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Based on facility tour and staff interview and verification, it was determined the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association with regards to ensuring exit access was arranged so that exits were readily accessible at all times and placement of smoke detectors was not affected by airflow devices. Potentially all patients, staff and visitors could be affected. The facility census was 43 patients at the time of the survey.

Findings include:

On 09/25/12, between 11:20 A.M. and 3:30 P.M. a tour of the facility was conducted with Staff G and H. The following findings were noted during the facility tour. Please refer to the life safety code report for more specific details.

K38, addressed the paths of egress for three exit discharges which required travel across uneven grassy areas to the public way and the presence of delayed egress locks which unlocked with activation of the fire alarm system but were also equipped with dead bolt type locks.

K130 , addressed the placement of smoke detectors in spaces serviced by airflow devices that could prevent the operation of the detectors.

The above findings were verified by Staff G and H who were present during the facility tour.

Based on policy review, record review and interview, the facility failed to provide timely revisions/updates of the Master Treatment Plans (MTPs) of 1 of 2 active sample patients (A1) who had been in seclusion and restraint while hospitalized. The treatment plan was not revised in a timely way to include specific interventions that staff would use to de-escalate the patient's aggressive behaviors in an effort to prevent additional seclusion/restraint events. This failed practice hampers staff's ability to provide effective interventions for patients needing assistance in maintaining behavior control.

Findings include:

A. Policy Review

1. Facility policy number "1000.44, Use of Seclusion and Restraint," updated September 2012, includes the following statements:
Page 4, item 5: "...for Inpatients, any incident of use of special treatment measures will trigger an additional treatment team review of the treatment plan. Involvement of the patient to review those identified coping skills, and triggers is completed and this new information is added to the treatment plan."
Page 5, item 11: "Following the first episode, and any additional episodes, of seclusion or restraint, the ISP (Interdisciplinary Service Plan)/treatment plan shall be reviewed and amended to include measures to prevent recurrence, this needs to be completed at the conclusion of the event."

2. Facility policy number "1000.44A (1), Seclusion for Acute Inpatients," updated July 2007, states on page 3, Item 12: "The treatment plan of patients requiring seclusion shall be reviewed and amended following the first episode of seclusion to include measures to prevent recurrence, as applicable."

3. Facility policy number "1000.44B (1), Restraint Use for Inpatients," updated July 2007, states on page 3, Item 12: "The treatment plan or ISP of patients requiring restraint shall be reviewed and amended following the first episode, and all episodes of restraint to include measures to prevent recurrence, as applicable."

B. Record Review (MTP review 9/26/12)

1. Patient A1 was a young adolescent admitted to the hospital on 9/22/12. The second day of hospitalization (9/23/12) at 3:10 p.m., the patient was placed in a 1 minute physical hold for "threatening to punch peers and hurt self." The following additional restraint and/or seclusion episodes took place during the next three days:
9/24/12: Seclusion (3:30-4:10 p.m.)
9/25/12: Restraint (9:39 a.m. to 9:40 a.m.); Seclusion (9:40 a.m. to 10:20 a.m.)
9/25/12: Restraint (6:13 p.m. to 6:15 p.m.); Seclusion (6:15 p.m. to 7:15 p.m.)
9/26/12: Restraint (6:05 p.m. to 6:07 p.m.)

2. The Master Treatment Plan, developed 9/23/12, included routine nursing interventions, e.g., "assault precautions" "encouraging (patient) to deep breath [sic] or take a timeout to calm down," and "15 minute checks," to address the patient's aggressive behaviors. The only addition to the written treatment plan after the restraint on 9/23/12 was a hand written note, documenting the 1 minute physical hold. There was no plan update after this event or after the seclusion/restraint events of 9/24/12 or 9/25/12, specifying what additional interventions would be used to de-escalate the patient. The treatment plan review of 9/26/12 included documentation of an increase in the patient's medication, and it noted that the patient "remains in PICU (Psychiatric Intensive Care Unit);" however, no specific de-escalation interventions (other than the medication change) were documented on the written treatment plan.

C. Observation

During an observation of an interdisciplinary treatment team meeting on 9/26/12 at 11:30 a.m., the staff discussed Patient A1's aggressive behaviors and the seclusion/restraint events noted above. However, no specific interventions to de-escalate the patient's aggressive behaviors on the unit were identified.

