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Based on staff interview and record review, the hospital failed to ensure that a patient was actively involved in the development, implementation and revision of his/her plan of care prior to discharge (Patient #2). Findings include:

Patient #2, with a diagnosis of schizophrenia, was admitted involuntarily for psychiatric treatment to the hospital on 8/24/2017 from another facility to facilitate the administration of court ordered psychotropic medications, which could not be implemented at his/her previous hospital placement. S/he required inpatient treatment due to a period of medication noncompliance resulting in an inability to care for his/herself and increasing symptoms of delusions and hallucinations.

On 9/1/2017 a Multidisciplinary Treatment Team plan was developed and stated Patient #2's plan was to "return to apartment with designated agency supports". The Psychosocial Assessment and Initial Discharge Plan written by the Social Worker on 8/25/2017 included the plan to, "gather collateral information from and collaborate with the patient, family and outpatient providers." A Progress Note on 9/1/2017 documented that the Social Worker had spoken to the patient and his/her community case manager.

On 9/4/2017 at 0109, Patient #2 was involved in a physical altercation with another patient on the unit, requiring staff to implement seclusion to de-escalate the conflict. This altercation resulted in Patient #2 sustaining a laceration on his/ her scalp requiring two staples. Subsequently, Patient #2 was placed on constant observation as a safety intervention. On 9/4/2017, Patient #2 was involved in a second physical altercation with the same patient, which staff were able to de-escalate verbally without the need to implement seclusion or restraint. The next day, a Nursing Progress note on 9/5/17 at 11:45 AM stated, "sheriffs arrived to the unit, writer in to explain to patient that s/he was being transferred" to another hospital. The Nursing Progress note further states,"Patient surprised but accepting of this information. Went willingly, without protest, accompanied by 2 sheriffs". The Inpatient Psychiatry Discharge Summary electronically signed 9/6/2017 states that Patient #2 was transferred to another hospital, "due to continued conflict" and the "..inability to separate these patients due to architectural constraints...".

Per record review, there was no evidence that Patient #2 was involved in the development of the discharge plan which included the transfer to another hospital on 9/5/17. Physician and Nursing Progress notes following the incidents of physical violence on 9/4/2017 did not address a possible transfer, either with the patient or among treatment team members, following the physical altercations on the unit. There were no Physician, Nursing or Social Work Progress notes documenting clinical indicators necessitating the transfer, transfer arrangements, or planning associated with Patient #2's discharge from the hospital.

In interview, the Team Lead for Case Management and Social Work confirmed the lack of discussion with Patient #2 regarding the transfer plan, and the absence of Progress Notes or a Discharge Summary reflecting the implementation of Patient #2's discharge plan. The lack of evidence of Patient #2's involvement in the development and implementation of his/her discharge plan was confirmed with the Director of Emergency Care, Access and Patient Transitions and the Team Leader for Case Management and Social Work at 10:30 AM on 2/14/18.

Based on staff interview and record review, the hospital failed to provide sufficient interventions to assure each patient's rights were protected by maintaining care in a safe setting as evidenced by the failure to recognize and implement a plan of care to reduce or eliminate the potential for harm for all patients. Findings include:

On 9/4/17 at approximately 1:09 PM Patient #1 and Patient #2 became involved in a significant altercation on Shepardson 6. Patient #1, was admitted to psychiatry for psychosis experiencing paranoid delusions. Patient #1 had a history of violence towards others and impulsivity and upon admission was assigned to 1:1 constant observations. While Patient #1 sat at a computer located in a hallway, Patient #2, also experiencing psychosis and paranoia, approached MHT (Mental Health Technician) who was providing 1:1 constant observations for Patient #1. An altercation erupted between Patient #1 and Patient #2. A fist fight resulted, with both patients sustaining injuries. Patient #1 was diagnosed with a left medial blowout orbital fracture (traumatic injury to the bone of the eye socket). Patient #2 fell to the floor resulting in a laceration to the occipital area (back of skull) of the patient's head requiring staples to close the laceration. Once separated, Patient #2 stated s/he wanted to "finish" the fight. As a result of imminent threats and inability to deescalate, Patient #2 was placed in seclusion for a period of time and also placed on 1:1, no other interventions were documented in the record.

