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Based on interview and record review, the facility failed to ensure restraint or seclusion was only used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm (A0164). The facility failed to ensure the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy (A0167). The facility failed to ensure the the use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy (A0168).

Based on interview and record review, the facility failed to ensure restraint or seclusion was only used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm for two of ten patients reviewed (Patient #1 and #7). The patient census was 162.

Findings include:

1. The medical record review for Patient #1 revealed the patient was brought to the facility's emergency department on 10/07/21 on a application for emergency admission dated 10/07/21 at 8:20 PM. A review of that application for emergency admission revealed the patient had had erratic behavior, paranoia, and threats of harm to himself and others. The application for emergency admission was completed by local police.

A review of the emergency physician's provider note dated 10/07/21 at 8:23 PM revealed the patient was aggressive and anxious with pressured speech. The note stated the patient tested positive for marijuana use.

The medical record review revealed a psychiatric evaluation dated 10/08/21 at 8:52 AM. The evaluation revealed the patient was found to be alert and oriented to person, place, and time, responding to internal stimuli with non commanding auditory hallucinations, and mumbling and talking himself. The patient was diagnosed with psychotic disorder and cannabis use disorder.

A nursing note dated 10/13/21 at 12:30 PM revealed Patient #1 was on the 3 east psychiatric unit and stated that he ran down the corridor and pushed the fire door. The note stated he was escorted back to his room. The note did not state who or how many staff escorted him from the fire door back to his room. The nursing note of 10/13/21 at 12:30 PM then stated when the patient was in his room he began kicking and punching the wooden door to his room. The note stated he was "assisted to the floor by 3 staff" in order to keep safe until he could be escorted to the quiet room.

Review of the nursing note dated 10/13/21 at 12:30 PM revealed the patient was next "escorted" to the seclusion room via six staff and placed in locked seclusion.

The medical record review revealed a psychiatric note and order dated 10/13/21 at 12:41 PM to place the patient in seclusion.

Review of a security incident report submitted on 10/13/21 at 9:37 PM was completed. The review revealed it was authored by Security Officer #1. The review revealed Security Officer #1 and Staff B "escorted him down to the floor." Further review revealed "he was lifted off the ground by his legs and arms and carried to the seclusion room."

The report also revealed "Shortly after the patient started yelling and screaming while kicking the door. Looking into the room while telling him to stop kicking the door and calm down he took off his shirt. And then said, 'come in and fight me.' I asked the patient 'are you talking to me' (sic) and his response was 'yes'. [Security Officer #1 and Staff B] went into the room where he was actively trying to strike us with closed fists. We gained control over his arms and escorted him down to the floor."

The review further revealed during the event that Patient #1 bit a nurse and spit in the face of Staff B.

A review of the patient's discharge summary dated 10/13/21 at 1:16 PM stated the patient was discharged (from seclusion) to the local police for having assaulted two staff members.

On 11/16/21 at 5:24 PM in an interview, Nurse Manager #1 said the police took the patient outside. Nurse Manager #1 stated the patient said " 'I appreciate you allowing me to stand in the sun,' he said and all he wanted was fresh air and thanked the officer."

On 11/17/21 at 11:26 AM in an interview, Physician #1 said the patient told him he wanted to go out to get fresh air. He said he could have discharged the patient that day or the next. He said when the patient learned he would be leaving the hospital, he calmed down and changed into his regular clothes.

On 11/17/21 at 1:32 PM in an interview Nurse E said six individuals from both the nursing and security staff carried the patient from his room to a seclusion room. He explained a staff member was holding a limb and another holding his head to ensure he would not spit.

On 11/17/21 at 2:00 PM in an interview, Nurse F said the patient was carried by arms, legs, and shoulders by security in a prone position. She said she remembered telling them to adjust their hold because the patient's back was getting to extended.

On 11/17/21 at 2:15 PM Staff B was interviewed. Staff B said he went to Patient #1 in his room shortly after his return from being redirected from the fire door. He said Patient #1 tried to barge through himself and at least one security officer, was stopped, then told to stay in his room and calm down. He said he told the patient to "take a time out." He said he and Security Officer #1 then left the patient's room. He said thereafter he and Security Officer #1 heard the patient kicking and punching the walls and door of the room. He said upon entry, Security Officer #1 asked the patient if he was going to hit him and said the patient responded that he would and then took a swing. He said he and Security Officer #1 used manual holds as outlined in the facility's Nonviolent Crisis Intervention program to bring the patient to the floor. He said the patient was on his back. Staff B also stated the patient told him, prior to being taken to the ground in his room, that he wanted to leave to get fresh air.

