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Based on medical record review, staff interview and policy review the facility failed to remove restraints at the earliest possible time for one of three restraint patients (Patient #2) and failed to use the least restrictive form of restraint for one of three restraint patients (Patient #10). The sample size of ten medical records were reviewed. The hospital census at the time of the survey was 263.

Findings Include:

Patient #2 had an episode of restraint use on 5/24/14 at 10:15 AM. The nurse documented, "Patient is very restless and confused. Unable to follow directions. Flailing arms and trying to stand up. Alternative methods tried such as distraction, ambulating, restroom, food and drink. Did not tolerate ambulation well, becomes tired quickly and only walked about 20 feet. Staff sitting one to one with patient but he is beginning to get agitated with redirection. Has multiple skin tears and is a very high risk for self injury and fall. Posey vest restraint applied at 10:15 AM for patient safety. Close monitoring continued." The nursing documentation reveals the patient remained in this restraint until 2:30 AM (5/25/14).
Nursing documentation in the medical record reveals the patient was asleep between the hours of 8:00 and 10:00 PM on 5/24/14 but there is no indication the restraint was removed during that time. The facility policy for restraint use reveals the restraint must be removed/discontinued at the earliest possible time.

Interview with the director of nursing for the behavioral health unit (Staff C) on 10/23/14 at 11:40 AM confirmed the absence of documentation regarding the need to keep the patient restrained while he slept.


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The clinical record review for Patient #10 in its electronic form was completed on 10/23/14. The clinical record review revealed a physician's note dated 10/19/14 at 3:37 P.M. that stated the patient presented with a chief complaint of alcohol problem and delirium tremens. The note stated the patient stated, "I came here for detox. "

The clinical record review revealed a nursing note dated 10/20/14 at 9:17 P.M. stating the patient was impulsive, was given Ativan, and had a bed alarm in place.

The clinical record review revealed a nursing note dated 10/21/14 at 12:38 A.M. that stated the patient was climbing over bed rails and the bed alarm had activated numerous times. The note stated, "Fearful that patient will fall without a sitter in place."

The clinical record review in its electronic form revealed a physician's order dated 10/02/14 at 1:36 A.M. that directed the patient to be restrained with a vest/jacket for "attempting to get out of bed without assistance."

The clinical record review did not reveal any physician order for a sitter or indicate where a sitter was attempted prior to the use of the vest restraint/jacket on 10/21/14 at 1:45 A.M.

On 10/23/14 at 10:09 A.M. in an interview Staff A and D confirmed a sitter was not used first as a least restrictive device and there was a concern the patient could fall.

On 10/23/14 a review of the facility's physical restraint policy as approved on 01/14, revealed, "The rationale that a patient should be restrained because he/she or he/she 'might' fall does not constitute an adequate basis for using a restraint." And, "A history of falling without a current clinical basis for a restraint intervention is inadequate to demonstrate the need for restraint".
This substantiates the Substantial Allegation OH00076687.

Based on interview and record review, the facility failed to update Patient #8's care plan after she twice laid in a vacant male patient's bed, failed to update Patient #4's care plan after he/she hit another patient in the back at the dining table, failed to update Patient #6's care plan after he/she threw and broke a wireless phone and then pushed another patient into the nursing station, and failed to update Patient #7's care plan when staff decided he/she needed a legal guardian although he/she lived alone and independently prior to her/his hospitalization.

Findings include:

See A396

Based on interview and record review, the facility failed to ensure patient care plans were kept current for when Patient #8 began wandering in and out of patient rooms, after Patient #4 and #6 exhibited violent behaviors resulting in their being placed in seclusion, and after staff decided Patient #7 needed to go to court for guardianship hearing. The total sample size was 10 medical records reviewed. The facility census was 263 at the time of the survey.

Findings include:

1. The clinical record review in its electronic form for Patient #8 was completed on 10/23/14. The clinical record review revealed the 30 year old female patient was admitted to the facility's psychiatric unit with a complaint of wandering. The clinical record review revealed an emergency department physician progress note dated 07/06/14 at 9:00 P.M. that stated the patient had wandered away from home two days prior to admission and was found by police on the date of admission. The note stated the patient was confused, not acting right, and was combative.

