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During the tour of the Emergency Department (ED) and review of the Emergency Equipment logs, it was determined that on the following dates October 7, 9, and 18, 20 ED staff assigned to check the equipment failed to sign the emergency checklist to authenticate that staff had checked the emergency equipment carts and validated that the equipment was ready for patient use in an emergent situation.

In addition, on October 12 respiratory staff failed to validate by signature that the Difficult Airway Cart was found sealed or if not sealed whether contents had been verified and resealed for use in case of a difficult airway emergent situation.

Based on a review of the policy for non-violent/non-self-destructive behavior and for violent/self-destructive behavior, it was determined that the policies do not meet the regulatory standards.

The hospital has two policies, one for non-violent/non-self-destructive behavior and another for violent/self-destructive behavior. Policy R-1 is the policy and procedure for non-violent/non-self-destructive behavior. The policy states in part, if a physician is not available to issue an order for restraint, an RN may initiate restraint use based upon an appropriate assessment of the patient. A verbal or written physician order must be obtained within 12 hours of initiation of restraint. Policy R-2 is the policy and procedure for violent/self-destructive behavior states "as soon as possible, but no longer than 1 hour after the initiation of restraint/seclusion, the RN notifies and obtains an order (verbal or written) from the physician. The regulation requires in emergency application situations the order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The hospital's current policies do not address this process and therefore the policies do not meet regulatory standards.

In addition, R-2 policy and procedure for violent/self-destructive behavior under physician order and application/continuation/discontinuation of restraint and seclusion number 13 states that when restraint or seclusion is terminated early and the same behavior is still evident, the original order can be reapplied if less restrictive alternatives remain ineffective. This section of the policy and procedure does not conform to the regulation and can allow for improper implementation of restraint or seclusion on a PRN (as needed) basis.

Based on review of a total of 19 patient records, inclusive of 2 open restraint patient records, it is determined that, the medical record did not contain evidence that the decision to continue or discontinue restraint was based on an assessment and re-evaluation of the patient's condition.

Based on review of 2 out of 14 open medical records for patient #6 and patient # 7, the shift documentation and every two hour monitoring lack evidence of an assessment and re-evaluation of the patient's condition and whether the restraint should be continued or discontinued. The documentation revealed restatement of the initial reason for the restraint but no indication of reassessment and the outcome.

Based on review of 2 out of 14 open medical records for patient # 6 and patient # 7, it was determined that the on-going every two hour monitoring and assessment was incomplete for both patients. On October 21, 2013 at 6:00 AM the documentation review revealed the 6:00 AM space was blank for both patients.

Based on a review of 19 patient records, inclusive of 1 open seclusion patient record, and physician/nursing training for conducting a face to face it is determined that the face to face assessment was performed by a physician for patient #8 failed to include all the listed elements of this requirement.

Patient # 8 was placed in seclusion after verbal interaction, medication and diversion activity was ineffective in preventing the patient from verbally threatening and assaultive behavior toward peer, nursing staff and security. The patient was placed in restraint on October 14, 2013 at 3:00 PM until October 15, 2013 at 12:45 PM. The patient became threatening again, paranoid about peer placed in seclusion on October 15, 2013 at 4:00 PM until October 17, 2013 at 10:30 AM.

Review of the face-to-face documentation revealed no discussion of the patient's reaction to the intervention, medical and behavioral condition and frequency the patient was referred to the psychiatrist for evaluation. The face-to-face was incomplete and did not give a true picture of the patient's condition or whether the seclusion should be continued or terminated.