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Based on review of records and interview, the facility failed to ensure that forms used to document restraints and seclusion for 3 patients (Patient #15, #16, and #17) out of 3 patient restraints reviewed, accurately and completely documented the restraint process.

Review of patient charts #15, 16, and 17 revealed they had received chemical restraints and physical holds. The charts revealed the facility was using two different form packets to document restraints.

An interview was conducted with Staff #3 on 8/18/21. Staff #3 reported the following:

Blue Form Packet
The blue form packet was for a patient that required a chemical restraint but did not required a physical hold before or during the administration. The form was 5 pages long and addressed all the elements required from the policy and procedure except staff debriefing.

The Purple Form Packet
The purple packet was 12 pages long and addressed a patient placed in a physical hold, mechanical restraints, or seclusion. Staff #3 stated that the purple form was used because the patient required a hold and a chemical restraint or could be used for seclusion.

Review of the purple form revealed it was designed to address mechanical restraints and interventions required while a patient is in a mechanical restraint such as range of motion, nutrition hydration, hygiene. The purple form was identified as an old form used at another facility in the organization and had been added onto and was difficult to follow.

Staff #3 confirmed on 8/18/21 that the facility did not use mechanical restraints and did not have any mechanical restraints on the premises. Staff #3 stated the facility rarely used the seclusion rooms. Staff #3 stated the facility preferred to use de-escalation interventions, physical holds, and chemical restraints when needed. Staff #3 stated that he was aware that, by using two sets of forms (purple packets and blue packets), it had created confusion among the nursing staff. He stated he realized this was causing a problem in staff choosing the correct form packet and documenting the forms appropriately.

Review of the policy and procedure Restraints and Seclusion 1000.42 revealed the following
Restraint or Seclusion Debriefing:

1. The use of restraint techniques or seclusion shall be discussed with all staff involved in the emergency safety intervention and the patient participates in a face-to-face discussion. This shall occur within the shift when the restraint or seclusion occurred but if the patient is unwilling, the facility has up to 24 hours to complete the debriefing.
2. This discussion may also include other staff and the patient's parent(s)/legal guardian(s) when it is deemed appropriate. The discussion must be in a language which is understood by all parties. The discussion will include:
a. An opportunity for both the patient and staff to discuss the circumstances resulting in the use of the restraint or seclusion
b. Strategies to be used by the staff, the patient, or others which could prevent the future use of a restraint or seclusion.
c. Evaluate if the patient's physical well-being, psychological comfort and right to privacy were addressed.
d. The de-briefing form will be placed in patient's chart
e. Provide counseling to the patient for any trauma which may have resulted from the incident.
f. All staff involved will meet in a post-intervention conference (debriefing) to discuss the event and offer feedback to one another before the end of shift concerning events which took place and possible alternate methods which could be used to change behaviors. The administrative staff are included in the staff debriefing process.
g. Patients Treatment Plan will be updated after each restraint or seclusion event."

Patient #15
Review of Patient # 15 revealed he was a 22 y/o male admitted on 8/2/21. He was admitted with a diagnosis of BPAD (Bipolar Affective Disorder) manic episode, poly substance abuse with mood induced disorder.
Review of the Patient #15's chart revealed he had a chemical restraint on 8/3/21 at 1459 (2:59PM) on the blue form. The form revealed there was no clear initial nursing assessment on the form, but the nurse did document in the nursing notes the initial assessment and patient behaviors. The nurse documented on the form when the medication was administered and documented on the form that vital signs were not obtained due to safety reasons. However, there was no documentation that vital signs were tried again, the patient's response, or effectiveness of the medication. The form revealed another RN assessed the patient for a face to face at 1550 (3:50PM). The nurse documented the patient refused an assessment and vital signs. There was no further documentation of an assessment concerning the chemical restraint on the form.

Review of the Nursing Progress Note dated 8/2/21 at 1537 stated, "Nurse notified that patient's admitting provider was changed to Dr.____ (Staff #4). Patient continued to be aggressive, tore shelf from wall, threatening staff. Patient then began punching walls in room, staff attempted to redirect patient. Unable to be redirected. Patient placed in physical manual hold at 1537 in the sitting position. Dr.____ (Staff #4) notified of restraint, patients' behavior, patient admitting background, and that Haldol 5 mg IM and Benadryl 25 mg IM was administered to patient at 1528 for previous aggressive behavior. New orders received for Benadryl 50 mg IM NOW, Ativan 2 mg IM NOW, and Haldol 10 mg IM NOW. Dr.____ (Staff #4) was again told of previous IM injection of Haldol 5 mg IM and Benadryl 25 mg IM was given at 1528. Provider continued with orders. TORS, provider confirmed. New orders received to discontinue Seroquel 100 mg TID PRN and Seroquel 200 mg QHS. New orders received for Seroquel 200 mg TID PRN. TORS provider confirmed. ______(therapist) talked with patient, patient calm and cooperative and released from manual hold at 1540. Small linear scratch on right forearm, first aid given. no other injuries noted. 1: 1 Time Spent with Patient: 10 minutes."

