HospitalInspections.org

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The hospital failed to ensure the Condition of Participation: CFR 482.13 Patient's Rights was met as evidenced by:

A123- Failed to ensure one patient (#2) had received written notice of the steps taken and resolution of his/her written complaint/grievance;

A143 - Failed to ensure one patient (#1) was provided psychiatric care in a manner that preserved physical privacy.

A144 - Failed to ensure one patient (#1) was provided with an emotionally safe environment during seclusion events.

A145 - Failed to ensure one patient (#1), out of 8 patients reviewed for restraints/ time-out/ seclusion, was free from potential verbal, emotional and physical abuse during care and treatment.

A162 - Failed to identify seclusion for three patients (#s 1, 12 and 13) who were prevented from leaving a room or area. Specifically, the facility implemented a Time-Out (a voluntary seclusion) that became a seclusion (involuntary) for the patients.

A167 - Failed to ensure one patient (#1) was safely and appropriately restrained and/or secluded during two separate events.

A174 - Failed to ensure one patient (#1) was released from seclusion in a timely manner in conjunction with the absence of immediate or imminent destructive and/or harmful behavior.

A175 - Failed to ensure the monitoring of 1 patient (#6) included offering fluids during multiple seclusion events

A178 - Failed to ensure one patient (#6) was evaluated face-to-face within one hour after the initiation of a restraint and seclusion.

The cumulative effect of these systemic problems resulted in failure of the facility to ensure patients were receiving quality care in a safe manner that promoted the rights of the patients and afforded them due process.
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Based on record review, interview, and policy review the facility failed to ensure one patient (#2) out of 2 patients reviewed that had filed grievances in the facility, had received written notice of the steps taken and resolution of his/her written complaint/grievance. This failed practice denied the patient written knowledge of the steps and actions taken on his/her behalf. Findings:

Patient #2

Record review on 3/27-29/18 revealed Patient #2 was admitted to the facility with diagnoses that included traumatic brain injury and diabetes mellitus type 2.

During an interview on 3/27/18 at 2:30 pm, Patient #2 stated he/she had filed "16" grievances while at the facility.

Review on 3/29/18 of Patient #2's written complaints/grievances revealed a concern "No#. 18-119" dated 3/5/18. The complaint/grievance had 2 concerns written on it. The first concern was documented by the Protective Services Specialist (PSS) as resolved: "Notified unit staff who said they would take care of request." The second concern was, "Have a grievance with...2 staff members that [harass] me...This has been going on about 80 % of the time I been here since 2-16-18." The second concern was not addressed.

During an interview on 3/29/18 at 10:40 am, the PSS confirmed the 2nd complaint/grievance had not been addressed.

Review on 3/29/18 of the facility's policy and procedures "Patient Complaint and Grievance Procedures" last revised 10/13/17, revealed "Patient Grievance: A concern or complaint filed by a patient ...that is unable to be resolved within three (3) business days." Additional review revealed, "...Level II grievances include, but are not limited to ...staff demeanor...Within seven (7) calendar days, provide the RSS [Recovery Support Services/Protective Services Specialist] staff with a written response...The final written response is due to the patient no later than fourteen (14) business days post receipt of the grievance."

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Based on record review, video review and interview the facility failed to ensure one patient (#1), out of 13 sampled patients, was provided psychiatric care in a manner that preserved physical privacy. This failed practice placed the patient at risk for psychosocial harm and trauma. Findings:

Record review on 3/27-29/18 revealed Patient #1 was admitted to the facility with a diagnosis of developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Seclusion: 3/5/18

Video review of the seclusion event on 3/5/18 at 10:46 am revealed LN (licensed nurse) #1 providing release criteria for Patient #1 who was in a 5-point mechanical restraint (straps that hold each wrist, each ankle and one over the torso that holds patient to a bed). The LN noted the patient had urinated while in the 5-point restrain. The LN told the patient to stand up and "drop them" while pointing to the patient's pants. The patient took off his/her pants resulting in him/her to be naked from the waist down. The LN then instructed the patient to walk out of the Oak Room (a room with a restraint bed and a secure door capable of being locked) and go to the bathroom in the next room. Multiple staff were present while the partially nude patient walked from the Oak Room to the bathroom.

During an interview on 3/28/18 at 4:00 pm, the Quality Improvement Coordinator (QIC) stated the LN should have illustrated a more respectful method while having the patient undress.

During an interview on 3/29/18 at 10:15 am the Director of the facility stated the staff should have provided a towel in efforts to provide more privacy and dignity to the patient while undressing.

Record review of the seclusion documentation for the event on 3/5/18 revealed a note dated 3/7/18 that described the events of the seclusion and mechanical restraint. The noted stated "[Patient] was release from restraints so [he/she] can shower after urinating on [himself/herself] while in restraints." Next, the patient took a shower. The note continued to state "[Patient] following direction but per behavioral plan was placed back into seclusion to reinforce that urinating on [himself/herself] will not result in release from restraint/seclusion."

