HospitalInspections.org

A hospital must protect and promote each patient's rights.

Based on review of hospital policies and procedures, documents, videos, personnel files, observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Condition of Participation for Patient Rights as evidenced by the following references to standard level deficiencies and immediate jeopardy:

Cross Reference: A-0144: ensure that patient bathrooms were free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk;

Cross Reference: A-0145: ensure that one of one patient (#24) was not subject to abusive behavior by one of one employee (employee #60); and
2) ensure that a physician order was received for each episode of restraint in a patient;

Cross Reference: A-0154: ensure the use of restraint was not used to coerce three of three patients (patient #17, #24, & #25) to stay in their rooms;

Cross Reference: A-0167: ensure the use of restraint or seclusion is implemented in accordance with safe and appropriate restraint and seclusion techniques;

Cross Reference: A-0168: ensure when patients are placed in seclusion and/or restraints the order is given (verbal/written) by a physician or, in an emergency situation, by a registered nurse (RN) not a Behavioral HealthTechnician (BHT).

Cross Reference: A-0174: ensure that eight of eight patients (#3, #5, #7, #8, #11, #13, #14, and #19) were released from a seclusion and/or restraint event timely after the patient was documented by facility personnel as remaining calm for ten minutes;

Cross Reference:A-0183: ensure that simultaneous restraint and seclusion use is only permitted if the patient is continually monitored according to policy and procedure;

Cross Reference: A-205: ensure when patients are placed in seclusion and/or restraints the staff follows the established criteria to assess the patient's nutrition, hydration, toileting, and circulation, at a minimum. with every 15-minute and these checks are documented on the Seclusion and Restraint Observation Form for nine of nine patients (Patients #3, #4, #5, #7, #8, #10, #11, #13, & #14), however, these patients were on Q (every) 5 minute monitoring;

The cumulative effect of this systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights, which poses a potential risk to the health and safety of patients.

Based on a review of hospital policy and procedure, video review, documents, and staff interviews, it was determined that the administrator failed to ensure patients had the least restrictive environment, free from coercive treatment by staff.

This deficient practice poses the risk of an nontherapeutic environment where patients receiving mental health treatment can feel safe, and a violation of patient rights.

Cross Reference: Tag A0115

Findings Include:

A review of the policy titled "Restraint and Seclusion," received on January 10, 2023, revealed: "...It is the intent of Destiny Springs Healthcare to provide a safe environment for patients and staff, utilizing the least restrictive environment needed to achieve the best outcomes...."

A review of the policy titled "Standards of Conduct," received on January 10, 2023, revealed: "...Destiny Springs Healthcare has endeavored to identify general work rules of conduct that it deems to be incompatible with appropriate professional business operations. While not an exhaustive list, the work rules shall function as guidelines for behavior while at work ...Work Rules. Violation of the following standards shall be deemed good cause for which an employee may be subject to disciplinary corrective action ...Conduct in violation of peace, good order, or general welfare of Destiny Springs Healthcare, its employees or patients...."

A review of the policy titled "Patient Rights," received on January 10, 2023, revealed: "...Employees are expected to treat each patient in a respectful and considerate manner and to immediately report any concern for a patient's safety...Patient Rights according to federal and state guidelines include the following at a minimum...The right to receive considerate, respectful care in the least restrictive environment ...."

A review of the policy titled "Abuse, Assault, or Neglect of a Patient," received on January 10, 2023, revealed: "...Employees are expected to treat each patient in a respectful and considerate manner and to immediately report any concern for a patient's safety...All staff members are expected to treat patients with the utmost respect and dignity. Any evidence to the contrary will not be tolerated...."

Medical record documentation for restraint and seclusion, dated and timed December 14, 2022 at 2002, for Patient #17 identified: "...the unit remains shut down for the evening...."

A review of the video, hallway, camera from Phoenix, an adolescent unit, on December 14, 2022 at 07:45 pm to 08:15 pm identified:

At 07:45:25 pm, Patient #24 is seen standing in the doorway of a bedroom. Employee #60 approaches the doorway and begins to struggle with Patient #24. This view is partially obscured by an unidentified patient. Patient #24 comes out into the hallway with Employee #60's hands around his/her arms. Employee #60 is seen pulling Patient #24 back towards the room. The unidentified patient again obscures the view, as Employee #60 bends over Patient #24. The employee stands upright and the patient and employee continue to struggle until the patient is back inside the doorway again. Employee #60 blocks the doorway as Patient #24 continues to attempt to leave. At 07:46:33, an unidentified employee approaches the room and Employee #60 walks away.

At 07:47:03, Employee #60 placed a hand on Patient #25's chest, and a hand on an unidentified patient's (Patient A) shoulder, and pushed them back into their respective rooms, then stood in the doorway.

At 07:47:24, Employee #60 placed his/her hands on Patient #25's shoulders and pushed him/her back into the room.

At 07:47:36, Employee #60 placed his/her hands on the backs of two unidentified patients (Unidentified Patients B and C), and pushed them down the hallway to their rooms, while posturing behind them.

At 07:48:28, Employee #60 placed his/her hands on the chest of Patient C and pushed him/her back into the room, then goes back to stand in the doorway of Patient #25.

At 07:49:45, Patient #25 leaves his/her room and walks towards the end of the hallway. Employee #60 wraps both arms around Patient #17 and escorts him/her back to his/her room. At 07:50:05, Patient #25 comes to the doorway of his/her bedroom and Employee #60, with both hands in his/her pockets, uses his/her body to push Patient #25 into the bedroom and continues to stand in the doorway until 07:53.
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At 07:50:08, Employee #61 grabs Patient #17 by the left arm with both hands, then with one hand and attempts to pull him/her toward the room. Patient #17 resists and Employee #61 lets go, walks off screen, and then comes back on and pushes Patient #17 towards the wall.

At 07:55:08, Employee #36 holds Patient #17 by the upper left arm and escorts him/her to the bedroom, then stands in the doorway.

At 07:59:12, Unidentified Patient C comes to the doorway of his/her bedroom and Employee #60 places both hands on the patient's shoulders and directs him/her back inside the room.

Employee #28 confirmed in an interview conducted on January 19, 2023, that when the unit is shut down, the patients are confined to the unit, but not their rooms. S/he could not confirm the reason the patients were made to stay in their rooms.

Based on a review of hospital policy and procedure, medical records, and staff interviews, the Department determined the administrator failed to ensure that a physician order was received for each episode of restraint in three of three patients (#17, #24, & #25).

This deficient practice poses the risk of three of three patients (#17, #25, and #24) being restrained unnecessarily, the use of restraint as a punishment, long physical restraint times, increased risk of injury to the patient being restrained, and the right of the patient to have an environment free from abuse.

Cross-reference: Tag# A-0115

Findings include:

A review of the facility policy titled "Restraint and Seclusion," received on January 10, 2023, revealed: "...Restraint-(42CFR 482.13 (c)(1)) Any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of(patient to move his or her arms, legs, body, or head freely)- Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient's body...Immediately following the initiation of restraint or seclusion, qualified staff shall: Notify and obtain an order (verbal or written) from the licensed independent practitioner...."

A review of the video, hallway, and camera from Phoenix, an adolescent unit, on December 24, 2022, from 07:45 pm to 08:15 pm identified the following:
1. 07:45:25, Patient #24 is seen standing in the doorway of a bedroom. Employee #60 approaches the doorway and begins to struggle with Patient #24. This view is partially obscured by an unidentified patient. Patient #24 comes out into the hallway with Employee #60's hands around [his/her] arms. Employee #60 was seen pulling Patient #24 back toward the room.
2. 07:49:45, Patient #25 leaves [his/her] room and walks towards the end of the hallway. Employee #60 wraps both arms around Patient #25 and escorts [him/her] back to [his/her] room.
3. 07:50:08, Employee #61 grabs Patient #17 by the left arm with both hands, then with one hand, and attempts to pull [him/her] toward the room.
4. 07:55:08, Employee #36 holds Patient #17 by the upper left arm and escorts [him/her] to the bedroom.

Employee #23 confirmed in an interview conducted on 01/19/2023 that there were no restraint orders for Patient #24 and Patient #25 on December 14, 2022. Also, Patient #17 had no restraint order for these two instances of restraint on December 14, 2022.

Employee #28 confirmed in an interview conducted on 01/19/2023, that Patients #17, #24, and #25 body movements were restricted by employees, Employees #60 and 61.

Based on a review of facility policies and procedures, facility definitions, facility formulary of antipsychotic medications, video surveillance, medical records, personnel files,and staff interviews, the Department determined the administrator failed to ensure that nine of nine patients (#3, #4, #5, #7, #8, #10, #11, #12, & #17) are not subjected to restraint(s) and/or seclusion when the patient is not displaying violent, aggressive or self-destructive behavior.

This failure has the potential risk that patients will be subjected to the physical and psychiatric injury in an unsafe and non-therapeutic environment.

