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Based on observation, document review, and interview, it was determined the Hospital failed to promote and protect the rights of the patients. As a result, the Condition of Participation 42 CFR 482.13, Patient Rights, was not met. This has the potential to affect all patients serviced by the Hospital with an average monthly census of 2550 patients.

Findings include:

1. The Hospital failed to ensure patients/patient representatives were informed of their Rights and Responsibilities including Advanced Directives. See A- 117

2. The Hospital failed to ensure the patient was involved in the development and implementation of the patient's discharge plan. See A-130

3. The Hospital failed to ensure an ARA (Authorization/Release Agreement to Pay/Consent for Treatment) was obtained by the patient or patient representative per policy. See A-131

4. The Hospital failed to ensure a safe environment. See A-144

5. The Hospital failed to ensure physician orders for restraint and/or seclusion were obtained. See A-168

6. The Hospital failed to ensure a face to face was conducted by the physician within an hour after initiation of restraint. See A-178

7. The Hospital failed to ensure all employees with direct care restraint responsibilities had the required training. See A-194

8. The Hospital failed to ensure all employees had an annual competency update in restraint/seclusion training. See A- 196

9. The Hospital failed to ensure training for restraint/seclusion was specific to the needs of the patient population. See A-199

10. The Hospital failed to ensure the all staff involved in restraint/seclusion usage maintained current CPR certification. See A-206

11. The Hospital failed to ensure that all staff conducting training for restraint/seclusion was qualified. See A-207

12. The Hospital failed to ensure staff were qualified and competent in restraint and seclusion monitoring. See A-208

A. Based on document review and interview, it was determined for 9 of 9 (Pt's #1, #2, #3, #4, #5, #6, #7, #8 and #9) patient's records reviewed, the Hospital failed to ensure patients/patient's representatives were informed of their Rights and Responsibilities including Advanced Directives. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. The policy titled "Registration Documents" (reviewed 3/20/18) was reviewed on 9/5/18. The policy noted "The following documents are to be given to the patient during registration... 2. Patient Rights and Responsibilities..."

2. The hospital utilized procedure form "Lippincott Procedures-Advanced directives (Revised: November 7, 2017)" was reviewed 9/5/18. The procedure required.... "Ask the patient whether he has an advance directive... If the patient doesn't have an advance directive, document that he was given written information concerning his rights... If the patient refuses information on an advance directive, document this refusal..."

3. The policy titled "Patient Rights and Responsibilities" (reviewed 7/3/18) was reviewed on 9/5/18. The policy required "... inform each patient and/or the patient's representative... of the patient's rights and responsibilities, prior to providing or discontinuing patient care..."

4. The following clinical records were reviewed throughout the survey on 9/4/18 to 9/6/18. The records lacked documentation that patients/patient representatives were informed of their Rights and Responsibilities including Advance Directives and/or the information was refused:
a) Pt #1, Date of Service (DOS): 6/12/18, Diagnosis: Suicidal Ideation
b) Pt #2, DOS: 6/7/18, 6/8/18 and 6/12/18, Diagnosis: Suicidal Ideation
c) Pt #3, DOS: 8/16/18, Diagnosis: Psychiatric Evaluation
d) Pt #4, DOS: 8/24/18, Diagnosis: Intentional Drug Overdose
e) Pt #5, DOS: 9/3/18, Diagnosis: Head Injury
f) Pt #6, DOS: 9/4/18, Diagnosis: Suicidal Ideation
g) Pt #7, DOS: 7/30/18, Diagnosis: Depression
h) Pt #8, DOS: 6/9/18, Diagnosis: Suicidal Ideation
i) Pt #9, DOS: 8/28/18, Diagnosis: Suicidal Ideation

5. During an interview on 9/5/18 at approximately 11:45 AM, E# 12 (Patient Registration Supervisor) stated "If they (patient) bring Power of Attorney (POA) papers in, we scan them in (Electronic Health Record) but generally we (PAS Representative) don't ask (if the patient has advanced directives). We don't give the patients any brochures (Patient Rights and Responsibilities/Advance Directives). The Rights are posted in the room."

B. Based on document review and interview, it was determined in 1 of 1 (Pt #9) patient's records reviewed with an advance directive on file, the Hospital failed to ensure advance directives were identified and reviewed per policy. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. The hospital utilized procedure form "Lippincott Procedures-Advanced directives (Revised: November 7, 2017)" was reviewed 9/5/18. The procedure required... "Ask the patient whether he has an advance directive... If the patient has an advance directive... review the advance directive with the patient and confirm that it still reflects his wishes... Notify the practitioner and the rest of the health care team... so that it can be used to guide care..."

