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Based on the systemic nature of the standard level deficiencies related to patient rights, the facility failed to comply with this condition.

The findings were:

A-0117
Based on interviews and the review of documents, it was determined the facility staff failed to include information related to restraints, seclusion, and timeouts in the patient rights information provided to patients.

A-0162
Based on interviews and the review of documents, it was determined the facility staff failed to have a policy and procedure in place to address the use of "timeouts".

A-0164

Based on interviews and document review, it was determined the facility staff failed to document behaviors resulting in restraints and/or seclusion, and failed to document interventions attempted prior to the use of restraints and/or seclusion for one (1) of three (3) patients sampled for restraint/seclusion (Patient #1).

A-0168
Based on interviews and the review of documents, it was determined the facility staff failed to ensure accurate and/or timely orders for restraints and/or seclusion for three (3) of three (3) patients sampled for restraint/seclusion (Patient #1, Patient #2, and Patient #3).

A-0169
Based on interviews and the review of documents, it was determined the facility staff used a PRN medication to address behaviors reported as violent and/or aggressive without obtaining a physician order for the medication to be administered to address the aforementioned behaviors for one (1) of three (3) patients sampled for restraint/seclusion (Patient #1).

A-0196
Based on interviews and the review of documents, it was determined the facility staff failed to have evidence of restraint/seclusion training for one (1) of six (6) nursing staff members and for four (4) of four (4) security staff members.

A-0200
Based on interviews and the review of documents, it was determined the facility staff failed to have evidence of current CPI (Crisis Prevention Intervention) training for four (4) of four (4) security staff members selected for training/education review.

A-0213
Based on interviews and the review of documents, it was determined the facility staff failed to report a death associated with the use of restraints and/or seclusion to CMS.

Based on interviews and the review of documents, it was determined the facility staff failed to include information related to restraints, seclusion, and timeouts in the patient rights information provided to patients.

The findings include:

Information provided to patients' on admission did not contain specific information related to restraints, seclusion, and timeouts.

On 12/19/18 at 10:00 a.m., Staff Member (SM) #4 provided the surveyor with a copy of the written information related to patient rights that is provided to patients. When asked about the information related to restraints/seclusion/timeout, SM #4 identified sections in this document that addressed: safe settings, being informed of consequences related to their decisions, and knowing hospital rules and regulations "that affect their behavior". SM #4 agreed this document did not use the wording of 'timeout, seclusion, and restraints'.

The following information was found in a facility policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date): "Notification of Rights ... The facility will provide patients/families the notice of Patient Rights and Responsibilities on admission ... The document includes patient rights as to restraints and seclusion and time out."

Based on interviews and the review of documents, it was determined the facility staff failed to have a policy and procedure in place to address the use of "timeouts".

The findings include:

The facility staff failed to ensure policies and procedures provided guidance that detailed the implementation, monitoring, and documentation of 'timeouts'.

The following nursing note was found in Patient #1's clinical documentation: "2300 Pt (patient) came out of room with a sheet wrapped around (him/her) like a toga, no shirt. Pt became hostile when writer verbally redirected pt back to (his/her) room to put a gown on. Pt then became physical trying to hit, kick and bite staff. Staff escorted pt into time out and administered IM Geodon. Pt fought security and staff but tolerated well. Staff explained to pt why (he/she) was in time out and what behavior was expected in order to be allowed to return to (his/her) room. Pt is banging on the door and yelling at staff ..." This note was documented for a "Date of Service" of 11/06/18 at 11:10 p.m.; this note was "Filed" and "Electronically signed" on 11/07/18 at 6:02 a.m. This note used the wording of "time out" but orders and additional documentation indicated the patient was placed into seclusion.

On the morning of 12/20/18, Staff Member (SM) #12 provided the survey team with a copy of the "Restraints and Seclusion" policy with the definition of 'timeouts' marked to identify where 'timeouts' were addressed in the facility's policy. This information did not address the documentation and monitoring of 'timeouts'.

