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Based on review of documents and interview of staff it was determined the facility failed to ensure patient rights to be free of abuse/neglect (see Tag A 145); failed to both file a complaint/grievance and do so through an outside agency (see Tag A 118); failed to have a physician's order for restraints (see Tag A 168); failed to receive an appropriate Face-to-Face evaluation during the restraint (see Tag A 179); and, failed to have their plan of care modified following the restraint (see Tag A 166).

A. Based on review of documents and staff interview it was determined the facility failed to ensure staff members followed the facility's complaint policy for one (1) of one (1) patient who had verbalized a complaint of physical abuse (Patient #1). Failure to communicate patient allegations of abuse infringes on the rights of all patients in the facility.

Findings include:

1. Facility policy entitled "Complaint Process", last revised 11/4/15, was reviewed on 4/12/16. It states, in part: "There is an obligation, legal and moral, to report suspected abuse, neglect, or mistreatment and such complaints shall be addressed within forty eight (48) hours". It further states, in part: "the staff person who is first made aware...shall provide a complaint form to the person for completion. If the person requests assistance a staff person shall help them complete the form".

2. Patient #1's medical record was reviewed on 4/11/16 and revealed the patient, a fifteen (15) year old, was in a physical hold and then mechanical restraints during the evening shift on 3/8/16. Review of the Physician's Progress Note on 3/9/16 at 8:37 a.m. revealed the physician met with the patient that morning. No documentation was noted related to a complaint of abuse.

3. Physician #1 was interviewed on 4/12/16 at 10:00 a.m. She recalled meeting with Patient #1 the morning after his episode of restraints. She reported the patient stated to her he'd been "slammed to the floor hard" and complained he "felt like he was bruised". When asked if she had reported the complaint on behalf of the patient she stated: "No, I believed he'd already reported it to somebody and I told him he should talk to the nursing supervisor". When asked if she'd followed up to verify the complaint had been filed by another staff member she said she had not done so.

4. An interview was conducted with Behavioral Health Technician (BHT) #1 on 4/12/16 at 2:22 p.m. He stated he recalled talking to Patient #1 on 3/9/16, the day following his hold and restraint. He stated the patient had verbalized to him "He did it too hard" and "My mom's getting a lawyer". When asked if he'd offered to give or assist the patient with a complaint form he stated he did not. When asked if he had reported the allegation to anyone else he stated he did not.

5. An interview was conducted with BHT #5 on 4/12/16 at 3:45 p.m. She stated she had participated in the bedside monitoring of Patient #1 on the evening of his hold and restraint as required by policy. She stated: "He was complaining his head hurt and said one of the staff had been too rough". She stated she had informed the Charge RN of this and had not followed up in any other way.

6. The facility's Complaint Log from January 2016 to the current date was reviewed on 4/11/16. No documentation was found of a complaint lodged by Patient #1.

7. An interview was conducted with the Director of Quality/Risk Management on 4/11/16 upon entrance to the facility. She reported the facility first became aware of Patient #1's allegations of abuse on 3/10/16 when one of the patient's therapists notified her she had received an email from the patient's Department of Health and Human Resources (DHHR) guardian informing them of the patient's allegations and his mandatory report to Child Protective Services. She stated the facility's internal investigation into the allegations began at that time.

B. Based on review of documents and interview of staff it was determined the facility failed to provide patients with the address and telephone number of the Office of Health Facility Licensure and Certification at the time of admission per facility policy. This failure infringes on the rights of all patients and family members to lodge a complaint with an outside agency.

Findings include:
1. Facility policy entitled "Complaint Process", last revised 11/4/15, was reviewed on 4/12/16. It states: "Parents/guardians/others who wish to complain to the DHHR Office of Health Facilities and Licensure (OHFLAC) may do so by contacting them at (phone number and address given). This reporting information is included in the Patient's Rights and Responsibilities. At admission a signed copy of the Patient's Rights and Responsibilities is given to the patient/guardian".

2. A copy of the document entitled "Highland Hospital Patient's Rights and Responsibilities" was reviewed on 4/12/16. No contact information for OHFLAC was found in the document.

3. A brief interview was conducted with the Director of Quality on 4/12/16 at 3:45 p.m. at which time she confirmed the document noted above is the current one (1) included in the patient/family admission packet and agreed the OHFLAC contact information required by hospital policy was not included.

