HospitalInspections.org

Based on observation, review of medical records, staff interview, and review of facility documents, it was determined that the facility failed to ensure that safety standards for patients at risk for harm to self and others, are implemented in accordance with facility policies and procedures.

Findings include:

1. The facility failed to ensure that adequate supervision is provided to ensure patient safety and well-being during one-to-one (1:1) care in adherence with facility policy. (Cross refer to Tag 144-A)

2. The facility failed to ensure that ligature risks are mitigated in the Crisis Area of the Emergency Department (ED) and on the Inpatient Psychiatric Unit (2B). (Cross refer to Tag 144-B, C, and D)

Based on one (1) of one (1) medical record review, staff interview, and review of facility policies, it was determined that the facility failed to ensure that patients with limited English proficiency receive a translator or interpreter services.

Findings include:

Reference #1: Facility policy titled, "Patient Rights and Responsibilities" states, "... The patient has the right to receive, as soon as possible, the services of a translator or interpreter if they need one to help the patient communicate with hospital personnel."

Reference #2: Facility policy titled, "Stratus Video and Audio Language Service" states, "... Policy... In order to protect the patient's rights to confidentiality and ensure accurate interpretation of information family members and non-certified interpreters should not be used for interpretation. ... Procedure ... Upon intake, the admitting nurse or outpatient health care provider identifies the patient's oral and written communication needs including the patient's preferred language preference. ... If the patient demonstrates limited English proficiency the hospital will utilize Stratus Video Services Associates to establish effective patient communications. ... Documentation ... Document Interrupter [sic] name and ID number in the electronic medical record, in flow sheets, cares and safety, select, interpreter services."

1. Review of Medical Record #12 on 2/4/21 at 11:30 AM, revealed the following:

a. The patient arrived in the Emergency Department (ED) on 1/31/21 at 10:12 PM, with complaints of lethargy and low oxygen levels at home. The patient was admitted to 5 West on 2/1/21 at 5:06 AM.

b. In the registration documents, the "Demographics" section of the medical record stated, "Interpreter needed? Yes: Preferred language: Polish."

c. Nurse's notes dated 2/2/21 at 11:35 PM stated, "Patient alert with confusion, very unsteady gait, refusing to get back to bed after using the bathroom. ... [the patient] pulled out IV lines, oxygen tubing, with continued attempts to get out of bed... Multiple attempts to reorient and reduce stimuli along with staff sitting next to pt [patient] for more than 1 hour however pt [patient] continued to be noncompliant. ... nonviolent soft wrist restraints initiated."

(i) There was no evidence that the nurse utilized Stratus video and audio language services in an attempt to reorient the patient or to communicate with the patient why he/she was being restrained.

d. Nurse's notes dated 2/3/21 at 9:15 PM stated, "Patient was restless and anxious. Continuous attempts to get out of bed as a high risk for falls. Continuous attempts to pull nasal cannula and IV. Educated patient on importance of bedrest and safety precautions to prevent a fall. Patient is confused, no evidence of learning or understanding. ... ."

(i) There was no evidence that the nurse utilized Stratus video and audio language services in an attempt to reorient the patient or when he/she was educating the patient.

e. On the nursing flowsheet, in the section marked "Interpreter Services," for the question, "Is an interpreter needed/used?" The nurse documented "No" on the following dates and times: 2/1/21 at 7:30 PM, 2/2/21 at 8:00 AM, 2/2/21 at 8:00 PM, 2/3/21 at 8:20 AM, 2/3/21 at 8:00 PM, and 2/3/21 at 10:47 PM.

2. The above findings were confirmed with Staff #1 on 2/5/21 at 3:00 PM.

A. Based on one (1) of one (1) observation of the bathroom located near the "P" Rooms (Psychiatric Rooms) of the Emergency Department (ED), staff interview, and review of facility policy and documents, it was determined that the facility failed to ensure that caregivers remain within arm's reach of the patient at all times.

Findings include:

Reference #1: Facility policy titled, "Close Observation - Patient Who Requires a 1:1 Attendant" states, "A ratio of one caregiver to one patient shall always be maintained for suicidal patient monitoring. The caregiver must remain within arm's reach of the patient at all times, including bathroom... In circumstances where there is a question of privacy versus safety, safety of the patient on 1:1 always takes precedence over privacy. Therefore, 1:1 sitter is maintained when the patient is sleeping, showering, or using the toilet."

