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Based on video surveillance review, interview and documentation review, the facility staff failed to protect patient rights for one (1) of three (3) patients in the survey sample, Patient #1, by failing to:

Protect the patient from abuse (A 145);

Follow facility policy on Restraints and Seclusion (A162);

Obtain a physician's order for seclusion within 30 minutes (A168);

Obtain assessment by a trained staff member within one hour (175);

Provide and/or offer hydration, nutrition and elimination (179);

Document alternative or less restrictive interventions prior to seclusion (A 186); and

Document patient response to seclusion and rationale for the continued use of seclusion (A 188).

Based on video surveillance review, interview and documentation review, the facility staff failed to ensure one (1) of three (3) patients, Patient #1, was protected from abuse when a nursing staff member used their foot to push Patient #1 on or about the head.

The findings include:

On 2/19/19 at approximately 10:00 A.M. the survey team with Staff Member #1 watched a video of Patient #1's seclusion event, which occurred on 1/18/19 from 6:48 P.M. to 11:31 P.M.

The video revealed the following occurrences on 1/18/19 during those times:
6:48 P.M.; Patient #1 was placed in timeout
6:49 P.M.; Patient #1 was observed, via the video, lying on the floor slithering out the door of the timeout room. Staff Member #12 was observed stepping over Patient #1 and grabbing the sleeve of the patient's jacket and pulling him/her into the timeout room. Staff Member #11, a registered nurse, was also observed holding onto the door frame and the door, pushing Patient #1 on or about the head with Staff Member #11's foot.

Staff Member #1 stated, "I never even saw that when I viewed the video!" Staff review of the video is documented as occurring on 2/2/19.

Review of medical records contained no documentation of abuse as depicted in the surveillance video.

Per Staff Member #3, Staff Member #11 was a full time employee. A review of the Daily Guidelines (as worked schedule) indicated Staff Member #11 worked thirty-eight or more hours per week and evidenced Staff Member #11 worked on 1/18/19 from 7:07 A.M. until 7:07 P.M., on Unit 6A.

On 2/19/19 at approximately 3:00 P.M., Staff Member #3 provided training information that Staff Member #11 had received related to managing patients. Staff Member #3 stated, "[Staff Member#11] received [his/her] initial training on 7/12/18 and had an annual competency review on 11/11/18 show proficiency in all areas." Training and competency assessments included seclusion and restraint review and observation.

On 2/19/19 at 4:00 P.M., the findings were reviewed with Staff Members #2 and #3 who confirmed actions will be taken, including reporting to the appropriate agencies.

Based on video surveillance review, interview and documentation review, the facility staff failed to identify seclusion and follow the facility's policy for seclusion for one (1) of three (3) patients, Patient #1.

The findings include:

On 2/19/19 at approximately 10:00 A.M., the survey team and Staff Member #1, watched a video of Patient #1's seclusion event which occurred on 1/18/19 at 6:48 P.M. to 11:31 P.M.

The video surveillance review on 2/19/19 revealed:
Patient #1 being placed in seclusion by two Staff Members; Staff Members #11 (Registered Nurse) and #12. Patient #1's egress from the room was blocked from 6:48 P.M. until 11:31 P.M. (4 hours and 43 minutes) by various staff members.

The egress door was blocked in the following ways: at times the door was held by a staff member's foot, arm or body; blocked by a chair while a staff member sat in the chair; locked door both while staff stepped away from the door or while staff sat beside or directly in front of the doorway; and sitting with the door open but blocking Patient #1's egress.

Patient #1 was removed from seclusion at 11:31 P.M, on 1/18/19. A physician's order for seclusion was obtained at 10:30 P.M on 1/18/19, more than three (3) after the seclusion began.

The nurse's note dated 1/18/19 at 11:05 P.M. documents, "Patient was in time out at the beginning of shift. Patient rolled around on the floor, kicked walls, door casing and floor. Patient paced around time out room charging door and running into walls. Patient charged door and was secluded at 21:49 (9:49 P.M.). Patient was given Thorazine 50 mg IM at 22:54 (10:54 P.M.) which was effective. Benadryl 50 mg IM was given at 23:15 (11:15 P.M.)..."