Cross-reference Tags: A0115, A0167, A0168, A0174, A0183. and A0205

Findings include:

A review of the policy/procedure titled "Seclusion and Restraint" Revision Date: 8/31/22, revealed: "...All patients have the right to be free from physical or mental abuse, and corporal punishment...All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff...Restraint or seclusion may only be initiated to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...Intent to provide a safe environment...utilizing the least restrictive environment needed to achieve the best outcomes...restraint or seclusion is clinically justified...
Seclusion...the involuntary confinement of an individual in a room alone for any period from which the individual is physically prevented from leaving...Seclusion may only be used for the management of violent or self-destructive behavior...
Restraint...Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...
Personal Restraint...application of a physical force without the use of a device...
Mechanical Restraint...any device, article, or garment attached to or adjacent to a member's body that the patient cannot easily remove and that restricts the member's freedom of movement or normal access to the patient's body...
Chemical Restraint...a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition...
The RN will document behaviors and failed interventions which led to the need for the use of restraint in the Seclusion and Restraint Individual Reporting Form...Approved holds are considered a physical restraint...
A practitioner or...RN shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status...documented in the Seclusion and Restraint Individual Reporting Form...."

A review of the policy titled "Patient Rights," revealed: "...Patient rights according to federal and state guidelines include the following at a minimum ...The right to receive considerate, respectful care in the least restrictive environment ...The right to be free from all forms of abuse or harassment ...The right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff ...."

The facility definitions of violent, aggressive, and self-destructive behavior delineated in the facility policy/procedure was requested , none was provided for review at the time of the complaint survey.

Employee #23 and employee #28 verified, during interviews conducted on 12/19/2022 through 01/19/2023, that the facility does not have a list of accepted definitions.

A review of the facility document titled "Formulary of Antipsychotic Medications" dated 01/06/20, revealed:
"...Chlorpromazine (Thorazine)...25, 100 mg (milligram) tablet...Typical...
Haloperidol (Haldol)...1, 5 mg tablet...5 mg/ml injection...Typical...
Olanzapine (Zyprexa)...10 mg injection...5, 10, 15 mg tablet...Atypical...
Quetiapine (Seroquel)...25, 50,100, 200 mg tablet...Atypical...
Risperidone (Risperdal)...0.5, 1, 2, 3 mg tablet...Atypical...
Ziprasidone (Geodon)...20, 40, 60 mg tablet...Atypical...."

Employee #16 verified, during an interview conducted on or about January 12, 2023, that Benadryl is not used as an antipsychotic medication.

A review of 11 of 11 patient (#3, #4, #5, #7, #8, #10, #11, #12, #13, #14, & #17) medical records to identify the patient's behavior that caused them to be placed in seclusion and/or restraints for "aggressive, violent, or self-destructive behavior" revealed: the application "...Seclusion...Personal restraint...Mechanical restraint and Chemical restraint.

Patient #3:
"...[November 22, 2022]...Personal restraint...physical hold...Start...1434(2:34 pm)...End...1435...
Mechanical restraint...four-soft...Start...1435...End...1610...
Medication restraint...Benadryl 50 mg...Zyprexa 10 mg...(no time of administration documented on form)...
Seclusion...Start...1435...End...1610...
Reason for Restraint/Seclusion DTO...Threw shoe...verbal threats to staff and peers...

[December 14, 2022]...Reason for seclusion/restraint and the conditions for release explained to the member...Yes...Psychotic breakdown...
Personal restraint...[12/14/2022] (#4 is written over the number 3)...hold...Start...1058...1100(sic)...
Mechanical restraint...(# 4 is written over the number 3)...Restraint-mechanical...Start...1100...End...1200...
Seclusion...Start...1100...End...1200...
Reason for restraint/seclusion...DTS...DTO...Screaming, Crying...."

Patient #4:
"...[November 22, 2022 1:02:09 pm]...
A review of the medical record document titled "Nursing Note" revealed: "...Pt banging door in the morning, demanding to be let in...When [she] refuses to stop, [she] takes voluntary 'time out' in seclusion room...."

"...[November 22, 2022 1:21:55 pm]...
A review of the medical record document titled "Nursing Note" revealed: "...Pt was overheard making a joke about throwing a chair at nurse yesterday...RN told [her] to stop and that it wasn't funny...Pt called the RN a 'bitch' and made a threat to throw a chair at [her]...Pt placed in seclusion and restraints...."

A review of the medical record document titled "Quick Note" date [November 22, 2022, 1:33:20 pm] revealed: "...[20:20]...Patient was then taken to seclusion...."

VIDEO SURVEILLANCE for Patient #4 [November 22, 2022 01:10:00 pm through 02:34:57] pm revealed:
"...[11/22/2022] 01:09:57 pm]...Patient #4 is seen voluntarily walking into the Phoenix seclusion room and is standing next to the bed...the room door is propped open with a chair...no staff is visible...
01:10:31...BHT (unidentified) sits in a chair that is propping the room door open...
01:10:34...Patient sits down on the bed...
01:11:22...Employee #13 motions to the patient to get up and directs [her] to the corner of the room and leans against the patient's body with [his] body...
01:11:26...unidentified BHTs and employee #47 [BHT] enter the seclusion room each carrying a two-point Velcro restraint...01:12:39...The BHTs completed placing the restraints on the bed...
01:12:47...Patient #4 is escorted to the bed and proceeds to lie down on the bed while the three BHTs [#13, #47, and 1 unidentified] begin applying the four-point restraints to all the patient's extremities...
01:14:05...The seclusion room door remains open...No BHT is visible outside of the room...
01:14:42...unidentified BHT returns to sitting in the door chair...
01:17:10...unidentified BHT leaves the door chair...the patient is seen turning [her] head and moving [her] feet...
01:17:40...unidentified BHT returns to the door chair...
01:18:01...unidentified BHT leaves the door chair...
01:18:20...unidentified BHT returns to the door chair...
01:18:47...A second unidentified staff member presents to the seclusion room carrying a small brown bag, which [he] places on the room floor,...and is showing the patient two (2) cups...Talking with patient still in four-point restraints...
01:19:23...second unidentified staff member leaves the seclusion room...
01:21:59...unidentified BHT leaves the door chair...door remains open...
01:22:30...unidentified BHT returns to the door chair...
01:29:29...unidentified BHT leaves the door chair...
01:30:46...unidentified BHT returns to the door chair...
01:32:13...unidentified BHT leaves the door chair...
01:32:44...unidentified BHT returns to the door chair...patient remains in four-point restraints...
01:58:41...unidentified BHT leaves the door chair...patient appears to be sleeping...
02:27:41...An unidentified female nurse [nurse in pink jacket] with both hands in [her] pockets...unidentified BHT remains in the doorway and area...
02:28:50...unidentified BHT leaves the door chair...and patient remains unobserved until 02:33:30...
02:33:29...unidentified BHT enters the seclusion room and begins to release the patient's four-point restraints...
02:34:08...Patient #4 and unidentified BHT exit seclusion room...."

Employee #23 verified, during an interview conducted on or about January 19, 2023, that patient #4 does not appear to be displaying violent, aggressive or self-destructive behavior in the aforementioned video. In fact, patient #4 voluntarily walks to the room corner and then voluntarily lays down on the bed so staff can put [her] in the four (4)-point restraints.

Patient #5:
[November 9, 22]
Seclusion...Start...1300...End...1400(2 pm)...
Reason for restraint/seclusion...DTS...DTO...Threatening to hit staff...Yelling...."

Patient #7:
"...[November 15, 2022 12:39:13 pm]...
Seclusion...(none)
Reason for restraint/seclusion...(none)...."

"...[November 15, 2022 12:39:13 pm]
A review of the medical record document titled "Quick Note" revealed: "...@1015 while in treatment writer heard noise and chaos from the day room...Writer came out to find multiple patient(sic) being taken off the unit to seclusion...Employee #8 [Lead BHT]...when patient's(sic) chose not to participated(sic) employee #8 ordered for the Patient to be taken to the seclusion area...Patient walked willing to the seclusion are(sic) in the observation room...Patient was able to calm [himself] and was able to return to the unit without any further redirection...."

A review of the facility document titled "Incident Report" date [November 15, 2022 10:15] revealed: "...Provider #[4] stated that [he] heard 'the loud commotion' during treatment team...[He] gave verbal order to Employee #8 [Lead BHT] to take the patient(s) to seclusion..."

VIDEO Surveillance for Patient #7 [November 15, 2022 10:21:52 through 10:52:52] revealed:
"10:21:52...door to room opens and patient #7 voluntarily walks into the room...
10:21:56...patient is sitting on the bed facing the open door...
10:22:01...unidentified BHT not visible outside seclusion room door...
10:22:23...unidentified BHT props door open with a chair...
10:22:33...unidentified BHT removes gloves from [his] hands and places them in [his] pants pockets...
10:22:39...unidentified BHT removes cell phone from [his] pants pocket and begins using it...patient is still sitting on the foot of the bed facing the open door...
10:28:27...staff member enters doorway then immediately turns around and exits doorway...
10:29:24...unidentified BHT leaves chair and door to seclusion room closes...
10:29:32...unidentified BHT returns and places chair against door to propping it open...
10:29:54...unidentified BHT resumes cell phone activity...Patient remains sitting at the foot of the bed...
10:29:59...unidentified BHT is seen talking with second staff member in hallway...
10:30:24...Patient #7 puts on [his] long sleeve shirt...unidentified BHT resumes cell phone activity...
10:31:06...Second staff member leaves area...
10:33:19...Patient handling one of [his] shoes...unidentified BHT resumes cell phone activity...
10:34:24...unidentified BHT leaves chair and door to seclusion room closes...
10:34:39...Employee #63 [BHT], resumes monitoring and props door open with a chair...begins cell phone activity...
10:35:51...Patient lays down on bed...
10:37:28...Patient sits up...
10:34:44...Employee #63 puts cell phone in [his] pants pockets...
10:38:07...Employee #63 resumes cell phone use...
10:43:05...Patient #7 lays down on bed...
10:52:18...unidentified nurse enters room and speaks with patient...
10:52:52...Patient #7 exits seclusion room...."