Reference #2: Facility document titled, "Risk Assessment - Summary" states, "Assessment Process: A comprehensive, room-by-room ligature risk assessment was conducted on 2B and the P Rooms in the ED (Emergency Department) during September 2019... Identified Risks: ...3. Bathroom in Emergency Department Psychiatric Area is shared with Main ED. ... Proposed Actions (with responsibility) ... 3. Suicidal Patients using ED bathroom are accompanied."

1. On 2/3/21 at 11:05 AM, during a tour of the "P Rooms" in the ED, Staff #1 and Staff #2 indicated that an adjacent bathroom was used by psychiatric patients, including suicidal patients.

a. Observation of the bathroom revealed safety concerns for at risk patients that included: a glass mirror; there was no cover over the pipes located under the sink (ligature risk); a wall mounted soap dispenser, toilet paper holder, and a toilet seat cover dispenser (which can be torn from the wall and used as a weapon).

b. Upon interview at 11:20 AM, Staff #2 stated that ligature and safety risks, present in the bathroom, are mitigated by placing patients on one-to-one (1:1) observation. Staff #2 confirmed that a 1:1 sitter accompanies the patient to the bathroom, stands in the doorway, does not allow the door to close, and maintains continuous observation at all times.

c. Upon interview at 11:40 AM, Staff #3 revealed that during 1:1 observation of a suicidal patient, he/she would accompany the patient to the bathroom and "close the door for privacy." Staff #3 stated that he/she would first check the bathroom before the patient entered and stated, "the door is not locked so it's okay."

On 2/3/21 at 2:55 PM, Staff #1 was notified that the above finding resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to facility staff at 3:07 PM. An acceptable IJ removal plan was received from the facility on 2/4/21 at 3:16 PM.

On February 23, 2021, an offsite IJ removal visit was conducted to assess implementation of the facility's IJ Removal Plan. The following documents were reviewed: signed safety education documents by staff, review of staff education, and photographs of a newly installed safety telephone and two ligature-safe television cases. The facility was found to be in compliance with the Removal Plan, and the IJ was removed.

B. Based on two (2) of four (4) observations of inpatient areas on the psychiatric unit, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that cords present on the inpatient psychiatric unit are less than twelve (12) inches and too short to wrap around the neck.

Findings Include:

Reference: Facility document titled, "Risk Assessment - Summary" states, "A comprehensive room-by-room ligature risk assessment was conducted of 2B ...during September 2019... 13. ...Cords should be too short to use to wrap around a neck and hang from any securing point (maximum of 12 inches). 34. ...If cords are present, they should be 12 inches or less."

1. On 2/3/21 at 12:01 PM, during a tour of the inpatient psychiatric unit "2B," the following was observed:

a. In the Staff Interview Room-Conference Room, a telephone was in the center of the conference table. The telephone cord could stretch well beyond 12 inches and was connected to the wall with a cord longer than 12 inches.

(i) A wall-mounted telephone was observed with a plastic coiled cord longer than 12 inches.

(ii) There were computer cords present in connection with two desktop computers with a plug that extended longer than 12 inches. The Staff Interview Room-Conference Room door was locked with no patients present.

(iii) Upon interview, Staff #2 indicated that patients utilize the room with staff members for physician interviews. Staff #1 and Staff #2 stated there were no safety concerns with patients using the room because staff members were "always with the patient."

b. In the hallway at the nurse's station, a telephone with a plastic coiled cord that could stretch longer than 12 inches, was on the counter and within reach of patients ambulating in the hallway.

(i) Upon interview at 12:30 AM, Staff #11 confirmed that the phone is left on the counter from 8:00 AM-10:00 PM for patient use but is removed during group activities.

On 2/3/21 at 2:55 PM, Staff #1 was notified that the above finding resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to facility staff at 3:07 PM. An acceptable IJ removal plan was received from the facility on 2/4/21 at 3:16 PM.

On February 23, 2021, an offsite IJ removal visit was conducted to assess the implementation of the facility's IJ Removal Plan. The following documents were reviewed: signed safety education documents by staff, review of staff education, and photographs of a newly installed safety telephone and two ligature-safe television cases. The facility was found to be in compliance with the Removal Plan, and the IJ was removed.

