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Based on record review and interview the facility staff failed to identify individual triggers and methods to reduce the need for restraints and/or seclusion in the Plan of Care for 9 of 10 patient records reviewed (#1, #2, #4, #5, #6, #7, #8, #9, #10). Pt. #1 was observed to be blue in color and unresponsive after being turned from a prone to supine position during the initiation of restraints. Pt. #1 later died at another hospital.

Findings:

Facility policy "Seclusion or Restraint" #216.02 dated 11/2014 states: "In assessing the need to use these interventions, the potential for any negative impact of the procedure on the patient is considered...A. The prevention of situations that could escalate into violence, aggression, harrassment, or abuse is of utmost importance. The primary objective is to identify, prevent, and treat behavior before it results in violence, aggression, harassment, or abuse to the patient, other patients, or staff...C. The use of seclusion or restraint can only be used: ...2. When the patient's Individual Treatment Plan (ITP) or Nursing Care Plan (NCP) is reviewed. The NCP is reviewed and modified (as needed) following the resolution of each incident of restraint or seclusion. The ITP is reviewed and modified (as needed) at each staffing or sooner as necessary to address the use of seclusion or restraint and methods to prevent its use in the future...A. The treatment team considers information obtained from initial and ongoing assessments to help prevent violence, aggression, harassment, or abuse...Information from the assessment includes: 1. Techniques, methods, or tools (e.g., stress reduction inventory, family as appropriate) that would help the patient control his/her behavior."

Pt. #1 was admitted to the facility on 5/21/2015 with a diagnosis of Intermittent Explosive Disorder. Per the MD Initial Assessment, dated 5/21/2015, Pt. #1 "has Down Syndrome and presents with cognitive limitations...states lives at home and admittedly was hitting. When asked what provokes pt. to hit, the patient would answer incoherently."

Subjective data documented in the Initial Nursing Assessment, dated 5/21/2015, is obtained by family member A. Per family member A, Pt. #1 has "outbursts" and "throws things" when frustrated. Family member A states to "leave [Pt. #1] alone and ignore behaviors" as an appropriate method to assist in Pt. #1's behaviors.

Shift summary on 5/24/2015 at 4:15 PM documents "[A]...came to visit today. [A] provided information that may be helpful for the treatment team, as [Pt. #1] has impaired communication skills...[A] reports [A] prefers, and uses, phrases such as, "[Pt. #1] this is not appropriate behavior," and [Pt. #1] understands it. [A] has pointed out to care team that it is better to use positive phrases and redirects vs. negative...[A] feels that therapy could be of benefit and hopes that [Pt. #1] can get help dealing with the traumatic events vs. behavior mangement...also noted that [Pt. #1] is a visual learner...if further information is needed, please contact [A] via telephone; [A] is willing to come to [facility] to meet with the treatment team as well."

On 5/30/2015 at 1:30 PM an order for restraint (floor containment) is obtained for aggressive behavior. The NCP is documented on the flowsheet as "reviewed."

Pt. #1's Individualized Treatment Plan, initiated 5/21/2015, documents "Psychiatric Impairment as evidenced by Aggression..." Pt. 1's goal: "The patient will identify stressors that lead to high-risk behaviors to self and/or others and develop coping skills that may assist in managing/preventing further crises." Method to aid patient in meeting goal is documented as "...primary RN, will complete Assessment of Learning Ability and Style (F-21819), Section II, ...to identify learning needs and develop an education plan..." Per form F-21819, dated 5/21/2015, barriers to learning include: Verbal skills; Alertness; Attention span; Motivation; Level of intelligence; Insight; Physical status; Reading ability. Strengths include: Cooperation; Emotional status; Cultural influences; Family involvement; Religious/Spiritual Beliefs. Section II "Identified Learning Needs" is blank.

Pt. #1's Nursing Care Plan includes a nursing diagnosis of "Risk for Other-Directed Violence related to cognitive impairment, poor frustration tolerance, poor impulse control." Goals include "Patient will have 1 or fewer aggressions toward others per week" and "Patient will have 1 or fewer object aggressions/property destruction per week."

Pt. #1's NCP and ITP are not modified to address the use of restraint, potential triggers or methods to reduce its use in the future. The NCP and ITP do not include methods or interventions that reflect Pt. #1's individual barriers to learning.

