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Based on record review and interview the facility failed to have 8 patients (P2-P9) out of 10 (P1-P10) patients reviewed to be evaluated after an intervention for the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and need to continue restraint or seclusion. This deficient practice may lead to improper coordination of care which could result in patient harm.

The findings are:

A. Record review of P2 "Flowsheet Print Request Date Range: 03/20/2022 04:00 (4 am) - 03/20/2022 19:00 (7 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems (list of questions, arranged by organ system, designed to uncover dysfunction and disease within that area) the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed at the beginning of a restraint, during the restraint and during the seclusion and not completed 1 hour after the initiation of the intervention.

B. Record review of P3 "Flowsheet Print Request Date Range: 07/13/2022 12:00 (12 pm)- 07/13/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed at the beginning of both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

C. Record review of P4 "Flowsheet Print Request Date Range: 07/17/2022 07:00 (7 am) - 07/17/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during a restraint and no assessment completed 1 hour after the initiation of the intervention

D. Record review of P5 "Flowsheet Print Request Date Range: 07/04/2022 07:00 (7 am) - 07/04/2022 11:00 (11 am)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

E. Record review of P6 "Flowsheet Print Request Date Range: 07/15/2022 08:00 (8 am) - 07/15/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

F. Record review of P7 "Flowsheet Print Request Date Range: 06/27/2022 20:00 (8 pm) - 06/28/2022 02:00 (2 am)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

G. Record review of P8 "Flowsheet Print Request Date Range: 06/28/2022 19:00 (7 pm) - 06/29/2022 11:00 (11 am)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during a documented restraint and no assessment completed 1 hour after the initiation of the intervention.

H. Record review of P9 "Flowsheet Print Request Date Range: 07/18/2022 15:30 (3:30 pm) - 07/18/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during a documented restraint and no assessment completed 1 hour after the initiation of the intervention.

I. In an interview on 07/22/2022 at 10 am with (Staff) S10, RN (Registered Nurse) Psych Inpatient, Interim Base Educator, confirmed that the debrief is a 6-question post assessment, that should be done within one hour, but is usually done immediately. S10 also confirmed that the face-to-face is documented in the I-View Debrief and it does not contain patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care.

Based on record review, observation and interview the facility failed to maintain that all patients have the right to be free from physical or mental abuse, and corporal punishment and 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 for 3 (P1.P3, P6) of 10 (P1-P10) patients reviewed. This failed practice can lead to restraint and seclusion being used for coercion, discipline and convenience and can lead to patient harm.

The findings are:

Patient 6 Findings:
A. On 07/21/22 at 10:00 am during observation of video 1 from 07/04/22 at 9:45 am through 10:07 am of P6 confirmed, "P#6 seen in the hallway pushing outside door, 2 staff watching patient pace and push the door, patient stops and looks outside. 9:48 am patient at the door pushing door, 2 staff approach and restrain patient (1 staff on each arm) and take patient to seclusion from 9:49 am to 10:07 am.

B. On 07/21/22 at 11:25 am during observation of video 2 from 05/17/22 at 9:39 am through 10:26 am of P6 confirmed, "9:39 am, Patient seen in hall area with peer and 3 staff. Patient hits the door, sat down at the end of the hall, gets up and kicks the door X 4 [appears to try to open door]. 9:41 am, Three staff respond and restrain patient (1 staff on each arm) ant take him to seclusion at 9:43 am to 10:25 am.

C. On 07/22/22 at 10:02 am during observation of video 3 from 07/15/22 at 12:05 pm through 12:34 pm of P6 confirmed, "At 12:15 pm patient seen in hallway and appears calm, joined by 1 staff and they are talking. Patient raises his hand to staff and is restrained and dragged/carried to the common room. Patient struggles in the restraint (1 staff restraining patient by using patient arms crossed in front facing away from staff). Restrained patient is held standing then sitting on the couch then standing, appears to break the restraint but staff was able to regain the restraint hold. Restraint continues from 12:15 pm to 12:18 pm when patient is transferred to seclusion until 12:34pm.