2. Pt #9 Date of Service (DOS): 8/28/18
Diagnosis: Suicidal Ideation. The record was reviewed throughout the survey on 9/4/18 through 9/6/18. The record noted previous Power of Attorney for Health Care (HPOA) papers were obtained and scanned into Pt # 9's record on 11/20/17. Pt #9 was admitted at 1:38 AM on 8/28/18 and was discharged at 8:46 AM on 8/28/18. The record noted "Adv Dir: Not Received". There was no documentation that the previously obtained advanced directives were reviewed with the patient, that the HPOA was identified as an emergency contact, and physician and staff notification was made.

3. During an interview on 9/5/18 at approximately 11:45 AM, E# 12 (Patient Registration Supervisor) stated "If they (patient) bring Power of Attorney (POA) papers in, we scan them in (Electronic Health Record) but generally we (PAS Representative) don't ask (if the patient has advanced directives)."

Based on document review and interview, it was determined in 1 of 4 (Pt #7) patient's record reviewed, the Hospital failed to ensure the patient was involved in the development and implementation of the patient's discharge plan. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings Include:

1. Pt #7 Date of Service (DOS): 7/30/2018
Diagnosis: Depression and Acute Alcohol Intoxication. The record was reviewed on 9/4/2018 at approximately 1:30 PM. Documentation indicated patient arrived in the Emergency Department on 7/30/18 at 5:09 PM and was discharged to home on 7/31/18 at 7:27 AM. The record lacked documentation of an order for discharge, that the discharge plan of care was developed and implemented, and the patient was involved in the process.

2. During an interview on 9/4/18 at approximately 2:00 PM, E#7 (Trauma Coordinator) verbally agreed the record lacked documentation the physician was notified of the discharge, a discharge order was obtained, discharge instructions with the discharge plan of care were developed and communicated to the patient.

Based on document review and interview, it was determined in 4 of 9 (Pts #3, #6, #8, and #10) patient's records reviewed, the Hospital failed to ensure an ARA (Authorization/Release Agreement to Pay/Consent for Treatment) was obtained by the patient or patient representative per policy. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. The policy titled "Registration Documents" (reviewed 3/20/18) was reviewed on 9/5/18. The policy noted "Registration... explain each part of the ARA (Authorization/Release Agreement to Pay) document to the patient or guardian prior to obtaining a signature.... each time a new encounter is created... 2. Persons authorized to sign the ARA form include: Patient (if adult), Parent or Legal Guardian, Healthcare Power of Attorney, Court-appointed guardian... 7. If patient refuses to sign the ARA, the PAS (Patient Access Services/Registration) Representative indicates "Refused to Sign" on the ARA. The ARA is signed by the PAS Representative in addition to one other staff member, who witnessed the refusal.... 8. If a patient cannot sign, the PAS Representative indicates "Unable to Obtain" on the ARA...."

2. Pt #3 Date of Service (DOS): 8/16/18
Diagnosis: Psychiatric Evaluation. The clinical record was reviewed throughout the survey on 9/4/18 to 9/6/18. The record noted Pt #3's mother as the Guarantor, Emergency Contact, and the Legal Guardian. The record noted the mother arrived on 8/16/18 at 7:49 AM, "Pt mother demonstrated verbal understanding of discharge instructions and medications prescribed using teach back method." and remained at the bedside until discharge at 11:06 AM. The ARA was initialed by "RW" on 8/16/18 at 9:35 AM. The signature was illegible and it was unable to be determined why "RW" initialed and signed the ARA and not the mother who was present and the Legal Guardian.

3. During an interview on 9/5/18 at approximately 9:30 AM, E#14 (Manager of Patient Access Services/Registration Department) reviewed Pt #3's ARA and verbally agreed it was unable to be determined who signed Pt #3's ARA. E#14 stated Pt #3's mother should have signed the ARA.

4. Pt #6 DOS: 6/12/18
Diagnosis: Suicidal Ideation. The clinical record was reviewed throughout the survey on 9/4/18 to 9/6/18. The record lacked an ARA and documentation the ARA was unable to be obtained, the patient refused to sign, or the spouse was contacted for verbal consent.

