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Based on staff interview and record review the facility failed to respect the right to refuse a specific medical intervention during the course of hospitalization for 1 patient. (Patient #4). Findings include:

Per record review Patient #4 presented to the ED at 6:48 PM on 11/27/12, with depression, suicidal ideation and mental status changes. A note by the ED provider stated the patient had gone to ED, reported an interest in talking to Crisis and was having thoughts of harming self and a history of attempts. The note further identified that the patient had a significant mental health history including PTSD and bipolar anxiety. The patient did report taking benzodiazipines in accordance with his/her prescription and reportedly denied overdose of medication on that date, but presented extremely drowsy with somewhat slurred speech. S/he stated a past medical history of a blood clotting disorder as well as DVT (Deep Vein Thrombosis), and reported that s/he had injected him/herself with 2 doses of Lovenox (medication used to prevent blood clotting), in the hopes it would cause bleeding from old self inflicted neck wounds, and cause death. The ED note also indicated that the patient denied any urinary symptoms, and a urine toxicology screen, collected while the patient was in the ED, showed evidence of benzodiazipines and marijuana. The ED provider note further stated that the patient appeared extremely sleepy and the provider questioned if the patient had ingested more benzodiazipines that s/he had admitted to. The note stated the patient did have Crisis screening done and it was recommended the patient be admitted for 1:1 observations, and then inpatient psychiatric consult, all of which was agreed upon by the patient. The patient was admitted to a medical unit at 1:13 AM on 11/28/12.

The H&P (History and Physical), completed on 11/28/12 at 12:20 AM by Physician #1, under whose care Patient #4 was admitted, reiterated that the patient had visited the ED seeking someone to talk to as s/he was considering suicide and had a history of previous suicide attempts. The H&P further stated that a Crisis worker had evaluated the patient, deemed him/her a suicide risk and suggested 1:1 observation. Despite the reference made to Crisis screening by both the ED provider and Physician #1, there was no documentation regarding this consult in the medical record.

A Restraint and Seclusion Physician Progress Note, dated 11/28/12 at 4:20 AM, and completed by Physician #1, identified the Reason for Restraint as "Prevention self harm". The note stated that the patient, who was admitted to medical service for close observation until mental status cleared, prior to transfer to psychiatric services, became agitated once on the floor, yelling and screaming that s/he was going to leave the hospital AMA (against medical advice) and attempted to physically leave. "At this point [his/her] safety was paramount and [s/he] was placed into 4 point restraints. [S/he] seemed calmer after this was taken care of." Nursing notes indicate the patient was placed in 4 point restraints, at 3:45 AM, as a result of attempts at self harm by head banging. Despite the evidence that restraints were initiated as a result of the patient's self harming behavior, the physician order directed staff to initiate Medical/Surgical Restraints; pt lacks capacity, interfer w/medial tx, keyed velcro, padded side rails. Per the physical exam conducted by Physician #1; "After restraints were place showed a young [male/female] who was still upset, still very negative and refusing many aspects of care." The note further stated there was some distention of the suprapubic area and a bladder scan revealed over 900 cc of urine in the bladder. The patient refused to use a bedpan and a straight cath was ordered. The patient stated s/he did not want a straight cath.

A Nurse's Note stated that at 4:15 AM the patient had reported a need to void. Although there was evidence that nursing staff offered use of a bedpan on multiple occasions, the patient refused it and there was no evidence that the patient was provided the option of using the bathroom or bedside commode. Although the patient also refused straight catheter, s/he was subsequently restrained by several nurses while a straight cath procedure was completed, and 1000 cc of urine was obtained. The nurse's note indicated that upon completion of the catheterization, the patient was calm in bed. A subsequent note, documented in the Clinician Notification section of the record, at 10:25 AM on 11/28/12, stated that the physician was notified of the patient's report of inability to void. A bladder scan revealed 600 cc of urine and a subsequent note, at 11:15 stated the patient had reported an inability to void, a bladder scan revealed over 800 cc of urine in the bladder, the patient was accepting of a catheter and a straight cath procedure was performed in which over 800 cc of urine was obtained. Although the patient remained hospitalized until the morning of 11/29/12, there was no evidence of any further reports of inability to void with or catheterization.