C. Based on two (2) of four (4) random observations of inpatient areas on the psychiatric unit, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that televisions mounted to the wall are secured in a manner that prevents removal and use as a weapon and prevents use as an anchor for hanging.

Findings Include:

Reference: Facility document titled, "Risk Assessment - Summary" states, "A comprehensive room-by-room ligature risk assessment was conducted of 2B ... during September 2019... 12. ... All items must be secured to the wall in a manner that presents removal or use as a weapon or for self-harm. It must be flush with the wall or beveled in a manner so that it cannot be used as an anchor for hanging."

1. On 2/3/21 at 12:01 PM, during a tour of the inpatient psychiatric unit "2B," the following was observed:

a. In the Dining Room, the television was not placed in a case flush against the wall; it was mounted in a way that posed a ligature risk and could be used to harm someone if pulled off the wall and used as a weapon.

(i) Upon interview, Staff #9 indicated that the room was no longer used as a patient dining area but that patients use the room to "spread out and watch TV." Staff #9 stated there were no safety concerns because there were "always two staff members present" when the room was used by patients.

b. In the Day Room/Solarium, the television was not placed in a case flush against the wall; it was mounted in a way that posed a ligature risk and could be used to harm someone if pulled off the wall and used as a weapon.

(i) Staff #1 and Staff #2 stated there were no safety risks as staff members were always present with the patients.

On 2/3/21 at 2:55 PM, Staff #1 was notified that the above finding resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to facility staff at 3:07 PM. An acceptable IJ removal plan was received from the facility on 2/4/21 at 3:16 PM.

On February 23, 2021, an offsite IJ removal visit was conducted to assess the implementation of the facility's IJ Removal Plan. The following documents were reviewed: staff signed safety education documents, review of staff education, and photographs of a newly installed safety telephone, and two ligature-safe television cases. The facility was found to be in compliance with the Removal Plan, and the IJ was removed.

D. Based on two (2) of three (3) observations of trash cans on the inpatient psychiatric unit, staff interview, and review of facility documents, it was determined that the facility failed to ensure that paper liners are used to line trash cans.

Findings include:

Reference: Facility document titled, "Risk Assessment - Summary" states, "A comprehensive room-by-room ligature risk assessment was conducted of 2B ...during September 2019... 34. ...The trash cans should be lined with paper liners."

1. On 2/3/21 at 12:01 PM, during a tour of the inpatient psychiatric unit "2B", the following was observed:

a. In the Staff Interview Room-Conference Room, a plastic liner was in the trash can.

(i) At 12:05 PM, Staff #2 indicated that patients utilize the room with staff members for physician interviews, and that there were no safety concerns because "the door is locked and there is always someone here with the patient."

b. In the Dining Room, a plastic liner was in the trash can.

(i) At 12:14 PM, Staff #2 indicated that there were no safety concerns because "there is always a staff member in here with the patients."

On 2/3/21 at 2:55 PM, Staff #1 was notified that the above finding resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 3:07 PM. An acceptable IJ removal plan was received from the facility on 2/4/21 at 3:16 PM.

On February 23, 2021, an offsite IJ removal visit was conducted to assess the implementation of the facility's IJ Removal Plan. The following documents were reviewed: signed safety education documents by staff, review of staff education, and photographs of a newly installed safety telephone and two ligature-safe television cases. The facility was found to be in compliance with the Removal Plan, and the IJ was removed.

E. Based on review of one (1) of two (2) medical records (Medical Record #2), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that a 1:1 Patient Observer is provided for an involuntarily committed patient waiting for a psychiatric bed in the Emergency Department (ED).

Findings include:

Reference: Facility policy titled, "Close Observation Patient Who Requires a 1:1 Attendant" states, " ... Purpose: To provide protection when a patient's behavior represents a danger to themselves or others. ... Procedure with Responsibility: 1. 1:1 Patient Attendant is used for the following: Patient waiting for a mental health screening to determine whether they are a danger to self, others, or property. Patients who are deemed committable for inpatient psychiatric care waiting for a bed due to dangerousness to self, others, or property."

