HospitalInspections.org

Based on record review and interview the Registered Nurse (RN) placed 1 0 1 (Patient #1) in seclusion on 04/07/24 without a physician order.

Findings included:

Patient #1's Shift Progress Note dated 04/07/24 at 01:50 PM reflected..."Patient became agitated this morning and began to hit and Kick RN and staff. Patient was unable to self-soothe and was walked to the quite room..." However a review of the video footage for 04/07/24 reflected the event happened at 08:36 AM and the patient was placed in the seclusion room with the door closed. A review of the medical record did not evidence an order for the seclusion of Patient #1.

During an interview on 04/15/24 at 01:35 PM Personnel #1 verified there was not an order for seclusion for Patient #1 on 04/7/24.

The policy titled Emergency Behavioral Interventions: Use of Restraint/ Seclusion dated 07/17/19 reflected..."Physician Order 1. A physician order from a member of the Hospital's medical staff is required for restraint or seclusion use as an emergency behavior management technique..."

Based on record review the facility failed to provide a 1-hour face-to-face medical and behavioral evaluation of 1 of 1 (Patient#1) patients after the use of seclusion on 04/07/24.

Findings included:

Patient #1's Shift Progress Note dated 04/07/24 at 01:50 PM reflected ..."Patient became agitated this morning and began to hit and kick RN (nurse) and Staff. Patient was unable to self-soothe and was walked to the quite room. However a video review reflected Patient #1 was place in the seclusion room on 04/07/24 at 08:36 AM with the door closed and released at 08:52 AM. Patient #1's medical record did not reflect a 1-hour face-to-face evaluation was completed for the use of seclusion.

During an interview on 0/15/24 at 01:35 PM Personnel #1 verified there was not a restraint/seclusion packet completed for the above incident, therefore there was not a 1-hour face-to-face evaluation completed.

The policy titled Emergency Behavioral Interventions: Use of Restraint/Seclusion dated 07/17/19 reflected...Face-to Face Evaluation 1. A physician or their qualified designee, Physician Assistant, Advanced practice Nurse, or QRN) shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restrain or seclusion to personally verify the need for restraint or seclusion..."

Based on record review the facility failed to maintain a clinical record for 1 of 1 (Patient #1) with records sufficient to permit CMS to determine the degree and intensity of treatment furnished.

Findings included:

A camera review reflected on 04/07/24 at 08:36 AM Patient #1 was placed in the seclusion room with the door closed and released at 08:52 AM. The Shift Progress Note dated 04/07/24 at 01:50 PM reflected ..."Patient became agitated this morning and began to hit and kick RN (nurse) and Staff. Patient was unable to self-soothe and was walked to the quite room. The medical record did not reflect an order for seclusion, a 1-hour face-to-face evaluation after the patient was released, or a notification of a legally authorized representative. The time of the incident was recorded as occurring over five hours after the seclusion occurred.

During an interview on 04/07/24 at 01:35 PM Personnel #1 stated if the patient is placed in a seclusion room and the door is left open it is not considered a seclusion and the restraint/seclusion packet does not need to be completed. Personnel #1 stated he reviewed the camera footage for the time charted and could not find the alleged incident on camera. Personnel #1 stated he spoke with the nurse involved and that nurse stated they did not recall the exact time the incident occurred and just put the time that they charted the incident. Personnel #1 stated he reviewed the camera footage and found Patient #1 was escorted to the seclusion room on 04/07/24 at 08:56 AM and the door was closed. Patient #1 remained in the seclusion room until 08:52 AM when they were released from the room. Personnel #1 stated the medical record did not reflect a restraint/seclusion packet.

The restrain/seclusion packet includes an order for restraint/seclusion, other methods attempted prior to restraint seclusion, the patient behavior prior to restraint seclusion, the 1-hour face-to-face evaluation, and if a legally authorized representative was notified of the restraint/seclusion.