On 11/17/21 at 2:50 PM Security Officer #1 was interviewed. Security Officer #1 confirmed speaking with Staff B and deciding to go into the patient's room because he was kicking and punching the walls screaming, "I want to go home." He said he and Staff B entered the room, the patient swung a punch, and then they took him to the ground. He said he was held on the ground face up.

On 11/17/21 at 3:20 PM in an interview, Security Officer #5 said the patient was carried by staff to the seclusion room with one at each limb and one on either side of his torso.

A review of Security Officer #5's supplemental to the security incident report confirmed nursing staff and security staff carried the patient to the seclusion room.

On 11/17/21 at 3:30 PM in an interview, Staff A said the patient went to the nursing station to ask to have his room unlocked so he could use its restroom. She said as she was getting the key, he left, and then continued past his room toward the fire escape. She confirmed he did activate the fire alarm by pressing on the door. She said she was able to redirect him away from the door and she was able to walk him to his room. She said he never threatened her or insulted her. She said she worked full time on the 3 east psychiatric unit and checked the patients' activity and location every 15 minutes. She said during Patient #1's stay and when she worked he never threatened her or insulted her.

On 11/17/21 at 3:45 PM in an interview, Security Officer #2 said he was part of the group that carried the patient to the seclusion room. He said he held a leg.

Review of Security Officer #2's supplemental to the security incident report confirmed the patient was carried to the seclusion room.

On 11/17/21 at 3:50 PM in an interview, Security Officer #3 said he participated in carrying the patient to the seclusion room.

Review of Security Officer #3's supplemental to the security incident report confirmed the patient was "lifted up and carried by Security and Pych (sic) staff to the seclusion room."

On 11/17/21 at 3:55 PM in an interview, Security Officer #4 said the patient was carried by his limbs to the seclusion room by his limbs with one person at his head. He said, "If he tried to walk he would resist and therefore decided to carry" him.

Review of Security Officer #4's supplemental to the security incident report confirmed the patient was carried to the seclusion room.

The medical record review did not reveal any attempts to provide fresh air or sun analogues on 10/13/21 after his attempt to leave the unit. Neither the medical record review nor a review of the security incident report revealed where the patient was given an opportunity to walk to the seclusion room.

Although Staff A was able to successfully redirect Patient #1 from the fire door without physical intervention, the clinical record did not reveal if she asked or attempted to direct the patient to the seclusion room.

On 11/18/21 at 11:45 AM in an interview, Nurse Manager #2 said if Staff A had made an attempt, it would have been documented. She said on that day there was not anyone who could have calmed him down.

2. The medical record review for Patient #7 was completed on 11/23/21. The medical record review revealed a history and physical dated 11/18/21 at 4:16 PM that stated while at his long term care facility he had "significant" behaviors that included climbing over his wheelchair and being confused. The history and physical assessed him with encephalopathy, planned for a neurology evaluation and consultation "to seek opinion on potential organic causes of the patient's a (sic) behaviors and altered sensorium." The history and physical noted the patient to have a visual impairment and difficulty with movement, noting to plan to consult with Physical and Occupational therapy to assess further rehab potential.

The medical record review revealed a physician order dated 11/22/21 at 11:17 AM to employ bilateral soft wrist restraints for non-violent behaviors creating a risk to the patient's safety.

The medical record review revealed the patient did not have intravenous access (having been discontinued on 11/18/21), a nasogastric tube, or indwelling urinary catheter.

The medical record review did not reveal how the patient's safety was at risk and what appropriate, less restrictive measures were first used to address that risk.

On 11/23/21 at 3:18 PM in an interview, Nurse Manager #3 confirmed the patient was in bilateral soft wrist restraints for agitation. She was unable to say what, without any medical devices in place, was the risk to the patient's safety. She was unable to show what less restrictive measure were then taken to address that risk.

Based on interview and record review, the facility failed to ensure the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy for one of ten patients reviewed (Patient #1). The facility's census was 162.

Findings include:

The medical record review for Patient #1 was completed on 11/23/21. The review revealed Patient #1 was brought to the facility's emergency department on 10/07/21 on a application for emergency admission dated 10/07/21 at 8:20 PM. A review of that application for emergency admission revealed the patient had had erratic behavior, paranoia, and threats of harm to himself and others. The application for emergency admission was completed by local police.

A review of the emergency physician's provider note dated 10/07/21 at 8:23 PM revealed the patient was aggressive and anxious with pressured speech. The note stated the patient tested positive for marijuana use.