During interview, at 11:00 AM on 3/21/13, the VP of Professional Support Services confirmed that a straight cath procedure had been completed on Patient #4 despite the patient's refusal to consent. S/he stated that Physician #1 had made the decision to use a straight cath based on the patient's exam, bladder scan showing a large amount of urine, and the concern of bladder rupture in the setting of the patient's self report of having injected 2 doses of Lovenox. S/he indicated use of the bathroom or bedside commode had reportedly not been offered to the patient, because Physician #1 had been concerned the patient might attempt self harm if restraints were removed. The VP of Medical Affairs agreed there was a lack of documentation in the medical record to support the decision by Physician #1 to use a straight catheter to empty the bladder of Patient #4 against his/her wishes.

The RN Unit Manager confirmed, during interview at 3:33 PM on 3/20/13, that Patient #4 had been restrained by staff for the purpose of performing a straight cath, despite the patient's refusal to consent to the procedure. The Unit Manager also confirmed the lack of evidence that use of the bathroom or bedside commode had been offered to Patient #4 prior to the straight cath procedure. S/he stated that staff providing care for the patient had reported concern the patient would attempt self harm if restraints were removed.

Based on staff interview and record review the facility failed to assure that there was indication for initiation of physical restraints and/or that restraints were discontinued at the earliest possible time for 2 applicable patients. (Patients #4 and #7). Findings include:

1. Patient #7 presented to the Emergency Department (ED) on 1/11/13 at 01:52 with a chief complaint of being unable to sleep and stating s/he stopped taking prescribed medication. Prior to arrival, Patient #7 was encouraged by his/her counselor to seek treatment in the ED, requesting an evaluation for suicidal and homicidal ideation. Patient #7 has a past history of depression, anxiety, substance abuse and PTSD. The ED Physician who examined Patient #7 described the patient as "...very tangential and disorganized....." and further states "the patient was demonstrating behaviors that were progressively more agitated and paranoid." Due to these symptoms, Patient #7 accepted Ativan 2 mg orally. Per the ED Note-Nursing states "Pt (patient) is fluctuating from calm and cooperative to violent and enraged. Patient refusing to get undressed into hospital clothing..." The ED physician further states " For staff and patient safety the patient was placed in four-point restraints and treated with Haldol and diphenhydramine". At approximately 02:50 Patient #7 was placed in restraints and was administered chemically restraining medication to include: Haldol 5mg Intramuscular (IM) and diphenhydramine 50 mg IM at 02:47.

Per review of the ED record , staff failed to assess and monitor Patient #7's condition on an ongoing basis to ensure that the patient was released from the four-point restraints at the earliest possible time. While the chemical and physical restraints were employed when the ED physician determined the provision of care for Patient #7 was an "unsafe situation", once the unsafe situation ends, the use of restraints should be discontinued. However, Patient #7 remained in restraints for over 3 hours despite the fact the ED physician had noted "......due to being too sedated to be fully evaluated." Patient #7 could not be evaluated by crisis services for determination of possible hospitalization.

Per interview on 3/21/13 at 3:55 PM the ED Medical Director confirmed the ED physician's written explanation for continued restraint use for Patient #7 "...was limited". The Medical Director also acknowledged the nursing notes did not provide a "....clear explanation" for the ongoing justification for continued use of the restraints.

2. Per record review Patient #4 presented to the ED at 6:48 PM on 11/27/12, with depression, suicidal ideation and mental status changes. A note by the ED provider stated the patient had presented to the ED, reported an interest in talking to Crisis and was having thoughts of harming self and had a history of attempts. The note further identified that the patient had a significant mental health history including PTSD and bipolar anxiety. The patient did report taking benzodiazipines in accordance with his/her prescription and reportedly denied overdose of medication on that date, but presented extremely drowsy with somewhat slurred speech. S/he stated a past medical history of a blood clotting disorder as well as DVT (Deep Vein Thrombosis), and reported that s/he had injected him/herself with 2 doses of Lovenox (medication used to prevent blood clotting), in the hopes it would cause bleeding from old self inflicted neck wounds, and cause death. The ED note further stated that the patient appeared extremely sleepy and the provider questioned if the patient had ingested more benzodiazipines that s/he had admitted to. The note stated the patient did have Crisis screening done and it was recommended the patient be admitted for 1:1 observations, and then inpatient psychiatric consult, all of which was agreed upon by the patient. The patient was admitted to a medical unit at 1:13 AM on 11/28/12.

