducted with Hospital Safety Officer and environmental safety issues will be communicated to hospital administration for follow-up and correction. . . ."

3. Review of documentation for Behavioral Health daily environmental checks from 7/2/18 to 8/7/18 failed to address any ligature risks including non-tamperproof screws, tear resistant clothing, and clothing with strings.

4. Review of document titled "Behavioral Health Risk Assessment 10-17-16" failed to address all elements of ligature risks for the Behavioral Health 2 North adult psychiatric unit including non-tamperproof screws, tear resistant clothing, and clothing with strings.

5. Review of patient medical records on 8/1/18 at 4:00 PM and 8/2/18 at 7:30 AM, with Staff B, Registered Nurse/Nursing Quality and Standards Specialist revealed Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13 were admitted with suicidal ideations and placed on suicide precautions.

a. Review of Patient #12 medical record revealed the patient was admitted with diagnoses of worsening depression and suicidal behavior with plans to hang himself.

b. Review of Patient #13 medical record revealed the patient was admitted with suicidal and homicidal thoughts and has attempted suicide by hanging in the past.

6. During an interview on 8/1/18 during tour from 8:40 AM to 10:00 AM, the Behavioral Health Nurse Manager confirmed the non-tamperproof screws, non-tear resistant clothing and clothing with strings may be utilized as a hazard that could pose a risk for self harm to patients.

During an interview on 8/1/18 at 9:00 AM, Staff C, Registered Nurse/Charge Nurse, stated all patients on the inpatient psychiatric unit were considered to be on suicide precautions.

During an interview on 8/1/18 at 12:45 PM, Staff C, Registered Nurse/Charge Nurse, stated patients changed into a hospital type gown with strings attached upon admission to the inpatient psychiatric unit until the patient's clothing was checked to be safe and then the patient's clothing was returned to the patient and the patient could then change into their own clothes. Staff C confirmed Patients #1, 8, and 13 was wearing hospital type gowns with strings attached and Patients #1 and 13 was wearing 2 hospital type gowns with strings attached.

During an interview on 8/8/18 at 11:50 AM, the Executive Director of Construction and Design stated he had been unable to find any Behavioral Health Risk Assessment since the one dated 10-17-16 which he completed. The Executive Director of Construction and Design stated an Environment of Care (EOC) Committee conducted risk assessment rounds that addressed safety issues for clinical areas two times a year but could not recall the last EOC Committee risk assessment round that addressed safety issues in the Behavioral Health Unit.

During an interview on 8/8/18 at 2:10 PM, the Safety and Emergency Preparedness Manager stated he walked around the inpatient psychiatric unit in March 2018 with the Behavioral Health Nurse Manager but did not look specifically for ligature risks throughout the Behavioral Health unit at the time of the walk around. The Safety and Emergency Preparedness Manager stated some ligature risks were identified at the time of the walk around such as a television cord was too long and needed to be shortened, but ligature risks was not the focus of the walk around. The Safety and Emergency Preparedness Manager produced a 36 page document of work orders as a result of the walk around in March 2018 but ligature risks were not identified in the work orders.

Based on policy, document, patient medical record review, and staff interviews, the hospital's administrative staff failed to ensure nursing staff prevented potential abuse during the application of violent 4 point restraints, on 1 of 1 patient's when a towel was placed over the patient's mouth and face. (Patient #19) The facility failed to include training to all hospital staff on the topics of Patient Abuse or Neglect, Restraint policy and a restraint teaching tool prior to the onsite investigation.

Finding include:

1. Review of policy titled "Patient Rights and Responsibilities/Non-Discrimination", dated reviewed/revised 2/15/18, revealed in part, ". . . The following rights and responsibilities will be communicated to patients and families. Patient Rights - While you are a patient, you and your legally designated representative have the right to: . . . Receive care in a safe environment and expect to be free from mental and physical abuse. . ."

Review of hospital document titled "Patient Rights and Responsibilities", provided to patients at the time of admission, contained information available to patients regarding their rights, revealed in part, ". . . While you are a patient in the hospital, you have the right to...receive care in a safe environment, and expect to be free from mental, physical abuse.. . ."

Review of hospital policy titled "Restraints", dated reviewed/revised 6/18, revealed in part, ". . . Consider less restrictive interventions based on individual assessment. . . ." Additional review of the policy revealed in part, "... Organizational approved "spit hoods" may be used in emergency situations... Spit hoods will only be used on units with specially educated staff... The units are Emergency Department and Behavioral Health Unit..."