The medical record review revealed a psychiatric evaluation dated 10/08/21 at 8:52 AM. The evaluation revealed the patient was found to be alert and oriented to person, place, and time, responding to internal stimuli with non commanding auditory hallucinations, and mumbling and talking himself. The patient was diagnosed with psychotic disorder and cannabis use disorder.

A nursing note dated 10/13/21 at 12:30 PM revealed Patient #1 was on the 3 east psychiatric unit and stated that he ran down the corridor and pushed the fire door. The stated he was escorted back to his room. The note did not state who or how many staff escorted him from the fire door back to his room. The nursing note then stated when the patient was in his room he began kicking and punching the wooden door to his room. The stated he was "assisted to the floor by 3 staff" in order to keep safe until he could be escorted to the quiet room. Further review of the nursing note revealed the patient was next "escorted" to the seclusion room via six staff and placed in locked seclusion.

The medical record review did not reveal whether the patient was "assisted" to the floor face up or face down.

Review of a security incident report submitted on 10/13/21 at 9:37 PM was completed. The review revealed it was authored by Security Officer #1. The review confirmed Security Officer #1 and Staff B "escorted him down to the floor." The report further revealed "Shortly after the patient started yelling and screaming while kicking the door. Looking into the room while telling him to stop kicking the door and calm down he took off his shirt. And then said, 'come in and fight me.' I asked the patient 'are you talking to me' (sic) and his response was 'yes'. [Specified Security Officer #1 and Staff B] went into the room where he was actively trying to strike us with closed fists. We gained control over his arms and escorted him down to the floor." Further review revealed "he was lifted off the ground by his legs and arms and carried to the seclusion room."

Review of the facility's code/stat communications log was completed. The review revealed on 10/13/21 at 12:16 PM a "team response" was called for Patient #1 at his room.

On 11/17/21 at 1:14 PM in an interview, Security Manager #1 said when a team response was called, staff were to follow the lead of the nurse.

On 11/17/21 at 1:32 PM in an interview Nurse E said six individuals from both the nursing and security staff carried the patient from his room to a seclusion room. He explained a staff member was holding a limb and another holding his head to ensure he would not spit.

On 11/17/21 at 2:00 PM in an interview, Nurse F said the patient was carried by arms, legs, and shoulders by security in a prone position. She said she remembered telling them to adjust their hold because the patient's back was getting too extended.

On 11/17/21 at 2:15 PM Staff B was interviewed. Staff B said he went to Patient #1 in his room shortly after his return from being redirected from the fire door. He said Patient #1 tried to barge through himself and at least one security officer, was stopped, then told to stay in his room and calm down. He said he told the patient to "take a time out." He said he and Security Officer #1 then left the patient's room. He said thereafter he and Security Officer #1 heard the patient kicking and punching the walls and door of the room and said Security Officer #1 said, "We got to go in or he's going to hurt himself." He said upon entry, Security Officer #1 asked the patient if he was going to hit him and said the patient said he would and then took a swing. He said he and Security Officer #1 used manual holds as outlined in the facility's Nonviolent Crisis Intervention program to bring the patient to the floor. He said the patient was on his back.

On 11/17/21 at 2:50 PM Security Officer #1 was interviewed. Security Officer #1 confirmed speaking with Staff B and deciding to go into the patient's room because he was kicking and punching the walls screaming, "I want to go home." He said he and Staff B entered the room, the patient swung a punch, and then they took him to the ground. He said he was held on the ground face up.

On 11/17/21 at 3:08 PM in an interview, Security Officer #6 said in a team response she would be directing security staff but would be working with nursing staff.

On 11/17/21 at 3:20 PM in an interview, Security Officer #5 said nobody really runs a team response. Security Officer #5 also said the patient was carried by staff to the seclusion room with one at each limb and one on either side of his torso.

Review of Security Officer #5's supplemental to the security incident report confirmed nursing staff and security staff carried the patient to the seclusion room.

On 11/17/21 at 3:45 PM in an interview, Security Officer #2 said he was part of the group that carried the patient to the seclusion room. He said he held a leg.

Review of Security Officer #2's supplemental to the security incident report confirmed the patient was carried to the seclusion room.

On 11/17/21 at 3:50 PM in an interview, Security Officer #3 said he participated in carrying the patient to the seclusion room. He said the decision to carry the patient (versus attempting to have him walk) was a group one.

Review of Security Officer #3's supplemental to the security incident report confirmed the patient was "lifted up and carried by Security and Pych (sic) staff to the seclusion room."