Review of Patient's behavioral plan, dated 3/27/18, revealed no indication or approval to place back into seclusion after urinating on self.

During an additional interview on 3/28/18 at 4:10 pm, the Quality Improvement Coordinator (QIC) stated there was not clinical indication or justification for the Patient to go back into seclusion after the shower.

During an interview on 3/28/18, Psychologist #1 stated the Oak Room should never be used as punishment.

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Based on record review, video review and interview the facility failed to ensure one patient (#1), out of 7 patients reviewed that had been placed in seclusion and/or time-out, was provided with an emotionally safe environment during seclusion events. This failed practice placed the patient at risk for emotional instability and psychosocial harm. Findings:

Record review on 3/27-29/18 revealed Patient #1 was admitted to the facility with a diagnosis of developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Seclusion: 3/5/18

Video review of the seclusion event on 3/5/18 at 10:46 am revealed LN (licensed nurse) #1 providing release criteria for Patient #1 who was in a 5-point mechanical restraint (straps that hold each wrist, each ankle and one over the torso that holds patient to a bed). The LN noted the patient had urinated himself/herself while in the 5-point restraint. The LN told the patient to stand up and "drop them" while pointing to the patient's pants. The patient took off his/her pants resulting in him/her to be naked from the waist down. The LN then instructed the patient to walk out of the Oak Room (a room with a restraint bed and a secure door capable of being locked) and go to the bathroom in the next room. Multiple staff were present while the partially nude patient walked from the Oak Room to the bathroom.

During an interview on 3/28/18 at 4:00 pm, the Quality Improvement Coordinator (QIC) stated the LN should have illustrated a more respectful method while having the patient undress.

During an interview on 3/29/18 at 10:15 am the Director of the facility stated the staff should have provided a towel in efforts to provide more privacy and dignity to the patient while undressing.


Seclusion: 3/13/18

Video review of the seclusion event on 3/13/18 at approximately 11:00 am revealed Patient #1 was having a difficult time on the milieu, opening doors and attempting to touch others. Staff instructed the patient to go to the Oak Room. Patient #1 verbally and physically indicated he/she didn't want to go. Staff assisted the Patient to the Oak Room indicating he/she needed a voluntary time out. Once in the Oak Room PNA #4, standing over the patient, punitively stated that he/she would bring the patient back and lock the door if the patient touched anyone else.

During an interview on 3/28/18 at 4:15 pm, the Quality Improvement Coordinator (QIC) stated staff should not tower over patients and use the Oak Room as a punitive measure.


Seclusion: 3/15/18


Video review of the seclusion event on 3/15/18 revealed Patient #1 was being guided to the Oak Room by multiple staff. Once in the Oak Room, LN #2 proceeded to give medication to the Patient at 5:56 pm. During medication administration the LN reprimanded the patient by standing over him/her and punitively stated he/she would give the Patient a shot if he/she refused to take the medication by mouth. Patient #1 began to become emotional. The LN stated "You can cry then." The LN continued to indicate if the patient does not comply then he/she would be locked in the Oak Room.

During an interview on 3/28/18 at 4:15 pm, the Quality Improvement Coordinator (QIC) stated the staff member in the video appeared to be scolding and threatening with the use of a shot and seclusion.

During an interview on 3/28/18, Psychologist #1 stated the Oak Room should never be used as punishment.

Review of the facility's policy "Management of Patient Behaviors," effective date 8/15/17, revealed the facility " ...will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients ..."

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Based on record review, video review and interview the facility failed to ensure one patient (#1), out of 8 patients reviewed for restraints/ time-out/ seclusion, was free from potential verbal, emotional and physical abuse during care and treatment. Specifically, the facility failed to ensure the patient free from improper physical handling, unreasonable confinement, verbally belittled and threatening of punishment by means of seclusion and injections. This failed practice placed the patient at risk for physical injury, emotional distress, less that optimal psychosocial well-being. Findings:

Record review on 3/27-29/18 revealed Patient #1 was admitted to the facility with a diagnosis of developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Seclusion #1: 3/5/18

Review on 3/28/18, of the 3/5/18 video revealed the Patient was in his/her bedroom at 8:36 am. The patient began to leave the room when PNA (Psychiatric Nursing Assistant) #4 stepped behind the Patient and pulled him/her back into the room by the backside collar of the Patient's top.

During an interview on 3/28/18, during the video review, the Assistant Director of Nursing (ADON) stated the use of the patient's collar to pull the Patient back into room was not the appropriate way to direct him/her. The ADON stated the PNA should have approached the patient from the front.