1. On 2/4/21 at 2:30 PM, review of Medical Record #2 revealed the following:

a. On 1/3/21 at 7:25 PM, Patient #2 arrived in the ED with Police and EMS (Emergency Medical Services) for psychiatric evaluation. The Police had been called by the patient's parents after a reported physical altercation initiated by the patient.

(i) At 9:20 PM, Staff #18, a Psychiatric Case Manager, documented in the "Crisis Notes" that the patient would be screened for inpatient admission. The patient remained in the ED overnight awaiting a mental health screening examination.

(ii) On 1/4/21 at 10:50 AM, Staff #19, a Case Manager, documented in the Crisis Notes that the Patient had received a mental health screening exam and the patient had been "deemed involuntarily committed."

(iii) Staff #19 documented that after informing the patient he/she was deemed involuntarily committed, the patient became "angry and upset" and eloped from the ED. A Code BERT (Behavioral Emergency Response Team) was initiated and the [name] Police Department was notified.

(iv) At 12:15 PM, Staff #19 documented that the [name] Police Department brought the patient back to the hospital.

(v) At 3:45 PM, Staff #20, a Registered Nurse (RN), documented in the "ED Notes" that the patient was becoming "verbally aggressive" and "once again ran out of ED."

b. On 1/26/21 at 2:12 PM, Staff #7, the ED Director, confirmed the following:

(i) There was no order for a 1:1 Patient Attendant, or documentation of a 1:1 present at the bedside, prior to the patient's elopement while he/she was waiting for a Mental Health Screening Exam.

(ii) There was no order for a 1:1 Patient Attendant, or documentation of a 1:1 present at the bedside, after the patient returned to the ED, was deemed committable, and was waiting for an inpatient psychiatric bed.

2. The above findings were confirmed with Staff #1 on 2/5/21 at 3:00 PM.

F. Based on review of two (2) of eleven (11) medical records (Medical Record #4 and Medical Record #5), staff interview, and review of facility policy, it was determined that the facility failed to ensure that patients in the ED, who are at risk for elopement, are assigned a 1:1 patient attendant.

Findings include:

Reference: Facility policy titled, "Close Observation Patient Who Requires a 1:1 Attendant" states, " ...Purpose: To provide protection when a patient's behavior represents a danger to themselves or others. ...Procedure with Responsibility: 2. Suicide Precautions ... In addition to a patient being placed on a 1:1 who is at risk for harm to self or others, a patient who is seemed a risk for elopement may also be placed on a 1:1."

1. On 2/4/21 at 11:44 AM, a review of Medical Record #5 revealed the following:

a. On 8/6/20 at 5:59 PM, Patient #5 arrived in the ED for a psychiatric evaluation, following a 911 call from a family member, stating that the patient was suicidal.

(i) At 7:15 PM, Staff #26, an ED RN, documented that the patient was "acting erratic, yelling at security and nurses" and that at 8:34 PM, the "patient was found trying to elope."

(ii) At 8:52 PM, Staff #26 documented that the patient eloped down a flight of stairs in the ED.

b. At 2/4/21 at 11:52 AM, Staff #20 confirmed the medical record lacked documentation that a 1:1 Patient Attendant was assigned to the patient.

2. On 2/4/21 at 11:57 AM, a review of Medical Record #4 revealed the following:

a. On 7/13/20 at 12:42 AM, Patient #4 arrived in the ED after his/her mother called 911 following a physical altercation.

(i) At 2:25 AM, Staff #27, an ED Physician, documented that the patient was medically stable for a crisis evaluation.

(ii) At 2:54 AM, Staff #27 documented that the patient was agitated, saying he/she had to leave to go to work, and that security escorted the patient back to Room #P3, in the crisis area of the ED.

(iii) At 3:36 AM, Staff #27 documented that the "patient left prior to evaluation by crisis counselor."

b. On 2/4/21 at 12:10 PM, Staff #20 confirmed the medical record lacked documentation that a 1:1 Patient Attendant was assigned to the patient.

3. Upon interview on 2/5/21 at 9:49 AM, Staff #1 stated, "Any patient brought in for SI (suicidal ideation), HI (homicidal ideation) or is an elopement risk, is automatically placed on a 1:1 by the first nurse encountering the patient. The nurse or other staff must stay with the patient until the sitter arrives. The 1:1 stays until the physician decides the patient no longer needs it. Elopements can be patients with a history of elopement, or they come in unwilling to stay and saying they are going to leave."