Based on review of documents and interview of staff it was determined the facility failed to ensure an allegation of abuse was reported per policy for one (1) of one (1) patient who verbalized an allegation of physical abuse to staff members (Patient #1). Failure to report allegations of abuse infringe on the rights of all patients in the facility to have those complaints investigated.

Findings include:

1. Facility policy entitled "Allegations of Patient Abuse", last revised 12/15, was reviewed on 4/12/16. It states, in part: "Any allegations, by patients or others, of patient abuse by hospital staff...will be fully investigated". It further states: "The individual receiving an allegation of abuse will obtain and carefully document all pertinent information regarding the complaint...".

2. Facility Policy entitled "Abuse Reporting - Adult/Child and Documentation", last revised 5/15, was reviewed on 4/12/16. It states, in part: "Suspected incidents of ... child abuse, neglect, or emergency situations will be reported as mandated under...West Virginia Child Protective Law".

3. Patient #1's medical record was reviewed on 4/11/16 and revealed the patient was in a physical hold and then mechanical restraints during the evening shift on 3/8/16. Review of the Physician's Progress Note on 3/9/16 at 8:37 a.m. revealed the physician met with the patient that morning. No documentation was noted related to a complaint of abuse.

4. Physician #1 was interviewed on 4/12/16 at 10:00 a.m. She recalled meeting with Patient #1 the morning after his episode of restraints. She reported the patient stated to her he'd been "slammed to the floor hard" and complained he "felt like he was bruised". When asked if she had reported the complaint on behalf of the patient she stated: "No, I believed he'd already reported it to somebody and I told him he should talk to the nursing supervisor". When asked if she'd followed up to verify the complaint had been filed by another staff member she said she had not done so.

5. An interview was conducted with Behavioral Health Technician (BHT) #1 on 4/12/16 at 2:22 p.m. He stated he recalled talking to Patient #1 on 3/9/16, the day following his hold and restraint. He stated the patient had verbalized to him "He did it too hard" and "My mom's getting a lawyer". When asked if he'd offered to give or assist the patient with a complaint form he stated he did not. When asked if he had reported the allegation to anyone else he stated he did not.

6. An interview was conducted with BHT #5 on 4/12/16 at 3:45 p.m. She stated she had participated in the bedside monitoring of Patient #1 on the evening of his hold and restraint as required by policy. She stated: "He was complaining his head hurt and said one (1) of the staff had been too rough". She stated she had informed the Charge RN of this and had not followed up in any other way.

7. No documentation was found of a complaint lodged by Patient #1. The facility's Complaint Log from January 2016 to the current date was reviewed on 4/11/16.

8. An interview was conducted with the Director of Quality/Risk Management on 4/11/16 upon entrance to the facility. She reported the facility first became aware of Patient #1's allegations of abuse on 3/10/16 when one of the patient's therapists notified her she had received an email from the patient's Department of Health and Human Resources guardian informing them of the patient's allegations and his mandatory reporting to the State Agency.

Based on review of documents and interview of staff, it was determined the facility failed to ensure the patients' plan of care was modified following an episode of restraint per policy for two (2) of three (3) restraint records reviewed (Patient #1 and Patient #5). Failure to communicate significant changes in a patient's condition to the treatment team can lead to inappropriate and/or inadequate care of the patient with possible negative outcomes.

Findings include:

1. Facility policy entitled "Seclusion and Restraint", last revised 3/16, was reviewed on 4/11/16. It states under the heading "Documentation" that "the possibility of loss of control should be addressed in the Master Treatment Plan".

2. Patient #1's medical record was reviewed on 4/11/16. It revealed the patient was placed in a physical hold and then mechanical restraints on 3/8/16. Review of the patient's Treatment Plan following this date revealed no documentation of an update of the plan to reflect the episode of restraints.

3. Patient #5's medical record was reviewed on 4/13/16. It revealed the patient was placed in a physical hold, received medication by injection and was placed in mechanical restraints on 4/4/16. Review of the patient's Treatment Plan following this date revealed no documentation of an update to the plan to reflect the episode of restraints.

4. The above medical records were reviewed with the Nurse Manager Adolescent/Children's Unit on 4/13/16 at 9:15 a.m. at which time she agreed with the above findings.

Based on review of documents and interview of staff it was determined the facility failed to ensure physician's orders were obtained for therapeutic holds and mechanical restraints for three (3) of three (3) restraint records reviewed (Patients # 1, # 2, and # 5). This infringes the rights of all patients to have physicians make the decisions about their care.