The History and Physical, completed on 11/28/12 at 12:20 AM by Physician #1, under whose care Patient #4 was admitted, reiterated that the patient had visited the ED seeking someone to talk to as s/he was considering suicide and had a history of previous suicide attempts A Restraint and Seclusion Physician Progress Note, dated 11/28/12 at 4:20 AM, and completed by Physician #1, identified the Reason for Restraint as "Prevention self harm". The note stated that the patient, who was admitted to medical service to clear toxidrome prior to transfer to psychiatric services, became agitated once on the floor, yelling and screaming that s/he was going to leave the hospital AMA (against medical advice) and attempted to physically leave. "At this point [his/her] safety was paramount and [s/he] was placed into 4 point restraints. [S/he] seemed calmer after this was taken care of." The note went on to say that the patient continued to have slurred speech and was at high risk for self harm, and the plan of management stated; "Use of 4 point restraint will be continued for the next 4 hours until such time that [s/he] can be re-evaluated, hopefully by the Department of Psychiatry, for suicidality." Nursing notes indicate the patient was placed in 4 point restraints, at 3:45 AM, as a result of attempts at self harm by head banging. Despite the evidence that restraints were initiated as a result of the patient's self harming behavior, the physician order directed staff to Initiate Medical/Surgical Restraints; pt lacks capacity, interferring w/medial tx, keyed velcro, padded side rails. Although staff conducted regular assessments of the use of restraints the Reason Necessitating Restraint was consistently documented as "pt lacks capacity interferring with medically necessary tx", and the Behavior Description identified "pt resistive to care" and "pt wants to go AMA." Per the physical exam conducted by Physician #1; "After restraints were place showed a young [male/female] who was still upset, still very negative and refusing many aspects of care."

Although there was documentation at 6:00 AM and 6:30 AM, that indicated the patient was, at those times agitated, yelling and uncooperative, there was no evidence that s/he posed a threat to the safety of self or others. A physician progress note, at 7:20 AM, identified the patient's behavior as tearful, acknowledged the patient's ability to contract for safety and indicated that s/he could have ankle restraints removed at that time. Despite the lack of evidence, between 6:00 AM and 9:00 AM, that the patient posed a threat to the immediate physical safety of self or others, and despite the fact that continuous 1:1 observation was conducted by staff from the time of the patient's admission, restraints were not removed from the patient until 9:00 AM.

During interview, at 3:33 PM on 3/20/12, the RN Unit Manager confirmed the restraints were initiated as the result of self harming behavior. S/he further agreed that there was a lack of evidence to indicate the patient's behavior was violent or self-destructive and jeopardized the immediate physical safety of himself/herself or others, necessitating a need for ongoing use of restraints, between the hours of 6:00 AM and 9:00 AM.

Based on interview and record review, staff failed to conduct an ongoing assessment of a patient's behavioral response after the application of restraints to include the rationale for continued use for 1 applicable patient. (Patient #7). Findings include:

1. Per review on 3/20/13, Patient #7 arrived to the Emergency Department (ED) on 1/11/13 at 01:50 AM requesting to be evaluated by a mental health screener after being unable to sleep and reporting s/he had stopped taking prescribed medications. Patient #7 has a previous history of anxiety, depression and drug abuse and was referred by his/her counselor after the patient expressed suicidal and homicidal ideation. Upon admission to the ED, Patient #7 was described in ED Note-Nursing to be "....mildly agitated". Per ED physician's "Final Report" for 1/11/13 at 02:24:00 states "While in the emergency department the patient was demonstrating behaviors that were progressively more agitated and paranoid........the patient was refusing to undress and when asked to by staff was becoming more and more confrontational and agitated. For staff and patient safety the patient was placed in four-point restraints and treated with Haldol and diphenhydramine".

