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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide safe care to four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

A review on March 20, 2023, at 11:23 A.M., of the facility's policy, Assessing Patient Risk for Suicide/Homicide, last updated, September 6, 2022, revealed, " IV. Procedure: a. Patients who are being evaluated for behavioral health conditions as their primary reason for care, will be screened for suicidal ideation using the validated Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS and the homicide risk assessment are located in the electronic medical record within the following locations: i. ED assessment, ii. ED Triage Assessment, ...c3. Reassessment of patients with a positive screen will be completed every discontinues the reassessment order or patients are discharged .... 12 hours until a physician. ...f. contraband and unsafe items not necessary for patient care should be removed from the patient's room... .".

A review on March 20, 2023, at 11:23 A.M., of the facility's Policy, Searching of a Patient and Their Belongings, last revised December 20, 2022, revealed, "Procedure:
1. A search of the patient's person, clothing and his/her personal belongings will be done immediately upon presentation for behavioral health evaluation and for patients who need constant observation for a behavioral health need. An explanation as to the reasons for the search will be provided to the patient. ...4. The patient shall be searched by use of a hand held metal detector by security prior to removal of clothes... .".

Review of MR1, on March 20, 2023, revealed that the patient was accompanied by two police officers and presented to the Emergency Department on March 16, 2023, at 8:28 P.M. MR1 was brought to the hospital by the police with a warrant that had already been granted prior to arrival for a 302, involuntary commitment for psych at 7:09 P.M. MR1 was immediately placed in the hall way with a sitter. The triage assesment was done but the
Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS and the homicide risk assessment was not completed. Further review of MR1 revealed that the patient was examined at 9:13 P.M. and lab tests were ordered to obtain medical clearance. The medical record revealed that the patient, was diagnosed with suicidal gestures, on March 16, 2023 additionally, the medical record failed to include that a reassessment of patients with a positive screen will be completed until the reassessment order is discontinued or patients are discharged A review of MR1, revealed that the patient eloped on March 17, 2023, at 8:25 A.M..

On March 20, 2023, at 09:39 A.M., EMP3 and EMP4 confirmed that MR1 remained in his own clothing and was moved to a non psychiatric room with his wife.

Review of MR2 on March 20, 2023, revealed that the patient presented to the Emergency Department, for a psychiatric evaluation on August 1, 2022, however, the medical record lacked documentation that a C-SSRS was completed, as per facility policy.

Review of MR3 on March 20, 2023, revealed that the patient presented to the Emergency Department for a psychiatric evaluation on December 12, 2022, however, the medical record lacked documentation that a C-SSRS was completed, as per facility policy.

Review of MR4 on March 20, 2023, revealed that the patient presented to the Emergency Department for a psychiatric evaluation on August 17, 2022, however, the medical record lacked documentation that a C-SSRS was completed, as per facility policy.

On March 20, 2023, EMP6 confirmed the above.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure each order for restraint used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others was time limited according to patient age for one of two restraint records reviewed (MR10).

Findings include:

Review of facility "POLICY: HS-NA0416 ... SUBJECT: Restraint and Seclusion DATE: July 1, 2022", revealed: " ... IX. USE OF RESTRAINT OR SECLUSION FOR VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR ... B. PHYSICIAN'S ORDER ...2. An order for restraint or seclusion used for Violent or Self Destructive behavior and any renewals are subject to the following limits: ... b. Two hours for children and adolescents ages 9 to 17. ...".

Review of MR10 revealed that the patient is a 17 year old who was placed in 4 point hard restraints in the emergency department for violent/aggressive behavior on March 18, 2023, between 16:22 and 18:40. Review of the physician order dated March 18, 2023 at 20:50 PM revealed: "Hard restaints ordered for patient and staff safety starting at 16:22 hrs, the restraints have been ordered to be D/C'd at 18:40 hr. ...".

During a medical record review with EMP6 on March 20, 2023, at approximately 2:15 PM, EMP6 confirmed the restraint order for MR10 exceeded 2 hours and stated that the order was entered using free text.

Based on Review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that a face-to-face evaluation was completed within one hour after the initiation of restraints used to manage violent or self-destructive behavior for one of two medical records reviewed for patients in restraints (MR10).

Findings include:

Review of facility "POLICY: HS-NA0416 ... SUBJECT: Restraint and Seclusion DATE: July 1, 2022", revealed: " ... IX. USE OF RESTRAINT OR SECLUSION FOR VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR ... 7. The physician, CRNP or PA must see the patient and evaluate the need for restraint or seclusion within one hour of initiation of restraint or seclusion and write an order or sign a verbal order for the restraint or seclusion. ...".

Review of MR10 revealed that the patient is a 17 year old who was placed in 4 point hard restraints in the emergency department for violent/aggressive behavior on March 18, 2023, between 16:22 and 18:40. Review of MR10 did not reveal that a face to face evaluation was conducted by a physician, CRNP or PA while MR10 was in restraints.

During a medical record review with EMP6 on March 20, 2023, at approximately 2:15 PM, EMP6 confirmed there was no documentation of a one hour face-to- face evaluation in the medical record for MR10.