The clinical record review revealed a history and physical that stated the patient did not speak English. The history and physical stated he/she was diagnosed with schizophrenia.

The clinical record review revealed a nursing note dated 07/07/14 at 9:43 A.M. that stated the patient did not have a history of sexual misconduct.

The clinical record review revealed a nursing note dated 07/07/14 at 5:42 P.M. that stated, "This nurse alerted by another patient that patient entered the shower room while another patient was showering and began to take her/his top off and entered the water. This nurse had to redirect patient out of shower room and back to patients own room to help her/him get dressed."

On 10/22/14 at 1:45 P.M. in an interview, Staff C stated not knowing what gender the other patient in the shower was.

The clinical record review revealed a nursing note dated 07/07/14 at 8:53 A.M. that stated, "Patient went into a male patients room and took her/his shirt off and lay down in his/her bed .... Patient was redirected to put shirt on and to stay out of other patient rooms."

The clinical record review revealed a nursing note dated 07/08/14 at 8:51 A.M. that stated, "Patient entered another male patients room and laid down in his bed. Nurse instructed patient he/she could not be in another patient's room and walked her/him back to her/his room."

The clinical record review revealed a nursing note dated 07/10/14 at 7:00 P.M. that stated, "Patient wandering about unit and into other patient rooms. Intrusive ....Frequently needs redirected due to continued intrusive behavior. "

On 10/22/14 at 3:47 P.M. in an interview Staff C said the male patients weren't in their beds at the same time the patient was found in them.

On 10/23/14 at 8:35 A.M. in an interview Staff E confirmed he/she was the registered nurse for the patient on 07/07/14 at 8:53 P.M. He/she confirmed the male patient was not in his bed at the same time as when the patient got into it.

Review of the clinical record did not reveal where the care plan was updated, and what interventions were added to or taken away to address the patient's going in and out of other patients' rooms.

On 10/22/14 at 3:00 P.M. in an interview, Staff C stated it sounded like the patient was just wandering around looking for a place to lie down. He/she confirmed the care plan was not changed to address the patients problematic wandering.

2. The clinical record review for Patient #7 was completed on 10/23/14. The clinical record review revealed a history and physical dated 10/14/14 at 9:13 P.M. that stated her/his reason for admission was altered mental status. It stated the patient had a significant amount of dementia/cognitive decline that he/she lacks insight of.

The record review revealed a consult dated 10/15/14 at 8:37 A.M. that stated he/she lived alone with four or five cats. It stated he/she admitted to getting lost while driving. It stated he/she was diagnosed with moderate to severe Alzheimer's.

The clinical record review revealed a social worker note dated 10/15/14 at 2:06 P.M. that indicated the patient also had a dog in the home. The note stated a relative was contacted who provided the name of the patient's attorney that may be willing to do guardianship for the patient.

The clinical record review revealed a social worker note dated for 10/16/14 at 9:25 A.M. and again at 4:53 P.M.; the attorney was attempted to be contacted.

The clinical record review revealed a case management note dated 10/17/14 at 3:55 P.M. which stated a lawyer called in and agreed to file for guardianship.

The clinical record review revealed a case management note dated 10/20/14 at 11:58 A.M. that stated the lawyer called to say he/she was not sure what he/she was doing with the case. He/she stated he/she would look at the documentation sent to him/her and call if he/she needed anything.

The clinical record review revealed a case management note dated 10/21/14 at 11:52 A.M. that stated the patient's hearing had been set for 10/23/14.

The clinical record review of the patient's care plan for discharge planning, in full, was "Interaction with patient/family and care team" and did not make any mention of notifying the patient of the aforementioned discharged planning.

On 10/22/14 at 12:28 P.M. in an interview, Staff F, the patient's current social worker, confirmed the patient had not been notified of any of the discharge planning. He/she said when he/she first notified the patient on 10/22/14 (the day before the hearing) the patient was taken aback by it, but was pleasant.

On 10/22/14 at 12:28 P.M. in an interview, Staff D confirmed the care plan did not reflect the appropriate discharge planning and did not reflect the patient's involvement in it.