Patient 1 Findings:
D. On 07/22/22 at 1:42 pm during observation of facility video footage for 03/08/22 starting at 9:50 am, shows P1 sitting on the couch next to a staff member with an ipad watching videos, there are 3 other staff present, patient attempts to take the ipad from the staff and is immediately restrained and removed to his living quarters, he comes back out to common room, staff tries to stop him from going back down the hall, he fights back, is restrained and taken to seclusion at 9:59 am. At 10:13 am P1 is released from seclusion and returned to the common area, P1 seen pacing, dancing, and twirling and interacting with staff, P1 pulls at staff mask and is restrained and returned to seclusion at 10:42 am. At 11:20 am P1 is released from seclusion. He is returned to the common area, continues to pace, twirl, and interact with staff. P1 attempts to go to his living quarters bypassing staff who attempts to restrain him, he crawls away from staff, P1 is pacing the hallway and gets restrained by 3 staff and is returned to seclusion at 11:38 am. At 11:53 P1 is released and returned to the common area where he is again twirling, pacing, and interacting with staff. He attempts to enter the room where other residents are sitting, is restrained again, and returned to seclusion at 11:58 am. At 12:44 pm P1 is released from seclusion and returned to the common area and continues pacing, twirling, and interacting with staff.

E. On 07/22/22 at 1:00 pm during observation of facility video footage for 03/17/22 starting at 8:09 am, shows P1 in the main area of the treatment cottage, he is seen pacing around and takes something off the housekeeping cart, gets very close to staff face and continues pacing up and down the hall, he is led to his living quarters where he enters and is unseen, he returns to the common area and tips over the coffee table at 8:09 am and is restrained by 3 staff and taken to seclusion in the BICU (Behavioral Intensive Care Unit), at 8:23 am patient is released from seclusion and escorted back to his living quarters.

Patient 3 Findings:
F. On 07/22/22 at 2:00 pm during observation of facility video footage for 03/10/22 starting at 5:56 am, shows P3 laying on the couch in common area of the BICU, staff sitting at nursing station, at 5:59 am P3 gets up off the couch, walks over to the nursing station, jumps up and looks over the plastic divider, goes back to the couch and lays back down. Three staff enter the common room at 6:00 am, ask patient to stand, restrain patient and he is led to his living quarters and secluded until 6:07 am when he is released and returns to laying on the couch.

G. Record review of facility policy titled, "Use of Restraint and Seclusion for Management of Violent or Self-Destructive Behavior" dated 10/05/2020, confirms, "Facility and staff strive to deliver patient care using the least restrictive interventions while respecting patient rights, safety and dignity. Providing a safe environment and preventing injury are essential to obtaining desired outcomes. Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members or others. Restraint and seclusion are used only with appropriate and adequate clinical justification when less restrictive interventions are ineffective and the least restrictive means of restraint or seclusion to ensure safety is applied. It is not used as a means of coercion, discipline, convenience, or staff retaliation."

H. On 07/21/22 at 10:13 am during interview with Staff S5 & S7 (Executive Director of Behavioral Health & Associate Chief Nursing Officer) in reference to Video 1 of P6 confirmed, S5 stated, "He [P6] was hitting the door pretty hard and winced according to the report [not observed on video]. S7 stated, "what did he[P6] do?[in reference to being restrained]"

I. On 07/21/22 at 11:25 am during interview with S5 (Executive Director of Behavioral Health) who confirmed, in reference to Video 2 of P6, "He [P6] was restrained/secluded because he was hitting/kicking the wall."

J. On 07/22/22 at 10:05 am during interview with S5 (Executive Director of Behavioral Health) and S7 (Associate Chief Nursing Officer) who confirmed in reference to Video 3, S7 confirmed, "it looks like he[P6] raised his hand to staff" and further confirmed, "This should have been a 2 person hold [restraint]" S5 confirmed, "That is a 1 person hold, I don't know why staff is doing that restraint alone."

K. On 07/20/22 at 1:40 pm during interview with S12 (Psychologist/Clinical Director) confirmed, "Restraint/Seclusion here is done if a person may be harm to self or other and need immediate intervention."

L. On 07/20/22 at 2:20 pm during interview with S 13 ( Psychiatrist) who confirmed, "Restraint/Seclusion is the last resort when a patient is a danger to self and others, if nothing else works like de-escalation."

M. On 07/20/22 at 2:50 pm during interview with S14 (Vice Chair for Child Psychology Division) who confirmed, "Restraint/Seclusion are done for immediate patient safety concerns."