The Restraints policy lacked identification of staff using a towel to prevent spitting as a authorized intervention and failed to identify the Neuro/Oncology unit as a unit with training and authorization to utilize spit hood.

2. Review of the hospital investigation of an incident that occurred on 6/20/18 at approximately 5:10 PM, Staff RN (Registered Nurse) E placed a towel over Patient #19's mouth holding it in place initially by both sides of the towel with each of RN E's hands. Then Staff RN E held the towel ends behind the patient's head with one hand for approximately 40 seconds following an incident where Patient #19 spit on 2 patient care technicians during the restraint application. Following completion of the facility investigation 6/20/18 Staff RN E was terminated from employment.

3. Review of Patient #19's medical record revealed Patient #19 was placed in 4 point restraints on 6/20/18 at 5:15 PM.

4. During interviews on 7/31/18 and 8/1/18 with Staff RN T, Staff RN X, Patient Care Technician (PCT) W, Nursing Assistant (NA) V, Security Officer (SO) S, and SO U, present during the time of the 4 point restraint application, confirmed that Staff RN E held a towel over Patient #19's mouth and face as described in the hospital's investigative findings.

During an interview on 8/1/18 at 12:15 PM, the Director of Nursing Operations verified the hospital failed to ensure all hospital staff involved in restraint applications received restraint and abuse education.

During an interview on 8/6/18 at 1:38 PM, Staff RN B/Nursing Quality and Standards Specialist, verified the hospital failed to ensure all hospital staff involved in restraint applications received restraint and abuse education.

5. Review of the facility investigation into the incident regarding Patient #19 revealed the facility initiated the following training only on the Neuro/Oncology Unit.
a. Recognition of the need for education related to concerns with restraint application for Neuro/Oncology
staff that included information on Patient Abuse or Neglect, Restraint policy review and a restraint teaching
tool.

Based on document review and staff interviews the administrative staff failed to ensure nursing staff that implemented restraints followed policy regarding updating the patient's Plan of Care after restraints were applied to 3 of 14 patients charts reviewed with orders for restraints (Patient #14, #17 and #18).

Failure of nursing staff to update the Plan of Care for patients with restraint orders could potentially result in nursing staff being unaware of a patient condition or interventions that had been used to control self-destructive behaviors during the patient's stay.

Findings Include

1. Review of policy titled: Restraints, effective date: 11/15/2009, revised 6/18 revealed, in part, " Policy: The Genesis Health System Administration and staff recognize that all patients have the right to be free from physical or mental abuse and corporal punishment ... C. Monitoring: 1. i. Revisions to the Plan of Care ..."

2. Review of Patient #14's medical record revealed Staff RN G (Registered Nurse), obtained an order for non-violent restraints from ARNP F (Advanced Registered Nurse Practitioner), due to Patient #14 pulling on the ventilator and medical tubing in place for Patient #14's breathing and healthcare needs.

3. Review of Patient #17's medical record revealed Patient #17 became combative on the evening of 3/13/2018. Staff RN M, obtained violent restraint orders from Physician L for Patient #17 at 11:46 AM and failed to update Patient #17's Plan of Care. Patient #17's restraints were removed at 3:30PM.

On 3/14/2018 at 7:25 AM Staff RN N, obtained a violent restraint order from Physician L for Patient #17 and failed to update Patient #17's Plan of Care. Patient #17's restraints were removed at 8:41 PM.

On 3/15/2018 at 8:33AM Staff RN O, obtained a violent restraint order from Physician L for Patient #17 due to combative behavior. Staff RN O failed to update Patient #17's Plan of Care.

4. Review of Patient # 18's medical record revealed Patient #18 was confused and trying to pull out medical tubing for a drain. Staff RN Q obtained an order from Physician P to implement non-violent restraints on 7/27/2018 at 8:44 PM. Staff RN Q failed to update Patient #18's Plan of Care after initiating the restraint order.

5. During an interview on 8/8/2018 at 9:10 AM Staff RN D/Nurse Manager accessed the patients records and visualized them at the time of the interview. Staff RN D/Nurse Manager revealed the expectation of nursing staff included an update of the Plan of Care after the first use of restraints as an intervention. Staff RN D/Nurse Manager confirmed she did not see in documentation where staff nurses had updated the Plan of Care for either Patient # 14, Patient # 17 or Patient # 18 after restraint orders.