The Physician's orders dated 1/18/19 at 10:54 P.M. included Thorazine for severe agitation and Benadryl for extreme agitation.

On 2/19/19 at approximately 3 P.M., Staff Member #3 stated, "I didn't know [patient] was secluded until about 9:30 P.M. or so."

The Hospital Policy on Restrictive Procedures, with a revision date of 04/2018, was provided by Staff Member #3 and documents the following information:

Page 10 section C defines Seclusion as "the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not."

Page 11 Authorization: #25 A: documents the following: "An RN (registered nurse) conducts the clinical assessment, authorizes the use of restrictive procedures and immediately (within 30 minutes) contacts the physician for a verbal order which she/he writes in the Physician Order Sheet for Restrictive Procedures. This order must be taken by an RN. The Physician's order will include:
The reason for using restraint/seclusion including specific behaviors and safety issues,
The type of restraint or seclusion used, Time limits not to exceed 4 hours for adults, 2 hours for children and adolescents ages 9-17 and 1 hour for children under the age of 9,
Behavioral criteria for discontinuation/release of restraint/seclusion,
The RN and MD names with dates and times of the telephone order.

B. The nurse must contact the Nursing Supervisor immediately to conduct a physical assessment of the patient....

F. RN Supervisor shall perform the One Hour Face-to-Face Assessment within one hour of the initiation of the restrictive procedure. The attending physician who is responsible for the care of the patient , must be consulted as soon as possible (within 30 minutes) after completion of the evaluation. The consultation should include a discussion of the findings of the one hour evaluation, the need fro other interventions or treatments and the continued need or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order....
Page 16 Observation of Patient #30:... Section A: Assessing (to be done every 15 minutes) by the RN include:
1. Vital signs (at least every 2 hours)
2. Nutrition
3. Hydration (offered every 2 hours)
4. Circulation
5. ROM (range of motion) (at least every hour
6. Elimination (offered every 2 hours)
7. Injuries/adverse events
8. Psychological Status/Behavior

#31 For Emergency Medications the patient will be monitored for 1-hour or per the physician order. Assessment including vital signs will be taken immediately following administration of the Emergency Medication and then every 15 minutes for one hour. The physician will be notified of any significant findings...."

The findings were reviewed with Staff Members #2 and #3 at 4:00 P.M. for a final time during the exit conference.

Based on video surveillance review, interview and documentation review, the facility staff failed to ensure one (1) of three (3) patients, Patient #1, had a physician's order for seclusion within 30 minutes of initiating seclusion, according to facility policy.

The findings include:

On 2/19/19 at approximately 10:00 A.M., a video of Patient #1's seclusion event which occurred on 1/18/19 at 6:48 P.M. to 11:31 P.M., was viewed with Staff Member #1.

The video showed Patient #1 being placed in seclusion by two Staff Members, Staff Members #11 (Registered Nurse) and #12. Patient #1's egress was blocked on 1/18/19 from 6:48 P.M. until 11:31 P.M. (4 hours and 43 minutes). Patient #1 was removed from seclusion at 11:31 P.M. A physician's order for seclusion was obtained at 10:30 P.M.

The nurse's note dated 1/18/19 at 11:05 P.M. documented, "Patient was in time out at the beginning of shift. Patient rolled around on the floor, kicked walls, door casing and floor. Patient paced around time out room charging door and running into walls. Patient charged door and was secluded at 21:49 (9:49 P.M.). Patient was given Thorazine 50 mg IM at 22:54 (10:54 P.M.) which was effective. Benadryl 50 mg IM was given at 23:15 (11:15 P.M.)..."

The Hospital Policy on Restrictive Procedures, with a revision date of 04/2018, was provided by Staff Member #3 and documents the following information:
Page 10 section C defines Seclusion as "the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not."

