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Based on observation, interview, and record review, the hospital failed to follow its policy and procedure for restraints/seclusion for two of 30 sampled patients (23 and 19). This resulted in patients being placed in restraints and seclusion without a physician's order.

Findings:

1. During an observation on 6/18/18, at 9:48 AM, Patient 23 was noted in the east wing hallway being placed in a manual hold by staff and assisted to a seclusion room located off the nurses station.

During an interview with Nurse Manager 2 (NM 2), on 6/19/18, at 10:08 AM, NM 2 reviewed the clinical record for Patient 23, NM 2 was unable to find documentation of a physician order for seclusion episode for 6/19/18, at 9:48 AM.

During an interview with Physician 1, on 6/20/18, at 11:43 AM, Physician 1 stated he forgot to write the physician order for the restraints applied to Patient 23.



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2. During a review of the clinical record for Patient 19, the Nursing Narrative Note dated 6/14/18, at 4:19 PM, indicated "Client [Patient 19] was taken to restraint starting 1440 [2:40 PM] for being a danger to self . . . Client in restraints for approximately 1 hour no change in behavior or affect . . . Client released from restraints 1631 [4:31 PM]."

During a concurrent interview with Registered Nurse 2 (RN 2) and review of the clinical record for Patient 19, on 6/19/18, at 4 PM, the Individual Observation Record dated 6/14/18, indicated Patient 19 was restrained in the seclusion room at 2:45 PM and remained in the seclusion room through 4:32 PM. RN 2 confirmed the findings and stated there was no physician's order for Patient 19 to be in restraints.

During an interview with RN 3, on 6/20/18, at 9:30 AM, he confirmed Patient 19 was restrained on 6/14/18, between 2:45 PM and 4:32 PM. RN 3 stated there was no documentation the physician was notified of the restraints and there was no physician's order.

The hospital policy and procedure titled "Restraints/Seclusion of Patients" dated 6/28/16, indicated "II. General Provisions: B. Initiation: Each episode of restraint or seclusion shall be initiated: 1. Upon the order of a licensed independent practitioner who is responsible for the patient, or 2. By a registered nurse if necessary to protect the patient, staff members or others from harm, provided that an order is obtained from a licensed independent practitioner who is responsible for the patient immediately after initiation, in this instance, "immediately" means as soon as it is clinically appropriate to pause in the process of providing care..."

Based on interview and record review, the hospital failed to ensure the nurses follow their policies and procedures when:

1. The risk of violence was not assessed upon admission for two of 30 sampled patients (2 and 8).

2. The risk of violence was not reassessed based on risk score for six of 30 sampled patients (1, 2, 8, 9, 17, and 19).

3. Interventions were not implemented for one of 30 sampled patients (20).

4. The physician's orders were not followed for two of 30 sampled patients (15 and 21).

5. The physician was not notified of critical laboratory results for one of 30 sampled patients (12).

This failure had the potential to place patients at risk for harm.

Findings:

1 a. During a concurrent interview with Registered Nurse 6 (RN 6) and the Director of Mental Health Services (DMHS) and review of the clinical record for Patient 8, on 6/19/18, at 3:40 PM, the DMHS stated the hospital utilizes a standardized, evidence-based violence risk assessment called the Broset Violence Checklist (BVC) to determine if patients are at risk for violent behavior. The DMHS stated the BVC is to be completed for each patient by a nurse upon admission and at least once per shift. The facesheet for Patient 8 indicated she was admitted to the hospital on 6/13/18, at 9:04 PM. Patient 8's initial BVC was completed on 6/14/18, at 9:23 AM. The DMHS confirmed the finding and stated a BVC should have been completed during Patient 8's admission assessment.

1 b. During a concurrent interview with Nurse Manager 1 (NM 1) and review of the clinical record for Patient 2, on 6/21/18, at 10:30 AM, the facesheet for Patient 2 indicated she was admitted to the hospital on 5/17/18 at 4:51 PM. The initial BVC was completed on 5/18/18, at 7:50 AM. NM 1 confirmed the finding and stated a BVC should have been completed upon admission.

The hospital policy and procedure titled "Persons at Risk for Violence: Safety, Screening, and Recovery Support", dated 6/19/18, indicated "II. Violence Risk Screening. . . Using a standardized, evidence-based tool, registered nurses screen all individuals for violence risk upon admission to [facility] and at least once each shift during hospitalization. The scoring algorithm identifies persons at risk as follows: A. High Risk; B. Moderate Risk; C. Low Risk. . ."

