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Based on medical record review, and staff interviews the hospital failed to protect the rights of Patient #1 when the hospital failed to provide a safe environment for Patient #1 who was continuously restrained, and in seclusion for 70 out of 74 days of his hospitalization on the Behaviorial Health Unit. This failure places the Condition of Participation of Patient Rights out of compliance.

See documentation tags: A144, A174, A185, and A186.

Based on interview and documentation review, the hospital failed to provide an environment which was physically and emotionally safe for 1 of 10 patients (Patient #1) records reviewed. Findings include:

A physician note dated 10/13/2010, was reviewed and revealed that Patient #1 was admitted to the hospital on 10/13/2010 with psychosis and hallucinations. He was admitted to the Behavior Health Unit. His diagnoses included Traumatic Brain Injury, Antisocial Personality disorder, and Bipolar Affective Disorder.

Hospital Encounter notes dated 10/19/2010 document that Patient #1 struck a staff member in the face knocking her unconscious. Following the assault, Patient #1 continued to make threats toward staff, and was placed in restraints on 10/19/2010, and remained in restraints for a total of 70 days, until his discharge to a behavioral health hospital on 12/27/2010. He was placed in seclusion and put in two point, three point, or five point restraints while in seclusion. Shackles was also used when he was walking on the unit, to the bathroom, or in the shower.

Patient #1 was interviewed on 3/17/2011 at 11:00 a.m. and stated that he was in restraints for over 75 days while at the hospital. He stated that he repeatedly asked the physician when he would be allowed out of restraints, and the physician kept stating that "I was a danger to myself and others." He stated that he was walked and showered with hobble restraints on, and he stated that he felt "like a prisoner." He was not given a plan to "work his way out of the restraints," and stated that he was always considered a danger to staff and others. He stated that he usually had one arm restrained, the opposite leg, and a waist belt on, and the staff would switch sides at least two times a shift.

Employee (F)/nurse was interviewed on 3/31/2011 at 1:15 p.m. and stated that Patient #1 was kept in restraints from the time that he injured a staff person due to the dangerousness that he presented, until his discharge on 12/27/2010. He was sometimes " OK ", and then continued to make verbal threats to staff. He was always determined to be a safety risk to staff and other patients, and was in restraints 24 hours a day. He was observed and evaluated daily by the physician, and orders were received daily for continued use of the restraints and seclusion.

Physician notes and Hospital Encounter notes dated 10/19/2010 through 12/27/2010 did not contain evidence that a plan was in place to remove the restraints when his behaviors improved, or when he was demonstrating less violent behaviors.

The hospital's policy entitled Restraint and Seclusion dated 2/2010 documents that restraints or seclusion will only be used to ensure the immediate physical safety of the patient, a staff member, or others, and will be discontinued at the earliest possible time.

Patient #1 continued in restraints while sleeping, showering, and when documentation indicated that he was demonstrating less violent behaviors.

Based on interviews and documentation review, the hospital failed to ensure that restraints were removed at the earliest possible time for 1 of 10 (Patient #1) who remained in restraints for 70 of the 74 days he was on the Behaviorial Health Unit. Findings include:

Physician notes dated 10/13/2010, were reviewed and revealed that Patient #1 was admitted to the hospital on 10/13/2010 with psychosis and hallucinations. He was admitted to the Behavior Health Unit. He has diagnoses including Traumatic Brain Injury, Antisocial Personality disorder, and Bipolar Affective Disorder.

Physician notes dated 10/13/2010, document that Patient #1 was at high risk for suicide, self-injurious behavior, physical aggressiveness, elopement, injury to others, and refuses direction.

Hospital Encounter notes dated 10/13/2010 through 10/19/2010 established that Patient #1's behaviors escalated, and he was intermittently restrained in seclusion and placed in two, three and five point restraints for behaviors including striking out at staff, attempting to bite staff, threatening to kill staff, spitting at staff, and threats of suicide. The Behavioral Restraints Flowsheet dated 10/15/2010 through 10/19/2010 established that the staff assessed the need for the restraints based on the behaviors exhibited by Patient #1. The restraints were released when Patient #1 demonstrated a reduction in the violent or self-destructive behaviors.

