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A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 3 (Pt #1) medical records reviewed in which a patient was placed in seclusion and a physical hold, the Hospital failed to obtain a physician's order for seclusion and physical hold.

Findings include:

1. The Hospital policy and procedure titled, "Initiation of Restraints/Seclusion" (Approved 4/15/10) that was in effect on 12/2/11 was reviewed on 1/23/11. It indicated under, "General Guidelines: 3. Obtain an order for each incident of restraint, seclusion, therapeutic hold or chemical restraint.

2. The medical record of Pt #1 was reviewed on 1/23/12. It indicated Pt #1 presented to the ED with chief complaints of Altercation/Alleged Assault. Documentation on the Behavioral Health Services and Emergency Department Handoff Communication Report, the behavioral health staff assessment at 0910 recommended Seclusion due to elopement risk. The form was signed as viewed by the ED nurse and ED physician. The safety sitter's "Observation Flow Sheet", dated 12/2/11, indicated that Pt #1 was placed in room 5 (a security room) at 9:30 AM. The CD video of Pt #1 indicated that numerous times when Pt #1 attempted to exit the room, he was stopped by staff, family, or contracted workers which indicated Pt #1 was in seclusion. An "Addendum" to "Nurse Documentation" indicated Pt #1 had been on the floor on a mattress, being controlled by 3 security guards. There was no documentation in the medical record of a physician's order for the clinical justification for seclusion, the duration of the seclusion and for the physical hold.

3. During an interview with the Chief Nursing Officer, conducted on 1/23/12 at 10:45 AM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 19 (Pt #19) medical records reviewed in which the patient was placed in restraints/seclusion, the Hospital failed to ensure all orders for restraints were never written on an as needed (PRN) basis.

Findings include:

1. The Hospital policy and procedure titled, "Initiation of Restraints/Seclusion", approved 4/15/10, was reviewed on 1/23/11. It indicated under, "Restraint or Seclusion Orders: ...A standing order or an order stating "Restraints PRN" or "Restraints as Needed" is an invalid order and cannot be accepted."

2. The medical record of Pt #19 was reviewed on 1/25/12. It indicated Pt #19 was admitted on 12/18/11 with diagnoses of Psychosis and Drug Abuse. A physician's order, dated 12/19/11 at 2430 (12:30 AM), was for "Restrain PRN for agitation."

3. During an interview with the Chief Nursing Officer, conducted on 1/25/12 at 11:15 AM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 3 (Pt #1) records in which the patient was in seclusion, the Hospital failed to ensure all patients in restraints/seclusion were properly assessed.

Findings include:

1. The Hospital policy and procedure titled "Initiation of Restraints/Seclusion" last approved 4/15/10 that was in effect on 12/2/11 was reviewed on 1/23/11. It indicated under "General Guidelines: 8. Patient is assessed by the RN within 15 minutes of restraint/seclusion, then every 15 minutes for behavioral management patients. The RN then checks at least every 2 hours for behavioral management patients...9. Initial vital signs are taken as soon as possible following the initiation of restraint/seclusion and as often as the patient's medical/behavorial condition warrants."

2. The medical record of Pt #1 was reviewed on 1/23/12. It indicated Pt #1 presented to the ED with chief complaints of Altercation/Alleged Assault. The record did not indicate an RN assessment was completed every 15 minutes once Pt. #1 was placed in seclusion room 5 at 9:30AM and monitored by a sitter every 15 minutes. There were no vital signs taken upon the initiation of placing the Pt. #1 in seclusion.

3. During an interview with the Chief Nursing Officer, conducted on 1/24/12 at 11:45 AM, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 3 (Pt #1) medical records reviewed in which the patient was placed in seclusion, the Hospital failed to ensure the 1 hour face to face was documented in the medical record.

Findings include:

1. The Hospital policy and procedure titled, "Initiation of Restraints/Seclusion", approved 4/15/10, that was in effect on 12/2/11 was reviewed on 1/23/11. It indicated under, "Restraint or Seclusion Orders: ...For behavorial management, a physician or a RN trained to evaluate the patient's immediate situation, reaction, medical and behavioral condition must see and evaluate the patient for the need for restrain/seclusion within 1 hour after the initiation of the intervention...."

2. The medical record of Pt #1 was reviewed. The medical record of Pt #1 was reviewed on 1/23/12. It indicated Pt #1 presented to the ED with chief complaints of Altercation/Alleged Assault. There was no documentation in the physician's or RN's notes that indicated the required 1 hour face to face was conducted after Pt. #1 was transferred to the security room #5 and placed in seclusion.

3. During an interview with the Chief Nursing Officer, conducted on 1/25/12 at 1:20 PM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 3 (Pt #1) medical records reviewed in which patients were placed in seclusion, the Hospital failed to ensure there was a description of the patient's behavior and the interventions used prior to placing the patient in seclusion.

Findings include:

1. The Hospital policy and procedure titled, "Initiation of Restraints/Seclusion" that was in effect on 12/2/11 was reviewed on 1/23/11. It indicated under "General Guidelines: 1. Assess the need for restraint/seclusion as demonstrated by patient behaviors and document findings on the Restraint/Seclusion Flowsheet..."

2. The medical record of Pt #1 was reviewed. The medical record of Pt #1 was reviewed on 1/23/12. It indicated Pt #1 presented to the ED with chief complaints of Altercation/Alleged Assault. There was no documentation in the physician's or RN's notes that described that patient's behavior prior to or after if any alternative interventions were initiated. Nor was there documentation of a "Restraint/Seclusion Flowsheet.