["...12/14/22]...
Seclusion...Start 2115 (9:15 pm)...End...2050...
Reason for restraint/seclusion...DTO...Danger to room mates(sic)...."

Patient #8
A review of the medical record document titled "Quick Note" date [11/15/2022 1:14:36 pm] revealed: "...Pt was put in seclusion this morning from 1018 to 1046 for yelling, cursing and not following redirection...."

A review of the facility document titled "Incident Report" date [11/15/22 10:15] revealed: "...Provider #[4] stated that [he] heard 'the loud commotion' during treatment team...[He] gave verbal order to Employee #8 [Lead BHT] to take the patient(s) to seclusion...."

"...[11.15.22]...Personal restraint...Physical hold...Start...10:18 am)...End...1020...Employee #8...Seclusion...Start...1018...End...1046...
Reason for restraint/seclusion...Pt refused to follow redirection...."

Patient #10
"...[November 20, 2022]...Physical restraint...Physical hold...Start...2110(9:10pm)...End...2115...Reason for restraint/seclusion...Combative, posturing at staff...."

A review of the medical record document titled "Nursing Note" date [November 20, 2022 10:52:40 pm] revealed: "...Pt initially refused scheduled HS (bedtime) medications...Patient required lots of redirection at bedtime and eventually ended up in seclusion...."

A review of the "AHCCCS Reporting Form" date [November 20, 2022] revealed that there is no physician order for the Seclusion procedure documented in the aforementioned Nursing Note as being performed on [November 20, 2022 at 10:52:40 pm].

Patient #11
"...[November 9, 2022]...Seclusion...Start...1300(1 pm)...End...1400...
Reason for restraint/seclusion...Yelling, Im(sic) going to start a riot...."

Provider [#4] verified, during an interview conducted on or about [December 27, 2022], that there is no trigger word, such as the word riot, that would automatically send a patient into seclusion.

Provider #4 did not offer a definition of a "commotion" behavior alleged by four of eleven (11) patients (patient #7, #8, #11, & #12) being placed in physical holds and seclusion.

"...[November 15, 2022]...Personal restraint...Seclusion(sic)...Start...1015 (10:15 am)...End...1045...
Seclusion...Start...1015...End...1045...DTO...encouraging other patients to 'riot'(sic) and escape...aggressive...posturing as to fight...."

Patient #12
"...[November 15, 2022]...
Personal restraint...Physical hold...Start...1020(10:20 am)...End...1025...
Seclusion...Start...1025...End...1045...
Reason for restraint/seclusion...Pt yelling at BHT...."

A review of the medical record document titled "Quick Note" date [November 15, 2022 12:49:06 pm] revealed: "...@1015 while in treatment writer heard noise and chaos from the day room...Writer came out to find multiple patients being taken off the unit to seclusion...Employee #8 [Staff Trainer, BHT] ordered the Patient to be taken to the seclusion area...Patient was taken to the seclusion room on the Monarch unit...Patient was put into seclusion at 1025...returned to the unit and...able to redirect [himself]...."

VIDEO SURVEILLANCE for Patient #12 [November 15, 2022 10:24 through 10:49] revealed:
"...10:24...Patient #12 enters the Monarch seclusion room and begins pacing around the bed with one non-skid sock on [his] left foot...
10:38:31...the room door opens and patient speaks with someone at the door...continues pacing...
10:38:47...the door closes and patient has a white plastic cup in [his] hand...continues pacing...
10:47:33...the door opens...patient converses with an unidentified staff member...
10:48:34...the door closes and the patient continues pacing...
10:49:38...the door opens and patient exits...
10:49:49...the door closes...."

The "Seclusion and Restraint Observation Form" was requested for this seclusion event on [November 15, /2022], none was provided for review during the complaint survey.

Patient #17
"...[December 14, 2022]...
Personal restraint...Start: 2002 End...2005...
Seclusion...Start time: 2005 End time: 2115...
Reason for restraint/seclusion...Danger to Self (DTS)...Pt accusing staff of wanting to rape [her]. PT also undressing and dancing in the hallway...."

VIDEO SURVEILLANCE for Patient #17 [December 14, 2022 07:49:48 through 08:03:31]:
[December 14, 2022] revealed:
"...07:49:48, patient was dancing in place at the end of the hallway...
07:50:02, the patient approached Employee #61 and danced. Employee #61 placed hands on the patients left arm and tried to pull the patient into the bedroom, then the employee let go and walked away...
07:52:01, Patient #17 approaches Employee #60 and is pushed down the hallway...
07:55:08, Employee #36 holds Patient #17 by the upper left arm and escorts him/her to the bedroom, then stands in the doorway...
07:56:29, Patient #17 is seen is his/her bra and underwear in the room dancing in place...
07:58, Patient #17 is seen dancing in the doorway for approximately 25 seconds, then goes back in the room as Employee #60 walks down the hallway...
07:59:55, Employee #62 enters Patient #17's bedroom...
08:01:16, Employee #62 and Patient #17 exit the bedroom...Patient #17 is fully dressed...They stand approximately four to five feet apart talking...
08:03:25, Employee #62 walks away from Patient #17 and points to him/her...
08:03:31, Employees #60 and #36 walk to Patient #17 and each take him/her by an arm and carry Patient #17 down the hallway...."

Employees #5, #7, #9, #20, and #23 verified, during interviews on or about December 20, 2022, through January 19, 2023, that nine of nine patients (#3, #4, #5, #7, #8, #10, #11, #12, & #17) are being ordered into restraints and/or seclusion when not displaying aggressive, violent, or self-destructive behavior and, on occasion, based on orders given by employee #8.

Based on review of hospital policies and procedures, video review, medical records, and staff interviews, the Department determined the administrator failed to ensure the use of restraint or seclusion is implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law by not ensuring when a patient is placed in restraint or seclusion, a patient is monitored and assessed according to policies and procedures.

This deficient practice poses the risk of physical harm up to and including death of a patient when they are restrained without proper monitoring.

Cross-reference Tags: A0115, A0154, A0168. A0174, A0183. and A0205

Findings include:

A review of the policy titled "Seclusion and Restraint" Revision date: 8/31/22, revealed:
" ...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ...This will be documented in the Seclusion and Restraint Individual Reporting Form ...."

"Seclusion and Restraint Observation Form" states "RN must assess Q15 minutes ...If no medical condition-Q15 RN observation ...."

Patient #23
"Seclusion and Restraint Observation Form" dated January 6, 2023, for Patient #23, is initialed every 5 minutes by a Behavioral Health Technician (BHT). The "Seclusion and Restraint Observation Form" also revealed the time of the restraint from: 1815 to 1915.

"Seclusion and Restraint Individual Reporting Form" for Patient #23, dated January 6, 2023, revealed an RN completed a "Face-to-Face" assessment after one hour at 1920. This form also notes the time of the restraint from 1815 to 1915.

Video titled "Lotus Seclusion" dated January 6, 2023 revealed Patient #23 placed in restraint with all four extremities in restraint at 06:15 pm. At that time, the RN checks the restraints and exits and an RN is not seen to enter the room at any time with the restraint ending at 07:15pm. An Employee identified as a BHT, completes in room checks of Patient #23 at 06:33, 06:58 and 07:15, at which time the BHT takes Patient #23 out of restraint.

Documentation of 15-minute checks by an RN was requested. None were provided.

Interview with Employee #45 and #46 on January 12, 2023, who reviewed the video of the restraint with this writer, confirmed the person completing the 15 minute checks was not an RN and no RN is observed ever evaluating the patient during the duration of the restraint, for 15-minute checks, the one hour face-to-face, or to release the patient from restraint.

Patient #16
"Seclusion and Restraint Observation Form" dated January 1, 2023, for Patient #16, is initialed every 5 minutes from 2005 to 2040 by a staff member identified as a BHT. The "Seclusion and Restraint Observation Form" also revealed the time of the restraint from: 1936 to 2044.

Video titled "Lotus Seclusion" dated January 1, 2023 revealed" Patient #16 in restraints on all four extremities. At 1955 an RN administers a shot and documents the shot. Checks are performed on the patient at 2012, 2029 and 2044, at which time the patient is taken out of restraint. The patient checks from 1955 to 2044, reveal no RN.

Patient #16 is an individual with a Body Mass Index of 42 and a comorbid diagnosis of asthma and therefore higher risk of positional asphyxiation. Video review reveals Patient #16 was not monitored at the appropriate intervals for patients in restraint.

Interview with Employee #45 and #46 on January 12, 2023, who reviewed the video of the restraint with this writer, confirmed the person completing the 15 minute checks from 1955 to 2044 was not an RN.

Based on a review of the facility policies and procedures (p/p), video surveillance, medical records, and staff interviews, it was determined the administrator failed to ensure when patients are placed in seclusion and/or restraints the order is given (verbal/written) by a physician or, in an emergency situation, by a registered nurse (RN) not a Behavioral HealthTechnician (BHT) employee [#8].