On 6/5/2015 at 8:30 PM Pt. #1 was placed in restraints for aggressive behavior. Seclusion or Restraint (S & R) Incident Documentation flowsheet documents the following at 8:30 PM: "Patient pushed female peer in DR...Patient walked out of DR and into the hallway. Staff attempted to use light touch and guide [Pt. #1] to bedroom. Patient then began attempting to elbow staff. Hands-on were placed to attempt to escort to room and de-escalate; however, pt. dropped weight and threw self onto the floor. Pt. was fighting with staff and yelling uncontrollably. Staff was unable to de-escalate pt. successfully, so the decision was made to place patient on the transboard..."

During an interview on 6/11/2015 at 3:25 PM, PCT C stated Pt. #1 became upset by a particularly aggressive "takedown" of Pt. #2.

During an interview on 6/11/2015 at 4:00 PM, PCT E stated Pt. #1 "was upset by previous takedown of [Pt. #2]." PCT E stated Pt. #1 was "very routine, normally would calm down real easy."

PCT C observed Pt. #1 exiting the dayroom and walking down hallway. PCT C and PCT B followed Pt. #1 down the hallway and as C and B approached Pt. #1, Pt. #1 began to "throw elbows" at the staff. As C and B attempted a 2 person escort, Pt. #1 dropped weight "down to pretzel leg on the floor." PCT B stated during an interview on 6/11/2015 at 2:45 PM, Pt. #1 "fell onto butt" and "we [B and C] went down with [Pt. #1]." Pt. #1 "was in a sitting position and still struggling."

Per PCT E, E observed PCT B and PCT C walking with Pt. #1. E stated E saw B and C turn Pt. #1 from a sitting position onto Pt. #1's stomach (prone position). PCT E stated Pt. #1 was "flailing" arms and legs at which point E "laid across back of legs."

During an interview on 6/11/2015 at 2:45 PM, PCT B stated PCT E "took [Pt. #1's] legs" and "other staff arrived and I ended up at [Pt. #1's] head." Per PCT B, Pt. #1 and assisting staff stayed in a floor containment position (with Pt. #1 lying face down on the floor with staff at each extremity and head). Per B, Pt. #1 continued to struggle.

Per PCT E, "[Pt. #1] was terrified, didn't know what was going on."

During an interview on 6/11/2015 at 4:30 PM, PCT G reports responding to a disturbance on the unit. G stated Pt. #1 was "verbal the whole time and fighting" saying "I want my Dad, I want to go home."

PCT C stated Pt. #1 was "struggling pretty aggressively" during the restraint application. PCT C stated that Pt. #1 was walking down the hall "towards bedroom" when PCT B and C approached. PCT C stated B and C decided to escort the patient to prevent any further issues, despite the fact that Pt. #1 had already removed self from the dayroom. PCT C stated "it's hard to have DD [developmentally disabled] patients on the same unit as the general population." PCT C was not aware of any special considerations communicated to staff in regards to effective methods of de-escalation.

Pt. #2's MR contains a Physical Restraint Incident Documentation flowsheet for floor containment dated 5/17/2015 for "increased agitation and verbal aggression." On 5/26/2015 at 6:10 PM an order is obtained for 5-person takedown, floor containment and team escort to SDCT for behavior. The flowsheet documents "NCP modified? No." On 5/28/2015 at 7:15 AM an order is obtained for 5-person takedown, floor containment, transboard with physical restraint to ankles, wrists, thighs, shins and forearms for aggressive behavior. The flowsheet documents "NCP modified? No." On 6/5/2015 at 7:45 PM an order is obtained for 5-person takedown, floor containment, wall containment, team escort, transboard with physical restraint to ankles, wrists, thighs, shins and forearms for aggressive behavior. The flowsheet documents "NCP modified? No."

Pt. #2's MR includes a NCP dated 5/15/2015 for "Risk for Other-Directed Violence related to: history of violence against others, increased agitation, ineffective problem solving strategies, poor frustration tolerance, poor impulse control, rage reaction." Pt. #2's NCP does not include the use of restraints/seclusion or individualized interventions/methods to prevent it's use in the future. On 5/15/2015 an ITP was initiated for "Psychiatric Impairment as evidenced by Agression." Pt. #2's ITP is not updated to reflect the need for restraints/seclusions or individualized interventions/methods to prevent it's use in the future.