The facility policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date) included a table which identified "Time Out (for Behavioral Restraints)"as one of the "SPECIFIC ALTERNATIVES WHICH MAY BE OFFERED" under the "CATEGORY of ALTERNATIVE OFFERED" to "Promote Cognitive, Psychological, and Physiological Well-Being". This policy also included the following definition for "timeouts": "Time Out: Timeout is not considered seclusion. Timeout is an intervention in which the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving. A Time Out is an alternative procedure used when the patient meets the criteria for Emergency use for Violent or Self-Destructive Behavior. The purpose of a Time Out is to assist the patient to regain emotional control by removing the patient from his or her immediate environment and restricting the patient to a quiet area or unlocked quiet room. A Time Out should not exceed 30 minutes and its use must be consistent with the patient's treatment plan."

Based on interviews and document review, it was determined the facility staff failed to document behaviors resulting in restraints and/or seclusion, and failed to document interventions attempted prior to the use of restraints and/or seclusion for one (1) of three (3) patients sampled for restraint/seclusion (Patient #1).

The findings include:

Patient #1's clinical documentation failed to include documentation to detail the progression of behaviors and the unsuccessful interventions attempted prior to obtaining an order for seclusion and administering a medication that was written as a PRN (as needed) medication for severe psychosis.

The following note was documented by a Registered Nurse (RN): "Patient was restless, confused and continues to go in and out of another patient's room. Patient was redirected and reoriented. Patient became more confused and agitated. Patient was escorted with security to the seclusion room at 2316..." This note was documented for a "Date of Service" of 11/08/18 at 12:08 a.m.; this note was "Filed" and "Electronically signed" on 11/08/18 at 11:08 p.m. No documentation was found by or provided to the surveyor to detail how long the behaviors had been occurring prior to assisting the patient to the seclusion room. No documentation was found by or provided to the surveyor to detail how many times staff attempted to "redirected and reoriented" Patient #1 prior to assisting the patient to the seclusion room.

On 12/20/18 at 9:25 a.m., Patient #1's clinical documentation was reviewed with Staff Member (SM) #4. SM #4 was asked when behaviors resulting in Patient #1 being taken to the seclusion room on the evening of 11/7/18 were first documented. SM #4 reported he/she did not find documentation of behaviors prior to the aforementioned nursing note summarizing the events. SM #4 reported documentation did not indicate how often Patient #1 was going into other patients' rooms and/or what Patient #1 was doing while in other patients' rooms. SM #4 reported documentation did not indicate how often Patient #1 was redirected. SM #4 did provide an 11/7/18 note timed 10:56 p.m. that indicated the patient was talking with staff.

The following information was found in a facility policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date):
- "Procedural Components of Restraints and Seclusion ... Assessed Needs of Patient ... The use of restraints and/or seclusion is based on the assessed needs of the patient ... Clinical justification for each episode must be substantiated in the medical record ..." and
- "Procedural Components of Restraints and Seclusion ... Least Restrictive Alternatives ... Least restrictive alternatives will be utilized prior to initiating restraint and/or seclusion ... "

Based on interviews and the review of documents, it was determined the facility staff failed to ensure accurate and/or timely orders for restraints and/or seclusion for three (3) of three (3) patients sampled for restraint/seclusion (Patient #1, Patient #2, and Patient #3).

The findings include:

1. Patient #1's clinical documentation failed to include orders to physically hold the patient to administer a medication.

The following note was documented by a Registered Nurse (RN): "Patient was restless, confused and continues to go in and out of another patient's room. Patient was redirected and reoriented. Patient became more confused and agitated. Patient was escorted with security to the seclusion room at 2316. Patient became very combative in the seclusion room and was banging on the window of the seclusion with a fist hand. Patient received Geodon 10 mg IM for aggressive and combative behavior. Patient became very agitated after receiving the Im [sic] medication and was trying to get out of the seclusion room ..." This note was documented for a "Date of Service" of 11/08/18 at 12:08 a.m.; this note was "Filed" and "Electronically signed" on 11/08/18 at 11:08 p.m.