This failure has the potential risk of harm to the patients when unqualified personnel members are giving verbal orders and no written physician order directing the BHTs (Behavioral Health Technicians) and/or nursing staff to place a patient in seclusion and/or restraints.

Cross-reference Tags: A0115, A0154. A0167, A0174, A0183. and A0205

Findings include:

A review of the policy/procedure titled "Physician Orders" Revision date: January 8, 2020, revealed: "...The...orders are written by the medical staff for care, treatment, and services in the hospital...Orders for seclusion and restraint...#11...In the case of seclusion and restraint, the RN may initiate seclusion or restraint first, then contact the physician for a supporting order...Doing so assures the immediate safety of the patient and others...."

A review of the policy/pocedure titled "Seclusion and Restraint" Revision date: August 31, 2022, revealed:
"...Policy...All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff...Restraint or seclusion may only be initiated to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...utilizing the least restrictive environment needed to achieve the best outcomes...
Procedure...RN may initiate restraint in the absence of a practitioner...immediately following the initiation of restraint or seclusion, qualified staff shall...Notify and obtain an order (verbal or written) from the LIP (licensed independent practitioner) and cannot be a standing order...Consult with the LIP regarding the physical and psychological condition of the individual served...The order shall indicate the reason and maximum duration of restraint, date and time of assessment, who completed the assessment and what parameters must be met for release from restraint...."

VIDEO SURVEILLANCE LOTUS UNIT-[November 15, 2022 (approximate times) 10:00:04 am through 10:54:06 am] revealed:
"...Fourteen 14 patients in day room area...
10:04:04...Provider #4 enters Lotus unit...
10:04:41...Provider #4 enters Treatment Team meeting room...
10:11:18...Employee #8 [Staff Trainer], BHT (Behavioral Health Technician) enters nurses station area...
10:11:58...Employee #8 leaves nurses station heading toward patients congregating in day room as a group...
10:15:03...Twelve patients are settled in chairs in a semi-circle...
10:18:95...Employee #8, BHT leaves group area walking down hallway to patient rooms...
10:15:23...Employee #8...re-enters day room area performing a physical hold, with a second unidentified BHT holding onto patient #8...
10:15:29...Patient #8 is removed from Lotus unit and taken to a seclusion room...
10:15:46...Employee #8 returns to Lotus unit...
10:16:01...Employee #8 can be seen pointing [his] left arm and speaking across the room...
10:18:00...Employee #8 directs, by pointing, two other unidentified BHTs down the hallway to the patient rooms...
10:18:53...Two employees' [BHTs'] exit the patient hallway performing a physical hold on a female patient (unidentified) and exiting the unit...
10:19:48...Employee #8 returns to the Lotus unit and can be seen walking down the hallway to the patient rooms followed by employee #7...
Twelve patients continue sitting in the semi-circle group...
10:20:30...Employee #8 returns to day room group...
10:20:55...Patient #7, who was sitting in a chair against the wall across from the nurses station, shows Employee #8 is pointing to a unit exit and looking at patient #7 and two (2) unidentified BHTs standing next to [him] when the two (2) unidentified BHT sescort patient #7 off of the unit to the Observation seclusion room...
Eleven patients continue sitting in the semi-circle group...
10:21:31...Employee #8 motions an unidentified BHT to come with [him] and both walk down the hallway to the patient rooms...
10:21:54...Employee #8 and the unidentified BHT re-enter the day room area performing a physical hold on patient #12...Employee #7 is seen walking ahead of them...Patient #12 is seen physically trying to get away or get loose of their grip...
10:23:02...Employee #8 and an unidentified BHT exit Lotus unit conducting a physical hold on both of patient #12's upper extremities...
Eleven patients continue sitting in the semi-circle group...
10:25:18...Employee #8 returns to the Lotus unit and sits in the group leader chair in front of remaining patients...BHT #63 is motioned or directed to leave the unit...
10:29:02...Provider #4 exits the Treatment Team room with three other unidentified employees (two females and one male)...
10:35:34...Employee #8 leaves group leader chair and goes to the nurses station...
10:36:33...Employee #8 exits the Lotus unit...
10:38:28...the patient group is disbanding and begin re-arranging their chairs...
10:44:39...the first female patient (unidentified) removed from the unit returns...
10:45:43...the second female patient (unidentified) removed from the unit returns...
10:52:10...Patient #12, the third patient removed from the unit returns...
10:54:06...Patient #7, the fourth patient removed from the unit returns...."

Provider #4 verified, during an interview conducted on or about December 22, 2022, that [he] was not aware that a BHT may not receive a verbal order to place patients in restraint and/or seclusion.

Employees #5, #7, #9, and #20, verified, during interviews on or about December 20, 2022 and intermittently through January 19, 2023, that patients are being placed in restraint and/or seclusion when not displaying aggressive, violent, or self-destructive behavior and based on orders given by Employee #8 [BHT]. There is no visualization of any de-escalation techniques by any employees.

Based on review of facility policies and procedures, medical records, and employee interview the Department determined the Administrator failed to ensure that eight of eight patients (#3, #5, #7, #8, #11, #13, #14, and #19) were released from a seclusion and/or restraint event timely after the patient was documented by facility personnel as remaining calm for ten minutes.

This deficient practice poses a potential risk to the health and safety of the patient when the patient is left in seclusion and/or restraint unnecessarily which is a patient rights violation as well as increases the possibility a patient will suffer additional physical/mental/emotional harm to their overall well-being.

Cross-reference Tags: A0115, A0167, A0168, A0174, A0183. and A0205

Findings include:

Facility policy for "Patient Rights" (last revised 10/21/2022) revealed the following: "Procedure: 1. ... b. The right to receive considerate, respectful care in the least restrictive environment which preserves your dignity and contributes to a positive self-mage ... that is humane treatment environment that ensures protection from harm ... j. The right to receive care in a safe setting. k. The right to be free from all forms of abuse or harassment ... r. The right to be free from physical or mental abuse, and corporal punishment. s. The right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff ... Patient Rights and Responsibilities ... The right to be free from physical or mental abuse, and corporal punishment."

Facility policy for "Seclusion and Restraint" (last revised 8/31/22) revealed the following: "Policy: All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. Restraint or seclusion may only be initiated to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. It is the intent of Destiny Springs Healthcare to provide a safe environment for patients and staff, utilizing the least restrictive environment needed to achieve the best outcomes. This includes the following: ... Procedure: ... I. Seclusion and/or Restraint will be terminated at the earliest possible time while maintaining the patient's safety and well being: There is no longer a risk for danger to self and/or others AND/OR The patient is receptive to engage in less restrictive intervention ..."

Medical records (facility seclusion and/or restraint reports) reviewed for eight patients #3, #5, #7, #8, #11, #13, #14, and #19 revealed the following:

#3:
Patient number three was secluded and/or restrained on November 21, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 1325 to 1335, yet remained in seclusion and/or restraint until 1400 (total of twenty-five extra minutes after the ten minutes of documented calm time).

Patient number three was secluded and/or restrained on November 22, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 1525 to 1535, yet remained in seclusion and/or restraint until 1605 (total of thirty extra minutes after ten minutes of documented calm time).

#5:
Patient number five was secluded and/or restrained on November 9, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 1310 to 1320, yet remained in seclusion and/or restraint until 1400 (total of forty extra minutes after ten minutes of documented calm time).

#7:
Patient number seven was secluded and/or restrained on December 15, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 2135 to 2145, yet remained in seclusion and/or restraint until 2150 (total of five extra minutes after ten minutes of documented calm time).

#8:
Patient number eight was secluded and/or restrained on November 15, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 1035 to 1045, yet remained in seclusion and/or restraint until 1046 (total of one extra minute after ten minutes of documented calm time).

#11:
Patient number eleven was secluded and/or restrained on November 9, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 1320 to 1330, yet remained in seclusion and/or restraint until 1400 (total of thirty extra minutes after ten minutes of documented calm time).

#13:
Patient number thirteen was secluded and/or restrained on November 13, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 0845 to 0855, yet remained in seclusion and/or restraint until 0905 (total of ten extra minutes after ten minutes of documented calm time).

#14:
Patient number fourteen was secluded and/or restrained on November 22, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 2038 to 2048, yet remained in seclusion and/or restraint until 2113 (total of twenty-five extra minutes after ten minutes of documented calm time).

#19:
Patient number nineteen was secluded and/or restrained on November 4, 2022, and documented upon the facility seclusion and/or restraint report as calm for ten minutes from 1305 to 1315, yet remained in seclusion and/or restraint until 1345 (total of thirty extra minutes after ten minutes of documented calm time).

Employee #23 and employee #28 verified, during multiple conversation conducted on 12/20/2022 through 01/19/2023, that eight of eight patients (#3, #5, #7, #8, #11, #13, #14, and #19) are not being released from a seclusion and/or restraint event timely after the patient was documented by facility personnel as remaining calm for ten minutes.

Based on review of hospital policies and procedures, video review, medical records, and staff interviews, the Department determined the administrator failed to ensure that simultaneous restraint and seclusion use is only permitted if the patient is continually monitored according to policy and procedure.

This deficient practice poses the risk of physical harm up to and including death of a patient when they are restrained without proper monitoring.