Findings include:

1. Facility policy entitled "Seclusion and Restraint", last revised 3/16, was reviewed on 4/11/16. It states: "Seclusion and restraint require a time limited physician's order" and "All restraints are physician ordered".

2. Patient #1's medical record was reviewed on 4/11/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 3/8/16, revealed the patient was placed in a therapeutic hold at 8:01 p.m. Review of the physician's order revealed the start time for this hold was 8:26 p.m. Further review of the Restraint Flow Sheet revealed the patient was placed in mechanical restraints at 8:10 p.m. Review of the physician's order revealed the start time for the mechanical restraints was 8:16 p.m.

3. Patient #2's medical record was reviewed on 4/13/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 4/11/16, revealed the patient was placed in mechanical restraints at 11:50 a.m. Review of the physician's order revealed the start time for the restraint was 12:10 p.m.

4. Patient #5's medical record was reviewed on 4/13/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 4/4/16, revealed the patient was placed in mechanical restraints at 4:10 p.m. Review of the physician's order revealed the start time for the restraint was 4:39 p.m.

5. The above records were reviewed with the Nurse Manager Adolescent/Childrens Unit on 4/13/16 at 9:15 a.m. at which time she agreed with the above findings.

Based on review of documents and interview of staff it was determined the facility failed to ensure the Face-to-Face evaluation of a restraint patient was conducted per facility expectations for three (3) of three (3) restraint records reviewed (Patients # 1, #2, and # 5). This failure can cause complications of the restraint, both physical and psychological, to remain undetected and untreated, and places all restraint patients at risk of harm.

Findings include:

1. Facility policy entitled "Seclusion and Restraint", last revised 3/16, was reviewed on 4/11/16. It states: "Regardless of duration of the restraint, the physician or RN must make a Face-to-Face evaluation of the patient within one (1) hour of initiation of the order and document the evaluation".

1. A facility policy addressing the required contents of the Face-to-Face examination was requested during the survey. On 4/11/16 at 2:30 p.m. the Director of Nursing reported the facility has no such policy and instead provided the educational materials he uses to train RNs in the facility in the correct procedures. He stated it was the expectation of the facility that the RNs conduct the evaluation using the procedure outlined in these materials. Review of the sections titled "General Medical Conditions" and "Conduct a Review of Systems" revealed the instructions "Obtain Vital Signs ASAP" and "Ask about pain or discomfort".

2. Patient #1's medical record was reviewed on 4/11/16. The document entitled "Restraint and Seclusion Flow Sheet", dated 3/8/16, was reviewed and revealed under the heading "Face-to-Face Assessment" the entry in it's entirety: "Pt. A&O X 3 (alert and oriented to time, place, and person), remains in 4 pt. restraint. Laughing. (Symbol for 'no') injury. (Symbol for 'no') harm to pt. RR WNL (respiratory rate within normal limits)/unlabored". The entry was signed by RN #2.

3. An interview was conducted with RN #2 on 4/12/16 at 2:45 p.m. at which time she was asked to describe her Face-to-Face procedure. She stated she "looks at the patient", checks breathing and looks for signs of distress". When asked if she performs a pain assessment she stated she expects the patient to tell her if he or she has pain. When asked if she obtains vital signs she stated she does not.

4. Patient #2's medical record was reviewed on 4/13/16. The document entitled "Restraint and Seclusion Flow Sheet", dated 4/11/16, revealed the patient was placed in mechanical restraints at 11:50 a.m. The Face-to-Face entry was timed for 1:00 p.m. and consisted of the entry: "Pt. in 5 pt restraints at this time. ROM (range of motion) limited d/t (due to) restraints. Breathing even & unlabored. Skin warm & S/W moist d/t sweating (Rm is a little warm). No injury noted at this time".

5. Patient #5's medical record was reviewed on 4/13/16. The document entitled "Restraint and Seclusion Flow Sheet", dated 4/4/16, revealed the patient was placed in mechanical restraints at 4:10 p.m. The Face-to-Face entry read: "Pt. remains in 4 pt. restraints. Quiet and attempting to calm down. Resp. even and unlabored, (symbol for 'no') S/S (signs or symptoms) of distress noted, (symbol for 'no') apparent injury noted".