3. The clinical record review for Patient #4 was completed on 10/23/14. The clinical record review revealed the patient was admitted to the facility's psychiatric facility from 07/03/14 to 07/08/14 with a diagnosis of major depressive disorder and intermittent explosive disorder. The clinical record review revealed on 07/03/14 at 11:18 P.M. the patient was assessed as having a small risk of violence.

The clinical record review revealed a nursing note dated 07/03/14 at 11:27 P.M. that stated the patient hit his/her caregiver because the caregiver was seeing more of his/her brother than him/her.

The clinical record review revealed a nursing note dated 07/04/14 at 9:00 A.M. that stated the patient turned toward the dining table and began hitting a female patient in the back. The note stated the patient was placed in seclusion.

The clinical record review revealed on 07/04/14 at 2:00 P.M. the patient was assessed as having a small risk of violence.

The clinical record review did not reveal a care plan that was formulated to address the patient's potential for violence or use of the seclusion room.

On 10/21/14 at 3:25 P.M. in an interview, Staff C confirmed the care plan lacked an update to address the patient's potential for violence.

4. The clinical record review for Patient #6 was completed on 10/23/14. The clinical record review revealed the patient was admitted to the facility on 07/05/14. The clinical record review revealed a history and physical dated 07/06/14 at 12:01 P.M. that stated her/his chief complaint was suicidal ideation with a plan. It stated he/she had called in a bomb threat and called 911 stating he/she wanted to kill someone. The note stated he/she denied wanting to kill a specific person. The note stated he/she had been hospitalized multiple times due to worsening mood swings. The note stated he/she was diagnosed with schizoaffective disorder and borderline personality disorder.

The clinical record review revealed on 07/06/14 at 12:11 A.M. (near the time of admission) the patient was assessed as low risk for violence.

The clinical record review revealed on 07/07/14 at 8:48 A.M. the patient was assessed as having a low risk for violence.

The clinical record review revealed a nursing note dated 07/07/14 at 10:30 A.M. that stated the patient threw the cordless phone and broke it.

The clinical record review revealed a nursing note dated 07/07/14 at 10:55 A.M. that stated at 10:32 A.M. the patient pushed another female patient into the nursing station and then threw pencils all over the dining area. The note stated at 10:45 A.M. the patient was placed in seclusion.

The clinical record review did not reveal where a care plan was generated to address the patient's potential for violence following this event or include use of the seclusion.

On 10/21/14 at 3:34 P.M. in an interview, Staff C confirmed the care plan did not contain an update to address the potential for violence following the event.

Based on medical record review, staff interview and policy review the facility failed to remove restraints at the earliest possible time for one of three restraint patients (Patient #2) and failed to use the least restrictive form of restraint for one of three restraint patients (Patient #10). The sample size of ten medical records were reviewed. The hospital census at the time of the survey was 263.

Findings Include:

Patient #2 had an episode of restraint use on 5/24/14 at 10:15 AM. The nurse documented, "Patient is very restless and confused. Unable to follow directions. Flailing arms and trying to stand up. Alternative methods tried such as distraction, ambulating, restroom, food and drink. Did not tolerate ambulation well, becomes tired quickly and only walked about 20 feet. Staff sitting one to one with patient but he is beginning to get agitated with redirection. Has multiple skin tears and is a very high risk for self injury and fall. Posey vest restraint applied at 10:15 AM for patient safety. Close monitoring continued." The nursing documentation reveals the patient remained in this restraint until 2:30 AM (5/25/14).
Nursing documentation in the medical record reveals the patient was asleep between the hours of 8:00 and 10:00 PM on 5/24/14 but there is no indication the restraint was removed during that time. The facility policy for restraint use reveals the restraint must be removed/discontinued at the earliest possible time.

Interview with the director of nursing for the behavioral health unit (Staff C) on 10/23/14 at 11:40 AM confirmed the absence of documentation regarding the need to keep the patient restrained while he slept.