Hospital Encounter notes dated 10/19/2010 document that Patient #1 struck a staff member in the face, causing her to become unconscious. Immediately following the assault, Patient #1 was placed in five point restraints and seclusion. He continued to make threats of violence toward staff, and remained in seclusion and five point restraints on 10/19/2010, and remained in restraints for a total of 70 days, until his discharge to a behavioral health hospital on 12/27/2010. He was maintained in seclusion and two point, three point, or five point restraints while in seclusion, and was restrained while sleeping. Shackles were used when he was walking on the unit, to the bathroom, or in the shower.

The notes document examples of periods of time that Patient #1 remained in seclusion and in five point restraints. Patient #1's medical record was reviewed and includes ongoing documentation of Patient #1's behaviors, and restraint use, but did not include any interventions for the discontinuation of the restraints and/or seclusion once the behavior decreased or discontinued. Hospital encounter notes includes:

*10/19/2010, Physician #1 documented that Patient #1 will be in restraints for the next 24 hours or longer, with waist belt and shackles to prevent further harm to others. This was following a physical assault on a staff person.
* 10/19/10 at 10:03 p.m. Physician notes document to keep Patient #1 in seclusion and restraints until tomorrow morning. The notes document that Patient #1 is currently sleeping and appears in no acute distress.
*10/20/2010 at 1:26 p.m., technician notes document that Patient #1 was in five point restraints all morning, and the notes document that he was labile all am shift.
*10/20/2010 at 10:16 p.m., Physician notes document that Patient #1 "now sleeping comfortably," continue restraints/seclusion per protocol.
*10/21/2010 at 1:50 p.m., nursing notes document that Patient #1 has been sleeping since after lunch.
*10/23/2010 at 11:01 a.m., technician notes document that Patient #1 is "intermittantly complaining and sleeping...cooperative and continues to ask for increased freedoms."
*10/24/2010 at 1:23 p.m., technician notes document that Patient #1 "continues in three point restraints for shift." His mood "continues to be labile," shifting between calm and episodes of crying and childlike behaviors. Patient #1 was given Benedryl and Ativan at 11:15 a.m., for increased anxiety, and "has been resting comfortably."
*10/25/2010 at 8:37 a.m., technician notes document that Patient #1 remains in seclusion and three point restraints. He is calm at times followed by "angry and crying if he doesn't get what he wants." At 10:15 a.m., the notes document that he has been much calmer with more consistent moods lately.
*10/25/2010 at 2:27 p.m., Physician #1 documented that Patient #1 has been able to go without extensive violence, and has been placed in restraints in order to ambulate, shower, and to go to the bathroom. He will advance to less retriction, balanced with safety to staff and others.
*10/28/2010 at 4:19 p.m., Physician #1's notes document that Patient #1 was reduced to two point restraints, as he has not exhibited "any violence recently," and staff are moving him out of restraints as tolerated.
*10/30/2010 at 9:04 a.m., Physician orders document to continue with 1:1 supervision and three point restraints, as Patient #1 has history of serious threats to staff and recurrent aggressive behaviors when opportunity given.
*10/31/2010 at 1:46 p.m., technician notes document that Patient #1 slept the majority of the morning, and remained in three point restraints.
*11/1/2010 at 2:07 p.m., Physician #1's notes document that Patient #1 has been more "reasonable" today. He is being "allowed privileges according to his ability to handle the degree of freedom." The notes did not document what privileges he was given, and the notes document that he continued in restraints during this time.
*11/2/2010 at 6:21 a.m., Physician #1's notes document that Patient #1, "given some freedoms, chose to hit one of the staff, he is not holding back on his violence."
*11/3/2010 at 9:19 p.m., technician notes document that Patient #1 continues in three point restraints. The notes document that he slept until dinner and has been cooperative with staff.
*11/9/2010 at 8:25 a.m., Physician #1 documented that Patient #1 would like to have his restraints removed, but is still a danger to self and others.
*11/10/2010 at 2:00 p.m. Physician #1 documented that Patient #1 has been doing "quite well," and wants to have another chance at proving himself, but the risk is "quite significant" expecially as the time nears an end, he would not have any restraint from harming others. Continue seclusion and restraints.
*11/26/2010 at 7:20 a.m., Physician #1 documented that Patient #1 has not been acting out or been threatening. Patient #1 has been requesting utensils rather than finger foods for no clear reason. Continue with current regimen of restraints and seclusion.
*11/29/2010 at 6:23 a.m., Physician #1 documented that Patient #1 is asking the staff to "take a risk on his behavior," and release him from the restraints and shackles. It documents that he has not had any recent violence or threats of violence.