N. On 07/21/22 at 4:15 pm during interview with S15 and S16 (Security Officers) who confirmed "S15 and S16 are stationed at this facility and are called as support for restraint/seclusion on a daily basis. All security are trained in MOAB (Management of Aggressive Behavior) for treatment of patients at this facility. Restraint/Seclusion is a last resort if a patient is a danger to themselves or others."

O. On 07/22/22 at 10:30 am during interview with S23 (Registered Nurse) who confirmed, "Restraint and seclusion process is only when the child is a danger to themselves or others. S23 states that nonphysical intervention skills include verbal de-escalation, diverting attention, those are usually successful."

P. On 07/22/22 at 11:00 am during interview with S24 (Mental Health Tech) who confirmed, "[in reference to restraint/seclusion] the patients have to be a risk to self or others to be restrained or secluded, restraints are usually pretty quick, nothing lasts longer than a minute. Nonphysical intervention skills include redirection, flexibility with limit setting, stuff like that. Signs of physical distress include breathing and trauma during a restraint. S24 stated, "there's been no instances that he has seen where restraint wasn't necessary."

Q. On 07/22/22 at 12:50 pm during interview with S22 (RN traveler) who confirmed, "Restraints and seclusion should only be done when there is risk of the child being injured from themselves or others. She states that she has not seen an instance where restraint wasn't necessary."

Based on observation and interview the facility failed to maintain that restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm for 3 (P1, P3, P6 ) of 10 (P1-P10) patients reviewed. This failed practice can lead to restraint and seclusion being used inappropriately and can lead to patient harm.

The findings are:

A. Record review of facility policy titled, "Use of Restraint and Seclusion for Management of Violent or Self-Destructive Behavior" dated 10/05/2020, confirms, "Facility and staff strive to deliver patient care using the least restrictive interventions while respecting patient rights, safety and dignity. Providing a safe environment and preventing injury are essential to obtaining desired outcomes. Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members or others. Restraint and seclusion are used only with appropriate and adequate clinical justification when less restrictive interventions are ineffective and the least restrictive means of restraint or seclusion to ensure safety is applied. It is not used as a means of coercion, discipline, convenience, or staff retaliation."

B. Record review of facility policy titled, "Use of Restraint and Seclusion for Management of Violent or Self-Destructive Behavior" dated 10/05/2020, confirms, in Section Titled, "Staff Training:
b.All staff providing restraint or seclusion emergency interventions must have ongoing education, training and be able to demonstrate knowledge of managing emergency safety situations through training exercises designed to test their competencies in:
i.Techniques to identify staff and patient behaviors, events and environmental factors that may trigger emergency safety situations necessitating the use of restraint or seclusion.
ii.The use of non-physical intervention skills such as de-escalation, mediation, conflict resolution, active listening, and verbal and observational methods to prevent emergency safety situations.
iii.Choosing the least restrictive intervention based on an individualized assessment of the patient's medical and behavioral status or condition.

Patient 6 Findings:
C. On 07/21/22 at 10:00 am during observation of video 1 from 07/04/22 at 9:45 am through 10:07 am of P6 confirmed, "P#6 seen in the hallway pushing outside door, 2 staff watching patient pace and push the door, patient stops and looks outside. 9:48 am patient at the door pushing door, 2 staff approach and restrain patient (1 staff on each arm) and take patient to seclusion from 9:49 am to 10:07 am. [No attempt at re-direction noted when viewing this video]

D. On 07/21/22 at 11:25 am during observation of video 2 from 05/17/22 at 9:39 am through 10:26 am of P6 confirmed, "9:39 am, Patient seen in hall area with peer and 3 staff. Patient hits the door, sat down at the end of the hall, gets up and kicks the door X 4 [appears to try to open door]. 9:41 am, Three staff respond and restrain patient (1 staff on each arm) ant take him to seclusion at 9:43 am to 10:25 am. . [No attempt at re-direction noted when viewing this video]

E. On 07/22/22 at 10:02 am during observation of video 3 from 07/15/22 at 12:05 pm through 12:34 pm of P6 confirmed, "At 12:15 pm patient seen in hallway and appears calm, joined by 1 staff and they are talking. Patient raises his hand to staff and is restrained and dragged/carried to the common room. Patient struggles in the restraint (1 staff restraining patient by using patient arms crossed in front facing away from staff). Restrained patient is held standing then sitting on the couch then standing, appears to break the restraint but staff was able to regain the restraint hold. Restraint continues from 12:15 pm to 12:18 pm when patient is transferred to seclusion until 12:34 pm. . [No attempt at re-direction noted when viewing this video]

