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Based on observation, interview, record review, policy review and video review, the facility restricted the rights of one patient (#49) of one patient reviewed, when the facility secluded the patient in his hospital room, restricted the patient from using the bathroom, failed to provide a psychiatrist upon request, failed to provide psychiatric care, and failed to diligently attempt psychiatric placement while the patient was held against his will (A-0129).

These failures had the potential to place all patients in an unsafe environment and at risk for poor patient outcomes..

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient Rights, resulting in Immediate Jeopardy (IJ).

On 10/25/17, the survey team notified the facility of the Immediate Jeopardy related to Conditions of Participation: Patient Rights, and on 10/26/17, the facility responded with a Plan of Correction (POC) to remove the IJ.

The facility's POC included:
- Immediate education of nursing and public safety staff related to affidavits, rights of patients who are at risk for self harm and seclusion.
- Immediate education of Patient Safety Assistants related to Harm Precautions, Constant Observation, and the rights of patients who are at risk for self harm.
- Knowledge drills/Scenarios to all nursing staff, ED staff, security staff who are assigned to care for psychiatric patients in non-psychiatric areas.
- Revision of nurse managers' daily rounding tool to include questions related to patients rights, with rounding to be completed daily..
- Policy revisions related to medical affidavits to include procedure specific duties when a patient who is at risk for self harm wants to leave the hospital.
- Policy development related to continued assessment of psychological patient needs for therapy while awaiting inpatient psychiatric services.
- Aggressive placement of medically cleared psychiatric patients.
- Revisions of electronic record forms that failed to align with patients rights and policies.
- Immediate monitoring and assurance of change through rounding, on the spot coaching and education, and reporting of those outcomes, with overall responsibility for implementation by the Chief Hospital Officer.
- Integration into the facility-wide Quality Assurance Performance Improvement program.

Based on interview, record review and policy review, the facility restricted the rights of one patient (#49) of one patient reviewed, when the facility secluded the patient in his hospital room, restricted the patient from using the bathroom, failed to provide a psychiatrist upon request, failed to provide psychiatric care, and failed to diligently attempt psychiatric placement while the patient was held against his will. This had the potential to affect all patients in the hospital by restricting their rights as a patient. The facility census was 438. There were 10 psychiatric patients on the acute medical floor.

Findings included:

1. Record review of the facility's undated policy titled, "Patient Rights," showed:
- Patient's may not be placed on an involuntary commitment (96 hour hold) in any area other than inpatient psychiatry.
- A medical surgical patient presenting a likely risk of harm to themselves or others requires affidavits be placed on the chart.
- Security may be notified anytime an affidavit is filled out within the hospital, if the patient is thought to be flight risk.
- The medical physician may call the Professional Answering Service for a psychiatric consult at any time.
- The psychiatrist, after evaluating the patient and reading the completed affidavits, may recommend that the patient meets criteria for an involuntary commitment.
- When the patient is medically stable, and meets the inpatient psychiatric criteria for admission, there are no beds available at the facility's psychiatric center, and the patient has a notarized affidavit in his medical record, the patient cannot leave against medical advice without first receiving a psychiatric of psychological evaluation.

2. Record review of the facility's undated policy titled, "Involuntary Admissions/96-Hour Holds/21 Day Holds" showed:
- An application for involuntary commitment must be initiated or completed to detain a patient (keep, prevent from leaving) in the hospital;
- An involuntary hold required an application, court order, witness list, notice of admission affidavits and patient rights.
- If no beds were available in the facility's psychiatric center, the Psychiatric Intervention Team would call for placement at outside "facilities".

3. Record review of the facility's policy titled, "Restraint Use," dated 02/13/17, showed that seclusion (to prevent a person from leaving a room or area) was used only in inpatient psychiatric units and in the Emergency Department.

4. Record review of the facility policy titled, "Harm Risk Patient in an Inpatient Non-Psychiatric Setting," dated 08/04/15, showed that patients identified as at risk for harm should not walk in the halls.

5. Record review of the Patient Rights (provided to Patient #49 on the morning of 10/24/17), showed that the patient had the right to:
- Be treated with respect and dignity;
- Fully participate in all decision related to his health care;
- Participate in the development and implementation of his plan of care, including treatment and discharge planning;
- Request of refuse treatment being offered or suggested;
- Visitors, who are allowed as long as access was clinically appropriate;
- File a complaint/grievance with the hospital; and
- Be free from seclusion and restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff.