An Ethics Committee team meeting note dated 11/16/2010, documents that the prolonged use of restraints and seclusion for Patient #1 is "appropriate given the situation." They determined a need to continue restraints and seclusion to protect the patient and staff.

A 12/27/2010 physician note documents that Patient #1 was placed in restraints for all but four days of his stay. It documents that there was a resolution of symptoms, and at the time of discharge, Patient #1 was without suicidal, homicidal ideation, and had no noted thought disorder. He continued in restraints until his discharge to an impatient behavioral health hospital on 12/27/2010.

Physician notes and Hospital Encounter notes dated 10/19/2010 through 12/27/2010 did not contain evidence that a plan was in place to remove the restraints when his behaviors improved, or when he was demonstrating less violent behaviors. Patient #1 continued in restraints while sleeping, showering, and when documentation indicated that his behaviors had improved.

A physician note dated 11/26/2011 documents that Patient #1 "has not acted out or been threatening," but with the upcoming court date, "we need to watch and be safe as this date approaches." The note documents that Patient #1 is requesting time out of his restraints, and the plan is to continue with current regimen. The notes document that Patient #1 is not having "any injury or physical problems with the restraints," and staff is continuing to have him "hobble" to the showers and to watch television.

The hospital's policy entitled Restraint and Seclusion dated 2/2010 documents that restraints or seclusion will only be used to ensure the immediate physical safety of the patient, a staff member, or others, and will be discontinued at the earliest possible time.

Employee (F)/nurse was interviewed on 3/31/2011 at 1:15 p.m. and stated that Patient #1 was not striking out at staff for the first day or two after admission, and then his behaviors increased. He injured two staff persons, and was verbally abusive to staff. He was kept in restraints from the time that he injured a staff person due to the danger he presented. He was sometimes " OK ", and then continued with verbal threats to staff. He was always determined to be a safety risk to staff and other patients, and was in restraints 24 hours a day. He was observed and evaluated daily by the physician and orders were received for continued use of the restraints.

Employee (G)/nurse was interviewed on 3/31/2011 at 1:56 p.m. and stated that Patient #1 was awaiting a court appointment for commitment, and was on the behavior health unit for a lengthly period of time. After he attacked a staff member, he was in restraints until discharge, due to the danger that he presented. He did go for short periods of time where he wasn't verbalizing threats to kill someone, or hurt someone, but the calm periods didn't last long. Employee (G) stated that Patient #1 was a rare case, and an exception to prolonged restraint use.

Employee (C)/nurse was interviewed on 3/31/2011 at 2:10 p.m. and stated that Patient #1 was on the behavior health unit for an extended period of time. On 10/19/2010, Patient #1 assaulted a staff person, and knocked her unconscious. From that time on, Patient #1 remained in seclusion, restraints, and was in shackles when ambulating on the floor. He continued to tell staff that he was not able to control himself. He was committed and determined to be mentally ill and dangerous. He remained on the unit awaiting placement to a behavior health hospital.

Patient #1 was interviewed on 3/17/2011 at 11:00 a.m. and stated that he was in restraints for over 75 days while at the hospital. He stated that he repeatedly asked the physician when he would be allowed out of restraints, and the physician kept stating that "I was a danger to myself and others." He stated that he was walked and showered with hobble restraints on, and he stated that he felt "like a prisoner." He was not given a plan to "work his way out of the restraints," and stated that he was always considered a danger to staff and others. He stated that he usually had one arm restrained, the opposite leg, and a waist belt on, and the staff would switch sides at least two times a shift.

Physician (H) was interviewed on 4/5/2011 at 2:23 p.m. and stated that Patient #1 was admitted to the behavior health unit after aggressive behaviors were noted at his group home. While on the unit, Patient #1 assaulted two staff persons, made ongoing threats of violence toward staff, physicians, and other patients. Following the assault on a staff person on 10/19/2010, Patient #1 was maintained in seclusion, restraints, and/or shackles for approximately 70 days, 24 hours a day, due to his level of danger to others. He was evaluated by a forensic psychologist prior to his court hearing on 11/12/2010, and hospital psychologists throughout his inpatient stay, who determined that his violence was not a result of mental illness, but a result of his antisocial personality. He was determined to be homicidal, and Physician (H) stated that Patient #1 could not be trusted with staff or other patients. He remained in seclusion with restraints, or shackles for 70 days of his hospital stay. He stated that Patient #1 needed a controlled environment, and could not be trusted without restraints or shackles.