Per hospital policy "Restraint and Seclusion" approved 2/22/13 states "Comprehensive Restraint Assessment (every 2 hours) - An RN shall document a Comprehensive Restraint Assessment following the initiation of BR/S (Behavioral Restraints/Seclusion), and every two (2) hours (plus or minus 15 minutes to allow for nursing to safely prioritize clinical situations)". However, per review of the ED "Violent and Self-Destructive Restraint and/or Seclusion Doctor's Order and Daily Record" the RN is required to perform hourly assessments for restraint use to determine patient needs, provide restraint release for range of motion and readiness for discontinuation. Patient #7 was placed in bilateral hard wrist and ankle restraints at 02:50. Only one hourly assessment was documented on this ED form, the time it was conducted was not documented. Patient #7 remained in restraints for approximately 3 hours and 10 minutes, there was no evidence during this time that the RN assessed the patient for restraint reduction or the patient's behavioral or physical response to being in four- point restraints or the rationale for continued use.

Per interview on 3/21/13 at 11:35 AM ED staff Nurse #1 confirmed the hourly RN assessment of Patient #7 and the ongoing need and rationale for the continued use of four-point restraints was not documented as required per hospital policy.

Based on staff interview and record review the medical record was lacking documentation of the results of consultative evaluations for 1 applicable patient. (Patient #4). Findings include:

Per record review Patient #4 presented to the ED at 6:48 PM on 11/27/12, with depression, suicidal ideation and mental status changes. A note by the ED provider stated the patient had gone to ED, reported an interest in talking to Crisis and was having thoughts of harming self and a history of attempts. The note further identified that the patient had a significant mental health history including PTSD and bipolar anxiety. The patient did report taking benzodiazipines in accordance with his/her prescription and reportedly denied overdose of medication on that date, but presented extremely drowsy with somewhat slurred speech. S/he stated a past medical history of a blood clotting disorder as well as DVT (Deep Vein Thrombosis), and reported that s/he had injected him/herself with 2 doses of Lovenox (medication used to prevent blood clotting), in the hopes it would cause bleeding from old self inflicted neck wounds, and cause death. The note also stated that the patient appeared extremely sleepy and the provider questioned if the patient had ingested more benzodiazipines that s/he had admitted to. The note further stated that the patient did have Crisis screening done and it was recommended the patient be admitted for 1:1 observations, and then inpatient psychiatric consult, all of which was agreed upon by the patient. The patient was admitted to a medical unit at 1:13 AM on 11/28/12.

The H&P (History and Physical), completed on 11/28/12 at 12:20 AM by Physician #1, under whose care Patient #4 was admitted, reiterated that the patient had visited the ED seeking someone to talk to as s/he was considering suicide and had a history of previous suicide attempts. The H&P further stated that a Crisis worker had evaluated the patient, deemed him/her a suicide risk and suggested 1:1 observation.

Despite the reference made to Crisis screening by both the ED provider and Physician #1, there was no documentation regarding this consult in the medical record. This was confirmed by the VP of Quality Improvement during interview on the afternoon of 3/21/13.

Based upon staff interview and record review there was no evidence of a physician order for the use of restraints for 1 applicable patient. (Patient #1). Findings include:

Per record review Patient #1, admitted on 1/30/12, under involuntary status with a diagnosis of Schizophrenia and Paranoid Ideation, had a CON (Certificate of Need), for Seclusion, Restraint and Emergency Medication, dated 3/14/12 at 1:25 PM, for use of restraint in the form of CPI Technique (hands on escort). The CON stated the patient was in the dining room and refused to leave, was loud, angry, agitated, intimidating and frightening other patients. Although the CON did note that the physician was notified in person, at 1:40 PM and approved the emergency procedure, and although there was a Patient Assessment conducted by the physician at 1:40 PM on 3/14/13, there was no written physician order for the restraint.

The lack of written physician order for the restraint was confirmed by the RN Unit Manager during interview at 2:35 PM on the afternoon of 3/21/13.