Based on document review and staff interviews the administrative staff failed to ensure nursing staff implementing restraints acquired new orders from providers for the restraints at appropriate time intervals for 2 of 14 patients reviewed with restraint orders in place during their stay (Patient #16 and #19).

Failure to ensure nursing staff call providers for new orders at appropriate time intervals resulted in 2 patients out of 14 patients being in restraints for longer than approved time frames.

Findings Include:

1. Review of policy titled: Restraints, effective date: 11/15/2009, revised 6/18 revealed, in part, " Policy: The Genesis Health System Administration and staff recognize that all patients have the right to be free from physical or mental abuse and corporal punishment ...VII. PRACTICE/PROCEDURE: A. Application ...e. Frequency of order renewal is as follows: 1). Nonviolent situation- unless otherwise specified, duration is assumed to be until the end of the next calendar day ...2). Violent situation- each order for restraints may only be renewed in accordance with the following limits for up to a maximum of 24 consecutive hours. aa. 4 hours for adults 18 years of age or older ..."

2. Review of Patient #16's medical record revealed Staff RN (Registered Nurse) J obtained an order from Physician I for violent restraints on 8/2/2018 at 8:44 PM, Patient #16 was released from violent restraints on 8/3/2018 at 6:44 AM. Staff RN J failed to document obtaining any continuation orders for Patient #16 to remain in violent restraints after the initial order on 8/2/2018 at 8:44 PM.

3. Review of Patient #19's medical record revealed on 6/20/18 at 5:15 PM Patient #19 became combative and was placed in 4 -5 point locked violent restraints. Patient #19 was removed from restraints on 6/20/18 at 9:45 PM. The medical record lacked documentation of a violent restraint renewal order after the 4 hour time limit ended.

4. During an interview on 8/7/18 at 3:00 PM, Staff RN D/Nurse Manager, confirmed Patient #19's medical records lacked documentation of a violent restraint renewal order after the 4 hour time limit ended.

5. During an interview on 8/8/2018 at 9:10 AM Staff RN D/Nurse Manager accessed the patients records and visualized them at the time of the interview. Staff RN D/Nurse Manager confirmed the lack of documentation to obtain an order for Patient #16. Staff RN D/Nurse Manager reported it is expected of nursing staff to obtain violent restraint orders every four hours and document accordingly in patient medical records.

Based on document review and staff interviews administrative staff failed to ensure nursing staff performed timed assessments for patients with restraint orders in 3 of 14 patient charts reviewed of patients in restraints (Patient #15. #16 and #18).

Failure of nursing staff to perform assessments on patients in restraints could potentially result in unfavorable physical or psychological effects.

Findings Include:

1. Review of policy titled: Restraints, effective date: 11/15/2009, revised 6/18 revealed, in part, "Policy: The Genesis Health System Administration and staff recognize that all patients have the right to be free from physical or mental abuse and corporal punishment ... C. Monitoring: 1. Reassessment and monitoring of the patient in restraints will be completed at a minimum every 2 hours in non-violent situations and a minimum of every 15 minutes in violent situations ..."

2. Review of Patient #15's medical record revealed Patient #15 was in non-violent restraints on the dates of 7/23/2018 at 12:00 PM through 7/26/2018 at 7:30 AM. Staff RN (Registered Nurse) H failed to document performing a 2-hour assessment on 7/25/2018 at 2:00 PM as directed by the facility policy.

3. Review of Patient #16's medical record revealed on 8/2/2018 at 12:44 AM Staff RN J documented an order for violent restraints from Physician I, no assessments were documented for the 4 hour period of the restraint order.

On 8/2/2018 at 5:44 AM, Staff RN J documented an order for violent restraints from Physician I be applied on Patient #16, no assessments were documented for the 4- hour period of the restraint order.

On 8/2/2018 at 8:44 PM, Staff RN J documented an order for violent restraints obtained from Physician I, RN J performed 2 hour assessments on Patient #16 instead of 15 minute assessments as directed by the facility policy.

4. Review of Patient #18's medical record revealed Patient #18 was in non-violent restraints from 7/27/2018 at 8:41 PM until 7/28/2018 at 9:03 AM. Staff RN Q failed to meet the 2 hour time for an assessment while Patient #18 was in non-violent restraints on 7/28/2018 at 12:41 AM. Staff RN Q documented her assessment of Patient #18 at 12:56 AM, 15 minutes later than facility policy directed.