5. Pt #8 DOS: 6/9/18
Diagnosis: Suicidal Ideation. The clinical record was reviewed throughout the survey on 9/4/18 to 9/6/18. The record noted the registration process was completed at 2:04 PM. The record noted Pt #8 was alert and oriented to person, place and time and answered all questions appropriately. The record lacked documentation of an ARA.

6. During an interview on 9/5/18 at approximately 9:30 AM, E#14 demonstrated a screen shot of a Registration tab within the electronic health record which stated Pt #8's ARA was "unable to obtain" and "Patient refused to sign ARA". E#14 verbally agreed the PAS Representative did not note, sign, or have a witness that Pt #8 refused to sign the ARA.

7. Pt #10 Date of Service (DOS): 6/12/18
Diagnosis: Suicidal Ideation. The clinical record was reviewed throughout the survey on 9/4/18 to 9/6/18. The record noted Pt #10 had a Guardian. The record lacked documentation the Guardian was notified of the admission or an attempt to obtain consent was conducted. The record lacked documentation the PAS Representative noted on the ARA consent was unable to be obtained and witnessed.

8. During the clinical record reviews on 9/4/18 an interview at approximately 2:30 PM was conducted with E#5 (Clinical Educator Emergency Department), E#7 (Trauma Coordinator) and E#15 (Manager of Emergency Department). E#5, E#7 and E#15 stated the consent for treatment (ARA) was completed by and the responsibility of the Registration Department. E#5, E#7 and E#15 were unable to view the scanned ARA in the electronic health record and stated they did not have access to it. E#5 stated "We don't know if the consent gets done or not." E#7 stated "We (nurses) should know if the consent is not completed because the patient's condition may change or a family member may come after registration is completed. We (nurses) also talk to the family via telephone and could get a verbal consent if the patient couldn't."

9. During an interview on 9/5/18 at approximately 11:45 AM, E# 12 (Patient Registration Supervisor) stated "If they (patient) brings Power of Attorney (POA) papers in, we scan them in (Electronic Health Record) but generally we (PAS Representative) generally don't ask. If POA papers are on file, we can get consent from the POA but we were told not even a spouse can sign (ARA) unless we have paperwork." When asked what the ARA abbreviation stood for, E#12 stated "I don't know but it's the Consent to Treat form."

Based on document review and interview, it was determined in 3 of 7 (Pt's #4, #7 and #8) patient's records reviewed for patients who were suicidal observation and received psychiatric treatment, the Hospital failed to ensure a safe patient environment per policy. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation and all staff.

Findings include:

1. The "Psych (Psychiatric)/Suicidal Observation Guidelines" (undated), printed on the duplicate side of the Psych/Suicide Observation Checklist was reviewed during record reviews on 9/4/18 through 9/6/18. The guidelines required "High Interventions:... 1 to 1 continuous observation... Document the original search of patient and room at top of checklist. Document every time a search is completed... Conduct search with two staff members (one staff is a RN) (Registered Nurse)..."

2. Pt #4 Date of Service (DOS): 8/24/18
Diagnosis: Intentional Drug Overdose: The clinical record was reviewed with E#8 (Supervisor, Clinical Educator ED) on 9/4/18 at approximately 1:30 PM. After review of the Psych/Suicide Observation Checklist, it was unable to be determined the search was completed. The form lacked documentation of the intervention level, date, time and the required 2 signatures of who completed and witnessed the patient search.

3. During an interview on 9/4/18 at approximately 1:30 PM, E#8 (Supervisor, Clinical Educator ED) stated Pt #4 was placed on high level interventions upon admission and the checklist was completed during the ED visit. E#8 verbally agreed it was unable to be determined if the patient search was completed and it should have been documented.

4. Pt #7 DOS: 7/30/18
Diagnosis: Depression. The clinical record was reviewed with E#8 on 9/4/18 at approximately 2:15 PM. After review of the Psych/Suicide Observation Checklist, it was unable to be determined the search was completed. The form lacked documentation of the intervention level, and the required 2 signatures of who completed and witnessed the patient search.

5. During an interview on 9/4/18 at approximately 2:15 PM, E#8 stated Pt #7 was placed on high level interventions upon admission. E#8 verbally agreed it was unable to be determined who completed and witnessed the patient search on 7/30/18 at 7:00 PM.