Cross-reference Tags: A0115, A0154, A0167, A0168, A0174, and A0205

Findings include:

A review of the policy titled "Seclusion and Restraint" Revision date: 8/31/22, revealed:
" ...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ...This will be documented in the Seclusion and Restraint Individual Reporting Form ...."

"Seclusion and Restraint Observation Form" states "RN must assess Q15 minutes ...If no medical condition-Q15 RN observation ...."

Patient #23
"Seclusion and Restraint Observation Form" dated January 6, 2023, for Patient #23, is initialed every 5 minutes by a Behavioral Health Technician (BHT). The "Seclusion and Restraint Observation Form" also revealed the time of the restraint from: 1815 to 1915.

"Seclusion and Restraint Individual Reporting Form" for Patient #23, dated January 6, 2023, revealed an RN completed a "Face-to-Face" assessment after one hour at 1920. This form also notes the time of the restraint from 1815 to 1915.

Video titled "Lotus Seclusion" dated January 6, 2023 revealed Patient #23 placed in seclusion and restraint with all four extremities in restraint at 06:15 pm. At that time, the RN checks the restraints and exits and an RN is not seen to enter the room at any time with the restraint ending at 07:15pm. An Employee identified as a BHT, completes in room checks of Patient #23 at 06:33, 06:58 and 07:15, at which time the BHT takes Patient #23 out of restraint.

Documentation of 15-minute checks by an RN was requested. None were provided.

Interview with Employee #45 and #46 on January 12, 2023, who reviewed the video of the seclusion and restraint with this writer, confirmed the person completing the 15 minute checks was not an RN and no RN is observed ever evaluating the patient during the duration of the restraint, for 15-minute checks, the one hour face-to-face, or to release the patient from restraint.

Patient #16
"Seclusion and Restraint Observation Form" dated January 1, 2023, for Patient #16, is initialed every 5 minutes from 2005 to 2040 by a staff member identified as a BHT. The "Seclusion and Restraint Observation Form" also revealed the time of the restraint from: 1936 to 2044.

Video titled "Lotus Seclusion" dated January 1, 2023 revealed" Patient #16 in seclusion and restraints on all four extremities. At 1955 an RN administers an injection and documents the injection. Checks are performed on the patient at 2012, 2029 and 2044, at which time the patient is taken out of restraint. The patient checks from 1955 to 2044, revealed the absence of an RN assessment or observations documented.

Patient #16 is an individual with a Body Mass Index of 42 and a comorbid diagnosis of asthma and therefore higher risk of positional asphyxiation. Video review reveals Patient #16 was not monitored at the appropriate intervals for patients in restraint.

Interview with Employee #45 and #46 on January 12, 2023, who reviewed the video of the seclusion and restraint with this writer, confirmed the person completing the 15 minute checks from 1955 to 2044 was not an RN.

Note: Many of the staff members and patients seen in the videos were deemed unidentifiable or have been misidentified by multiple staff members. and have been identified as such.

Based on a review of facility policy and procedures, personnel files, medical records, and staff interviews, the Department determined that the administrator failed to ensure when patients are placed in seclusion and/or restraints the staff follows the established criteria to assess the patient's nutrition, hydration, toileting, and circulation, at a minimum. with every 15-minute and these checks are documented on the Seclusion and Restraint Observation Form for nine of nine patients (Patients #3, #4, #5, #7, #8, #10, #11, #13, & #14), however, these patients were on Q (every) 5 minute monitoring.

This failure poses the potential risk that a patient may develop an acute medical condition and distress which may exacerbate their physical and psychiatric diagnosis.

Cross-reference Tags: A0115, A0154, A0167, A0168, A0174, and A0183

Findings include:

A review of the policy/procedure titled "Seclusion and Restraint" Revision Date: 08/31/22... Added Referral to Treatment Team form and revealed: "...The nurse in charge will assign trained staff to continuously monitor the patient during the...event...Continuous means ongoing without interruption...Nutrition and Hydration...Patient needs for nutrition, hydration, toileting and circulation are addressed at a minimum with every 15-minute check...This will be documented in the Seclusion and Restraint Observation Form...."

A review of the facility document titled "Seclusion and Restraint Observation Form" delineate patient monitoring every 5 minutes (Q5').

A review of the training document titled "BHT (behavioral health technician) Seclusion and Restraint Competency" revealed: "...Demonstrates the understanding that patient need for nutrition, hydration and toileting and documented, at a minimum of every 15 minutes...."

A review of the personnel files for four BHTs (#3, #8, #11, and #13) and five Registered nurses (#5, #7, #9, #20, and #28) revealed completion of the Seclusion and Restraint Competency form and were deemed to have met the competency by Direct Interview and or Observation.

Patient #3 [November 20, 2022]
A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
Started...1915...Ended...2000]...
Food Offered...No...1915...1920...1925...1930...1935...1943...1945...1950...2000]...
Fluid Offered...No...[1915...1920...1935]...
Toilet Offered...No...[1915...1920...1940...2000]...
Circulation Check...No...[1915]...

A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[November 21, 2022...Started...2015...Ended...2053]...
Food Offered...No...[2015...2020...2025...2035]...
Fluid Offered...No...[2015...2020...2025...2035]...
Toilet Offered...No...[2015...2025...2030...2035]...
Circulation Check...No...[2015...2020...2025...2030...2035]...

A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[November 22, 2022...Started...1435...Ended...1610]...
Food Offered...No...[1435...1440...1445...1450...1455...1505 (blank)...1510...1515...1520...1525...1530...1535...1540...1545...1550...1555...
1600...1605]...
Fluid Offered...No...[1435...1440...1445...1450...1455...1505 (blank)... 1510...1515...1520...1525...1530...1535...1540...1545...1550...1555...
1600...1605]...
Toilet Offered...No...[1435...1440...1445...1450...1455...1500...1505 (blank)... [1525...1530...1535...1540...1545...1550...1555...1600...1605]...
Circulation Check...No...[1435...1440...1445...1450...1455...1500...1505 (blank)...1510...1515...1520...1525...1530...1535...1540...1545...1550...1555...1600...1605]...

A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[December 14, 2022...Started...1100...Ended...1200]...
Food Offered...No...1120...1125...
Fluid Offered...No...1120...1125...
Toilet Offered...No...1120...1125...
Circulation Check...No...1120...1125...."

Patient #4: [November 20, 2022]:
A review of the medical record document titled "Ancillary Order" revealed:
"...Adolescent Seclusion and Restraint...
Indication: Danger to Others...
Start...[11/19/22...19:15...Stop...11/20/22 21:14]...
Ordered By: Provider #2...[Certified Nurse Practitioner (CNP)]...

The Seclusion and Restraint Observation Form associated with this order delineating the patient had Food Offered, Fluid Offered, Toilet Offered, and a Circulation Check every 5 minutes, was requested, none was provided for review at the time of the complaint survey.

A review of the medical record document titled "Nursing Note" date: [November 22, 2022 1:02:09 pm], revealed: "...
[11/22/2022] Interval History...Pt (patient) banging on bedroom door in the morning, demanding to be let in...When [she] refuses to stop, [she] takes voluntary "time out" in seclusion room...
[1:21:55 pm]...Pt call this [RN] a 'bitch' and made a threat to throw a chair at [her]...Pt placed in seclusion and restraints...."

The Seclusion and Restraint Observation Form associated with this event delineating the patient had Food Offered, Fluid Offered, Toilet Offered, and a Circulation Check every 5 minutes, was requested, none was provided for review at the time of the complaint survey.

VIDEO SURVEILLANCE for Patient #4 [November 22, 2022 01:10:00 pm through 02:34:57] pm revealed:
"...[11/22/2022] 01:09:57 pm]...Patient #4 voluntarily walks into the Phoenix seclusion room and is standing next to the bed...the room door is propped open with a chair...no staff is visible...
01:10:31...BHT (unidentified) sits in a chair that is propping the room door open...
01:10:34...Patient sits down on the bed...
01:11:22...Employee #13 directs the patient to get up and stand in the corner of the room while using [his] body as a shield...
01:11:26...unidentified BHTs and employee #47 enter the seclusion room each carrying a two-point Velcro restraint...
01:12:39...The BHTs completed placing the restraints on the bed...
01:12:47...Patient #4 is escorted to the bed and proceeds to lay down on the bed while the three BHTs [#13, #47, and 1 unidentified] begin applying the four-point restraints to all the patient's extremities...
01:14:05...The seclusion room door remains open...No BHT is visible outside of the room...
01:14:42...unidentified BHT returns to sitting in the door chair...
01:17:10...unidentified BHT leaves the door chair...the patient is turning [her] head and moving [her] feet...
01:17:40...unidentified BHT returns to the door chair...
01:18:01...unidentified BHT leaves the door chair...
01:18:20...unidentified BHT returns to the door chair...
01:18:47...A second unidentified staff member presents to the seclusion room carrying a small brown bag, which [he] places on the room floor,...and is showing the patient two (2) cups...Talking with patient still in four-point restraints...
01:19:23...second unidentified staff member leaves the seclusion room...
01:21:59...unidentified BHT leaves the door chair...door remains open...
01:22:30...unidentified BHT returns to the door chair...
01:29:29...unidentified BHT leaves the door chair...
01:30:46...unidentified BHT returns to the door chair...
01:32:13...unidentified BHT leaves the door chair...
01:32:44...unidentified BHT returns to the door chair...patient remains in four-point restraints...
01:58:41...unidentified BHT leaves the door chair...patient appears to be sleeping...
02:27:41...An unidentified nurse [nurse in pink jacket] with both hands in [her] pockets...unidentified BHT remains in the doorway and area...
02:28:50...unidentified BHT leaves the door chair...and patient remains unobserved until 02:33:30...
02:33:29...unidentified BHT enters the seclusion room and begins to release the patient's four-point restraints...
02:34:08...Patient #4 and unidentified BHT exit seclusion room...."