Further review of the video from 3/5/18 at 8:40 am revealed the patient, standing in doorway of room, began to kick at the PNA. Next, the PNA directed the patient back into the room with an open hand on the front chest/shoulder area. When the Patient attempted to leave the bedroom, the PNA used his/her foot to block the bedroom door from opening more than 6 inches. The patient made multiple attempts to squeeze through the small opening.

During an interview on 3/28/18 at 3:30 pm, the Quality Improvement Coordinator (QIC) stated the patient was secluded in his/her bedroom. The QIC further stated secluding a patient in a bedroom could be approved if the behavior plan indicated it necessary. The QIC continued to state, placing the patient in a facility approved physical hold and the use of a gurney for transportation would have been a safer and more appropriate method of handling the patient's behaviors.

Review of Patient's behavioral plan, dated 3/27/18, revealed no indication or approval to use his/her bedroom as a place for seclusion.


Physical Hold: 3/5/18


Additional review of the video from 3/5/18 revealed the patient was moved into the Oak Room (a room with a restraint bed and a secure door capable of being locked). While in the Oak Room the Patient began to bang head on the locked door. At approximately 8:55 am two staff members came into the Oak Room and placed the Patient abdomen first against the corner of two walls. The Patient, while standing, was held against the corner until the bed restraints were in place.

During an interview on 3/29/18 the Medical Officer stated staff should not have placed the Patient face forwards into a wall.

During an interview on 3/29/18 at 10:00 am the Protective Service Specialist of the facility stated the staff should have used a more appropriately NAPPI (Non-Abusive Psychological and Physical Intervention) technique such a capture wrap (a physical hold technique that 1 or 2 people place a hug-like hold on the patient).

During an interview on 3/29/14 at 2:07 the NAPPI Trainer stated a one arm body wrap would have been the most appropriate physical hold. The NAPPI Trainer further stated placing patients against the wall is not an approved NAPPI technique nor is that type of hold taught in the NAPPI certification class.

Review of the facility's policy "Seclusion and or Restraint, Time-Out, Patient Safety Equipment (PSE)," effective date 10/27/17, revealed "..Only NAPPI approved techniques for physical intervention will be used."

Review of the NAPPI Trainers Manual, provided by the facility on 3/29/18, revealed placing a patient face-forward into a wall was not an approved NAPPI technique.


Seclusion #2: 3/5/18


Video review of the seclusion event on 3/5/18 at 10:46 am revealed LN (licensed nurse) #1 providing release criteria for Patient #1 who was in a 5-point mechanical restraint (straps that hold each wrist, each ankle and one over the torso that holds patient to a bed). The LN noted the patient had urinated while in the 5-point restraint. The LN told the patient to stand up and "drop them" while pointing to the patient's pants. The patient took off his/her pants resulting in him/her to be naked from the waist down. The LN then instructed the patient to walk out of the Oak Room (a room with a restraint bed and a secure door capable of being locked) and go to the bathroom in the next room. Multiple staff were present while the partially nude patient walked from the Oak Room to the bathroom.

When the shower was completed at 11:08 am, Patient #1 was returned to seclusion with no imminent behaviors to self or others being displayed. At 11:22 am the Patient approached the door and knocked calmly to gain the attention of the observer, PNA #5. No obvious acknowledgement of the patient was noted. Patient #1 was released at 11:52 am.

Record review of the seclusion documentation for the event on 3/5/18 revealed a note dated 3/7/18 that described the events of the seclusion and mechanical restraint. The noted stated "[Patient] was release from restraints so [he/she] can shower after urinating on [himself/herself] while in restraints." Next, the patient took a shower. The note continued to state "[Patient] following direction but per behavioral plan was placed back into seclusion to reinforce that urinating on [himself/herself] will not result in release from restraint/seclusion."

Review of Patient's behavioral plan, dated 3/27/18, revealed no indication or approval to place back into seclusion after urinating on self.

During an interview on 3/28/18 at 4:00 pm, the Quality Improvement Coordinator (QIC) stated the LN should have illustrated a more respectful method while having the patient undress. The QIC further stated there was no clinical indication or justification for the Patient to go back into seclusion after the shower and the re-seclusion was unnecessary.

During an interview on 3/28/18, Psychologist #1 stated the Oak Room should never be used as punishment.

During an interview on 3/29/18 at 10:15 am the Protective Service Specialist of the facility stated the staff should have provided a towel in efforts to provide more privacy and dignity to the patient while undressing.


Seclusion: 3/13/18


Video review of the seclusion event on 3/13/18 at approximately 11:00 am revealed Patient #1 was having a difficult time on the milieu, opening doors and attempting to touch others. Patient #1 was asked by a staff to go to the Oak Room for a time-out. The patient sat down and replied "I don't want to go." As the Patient was being walked to the Oak Room, he/she began to yell "No Oak Room! No Oak Room! No Oak Room!" Staff assisted the Patient to the Oak Room indicating he/she needed a voluntary time out.