D. Interview

1. In an interview on 9/27/12 at approximately 10 a.m., MD1 (the attending physician for patient A1) acknowledged the need for additional interventions to de-escalate patient A1's aggressive behaviors. He also noted that psychologist- recommended Behavioral Intervention Plans were sometimes available for patients who had been in the facility's residential care or day treatment program prior to a hospitalization, but this type of plan was not yet available for Patient A1.

2. In an interview on 9/27/12 at 11:30 a.m., the Director of Nursing (DON) and the Director of Acute (Inpatient) Services (person responsible for treatment programming on the inpatient unit) acknowledged the need for a stronger focus on developing timely interventions to de-escalate the disruptive behaviors of patients needing Seclusion/Restraint.

Based on record review and interview, the facility failed to provide Master Treatment Plans for 5 of 8 active sample patients (A1, A2, A3, A4 and C1) that were based on patient strengths/assets as well as disabilities. Many of the patient strengths/assets identified on the psychosocial assessments were not utilized to develop the treatment plan. In addition, the treatment plans incorrectly identified external resources, e.g., "supportive family" or "support of family and friends" as personal strengths. These deficiencies hamper staff's ability to help patients use their strengths to overcome their disabilities, potentially diminishing the effectiveness of treatment.

Findings include:

A. Record Review (MTP dates in parentheses)

1. The facility's Master Treatment Plan form had a section on the last page of the form titled "Patient Strengths and Assets." There was a check-list of 10 items which could be identified as patient strengths, including the item "other" where staff could write in additional identified strengths.

2. Patient A1 (MTP update 9/26/12). The only item checked on the MTP "Patient Strengths and Assets" list was "Support of family and friends." This is an external resource, not a personal strength that the patient brought to treatment. This patient had multiple episodes of seclusion/restraint; yet, there was no evidence that attempts had been made to identify personal strengths/assets that could be used to develop an effective intervention plan to assist the patient to maintain behavioral control.

3. Patient A2 (MTP 9/24/12). The only item checked on the MTP "Patient Strengths and Assets" list was "Support of family and friends." This is an external resource, not a personal strength that the patient brought to treatment. There was no evidence that patient strengths identified in the psychosocial assessment, e.g., "good organizer, verbal" were utilized to develop the treatment plan.

4. Patient A3 (MTP 9/24/12). The only item checked on the MTP "Patient Strengths and Assets" list was "Support of family and friends." This is an external resource, not a personal strength that the patient brought to treatment. There was no evidence that patient strengths identified in the psychosocial assessment, e.g., "artist; sports; good student; verbal; love for animals" were utilized to develop the treatment plan.

5. Patient A4 (MTP update 9/26/12). The only item checked on the MTP "Patient Strengths and Assets" list was "Support of family and friends." This is an external resource, not a personal strength that the patient brought to treatment. There was no evidence that patient strengths identified in the psychosocial assessment, e.g., interest in "baseball and sports" were utilized to develop the treatment plan.

6. Patient C1 (MTP update 9/26/12). The only item checked on the MTP "Patient Strengths and Assets" list was "Support of family and friends." This is an external resource, not a personal strength that the patient brought to treatment. This patient had been placed in a physical restraint on 9/24/12 at 5:05 p.m. due to aggression toward staff. The psychosocial assessment had identified the patient's strengths/assets as interest in "video games"; "playing on computer" and "basketball." There was no evidence of how/if this information was used to assist the patient to maintain behavioral control.

B. Staff Interview

In an interview on 9/27/12 at approximately 11 a.m., the Director of Nursing (DON) and the Director of Acute (Inpatient) Services acknowledged that patient strengths/assets were not adequately utilized in developing the written Master Treatment Plans.

Based on record review, policy review and interview, it was determined that the Director of Nursing (DON) failed to assure that the medical record of 1 of 10 non-active (discharged) patients (SR 3) who had multiple episodes of seclusion and/or restraint in July/August 2012 included accurate documentation of all seclusion/restraint events. On one seclusion/restraint record for this patient, the written time of the seclusion was inconsistent with other documented S/R procedures and with staff reports of the event. The documentation error was not identified during multiple steps of the utilization review process. These deficiencies can result in the facility's failure to identify staff's non-compliance with Seclusion/Restraint policy and procedures, potentially putting patients at risk.
Findings include:

A. Record Review

1. Patient SR3 was an adolescent who was readmitted to the hospital from a RTC (Residential Treatment Center) on 7/24/12.