Per Psychiatry Emergency Note for 9/4/17 at 1:54 Patient #1 was "...euphoric following fight..". Again on 9/4/17 and within 2 hours of first incident, Patient #1 assaulted a Mental Health Technician (MHT) punching the employee 4 times on the head. Shortly after this assault both Patient #1 and Patient #2 were able to engage in further conflict. Despite being on 1:1, Patient #1 was able to approach and confront Patient #2 further threatening and challenging Patient #2 to fight. Patient #2 punched Patient #1 in the previously injured left eye. Staff intervened, patients were separated. On 9/5/17 at approximately 08:35, Patient #1 and Patient #2 were co-mingled during breakfast. Although unprovoked, Patient #1 threw a breakfast tray towards the face of Patient #2. Subsequently, Patient #1 was placed in seclusion. Besides the initiation of 1:1 and constant observations for Patient #1 the Psychiatry Multidisciplinary Treatment Team failed to develop a timely plan with a more coordinated effort among staff to maximize safety and ensure each patient's right to receive care in an environment that is safe, protecting both the physical and emotional well being for all patients.

Based on staff interview and record review, the hospital failed to revise the restraint/seclusion policy for Psychiatric Emergencies for the inpatient psychiatry unit to reflect the current required regulation. Findings include:

Per review the hospital's policy Manual Restraint, Mechanical Restraint and Use of Seclusion: Psychiatric Emergency - Inpatient Psychiatry effective 6/17/2016 states: "Restraints and seclusion will only be used when an individual is in imminent danger of harm to self and others...The staff's goal will be to release restraints or end seclusion as soon as possible while protecting the safety of the individual and others. This will occur when the unsafe behavior ends or a least restrictive alternative is feasible." However, the hospital policy further states: " 8. If the individual in seclusion falls asleep, unlock seclusion room door within one hour..." Per interview on 2/14/17 at 2:15 PM, the nurse manager for Shepardson 3 & 6 confirmed staff will continue to keep the seclusion door locked for up to 1 hour although the patient who was placed in seclusion is sleeping and no longer poses a threat of harm to self and others. The nurse manager acknowledged this was in accordance with hospital policy. However, the process and present hospital policy does not comply with the requirement for the Condition of Participation for Acute Hospital Regulations/Appendix A: A-0174 (482.13(e)(9) which states: "Restraints or seclusion must be discontinued at the earliest possible time, regardless of length of time identified in the order".

Based on staff interview and record review, the hospital failed to ensure that episodes of seclusion were discontinued at the earliest possible time for 5 out of 10 patients in the sample (Patient #1, Patient #3, Patient #7, Patient #9, and Patient #10). Findings include:

1. Per record review, Patient #1 was admitted to Shepardson 6 on 9/2/17 with schizophrenia and psychosis. Patient #1 demonstrated impulsive and violent behaviors. On the morning of 9/5/17 Patient #1 became involved in an incident with another patient on the unit. Patient #1 threw a meal tray at a patient s/he had targeted. After the event Patient #1 went to his/her room but demonstrated increased anxiety, anger and became threatening to staff resulting in seclusion being ordered. Per review of the Seclusion Monitoring Flowsheet seclusion began at 09:05. Every 15 minutes the MHT would document Patient #1's behaviors while in seclusion. At 09:15; 09:30 documentation noted Patient #1 was "sleeping". At 09:44 documentation describes Patient #1 as "calm/composed" and at 09:45 "in blanket", however seclusion door remained locked. At 10:05 a nursing assessment was conducted, at which time patient awakened and became agitated. From that point on, Patient #1 remained in seclusion until finally discontinued at 12:15.