At 11:03 am multiple staff physically stood in doorway of the Oak Room. As a result this created a physical wall that prevented Patient #1 from exiting the room. Once in the Oak Room PNA #4, standing over the patient, punitively stated that he/she would bring the patient back and lock the door if the patient touched anyone else.

Further video review until 11:12 am revealed the patient was in the Oak Room alone with the door appearing to be shut. Medication was administered at 11:12 am by LN (licensed nurse) #1. Next, the Patient calmly asked if he/she could leave the Oak Room immediately after 11:12 am. The LN denied the request and the Patient sat in the Oak Room from 11:12 to 12:14 with no signs of threatening behaviors.

Review of the Seclusion Face to Face Flow Sheet, dated 3/13/18, revealed the staff documented Patient #1 was quietly sitting and/or lying down from 11:30 am to 12:14 pm.

During an interview on 3/28/18 at 3:30 pm, the Quality Improvement Coordinator (QIC) stated staff did not follow protocol. When asked to describe the violent and/or destructive behavior, the QIC stated no immediate violent or destructive behavior warranted the seclusion

During a second interview on 3/28/18 at 4:15 pm, the Quality Improvement Coordinator stated staff should not tower over patients and use the Oak Room as a punitive measure.


Seclusion: 3/15/18:


Video review of the seclusion event on 3/15/18 revealed Patient #1 was being guided to the Oak Room by multiple staff. Once in the Oak Room, LN #2 proceeded to give medication to the Patient at 5:56 pm. During medication administration the LN reprimanded the patient by standing over him/her and punitively stated he/she would give the Patient a shot if he/she refused to take the medication by mouth. Patient #1 began to become emotional. The LN stated "You can cry then." The LN continued to indicate if the patient does not comply then he/she would be locked in the Oak Room.

During an interview on 3/28/18 at 4:15 pm, the Quality Improvement Coordinator (QIC) stated the staff member in the video appeared to be scolding and threatening with the use of a shot and seclusion.

During an interview on 3/28/18, Psychologist #1 stated the Oak Room should never be used as punishment.

Review of the facility's policy "Management of Patient Behaviors," effective date 8/15/17, revealed the facility " ...will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients..."

Review of the facility's policy "Seclusion and or Restraint, Time-Out, Patient Safety Equipment (PSE)," effective date of 10/27/17, revealed the policy defined a seclusion as "The involuntary confinement of a patient alone in a room or an area whereas he/she is physically prevented from leaving that room or area. The room or area may be unlocked or locked ...[Alaska Psychiatric Institute] only uses restraints or seclusion when a patient's behavior results in an imminent risk of patient harming himself or herself or other ...when safety issues require an immediate physical response to prevent harm."

Review of the facility's policy "Conduct Involving Patients," effective date 10/13/17, revealed "All patients will be treated in a respectful an culturally sensitive manner at all times ...[API - Alaska Psychiatric Institute] prohibits any harmful exchanges by employees towered patients at any time during and after hospitalization ...Physical abuse includes ...using more force than reasonable for a patient's control, treatment or management ...defined as the appropriate use of [NAPPI] techniques ...the improper or illegal restraint of seclusion of a patient; including the use of restraint or seclusion imposed as a means of coercion, discipline, convenience, or retaliation by staff ...Verbal abuse includes use of oral or written words ...or statements that belittle, goad, sneer at, condemn, or threaten a patient with bodily harm ...pattern of disrespectful verbalizations ...also meet the definition of abuse ...Emotional abuse includes humiliation of a patient and threats of corporal punishment."

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Based on record review, interview and video review the facility failed to identify seclusion for three patients (#s 1, 12 and 13) out of 7 patients placed in situation that prevented them from leaving a room or area. Specifically, the facility implemented a Time-Out (a voluntary time that allowed patients to be in a low stimulus area) that resulted in the patients inability to move freely about the unit. This failed practice resulted in the patients to be inadvertently secluded and created a risk for psychological harm. Findings.

Patient #1 - Seclusion #1 on 3/5/18

Record review on 3/27-29/18 revealed Patient #1 was admitted to the facility with a diagnosis of developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Review on 3/28/18, of the 3/5/18 video revealed the Patient was in his/her bedroom at 8:36 am. The patient began to leave the room when PNA (Psychiatric Nursing Assistant) #4 stepped behind the patient and pulled him/her back into the room by the backside collar of the patient's top.

During an interview on 3/28/18, during the video review, the Assistant Director of Nursing (ADON) stated the use of the patient's collar to pull patient back into room was not the appropriate way to direct him/her. The ADON then stated the PNA should have approached the patient from the front.