Patient 1 Findings:
F. On 07/22/22 at 1:42 pm during observation of facility video footage for 03/08/22 starting at 9:50 am, shows P1 sitting on the couch next to a staff member with an ipad watching videos, there are 3 other staff present, patient attempts to take the ipad from the staff and is immediately restrained and removed to his living quarters, he comes back out to common room, staff tries to stop him from going back down the hall, he fights back, is restrained and taken to seclusion at 9:59 am. At 10:13 am P1 is released from seclusion and returned to the common area, P1 seen pacing, dancing, and twirling and interacting with staff, P1 pulls at staff mask and is restrained and returned to seclusion at 10:42 am. At 11:20 am P1 is released from seclusion. He is returned to the common area, continues to pace, twirl, and interact with staff. P1 attempts to go to his living quarters bypassing staff who attempts to restrain him, he crawls away from staff, P1 is pacing the hallway and gets restrained by 3 staff and is returned to seclusion at 11:38 am. At 11:53 P1 is released and returned to the common area where he is again twirling, pacing, and interacting with staff. He attempts to enter the room where other residents are sitting, is restrained again, and returned to seclusion at 11:58 am. At 12:44 pm P1 is released from seclusion and returned to the common area and continues pacing, twirling, and interacting with staff. . [No attempt at re-direction noted when viewing this video]

G. On 07/22/22 at 1:00 pm during observation of facility video footage for 03/17/22 starting at 8:09 am, shows P1 in the main area of the treatment cottage, he is seen pacing around and takes something off the housekeeping cart, gets very close to staff face and continues pacing up and down the hall, he is led to his living quarters where he enters and is unseen, he returns to the common area and tips over the coffee table at 8:09 am and is restrained by 3 staff and taken to seclusion in the BICU (Behavioral Intensive Care Unit) at 8:23 am patient is released from seclusion and escorted back to his living quarters.

Patient 3 Findings:
H. On 07/22/22 at 2:00 pm during observation of facility video footage for 03/10/22 starting at 5:56 am, shows P3 laying on the couch in common area of the BICU, staff sitting at nursing station, at 5:59 am P3 gets up off the couch, walks over to the nursing station, jumps up and looks over the plastic divider, goes back to the couch and lays back down. Three staff enter the common room at 6:00 am, ask patient to stand, restrain patient and he is led to his living quarters and secluded until 6:07 am when he is released and returns to laying on the couch. . [No attempt at re-direction noted when viewing this video]


I. On 07/20/22 at 2:20 pm during interview with S(Staff)13 (Psychiatrist) confirmed, "If he [P3] is screaming, banging head, second line medication is administered. 3rd line is maximum, and we use treatment de-escalation plan for safety for him and staff."

J.On 07/22/22 at 10:30 am during interview with S23 (Register Nurse) who confirmed, "Restraint and seclusion process is only when the child is a danger to themselves or others. S23 states that nonphysical intervention skills include verbal de-escalation, diverting attention, those are usually successful."

K.On 07/22/22 at 11:00 am during interview with S24 (Mental Health Tech) who confirmed, "[in reference to restraint/seclusion] the patients have to be a risk to self or others to be restrained or secluded, restraints are usually pretty quick, nothing lasts longer than a minute. Nonphysical intervention skills include redirection, flexibility with limit setting, stuff like that. Signs of physical distress include breathing and trauma during a restraint. S24 stated, "there's been no instances that he has seen where restraint wasn't necessary."

L.On 07/22/22 at 12:50 pm during interview with S22 (RN traveler) who confirmed, "Restraints and seclusion should only be done when there is risk of the child being injured from themselves or others. She states that she has not seen an instance where restraint wasn't necessary."

Based on record review and interview, the facility failed to obtain an order prior to initiation of restraint or seclusion from a Physician or Licensed Practitioner for 4 (P1, P7, P8, P9) of 10 (P1-10) patients reviewed. This deficient practice may lead to a violation of patients' rights by being restrained or secluded without a physician ordering.