A review of the medical record document titled "Quick Note" date [November 22, 2022 1:33:20 pm] revealed: "...[20:20]... the patient walked into the day room, picked up a chair, and threw it toward the nurses station...The chair first struck another patient [patient 24] and then struck this [RN] employee #67 in the head...Patient was then taken to seclusion...."

The Seclusion and Restraint Observation Form associated with this event delineating that the patient had Food Offered, Fluid Offered, Toilet Offered, and a Circulation Check every 5 minutes was requested, none was provided for review at the time of the complaint survey.

Patient #5: [October 29, 22]:
A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
Started...19:20...Ended...20:50]...
Food Offered...Blank...1925..1935...1945...1955...2005...2015...2025...2035...2045...
Fluid Offered...Blank...1925...1935...1945...1955...2005...2015...2025...2035...2045...
Toilet Offered...Blank...1925...1935...1945...1955...2005...2015...2025...2035...2045...
Circulation Check...Blank...1925...1930...Yes and No...1935...Blank...1945...1955...2005...2015...2025...2035...2045...."

A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[November 9, 22...Started...13:00...Ended...1400]...
Food Offered...No...1300...1305...1310...1315...1320...1325...1335...1340...1345...
Fluid Offered...No...1300...1305...1310...1315...1320...1325...1335...1340...1345....
Toilet Offered...No...1300...1305...1310...1315...1320...1325...1335...1340...1345...
Circulation Check...No...1300...1305...1310...1315...1320...1325...1330...1335...1340...1345...1400...."

A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[November 30, 2022...Started...1930...Ended...1940]...
Food Offered...No...1300...1335...1340...
Fluid Offered...No...1300...1335...1340...
Toilet Offered...No...1300...1335...1340...
Circulation Check...No...1300...1335...1340...."

Patient #7: [November 15, 2022 10:15]
A request for the Seclusion and Restraint Observation Form completed for patient #7's seclusion on [November 15, 2022 10:15] was requested, none was provided for review at the time of the complaint survey.

Employee #23 verified, during an interview conducted on or about December 19, 2022, that the AHCCCS Medical Policy Manual packet with the Seclusion and Restraint Observation Form was not completed for patient #7's seclusion on [November 15, 2022 10:15].

VIDEO Surveillance for Patient #7 [November 15, 2022 10:21:52 through 10:52:52] revealed:
"10:21:52...door to room opens and patient #7 enters...
10:21:56...patient is sitting on the bed facing the open door...
10:22:01...BHT not visible outside seclusion room door...
10:22:23...unidentified BHT props door open with a chair...
10:22:33...unidentified BHT removes gloves from [his] hands and places them in his pants pockets...
10:22:39...unidentified BHT removes cell phone from [his] pants pocket and begins using it...patient is still sitting on the foot of the bed facing the open door...
10:28:27...unidentified staff member enters doorway then immediately turns around and exits doorway...
10:29:24...unidentified BHT leaves chair and door to seclusion room closes...
10:29:32...unidentified BHT returns and places chair against door to proping it open...
10:29:54...unidentified BHT resumes cell phone activity...Patient remains at the foot of the bed...
10:29:59...unidentified BHT is seen talking with second staff member in hallway...
10:30:24...Patient #7 puts on [his] long sleeve shirt...unidentified BHT resumes cell phone activity...
10:31:06...Second unidentified staff member leaves area...
10:33:19...Patient handling one of [his] shoes...unidentified BHT resumes cell phone activity...
10:34:24...unidentified BHT leaves chair and door to seclusion room closes...
10:34:39...A different BHT, [with dread locks is tentatively identified as] employee #63, returns and props door open with a chair...begins cell phone activity...
10:35:51...Patient lays down on bed...
10:37:28...Patient sits up...
10:34:44...Employee #63 puts cell phone in [his] pants pockets...
10:38:07...Employee #63 resumes cell phone use...
10:43:05...Patient #7 lays down on bed...
10:52:18...unidentified staff member [nurse] enters room and speaks with patient...
10:52:52...Patient #7 exits seclusion room...."

There is no visual evidence that patient #7 was offered food, fluid, toileting, had circulation checked during the thirty-one [31] minutes in the seclusion room.

[December 14, 22]
A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[December 15, 2022...Started...2115...Ended...22 21.53 is written over to read 21:50]...
Food Offered...No...[2115...2120..2125...2130...2135...2140...2145...2150]...
Fluid Offered...No...[2115...2120..2125...2130...2135...2140...2145...2150]...
Toilet Offered...No...[2115...2120..2125...2130...2135...2140...2145...2150]...
Circulation Check...No...[2115...2120..2125...2130...2135...2140...2145...2150]...."

Patient #8: [November 15, 2022]:
A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
Started...1018...Ended...1046]...
Physical Hold...1018-1020...2 Minutes...
Seclusion...1018-1046...28 Minutes...
Injuries...cut on Right pinky finger and scratch on upper arm Right...Medical intervention...First aid...
Food Offered...No...1018...1020...
Fluid Offered...No...1018...1020...
Toilet Offered...No...1018...1020...
Circulation Check...No...1018...1020...1025...1030...1035...1040...1045...1046...."

Patient #10 [November 20, 2022]:
A review of the medical record document titled "Nursing Note" [10:52:40 pm] revealed: "...Interval History...Patient required lots of redirection at bedtime and eventually ended up in seclusion...refusing to go to [her] room as it was [2053] ...being disruptive to the rest of the unit...."

The Seclusion and Restraint Observation Form associated with this event at [2053] delineating the patient was Offered Food, Fluid, Toileting, and had a Circulation Check every 5 minutes, was requested, none was provided for review at the time of the complaint survey.

Patient #11 [November 09, 2022]:
A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
Started...1300...Ended...1400]...
Food Offered...No...1300...1305...1310...1315...1320...1325...1330...1335...
1:55...2:00...
Fluid Offered...No...1300...1305...1310...1315...1320...1325...1330...Yes & No...1335...1:55...2:00...
Toilet Offered...No...1305...1310...1315...1320...1330...1335...2:00...
Circulation Check...No...1300...1305...1310...1315...1320...1325...1330...1335...1:40...1:45...1:50...1:55...2:00...

The "Seclusion and Restraint Observation Form" was requested for this seclusion event on [November 15, /2022 1015 through 1045], none was provided for review during the complaint survey to ensure documentation indicating that the patient was monitored Q5" (minutes) per instruction delineated on the aforementioned form for and Offered Food, Fluid, Toileting, and had Circulation Checks Q5' while in seclusion.

Patient #13 [November 12, 2022]:
A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
Started...1622...Ended...1647]...
Food Offered...No...1622...1627...1632...1637...1642...1647...blank...
Fluid Offered...No...1622...1627...1632...Yes and No...1637...1642...1647...blank...
Toilet Offered...No...1622...1627...1632...1637...1642...1647...blank...
Circulation Check...Yes...1622...No...1627...1632...1637...1642...1647...blank...."

A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[November 13, 22...Started 7:55 am...Ended 9:10 am]...
Food Offered...No...7:55...8:00...8:05...8:10...8:15...8:20...8:25...8:30...8:35...8:40...8:45...8:50...8:55...9:00...9:05...9:10...Fluid Offered...No...7:55...8:00...8:05...8:10...8:15...8:20...8:30...8:35...8:40...8:45...8:50...9:00...9:05...9:10...
Toilet Offered...No...7:55...8:00...8:05...8:10...8:15...8:20...8:25...8:30...8:35...8:40...8:45...8:50...8:55...9:00...9:05...9:10...Circulation Check...No...7:55...8:00...8:05...8:10...8:15...8:20...8:25...8:30...8:35...8:40...8:45...8:50...8:55...9:00...9:05...9:10...."

Patient #14 [November 22, 2022:
A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
Started...20:18...Ended...21:13 (written over 20:13]..
Food Offered...No...2018...2038...2043...2048...2053...2058...2103...2008...2013...
Fluid Offered...No...2018...2038...2043...2053...2058...2103...2108...2113...
Toilet Offered...No...2018...2038...2043...2048...2053...2058...2103...2108...2013...
Circulation Check...No...2018...2043...2048...2053...2058...2103...2108...2113...."

A review of the medical record document titled "Seclusion and Restraint Observation Form" revealed: "...Monitoring Q5" (minutes)...
[November 24, 2022...Started...1740...Ended...blank]...
Food Offered...No...1740...1745...1750...1755...1805...1810...1815...1820...1830...1835...1840...
Fluid Offered...No...1740...1745...1750...1800...1805...1810...1820...1825...1830...1840...
Toilet Offered...No...1740...1745...1750...1755...1800...1805...1815...1820...1830...1840...
Circulation Check...No...1740...1745...1750...1755...1800...1805...1810...1815...1820...1825...
1830...1835...1840...."

