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Based on record review and interview, it was determined that for 4 of 8 active sample patients (A1, A2, B1, and C3) and one of one non-sample patients (B2), the hospital failed to provide psychiatric evaluations that reported memory functioning and/or intellectual functioning in terms which clearly reflected the patient's ability to function in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient A1: In a psychiatric evaluation dated 1/19/11 under the section titled "Mental Status Exam", memory was noted as: "He denies any problems with his memory." There was no supportive information provided regarding specific memory testing.

2. Patient A2: In a psychiatric evaluation dated 2/5/11 under the section titled "Mental Status Exam", memory and intellectual functioning were noted as: "Recent and remote memory she feels are impaired, because she is confused and can't concentrate. She is of average intelligence." There was no supportive information provided regarding memory testing and intellectual functioning.

3. Patient B1: In a psychiatric evaluation dated 1/29/11 under the section titled "Mental Status Exam", memory was not described or discussed, and intellectual functioning was described as "His I.Q. by gross clinical examination could not be assessed. Having known this child during his last hospitalization, his/intellectual functioning appears to be below average." There was no evidence in the patient's medical record that the physician completed the examination at later date as of the date of the survey (2/15/11).

4. Patient B2: In a psychiatric evaluation dated 2/8/11 under the section titled "Mental Status Exam", memory was not evaluated, and intellectual functioning was described as "His outpatient psychiatrist has not mentioned any mental retardation or intellectual impairment in this child." There was no evidence of any further attempts to complete memory testing or estimate intellectual function in the patient's record as of the date of the survey, 2/15/11.

5. Patient C3: In a psychiatric evaluation dated 2/10/11 under the section titled "Mental Status Exam", memory was noted as: "He denies problems with recent or remote memory. He is of above average intelligence." There was no supportive information provided regarding memory testing and intellectual functioning.

B. Interview

In an interview on 2/15/11 at 2:00p.m. with the Medical Director, the five psychiatric evaluations noted above were reviewed and discussed. The Medical Director agreed with the findings and stated "We could be more specific."

Based on observation, interviews, policy and record review, the facility failed to implement seclusion protocol for 1 of 1 non-sample patient (B2) who was placed in his room for a "time-out" and was not permitted to leave the room when he asked to leave. The young child had the "time-out" for acting out on the unit and not following staff direction. While he was on the time-out, a MHT (Mental Health Technician) sat in a chair in the doorway of his room, preventing the patient from leaving the room. The child's request to leave the room was denied. The staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors described what was observed to the Director of Nursing ten minutes later. Failure to implement seclusion protocol for a patient who is in seclusion results in lack of timely assessments and documentations of the patient's condition, potentially leading to an unsafe situation for the patient.

Findings include:

A. Observation

In an observation on 2/15/11 at 10:45a.m. on the children's unit, the surveyor observed MHT1 sitting in a chair blocking the doorway of Patient B2's room. The patient was sitting on the bed inside the room and appeared to be in control. He asked MHT 1 if he [patient] could leave the room. MHT1 denied the request. When both surveyors returned to the room area on 2/15/11 at 10:55a.m., the chair that MHT1 had been sitting on had been moved to the hallway. Patient B2 was sitting on his bed eating a snack and appeared to be calm.MHT1 was speaking with the DON (Director of Nursing) in the hallway outside of the patient's room.

B. Interviews

1. In an interview on 2/15/11 at 10:55a.m. (right after the observation above), Patient B2 was asked by the nurse surveyor if he would be allowed leave his room. Patient B2 responded "No." The patient was then asked if he had been told to stay in his room by staff. Patient B2 responded "Yes."

2. In an interview on 2/15/11 at 11:00a.m., RN1 stated, "We had [patient B2] on a room time-out, but if the door was blocked that would be seclusion. I need to then write it up as a seclusion episode."

