HospitalInspections.org

Based on document review and interview, it was determined that the Hospital does not have a policy to define seclusion requirements for the emergency department (ED), potentially affecting all patients who present with violent behavioral health conditions.

Findings include:

1. The Hospital's policy titled, "Restraint Use and Indications" (revised 10/18/16), was reviewed on 6/12/18 and included, "Definitions: ... Seclusion takes place only in the Behavioral Health Services Units or in the Emergency Department. See the Seclusion Policy."

2. The Seclusion Policy was requested on 6/13/18 at approximately 9:30 AM, during a tour of the ED. The Manager of the ED (E#12) and the Executive Director of the ED (E#13) stated they were unaware of a specific policy for seclusion. They stated that the practice was to place the patient in a room and lock the door for safety. The patient is visually monitored on camera and the key to unlock the door is available in the monitoring room in case of an emergency. Neither E#12 or E#13 were able to verbalize when or how that practice was initiated or communicated to the staff. The practice is not in writing. No patients were in seclusion at the time of the tour.

Based on document review and interview, it was determined that for 2 of 4 (Pt. #1 and Pt. #9) patients in restraints, the Hospital failed to ensure there was a physician's order for restraints/seclusion.

Findings include:

1. The Hospital's policy titled, "Restraint and Seclusion in Behavioral Health Services" (revised 10/20/17), was reviewed on 6/12/18 and required, "If a patient requires the use of seclusion, in addition to restraints, a separate order for seclusion must be obtained."

2. The Hospital's policy titled, "Restraint Use and Indications" (revised 10/18/16), was reviewed on 6/12/18 and required, "Restraints will be used in accordance with an order from a physician ... An order from a physician must be issued immediately, but not more than one (1) hour after initiation of restraint."

3. The clinical record of Pt. #1 was reviewed on 6/12/18. Pt. #1 was a 27 year old male, who presented to the emergency department (ED) on 5/6/18 with a diagnosis of schizoaffective disorder (Bipolar type). Pt. #1 was placed in restraints and seclusion on 5/6/18 at 10:32 PM. The physician's order dated 5/6/18 at 10:27 PM included 4 point restraints (both wrists and legs). The order lacked documentation of a seclusion order. Pt. #1 was placed in restraints and seclusion again on 5/7/18 at 11:15 AM. An additional order dated 5/7/18 at 11:24 AM included 4 point restraints; however, the clinical record lacked documentation of a seclusion order. The nursing documentation indicated that Pt. #1 was in seclusion on 5/6/18 from 10:32 PM to 5/7/18 at 12:23 AM and again on 5/7/18 from 11:15 AM to 1:11 PM.

4. The clinical record of Pt. #9 was reviewed on 6/12/18. Pt. #9 was an 18 year old male, who presented to the ED on 6/11/18 with a diagnosis of autism. A nurse's note dated 6/12/18 at 11:50 AM included that Pt. #9 was placed in a vest restraint to prevent flight, as well as, aggressiveness with staff. As of 1:30 PM on 6/12/18, the clinical record lacked a physician's order for restraints. A request was made to verify that an order was in record. A restraint order was then placed in the clinical record on 6/12/18 at 1:34 PM (1 hour and 44 minutes after initiation).

5. During an interview on 6/13/18 at approximately 9:00 AM, the Vice President Chief Quality Officer (E#1) stated that there was no initial order for Pt. #9 and a seclusion order could not be found for Pt. #1.

Based on document review and interview, it was determined that for 1 of 4 patients (Pt. #1) in behavioral restraints (violent), the Hospital failed to ensure that restraint orders were renewed every 4 hours.

Findings include:

1. The Hospital's policy titled, "Restraint and Seclusion in Behavioral Health Services" (revised 10/20/17), was reviewed on 6/12/18 and required, "When restraint/seclusion is required, the RN (registered nurse) may initiate the use of restraint/seclusion and an order is obtained from the attending psychiatrist within one (1) hour of the initiation... Orders are renewed by the psychiatrist as follows: Four hours for adults 18 and older..."

2. The clinical record of Pt. #1 was reviewed on 6/12/18. Pt. #1 was a 27 year old male, who presented to the emergency department (ED) on 5/6/18 with a diagnosis of schizoaffective disorder (Bipolar type). The nursing documentation included that Pt. #1 was in 4 point (both wrists and legs) restraints from 5/7/18 at 11:15 AM until 5/8/18 at 1:44 AM. The clinical record included the following physician's orders for restraints: 5/7/18 at 11:24 AM; 5/7/18 at 7:17 PM - late order entry for 3:15 PM (entered approximately 4 hours later) and an additional order on 5/7/18 at 7:17 PM. The clinical record lacked documentation of a physician's order for Pt. #1 to remain in restraints on 5/7/18 from 11:17 PM until 1:44 AM on 5/8/18.

3. During an interview on 6/13/18 at approximately 9:00 AM, the Vice President Chief Quality Officer (E#1) stated that there should have been an additional order on 5/7/18 around approximately 11:15 PM. E#1 stated that the order was missed.

Based on document review and interview, it was determined that for 2 of 5 (E#10 and E#14) staff personnel files reviewed, of staff who work with behavioral health patients, the Hospital failed to ensure employees had training in de-escalation (decrease conflict) skills.

Findings include:

1. The "Classes Offered at [the Hospital] List" was reviewed on 6/13/18. The list included that Crisis Prevention Intervention (CPI) Certification Class is required for all Security, emergency department (ED) and behavioral health staff.

2. The personnel file of E#10 (nurse in the ED) was reviewed on 6/13/18. The file included CPI training dated 11/10/15 (expired 11/10/17).

3. The personnel file of E#14 (Patient Care Technician in the float pool) was reviewed on 6/13/18. The file lacked documentation of CPI training. E#14 was interviewed on 6/12/18 at approximately 1:20 PM while working in the monitor room in the ED. E#14 stated, "I think I am required to have CPI training to work here."

4. During an interview on 6/13/18 at 4:25 PM, the Senior Human Resource Advisor (E#15) stated, "The nurse's [E#10] CPI training has expired. A decision was made not to have the float pool (even though they can work in the ED) trained in CPI."