Further review of the video from 3/5/18 at 8:40 am revealed Patient #1 while standing in doorway of room, began to kick at the PNA. Next, the PNA directed the patient back into the room with an open hand on the front chest/shoulder area. The Patient attempted to leave the bedroom. The PNA used his/her foot to block the bedroom door from opening more than 6 inches. The Patient #1 made multiple attempts to squeeze through the small opening.

During an interview on 3/28/18 at 3:30 pm, the Quality Improvement Coordinator (QIC) stated the patient was secluded in his/her bedroom.

Record review revealed no seclusion paperwork or indication was located in Patient #1's medical record for the event that occurred with PNA #4 and the Patient in the bedroom on 3/5/18.

Patient #1 - Seclusion: #2 on 3/5/18

Video review of the seclusion event on 3/5/18 at 10:46 am revealed LN #1 providing release criteria for Patient #1 who was in a 5-point mechanical restraint (straps that hold each wrist, each ankle and one over the torso that holds patient to a bed). The LN noted the patient had urinated himself while in the 5-point restraint. The LN then instructed the patient to walk out of the Oak Room (a room with a restraint bed and a secure door capable of being locked) and go to the bathroom in the next room.

Record review of the seclusion documentation for the event on 3/5/18 revealed a note dated 3/7/18 that described the events of the seclusion and mechanical restraint. The noted stated "[Patient] was release from restraints so [he/she] can shower after urinating on [himself/herself] while in restraints." Next, the patient took a shower. The note continued to state "[Patient] following direction but per behavioral plan was placed back into seclusion to reinforce that urinating on himself will not result in release from restraint/seclusion."

Review of Patient's behavioral plan, dated 3/27/18, revealed no indication or approval to place back into seclusion after urinating on self.

During an interview on 3/28/18 at 4:10 pm, the Quality Improvement Coordinator (QIC) stated there was no clinical indication or justification for the Patient to go back into seclusion after the shower. The QIC further stated the re-seclusion was unnecessary.

Patient #1 - Time-Out 3/13/18

Review of an "Emergency Seclusion" document, dated 3/13/18, revealed Patient #1 was directed to the Oak Room for "voluntary timeout." after throwing liquids on facility staff.

Review on 3/28/18, of the 3/13/18 video revealed Patient #1, near his/her room, was asked by a staff to go to the Oak Room (a room with a restraint bed and a secure door capable of being locked) for a time-out at 11:00 am. The patient sat down and replied "I don't want to go." As the Patient was being walked to the Oak Room, he/she began to yell "No Oak Room! No Oak Room! No Oak Room!" At 11:03 am multiple staff physically stood in doorway of the Oak Room and created a physical wall that prevented Patient #1 from exiting the room. From 11:03 am to 11:12 am the Patient was in the Oak Room alone with the door appearing to be shut. After medication was administered to the Patient, at 11:12 am, by LN (Licensed Nurse) #1. Next, the Patient calmly asked if he/she could leave the Oak Room. The LN denied the request and the Patient sat in the Oak Room from 11:12 to 12:14 with no signs of threatening behaviors.

Review of the Seclusion Face to Face Flow Sheet, dated 3/13/18, revealed the staff did not document the seclusion until 11:18 am.

During an interview on 3/28/18, Psychologist #1 stated the Oak Room should never be used as punishment.

During an interview on 3/28/18 at 3:30 pm, the QIC stated staff did not follow protocol. When asked to describe the violent and/or destructive behavior, the QIC stated no violent or destructive behavior warranted the seclusion.

Patient #12 - Time-Out

Record review on 3/27-29/18 revealed Patient #12 was admitted to the facility with a diagnosis of schizophrenia.

During an interview on 3/27/18 at 2:15 pm, Patient #12 stated he/she had been in a Time-Out the previous Saturday (3/24/18).

Review of the seclusion/restraint log for the date of 3/24/18 revealed no seclusion was documented for Patient #12.

Review of Patient #1's medical record revealed no documentation of a seclusion on 3/24/18. The only seclusion documented in the medical record was dated 3/20/18.

Review on 3/29/18 at 1:15 pm, of the 3/24/18 video revealed the Patient went to the seclusion room at 4:07 pm, voluntarily. At 4:21 pm the Patient stated "I want to go in my room". The Patient came out of the Oak Room and proceeded to escalate his/her behaviors towards the staff. The staff then escorted the Patient back to the Oak Room at 4:25 pm and closed the door.

During an interview on 3/29/18 at 1:15 pm, the QIC stated for a time-out the Staff should have informed the Patient that the door was unlocked.

Patient #13 - Time-Out

Record review on 3/27-29/18 revealed Patient #13 was admitted to the facility with diagnoses that included schizophrenia and antisocial personality disorder.