5. During an interview on 8/8/2018 at 9:10 AM Staff RN D/Nurse Manager accessed the patients records and visualized them at the time of the interview. Staff RN D/Nurse Manager confirmed the lack of assessments in the medical records for Patient #15, #16 and # 18. Staff RN D/Nurse Manager reported this lack of documentation does not meet the expectation of the hospital policies.

Based on document review and staff interviews administrative staff failed to ensure providers followed hospital policy regarding face-to-face assessments for patients in restraints in a timeframe dictated by hospital policy. During review of 14 patient records with restraint orders, 3 patients failed to have face-to-face assessments done (Patient #16, #17 and #19).

Failure of providers to perform a face-to-face assessment of patients in restraints could potentially result in unfavorable medical or psychological effects.

Findings Include:

1. Review of policy titled: Restraints, effective date: 11/15/2009, revised 6/18 revealed, in part, " Policy: The Genesis Health System Administration and staff recognize that all patients have the right to be free from physical or mental abuse and corporal punishment .... 2). Violent situation- each order for restraints may only be renewed in accordance with the following limits for up to a maximum of 24 consecutive hours. aa. 4 hours for adults 18 years of age or older; ... dd. After 24 hours, before writing a new order for the use of restraint or seclusion for violent situations, a Practitioner who is responsible for the care of the patient must see and assess the patient ...6. When restraints are applied in violent situations, the patient must be evaluated face-to-face within 1 hour after the initiation: ...d. The evaluation should be documented in the patient's medical record, and should include: 1). An evaluation of the patient's immediate situation. 2). The patient's reaction to the intervention(s).3). The patient's medical and behavioral condition. 4). The need to continue or terminate the restraint or seclusion ..."

2. Review of Patient #16's medical record revealed Physician I ordered violent restraints to be initiated on 8/2/2018 at 8:44 PM. Physician I failed to present to Patient #16's room and perform a face-to-face assessment after the application of violent restraints as directed by hospital policy. The medical record failed to contain documentation acknowledging Patient #16 was in restraints the night prior, or released on the morning of 8/3/2018 at 6:44 AM.

3. Review of Patient #17's medical record revealed Physician L ordered violent restraints on 3/13/2018 at 11:46 AM due to combative behavior. Physician L failed to present within the 1-hour timeframe to perform a face-to-face assessment after the application of violent restraints as directed by hospital policy. Physician L presented to assess Patient #17 on 3/13/ 2018 at 4:53PM.

On 3/14/2018 at 7:25 AM Physician L ordered violent restraints to be applied to Patient #17. Physician L failed to present within the 1-hour timeframe to perform a face-to-face assessment after the application of violent restraints as directed by hospital policy. Physician L presented to assess Patient #17 on 3/14/2018 at 11:59 AM.

On 3/15/2018 at 8:34 AM Physician L ordered violent restraints to be applied to patient # 17 due to combative behavior. Physician L failed to present within the 1-hour timeframe to do a face-to-face assessment after the application of violent restraints dictated by hospital policy. Physician L presented to assess Patient # 17 on 3/15/2018 at 2:25 PM.

4. Review of Patient #19's medical record revealed on 6/20/18 at 5:13 PM Patient #19 became combative and an order for locked 4 -5 point violent restraints was obtained from Physician Z. The medical record lacked documentation of a face-to-face evaluation by qualified personnel within 1 hour of restraint application.

During an interview on 8/1/18 at 1:06 PM, Staff RN (Registered Nurse) T confirmed the failed completion of the required face-to-face evaluation. Staff RN T reported nursing staff should have reminded Physician Z to come and perform a face-to-face evaluation but failed to do so.

During an interview on 8/6/18 at 4:10 PM, Staff RN D/Nurse Manager, confirmed Patient #19's medical record lacked documentation that a face-to-face evaluation by qualified personnel in accordance with the hospital policy occurred.

During an interview on 8/8/2018 at 9:10 AM, Staff RN D/Nurse Manager accessed the patient's records and visualized them at the time of the interview. Staff RN D/Nurse Manager confirmed she did not observe face-to-face documentation in accordance with hospital policy. Staff RN D/Nurse Manager then reported it is the expectation of physicians to follow policy and perform a face to face after an initial violent restraint order is given. Staff RN D/Nurse Manger revealed she would expect nursing staff to remind physicians to present to the patients room and complete a face-to-face evaluation per policy.