Pt. #4's MR contains a Physical Restraint Incident Documentation flowsheet dated 11/25/2014 for floor containment, gurney, transboard with physical restraint to ankles, wrists, biceps, thighs, shins and forearms for aggressive behavior. Pt. #4 was in restraints from 8:30 PM to 9:45 PM. Debriefing after the use of restraints documents: "1. Brief description of incident and staff impression of triggering events: Ineffective deescalation." "What could we as staff have done to help you prevent this?" Pt. #4 answered: "Given me space."

Restraint/seclusion use is documented on 11/29/2014 from 5:15 AM to 9:00 AM for agressive behavior. "Pt. was throwing food around dayroom, hitting walls and cabinets with hands, antagonizing peers, pounding on table with hands. Pt. refused to redirect. Pt. directed to SDCT, Pt. began walking then turned and lunged towards staff. Staff put hands-on, wall contained, Pt. taken down and placed on transboard with restraints. Pt. struggling with staff during entire procedure." The flowsheet documents "NCP modified? No."

Restraint use is documented on 12/3/2014 from 5:15 AM to 6:45 AM for aggressive behavior. "Pt. would not redirect." "What less restrictive interventions were considered prior to S or R? Check all that apply: Methods described in Individualized Treatment Plan; Clear, firm limit-setting." "NCP modified? No."

Pt. #4's MR includes a NCP initiated 11/25/2014 for "Risk for Other-Directed Violence related to: delusional thinking, increased agitation." The NCP includes a goal of "Patient will have 0 or fewer episodes of restraint use per week." Methods to aid patient in achieving goal include: "assigned staff will assist [Pt. #4] to identify situations/triggers and proactive interventions that could be used to calm or deescalate. Trigger: _______; Response: _________; Interventions: _________" Trigger, response and interventions are left blank.

Pt. #5's MR contains a Physical Restraint Incident Documentation flowsheet dated 8/28/2014. Pt. #5 was in seclusion from 1:00 PM to 1:45 PM due to "Ineffective deescalation." Effective responses in the debriefing documentation states "Removing from DR stimuli effective." "NCP modified? No." Seclusion use is documented on 9/4/2014 from 8:20 PM to 9:20 PM and again from 11:05 PM to 1:20 AM on 9/5/2014 due to "Ineffective verbal deescalation." "NCP reviewed."

Review of Pt. #5's NCP includes problems of "Noncompliance: Medication; Risk for Falls; Impaired Social Interaction." There is no documentation in the NCP or ITP to reflect the need for restraint/seclusion.

Pt. #6's MR contains a Physical Restraint Incident Documentation flowsheet dated 4/23/2015 for transboard restraint from 6:15 PM to 7:15 PM due to "verbal deescalation ineffective." "Changes recommended to NCP? N/A none." On 5/5/2015 Pt. #6 was restrained by 5-person takedown, floor containment and transboard with physical restraint to extremities from 9:00 AM to 10:15 AM followed by seclusion from 10:15 AM to 11:00 AM. Debriefing states "attempted verbal deescalation, SDCT." "NCP modified? No." On 5/17/2015 Pt. #6 was in seclusion from 8:15 AM to 9:45 PM. Debriefing states "Attempted verbal redirects, not successful." NCP modified? No." On 5/17/2015 Pt. #6 was restrained by 5-person takedown, floor containment and transboard with physical restraint to extremities from 3:00 PM to 4:00 PM. Debriefing states "verbal prompts not effective." "NCP modified? No."

Pt. #6's MR includeds an ITP initiated on 4/16/2015 for "Psychiatric Impairment as evidenced by Pt. becoming increasingly agitated-aggressive when redirected." The ITP is not updated to reflect patient progress toward goals or individualized methods to aid patient in meeting goals. Pt. #6 has a NCP for "Ineffective Coping related to situational crisis as evidenced by destructive behavior toward self or others. Goal: Patient will demonstrate 3 coping skills in stressful situations within 1 month." Methods to aid patient in meeting goal state "staff will assist [Pt. #6] to identify situations/triggers that create anxiety/anger/frustration...and proactive interventions that could be used to calm or deescalate." The NCP is not updated to reflect the use of restraints/seclusion or methods to reduce the use of restraints/seclusion.