3. In an interview on 2/15/11 at 11:05a.m., MHT1 acknowledged that he had blocked the door with his chair and stated "I didn't think I was allowed to let [B2] out of the room if [B2] is on a time-out."

4. In an interview on 2/15/11 at 11:05a.m., the Director of Nursing agreed that blocking the doorway and not letting a patient leave the room if the patient requested to leave was a seclusion event.

5. In an interview on 2/15/11 at 1:30p.m., the Director of Nursing stated, "Our CPI (Behavioral Management Program) instructor heard about the event with Patient B2 and agreed that this episode should have been treated as seclusion; she was upset because she felt she had emphasized over and over during training that not letting the patient leave a room is seclusion."

C. Policy Review

1. Facility Policy and Procedure titled "Time Out Program", revised on 11/03 and approved by JMBHC (John Muir Behavioral Health Center) Board on 2/10, states the following:

"Section A: A Timeout is established to provide patients with a structured environment in which to identify problem behaviors and attitudes and set goals which will help them change. Timeouts are not intended to be used as long-term interventions, but are utilized to achieve immediate short-term goals, and should be implemented immediately after an incident of inappropriate behavior."

"Section C: The staff will also attempt to use art therapy (drawing) with children and/or those patients who are not able to verbalize expressions of their feelings." "1. Patients must voluntarily agree, [sic] participate in time-out. It can never be enforced by staff."

2. Facility Policy and Procedure titled "Locked Seclusion," revision 1/07, last approved by JMBHC Board on 2/10 states the following:

"I. Seclusion is used only when alternative methods have been attempted and have been ineffective to protect a patient from immediate threat of injury to him/herself and/or others." "Definitions: Locked seclusion is defined as involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving."

D. Record Review

At 1:15p.m. on 2/15/11, the facility presented documentation of the observed "time out" event for Patient B2 and identified it as seclusion. According to the documentation, the patient was released from the seclusion (time-out in his room) at 11:00a.m. There was a physician's order for seclusion, a face-to-face physician evaluation, and a patient debriefing. For the item, "Behavior indicating DTS/DTO [reasons] for seclusion &/or restraint procedure:" the following documentations were written: "Pt. [patient] running around in hallway banging on door & walls. Staff asked pt to come into room with him so he could calm down & not disturb peers. Pt did go into room, was lying on bed, tried to hit staff. Pt told to stay in his room w/staff there." The Director of Nursing acknowledged that the documentation was done "after the fact" (meaning after the surveyors identified the event as seclusion).

Based on record review and interview, the facility failed to provide a discharge summary that summarized treatment received in the hospital and the patient's response (other than medication management) for 6 of 6 discharged patients whose records were reviewed (S1, S2, S3, S4, S5 and S6). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings Include:

A. Record Review

1. Patient S1: In a discharge summary dated 1/17/11 under the section titled "Hospital Course," the physician dictated information related to the use of medication to treat the patient's illness. There was no discussion of the patient's response to the milieu or to specific assigned group/individual therapies.

2. Patient S2: In a discharge summary dated 1/09/11 under the section titled "Hospital Course," the physician dictated information related to the use of medication to treat the patient's illness. There was no discussion of the patient's response to the milieu or to specific assigned group/individual therapies other than a statement that noted: "In fact, he was attending group on a regular basis with no signs of significant depression with a need for further intervention."

3. Patient S3: In a discharge summary dated 2/2/11 under the section titled "Hospital Course," the physician dictated information related to the use of medication to treat the patient's illness. There was no discussion of the patient's response to the milieu or to specific assigned group/individual therapies.

4. Patient S4: In a discharge summary dated 1/17/11 under the section titled "Hospital Course," the physician dictated information related to the use of medication to treat the patient's illness. There was no discussion of the patient's response to the milieu or to specific assigned group/individual therapies other than a statement that noted: "The patient received individual, group and milieu therapies through the length of his stay."