6. Record review of Patient #49's medical record showed:
- A History and Physical dated 10/17/17, which documented that the patient had overdosed on pills.
- An Affidavit dated 10/17/17, which documented that the patient admitted he tried to harm himself by ingesting a large amount of pills.
- A physician's order dated 10/19/17 at 8:00 AM, for a "psychology evaluation and treat".
- A psychiatrist consultation report dated 10/19/17, which documented that the patient would benefit from inpatient psychiatric, services, and should be transferred to the facility's inpatient psychiatric center as soon as the patient was medically stable.
- A physician's order dated 10/21/17 at 11:37 AM, for medical discharge to inpatient psychiatric facility (indicated that the patient was medically cleared and could be admitted to a psychiatric facility).
- No further psychiatric care or treatment was provided to the patient until 10/24/17.
- A psychiatric progress note dated 10/24/17, which documented that the patient presented no danger to himself or others, and was safe for discharge.
- No orders for seclusion.

During an interview on 10/24/17 at 11:01 AM, Patient #49 stated:
- He was medically cleared on Saturday, 10/21/17 (three days prior) and awaited inpatient psychiatric admission for attempted suicide.
- He wanted to leave the hospital because he no longer felt suicidal, because he was concerned he would lose his job due to the long hospital stay, because he was not receiving psychiatric care and because he had not been admitted to a psychiatric center.
- He requested re-evaluation by a psychiatrist, was informed a psychiatrist would see him on Monday 10/23/17, but the psychiatrist did not come.
- His psychiatric medications were changed without his knowledge.
- He was required to use a urinal (plastic bottle used to urinate in) as opposed to the bathroom, could not leave his alarmed bed (bed alarm makes a loud noise to notify staff the patient is out of bed), could not have visitors, could not leave his hospital room, could not leave the hospital, and was informed he was under a 96 hour court ordered psychiatric hold.
- He exited his hospital room on 10/23/17 with his sitter (staff member assigned to constantly observe the patient for safety) to walk the halls of the medical unit, was told to return to his hospital room, and staff contacted security who responded to his room and asked the patient if there were "going to be any problems".
- He requested to speak to a nursing supervisor on 10/23/17 to file a complaint about violation of his patient rights, and was informed by Staff VV, RN, that it was too late in the day (approximately 5:30 PM) to speak to a nursing supervisor.
- He was informed by a psychologist on 10/24/17, that psychiatric patients in the Emergency Department (ED) awaiting psychiatric center admission, took priority over his admission to the psychiatric center.

During an interview on 10/24/17 at 3:55 PM, Staff J, Nurse Manager, stated Patient #49:
- He was medically cleared two or three days ago;
- Had not been seen by a psychiatrist since the previous week;
- Requested to see a psychiatrist on Monday, 10/23/17, but no psychiatrist was available to see him;
- Did not have a 96 hour court ordered psychiatric hold in place; and
- Could not leave the hospital because he was a risk to himself.

During an interview on 10/25/17 at 9:40 AM, Staff VV, Registered Nurse (RN), stated that he was the patient's primary nurse 10/21/17 through 10/23/17, and that Patient #49:
- Walked out of his hospital room on 10/23/17, so security was called.
- Could not leave his hospital room because he was a psychiatric patient.
- Was not allowed to use the bathroom, and was limited to the use of a urinal.
Staff VV added that nursing staff directed the restrictions (seclusion, bathroom privileges, etc.) of the psychiatric patients, and that none of the psychiatric patients could leave their hospital room unless there was a physician's order to do so.

Record review of Patient #49's Harm Risk Assessments (completed by nursing staff) dated 10/18/17 through 10/24/17, showed that the patient was at "moderate risk for harm". The safety interventions listed for "moderate risk" did not restrict the patient from bathroom privileges or walking in the halls.

During an interview on 10/25/17 at 10:50 AM, Staff UU, RN, stated that patients who were on medium suicide risk could ambulate in the halls.
This showed that safety interventions for psychiatric patients on the medical floor were inconsistent between nursing staff.

During an interview on 10/24/17 at 4:46 PM, Staff CC, Patient Safety Associate (PSA), stated that during shift to shift report, he was informed that Patient #49:
- Must remain in bed with the bed alarm on;
- Was required to use the urinal, and not allowed to use the bathroom;
- Was an elopement risk; and
- Was not allowed to leave his hospital room.

During an interview on 10/25/17 at 4:03 PM, Staff QQ, PSA, stated:
- She was Patient #49's sitter (staff who provide constant observation of a patient for safety) on 10/23/17, from 7:00 AM until 3:00 PM.
- The patient could not leave his room.
- The patient requested to see a psychiatrist on 10/23/17 before 11:00 AM, because he no longer felt suicidal and was concerned that he was going to lose his job due to the long hospital stay.
- Staff J, Nurse Manager, informed him that a psychiatrist would come see him, but never did.