3. During an interview with the Chief Nursing Officer, conducted on 1/25/12 at 1:20 PM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 3 (Pt #1) medical records reviewed in which the patient was placed in seclusion, the Hospital failed to ensure the Physician documented a reason for the seclusion.

Findings include:

1. The Hospital policy and procedure titled, "Initiation of Restraints/Seclusion" approved 4/15/10, that was in effect on 12/2/11 was reviewed on 1/23/11. It indicated under "Restraint or Seclusion Orders: ..."A physician order is obtained prior to application, except for emergency situations. When emergency restraint is necessary and clinically justified, patient care staff competent in restraint use may apply restraints prior to obtaining a physician's order.....

2. The medical record of Pt #1 was reviewed. The medical record of Pt #1 was reviewed on 1/23/12. It indicated Pt #1 presented to the ED with chief complaints of Altercation/Alleged Assault. There was no documentation in the physician's or RN's notes that indicated the clinical justification for the seclusion or physical hold of Pt. #1.

3. During an interview with the Chief Nursing Officer, conducted on 1/25/12 at 1:20 PM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, interviews, and staff interview, it was determined that the Hospital failed to ensure all staff involved with the care of Pt #1 while he was in seclusion, were appropriately trained.

Findings include:

1. The Hospital policy and procedure titled, "Initiation of Restraints/Seclusion" and approved 4/15/10, that was in effect on 12/2/11 was reviewed on 1/23/11. It indicated under "Staff Education and Training Restraint/Seclusion will be applied only by competent staff who have received initial orientation and on going education and training, including return demonstration in the minimum use of safe application of restraints/seclusion, monitoring assessment, and providing care for the patient while in restraint/seclusion. All direct care staff have ongoing education and training in the proper and safe use of restraints, restraint application and techniques, alternative method for handling behavior problems and situations traditionally treated through the use of restraint/seclusion."

2. During an interview conducted with F1( ED Physician) on 1/24/11 at 12:56 PM , it was verbalized that he had not received any training related to the use of restraint and seclusion or the Crisis Prevention Intervention (CPI) course.

3. During an interview with F3(Security Officer), conducted on 1/24/12 at 11:01. He verbalized that he was involved in the take down of Pt #1 on 12/2/11. He stated that he had not been trained in CPI or restraint/seclusion prior to 12/2/11.

4. During an interview with F4 (ED technician), conducted on 1/24/11 at 9:37 AM, it was verbalized that although he often assists with restraint and seclusion, he has not received any training in CPI or restraint/seclusion.

5. During an interview with the Chief Nursing Officer, conducted on 1/25/12 at 10:50 AM, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 1 (Pt #1) medical records reviewed in which the patient expired while in seclusion and after a physical hold, the Hospital failed to notify Central Medicare and Medicaid Services (CMS) within the required time frame.

Findings include:

1. The Hospital policy and procedure titled, "Initiation of Restraints/Seclusion", approved 4/15/10, that was in effect on 12/2/11 was reviewed on 1/23/11. It indicated under "General Guidelines: 20. ...The hospital's administrative team reports to the CMS Regional Office by the close of the next business day following the knowledge of the death, any death that occurs while in restraint/seclusion, death that occurs within 24 hours after the restraint or seclusion has been removed and a death known to the hospital that occurs within one week after restraint or seclusion where it is "reasonable to assume" that the use of restraint or seclusion contributed to the patient's death. Documentation occurs in the medical record the date and time any restraint and seclusion associated death is reported to CMS."

2. The medical record of Pt #1 was reviewed on 1/23/12. It indicated Pt #1 presented to the ED with chief complaints of Altercation/Alleged Assault on 12/2/11 and expired 12/2/11 while in seclusion. The hospital reported the death to CMS on 12/8/11, 5 days late.

3. During an interview with the Chief Nursing Officer, conducted on 1/23/12 at 12:45 PM, it was verbalized that administration was made aware of the death on Friday 12/2/11. When reviewing the compact disk (CD) video on 12/5/11 of Pt #1 while in seclusion, it was determined that Pt #1's death occurred while in seclusion. It was verbalized that the Hospital notified CMS on 12/8/11 and confirmed the finding above.

A. Based on review of Hospital policy, record review and staff interview, it was determined that Hospital failed to ensure a registered nurse supervised and evaluated the nursing care in 1 of 19 (Pt#1) records reviewed.

Findings include:

1. The ED policy and procedure titled, "Assessment and Reassessment of Patient (5 Tier)" and Effective March 2005, indicated under, "II. Procedure: M. In addition, vital signs (blood pressure, pulse, respirations, and temperature) should be monitored as follows: 3. Vital signs should be taken at least every 15-30 minutes if patient has been administered medication that affects the hemodynamic status, or as indicated by the type of medication administered (excluding temperature)..." Vital signs should be taken at least every two hours until discharge."

2. The medical record of Pt #1 was reviewed on 1/23/12. It indicated Pt #1 presented to the ED with chief complaints of Altercation/Alleged Assault. The record indicated that Pt #1 was administered 5 mg of Ativan IV, Zyprexa 10 mg IM, and Haldol 5 mg IM between 8:14 AM and 1:28 PM. Vital signs were recorded in the medical record at 8:00 AM and at 12:30 PM. There was no documentation in the medical record that indicated Pt #1 had his vital signs assessed every 15 minutes after the administration of medications that could affect his hemodynamic status.

3. During an interview with the Chief Nursing Officer, conducted on 1/25/12 at 1:20 PM, the above finding was confirmed.