2. A log of Seclusion/Restraint events for the 3 months prior to the survey (June-August 2012), provided by the facility at the request of the surveyors, had the following seclusion/restraint events listed for Patient SR3 during the patient's hospitalization on the inpatient unit:
July 26, 2012:
Restraint: 1:30 p.m. (less than 1 minute);
Seclusion: 3:45 p.m. to 4:30 p.m.
July 27, 2012:
Seclusion/Restraint: 10:04 a.m. to 11:00 a.m.; 5:17 p.m. to 6:05 p.m.; 6:55 p.m. to 7:57 p.m.
July 28, 2012:
Restraint: 7:10 a.m. to 7:18 a.m.; 7:25 a.m. to 7:32 a.m.; 7:39 a.m.to 7:50 a.m.
Seclusion: 9 a.m. to 9:30 a.m.; 3:45 p.m. to 4:45 p.m.;
Seclusion/Restraint: 1:38 p.m. to 2:45 p.m.

3. The July 28 (2012) Seclusion/Restraint record for the 7/28/12 1:38 p.m. Seclusion/Restraint event documented that the patient was put in a physical hold (restraint) at 1:38 p.m. and given emergency medication at 1:40 p.m. per physician order. According to the record, the patient was placed in seclusion at 1:45 p.m. (immediately after the restraint and emergency medication), and was released at 2:45 p.m. The same S/R record noted that the patient also was in seclusion from 3:45 p.m. until 4:45 p.m. (another 60 minutes, with an hour between the seclusion events). There was no separate S/R record for the second seclusion event. However, there were two Seclusion/Restraint Orders, written and signed by the physician. The first order, written at 1:45 p.m., was for the restraint and first hour of seclusion. A second order, for an additional hour of seclusion, was written at 2:45 p.m.

B. Staff Interviews

1. On 9/26/12 at 5:20 p.m., the surveyor met with the DON and RN1 (the inpatient nursing supervisor) to review the 7/28/12: 1:38 p.m. Seclusion/Restraint record for Patient SR3. When shown the S/R record, RN1 stated that the documentation of the time of the second seclusion event was an error on the record. He stated that he had intended to release the patient from seclusion at 2:45 p.m. (end of first 60 minutes of seclusion), but that when he started to do this, the patient became agitated and threatening again, so he obtained an MD order to continue the seclusion for another hour. According to RN1, the seclusion was continued without a break (with the MD order for continuation) for another 60 minutes. RN1 stated that because he perceived the 2 hours of seclusion to be one seclusion episode, he documented it on one S/R form. He stated, "I made a mistake on the form in writing the second hour of seclusion as 3:45 p.m. to 4:35 p.m. It should have been 2:45 p.m. to 3:45 p.m."

2. On 9/27/12 at 10:10 a.m., the surveyors met with the DON, the Director of Inpatient Services, and the Director of Quality Improvement to discuss the S/R documentation error noted above and the process used for quality review of S/R records. All three administrators, and the Chief Executive Officer (CEO) who also attended the meeting, acknowledged the documentation error on the 7/28/12: 1:38 p.m. S/R record for Patient SR3. They expressed surprise that the error was not detected during the Process Improvement (PI) reviews, despite a multi-stage process that included initial record reviews by the charge nurse and RN supervisor on the inpatient unit, and subsequent reviews by the administrative team (DON, the Director of Inpatient Services, and the Director of Quality Improvement) and the medical records staff. There was no explanation for the failure to detect the error.

C. Policy Review

The facility's policy number 1000.44, titled "Use of Seclusion and Restraint-Philosophy & Overview of Special treatment & Safety Measures," includes the following statement on page 5, Item 14: "The facility shall maintain ongoing trending of factors associated with seclusion and restraint as part of the hospital Process Improvement (PI) effort. Concurrent PI review of all special treatment and safety measures will be done at the conclusion of the episode by the clinical supervisor on duty at the time of the episode. The loop of PI shall endeavor to reduce and where possible eliminate S&R."