During an interview on 10/25/17 at 4:18 PM, Staff PP, Patient Safety Associate (PSA) stated that:
- She was Patient #49's sitter on 10/23/17 from 3:00 PM until 10/24/17 at 7:00 AM;
- The patient could not leave his room;
- The patient requested to see a psychiatrist, was informed one would come, but never did;
- At 6:00 PM, the patient requested to talk to a nurse manager/supervisor, but was told it was too late to speak to someone;
- Nursing staff informed the patient that he needed to "relax" because he could not leave the hospital;
and
- The patient felt lied to and became agitated, so security was called.

Record review of a Security Log Report showed that on 10/23/17 at 5:39 PM, Patient #49 wanted to leave the hospital, so security was contacted, and responded to the patient's room.

Record review of Patient #49's medical record showed Case Management Discharge Planning Assessments dated:
- 10/21/17, which documented that a psychiatric referral for inpatient care was made to one outside psychiatric hospital, because the facility's inpatient psychiatric units did not have available beds.
- 10/23/17, which verified that the referral had been sent to the one outside psychiatric hospital.
- 10/24/17, showed that the outside psychiatric hospital had not responded to accept the patient for admission, so a request was made to the facility's inpatient psychiatric units to attempt to place the patient.

Record review of Bed Count Sheets from the facility's psychiatric center, showed that between 10/21/17 - 10/24/17, (dates Patient #49 was medically cleared) 21 patients were admitted to inpatient psychiatric services from the facility's Emergency Department (ED). This showed that while Patient #49 was held in the hospital against his will, and while he received no psychiatric care, his admission for inpatient psychiatric care was continually bypassed for ED patients.

During an interview on 10/25/17 at approximately 3:00 PM, Staff OO, Provisionally Licensed Professional Counselor (PLPC) and Staff RR, Psychologist, stated:
- An initial order for psychiatric services to see Patient #49 was written on 10/19/17 (Thursday);
- Four psychologists cover the hospital, but for unknown reasons, the patient did not receive a "formal risk assessment" (assessment completed by a psychologist or psychiatrist to determine risk and intent of harm to self or others);
- There was no LPC coverage over the weekend (10/21/17 and 10/22/17), and since Staff OOO was off on Monday (10/23/17), the patient did not receive individual psychiatric therapy.

During an interview on 10/25/17 at 2:15 PM, Staff SS, Psychiatrist, stated that:
- The facility had a consult team (group of psychiatrists), and could provide emergency consult (to determine if the patient still required inpatient psychiatric admission after he was medically cleared);
- He became involved with Patient #49's care on 10/24/17; and did not realize the patient had been medically cleared for three days;
- When he examined Patient #49, the patient was not suicidal, not homicidal and was safe for discharge;
and
- A 96 hour court ordered hold was required to prevent a patient from leaving the hospital.

During an interview on 10/25/17 at 11:55 AM, Staff TT, Chief Nursing Officer; Staff CCC, Administrative Director of Regulatory Affairs; and Staff DDD, Chief Hospital Operator, stated that a signed affidavit allowed the hospital to prevent a psychiatric patient from leaving the hospital.

Based on interview, record review and policy review, the facility failed to obtain physician orders for restraints which included the reason for restraint, the type of restraint and the duration for restraint for 22 patients (#11, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47 and #49) of 22 patients' restraint orders reviewed. This failure had the potential to affect all patients who were placed in restraints. The facility census was 438.

Findings included:

1. Record review of the facility policy titled, "Restraint Use" reviewed 02/13/17 showed:
- Restraint orders can only be given by a licensed physician or advanced practice registered nurse (APRN) in a collaborative practice arrangement with the attending licensed physician.
- Initiation of Restraint Orders for Non-Violent/Non-Self Destructive Behavior are entered Electronically. A restraint assessment form including reason, type (starting with least restrictive), and criteria for early release will also be entered electronically.
- The attending or on-call physician must be contacted as soon as possible for an order which may be verbal.
- The initial physician order will last for the episode of restraint.

2. During an interview on 10/26/17 at 9:50 AM, Staff GGG, Director of Nursing, Emergency Department, stated that the physician does not specify the type of restraint in the order. The physician reviews the restraint assessment form on line or the nurse verbally tells him of the restraint assessment findings. The nurse does not call the physician for an order if adding additional restraints.

3. Record review of Patient #11, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47 and #49 showed the physicians orders for restraints did not include the reason for restraint, type of restraint or the duration of the restraint.