The purple packet was found on the chart that addressed the hold and chemical restraint. There were no vital signs obtained due to patient refusal. The nurse documented on the patient at 1537 (3:37PM) and again at 1540 (3:40PM) on the form when he was released from the physical hold. The face to face was performed at 1540 by an RN. The RN marked through the behavioral condition/ mental status assessment and marked refused. Review of the Nursing admission assessment revealed the patient had calmed down and vital signs were obtained at 1810 (6:10PM).

Review of the policy and procedure Restraint and Seclusion stated, "Page 13 #5) 5. The condition of the patient who is restricted is monitored by a registered nurse and/or trained staff.

a. Restricted patients are continuously observed in-person by trained and competent staff who has completed and maintained periodic training updates. Continuous observations are documented every 15 minutes. If staff are unable to visualize the patient, the door will be opened, in order to fully assess the patient. Direct patient care staff observations include: any signs of injury or distress, patient's behavior, hydration and nutritional needs, skin integrity, signs of exhaustion, and indicators or readiness for discontinuation of the restraint or seclusion and recognize when to contact a medically trained license independent practitioner. Documentation includes any interventions provided and patient's response to interventions.

b. An RN assesses the patient in restraint or seclusion and documents the assessment every 15 minutes or more frequently as warranted by the patient's condition. The RN assessment includes the patient's physical and psychological status, vital signs, patient care requirements, and determination of continued need for intervention. Full vital signs are taken at the frequency determined by the RN assessment, but no less than one hour with restraint or seclusion renewal.

c. At least every two hours the patient is offered toileting and hydration.

d. Nursing staff/direct care staff monitors the physical and psychological status of the patient for a minimum of 30 minutes or as clinically indicated following release from seclusion or restraint.

e. Range of motion exercises shall be done to each limb, releasing one limb at a time. Rationale for not doing R.O.M must be noted."

The policy and procedure for restraint and seclusion addresses time frames for assessments and reassessments for physical restraints but does not address the assessment time frames for chemical restraints only. There was nothing in the policy or on the forms that directs the RN on the frequency or duration for assessment after the chemical restraint was administered. Since blue form packets were being used for chemical restraints without any other intervention and purple form packets were being used for physical holds, seclusions, and when chemical restraints were used with a physical hold and/or seclusions, nursing staff were unsure of documentation requirements when a chemical restraint was the only intervention and a blue form packet was used.

Patient #17

Review of Patient # 17's chart revealed he was admitted on 8/7/21 for AVH (audio, and visual hallucinations) and withdrawal of Fentanyl. A blue restraint packet was found dated 8/9/21 at 9:30AM. Patient #17 was administered Geodon and Ativan IM for disruptive behavior. The form failed to give a clear assessment of the patient and behaviors. The form stated the patient was "highly agitated" but no description of actions or behaviors. There were no vital signs documented on the form. The nurse documented "Patient Refused." There was no documentation of effectiveness of medications.

Patient #16
Review of patient # 16's chart revealed she was a 12-year-old female with a diagnosis of depression and suicidal ideation. She was admitted on 7/23/21. The chart revealed a purple packet was filled out on 8/3/21 at 1512 (3:15PM). Patient # 16 was placed in a physical hold for 15 minutes. A box was checked that the patient had violent self-destructive behavior, staff assault, and patient assault but no descriptive documentation of what the behavior or actions were. There were no vital signs documented. The nurse stated, "unable to safely obtain."

There was no further assessment or reassessment documented until 8/3/21 at 2037(8:37PM). Review of the Nursing Admission Assessment stated, "_____ (Patient #16) was in PHP when she got agitated, a code purple was called, and she was restrained and medicated. She became then an inpatient. Initially she was very agitated, unable to do assessment. Later she was calm in her room on a 1:1 and she cooperated with assessment. Denied any issue at the time. Skin assessment done and documented in skin assessment form." Vital signs were obtained.

An interview was conducted with Staff # 4 Medical Director on the morning of 8/19/21. Staff #4 stated that he and the other psychiatrist have found that mechanical restraints were not the desired method of treatment they chose to use at the facility. Staff #4 stated that seclusion may be an option, but his method of desired treatment was physical hold and chemical restraints. Staff #4 stated that he was aware that there needs to be a clearer understanding for the staff on appropriate assessment times and forms that reflect the restraint usage in the facility. Staff #4 stated that he was addressing the issue with medical staff and administration.

An interview was conducted on 8/19/21 with Staff #1, #2, and #3. Staff # 2 stated that they have been following the restraints through Quality and realize there was a problem with the multiple forms and policy. Staff #2 and #3 confirmed that the facility needs more time to improve the process and clean up the finer details of the restraint process. Staff #2 stated that he will be monitoring 100% of the restraint packets. Medical staff will be giving clear instructions on assessment times desired for chemical restraints and will be implemented with policy change.