6. The documentation noted above was reviewed with the Director of Quality on 4/12/16 at 3:30 p.m. at which time she agreed the Face-to-Face did not occur within one (1) hour in the case of Patient #2 and no vital signs or pain assessments had been documented in all three (3) records reviewed.

A. Based on review of documents and interview of staff, it was determined the facility failed to ensure an assessment of a patient following an episode of restraints was conducted, per policy, for three (3) of three (3) restraint records reviewed (Patients # 1, #2, and # 5). This has the potential for changes in a patient's condition to remain undetected and untreated, with possible negative outcomes.

Findings include:

1. Facility policy entitled "Seclusion and Restraint", last revised 3/16, was reviewed on 4/11/16. It states under the heading "Documentation: Follow-up entry to be made by the RN two (2) hours after return to community to reflect patients behavior".

2. Patient #1's medical record was reviewed on 4/11/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 3/8/16, revealed the patient was released from mechanical restraints at 9:20 p.m.
The next nursing note found in the patient's record was dated 3/9/16 at 3:38 a.m.

3. Patient #2's medical record was reviewed on 4/13/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 4/11/16, revealed the patient was released from mechanical restraints at 1:30 p.m. The next nursing note found in the patient's record was at 6:56 p.m. on this date.

4. Patient #5's medical record was reviewed on 4/13/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 4/4/16, revealed the patient was released from mechanical restraints at 5:15 p.m. The next nursing note found in the patient's record was dated 4/5/16 at 3:24 a.m.

5. The above records were reviewed with the Nurse Manager Adolescent/Children's Unit on 4/13/16 at 3:05 p.m. at which time she agreed with the above findings.

B. Based on review of documents and interview of staff it was determined the facility failed to ensure nursing staff conduct a debriefing interview with a patient following an episode of restraint per policy for one (1) of three (3) restraint records reviewed (Patient #1). This creates missed opportunities to have patients verbalize perceptions and concerns regarding the episode and therefore infringes the rights of all patients to participate in their own plan of care.

1. Facility policy entitled "Seclusion and Restraint", last revised 3/16, states: "A debriefing will be held ASAP but no (symbol for greater than) twenty four (24) hours after the episode. The debriefing form will be utilized and filed behind the seclusion/restraint flowsheet".

2. Patient #1's medical record was reviewed on 4/11/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 3/8/16, revealed the patient was released from mechanical restraints at 9:20 p.m.
The "Debriefing" form was found to be undated and untimed.

3. The above record was reviewed with the Director of Quality on 4/11/16 at 3:20 p.m. at which time she agreed with the above findings.

C. Based on review of documents and interview of staff it was determined the facility failed to ensure documentation was completed by the nurse providing care per policy for one (1) of ten (10) medical records reviewed (Patient #1). Failure for nursing to provide accurate documentation of patient care can lead to incorrect and/or uncoordinated decisions by treatment team members with possible negative outcomes.

Findings include:

1. Facility policy entitled "Documentation", last revised 12/15, was reviewed on 4/12/16. It states: "Each nursing staff member is responsible and will be held accountable for the care he/she provides and is responsible for documenting such care into the medical record".

2. Patient #1's medical record was reviewed on 4/11/16. Review of the document entitled "Restraint and Seclusion Flow Sheet", dated 3/8/16, revealed an episode of therapeutic hold and then mechanical restraints on the evening shift on the Adolescent Unit. Review of the Nursing Shift Note for that date at 8:40 p.m. revealed an entry by RN #1 describing the patient behaviors, staff interventions and the hold/restraints. Review of the staffing schedule for the Adolescent Unit for that date and shift revealed RN #1 was not assigned to the unit.

3. An interview was conducted with RN #1 on 4/12/16 at 11:10 a.m. She reported being Nursing Supervisor on that date for evening shift. She stated she responded to an overhead page for "All Available Help" on that evening. She stated when she arrived on the Adolescent Unit several staff members were already in Patient #1's room and she was informed her help was not needed in the room. She stated she remained in the hallway and then returned to the nurse's desk. She stated when the RN #3 came out of the patient's room "he told me what happened". She stated she then documented the note in the medial record "because (RN #3) was busy with another patient escalating". When asked she agreed she had documented solely by report and had not witnessed any of the events leading up to or pertaining to the actual restraint.

4. A brief interview was conducted with the Director of Quality on 4/12/16 at 1:45 p.m. at which time she agreed with the above findings.