5. Patient S5: In a discharge summary dated 2/12/11 under the section titled "Hospital Course," the physician dictated information related to the use of medication to treat the patient's illness. There was no discussion of the patient's response to the milieu or to specific assigned group/individual therapies.

6. Patient S6: In a discharge summary dated 1/17/11 under the section titled "Hospital Course," the physician dictated information related to the use of medication to treat the patient's illness. There was no discussion of the patient ' s response to the milieu or to specific assigned group/individual therapies.

B. Interview

In an interview on 2/15/11 at 2:00p.m. with the Medical Director, the six discharge summaries noted above were reviewed and discussed. The Medical Director agreed with the findings and stated "The physicians could add some detail about care to the reports."

Based on record review and interview, the facility failed to ensure that the discharge summaries for 5 of 6 discharged patients (S1, S2, S3, S5 and S6) contained a summary of the patient's condition. This failed practice results in critical clinical information about the patient's level of psychiatric symptomatology not being available to aftercare providers.

Findings include:

A. Record Review

1. Patient S1: In a discharge summary dated 1/17/11, there was no description of the patient's condition at time of discharge.

2. Patient S2: In a discharge summary dated 1/9/11, there was no description of the patient's condition at time of discharge.

3. Patient S3: In a discharge summary dated 2/2/11, there was no description of the patient's condition at time of discharge other than: "On 1/6/11, she was discharged in a stable condition."

4. Patient S5: In a discharge summary dated 2/12/11, there was no description of the patient's condition at time of discharge other than: "By the time of discharge (1/14/11), he was slightly disorganized, but much improved."

5. Patient S6: In a discharge summary dated 1/17/11, there was no description of the patient's condition at time of discharge.

B. Interview

In an interview on 2/15/11 at 2:00p.m. with the Medical Director, the five discharge summaries noted above were reviewed and discussed. The Medical Director stated "I agree; we need to do a better job."

Based on record review and interview, the Medical Director failed to ensure that physicians completed psychiatric evaluations and discharge summaries. These failures make treatment more difficult for other inpatient providers as well as making it difficult to accurately relay treatment information to the next level of care after the hospitalization. The Medical Director also failed to ensure that staff always follows seclusion protocol when patients have seclusion events.

Specifically, the Medical Director failed to:

I. Ensure that the psychiatric evaluations for 4 of 8 active sample patients (A1, A2, B1 and C3) and 1 of 1 non-sample patient (B2) included a report of memory functioning and/or intellectual functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

II. Ensure that staff implemented seclusion protocol for 1 of 1 non-sample patient (B2) who was placed in his room for a "time-out" and was not permitted to leave the room when he asked to leave. The young child had the "time-out" for acting out on the unit and not following staff direction. While he was on the time-out, a MHT (Mental Health Technician) sat in a chair in the doorway of his room, preventing the patient from leaving the room. The child's request to leave the room was denied. The staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors described what was observed to the Director of Nursing ten minutes later. Failure to implement seclusion protocol for a patient who is in seclusion results in lack of timely assessments and documentations of the patient's condition, potentially leading to an unsafe situation for the patient. (Refer to B125)

III. Ensure that physicians provided a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment for 6 of 6 discharged patients whose records were reviewed (S1, S2, S3, S4, S5 and S6). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

IV. Ensure that the discharge summaries for 5 of 6 discharged patients (S1, S2, S3, S5 and S6) included a summary of the patient's condition.This failed practice results in critical clinical information about the patient's level of psychiatric symptomatology not being available to aftercare providers. (Refer to B135)

Based on observation, interviews, policy and record review, the Director of Nursing failed to ensure that nursing staff implemented seclusion protocol for 1 of 1 non-sample patient (B2) who was placed in his room for a "time-out" and was not permitted to leave the room when he asked to leave. The young child had the "time-out" for acting out on the unit and not following staff direction. While he was on the time-out, a MHT (Mental Health Technician) sat in a chair in the doorway of his room, preventing the patient from leaving the room. The child ' s request to leave the room was denied. The staff failed to recognize this situation as a seclusion event and did not initiate seclusion protocol until the surveyors described what was observed to the Director of Nursing ten minutes later. Failure to implement seclusion protocol for a patient who is in seclusion results in lack of timely assessments and documentations of the patient's condition, potentially leading to an unsafe situation for the patient.