4. Record review of Patient #44 restraint order showed:
- A verbal restraint order was entered electronically by a Registered Nurse (RN) on 10/19/17 at 11:08 AM and signed electronically by Staff EEE, Physician, on 10/20/17 at 7:00 AM.
- The Restraint Assessment entered on 10/19/17 at 11:08 AM, 10/20/1 at 9:50 AM, 10/21/17 at 10:58 AM entered electronically by an RN showed the restraint to be for Limb; left and right wrist.
- The Restraint Assessment entered on 10/22/17 at 6:56 AM and 10/23/17 at 12:48 PM by an RN showed the restraint to be Limb, right and left wrist and Side rails.

No physicians order was found in the medical record to add side rails as a restraint.

5. Record review of Patient #41 restraint order showed:
- A verbal restraint order for limb restraint, left wrist, was entered electronically by a RN on 10/19/17 at 9:03 PM and signed electronically by Staff HHH, Physician, on 10/20/17 at 7:26 AM.
- On 10/20/17 at 10:16 AM, the risk assessment showed limb, left and right wrist.
- On 10/21/17 at 10:45 AM, the risk assessment showed limb, left and right wrist, left ankle and lap belt.

6. Record review of Patient #33 risk assessment showed:
- The restraint for limb, right and left wrist was initiated on 10/15/17 at 6:55 PM and continued through 10/24/17.
- The risk assessment on 10/25/17 showed the restraint was changed to Limb, left and right ankle.

No physicians order was found in the medical record to discontinue the right and left wrist restraints and add the left and right ankle restraints.

7. Record review of Patient #46 risk assessment showed:
- The restraint for Limb, right and left wrist was initiated on 10/15/17 at 4:30 PM and continued until 10/20/17 at 8:00 AM.
- The risk assessment on 10/20/17 showed the restraint was changed to Limb, left and right wrists and siderails.
- The risk assessment on 10/21/17 showed the restraint again was for left and right wrists with no siderails and continued until 10/26/17.

No physicians order was found in the medical record to add siderails.

8. Record review of Patient #11's restraint order showed:
- A verbal restraint order for non-violent behavior was placed on 10/09/17 at 5:56 AM.
- No specification of type of restraint.
- The patient was in restraints between 10/09/17 through 10/14/17.
- Staff added and removed lap belts, wrist restraints and ankle restraints as needed without obtaining new orders for each change.
- The changes in the type of restraint occurred 18 times throughout Patient #11's admission.

9. Record review of Patient #49's medical record showed:
- A Physician order for restraint dated 10/17/17 at 6:21 AM. The order did not include the type of restraint (behavioral verses non-behavioral) or the specific restraints to be used (wrist, ankle, lab belt).
- An "Assessment for Restraints" (assessment done by nursing at the time the restraint order was requested) dated 10/17/17 at 5:40 AM, documented that the patient required non-violent (soft) restraints to the left and right wrist.
- "Restraint Assessments" dated 10/17/17 at 8:00 AM through 10/18/17 at 10:00 AM, documented the patient was in nonviolent restraints (soft).
- On 10/17/17 at 8:00 AM and 10:00 AM, the patient was in wrist restraints to the left and right wrist.
- On 10/17/17 at 12:00 PM, the patient continued in right and left wrist restraints, and a lap belt was added to further restrain the patient.
- On 10/17/17 at 2:00 PM, the patient was restrained with wrist and ankle restraints, and the lab belt was removed.
- On 10/17/17 at 4:00 PM, the patient continued in right and left wrist restraints, and a lap belt was added to further restrain the patient.
- The specific restraints used on the patient continued to vary until the restraints were removed on 10/18/17 at 10:00 AM.
- No additional restraint orders related to the initiation of a lap belt were found.

During an interview on 10/23/17 at 4:15 PM, Staff J, Nurse Manager, stated that nursing staff determined the type of restraint (violent or non-violent) and the specific restraints to be used (wrist, ankle, chest) was based on their assessment of the patient. Staff J also added that the specific restraints used could vary during the restraint episode without obtaining a new physician order.

During an interview on 10/24/17 at 9:09 AM, Staff WW, Registered Nurse (RN), stated the type of restraint used on a patient was determined by the nurse. Staff WW added that nursing staff would initiate restraints for the arms (wrists) first, then add additional restraints as needed (lap belt, for example).

During an interview on 10/24/17 at 2:25 PM, Staff AAA, Charge Nurse, stated that she knew what restraints to place on a patient based on the patient's history (not the physician's order).

During an interview on 10/25/17 at 10:50 AM, Staff UU, RN, stated that the type and specific restraints used on a patient were determined by a team of patient care staff.














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