21521

The clinical record review for Patient #10 in its electronic form was completed on 10/23/14. The clinical record review revealed a physician's note dated 10/19/14 at 3:37 P.M. that stated the patient presented with a chief complaint of alcohol problem and delirium tremens. The note stated the patient stated, "I came here for detox. "

The clinical record review revealed a nursing note dated 10/20/14 at 9:17 P.M. stating the patient was impulsive, was given Ativan, and had a bed alarm in place.

The clinical record review revealed a nursing note dated 10/21/14 at 12:38 A.M. that stated the patient was climbing over bed rails and the bed alarm had activated numerous times. The note stated, "Fearful that patient will fall without a sitter in place."

The clinical record review in its electronic form revealed a physician's order dated 10/02/14 at 1:36 A.M. that directed the patient to be restrained with a vest/jacket for "attempting to get out of bed without assistance."

The clinical record review did not reveal any physician order for a sitter or indicate where a sitter was attempted prior to the use of the vest restraint/jacket on 10/21/14 at 1:45 A.M.

On 10/23/14 at 10:09 A.M. in an interview Staff A and D confirmed a sitter was not used first as a least restrictive device and there was a concern the patient could fall.

On 10/23/14 a review of the facility's physical restraint policy as approved on 01/14, revealed, "The rationale that a patient should be restrained because he/she or he/she 'might' fall does not constitute an adequate basis for using a restraint." And, "A history of falling without a current clinical basis for a restraint intervention is inadequate to demonstrate the need for restraint".
This substantiates the Substantial Allegation OH00076687.

Based on interview and record review, the facility failed to ensure patient care plans were kept current for when Patient #8 began wandering in and out of patient rooms, after Patient #4 and #6 exhibited violent behaviors resulting in their being placed in seclusion, and after staff decided Patient #7 needed to go to court for guardianship hearing. The total sample size was 10 medical records reviewed. The facility census was 263 at the time of the survey.

Findings include:

1. The clinical record review in its electronic form for Patient #8 was completed on 10/23/14. The clinical record review revealed the 30 year old female patient was admitted to the facility's psychiatric unit with a complaint of wandering. The clinical record review revealed an emergency department physician progress note dated 07/06/14 at 9:00 P.M. that stated the patient had wandered away from home two days prior to admission and was found by police on the date of admission. The note stated the patient was confused, not acting right, and was combative.

The clinical record review revealed a history and physical that stated the patient did not speak English. The history and physical stated he/she was diagnosed with schizophrenia.

The clinical record review revealed a nursing note dated 07/07/14 at 9:43 A.M. that stated the patient did not have a history of sexual misconduct.

The clinical record review revealed a nursing note dated 07/07/14 at 5:42 P.M. that stated, "This nurse alerted by another patient that patient entered the shower room while another patient was showering and began to take her/his top off and entered the water. This nurse had to redirect patient out of shower room and back to patients own room to help her/him get dressed."

On 10/22/14 at 1:45 P.M. in an interview, Staff C stated not knowing what gender the other patient in the shower was.

The clinical record review revealed a nursing note dated 07/07/14 at 8:53 A.M. that stated, "Patient went into a male patients room and took her/his shirt off and lay down in his/her bed .... Patient was redirected to put shirt on and to stay out of other patient rooms."

The clinical record review revealed a nursing note dated 07/08/14 at 8:51 A.M. that stated, "Patient entered another male patients room and laid down in his bed. Nurse instructed patient he/she could not be in another patient's room and walked her/him back to her/his room."

The clinical record review revealed a nursing note dated 07/10/14 at 7:00 P.M. that stated, "Patient wandering about unit and into other patient rooms. Intrusive ....Frequently needs redirected due to continued intrusive behavior. "

On 10/22/14 at 3:47 P.M. in an interview Staff C said the male patients weren't in their beds at the same time the patient was found in them.

On 10/23/14 at 8:35 A.M. in an interview Staff E confirmed he/she was the registered nurse for the patient on 07/07/14 at 8:53 P.M. He/she confirmed the male patient was not in his bed at the same time as when the patient got into it.

Review of the clinical record did not reveal where the care plan was updated, and what interventions were added to or taken away to address the patient's going in and out of other patients' rooms.

On 10/22/14 at 3:00 P.M. in an interview, Staff C stated it sounded like the patient was just wandering around looking for a place to lie down. He/she confirmed the care plan was not changed to address the patients problematic wandering.