Pt. #7's MR contains a Physical Restraint Incident Documentation flowsheet dated 4/12/2015 for team escort and geri-chair restraint from 6:45 AM to 7:45 AM followed by seclusion until 8:15 AM. Debriefing states "All possible interventions exhausted." "2. Brief description of verbal/physical intervention: Verbal deescalation; team escort; SDCT; hands-on; PRN med; Geri-Chair." "NCP modified? No." Pt. #7's NCP, initiated 4/11/2015, for "Risk for Other-Directed Violence related to cognitive impairment, delusional thinking, history of violence against others, increased agitation, ineffective problem solving strategies" is not updated to reflect the use of restraints/seclusion or methods to reduce the use of restraints/seclusion.

Per Pt. #8's MR, Pt. #8 was in seclusion on 1/11/2015 from 12:55 PM to 2:00 PM because "Pt. was attempting to call 911 on payphone. Pt. needed multiple prompts to walk away from phone." Debriefing states "Agitated when redirected for calling 911, multiple verbal prompts not effective." "NCP modified? No." On 1/13/2015 Pt. #8 was restrained by 5-person takedown, floor containment and transboard with physical restraint to extremities from 2:00 AM to 2:30 AM for physical aggression. Debriefing states "Pt. non-redirectable." "NCP reviewed: no changes at this time."

Pt. #8's ITP for Psychiatric Impairment and NCP for Risk for Other-Directed Violence are not updated to reflect the use of restraint/seclusion. The ITP and NCP do not include individualized methods to reduce the use of restraint/seclusion.

Pt. #9 was placed in restraints upon admission on 3/2/2015 from 1:45 PM to 5:35 PM for aggressive behavior. On 3/2/2015 Pt. #9 was restrained by 3-person takedown, floor containment and transboard with physical restraint to extremities from 10:00 PM to 4:30 AM on 3/3/2015. Debriefing states "unable to deescalate pt. with verbal prompting." "NCP modified? No." On 3/4/2015 Pt. #9 was placed in seclusion from 5:45 AM to 7:00 AM due to "ineffective redirection." "NCP modified? No."

Pt. #9's ITP for Psychiatric Impairment, initiated on 3/2/2015, does not include individualized methods to reduce the use of restraint/seclusion. Pt. #9's NCP for Ineffective Coping, initiated 3/2/2015, includes the following goals: "Patient will have 2 or fewer episodes of restraint per week; Patient will have 2 or fewer episodes of seclusion per week." Methods to aid patient in meeting goals contains Trigger, Response and Intervention section that is blank and crossed out.

Pt. #10 was restrained with transboard and physical restraint to extremities on 3/7/2015 from 11:45 AM to 12:45 PM. Debriefing states "Attempted to verbally deescalate." "NCP modified? No." Pt. #10 was placed in seclusion on 3/8/2015 from 6:45 PM to 8:15 PM as a result of threatening to throw chairs. There is no evidence that less restictive evidence was considered prior to seclusion. "NCP modified? No." On 3/9/2015 Pt. #10 was restrained by 3-person takedown, floor containment and transboard with physical restraint to extremities from 8:15 PM to 9:00 PM as "Pt. very upset at bedtime began demanding to watch a movie when advised it wasn't an option patient began karate chopping staff. Redirected into bedroom but once in room began kicking door." "NCP modified? Yes." On 3/12/2015 Pt. #10 was restrained by 5-person takedown, floor containment and transboard with physical restraint to extremities from 5:25 PM to 5:55 PM for "severe agitation." "NCP modified? No."

Pt. #10's ITP for Psychiatric Impairment, initiated on 3/7/2015, does not include individualized methods to reduce the use of restraint/seclusion. Pt. #10's NCP for Risk for Other-Directed Violence, initiated on 3/7/2015, does not reflect the use of restraint/seclusion. There is no evidence in the MR that the NCP was updated on 3/9/2015 to reflect the use of restraint/seclusion or that the NCP was modified in any way.

During an interview on 6/12/2015 at 12:00 PM, DON K stated ITP and NCP are "incorporated together." Per DON K, nursing staff is "not expected to document outcome of goals on the NCP or the ITP." In regards to restraints, K stated staff "updates the NCP if appropriate, but it's not required."