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Based on medical record review, policy review, and review of additional pertinent documentation, it was determined that the hospital failed to ensure a seclusion order was entered for 1 out of 4 seclusion episodes reviewed.

The surveyor reviewed the policy titled, "Restraint and/or Seclusion for the Patient with Violent/Self-Destructive Behavior Policy." Section "V. Responsibility" stated, "B. Authorized Prescribers shall: ...6. Provide a new order for each Restraint and/or Seclusion episode or for a change in Restraint type ..."

Patient #8 (P8) was a 50 + year old patient who was brought to the Emergency Department (ED) by ambulance for suicidal ideations. P8 had a history of mental illness and admitted that they only stated they had suicidal ideations so they could be hospitalized.

Following arrival and triage, P8 was taken to the psychiatric ED area where they awaited a bed for a voluntary psychiatric admission. The following day, P8 was transferred to a psychiatric unit within the hospital.

Throughout their admission, P8 had 1 episode of physical restraint and 4 episodes of seclusion and physical restraint. One episode of seclusion and physical restraint occurred on day 8 of P8's admission. The episode began with a 1-minute physical hold. The Registered Nurse (RN) documented, "Patient attempted to leave room while half dressed. [Patient] shoved SO (Security Officer) [name] while attempting to push through [him/her] and not following verbal redirection. Extra security along with SO [name] assisted the patient to the ground. Patient was yelling threats at officers. RNs and officers used a physical hold to assist patient to the seclusion room. STH (short term hold) was discontinued in order to start LDS (locked door seclusion)."

The surveyor reviewed the order for this episode, titled "Restraints for Violent or Self-destructive Behavior, Age 18 and Older (Adult) Physical Hold for Physical Escort; All = Violent/Imminent risk of harm to self and other (Order [number])." It was ordered by the provider 4 minutes after the initiation of the physical restraint. Under "Restraint Type" the "Answer" was entered as "Physical Hold for Physical Escort." The order did not address the seclusion intervention. No additional orders were located within the medical record for this episode.

P8 remained in locked door seclusion for approximately 41 minutes.

Based on medical record review, policy review, and review of additional pertinent documentation, it was determined that the hospital failed to ensure a face-to-face assessment was entered for 1 out of 4 seclusion episodes reviewed.

The surveyor reviewed the policy titled, "Restraint and/or Seclusion for the Patient with Violent/Self-Destructive Behavior Policy." Section "VI. Process" stated, "B. Restraint and/or Seclusion initiation. 3. Within 1 hour of applying Restraints and/or initiation of Seclusion, an in-person (face-to-face) evaluation must be performed by an authorized prescriber."

Patient #8 (P8) was a 50 + year old patient who was brought to the Emergency Department (ED) by ambulance for suicidal ideations. P8 had a history of mental illness and admitted that they only stated they had suicidal ideations so they could be hospitalized.

Following arrival and triage, P8 was taken to the psychiatric ED area where they awaited a bed for a voluntary psychiatric admission. The following day, P8 was transferred to a psychiatric unit within the hospital.

Throughout their admission, P8 had 1 episode of physical restraint and 4 episodes of seclusion and physical restraint. One episode of seclusion and physical restraint occurred on day 8 of P8's admission. This episode began with a 1-minute physical hold. The Registered Nurse (RN) documented, "Patient attempted to leave room while half dressed. [Patient] shoved SO (Security Officer) [name] while attempting to push through [him/her] and not following verbal redirection. Extra security and SO [name] assisted the patient to the ground. Patient was yelling threats at officers. RNs and officers used a physical hold to assist patient to the seclusion room. STH (short term hold) was discontinued in order to start LDS (locked door seclusion)."

The surveyor reviewed the face-to-face assessment for this episode, titled "Face-to-Face Evaluation for Response to Intervention of Restraint/Hold/Seclusion for Violent or Self-destructive Behavior." It was completed by the provider 4 minutes after the initiation of the physical restraint. Under "Restraint Type" the "Answer" was entered as "Physical Hold for Physical Escort." The face-to-face assessment did not address the seclusion intervention. No additional face-to-face assessments were located within the medical record for this episode.

P8 remained in locked door seclusion for approximately 41 minutes.