Page 11 Authorization: #25 A: documents the following: "An RN (registered nurse) conducts the clinical assessment, authorizes the use of restrictive procedures and immediately (within 30 minutes) contacts the physician for a verbal order which she/he writes in the Physician Order Sheet for Restrictive Procedures. This order must be taken by an RN. The Physician's order will include:
· The reason for using restraint/seclusion including specific behaviors and safety issues
· The type of restraint or seclusion used
· Time limits not to exceed 4 hours for adults, 2 hours for children and adolescents ages 9-17 and 1 hour for children under the age of 9
· Behavioral criteria for discontinuation/release of restraint/seclusion
· The RN and MD names with dates and times of the telephone order

F. RN Supervisor shall perform the One Hour Face-to-Face Assessment within one hour of the initiation of the restrictive procedure. The attending physician who is responsible for the care of the patient , must be consulted as soon as possible (within 30 minutes) after completion of the evaluation. The consultation should include a discussion of the findings of the one hour evaluation, the need fro other interventions or treatments and the continued need or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order...."


The findings were reviewed with Staff Members #2 and #3 at 4:00 P.M., for a final time during the exit conference.

Based on video surveillance review, interview and documentation review, the facility staff failed to ensure one (1) of three (3) patients, Patient #1, was assessed by a Registered Nurse (RN) or physician and provided and/or offered hydration, nutrition and elimination during seclusion per the facility policy.

The findings include:

On 2/19/19 at approximately 10:00 A.M., the survey team and Staff Member #1, watched a video of Patient #1's seclusion event which occurred on 1/18/19 at 6:48 P.M. to 11:31 P.M.

The video review revealed the following:

Patient #1 was placed in seclusion on 1/18/19 by two Staff Members, Staff Members #11 (Registered Nurse) and #12, from 6:48 P.M. until 11:31 P.M. (4 hours and 43 minutes). Patient #1 was monitored by various staff members during these times. The video showed no evidence that Patient #1 was offered hydration or the use of a bathroom. Medical record documentation indicated staff offered Patient #1 hydration and use of the bathroom at 11:03 P.M. on 1/18/19.

The video showed Staff Member #8 entering the hallway where Patient #1 was secluded at 10:43 P.M. At that time, Staff Member #8 stood at the entrance hallway and did not go to or look into the seclusion room where Patient #1 was located. Staff Member #8 did not observe Patient #1 until 10:50 P.M. when Staff Member #8 entered the seclusion room with a syringe.

On 1/18/19, Staff Member #8 documented an assessment of Patient # 1 on the Restrictive Procedure RN Assessment every 15 minutes from 9:49 P.M. until 11:16 P.M. Though, as noted above, the video did not show Staff Member #8 observing the patient until 10:50 P.M.

The nurse's note dated 1/18/19 at 11:05 P.M. documented, "Patient was in time out at the beginning of shift. Patient rolled around on the floor, kicked walls, door casing and floor. Patient paced around time out room charging door and running into walls. Patient charged door and was secluded at 21:49 (9:49 P.M.). Patient was given Thorazine 50 mg IM at 22:54 (10:54 P.M.) which was effective. Benadryl 50 mg IM was given at 23:15 (11:15 P.M.)..."

Staff Member #3 stated, "I didn't know [Patient #1] was secluded until about 9:30 P.M. or so."

The RN who was present during the seclusion did not make any documentation as to why Patient #1 was placed in seclusion. There was no documentation by an RN until 9:49 P.M. by Staff Member #8.

The Hospital Policy on Restrictive Procedures, with a revision date of 04/2018, was provided by Staff Member #3 and documented the following information:

Page 11 Authorization: #25 A: documented the following: "An RN (registered nurse) conducts the clinical assessment, authorizes the use of restrictive procedures and immediately (within 30 minutes) contacts the physician for a verbal order which she/he writes in the Physician Order Sheet for Restrictive Procedures. This order must be taken by an RN. The Physician's order will include:
The reason for using restraint/seclusion including specific behaviors and safety issues,
The type of restraint or seclusion used,
Time limits not to exceed 4 hours for adults, 2 hours for children and adolescents ages 9-17 and 1 hour for children under the age of 9,
Behavioral criteria for discontinuation/release of restraint/seclusion,
The RN and MD names with dates and times of the telephone order.