2. The clinical record review for Patient #7 was completed on 10/23/14. The clinical record review revealed a history and physical dated 10/14/14 at 9:13 P.M. that stated her/his reason for admission was altered mental status. It stated the patient had a significant amount of dementia/cognitive decline that he/she lacks insight of.

The record review revealed a consult dated 10/15/14 at 8:37 A.M. that stated he/she lived alone with four or five cats. It stated he/she admitted to getting lost while driving. It stated he/she was diagnosed with moderate to severe Alzheimer's.

The clinical record review revealed a social worker note dated 10/15/14 at 2:06 P.M. that indicated the patient also had a dog in the home. The note stated a relative was contacted who provided the name of the patient's attorney that may be willing to do guardianship for the patient.

The clinical record review revealed a social worker note dated for 10/16/14 at 9:25 A.M. and again at 4:53 P.M.; the attorney was attempted to be contacted.

The clinical record review revealed a case management note dated 10/17/14 at 3:55 P.M. which stated a lawyer called in and agreed to file for guardianship.

The clinical record review revealed a case management note dated 10/20/14 at 11:58 A.M. that stated the lawyer called to say he/she was not sure what he/she was doing with the case. He/she stated he/she would look at the documentation sent to him/her and call if he/she needed anything.

The clinical record review revealed a case management note dated 10/21/14 at 11:52 A.M. that stated the patient's hearing had been set for 10/23/14.

The clinical record review of the patient's care plan for discharge planning, in full, was "Interaction with patient/family and care team" and did not make any mention of notifying the patient of the aforementioned discharged planning.

On 10/22/14 at 12:28 P.M. in an interview, Staff F, the patient's current social worker, confirmed the patient had not been notified of any of the discharge planning. He/she said when he/she first notified the patient on 10/22/14 (the day before the hearing) the patient was taken aback by it, but was pleasant.

On 10/22/14 at 12:28 P.M. in an interview, Staff D confirmed the care plan did not reflect the appropriate discharge planning and did not reflect the patient's involvement in it.

3. The clinical record review for Patient #4 was completed on 10/23/14. The clinical record review revealed the patient was admitted to the facility's psychiatric facility from 07/03/14 to 07/08/14 with a diagnosis of major depressive disorder and intermittent explosive disorder. The clinical record review revealed on 07/03/14 at 11:18 P.M. the patient was assessed as having a small risk of violence.

The clinical record review revealed a nursing note dated 07/03/14 at 11:27 P.M. that stated the patient hit his/her caregiver because the caregiver was seeing more of his/her brother than him/her.

The clinical record review revealed a nursing note dated 07/04/14 at 9:00 A.M. that stated the patient turned toward the dining table and began hitting a female patient in the back. The note stated the patient was placed in seclusion.

The clinical record review revealed on 07/04/14 at 2:00 P.M. the patient was assessed as having a small risk of violence.

The clinical record review did not reveal a care plan that was formulated to address the patient's potential for violence or use of the seclusion room.

On 10/21/14 at 3:25 P.M. in an interview, Staff C confirmed the care plan lacked an update to address the patient's potential for violence.

4. The clinical record review for Patient #6 was completed on 10/23/14. The clinical record review revealed the patient was admitted to the facility on 07/05/14. The clinical record review revealed a history and physical dated 07/06/14 at 12:01 P.M. that stated her/his chief complaint was suicidal ideation with a plan. It stated he/she had called in a bomb threat and called 911 stating he/she wanted to kill someone. The note stated he/she denied wanting to kill a specific person. The note stated he/she had been hospitalized multiple times due to worsening mood swings. The note stated he/she was diagnosed with schizoaffective disorder and borderline personality disorder.

The clinical record review revealed on 07/06/14 at 12:11 A.M. (near the time of admission) the patient was assessed as low risk for violence.

The clinical record review revealed on 07/07/14 at 8:48 A.M. the patient was assessed as having a low risk for violence.

The clinical record review revealed a nursing note dated 07/07/14 at 10:30 A.M. that stated the patient threw the cordless phone and broke it.