Interviews with members of the facility's staff (Staff Member (SM) #13, SM #24, and SM #27) indicated the patient had been physically held in order to administer an IM (intramuscular) injection of Geodon on 11/7/18 (prior to midnight). No orders for a physical hold, for the medication administration in question, was found by or provided to the survey team.

The following information was found in a facility policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date): "Physical Holding for Forced Medications: ... The use of force in order to medicate a patient, as with other restraint [sic], must have a physician's order prior to the application of the restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1 hour face-to-face evaluation requirement would also apply."

On 12/20/18 at 10:59 a.m., Staff Member (SM) #10, after reviewing the facility's restraint and seclusion policy, agreed a physical hold to administer a medication would require a physician order.


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2. A surveyor reviewed Patient #2's medical record on 12/20/18 with the facility's administrative director of behavioral health (staff member - SM#6) as the navigator. One of the restraint orders was for a four (4) hour time period starting 11/12/18 at 1:15 p.m. through 5:14 p.m. The order was dated 11/12/18 at 5:48 p.m., four (4) hours and 33 minutes after the restraints were started. The restraint order was also written for four (4) point violent restraints for adults and included comments for restraint type, "Neoprene Locking right ankle, right wrist, left ankle and left wrist" and a reason for restraints noted as, "danger to others." Two (2) behavioral health notes, written by one (1) registered nurse (RN), during the same restraint time period described that Patient #2 was in five (5) point restraints:
· 11/12/18 at 3:10 p.m.: "Received pt (patient) in 5 point restraints. Pt is agitated, yelling and attempting to sit up, while verbally threatening staff. Pt is not receptive to staffs [sic] attempts to explain criteria for release. Will continue to monitor pt 1 to 1 for safety and support and will safely remove the pt from restraints when possible.
· 11/12/18 at 4:12 p.m.: "Pt continues in 5 point restraints. Pt remains agitated but not threatening staff for the last 15 minutes. Pt has periods of rest but yells at staff periodically. Pt does not appear to be in any pain or distress. Pt refuses to acknowledge criteria for released [sic] as explained by staff. Will continue to monitor pt 1 to 1 for safety and support and will safely remove the pt from restraints when possible."

The medical record's flowsheet (where the facility's staff documented their restraint monitoring) provided evidence staff monitored Patient #2's four (4) point restraints: polyurethane locking wrist-right, wrist-left, ankle-right, and ankle-left however, there was no mention of monitoring a fifth restraint. SM#6 informed the surveyor that when patients were placed in four (4) point restraints, there was a way they could maneuver their hips that could cause themselves harm and therefore a fifth restraint (referred to as a chest belt or waist belt) was sometimes used for safety. SM#6 acknowledged the expectation was that the order would also include the fifth restraint and that all orders would be obtained as soon as possible after the restraint application if obtaining the order prior to the restraints application was not possible.

3. A surveyor reviewed Patient #3's medical record on 12/20/18 with the facility's administrative director of behavioral health (SM#6) as the navigator. One of the restraint orders was written for four (4) hour violent adult restraints starting on 11/14/18 at 3:30 a.m. through 7:29 a.m. That order contained comments for restraint type: "polyurethane Non-Locking: right ankle, right wrist, left ankle, and left wrist" (four points) with a reason documented as "danger to others." The facility's flowsheet indicated the staff monitored Patient #3 for five (5) point restraints between 11/14/18 at 3:21 a.m. and 6:17 a.m. The five (5) point restraints that were monitored were: 1) chest belt, 2) polyurethane non-locking wrist-right, 3) polyurethane non-locking wrist-left, 4) polyurethane non-locking ankle-right and, 5) polyurethane non-locking ankle-left. SM#6 acknowledged the restraint order did not indicate five (5) point restraints. At 6:17 a.m. the documentation showed the five (5) point restraints were discontinued and Patient #3 was placed in seclusion. An order for seclusion was written on 11/14/18 at 7:57 a.m. for 11/14/18 starting at 7:30 a.m. through 11:29 a.m. The medical record indicated the patient remained in seclusion from 6:17 a.m. until 9:51 a.m. on 11/14/18. Therefore, Patient #3 was in seclusion on 11/14/18 from 6:17 a.m. through 7:30 a.m. without an order.

