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Based on the manner and degree of the standard level deficiency, it was determined §482.13 Condition of Participation: Patient Rights was out of compliance.

A-0115- A hospital must protect and promote each patient's rights. Based on interviews and document review, the facility failed to ensure staff removed patients from locked seclusion when patients no longer presented a threat to the safety of themselves or staff. Document review showed 7 of 11 episodes of patients in locked seclusion on the behavioral health unit were locked in seclusion while sleeping, subdued or both (Patient #7, Patient #8, Patient #9, Patient #10, Patient #12 and Patient #13).

Based on interviews and document review, the facility failed to ensure staff removed patients from locked seclusion when patients no longer presented a threat to the safety of themselves or staff. Document review showed 7 of 11 episodes of patients in locked seclusion on the behavioral health unit were locked in seclusion while sleeping, subdued or both (Patient #7, Patient #8, Patient #9, Patient #10, Patient #12 and Patient #13).

Findings include:

Facility Policies:

The Restraints and Seclusion: Violent Patient policy read, the purpose of the policy was to address patient management and documentation requirements regarding the use of restraints for the violent or self-destructive patient. Seclusion was limited to clinically appropriate situations. Seclusion was used to protect the patient's safety or when patient behavior threatens the safety of staff or others. Seclusion was utilized when alternative strategies had failed. The least restrictive intervention needed was used. Seclusion should be discontinued at the earliest possible time by a Registered Nurse (RN) when the patient's behavior meets expectations. The policy defined seclusion as: the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving.

The Patient Rights and Responsibilities policy read patients would be free from seclusion or restraint for behavioral management unless there was a need to protect the patient's physical safety or the safety of others.

1. The facility failed to remove patients from seclusion when they were sleeping or subdued and no longer presented a threat to the safety of themselves or staff.

a. Interviews with staff revealed the facility kept patients in a locked room and did not allow the patient to leave after patients no longer presented a threat to staff safety or a threat to themselves.

i. On 4/14/21 at 8:20 a.m., an interview was conducted with Registered Nurse (RN) #1. RN #1 stated patients often fell asleep when they were secluded. RN #1 stated she was instructed by leadership to leave patients in locked seclusion after they fell asleep. RN #1 stated she was trained to keep the seclusion room door locked to prevent patients from falling if the patient was groggy after they received medications.

ii. On 4/14/21 at 8:30 a.m., an interview was conducted with RN #2. RN #2 stated seclusion was used at the facility as a last resort after all other options to ensure patient safety were exhausted. RN #2 stated staff were educated to seclude a patient for as little time as possible. RN #2 stated patients should not remain in seclusion while they were asleep. RN #2 stated patients were safer sleeping in their assigned room as opposed to sleeping in the locked seclusion room. RN #2 stated the facility instructed staff to keep patients in the locked seclusion room if the patient fell asleep while in seclusion. RN #2 stated the facility instructed staff to keep the seclusion room door locked at all times when a patient was in the seclusion room.

iii. On 4/15/21 at 8:09 a.m., an interview was conducted with the Director of Nursing (DON) #3 for the Behavioral Health Unit. DON #3 stated the facility took seclusion seriously and exhausted all other possible means to ensure safety before patients were locked in seclusion. DON #3 stated the policy regarding seclusion must be followed for all occasions when patients were secluded. DON #3 stated if patients did not present a danger to themselves or others, staff should not seclude patients. DON #3 stated seclusion was to be used only as a last resort for patient and staff safety because seclusion was a traumatic and frightful experience and there was the psychological harm of seclusion. DON #3 stated a patient did not present a threat to themselves or others if the patient was asleep or subdued. However, DON #3 stated the facility kept patients in locked seclusion when subdued or sleeping because of previous recommendations for patient safety. DON #3 was unable to provide any evidence the practice aligned with facility policy or regulations.

b. The facility policy read, patients would be free from seclusion unless there was a need to protect the patient's physical safety or the safety of others. Additionally, seclusion was utilized when alternative strategies had failed and should be discontinued at the earliest possible time when the patient's behavior meets expectations.

c. Review of the seclusion log and patient records revealed from 12/20/20 to 3/25/21, multiple patients were documented as asleep, subdued or both while locked in seclusion. Examples included:

i. Record review of Patient #7's 15 minute High Risk Monitoring Sheet read, Patient #7 was in seclusion on 1/4/21 from 2:54 p.m. to 6:45 p.m. Review revealed Patient #7 was asleep from 3:45 p.m. to 6:45 p.m., for a total of three hours. According to the policies, Patient #7 should have been removed from seclusion at 3:45 p.m., the patient remained in seclusion for another three hours.

ii. Record review of Patient #7's 15 minute High Risk Monitoring Sheet read, Patient #7 was in locked seclusion again on 1/5/21 from 7:40 a.m. to 9:40 a.m. The document read Patient #7 was calm and composed at 8:45 a.m. and at 9:00 a.m. Patient #7 was documented sleeping at 8:30 a.m., 9:15 a.m. and 9:30 a.m., while he remained in seclusion. Patient #7 should have been removed from seclusion at 8:30 a.m., when he longer exhibited harmful behavior.

iii. Record review of Patient #8's 15 minute High Risk Monitoring Sheet read, Patient #8 was in seclusion on 12/20/20 from 12:20 p.m. to 2:40 p.m. The document read Patient #8 presented as: guarded and composed at 12:30 p.m.; worried and anxious at 12:45 p.m. and 1:00 p.m.; composed at 1:15 p.m.; and sleeping from 1:30 p.m. to 2:15 p.m., while he remained in seclusion.

iv. Record review of Patient #9's Restraint Flow Sheet read, Patient #9 was in seclusion on 1/13/21 from 12:13 p.m. to 2:13 p.m. The document read Patient #9 was subdued at 1:13 p.m. and was sleeping from 1:28 p.m. to 1:58 p.m.

v. Record review of Patient #10's Restraint Flow Sheet read, Patient #10 was in locked seclusion on 1/17/21 from 2:00 p.m. to 4:00 p.m. The document read Patient #10 was tearful and subdued from 2:15 p.m. to 2:45 p.m. and subdued at 3:00 p.m. There was no documentation why Patient #10 remained in seclusion.

vi. Record review of Patient #12's 15 minute High Risk Monitoring Sheet read, Patient #12 was in locked seclusion on 3/3/21 from 6:07 p.m. to 8:11 p.m. The document read Patient #12 was calm and composed from 6:30 p.m. to 7:00 p.m. and was sleeping from 7:15 p.m. to 8:11 p.m. when the patient was released.

vii. Record review of Patient #13's 15 minute High Risk Monitoring Sheet read Patient #13 was in locked seclusion on 3/24/21 from 12:57 p.m. to 2:35 p.m. The document read Patient #13 was calm and composed at 1:00 p.m. and was sleeping from 1:30 p.m. to 2:45 p.m.

These examples were in contrast to facility policy and interviews with facility staff which stated patients were to be released from seclusion when they no longer presented as a danger to themselves or others.