Findings include:

A. Observation

In an observation on 2/15/11 at 10:45a.m. on the children's unit, the surveyor observed MHT1 sitting in a chair blocking the doorway of Patient B2's room. The patient was sitting on the bed inside the room, Patient B2 asked the MHT if he [patient] could leave the room. MHT1 denied the request. When both surveyors returned to the room area on 2/15/11 at 10:55a.m., the chair that MHT1 had been sitting on had been moved to the hallway. Patient B2 was sitting on his bed eating a snack and continued to appear calm. MHT1 was speaking with the DON (Director of Nursing) in the hallway outside of the patient's room.

B. Interviews

1. In an interview on 2/15/11 at 10:55a.m., (right after the above observation), Patient B2 was asked by the nurse surveyor if he was allowed leave his room. Patient B2 responded "No." The patient was then asked if he had been told to stay in his room by staff. Patient B2 responded "Yes."

2. In an interview on 2/15/11 at 11:00a.m., RN1 stated "We had [patient B2] on a room time-out, but if the door was blocked that would be seclusion. I need to then write it up as a seclusion episode."

3. In an interview on 2/15/11 at 11:05a.m., MHT1acknowledged that he had blocked the door with his chair and stated "I didn't think I was allowed to let [B2] out of the room if [B2] is on a time-out."

4. In an interview on 2/15/11 at 11:05a.m., the Director of Nursing agreed that blocking the doorway and not letting a patient leave the room if the patient requested to leave was a seclusion event.

5. In an interview on 2/15/11 at 1:30p.m. the Director of Nursing stated, "Our CPI (Behavioral Management Program) instructor heard about [the event with Patient B2] and agreed that this episode should have been treated as seclusion; she was upset because she felt she had emphasized over and over during training that not letting the patient leave the room is seclusion."

C. Policy Review

1. Facility Policy and Procedure titled "Time Out Program", last revised 11/03 and approved by JMBHC (John Muir Behavioral Health Center) Board on 2/10, states the following:

"Policy: Section A: A Timeout is established to provide patients with a structured environment in which to identify problem behaviors and attitudes and set goals which will help them change. Timeouts are not intended to be used as long-term interventions, but are utilized to achieve immediate short-term goals, and should be implemented immediately after an incident of inappropriate behavior."

"Section C: The staff will also attempt to use art therapy (drawing) with children and/or those patients who are not able to verbalize expressions of their feelings." "1. Patients must voluntarily agree, [sic] participate in time-out. It can never be enforced by staff."

2. Facility Policy and Procedure titled "Locked Seclusion", last revised1/07 and approved by JMBHC Board 2/10, states the following:

"I. Seclusion is used only when alternative methods have been attempted and have been ineffective to protect a patient from immediate threat of injury to him/herself and/or others."
"Definitions: Locked seclusion is defined as involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving."

D. Record Review

At 1:15 pm on 2/15/11, the facility presented documentation of the observed "time out" event with patient B2 as seclusion; including a physician's order for seclusion, a one hour face-to-face evaluation and patient debriefing. For the item "Behavior indicating DTS/DTO [reasons] for seclusion &/or restraint procedure" the following documentation was written: "Pt. [patient] running around in hallway banging on door & walls. Staff asked pt to come into room with him so he could calm down & not disturb peers. Pt did go into room, was lying on bed, tried to hit staff. Pt told to stay in his room w/ staff there." The Director of Nursing acknowledged that this documentation was being done "after the fact" (meaning after the surveyors identified the event as seclusion).