During an interview on 3/27/18 at 2:30 pm, Patient #13 stated he/she had been in a voluntary "Time-Out" on 3/26/18.

Review of the medical record revealed no documentation of a Time-Out or seclusion on 3/26/18. Review of the seclusion log for 3/26/18 revealed no seclusions were documented for Patient #13.

Review on 3/29/18 at 1:30 pm, of the 3/26/18 at 1:11 pm video revealed the Patient was walking down the hall with PNA #1. The PNA stated to the Patient "Do you think I want to agitate you?" The Patient started swearing and the PNA called a code gray (a behavior emergency-where additional staff respond quickly). Other staff responded and the Patient was taken to the Oak Room. The Patient was then patted down and the door was closed.

During an interview on 3/29/18 at 1:30 pm, the QIC confirmed the placement of the Patient in the Oak Room was a seclusion, not a time-out.

During an interview on 3/27/18 at 2:20 pm, PNA #3, stated the facility did not use time-outs.

During an interview on 3/27/18 at 1:45 pm, PNA #2 stated time-outs were voluntary and usually occurred in the patient's bedroom. The PNA stated the patient could also go into the Oak Room to yell and scream, but then they would be on 1:1 (one staff member to one patient) observation.

During a subsequent interview on 3/28/18 at 11:45 am PNA #2 stated the facility policy explained when and what a Time-Out was. The PNA stated the facility always documented Time-Outs when a patient was in their room, because the patient would then be on 15 minute checks.

Review of the facility's policy and procedure (P&P) "Seclusion and or Restraint, Time-Out, Patient Safety Equipment (PSE) dated 10/27/17 revealed "TIME-OUT: A voluntary procedure used to assist the patient to regain emotional control. Use of a staff-approved area ...for time alone, for any period of time and from which the patient is not prevented from leaving nor given the impression that they are not allowed to leave. When a patient is physically prevented from leaving the Time-Out, or given the impression that they are not allowed to leave, the intervention is no longer a Time-Out, and instead becomes a seclusion.

Further review of the P&P revealed the definition for seclusion was "The involuntary confinement of a patient alone in a room or an area whereas he/she if physically prevented from leaving that room or area. The room or area may be unlocked or locked."

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Based on record review, interview and video review the facility failed to ensure one patient (#1), out of 7 patients reviewed for restraint/seclusion, was safely and appropriately restrained and/or secluded according to facility approved standards of practice, during two separate events. This failed practice place the patient at risk for injury, trauma and psychological harm. Findings:

Record review on 3/27-29/18 revealed Patient #1 was admitted to the facility with a diagnosis of developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Review on 3/28/18, of the 3/5/18 video revealed the Patient was in his/her bedroom at 8:36 am. The patient began to leave the room when PNA (Psychiatric Nursing Assistant) #4 stepped behind the Patient and pulled him/her back into the room by the backside collar of the Patient's top.

During an interview on 3/28/18, during the video review, the Assistant Director of Nursing (ADON) stated the use of the patient's collar to pull the Patient back into room was not the appropriate way to direct him/her. The ADON stated the PNA should have approached the patient from the front.

Further review of the video from 3/5/18 at 8:40 am revealed the patient, standing in doorway of room, began to kick at the PNA. Next, the PNA directed the patient back into the room with an open hand on the front chest/shoulder area. When the Patient attempted to leave the bedroom, the PNA used his/her foot to block the bedroom door from opening more than 6 inches. The patient made multiple attempts to squeeze through the small opening.

During an interview on 3/28/18 at 3:30 pm, the Quality Improvement Coordinator (QIC) stated the patient was secluded in his/her bedroom. The QIC further stated secluding a patient in a bedroom could be approved if the behavior plan indicated it necessary. The QIC continued to state, placing the patient in a facility approved physical hold and the use of a gurney for transportation would have been a safer and more appropriate method of handling the patient's behaviors.

Review of Patient's behavioral plan, dated 3/27/18, revealed no indication or approval to use his/her bedroom as a place for seclusion.
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Additional review of the video from 3/5/18 revealed the patient was moved into the Oak Room (a room with a restraint bed and a secure door capable of being locked). While in the Oak Room the Patient began to bang head on the locked door. At approximately 8:55 am two staff members came into the Oak Room and placed the Patient abdomen first against the corner of two walls. The Patient, while standing, was held against the corner until the bed restraints were in place.

During an interview on 3/29/18 the Medical Officer stated staff should not have placed the Patient face forwards into a wall.

During an interview on 3/29/18 at 10:00 am the Director of the facility stated the staff should have used a more appropriately NAPPI (Non-Abusive Psychological and Physical Intervention) technique such a capture wrap (a physical hold technique that 1 or 2 people place a hug-like hold on the patient).