VIDEO SURVEILLANCE for Patient #14 [November 24, 2022 05:41:51 pm through 06:44:51 pm] revealed:
05:42:10...Patient #14 enters the seclusion room, unescorted and sits on the foot of the bed facing the door...
05:53:47...A unidentified nurse enters the room accompanied by a unidentified BHT...The nurse shows the patient a syringe...
05:54:18...The patient pulls up the pants leg over [her] right leg and the nurse declines and motions patient to turn on right side...
05:54:31...unidentified nurse administers injection into patient's left buttocks...unidentified BHT remains at doorway holding the door partially open...
05:55:28...unidentified Nurse opens the door and exits at [06:12:00]...
06:39:15...unidentified BHT enters the room and patient is moving around on the bed in a prone position...
06:40:19...Patient exits the seclusion room...."

VIDEO SURVEILLANCE excerpt for Patient #14 [November 22, 2022 08:16:02 pm until 08:53:36 pm] revealed:
[08:17:40 pm]...Six unidentified staff members conducting a physical hold on patient #14 while bringing [her] into the seclusion room and placing [her] on the bed...
Staff proceeds to apply the four-point velcro restraints to all extremities...
An employee, later identified as, #46 [Lead BHT] tightens the restraints beginning with the patient's right ankle, then right wrist, left ankle and left wrist...
As employee #46 is tightening the right sided restraints it can be seen on video that [he] places [his] right hand at the top of the excess strap then pushes down on the strap, towards the floor, (leaning onto it) with all [his] weight and tucks the excess strap under the bed frame...This is repeated with the remaining restraints...

As the video progresses patient #14 can be seen periodically looking at [her] left hand and moving the fingers...
The surveyor can see the patient's left hand changing color from white to a cyanotic (blue) color to almost a brown color and the patient continues to look at [her] hand and move the fingers...
On or about [08:30 pm], or 15 minutes later, employee #46 enters the seclusion room and goes to the bed and loosens the left wrist restraint...The color of the left hand returns to a white color and now appears to be the same color as the patient's right hand...
At this point employee #46 and an unidentified female employee can be seen finger checking the remaining restraints and adjusting them according...both exit the seclusion room at [November 22, 2022 08:30 pm]...."

A review of the medical record document titled "Seclusion and Restraint Observation Form" date [November 22, 22 20:18 through 21:13] revealed: "Circulation Check...[20:23 through 20:38]...."

This is the time frame that coincides with the video surveillance when it is observed the employee #46 enters the seclusion room, loosens the left hand restraint and the color of the patient's left hand returns to the color matching [her] right hand.

Employee #23 verified, during an interview conducted on or about January 19, 2023, that there was no incident report filed related to the aforementioned event.

Employee #23 verified, during an interview conducted on or about December 29, 2022 and January 19, 2022, that the staff is not creating and completing the required AHCCCS Medical Policy Manual-Seclusion and Restraint Individual Reporting Form, Seclusion and Restraint Observation Form and accurately documenting the Q5 Minutes assessments on nine of nine patients (patients #3, #4, #5, #7, #8, #10, #11, #13, & #14) when they are placed in restraints and/or seclusion as delineated in the facility policies and procedures.

Based on review of policies and procedures, medical records, and interview, the Department determined the administrator failed to ensure that provider telephone orders for three of three (#16, #17, & #22) were authenticated within 48 hours of the order being placed as per policy.

This deficient practice poses a potential risk to the health and safety of patients due to an increased risk of medical errors that may lead to an adverse patient event.

Findings include:

A review of the policy titled "Physician Orders" revealed: " ...Telephone orders are permissible during times in which the provider is not on site at the hospital ...All verbal and telephone orders must be authenticated by the prescriber within forty-eight (48) hours of giving the order...."

Medical record review of physician orders for Seclusion and Restraint revealed the as of January 10, 2023 the orders were never signed for the following patients:
#16 ordered on January 1, 2023 (nine days ago)
#17 ordered on December 14, 2022 (27. 5 days ago); and
#22 ordered on October 25, 2022 (77.5 days ago).

Employee #21 confirmed during an interview conducted on January 10, 2023, that the providers for patient #16, #17, and #22 did not authenticate their telephone orders according to policy.

The hospital must be maintained to ensure the safety of the patient:

Based on review of hospital policies and procedures, documents, observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Condition of Participation for Physical Environment as evidenced by the following references to standard level deficiencies and immediate jeopardy.

Cross Reference: A-0701 ensure the condition of the physical plant and the overall hospital environment be developed and maintained in such a manner that the safety and well-being of patients are assured.that patient bathrooms were free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk.

The cumulative effect of the severity of this systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Physical Environment, which poses a potential risk to the health and safety of patients.

Based on review of facility policy, observation, and interview, the Department determined that the administrator failed to ensure the condition of the physical plant and the overall hospital environment be developed and maintained in such a manner that the safety and well-being of patients are assured.that patient bathrooms were free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk.

This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients.

Cross Reference Tag A-0700

Findings inlcude:

Review of policy titled "Patient Rights" with a revision date of 10/21/2022, revealed " ...Patient Rights according to federal and state guidelines include the following at a minimum: ...The right to receive care in a safe setting ...."

Job description titled "Director of Operation/Safety Officer" notes " ...This position is responsible for the development, implementation and evaluation of DSH Safety Program to maintain a safe environment for patients, visitors and employees ...Actively conducts surveillance of the facility to identify safety hazards that pose a risk to the organization ...."

Document titled "Environmental Rounds" notes " ...Walls are free of breaks and penetrations ...." Environmental rounds for October, November and December 2022 were reviewed. No indication on any unit of issues with any bathroom fixtures.

Tour on January 10, 2023 at 0900 with Employee #19 revealed the following issues:

1. Observation of Lotus and Koi unit Restraint and Seclusion Bathroom mirror fixture had caulk placed around it that had deteriorated and now was a tie off point as you could now place a string behind it and create a tie-off point.

2. Observation of Lotus, Phoenix, Cicada, Koi, and Monarch patient bathrooms revealed patient in room bathroom mirror fixtures had caulk placed around it that had deteriorated and now was a tie off point as you could now place a string behind it and create a tie-off point.

3. Observation of Phoenix Restraint and Seclusion Bathroom had a panel behind the toilet that holes large enough to be a ligature risk that were not properly sealed along the top and sides of the panel.

Tour on January 10, 2023 at 1500 with Employee #19 revealed the following issues:

1. Observation Lotus, Phoenix, Cicada, Koi, and Monarch patient bathrooms had a panel under the sinks that were not properly attached, missing screws and away from the walls creating a tie-off point.

2. Observation on Lotus, Phoenix, Cicada, Koi, and Monarch patient bathrooms revealed tamper resistant screws under the patient sinks that were not properly installed, were loose, halfway unscrewed, and at times altogether missing.

Immediate Jeopardy:
Ensure that the condition of the physical plant and the overall hospital environment related to ligature risks (seclusion and patient bathroom's) were maintained in such a manner that the safety of the patients were protected from harm. Failure to prevent harm to patients from ligature points poses the high potential risk that patients will be subject to harm and does not provide for their safety and well-being.

Interview with Employee #19 and Employee #28 confirmed that the majority of patient bathrooms on each unit had multiple areas that created an opportunity for a patient to use as a tie-off point.

The hospital must permit determination of the degree and intensity of the treatment provided to patients receiving services at the Special hospital.

Based on review of hospital policies and procedures, documents, videos, personnel files, observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Condition of Participation for Special Medical Record Requirements for Psychiatric Hospitals as evidenced by the following references to standard level deficiencies and immediate jeopardy:

Cross Reference: A-1640: ensure that eighteen (18) out of 24 (18/24 = 75%) patients (#3, #4, #5, #7, #8, #10, #11, #12, #13, #14, #17, and #19) treatment plans were updated after a qualifying event of seclusion and/or restraint. Also, based on review of facility policies and procedures and medical records the Department determined the administrator failed to ensure that 19 out of 24 (19/24 = 79%) patients (#3, #4, #5, #7, #8, #10, #11, #12, #13, #14, #17, and #19) trThe cumulative effect of this systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights, which poses a potential risk to the health and safety of patients.

Based on review of facility policies and procedures, medical records, and staff interviews, it was determined the administrator failed to ensure that eighteen (18) out of 24 (18/24 = 75%) patients (#3, #4, #5, #7, #8, #10, #11, #12, #13, #14, #17, and #19) treatment plans were updated after a qualifying event of seclusion and/or restraint. Also, based on review of facility policies and procedures and medical records the Department determined the administrator failed to ensure that 19 out of 24 (19/24 = 79%) patients (#3, #4, #5, #7, #8, #10, #11, #12, #13, #14, #17, and #19) treatment team referral forms were completed after a qualifying event of seclusion and/or restraint.

These deficient practices pose a potential risk to the health and safety of the patient when the patient's treatment plan is not re-evaluated and updated after a qualifying event of seclusion and/or restraint to determine whether the current treatment plan is effective or needs to be modified per facility policy.