Physician (H) stated that Patient #1 continued to make threats to kill the staff and physicians. He met with Patient #1 daily, and attempted medication adjustments to assist in behavior control, and stated that within a couple weeks of discharge, Patient #1 was more settled, and more cooperative, but was still considered to be dangerous, and homicidal. Patient #1's was never removed from restraints, and/or seclusion during his hospitalization, due to his history and threats of violence to staff. Physician (H) stated that Patient #1 was unpredictable, and staff was unaware of when he would strike out, so he was maintained in restraints and seclusion, and was assigned a 1:1 staff person until his discharge to a behavior health hospital. His discharge was delayed on several occasions, due to rescheduling of the committment hearings, and bed availability at the behavioral health hospitals. Physician (H) stated that Patient #1 did not have any skin issues, or injuries noted as a result of the restraint use.

Based on interviews and documentation review, the hospital failed to ensure the documented interventions were appropriate for the documented behaviors for 1 of 10 patients (Patient #1) records reviewed. Findings include:

Patient #1's medical record was reviewed and included ongoing documentation of Patient #1's behaviors, and restraint use, but did not include any interventions for the discontinuation of the restraints and/or seclusion once the behavior decreased or discontinued. Hospital encounter notes include:

*10/19/2010, Physician #1 documented that Patient #1 will be in restraints for the next 24 hours or longer, with waist belt and shackles to prevent further harm to others. This was following a physical assault on a staff person.
* 10/19/10 at 10:03 p.m. Physician notes document to keep Patient #1 in seclusion and restraints until tomorrow morning. The notes document that Patient #1 is currently sleeping and appears in no acute distress.
*10/20/2010 at 1:26 p.m., technician notes document that Patient #1 was in five point restraints all morning, and the notes document that he was labile all am shift.
*10/20/2010 at 10:16 p.m., Physician notes document that Patient #1 "now sleeping comfortably," continue restraints/seclusion per protocol.
*10/21/2010 at 1:50 p.m., nursing notes document that Patient #1 has been sleeping since after lunch.
*10/23/2010 at 11:01 a.m., technician notes document that Patient #1 is "intermittantly complaining and sleeping..cooperative and continues to ask for increased freedoms."
*10/24/2010 at 1:23 p.m., technician notes document that Patient #1 "continues in three point restraints for shift." His mood "continues to be labile," shifting between calm and episodes of crying and childlike behaviors. Patient #1 was given Benedryl and Ativan at 11:15 a.m., for increased anxiety, and "has been resting comfortably."
*10/25/2010 at 8:37 a.m., technician notes document that Patient #1 remains in seclusion and three point restraints. He is calm at times followed by "angry and crying if he doesn't get what he wants." At 10:15 a.m., the notes document that he has been much calmer with more consistent moods lately.
*10/25/2010 at 2:27 p.m., Physician #1 documented that Patient #1 has been able to go without extensive violence, and has been placed in restraints in order to ambulate, shower, and to go to the bathroom. He will advance to less retriction, balanced with safety to staff and others.
*10/28/2010 at 4:19 p.m., Physician #1's notes document that Patient #1 was reduced to two point restraints, as he has not exhibited "any violence recently," and staff are moving him out of restraints as tolerated.
*10/30/2010 at 9:04 a.m., Physician orders document to continue with 1:1 supervision and three point restraints, as Patient #1 has history of serious threats to staff and recurrent aggressive behaviors when opportunity given.
*10/31/2010 at 1:46 p.m., technician notes document that Patient #1 slept the majority of the morning, and remained in three point restraints.
*11/1/2010 at 2:07 p.m., Physician #1's notes document that Patient #1 has been more "reasonable" today. He is being "allowed privileges according to his ability to handle the degree of freedom." The notes documented that he was allowed to watch TV, and the notes document that he continued in restraints during this time.
*11/2/2010 at 6:21 a.m., Physician #1's notes document that Patient #1, "given some freedoms, chose to hit one of the staff, he is not holding back on his violence."
*11/3/2010 at 9:19 p.m., technician notes document that Patient #1 continues in three point restraints. The notes document that he slept until dinner and has been cooperative with staff.
*11/9/2010 at 8:25 a.m., Physician #1 documented that Patient #1 would like to have his restraints removed, but is still a danger to self and others.
*11/10/2010 at 2:00 p.m. Physician #1 documented that Patient #1 has been doing "quite well," and wants to have another chance at proving himself, but the risk is "quite significant" expecially as the time nears an end, he would not have any restraint from harming others. Continue seclusion and restraints.
*11/16/2010 at 11:01 p.m. technician notes document that Patient #1 was aggitated at times with the noise on the unit, but "overall had goo behavior this shift."
*11/22/2010 at 11:03 p.m., Physician notes document that the plan is to keep Patient #1 in restraints until he is transferred.
*11/26/2010 at 7:20 a.m., Physician #1 documented that Patient #1 has not been acting out or been threatening. Patient #1 has been requesting utensils rather than finger foods for no clear reason. Continue with current regimen of restraints and seclusion.
*11/29/2010 at 6:23 a.m. Physician #1 documented that Patient #1 is asking the staff to "take a risk on his behavior," and release him from the restraints and shackles. It documents that he has not had any recent violence or threats of violence.