B. The nurse must contact the Nursing Supervisor immediately to conduct a physical assessment of the patient....

F. RN Supervisor shall perform the One Hour Face-to-Face Assessment within one hour of the initiation of the restrictive procedure. The attending physician who is responsible for the care of the patient , must be consulted as soon as possible (within 30 minutes) after completion of the evaluation. The consultation should include a discussion of the findings of the one hour evaluation, the need fro other interventions or treatments and the continued need or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order....

Page 16 Observation of Patient #30:... Section A: Assessing (to be done every 15 minutes) by the RN include:
1. Vital signs (at least every 2 hours)
2. Nutrition
3. Hydration (offered every 2 hours)
4. Circulation
5. ROM (range of motion) (at least every hour
6. Elimination (offered every 2 hours)
7. Injuries/adverse events
8. Psychological Status/Behavior"

The findings were reviewed with Staff Members #2 and #3 at 4:00 P.M. for a final time the exit conference.

Based on video surveillance review, interview and documentation review, the facility staff failed to ensure one (1) of three (3) patients, Patient #1, was assessed by a trained staff member within one hour of initiating seclusion.

The findings include:

On 2/19/19 at approximately 10:00 A.M., the survey team and Staff Member #1, watched a video of Patient #1's seclusion event which occurred on 1/18/19 at 6:48 P.M. to 11:31 P.M.

The video revealed Patient #1 being placed in seclusion by two Staff Members, Staff Members #11 (Registered Nurse) and #12 (a Behavioral Tech).

Medical record review revealed:
No documentation by a registered nurse (RN) about why Patient #1 was placed in seclusion. An RN assessment of Patient #1 at 9:49 P.M.
Staff Member #6 (Nursing Supervisor) failed to document the date and time of Patient #1's assessment. Staff Member #6 documented that the seclusion started at 9:49 P.M. The video shows Staff Member #6 in the area of the seclusion room at 9:44 P.M. and exiting at 9:45 P.M.

Staff Member #6 was interviewed via telephone on 2/19/19 at approximately 3:30 P.M. and stated, "I don't recall the incident with [Name of Patient #1]. Sometimes the staff don't inform me they have a patient in time out. So until I make rounds, I don't know they have gone into seclusion to do my assessment."

The Hospital Policy on Restrictive Procedures, with a revision date of 04/2018, was provided by Staff Member #3 and documented the following information:

Page 11 Authorization: #25 A: "An RN (registered nurse) conducts the clinical assessment, authorizes the use of restrictive procedures and immediately (within 30 minutes) contacts the physician for a verbal order which she/he writes in the Physician Order Sheet for Restrictive Procedures. This order must be taken by an RN. The Physician's order will include:
The reason for using restraint/seclusion including specific behaviors and safety issues
The type of restraint or seclusion used
Time limits not to exceed 4 hours for adults, 2 hours for children and adolescents ages 9-17 and 1 hour for children under the age of 9
Behavioral criteria for discontinuation/release of restraint/seclusion
The RN and MD names with dates and times of the telephone order

B. The nurse must contact the Nursing Supervisor immediately to conduct a physical assessment of the patient....

F. RN Supervisor shall perform the One Hour Face-to-Face Assessment within one hour of the initiation of the restrictive procedure. The attending physician who is responsible for the care of the patient, must be consulted as soon as possible (within 30 minutes) after completion of the evaluation. The consultation should include a discussion of the findings of the one hour evaluation, the need fro other interventions or treatments and the continued need or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order...."

The findings were reviewed with Staff Members #2 and #3 at 4:00 P.M., for a final time during the exit conference.

Based on interview and document review, the facility staff failed to document all alternatives or less restrictive interventions attempted prior to seclusion for one (1) of three (3) patients, Patient #1.