The facility's director of quality and infection control (SM#4) provided their policy titled, "Restraints and Seclusion" number BSR 02-03 with a revision date of 11/2018 on 12/18/18. The policy was reviewed throughout the survey and SM#4 acknowledged that the policy provided was in effect during the month of November 2018. The 27 page policy read in part,
"4.6 Other Procedural Components
· (Facility name) recognizes there are situations where emergencies occur and a patient's attending physician or designee is not onsite to order the restraint and/or seclusion. During such emergency situations, the order must be obtained either during the emergency application of the restraint and/or seclusion or immediately (within a few minutes) after the restraint and/or seclusion has been applied." And,
"10.12. Physician Order
· Each order must specify on the Physician's Restraint Order Form:
1. Rationale for use of restraint
2. Type of restraint to be used.
3. Duration of use"

Based on interviews and the review of documents, it was determined the facility staff used a PRN medication to address behaviors reported as violent and/or aggressive without obtaining a physician order for the medication to be administered to address the aforementioned behaviors for one (1) of three (3) patients sampled for restraint/seclusion (Patient #1).

The findings include:

Patient #1 was administered a PRN (as needed) medication to address behaviors documented by a nurse as "aggressive and combative".

The following note was documented by a Registered Nurse (RN): "Patient was restless, confused and continues to go in and out of another patient's room. Patient was redirected and reoriented. Patient became more confused and agitated. Patient was escorted with security to the seclusion room at 2316. Patient became very combative in the seclusion room and was banging on the window of the seclusion with a fist hand. Patient received Geodon 10 mg IM for aggressive and combative behavior ..." Interviews with members of the facility's staff (Staff Member (SM) #13, #24, and SM #27) indicated the patient had been physically held in order to administer an IM (intramuscular) injection of Geodon on the evening of 11/7/18 (prior to midnight).

The following as needed (PRN) order was found in Patient #1's clinical documentation: ziprasidone (GEODON) 10 mg / 0.5 mL injection BID (twice a day) PRN with a "PRN Comment: severe psychosis". This order was entered on 11/6/18 at 9:21 p.m. and signed by the provider on 11/9/18 at 11:09 a.m.

Patient #1's clinical documentation was reviewed with Staff Member (SM) #4 on the morning of 12/20/18. SM #4 reported that Patient #1 was not on Geodon prior to admission but that the patient was on other psychotropic medications.

On 12/20/18 at 3:22 p.m., SM #4 reported that Geodon was administered twice to Patient #1.

The following nursing note was found in Patient #1's clinical documentation: "2300 Pt (patient) came out of room with a sheet wrapped around (him/her) like a toga, no shirt. Pt became hostile when writer verbally redirected pt back to (his/her) room to put a gown on. Pt then became physical trying to hit, kick and bite staff. Staff escorted pt into time out and administered IM Geodon. Pt fought security and staff but tolerated well. Staff explained to pt why (he/she) was in time out and what behavior was expected in order to be allowed to return to (his/her) room. Pt is banging on the door and yelling at staff ..." This note was documented for a "Date of Service" of 11/06/18 at 11:10 p.m.; this note was "Filed" and "Electronically signed" on 11/07/18 at 6:02 a.m.

Patient #1's aforementioned clinical documentation indicated he/she had violent/combative behaviors documented at both times the patient was administered the PRN (as needed) Geodon. Interviews with nursing and security staff revealed that Patient #1 was physically restrained to administer the 11/7/18 (before midnight) Geodon injection.

The following definition of a chemical restraint was found in the facility's policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date): "Chemical Restraint (Medication): A restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

Based on interviews and the review of documents, it was determined the facility staff failed to have evidence of restraint/seclusion training for one (1) of six (6) nursing staff members and for four (4) of four (4) security staff members.

The findings included:

One (1) registered nurse (RN) and four (4) security staff members had no documented evidence of restraint/seclusion/timeout training.

