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Based on staff interview and record review, the hospital failed to assure the less restrictive interventions had been attempted and determined to be unsuccessful to protect the patient and/or others from harm during the course of extended use of seclusion for 1 of 2 applicable patients. (Patient #3) Findings include:

Per record review, Patient # 3 was placed in seclusion (locked in assigned hospital room) on 5/24/17 at 15:26 when s/he refused to change urine soaked clothes and socks with or without staff assistance, refused to remain voluntarily in assigned hospital room and repeatedly attempted to mingle in the milieu while only partially dressed wearing a urine soaked hospital gown. Prior to seclusion, Patient #3 had refused redirection, encouragement and refused medication.

When Patient #3's bedroom door was locked at 15:26 and seclusion was implemented, the patient began pulling on the door handle and pushing against the hospital room door. Per review of Psychiatric Ongoing Assessment for 5/24/17 at 19:30 Patient #3 struck a staff member who had entered his/her room to empty the toilet of several objects. Per Psychiatric Ongoing Assessment at on 5/24/17 at 23:25 states; " Patient is being monitored for mania and psychosis.....patient glaring out and would not respond to any questions. Patient remains in soiled clothing. Has not changed...." Per the Emergency Involuntary Procedures /Nursing Seclusion Flow Sheet for 5/24/17 and 5/25/17 states the reason for continued use of seclusion " (what patient behavior continues a risk of harm to self/others)" included at 16:41"....Pt asked if s/he was able to change clothes to come out of room. Pt. staring straight ahead....refusing to allow staff to help change"; at 21:05 " Pt remains partially clothed in urine soaked gown and socks...pt refused scheduled and PRN (as needed) medications; at 5/25/17 at 02:51 " Pt. continues to wear urine soaked clothes...Pt is agitated and pushing on door; refusing medications." Documentation of "Patient Behavior" on the Nursing Seclusion Flow Sheet over 13 hours repeatedly describes the patient as " Refusing to change soiled clothes"; "Aggressively trying door handle"; "Staring through window"". Per Psychiatric Ongoing Assessment for 5/25/17 at 02:15 notes after Patient #3 had defecated on the floor staff entered patient's room, cleaned floor while the patient walked away from the door.

Per interview on 7/25/17 at 9:10 AM, the Psychiatric Services Director of Nurses for the PSIU (Psychiatric Services Inpatient Unit) confirmed staff were concerned of impending risk for infection control exposure to other patients if Patient #3 was allowed to leave his/her room and become integrated into the milieu. Per review of hospital policy Restraint and Seclusion last approved 05/26/2017 " C. Policy 5. Less Restrictive Alternatives-...Seclusion may not be used when a less restrictive intervention would be appropriate.....Seclusion must be based on a comprehensive individualized patient assessment to determine whether the use of less restrictive measures such as intensified supervision poses a greater risk than the risk of using Restraint or Seclusion". Despite frequent communication with the attending psychiatrist who continued to re-order seclusion there was no indication of other less restrictive interventions were tried and documented or other evidence that alternatives were considered and determined to be insufficient during the 13 hours of seclusion.

Remaining awake throughout the length of seclusion, after 10 hours Patient #3's behaviors demonstrated increased agitation, resulting in pushing on the room door more violently, throwing articles in room, and lack of any association with staff or complying with requests to change clothes. It was not until 05:00 on 5/25/17 seclusion was discontinued when Patient #3 agreed to shower. During a debriefing with Patient #3, on 5/25/17 a Psychiatric Ongoing Assessment note states: "..while debriefing, patient wasn't sure at first what led to seclusion. When this writer explained what had happened s/he said ' I have accidents when I'm stressed' The patient told this writer 'I was scared....what happened in seclusion before had me scared and I shut down because of PTSD' The patient told this writer that s/he didn't remember everything that happened over the course of seclusion".

Based on staff interview, medical record and policy review, the hospital failed to evaluate a patient's medical condition and assure that the face to face evaluation conducted within 1 hour after the initiation of restraint and/or seclusion included all elements of a medical and behavioral assessment, necessary to determine if other factors could be contributing to the behavior that warranted the need for implementation of the use of restraint/ and or seclusion for 1 of 2 patients (Patient #2). Findings include:

Per record review, Patient #2, who was admitted involuntarily on 9/1/2016, had multiple episodes of the use of restraints and/or seclusion between the date of admission and 9/25/2016. The Emergency Involuntary Procedures form used by staff to document the use of seclusion and/or restraint includes a Patient Assessment (to be completed within one hour of initiation of the emergency procedure) directing staff to : describe of the condition of the patient upon examination; describe less intrusive measures attempted to reduce the need for the emergency procedure; describe potential risks and benefits of the procedure; identify risk factors, and complete a physical assessment. The physical assessment is to include documentation of vital signs, injuries, respiratory status, assessment of hyperthermia and a behavioral assessment. Per review of 4 separate Emergency Involuntary Procedure forms completed for the use of restraints/ seclusion with Patient #2 between 9/4/2016 and 9/7/2016, there was no evidence in the documentation of the 1 hour Patient Assessment that Patient #2 had been assessed for injury as part of the physical assessment. Per record review, a Patient Debriefing form was completed by a Registered Nurse with Patient #2 following the episode of seclusion/ restraint that occurred on 9/7/2016 at 1230. When asked, "How do you feel as a result of this event?" Patient #2 responded, "You injured and abused me". Per record review, a Patient Debriefing form was completed on 9/12/2016 by a Registered Nurse with Patient #2 following the episode of seclusion/ restraint that occurred on 9/7/2016 at 1400. When asked, "How do you feel as a result of this event?" Patient #2 responded, "I felt tortured, they hurt me". The above stated Emergency Involuntary Procedure forms were reviewed with the Director of Nursing at 11:45 AM on 7/25/2017.

The hospital policy, Restraint and Seclusion: Addendum to Restraint and Seclusion Policy for Patients on PSIU (last reviewed 3/2017), states that the Patient Assessment must be completed within 1 hour of the initiation of the emergency procedure by the physician, LIP, or specially trained Registered Nurse and is to include documentation of injuries sustained during the restraint (Section E.2.a.x.). There was no evidence of Patient #2 being assessed for injuries during the physical assessment as stated in hospital policy for emergency procedures occurring between 9/4/2016 and 9/7/2016.