During an interview on 3/29/14 at 2:07 the NAPPI Trainer stated a one arm body wrap would have been the most appropriate physical hold. The NAPPI Trainer further stated placing patients against the wall is not an approved NAPPI technique nor is that type of hold taught in the NAPPI certification class.

Review of the facility's policy "Seclusion and or Restraint, Time-Out, Patient Safety Equipment (PSE)," effective date 10/27/17, revealed "..Only NAPPI approved techniques for physical intervention will be used."

Review of the NAPPI Trainers Manual, provided by the facility on 3/29/18, revealed placing a patient face-forward into a wall was not an approved NAPPI technique.

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Based on record review, video review and interview the facility failed to ensure one patient (#1), out of 7 patients reviewed for seclusion/ Time-Out, was released from seclusion in a timely manner in conjunction with the absence of immediate or imminent destructive and/or harmful behavior. This failed practice placed the patient at risk for excessive seclusion time and psychosocial instability. Findings:

Record review on 3/27-29/18 revealed Patient #1 was admitted to the facility with a diagnosis of developmental delay (a condition which represents a significant delay in the process of development), mild mental retardation, cognitive disorder and anoxic brain injury (injury to the brain due to lack of oxygen).

Seclusion: 3/5/18

Video review of the seclusion event on 3/5/18 at 10:46 am revealed LN #1 providing release criteria for Patient #1 who was in a 5-point mechanical restraint (straps that hold each wrist, each ankle and one over the torso that holds patient to a bed). The LN noted the patient had urinated himself while in the 5-point restraint. The LN then instructed the patient to walk out of the Oak Room (a room with a restraint bed and a secure door capable of being locked) and go to the bathroom in the next room. The LN informed the patient that he/she would return to the seclusion when shower was completed. Patient #1 complied with request to shower. When shower was completed at 11:08 am, Patient #1 was returned to seclusion with no imminent behaviors to self or others being displayed. At 11:22 am the Patient approached the door and knocked calmly to gain the attention of the observer, PNA #5. No obvious acknowledgement of the patient was noted. Patient #1 was released at 11:52 am.

Review of the Seclusion Face to Face Flow Sheet, dated 3/5/18 from 11:15 am to 11:51 am, revealed the patient was returned to seclusion. During this time, Patient #1 was documented as standing still, singing, hopping and/or laughing. The form did not have documentation of the staff member engaging or acknowledging Patient #1 at 11:22 am.

Record review of the seclusion documentation for the event on 3/5/18 revealed a note dated 3/7/18 that described the events of the seclusion and mechanical restraint. The noted stated "[Patient] was release from restraints so [he/she] can shower after urinating on [himself/herself] while in restraints." Next, the patient took a shower. The note continued to state "[Patient] following direction but per behavioral plan was placed back into seclusion to reinforce that urinating on himself will not result in release from restraint/seclusion."

Review of Patient's behavioral plan, dated 3/27/18, revealed no indication or approval to place back into seclusion after urinating on self.

During an interview on 3/28/18 at 4:10 pm, the Quality Improvement Coordinator (QIC) stated there was no clinical indication or justification for the Patient to go back into seclusion after the shower. The QIC further stated the re-seclusion was unnecessary.

Seclusion: 3/13/18

Review of the Emergency Seclusion document, dated 3/13/18 revealed that the patient threw liquids on staff but was directed to the Oak Room for "voluntary timeout."

Review on 3/28/18, of the 3/13/18 video revealed the Patient, near his/her room, was asked to go to the Oak Room (Oak Room-a room with a bed, no windows, and a secure door capable of being locked) for a time out at 11:00 am. The patient sat down and replied "I don't want to go." As the Patient was being walked to the Oak Room, he/she began to yell "No Oak Room! No Oak Room! No Oak Room!" At 11:03 am multiple staff physically stood in doorway of the Oak Room. As a result this created a physical wall that prevented Patient #1 from exiting the room. From 11:03 am to 11:12 am the patient was in the Oak Room alone with the door appearing to be shut. Medication was administered at 11:12 am by LN (licensed nurse) #1. Next, the Patient calmly asked if he/she could leave the Oak Room immediately after 11:12 am. The LN denied the request and the Patient sat in the Oak Room from 11:12 to 12:14 with no signs of threatening behaviors.

Review of the Seclusion Face to Face Flow Sheet, dated 3/13/18, revealed the staff did not document the seclusion until 11:18 am. Further review revealed the staff documented Patient #1 was quietly sitting and/or lying down from 11:30 am to 12:14 pm. Release criteria was not instructed to the Patient until 12:14 pm.

During an interview on 3/28/18 at 3:30 pm, the Quality Improvement Coordinator (QIC) stated staff did not follow protocol. When asked to describe the violent and/or destructive behavior, the QIC stated no immediate violent or destructive behavior warranted the seclusion. The QIC stated the staff stated the patient was calm and should have been assessed sooner for release.