Physician (H) was interviewed on 4/5/2011 at 2:23 p.m. and stated that following an assault on a staff person, Patient #1 was maintained in seclusion, restraints, and/or shackles for approximately 70 days, 24 hours a day, due to his level of danger to others. He stated that Patient #1 was homicidal. He needed a controlled environment, and could not be trusted without restraints or shackles. Patient #1 made ongoing threats to kill staff and the physicians. Within a couple weeks of discharge, he was more settled, and more cooperative, but was still considered to be dangerous, and homicidal. Patient #1 was assessed daily, but was never removed from restraints, and/or seclusion during his hospitalization, due to his history and threats of violence to staff. Physician (H) stated that Patient #1 was unpredictable, and staff was unaware of when he would strike out, so he was maintained in restraints and seclusion, and monitored by a 1:1 staff person until his discharge to a behavior health hospital. His discharge was delayed on several occasions, due to rescheduling of the committment hearings, and bed availability at the behavioral health hospitals. Physician (H) stated that Patient #1 did not have any skin issues, or injuries noted as a result of the restraint use.

Based on documentation review, Patient #1's medical record failed to include documentation that attempts were made to remove restraints from 1 0f 10 patients (Patient #1) who was restrained for 70 consecutive days. Findings include:

Patient #1's medical record was reviewed and revealed that he was admitted to the hospital on 10/13/2010 with psychosis and hallucinations. He was admitted to the Behaviorial Health Unit, and placed on a 72 hour hold. He has diagnoses including Traumatic Brain Injury and Antisocial Personality Disorder, and Bipolar Affective Disorder.

Hospital Encounter notes dated 10/19/2010 document that Patient #1 struck a staff member in the face, causing her to become unconscious. Following the assault, Patient #1 continued to make threats toward staff, and was immediately placed in restraints on 10/19/2010, and remained in restraints for a total of 70 days, until his discharge to a behavioral health hospital on 12/27/2010. He was maintained in seclusion and two point, three point, or five point restraints while in seclusion. Shackles was also used when Patient #1 was walked on the unit, to the bathroom, or in the shower.

Physician notes, interviews, and Hospital Encounter notes dated 10/19/2010 through 12/27/2010 did not contain documentation of attempts to remove Patient #1 from restraints to evaluate his response. Patient #1 continued in restraints while sleeping, showering, and when documentation indicated that his behaviors had improved, due to his history and continued threats of violence to the staff and physicians.

The hospital's policy entitled Restraint and Seclusion dated 2/2010 documents that restraints or seclusion will only be used to ensure the immediate physical safety of the patient, a staff member, or others, and will be discontinued at the earliest possible time.

Although Patient #1's medical record documents a description of his behaviors, and the interventions used, it did not include alternate interventions, or interventions to move toward removal of the restraints for times when he was calm, resting, or sleeping.