Cross Reference Tag A-1620

Findings include:

A review of the policy for "Patient Rights" revealed the following:
"...1. Patient Rights according to federal and state guidelines include the following at a minimum:...
a. The right to participate in the development and implementation of his or her plan of care ... d. The right to make informed decisions regarding his or her care, including ... being involved in care planning and treatment...
n. The right to participate actively in the development and review of an individualized treatment and discharge plan...."

A review of the policy for "Interdisciplinary Treatment Plan (ITP) Team Meetings" revealed: "...Procedures: 1...
i...Although every patient shall be reviewed every day in the treatment team meeting, all patients shall have a formal Treatment Team Review every seven (7) days and/or by next ITP for any qualifying event, whichever is sooner...Examples of qualifying events include, but are not limited to...
ii. Any seclusion/restraint event...v. Any behavior requiring increased level of observation (such as 1:1)...."

A review of the policy and procedure for "Interdisciplinary Treatment Planning (ITP) Documentation" revealed: "...Policy: It is the policy of Destiny Springs Healthcare that each patient is provided with individualized, planned, and appropriate interventions that are designed to meet the patient's need for treatment...Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress...
Procedure:...
II...The comprehensive interdisciplinary treatment plan (ITP)...
iv. Problem List:
...4. The problem list should be reviewed daily and updated every seven (7) days, with each treatment plan review, or next treatment team meeting following any qualifying event...See ITP Team Meeting Policy...
IV. ITP Review...
a. Treatment plan reviews occur whenever there is a significant change in the individual's condition and or reviewed for progress at any time...
c. The ITP is also reviewed following any qualifying event...
See ITP Team Meetings Policy...
e. Elements of the Treatment Plan Review are:...
iii. Treatment and Discharge Planning Changes - describe the specific ways in which the team will modify the care provided to assist the patient in achieving goals...
1. Modality of Intervention Changes...
4. Any new issues identified by the patient or the clinical team..."

A review of the policy and procedure for "Seclusion and Restraint" revealed:
"...Procedure:...
H. The interdisciplinary treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence...Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion...
A referral to Treatment Team form will be completed after any seclusion or restraint...."

A review of the policy and procedure for "Written Plan of Service and Staff Composition" revealed: "...Continued stay criteria...
Treatment planning is individualized and appropriate to the individual's changing condition with realistic and specific goals and objectives stated..Treatment planning has included active family or other support systems, social, occupational, and interpersonal assessment with involvement of all treating disciplines unless contraindicated...Treatment planning goals are realistic and attainable...
Expected benefits from all relevant modalities, including group, individual, and family therapy (as appropriate) are documented in the clinical record. Services and treatment are carefully structured to achieve optimum results in the most time-efficient manner possible and are consistent with sound clinical practice...
Adjustments in the treatment plan have occurred to address lack of progress and/or psychiatric/medical complications are addressed in the planning and implementation of care...The patient is actively participating in the plan of care and treatment to the extent possible and consistent with his/her ability and condition...Description Of The Assessment Processes...
Reassessments by each treating discipline will occur at appropriate intervals...Changes in assessment findings will be reflected in the medical documentation and revision of the treatment plan...
Description Of The Treatment Planning Process:...In contrast to other earlier methods for providing psychiatric care, Destiny Springs utilizes the recovery model of care, where the focus of treatment planning is on supporting the individual to not only survive but also thrive even in the presence of mental illness...
To achieve better outcomes for individual patients in the inpatient setting a mind shift must occur by the treatment team from the medical model to a recovery-oriented model of care...
Recovery planning, therefore, begins with the patient...
Planning starts upon admission and continues throughout the patient stay and is intricately aligned with the patient's personal goals for recovery...The plan includes long term and short-term goals that are individualized for each patient, cover psychiatric and medical needs, include all disciplines active in the patient's care, and are geared toward patient strengths. Interdisciplinary team meetings are held within 48 hours after admission and at a minimum, every 7 days thereafter...
Medical Records...Treatment plans and treatment plan reassessments;...
Treatment Plan Review:...Treatment plan reviews will occur so that the team can quickly and consistently respond to changes in the patient's clinical presentation...."

A review of the policy for "Suicide Assessment and Prevention" revealed: "...Any treatment team plan updated will be completed as needed...."

A review of the policy for "Nursing Standards of Care" revealed:
"...3. Outcomes identification...
a. The PMH (Psychiatric Mental Health)-RN anticipates expected outcomes and formulates goals based upon the patient's individualized plan of care, current research and practice, and realistic time frames for which goals can be achieved...
The patient's treatment goals are also created in collaboration with the patient and/or family/caregivers, with the patient's permission...
4. Planning...
a. The PMH-RN derives a plan of care using specific strategies to help the patient achieve treatment goals and modifies the plan as the patient's condition changes...
5. Implementation...
a. The PMH-RN implements the plan of care for the patient, using the therapeutic relationship, recovery-oriented practice, and utilizing all resources available to the nurse...."

A review of the medical records for 12 of 12 patients (patient # 3, #4, #5, #7, #8, #10, #11, #12, #13, #14, #17, and #19) revealed:
Patient #3 secluded and/or restrained on November 11, 2022, November 21, 2022, November 22, 2022, and December 14, 2022 with treatment plan updates on November 20, 2022, November 21, 2022, November 22, 2022, and December 14, 2022 four out of four treatment plans updated after seclusion and/or restraint events) and no corresponding treatment team referral forms zero out of four treatment team referral forms).

Patient #4 secluded and/or restrained on November 22, 2022, December 14, 2022, and December 15, 2022 with no treatment plan updates zero out of three treatment plans updated after seclusion and/or restraint events) and one corresponding treatment team referral form one out of three treatment team referral forms).

Patient #5 secluded and/or restrained on October 29, 2022, November 09, 2022, and November 30, 2022 with treatment plan update on November 01, 2022 and no other treatment plan updates one out of three treatment plans updated after seclusion and/or restraint events) and one corresponding treatment team referral form one out of three treatment team referral forms).

Patient #7 secluded and/or restrained on November 15, 2022, December 14, 2022, and December 15, 2022 with no treatment plan updates zero out of three treatment plans updated after seclusion and/or restraint events) and one corresponding treatment team referral form one out of three treatment team referral forms).

Patient #8 secluded and/or restrained on November 15, 2022 with no treatment plan update zero out of one treatment plan updated after seclusion and/or restraint event) and one corresponding treatment team referral form one out of one treatment team referral form).

Patient #10 secluded and/or restrained on November 20, 2022 with treatment plan update on November 11, 2022 one out of one treatment plan updated after seclusion and/or restraint event) and no corresponding treatment team referral form zero out of one treatment team referral form).

Patient #11 secluded and/or restrained on November 09, 2022 and Novermber 15, 2022 with no treatment plan update zero out of two treatment plans updated after seclusion and/or restraint event) and one corresponding treatment team referral form one out of two treatment team referral forms).

Patient #12 secluded and/or restrained on November 15, 2022 with no treatment plan update zero out of one treatment plan updated after seclusion and/or restraint event) and no corresponding treatment team referral form zero out of one treatment team referral form).

Patient #13 secluded and/or restrained on November 12, 2022 and November 13, 2022 with no treatment plan updates zero out of two treatment plans updated after seclusion and/or restraint event) and no corresponding treatment team referral forms zero out of two treatment team referral forms).

Patient #14 secluded and/or restrained on November 22, 2022 and November 24, 2022 with no treatment plan updates zero out of two treatment plans updated after seclusion and/or restraint event) and no corresponding treatment team referral forms zero out of two treatment team referral forms).

Patient #17 secluded and/or restrained on December 14, 2022 with no treatment plan update zero out of one treatment plan updated after seclusion and/or restraint event) and no corresponding treatment team referral form zero out of one treatment team referral forms).

Patient #19 secluded and/or restrained on November 04, 2022 with no treatment plan update zero out of one treatment plan updated after seclusion and/or restraint event) and no corresponding treatment team referral form zero out of one treatment team referral form).

Employee #21 verified, during an interview conducted on or about January 19, 2023, that when a qualifying event of a restraint and/or seclusion occurs the treatment plans are updated within seven (7) days per facility policy/procedure.

The cumulative effect of this systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Special Medical Record Requirements for Psychiatric Hospitals, which poses a potential risk when the patient's treatment plan is not re-evaluated and updated after a qualifying event of seclusion and/or restraint to determine whether the current treatment plan is effective or needs to be modified per facility policy.

Based on a review of hospital job descriptions, employee files, and staff interviews, it was determined the administrator failed to ensure that one of one employee (#28) meets the required education, training, and skills as outlined in each of the job description of personnel hired by the facility.

This failure has the potential risk that unqualified personnel may be hired to direct and supervise the scope of nursing services provided to the patient population of the facility.

Findings include:

A review of the job description titled "Director of Nursing" Prepared/Approved Date...August 1, 2018, revealed: "...Department...Nursing...has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities and clinical education and development, including continuous improvement of nursing services and staff to meet the needs and expectations of those served by the department...responsible for driving...patient safety...the overall patient experience...Required Education/Experience...Master's degree in Nursing...."

A review of the employee file for employee (#28) revealed: "...Required Education/Experience: a current Registered Nurse license...."

Employee #6 verified, during an interview conducted on December 22, 2022, that one of one Employee (#28) does not have a Master's degree in Nursing as set forth in the job description for the Director of Nursing Services that [she] has held since [June 25, 2018].