2 a. During a concurrent interview with RN 6 and the DMHS and review of the clinical record for Patient 9, on 6/19/18, at 3:50 PM, Patient 9's BVC score was 3 on 5/1/18, at 6 AM. The score key for the BVC indicated "0 - low risk for violence. 1-2 - moderate risk for violence. >2 (greater than 2) - very high risk for violence." The score interpretation for the BVC indicated "High Risk. . . Reassess and document violence risk q 2 hours (every two hours) . . ." and "Moderate Risk. . . Reassess and document violence risk q 4 hours (every four hours) . . ." The DMHS stated the BVC is used to reassess violence risk. The second BVC assessment for Patient 9 was completed on 5/1/18, at 6:50 PM, approximately 13 hours after the previous assessment. Further review of the BVC assessments performed 5/2/18 - 6/19/18 were reviewed and indicated reassessments were not completed per policy and procedure for 12 reassessment periods. RN 6 and the DMHS confirmed the finding.

2 b. During a concurrent interview with RN 8 and the DMHS and review of the clinical record for Patient 8, on 6/20/18, at 8:40 AM, Patient 8's BVC score on 6/14/18, at 9:23 AM, was 3. The next BVC assessment for Patient 8 was completed on 6/14/18, at 5:40 PM, approximately eight hours after the previous assessment. RN 8 and the DMHS confirmed the finding and stated Patient 8's BVC score was not reassessed per policy according to her risk score. Further review of the BVC assessments performed 6/15/18 - 6/19/18 were reviewed and indicated reassessments were not completed per policy and procedure for 10 reassessment periods. RN 6 and the DMHS confirmed the findings.

2 c. During a concurrent interview with NM 1 and review of the clinical record for Patient 1 on 6/21/18, at 10:30 AM, Patient 1's BVC score was 1 on 5/3/18 at 6:40 PM. The next BVC assessment for Patient 1 was completed on 5/4/18 at 2:50 PM, approximately 20 hours after the previous assessment. Further review of the BVC reassessments performed 5/19/18 - 6/14/18 were reviewed and indicated the BVC reassessments were not completed per policy and procedure for 13 reassessment periods. NM 1 confirmed the findings.

2 d. During a concurrent interview with NM 1 and review of the clinical record for Patient 2, on 6/21/18, at 10:35 AM, Patient 2's BVC score was 1 on 5/18/18 at 7:50 AM. The next BVC assessment for Patient 2 was completed on 5/18/18 at 6:50 PM, approximately 11 hours after the previous assessment. Further review of the BVC assessments performed 5/19/18 - 6/14/18 were reviewed and indicated the BVC reassessments were not completed per policy and procedure for nine reassessment periods. NM 1 confirmed the findings.

2 e. During a concurrent interview with RN 3 and review of the clinical record for Patient 19, on 6/20/18, at 9:30 AM, the BVC on 6/14/18, at 7:20 AM, indicated a score of 1 and no other BVC was completed that day. The BVC completed on 6/15/18, at 7:18 AM and 6/15/18, at 8:52 PM, indicated a score of 2. The BVC on 6/19/18, at 7:14 PM, indicated a score of 1. RN 3 confirmed the findings and stated the BVC should be completed each shift and "as things change." RN 3 also stated Patient 19 should have been reassessed for violence after four hours with a score of 1 or 2 and he was not reassessed.

2 f. During a concurrent interview with RN 4 and review of the clinical record for Patient 17, on 6/20/18, at 10:45 AM, the BVC on 6/17/18, at 1:46 PM, indicated a score of 1. On 6/18/18, at 11:49 AM, the BVC score was 3. RN 4 stated when a patient scores a 1 they should be reassessed after four hours and when a patient scores a 3 they should be reassessed after two hours. RN 4 acknowledged no reassessments were completed.

The hospital policy and procedure titled "Persons at Risk for Violence: Safety, Screening, and Recovery Support" dated 6/19/18, indicated "II. Violence Risk Screening. . . Using a standardized, evidence-based tool, registered nurses screen all individuals for violence risk upon admission to [facility] and at least once each shift during hospitalization. The scoring algorithm identifies persons at risk as follows: A. High Risk; B. Moderate Risk; C. Low Risk . . ."



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3. During a review of the clinical record for Patient 20, the Behavioral Risk Assessment dated 12/19/17, at 12:25 PM, indicated a behavioral score total of 12 - High Risk Precaution. The Psychiatric Admit Eval[uation], dated 12/19/17, at 4:05 PM, indicated ". . . [Patient 20] was spitting water out of his mouth, screaming, and being violent with a resident doctor. He [Patient 20] is not responsive to questions, laughing and screaming inappropriately. Patient in [sic] an imminent danger to himself and others."

During a concurrent interview with RN 1 and review of the clinical record for Patient 20 on 6/21/18, at 10:30 AM, the Behavioral Risk Assessment was reviewed. RN 1 stated Patient 20 was at high risk throughout his stay and should have been on a one-to-one (1:1) supervision (one staff is assigned to supervise one patient).

