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Based on review of the medical record for patient #1, review of policies, procedures, and staff education, and staff interviews on 2/10/2016 and 2/26/2016, it was determined that the hospital failed to provide all staff with the required appropriate education and training in regard to the application of restraints, physical holds and seclusion.

Patient #1 was a 15 year old male who was voluntarily admitted for inpatient psychiatric treatment on 01/05/2016. The patient had a history of mood instability, depression and "at risk aggression." The patient was referred by his outpatient psychiatrist for inpatient treatment due to increasing and worsening psychiatric symptoms.

On 1/9/2016 Patient #1 was escorted from the cafeteria. The hospital staff submitted their investigative findings of the event to the Office of Health Care Quality on 1/20/2016. According to the Risk Manager "the patient was in the dining room on 1/9/16 and was told that he needed to eat healthy items before getting ice cream. He ate a few bites of chicken and asked if he could get ice cream. He was told no that he had to eat the chicken and 1 other healthy item and gave him options. He raised his voice complaining and was told if he continued being loud and yelling that he would have to go upstairs to his room. He did eventually eat the chicken and got ice cream. He then began picking pretzels out of the ice cream with his fingers. His peer told him to use a spoon and he began yelling at the peer. He was told by staff it was time to go to his room. While walking out of the dining room he was cursing and then ran back toward staff in a threatening manner. He was being escorted by 2 staff and broke away from those staff members and began yelling and charging towards another staff as if he was going to get physically aggressive. The two staff grabbed him in a 2 person backwards take and took him back to the unit. During this take [the patient] dropped all his weight on them."

The Certified Registered Nurse Practitioner's (CRNP) daily progress note dated 1/9/2016 at 12:20 PM stated, " Problem #1- Mood: Upset after being escorted from dining hall. Met with him in the quiet room where he was angry and yelling but eventually able to calm down" and "Problem #3: Safety: No aggression."

A Mental Health Associate (MHA) documented at 2:06 PM on 1/9/2016 "During lunch he (the patient) began raising his voice because he was told he had to eat more healthy items before he could get ice cream. He did eat enough to get it, but yelled at his peer when he (the peer) told him (the patient) to use a spoon. Then he (the patient) was told to go upstairs, began cursing and running from staff and was escorted to the quiet room."

A Therapy Session (from 2:53 PM until 4:00 PM) note dated 1/9/2016 stated, "Agitation - patient is agitated with having to be escorted from cafeteria." Also documented under Patient/Family Response: "The patient was tearful, crying and escalated as he shared about having to be escorted from the cafeteria." And, "Mom expressed frustration that he (the patient) was escorted and per the patients report he was hurt." In summary, this documentation stated that the patient's mother was "upset that she had not been in contact by anyone from the hospital" to inform her of the restraint event for her son on 1/9/2016 prior to learning about the event from her son.

The hospital's "Review and Revision of Inpatient Treatment Plan" is to be completed daily for each patient. The document reviews teaming notes and notes if the patient had been involved in restraint or seclusion since his last review. The document was completed for Patient #1 on 1/6/2016, 1/7/2016, 1/8/2016 and 1/11/2016. No Review and Revision of Inpatient Treatment Plan for 1/9/2016 was found in the patient's medical record. There was no documentation that the patient required restraint and the record lacked teaming notes in regard to the patient's behavior in the cafeteria that prompted staff to intervene and "escort" him out.

Interviews with the Risk Manager on 2/10/16 at 10:50 AM and with the Director of Patient Care Services on 2/26/16 revealed that the hospital does not consider a "2 person backwards take" as a restraint or physical hold even though staff are placing their hands on the patient. According to both staff members a backwards take is documented as an "escort."

The Risk Manager provided documentation of staff crisis training known as "TIPS." The TIPS training noted "physical intervention" and listed definitions for escorts as being backwards take, basket hold, and upper body escort. Restraints were defined as a passive restraint takedown, two man takedown or supine team takedown.

According to the Restraint and Seclusion policy, last reviewed by the hospital in 9/2015, the Performance Improvement (PI) Committee was to conduct regular reviews of the use of restraint and seclusion to ensure that the usage of these procedures was consistent with the patient's rights as well as the policies governing the use of these procedures. The PI Committee was also to collect data to identify trends to try to decrease the use of the procedures. Because a "backwards take" was not identified by the hospital as being a restraint/hold, no reviews had been completed to track its use or to identify trends, and no incident reports were documented for Patient #1. The Restraint and Seclusion policy also states that physical restraints/basket holds are a "technique by which one or more staff members hold the patient's limbs so that the patient can not hurt himself/herself or others." The policy states the expectations of documentation when a physical restraint is initiated, consisting of the behaviors that led to the physical restraint, starting time, response of the patient and the time the restraint was terminated. These items were not documented in the medical record for Patient #1 for 1/9/2016 event.

The Mental Health Associates (MHA) involved with the backwards take for Patient #1 were interviewed on 2/26/16. MHA #1 stated that he did place his hands on the patient as training for a backwards take indicated for patient and staff safety. With MHA #2, he "then escorted the patient upstairs to the quiet room and closed the door to the room." MHA #1 further stated that he was seated outside the room while another staff member notified the nurse and staff for that area. According to MHA #1 Patient #1 calmed down quickly (within a minute or two) and was able to leave the quiet room and return to activities. MHA #1 also confirmed that, at times, staff would leave the door to the Quiet Room open and sit outside the doorway, but that patients would not be allowed to exit the room until the nurse stated the patient could do so. According to MHA #1 if the door to the quiet room is open with staff sitting outside the room to prevent the patient from exiting, the patient would not be considered in seclusion. The Director of Patient Care Services was present for this interview and stated that the statements from MHA #1 were not the details of the staff training for seclusion and that staff would be reeducated to ensure consistency with this practice as being seclusion.

Because a backwards take was not listed as a restraint, the required documentation of the provider's notification and order, patient assessments including the face-to-face assessment and the debriefing of Patient #1 and involved staff were not completed for the restraint and seclusion event of 1/9/2016.

Failure of the hospital to provide the appropriate education to all staff about the use of restraints/physical holds and seclusion, according to regulatory definitions and guidelines, placed the staff at risk for violating patient rights. The use of restraints, holds, and/or seclusion must have the necessary documentation of the patient behavior that warrants its use and all the required elements of the patients' assessments.