On the afternoon of 12/20/18, Staff Member (SM) #10 and SM #4 reviewed nursing staff training documentation with the surveyor. It was noted one (1) of the six (6) nursing staff members reviewed did not have evidence of restraint/seclusion/timeout training.

On the afternoon of 12/20/18, Staff Member (SM) #4 was interviewed about training for security staff members. SM #4 confirmed none of the four security staff members selected for review had received training related to restraints/seclusion/timeouts. SM #4 reported one (1) of the four (4) security staff members reviewed was a new employee still in his/her probationary period and would not have had all his/her training completed.

The following information was found in a facility policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date): "Training Requirements for Staff, Physicians, Designees, Qualified RN ... Staff applying and monitoring restraint and seclusion, as applicable, must be trained and able to demonstrate competency in the application of restraints, the implementation of seclusion, monitoring, assessing and providing care to a patient in seclusion or in restraints. The training must occur as a part of that staff member's orientation and before performing an action related to restraint/seclusion and should also be initiated on an annual basis ... Appropriate staff must have education, training and demonstrated knowledge on the specific needs of the patient population in at least the following: ... Use of non-physical intervention skills ... Safe application and use of all types of restraints or seclusion used in the hospital, including how to recognize and respond to signs of physical and psychological distress ..."

Based on interviews and the review of documents, it was determined the facility staff failed to have evidence of current CPI (Crisis Prevention Intervention) training for four (4) of four (4) security staff members selected for training/education review.

The findings include:

Four (4) security staff members did not have evidence of current CPI training.

On the afternoon of 12/20/18, Staff Member (SM) #4 was interviewed about security staff training. SM #4 reported that of the four (4) security staff members training requested that one (1) had CPI training that expired on 10/11/18, two (2) had no evidence of CPI training, and one (1) was a new employee still on his/her probationary period and would not have had all his/her training completed.

The following information was found in a facility policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date): "Training Requirements for Staff, Physicians, Designees, Qualified RN ... Staff applying and monitoring restraint and seclusion, as applicable, must be trained and able to demonstrate competency in the application of restraints, the implementation of seclusion, monitoring, assessing and providing care to a patient in seclusion or in restraints. The training must occur as a part of that staff member's orientation and before performing an action related to restraint/seclusion and should also be initiated on an annual basis ... Appropriate staff must have education, training and demonstrated knowledge on the specific needs of the patient population in at least the following: ... Use of non-physical intervention skills ..."

Based on interviews and the review of documents, it was determined the facility staff failed to report a death associated with the use of restraints and/or seclusion to CMS.

The finding include:

Facility staff members failed to report a death associated with the use of restraints and/or seclusion to CMS within the required time limit.

Patient #1 clinical documentation indicated on 11/7/18, the patient was administered an injection and was being placed into seclusion to address aggressive/violent behaviors when the patient fell.
An order for seclusion was found documented on 11/7/18 at 11:16 p.m.; the heading for this order was "RESTRAINTS VIOLENT ADULT".

A CT scan of Patient #1's head was obtained after his/her fall in the seclusion room. The "impression" of the CT scan was as follows: "Nondisplaced [sic] left skull fracture with acute subdural and subarachnoid hemorrhages with 9 mm left-to-right midline shift. Nonspecific white matter changes most compatible with chronic small vessel ischemic change and atrophy."

Patient #1 was transferred to another facility due to his/her clinical findings after the fall in the seclusion room.

On the morning of 12/20/18, Staff Member (SM) #15 reported he/she became aware of Patient #1's death on 11/12/18 or 11/13/18; he/she said the medical examiner had called the facility.

SM #4 provided the survey team evidence, on 12/20/18, that CMS was notified of Patient #1's death after the initiation of this survey, which began on 12/18/18. The evidence of the report of Patient #1's death indicated seclusion for the type of restraint.

The following information was found in a facility policy titled "Restraints and Seclusion" (with 11/18 being the most recent reviewed and/or revised date): "CMS Death Reporting ... Hospitals are required to report to CMS when a death occurs: ... Within one week after restraint or seclusion where it is reasonable to assume that the use of restraint or seclusion directly or indirectly contributed to a death."