6. Pt #8 DOS: 6/9/18
Diagnosis: Suicidal Ideation. The clinical record was reviewed with E#7 (Trauma Coordinator) on 9/5/18 at approximately 10:45 AM. The Psych/Suicide Observation Checklist lacked documentation of who witnessed the patient search.

7. During an interview on 9/5/18 at approximately 10:45 AM, E# 4 (Trauma Coordinator) verbally agreed Pt. #8's checklist lacked a witness's signature and should have been signed.

Based on document review and interview, it was determined for 3 of 4 (Pt's #3, #5 and #7) records reviewed of patients who were restrained for violent or self-destructive behavior, the Hospital failed to ensure physician orders for restraint and/or seclusion were obtained per policy. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings Include:

1. The policy titled "Restraint and Seclusion Management" (revision date 4/3/2018) was reviewed on 9/4/18 at approximately 230 PM. The policy noted "6. Restraints or seclusion are ordered by licensed physicians... 8. In an emergency situation, a Registered Nurse (RN) may apply a restraint or initiate seclusion prior to receiving an order. An order is obtained immediately (within a few minutes) following."

2. Pt #3 Date of Service (DOS): 8/16/18
Diagnosis: Psychiatric Evaluation. The clinical record was reviewed on 9/4/18 at approximately 12:30 PM. The record noted that Pt #3 arrived by ambulance on 8/16/18 at 1:26 AM. The restraint flowsheet noted on 8/16/18 at 2:15 AM "Restraints initiated prior to this RN's (Registered Nurse) acquisition of pt." and were discontinued at 2:27 AM. The Verbal Order for "Restraint for Violent/SelfDestructive..." was entered into the electronic health record by a nurse on 8/16/18 at 7:15 AM, 5 hours after initiation and electronically signed by the physician on 8/17/18 at 3:05 AM, greater than 24 hours after the restraints were applied.

3. Pt #5 DOS: 9/3/18
Diagnosis: Head Injury. The clinical record was reviewed on 9/4/18 at approximately 1:30 PM. The record noted that Pt #5 arrived on 9/3/18 at 2:27 AM. The restraint flowsheet noted restraints were applied on 9/3/18 at 3:25 AM. The last entry on the flowsheet at 7:25 AM stated restraints were continued although no further assessments were noted. The restraint order was documented and electronically signed by the physician at 7:56 AM, greater than 4 hours after initiation. The record lacked a discontinuation of restraint order. An Emergency Medicine Attending Note dated 9/3/18 at 7:56 AM stated "... The order was just placed as a late entry due to patient care; however it is to reflect that they were used from 3:20 AM this morning." The record noted the restraints were initiated, utilized, and discontinued without a physician's verbal order.

4. Pt #7 DOS: 7/30/2018
Diagnosis: Depression and Acute Alcohol Intoxication The clinical record was reviewed on 9/4/2018 at approximately 1:30 PM. A nurse noted at 8:18 PM "Verbal order per... to place 4 hard limb restraints on pt for suicidal precautions to protect staff and pt." The record noted restraints were initiated at 7:15 PM and discontinued at 10:00 PM. The record lacked a signed physician's order for Pt #7's restraints.

5. During an interview on 9/4/2018 at approximately 2:00 PM, E#7 (Trauma Coordinator) verbally agreed the record lacked a restraint order for Pt #7. E#7 stated Pt #3's verbal order for restraints should have been put into writing and signed by the physician immediately following the initiation of the restraints. E#7 stated a verbal order should have been obtained for the use of Pt #5's restraints immediately after initiation.

Based on document review and interview, it was determined for 2 of 2 (Pt #5 and Pt #7) records reviewed of patients who were restrained for violent or self-destructive behavior, the Hospital failed to ensure a face to face assessment/evaluation was conducted by the physician within an hour after initiation of restraint. This has the potential to affect approximately 1550 patients per month who present to the Emergency Department (ED) for a medical screening exam.

Findings include:

1. Pt #5 Date of Service (DOS): 9/3/18
Diagnosis: Head Injury. The clinical record was reviewed on 9/4/18 at approximately 1:30 PM. The restraint flowsheet authored by a nurse, noted that restraints for violent and/or self-destructive behavior were initiated on 9/3/18 at 3:25 AM and a "Face to Face Evaluation" was completed at 3:25 AM. An "ED Provider Note" authored by MD#2 (physician) noted Pt #5 was evaluated at 3:54 AM, although the note was completed on 9/3/18 at 10:54 AM.