On 11/17/21 at 3:55 PM in an interview, Security Officer #4 said the patient was carried by his limbs to the seclusion room by his limbs with one person at his head. He said, "If he tried to walk he would resist and therefore decided to carry" him.

Review of Security Officer #4's supplemental to the security incident report confirmed the patient was carried to the seclusion room.

A review of the facility's psychiatry restraints for violent or self-destructive behavior revealed a restraint is any method that "reduces the ability of a patient to move his or her arms, legs, body or head freely." The review revealed the patient is to be restrained "following the process outlined in Nonviolent Crisis Intervention."

A review of the holds in the facility's crisis prevention program did not contain one as described by Security Officer #2, #3, #4, and #5, and Nurse F to take the patient to the seclusion room.

On 11/18/21 at 11:45 AM in an interview, Nurse Manager #2 confirmed the method used by nursing and security staff to carry the patient from his room to the seclusion room was not a part of the crisis prevention program.

Based on interview and record review, the facility failed to ensure the the use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy for four of ten patients reviewed (Patient #1, #4, #5, and #6). The patient census was 162 patients.

Findings include:

1. The medical record review for Patient #1 was completed on 11/23/21. The review revealed Patient #1 was brought to the facility's emergency department on 10/07/21 on a application for emergency admission dated 10/07/21 at 8:20 PM. A review of that application for emergency admission revealed the patient had had erratic behavior, paranoia, and threats of harm to himself and others. The application for emergency admission was completed by local police.

A review of the emergency physician's provider note dated 10/07/21 at 8:23 PM was completed on 11/23/21. The review revealed the patient was aggressive and anxious with pressured speech. The note stated the patient tested positive for marijuana use.

The medical record review revealed a psychiatric evaluation dated 10/08/21 at 8:52 AM. The evaluation revealed the patient was found to be alert and oriented to person, place, and time, responding to internal stimuli with non commanding auditory hallucinations, and mumbling and talking himself. The patient was diagnosed with psychotic disorder and cannabis use disorder.

A nursing note dated 10/13/21 at 12:30 PM revealed Patient #1 was on the 3 east psychiatric unit and stated that he ran down the corridor and pushed the fire door. The note stated he was escorted back to his room. The note did not state who or how many staff escorted him from the fire door back to his room. The nursing note then stated when the patient was in his room he began kicking and punching the wooden door to his room. The stated he was "assisted to the floor by 3 staff" in order to keep safe until he could be escorted to the quiet room. The nursing note revealed the patient was next "escorted" to the seclusion room via six staff and placed in locked seclusion.

The medical record review revealed a psychiatric note and order dated 10/13/21 at 12:41 PM to place the patient in seclusion. There was no order for the forced hold in the patient's room, nor was there an order for the forced hold to take the patient to seclusion.

Review of a security incident report submitted on 10/13/21 at 9:37 PM was completed. The review revealed it was authored by Security Officer #1. The review confirmed Security Officer #1 and Staff B "escorted him down to the floor." The review stated prior to that, a group that included Security Officer #1 "did have to manually restrain his shoulders while the shot was administered due to safety concerns based on his constant movement." The note stated he was told by staff "to try and relax and take it easy" and then all staff left the room. Further review revealed "Shortly after the patient started yelling and screaming while kicking the door. Looking into the room while telling him to stop kicking the door and calm down he took off his shirt. And then said, 'come in and fight me.' I asked the patient 'are you talking to me' (sic) and his response was 'yes'. [Security Officer #1 and Staff B] went into the room where he was actively trying to strike us with closed fists. We gained control over his arms and escorted him down to the floor." The report further revealed "he was lifted off the ground by his legs and arms and carried to the seclusion room."

A review of the facility's psychiatry restraints for violent or self-destructive behavior revealed a restraint is any method that "reduces the ability of a patient to move his or her arms, legs, body or head freely." The review revealed "an order needs to be obtained from the psychiatrist prior to the initiation of the restraint as soon as possible in an emergency application situation."

On 11/17/21 at 1:00 PM in an interview, Nurse Manager #1 confirmed there was no order for a forced hold to transport to the seclusion room. Nurse Manager #1 said that that was within the order to place the patient in seclusion. Nurse Manager #1 also said the holds described in the crisis intervention program did not require an order to be used on a patient. He confirmed there was no order to escort the patient to the ground in his room.