4. On 2/5/21 the above findings were confirmed by Staff #1 at 3:00 PM.

G. Based on review of two (2) of eleven (11) medical records (Medical Record #2 and Medical Record #5), staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that a Columbia Suicide Risk Assessment was immediately completed.

Findings include:

Reference: Facility Policy titled, "Suicide/Homicide Risk Assessment" states, " A Suicidal/Homicidal risk assessment will be completed when any Emergency Department (ED) patient expresses suicidal or homicidal ideation by identifying individuals at risk for attempting suicide; determining if urgent treatment is indicated and providing the appropriate intervention immediately including prevention of the patient from leaving the ED. ... Procedure ... F. The ED nurse should complete an assessment of the suicidal/homicidal patient immediately using the Columbia Suicide Risk Assessment (Attachment A)."

1. On 2/4/21 at 11:44 AM, a review of Medical Record #5 revealed the following:

a. On 8/6/20 at 5:59 PM, Patient #5 arrived in the ED for a psychiatric evaluation following a 911 call from a family member stating that the patient was suicidal.

(i) Staff #28, an ED physician, documented in the ED Provider Notes that the patient reported a suicide attempt several months ago by medication overdose.

(ii) At 8:15 PM, Staff #29, a Crisis Counselor, documented notifying Staff #30, a psychiatrist, that the patient had a BAL (Blood alcohol level) of 177, and that the patient "has a history of vague suicidal ideation and was handling a knife today." Staff #29 documented that Staff #30 wanted the patient to remain overnight in the ED to be evaluated in the morning.

(iii) At 8:21 PM, Staff #28 documented in the "ED Course" that the patient would receive a "Psych (psychiatric) Eval (evaluation) in AM."

(iv) At 8:52 PM, Staff #26 documented that the patient eloped down a flight of stairs in the ED.

b. On 2/4/21 at 11:53 AM, Staff #20 confirmed that the medical record lacked documentation of a Columbia Suicide Risk Assessment.

2. On 2/4/21 at 2:30 PM, a review of Medical Record #2 revealed the following:

a. On 1/3/21 at 7:25 PM, Patient #2 arrived in the ED with Police and EMS (Emergency Medical Services) for psychiatric evaluation following a physical assault on his/her father, and was triaged by Staff #33, an ED RN.

(i) At 1:17 AM, an initial Columbia Suicide Risk Assessment was completed by Staff #33, 5 hours and 52 minutes after the patient was triaged.

3. During interview on 2/5/21 at 9:49 AM, Staff #1 stated, "the first nurse to encounter the patient should do the Columbia Suicide Screening evaluation as part of the triage assessment. Sometimes that may be the triage nurse; or if the patient is brought by ambulance and goes straight to the back, it may be the nurse assigned to the patient."

4. The above findings were confirmed with Staff #1 on 2/5/21 at 3:00 PM.

Based on review of one (1) of three (3) medical records (Medical Record #12), staff interview, and review of facility policy, it was determined that the facility failed to ensure that restraints are initiated in accordance with a physician's order.

Findings include:

Reference: Facility policy titled, "Restraint & Seclusion Use" states, "... 2. Orders for restraint use are obtained prior to initiation of restraints and may only be provided by a physician or LIP. ... i) Restraint orders are obtained as soon as possible after the application of restraint, generally within 15 minutes. ...8. When a restraint is discontinued and behavior requires reapplication, a new order for restraint is required."

1. Review of Medical Record #12, on 2/4/21 at 11:30 AM, revealed the following:

a. The patient arrived in the ED on 1/31/21 at 10:12 PM, with complaints of weakness and lethargy. The patient was admitted to the facility on 2/1/21 at 5:04 AM.

b. The nurse's notes dated 2/2/21 at 11:35 PM stated, "Patient alert with confusion, very unsteady gait, refusing to get back to bed after using the bathroom. ... Once in bed, patient refused to remain in bed with attempts to get herself out, with [his/her] legs hanging over the side rail. [He/She] pulled out IV lines, oxygen tubing, with continued attempts to get out of bed by changing positions to where [his/her] head was at the bottom of the bed. ... Nonviolent soft wrist restraints initiated."