2. Pt #7 DOS: 7/30/18
Diagnosis: Suicidal Ideation: The clinical record was reviewed on 9/5/18 at approximately 10:45 AM. The restraint flowsheet authored by a nurse noted restraints for violent and/or self-destructive behavior were initiated on 8/3/18 at 7:15 PM and a "Face to Face Evaluation" was completed on 8/3/18 at 7:15 PM. An "ED Provider Note" authored by MD#4 (physician) dated and timed as completed on 8/3/18 at 7:02 PM, lacked documentation of a face to face evaluation. Therefore, it was unable to be determined if and when MD#4 conducted a face to face on Pt #7.

3. During the clinical record reviews an interview was conducted with E#7 (Trauma Coordinator). E#7 verbally agreed it was unable to be determined when or if the face to face was conducted on Pt #5 and #7. E#7 stated the provider notes only show when the file is closed and not when an entry is made by the provider.

4. During and interview on 9/5/18 at approximately 10:00 AM, E#3 (Regulatory Coordinator) stated "Nurses don't do face to face evaluations at this hospital. The policy is a corporate policy but only physicians are allowed to do the evaluation."

Based on a document review and interview, it was determined in 2 of 16 (E# 28 and Medical Doctor (MD) #3) employee files reviewed of staff with direct care restraint responsibilities, the Hospital failed to ensure the required training for restraints/seclusion. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. The policy titled "Restraint and Seclusion Management" was reviewed on 9/5/18 at approximately 1:00 PM, the policy required "Policy:...9...c. Staff with direct care restraint responsibilities are trained and competent in application of restraints, implementation of seclusion, monitoring, assessment and care for patients prior to providing care. d. training occurs during orientation and annually."

2. The employee files of the following employees were reviewed on 9/5/18 at approximately 1:15 PM.

a. MD #3's (Medical Doctor) file lacked restraint/seclusion training.
b. E# 28's (security guard) file lacked what specific restraint/seclusion training was conducted.

3. During an interview with E# 9 (Director of Employee Relations) and E# 10 (Human Resources Business Partner), both verbally confirmed the files of MD #3 and E #28 lacked the required restraint/seclusion training.

4. During an interview with E# 3 (Regulatory Coordinator) on 9/6/18 at approximately 12:45 PM, it was verbally confirmed MD #3 did not have restraint/seclusion training documented.

5. On 9/6/18 at approximately 12:50 PM, E# 13 (Management of Protective Services) verbally confirmed they don't have documentation of the specific training that was done for E# 28. Therefore unable to determine if the appropriate training was conducted for E# 28.

Based on a document review and interviews, it was determined in 2 of 11 (E#7 and #11) employee's files reviewed, the Hospital failed to ensure all employees had an annual competency update in restraint/seclusion training as per policy. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.


Findings include:

1. The policy titled "Restraint and Seclusion Management", was reviewed on 9/5/18 at approximately 1:00 PM, the policy required "Policy:...9...c. Staff with direct care restraint responsibilities are trained and competent in application of restraints, implementation of seclusion, monitoring, assessment and care for patients prior to providing care. d. training occurs... annually."

2. The employee files of the following employees were reviewed on 9/5/18 at approximately 1:15 PM and lacked an annual update of restraint/seclusion training:

a. E# 7's (Registered Nurse) file included the last restraint/seclusion training was dated 2/11/17
b. E# 11's (Registered Nurse) file included the last restraint/seclusion training was dated 12/2016

3. During an interview with E# 9 (Director of Employee Relations) and E# 10 (Human Resources Business Partner) on 9/5/18 at approximately 1:15 PM, both verbally confirmed the files lacked updated restraint/seclusion training

Based on document review and interview, it was determined for 1 of 2 (E# 28) security guards, the Hospital failed to ensure the appropriate restraint/seclusion training was conducted. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. On 9/6/18 at approximately 12:30 PM, E# 13 (management of protective services) presented a form titled "Employee Competency Pathway." E# 13 stated "the form was for orientation for security guards." The form included E #28 had training on 1/20/18 for "Role and Regulations in restraining patients/visitors/staff." Surveyor requested the specific training that was conducted for E# 28. The training lacked specific training related to staff behaviors, events and environmental factors that trigger use of restraint or seclusion and use of other interventions.

2. On 9/6/18 at approximately 12:50 PM, E# 13 verbally confirmed E #28's file lacked documentation of the specific training of restraint/seclusion. Therefore, it was unable to be determine if the appropriate training was conducted for E# 28.