The findings are:

A. Record review of facility policy titled, "Use of Restraint or Seclusion for Management of Violent or Self-Destructive Behavior" effective on 10/05/2020 states in section 2.c.ix.1.a, "Contact the Attending Physician or LIP (Licensed Independent Practitioner) regarding the patient's condition within 15 minutes of the initiation of restraint or seclusion". b. "Request a time limited order for restraint or seclusion". i. This order must be received within one hour of the initiation of restraint or seclusion ...".

B. Record review of "BH RN Inpt [Behavioral Health Registered Nurse Inpatient] Child Progress Note Form" dated 05/30/2022 for P(patient)1 states, "placed patient in physical hold at 10:10. Maintained until 10:14. Patient in a physical restraint again at 10:16. Hold continued until 10:18. Patient placed in hold at 10:20. Hold maintained until 10:35. Patient given second line PRN (as needed) at 10:36. Debrief completed. Patient calm. Doctor notified"

C. Record review of "Flowsheet Print Request Date Range: 06/27/2022 20:00 (8 pm) - 06/27/20222 02:00 (2 pm)" for P7, document referred to as 'I-View Debrief', states on page 5 "Provider Consulted Date/Time 06/27/2022 21:35 (9:35 pm)" on page 13 "Provider Consulted Date/Time 06/27/2022 21:32 (9:32 pm)". Record review of "Support Team Seclusion and Restraint Log" shows that P7 was in a restraint on 06/27/2022 from 21:31 (9:31 pm) to 21:35 (9:35pm) and in seclusion from 21:35 (9:35 pm) to 21:49 (9:49 pm). Both times that the provider was consulted are beyond the start times of the restraint and seclusion.

D. Record review of "BH RN Inpt Child Progress Note Form" dated 06/29/2022 at 4:52 am for P8 states, "Patient was taken to seclusion and did require a restraint". Record review of "Support Team Seclusion and Restraint Log" shows that P8 was in a restraint and seclusion on 06/27/2022 from 19:16 (7:16 pm) to 19:30 (7:30 pm). Record review of "Orders" for P8 shows an order obtained for restraint at 06/28/2022 at 19:16 (7:16 pm) and no order for seclusion obtained.

E. Record review of "Flowsheet Print Request Date Range: 07/18/2022 15:30 (3:30 pm) - 07/18/20222 18:00 (6pm)" for P9, document referred to as 'I-View Debrief', states on page 16 "Provider Consulted Date/Time 07/18/2022 16:20 (4:20 pm)". Record review of "Support Team Seclusion and Restraint Log" shows that P9 was in a restraint on 07/18/2022 from 16:14 (4:14 pm) to 16:16 (4:16 pm) and in seclusion from 16:16 (4:16 pm) to 16:32 (4:32 pm). The provider was consulted beyond the start times of the restraint and seclusion.

F. In an interview on 07/21/2022 at 2:00 pm with Staff S5, Executive Director of Behavioral Health, when asked to explain the process of obtaining an order for restraint or seclusion stated, "When the event is occurring the nurse will delegate to another nurse to call the doctor." When asked if they receive an order before the restraint or seclusion begins, S5 stated, "No, I wish we could". When asked if the facility has ever received an order prior to a restraint or seclusion S5 stated "No".

Based on record review and interview, the facility failed to have a Registered Nurse (RN) who was trained in CPI (Crisis Prevention and Intervention Training), to perform the 1 hour face-to-face assessment after a restraint for 1 (P6) of 10 (P1-10) patient's reviewed. This deficient practice could lead to not conducting a focused assessment and missing a potentially serious medical or psychological need of the patient.

The findings are:

A. Record review of facility policy titled, "Use of Restraint or Seclusion for Management of Violent or Self-Destructive Behavior" effective on 10/05/2020 states in section 5. a "All staff providing restraint or seclusion emergency interventions must receive training by qualified individuals and demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion." 5.a.i "Before the first time they perform any intervention involving restraint or seclusion." 5.g "RN's who provide first hour face-to-face assessments receive the training outlined in (a) through (c) above, during orientation, as well as training in:" 5.g.i "Comprehensive review of patient's condition to include the effects of laboratory data, medication interactions, medical conditions effects on behavior and impulse control and other factors that influence overall patient condition."