During an interview with NM 1, on 6/21/18, at 10:30 AM, she confirmed Patient 20 should have been 1:1 supervision and was not.

The hospital policy and procedure titled "Behavioral Risk Assessment" revised 2/12, indicated " . . . Scoring Key High-risk precautions = 9 or more (1:1)."

4 a. During a concurrent interview and review of the clinical record for Patient 15, with RN 1, on 6/21/18, at 9:41 AM, the physician's order dated 4/6/18, at 7:25 PM, indicated "Urine Drug Screen CPOE [Computerized Provider Order Entry] Stat [common medical abbreviation for urgent or rush] Nurse Draw, Urinalysis-Culture if indicated (UA) CPOE Stat Clean Catch Nurse Draw." RN 1 stated the labs (laboratory tests) were not done and they should have been.

4 b. During a concurrent interview and review of the clinical record for Patient 21, with NM 1, on 6/21/18, at 1:49 PM, the physician's orders dated 12/29/17, at 1:36 AM, indicated "Urine Drug Screen Telephone Order Stat Nurse Draw, Urinalysis-Culture if Indicated (UA) Telephone Order Stat Clean Catch Nurse Draw." NM 1 stated the labs were not done and they should have been.

The hospital policy and procedure titled "Orders: Processing and Notation of Non-Medication Orders" dated 5/26/18, indicated "The Registered Nurse (RN) is accountable for the accuracy of order input and ultimately accountable for the implementation of Licensed Independent Practitioner (LIP) orders as indicated . . .".

The hospital policy and procedure titled "Laboratory: Test Turnaround Guidelines" dated 10/13/18, indicated ". . . STAT: A request for testing, which has immediate implication for patient care, yielding information that might alter either the course of the disease or the patient's outcome. STAT orders will be drawn by nursing staff within 10 minutes of the order entry in the computer."

5. During a concurrent interview with RN 1 and review of the clinical record for Patient 12, on 6/21/18, at 9:23 AM, the Laboratory Results Report dated 3/13/18, at 7 AM, indicated Patient 12 had a glucose result of 47 (Normal Range 74 - 118). On 3/13/18, at 9:50 AM and 9:52 AM, the Registered Nurse was notified by the laboratory, of the critical lab result. RN 1 stated the physician should have been notified and documentation completed within one hour. RN 1 stated there was no documentation of the physician being notified of the critical lab result.

The hospital policy and procedure titled "Documentation, Nursing: Acute Patient Care" dated 7/28/17, indicated ". . . What to Chart . . . 4. Contacts with and outcomes of interactions with primary care providers . . . 6. Changes in condition and follow up actions/responses to symptoms or condition changes . . . D. Documentation should include the status of the identified problems until they are resolved in the medical record or become inactive."

Based on interview and record review, the hospital failed to develop care plans for three of 30 sampled patients (1, 8, and 18). This failure had the potential to result in patients' needs not being met.

Findings:

1. During a concurrent interview with Registered Nurse 5 (RN 5) and review of the clinical record for Patient 8, on 6/19/18, at 9:20 AM, RN 5 stated the hospital uses the Broset Violence Checklist (BVC) to assess patients for risk of violence. The BVC score for Patient 8 on 6/14/18, at 9:23 AM, was 3. The BVC scoring key indicated ". . .>2 (greater than 2) = very high risk [for violence] . . . A plan should be developed to manage violence risk." RN 5 was unable to provide evidence of a care plan being developed for Patient 8's risk for violence, based on the BVC assessment.

2. During a concurrent interview with Nurse Manager 1 (NM 1) and review of the clinical record for Patient 1 on 6/21/18, at 10:30 AM, the BVC score was 3 for Patient 1, on 5/10/18, at 7:05 PM. NM 1 was unable to provide evidence of a care plan being developed for Patient 1's risk for violence, based on the assessment.



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3. During a review of the clinical record for Patient 18, the Initial Assessment dated 6/7/18, at 3:04 PM, was completed upon admission to the hospital.

During an interview with RN 1, on 6/21/18, at 11:40 AM, she stated care plans should be developed after the initial assessment are completed. RN 1 was unable to provide evidence a care plan was developed after the initial assessment for Patient 18.

The hospital policy and procedure titled "Interdisciplinary Pt (Patient) Assessment, Reassessment & Care Planning for the Acute Setting" dated 5/24/18 indicated ". . . All patients entering [name of hospital] will receive an initial assessment performed by the admitting licensed nurse, identifying their immediate and emerging needs. Care decisions will be based on this initial assessment, including the need for any further assessment, treatment, interventions, and reassessments . . . VII. An individualized, goal-directed care patient centered plan of care [sic] will be initiated or discontinued by the Registered Nurse. . . The plan of care guides the ongoing provision of nursing care and assists in the evaluation of that care. . ."