Based on a document review and interviews, it was determined in 1 of 2 (E# 13) security guard employee files reviewed, the Hospital failed to ensure that all staff involved in restraint/seclusion usage maintained current CPR certification. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. The employee files of the currently employed security guards were reviewed on 9/5/18 at approximately 1:15 PM, E# 13's file lacked a current CPR certification.

2. During an interview with E# 9 (Director of Employee Relations) and E# 10 (Human Resources Business Partner) on 9/5/18 at approximately 1:15 PM, both verbally confirmed the file lacked CPR certification.

3. On 9/6/18 at approximately 1:00 PM, E# 13 (management of protective services) verbally confirmed E# 13 lacked a current CPR certification.

Based on a document review and interviews, it was determined in 1 of 2 (E# 13) security guard employee files reviewed, the Hospital failed to ensure that all staff conducting training for restraint/seclusion was qualified. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. The employee files of the currently employed security guards were reviewed on 9/5/18 at approximately 1:15 PM, the file of E# 13 (management of protective services) lacked documentation of training for restraints/seclusion training.

2. On 9/6/18 at approximately 12:30 PM, E# 13 (management of protective services) presented a form titled "Employee Competency Pathway." E# 13 stated "the form was for orientation for security guards." The form included E# 28 had training on 1/20/18 for "Role and Regulations in restraining patients/visitors/staff" the training was documented as being done by E#13 (management of protective services).

3. On 9/6/18 at approximately 12:45 PM, E# 13 verbally confirmed that he has not had any training that qualifies E# 13 to be able to train another employee on restraints/seclusion.

Based on document review and interview, it was determined for 4 of 4 (Pt's #3, #6, #7 and #9) records reviewed of patients who were restrained for violent or self-destructive behavior and required continuous observation by a staff member, the Hospital failed to ensure staff were qualified and competent in restraint and seclusion monitoring. This has the potential to affect approximately 2550 patients per month who present to the Emergency Department (ED) for a medical screening evaluation.

Findings include:

1. The policy titled "Restraint and Seclusion Management" (reviewed 4/3/18) was reviewed on 9/4/18. The policy stated "9. Training... c. Staff with direct patient care restraint responsibilities are trained and competent in the application of restraints, implementation of seclusion, monitoring, assessment and care for patients prior to providing patient care...1. When restraints and seclusion are used... the patient is continually monitored by trained staff..."

2. The clinical records were reviewed throughout the survey on 9/4/18 to 9/6/18. The "Psych (Psychiatric)/Suicide Observation Checklist" form required the staff member who provided continuous observation of a patient in restraints and seclusion for Violent and/or Self-destructive behaviors to initial the patient's location and activity every 15 minutes. The following patients were restrained, secluded and were continuously monitored for Violent and/or Self-destructive behaviors, The observer's initials and signature on the checklist were unidentifiable, therefore unable to determine if the staff member was qualified and competent:
a) Pt #3, Date of Service (DOS): 8/16/18, Diagnosis: Psychiatric Evaluation
b) Pt #6, DOS: 6/12/18, Diagnosis: Suicidal Ideation
c) Pt #7, DOS: 7/30-31/18, Diagnosis: Depression
d) Pt #9, DOS: 8/28/18, Diagnosis: Suicidal Ideation

3. During an interview on 9/4/18 at approximately 2:30 PM, E#7 (Trauma Coordinator) and E#15 (Manager of ED) reviewed Pt #3, #6 and #9's Psych (Psychiatric)/Suicide Observation Checklist and were unable to identify the initials and signature of the observers. E#15 stated "They (sitter/observer) could be someone who doesn't even work in our department. If we need a sitter, the House Supervisor will find one and send them (sitter/observer) down (to ED) or they (sitter/observer) could be floating from another hospital."

4. During an interview on 9/6/18 at approximately 11:00 AM, E#3 (Regulatory Coordinator) stated "The House Supervisor" has a pool of staff that have received training (restraint and seclusion monitoring). They (House Supervisor) would only send someone down to sit with the patient if they (Sitter) was competent." E#3 reviewed Pt #3, #6, #7 and #9 Psych (Psychiatric)/Suicide Observation Checklist and verbally agreed the initials and signatures were unidentifiable and competence could not be determined. E#3 stated "They (sitter) should print their name so we can tell who it is."