(i) Review of the physician orders indicated that on 2/2/21 at 11:40 PM, an order for non-violent or non-self-destructive restraints was entered.

(ii) Review of the nurse's restraint flowsheet revealed that the patient was in bilateral soft wrist restraints from 2/2/21 at 11:40 PM until 2/3/21 at 6:00 AM, when the restraints were discontinued.

c. The nurse's notes dated 2/3/21 at 9:15 PM stated, "Patient was restless and anxious. Continuous attempts to get out of bed as a high risk for falls. ... Patient is confused... Notified daughter [name of daughter] for need of restraints."

(i) Review of the nurse's restraint flowsheet revealed that the patient was in bilateral soft wrist restraints from 2/3/21 at 9:00 PM until 2/4/21 at 6:00 AM, when the restraints were discontinued.

(ii) Review of physician orders indicated that a second order for non-violent or non-self-destructive restraints was entered on 2/4/21 at 6:34 AM, nine (9) hours and thirty-four (34) minutes after the restraints were initiated and thirty-four (34) minutes after the restraints were discontinued.

2. Staff #1 confirmed the above findings on 2/5/21 at 3:00 PM.

Based on review of one (1) of three (3) Medical Records (Medical Record #15), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that restraint orders for violent or destructive behavior are renewed every four (4) hours.

Findings include:

Reference: Facility policy titled, "Restraints & Seclusion Use" states, "... 2) For Violent/Self Destructive restraint or Seclusion... v) Provider/LIP issues order for time-limited restraint, not to exceed: (1) 4 hours for patients age 18 or older..."

1. Review of Medical Record #15 on 2/5/21 at 10:35 AM, revealed the following:

a. The patient arrived in the ED, on 2/3/21 at 3:10 PM, with complaints of erratic behavior and delusions. Nurse's notes dated 2/3/21 at 3:44 PM stated, "During triage and initial assessment, pt (patient) became agitated and advanced on this writer with fists raised. Code BERT called. ... Pt placed in isolation with door locked as per provider order. 1:1 initiated."

(i) Review of the nursing restraint flowsheet indicated that the patient remained in seclusion from 2/3/21 at 3:45 PM until 2/4/21 at 8:32 AM, when the order for seclusion was discontinued.

b. Review of physician orders indicated that an order for seclusion was entered on 2/3/21 at 3:51 PM. The subsequent renewal order for seclusion was entered at 8:21 PM, four (4) hours and thirty (30) minutes after the previous order was entered.

(i) Review of physician orders indicated that an order for seclusion was entered on 2/4/21 at 12:23 AM. The subsequent renewal order for seclusion was entered at 6:20 AM, five (5) hours and fifty-seven (57) minutes after the previous order was entered.

2. Staff #1 confirmed the above findings on 2/5/21 at 3:00 PM.

Based on one (1) of three (3) Medical Records (Medical Record #15), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that face-to-face evaluations by a licensed independent practitioner (LIP) occur within one (1) hour after the initiation of seclusion for violent or destructive behavior.

Findings include:

Reference: Facility policy titled, "Restraint & Seclusion Use" states, "... iii) The provider/LIP/designee conducts a comprehensive medical/behavioral face-to-face assessment within 1 hour of restraint application... iv) The comprehensive 1 hour face-to-face evaluation includes the following components: (1) An evaluation of the patient's immediate situation; (2) The patient's reaction to the intervention; (3) The patient's medical and behavioral condition; (4) The need to continue or terminate the restraint or seclusion..."

1. Review of Medical Record #15 on 2/5/21 at 10:35 AM, revealed the following:

a. The patient arrived at the ED via EMS on 2/3/21 at 3:10 PM, with complaints of erratic behavior and delusions. The patient was triaged at 3:39 PM and assigned to Room #P1.

b. Nurse's notes dated 2/3/21 at 3:44 PM stated, "During triage and initial assessment, pt (patient) became agitated and advanced on this writer with fists raised. ...Code BERT called. ... Pt placed in isolation with door locked as per provider order. 1:1 initiated."

c. Review of physician's order indicated that an order for seclusion was entered at 3:51 PM.

d. There was no evidence of a face-to-face evaluation performed by an LIP within one (1) hour after the patient was placed in seclusion.

2. Staff #1 confirmed the above finding on 2/5/21 at 3:00 PM.