During an interview on 3/28/18 at 4:00 pm LN #1 stated Patient #1 should be release from seclusions when negative behaviors are absent. LN #1 further stated frequent verbal checks should be done with the Patient.

Review of the facility's policy "Seclusion and or Restraint, Time-Out, Patient Safety Equipment (PSE)," effective date of 10/27/17, revealed the policy defined a seclusion as "The involuntary confinement of a patient alone in a room or an area whereas he/she is physically prevented from leaving that room or area. The room or area may be unlocked or locked ...[Alaska Psychiatric Institute] only uses restraints or seclusion when a patient's behavior results in an imminent risk of patient harming himself or herself or other ...when safety issues require an immediate physical response to prevent harm."

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Based on record review, interview and policy review the facility failed to ensure the monitoring of 1 patient (#6), out of 7 patients reviewed for seclusion/restraints, included offering fluids during multiple seclusion events. These failures placed the Patient at risk not receiving the needed fluids and dehydration. Findings:

Patient #6:

Record review on 3/27-29/18 revealed Patient #6 was admitted to the facility with a diagnosis that included schizophrenia.

Further review revealed the Patient had numerous seclusion/restraint episodes since admittance. Review of the following "Seclusion Face to Face Flow Sheet" in the medical record review revealed missing documentation related to fluids offered to the Patient at least every hour:

- 3/10/18 at 7:42 pm to 9:43 pm - no documentation of fluids provided and/or offered were documented until 9:15 pm;
- 3/22/18 at 8:13 pm to 4:30 am - no documentation of fluids provided and/or offered at least hourly;
- 3/23/18 at 12:40 am to 7:42 am - no documentation of fluids were provided and/or offered until 6:35 am; and
- 3/24/18 at 10:23 am to 12:55 pm - no documentation of fluids provided and/or offered.

During an interview on 3/29/18 at 2:15 pm, the Quality Improvement Coordinator confirmed the above seclusion flow sheets were missing documentation of the Patient receiving fluids, or offered fluids while secluded.

Review of the facility's policy and procedure "Seclusion and or Restraint, Time-Out, Patient Safety Equipment (PSE) dated 10/27/17, revealed "D. Psychiatric Nursing Assistant (PNA) responsibilities ...Face to Face Flow Sheet will be documented in real time by staff member observing the patient to include documentation ...of fluids q [every] 60 minute & PRN [as needed]...Staff must write a comment on Flow Sheet to clinically justify any required patient assessment/assistance that is not offered or performed ...6. Staff must note any patient refusals for care on the S/R Flow Sheet ..."
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Based on record review, interview and policy review the facility failed to ensure one patient (#6), out of 7 patients reviewed for restraints/seclusion, was evaluated face-to-face within one hour after the initiation of a restraint and seclusion. The failure to complete the evaluation within one hour placed the Patient at risk for a negative outcome from the restraint and seclusion. Findings:

Record review on 3/27-29/18 revealed Patient #6 was admitted to the facility with a diagnosis that included schizophrenia.

Further review revealed Patient #6 was on Close Observation Status Scale (COSS-a system of increased vigilance and monitoring) with 2nd degree in the milieu (continuous, strict visual monitoring by assigned staff within arm's length), and 1st degree in bed area (15 minute observation and engagement checks).

Review of the medical record revealed the Patient was secluded on 3/25/18 at 10:23 pm and released from seclusion on 3/26/18 at 12:27 am. At the initiation of the seclusion the Patient was restrained by a "Brief Manual Restraint" (BMR).

Further review of the medical record revealed the facility did not document a 1-hour face-to-face. The face-to-face was completed on 3/26/18 at 4:38 am, which was greater than 6 hours since the start of the BMR and seclusion.

During an interview on 3/29/18 at 12:25 pm the Quality Improvement Coordinator (QIC) confirmed the face-to-face evaluation was not completed within 1 hour.

During an interview on 3/29/18 at 2:00 pm, the QIC, stated all the RNs received specialty training as a Special Procedures Nurse (SPN) in order to be trained in 1 hour face-to-face evaluations.

Review of the facility's policy and procedure "Seclusion and or Restraint, Time-Out, Patient Safety Equipment (PSE) dated 10/27/17, revealed "III. INITIATING, IMPLEMENTING, MONITORING AND DOCUMENTING SECLUSION/RESTRAINT: ...G. Assess the patient, in person face-to-face, within one (1) hour of initiating the use of restraint (including manual and gurney restraint) and seclusion. The assessment will be documented at the time of the assessment using the in-person one (1) HR [hour] Face-to-Face Assessment ...h. A Special Procedures Nurse (SPN) may perform this function if an LIP [Licensed Independent Practioner] is not on site3 ...The SPN must follow the same assessment guidelines."

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