2. Patient #3 was admitted on 10/4/17 voluntarily with a diagnosis of paranoia, delusions and depression. On 10/5/17 Patient #3 became intrusive, grabs and pulls a physician towards him/herself. With assistance from security Patient #3 was escorted to seclusion which began at 0430. Per review of Seclusion Monitoring Flowsheet, Patient #3 was agitated and restless, by 05:15 the patient's behavior was subdued and from 05:30 to 06:15 the MHT recorded the patient as "Asleep". It was not until 06:28 seclusion was discontinued and the door was opened. Patient #3 remained in seclusion for almost 60 minutes beyond criteria for the use of seclusion.

3. Patient #7 was admitted to the psychiatric unit on 9/20/17 with Bipolar affective disorder and delirium. On 9/24/17 the patient was described in a Psychiatry Emergency Note to be "...in a state of acute mania...." After assaulting a MHT, a Code 8 (behavioral emergency which alerts security and other staff to come to the unit to assist as needed). The patient received emergency medications and was placed in seclusion starting at 06:06. Per the Seclusion Monitoring Flowsheet at 06:15 the MHT documented Patient #7 was "awake & calm". At 06:30 and 06:45 Patient #7 was noted to be sleeping. At 06:49 the seclusion room door was unlocked. Patient #7 had remained in seclusion for greater than 30 minutes although observed to be calm.

4. Patient #9 was admitted involuntarily to the hospital on 1/5/18 due to worsening psychotic symptoms including command auditory hallucinations. On 1/6/18 Patient #9 became agitated while doing laundry. S/he returned to his/her room and shortly after threw a meal tray at staff conducting 1:1 supervision with Patient #9. The patient was placed in seclusion at 11:56. By 12:15 Patient #9 was observed by MHT to be "asleep". At 12:30, 12:45 & 13:00 "awake and subdued " At 13:09 seclusion was discontinued. On 1/9/18 around noon Patient #7 threw several meal trays on the kitchen floor and slapped a physician in the face. Patient # 9 could not contract for safety and was escorted to seclusion and accepted oral Ativan and Olanzapine. Seclusion was initiated at 12:22. At 12:30 Patient #9 was "agitated & restless". At 12:45 the MHT describes Patient #7 as laying down and calm. At 13:00 & 13:15 Patient #9 was "awake & subdued". Seclusion is discontinued at 13:25, despite the earlier opportunity to end seclusion when Patient #9 was calm/subdued.

In addition, on 2/14/18 at 2:30 PM the nurse manager for Shepardson 3 & 6 further confirmed seclusion had not been discontinued at the earliest possible time for Patients # 1, 3, 7 & 9 who were not demonstrating a risk of harm to selves or others. The nurse manager acknowledged staff presently utilize the hospital policy which allows staff to keep patients in seclusion for up to 1 hour despite meeting criteria for discontinuing seclusion.

5. Per record review, Patient #10, with a diagnosis of schizophrenia, was admitted to the facility on 9/19/2017 following a period of psychiatric overcompensating due to medication noncompliance. Patient #10 exhibited deficits in self-care and symptoms of paranoid delusions and hallucinations. The Seclusion/ Restraint Note written by the Registered Nurse on 11/7/2017 documented that Patient #10 "appeared to be getting more and more agitated throughout the shift". S/he exhibited behavior including clenched fists, physically advancing toward the RN, and swinging their arms at the RN. S/he was escorted to seclusion without the need for manual restraint.

The episode of seclusion was initiated at 1728. Per review of the Seclusion Monitoring Flowsheet, Patient #10's behavior was documented by Mental Health Technicians in 15 minute intervals. Per documentation, at 1815, Patient #10 was, "laying with eyes closed but making facial expressions." At 1830, Patient #10 was documented as "asleep". At 1845, documentation states, "seems to be back at baseline". At 1901, Patient #10 was documented as being "subdued".