The findings include:

Patient #1's medical record was reviewed on 2/19/19 and there was no information documented about what types of interventions had been tried on 1/18/19 prior to seclusion. On 1/18/19 at 11:03 P.M., a note documented: "Pt (Patient) began to run around the unit and was non complaint with staff redirections. Pt had PA (physical aggression) twice toward staff. Pt throwing (himself/herself) on the floor and running in and out of peers' rooms. Pt was talking to self and laughing. Pt walked into timeout."

Staff Member #8 was interviewed via telephone on 2/19/19 at 2:09 P.M. and stated, "When I came on duty at 7:00 P.M. (Name of Patient #1) was already in the timeout room. I was not aware at that time (he/she) was actually in seclusion. I do not know what was done prior to placing (him/her) in timeout."

The Hospital Policy on Restrictive Procedures, with a revision date of 04/2018, was provided by Staff Member #3 and documents the following information:
Page 2 Philosophy/Patient Rights Section #3 "...Whenever possible, staff must attempt to first implement less restrictive verbal and nonverbal de-escalation, as well as CPI personal safety techniques, prior to considering the use of seclusion or restraint. Seclusion and restraint must only be used for the minimum amount of time necessary to regain safety, and, may not, under any circumstances be used as:
· discipline
· punishment
· as a threat or coercion
· for staff convenience
· retaliation by staff
· because there are not enough staff on duty
· because the patient is noncompliant or because property is being damaged (Note: it is only when any action, including destroying or damaging property, puts the patient or others at risk, that seclusion or restraint is considered an appropriate staff response)."

The findings were reviewed with Staff Members #2 and #3 at 4:00 P.M. for a final time during the exit conference.

Based on video surveillance review, interview and documentation review, the facility staff failed to ensure they documented patient response to seclusion, medical restraint, and the continued rationale for the use of seclusion for one (1) of three (3) patient, Patient #1.

The findings include:

On 2/19/19 at approximately 10:00 A.M., the survey team and Staff Member #1, watched a video of Patient #1's seclusion event which occurred on 1/18/19 at 6:48 P.M. to 11:31 P.M.

The video revealed the following:
At 10:52 P.M., Staff Member #8 and Staff Member #10 entered the seclusion room with Staff Member #8 carrying a syringe. The Medication Administration Record (MAR) indicated Patient #1 received an injection of Thorazine 50 mg at 10:54 P.M. Both Staff Members #8 and #10 exited the seclusion room and the room was re-locked.

At 11:15 P.M., Staff Member #8 and Staff Member #14 entered the seclusion room with Staff Member #8 carrying a syringe. The Medication Administration Record (MAR) indicated Patient #1 received an injection of Benadryl 50 mg IM at 11:00 P.M. Upon exiting the seclusion room, the door was left open but Staff Member #14 remained seated in front of the doorway blocking Patient #1's egress. From 11:16 P.M. to 11:30 P.M., Patient #1 paced the floor, laid down on the floor, conversed with Staff Member #14, and made no attempts to exit the seclusion room.

At 11:30 P.M., Staff Member #8 entered the hallway where the seclusion room was located and at 11:31 P.M. Patient #1 exited the seclusion room.

There was no documentation beyond 11:16 P.M. indicating why Patient #1 remained in seclusion.

On 2/19/19 at various times, the findings were shared with Staff Member #3 who stated, "I could not find documentation other than what you have been given."

The Hospital Policy on Restrictive Procedures with a revision date of 04/2018 was provided by Staff Member #3 and documented the following information:

Page 10 Definition: Section #23; C. defined Seclusion as "the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not."

F. RN Supervisor shall perform the One Hour Face-to-Face Assessment within one hour of the initiation of the restrictive procedure. The attending physician who is responsible for the care of the patient, must be consulted as soon as possible (within 30 minutes) after completion of the evaluation. The consultation should include a discussion of the findings of the one hour evaluation, the need for other interventions or treatments and the continued need or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order...."


The findings were reviewed with Staff Members #2 and #3 at 4:00 P.M. for a final time during the exit conference.