B. In an interview on 7-21-2022 at 2:00 pm with Staff S5, Executive Director of Behavioral Health, when asked why the facility is switching from CPI (Crisis Prevention Institute) to MOAB (Management of Aggressive Behavior) S5 stated "MOAB is used in other the departments of the hospital. We wanted to make it all one program. MOAB training started on May 1st and we will start using it on October 1st." If one staff is trained in CPI and one in MOAB, how does that work? S5 stated "CPI is the active program right now". So are there staff on the floor that are not CPI trained right now? S5 stated, "Correct, the MOAB trained people do not have CPI training and are working."

C. Record review of S22, Traveler RN, who has been working at facility since 06/27/2022, completed trainings provided by facility shows that training in CPI (Crisis Prevention Institute) has not been completed.

D. In an interview on 7/22/2022 at 12:50 pm with S22, Traveler RN, when asked about being trained in CPI, states "I have not been 'hands on' with any restraint or seclusion, I'm usually assigned to the smaller kids". When asked if she monitors kids while in restraints she states, "Yes, I do monitor them." When asked about how many restraints and or seclusions she has been involved with, she states, "About 7 incidents". When asked if all those restraints and seclusions were while not being trained in CPI she states "Yes, I wasn't trained in CPI yet, I'm taking the training today". This nurse has been working at the facility since 06/27/2022.

E. Record review of P6 "Flowsheet Print Request Date Range: 07/15/2022 08:00 (8am)- 07/15/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows the nurse that documented and conducted the face-to face assessment after 2 separate restraints on 07/15/2022 was S22, Traveler RN.

F. Record review of other Traveler RN Personnel Training shows that there are 3 other Traveler RN's not trained in CPI. Record Review of Regular Staff Personnel Training shows that 35 other staff are not currently trained in CPI.

Based on record review and interview the facility failed to have 8 (P2-P9) patients out of 10 (P1-P10) patients reviewed to be evaluated one hour after an intervention for the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and need to continue restraint or seclusion. The deficient practice may lead to improper coordination of care which could result in patient harm.

The findings are:

A. Record review of P2 "Flowsheet Print Request Date Range: 03/20/2022 04:00 (4 am) - 03/20/2022 19:00 (7pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems (list of questions, arranged by organ system, designed to uncover dysfunction and disease within that area), the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed at the beginning of a restraint, during the restraint and during the seclusion and not completed 1 hour after the initiation of the intervention.

B. Record review of P3 "Flowsheet Print Request Date Range: 07/13/2022 12:00 (12 pm)- 07/13/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed at the beginning of both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

C. Record review of P4 "Flowsheet Print Request Date Range: 07/17/2022 07:00 (7 am) - 07/17/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during a restraint and no assessment completed 1 hour after the initiation of the intervention

D. Record review of P5 "Flowsheet Print Request Date Range: 07/04/2022 07:00 (7 am) - 07/04/2022 11:00 (11 am)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

E. Record review of P6 "Flowsheet Print Request Date Range: 07/15/2022 08:00 (8 am) - 07/15/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

F. Record review of P7 "Flowsheet Print Request Date Range: 06/27/2022 20:00 (8 pm) - 06/28/2022 02:00 (2 am)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during both documented restraints and no assessment completed 1 hour after the initiation of the intervention.

G. Record review of P8 "Flowsheet Print Request Date Range: 06/28/2022 19:00 (7 pm) - 06/29/2022 11:00 (11 am)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during a documented restraint and no assessment completed 1 hour after the initiation of the intervention.

H. Record review of P9 "Flowsheet Print Request Date Range: 07/18/2022 15:30 (3:30 pm) - 07/18/2022 18:00 (6 pm)", document referred to as 'I-View Debrief', shows that a F2F (Face to Face) assessment does not contain information such as the patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care. It also shows that the current F2F assessment was completed during a documented restraint and no assessment completed 1 hour after the initiation of the intervention.

I. In an interview on 07/22/2022 at 10 am with Staff S10, Registered Nurse Psych Inpatient, Interim Base Educator, confirmed that the debrief is a 6-question post assessment, that should be done within one hour, but is usually done immediately. S10 also confirmed that the face-to-face is documented in the I-View Debrief and it does not contain patient's history, a complete review of systems, the patient reaction to the intervention or the recommended changes to the patient plan of care.