Per documentation, at 1828 the Registered Nurse justified the continuing need of the seclusion due to, "imminent risk of harm to self or others". Documentation by the RN indicated the discontinuation criteria for the seclusion included, "absence of behavior that required restraint". The seclusion was discontinued at 1912. Descriptions of Patient #10's behavior did not indicate a risk of serious harm after 1815. The lack of evidence of continued need for seclusion for Patient #10 was confirmed with the Psychiatry Nurse Manager on 2/14/2018 at 2:15 PM.

Based on staff interview and record review, there was a failure of hospital staff to appropriately reassess a discharge plan after changes in a patient's condition warranted adjustments to previously identified continuing care needs for 1 of 10 patients in the sample (Patient #2).

Patient #2 was admitted involuntarily to the hospital on 8/24/2017 from another facility to facilitate the administration of court ordered psychotropic medications, which could not be implemented at the prior facility. S/he initially required psychiatric admission due to a period of medication noncompliance, which resulted in an inability to care for his/her self and increasing symptoms of delusions and hallucinations. Per record review, Patient #2 was diagnosed with schizophrenia, had a prior history of community mental health services and previous inpatient psychiatric admissions.

On 9/1/2017 a Multidisciplinary Treatment Team plan was developed and documented Patient #2's plan to "return to apartment with designated agency supports". The Psychosocial Assessment and Initial Discharge Plan developed by the Social Worker on 8/25/2017 included interventions to, "gather collateral information from and collaborate with the patient, family and outpatient providers in the Discharge Plan. A Social Work Progress Note on 9/1/2017 states, "Spoke with community case manager and patient".

On 9/4/2017 at 0109, Patient #2 was involved in a physical altercation with another patient on the unit, requiring staff to implement seclusion to de-escalate the conflict. This altercation resulted in a laceration on his/ her scalp requiring two staples, and Patient #2 was subsequently placed on constant observation as a safety intervention. On 9/4/2017, Patient #2 was involved in a repeated physical altercation with the same patient, which staff were able to de-escalate verbally without the need to implement seclusion or restraint. On 9/4/2017 at 20:25, an Attending On-Call note states, "Events of the past 24 hours reviewed with nursing staff and written sign-out reviewed. See multiple chart notes about emergency events. Patient sleeping when I did rounds and I did not wake him given the necessity of sleep to improve his condition". The Attending On-Call note states under Plan: "Unchanged, refer to orders and multidisciplinary team treatment plan. Per Nursing Progress note on 9/5/17 at 11:45 AM, "sheriffs arrived to the unit, writer in to explain to patient that s/he was being transferred" to another hospital. Per RN note, "Patient surprised but accepting of this information. Went willingly, without protest, accompanied by 2 sheriffs". The Inpatient Psychiatry Discharge Summary electronically signed 9/6/2017 states that Patient #2 was transferred to another hospital, "due to continued conflict" and the "inability to separate these patients due to architectural constraints".

Per review of Patient #2's record, there was no evidence of a re-assessment of his/her discharge needs following his/her change in clinical presentation and involvement in physical altercations at the hospital. The Initial Treatment Plan completed by the Social Worker on 8/25/2017 was not updated to reflect a reassessment, nor did it indicate a need to transfer to another hospital. The last social work progress note was dated 9/1/2017, and there was no evidence in the medical record of communication with Patient #2, his/her family, or community treatment providers regarding the clinical events necessitating transfer to another hospital. The hospital policy, "Discharge Planning and Patient Discharge" effective 2/3/2017 lacks an identified process for triggering a reassessment of a patient's post-discharge needs, capabilities and discharge plan following a change in condition.

During an interview, the Team Lead of Case Management and Social Work (identified as clinical supervisor) stated that assessments completed by the social workers are expected to be incorporated into the multidisciplinary treatment plan and form the basis of the discharge plan. The lack of re-assessment of Patient #2's discharge plan following a change in his/her status was confirmed with the Director of Emergency Care, Access and Patient Transitions and the Team Lead for Case Management and Social Work on 2/14/2018 at 10:30 AM.