2. The medical record review for Patient #4 was completed on 11/23/21. The medical record review revealed the patient was admitted to the facility on 10/18/21 after being brought to the emergency department by local police. The medical record review revealed a psychiatric evaluation dated 10//19/21 at 12:24 PM that stated the patient was "very psychotic and exhibiting bizarre behavior" and "exhibiting delusional thoughts and was religiously preoccupied."

The medical record review revealed a nursing note dated 10/21/21 at 5:32 PM that stated the patient was agitated, threatening, trying to hit staff, and elope from the unit. The note said the patient was medicated according to a physician's order. The medical record review revealed the patient was medicated with two milligrams of Ativan (sedative) and 10 milligrams of Haldol (antipsychotic) given intramuscularly. The medical record review did not reveal how the injection was given.

Review of a security incident report for 10/21/21 at 5:40 PM revealed a supplemental report by Security Officer #7. The review of that report revealed "I gained control of the patient's legs while [Security Officer #8] had the patient's arms and upper body." The note then stated the nurse then administered the medication by injection.

The note continued that Security Officer #7 and #8 then escorted the patient using a hands-on technique from the facility's Nonviolent Intervention program that was self-described as a restraint, specifically a "level 2 benevolent restraint," to the seclusion room.

The medical record review did not reveal a physician order to hold the patient for that injection. The medical record review did not reveal an order for hands on restraint to take the patient to the seclusion room.

The medical record review did reveal an order for seclusion dated 10/21/21 at 5:45 PM.

On 11/22/21 at 1:40 PM in an interview, Nurse Manager #2 explained there would not be an order to manually hold the patient for the injection or to escort him to seclusion because they all flow up in the process of implementing the seclusion order.

3. The medical record review for Patient #5 was completed on 11/23/21. The medical record review revealed the patient was directly admitted to the psychiatric unit on 10/28/21 via an application for emergency admission via another facility's emergency department.

A review of the inpatient psychiatric admission note dated 10/28/21 at 9:51 PM revealed the patient was described as "agitated, loud belligerent, incoherent and uncooperative." He was unable to follow the simplest directions. The note described the patient as attempting to grab female genitalia. The note stated the patient was placed in seclusion and thereupon took off all his clothes and ran around the room naked. The admission note concluded with a diagnosis of schizophrenia.

The medical record review revealed a psychiatric evaluation dated 10/29/21 at 12:32 PM that stated upon arrival to the facility he was "extremely" combative, agitated, and violent.

The medical record review revealed a nursing note dated 10/29/21 at 6:05 AM that stated, "patient became agitated making animal noises and did not appear to understand what I was saying or answer questions."

The medical record review revealed in order to medicate the patient with an injection on 10/29/21 at 6:20 AM, the staff had to assist the patient. Further review revealed on 10/29/21 at 6:20 AM four members of clinical staff and two members of security had to perform a manual hold on the patient.

The medical record review did not reveal an order for this hold.

On 11/22/21 at 1:40 PM in an interview, Nurse Manager #2 explained there would not be an order to manually hold the patient for the injection because it would flow up in the process of implementing the seclusion order.

The medical record review did reveal an order dated 10//29/21 at 6:22 AM to continue the seclusion.

4. The medical record review for Patient #6 was completed on 11/23/21. The medical record review revealed the patient was admitted to the facility on 11/07/21. An emergency physician note dated 11/07/21 at 1:15 AM stated the local police department brought the patient into the emergency department for a psychiatric evaluation. The note said the police said the patient was having hallucinations, chasing her friends, and stating she was going to kill them. The note stated the patient perceives auditory and visual hallucinations with delusional thought content containing homicidal ideation.

The medical record review revealed a behavioral health evaluation dated 11/08/21 at 10:54 AM that stated the patient was admitted to the psychiatric unit for hallucinations, agitation, and inability to take care of daily routines. The evaluation concluded with a diagnosis of bipolar disorder, manic.

The medical record review revealed a nursing note dated 11/13/21 at 8:30 AM that described the patient as intrusive to peers, does not respect boundaries, and could not be redirected.

The medical record review revealed on 11/13/21 at 9:45 AM the patient was resistive, combative with staff, and threatening to hit people. At that time a transitional hold on the patient was implemented involving four members of the clinical staff and four members of security staff to place the patient in seclusion.

The medical record review revealed a physician's order dated 11/13/21 at 9:48 AM to place the patient in seclusion.

The medical record review did not contain an order for any hold, transitional or otherwise.

On 11/22/21 at 1:40 PM in an interview, Nurse Manager #2 explained there would not be an order to manually hold the patient because it would flow up in the process of implementing the seclusion order.