Based on record review and interview the facility failed to maintain that staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion for 7 (S22, S25, S26, S27, S28, S29, S30) of 44 (P1 - P44) staff training records reviewed. This failed practice can lead to untrained staff performing restraint and seclusion and can lead to patient harm.

The findings are:

A. Record review of facility list of "Travel Nurses and Mental Health Tech Trainings" not dated, confirms:
1. There are (2) travel nurses S(staff)22 date of hire 06/27/22 and S25 date of hire 06/27/22 who are working the floor and have no CPI (Crisis Prevention Institute) or MOAB (Management of Aggressive Behavior) training completed.
2. There are (2) travel Mental Health Technicians S26 date of hire 07/18/22 and S27 date of hire 07/18/22 who are working the floor and have no CPI or MOAB training completed.

B. Record review of facility "Daily Staff Schedule" dated 07/21/22 with training dates for MOAB and CPI filled in for each staff member by S10 (Registered Nurse) confirms:
1. S28 date of hire 11/05/01 has been working the floor and has expired CPI and no MOAB training.
2. S29 date of hire 07/01/00 has been working the floor and has expired CPI and no MOAB training.
3. S30 date of hire 05/24/21 has been working the floor and has expired CPI and no MOAB training.

C. Record review of facility policy titled, "Use of Restraint and Seclusion for Management of Violent or Self-Destructive Behavior" dated 10/05/2020, confirms, in Section Titled, "Staff Training:
a. All staff providing restraint or seclusion emergency interventions must receive training by qualified individuals and demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion.
i. Before the first time they perform any intervention involving restraint or seclusion,
ii. As part of orientation
iii. On an annual basis thereafter
b. All staff providing restraint or seclusion emergency interventions must have ongoing education, training and be able to demonstrate knowledge of managing emergency safety situations through training exercises designed to test their competencies in:
i. Techniques to identify staff and patient behaviors, events and environmental factors that may trigger emergency safety situations necessitating the use of restraint or seclusion.
ii. The use of non-physical intervention skills such as de-escalation, mediation, conflict resolution, active listening, and verbal and observational methods to prevent emergency safety situations.
iii. Choosing the least restrictive intervention based on an individualized assessment of the patient's medical and behavioral status or condition.

D. On 07/22/2022 at 10:20 am during interview with S23 (Mental Health Tech) who confirmed, "I have worked here since June 20th, and is a traveler from Seattle. S23 states "I had "minimal training" which consisted of two days of orientation at (Facility Name) and two days on the floor at (Facility Name)."

E. On 07/22/22 at 12:50 pm during interview with S22 (Registered Nurse Traveler) who confirmed, "I am currently signed up today for the CPI class. She states that she has not been hands on with any restraint or seclusion. [in reference to how many incidents she has been involved in] "about seven incidents" and confirms that these incidents while not being CPI trained.

F. On 07/21/22 at 2:00 pm during interview with S5 (Executive Director) and S10 (Registered Nurse, Interim Unit-Based Educator) who confirmed, "The facility is in the process of changing from CPI to MOAB Training, the difference is: 1 year certification for CPI, MOAB is 2 years with skills drills every week, CPI is the active program right now. [Question] There are staff on the floor that are not CPI trained right now? S5 confirmed, "Correct, the MOAB trained people do not have CPI training and are working." [Question] A traveler can be on the floor and potentially be involved in a restraint and not be trained? S10 confirmed, "It could happen." S10 further confirmed, "Travel nurses receive training that includes hospital orientation, charting, seclusion/ restraint, online module about Policy and Procedure, Self-paced, I sign them off on skills. 12-hour training on restraint/seclusion and 1.5 for application of seclusion and restraints.

Based on observation and interview the facility failed to have an outside window in 1 (Behavioral Intensive Care Unit (BICU) of 3 buildings observed. This deficient practice may result in loss of time for the patient which could lead to increased depression or a disturbance in sleep-wake cycle.

The findings are:

A. During on observation on 07/22/2022 at approximately 10:00 am while visiting P(Patient)1 in the BICU area, it was observed that in the bedroom and the day room there was no outside window.

B. In an interview on 07/22/2022 at approximately 2:00 pm with S(Staff)5, Executive Director of Behavioral Health, when asked about a window to see out in the BICU room confirmed that the facility was not aware that there had to be a window in the room.