HospitalInspections.org

Based on observation, interview and document review, the hospital failed to maintain medical records that contained accurate and complete information regarding the assessment and active treatment of 8 of 8 sample active patients (1, 2, 3, 4, 5, 6, 7 and 8), 1 non-sample patient added for treatment review (10) and 2 of 2 discharged patients (D7 and D8) reviewed for the use of seclusion/restraints.

Findings include:

I. The hospital failed to develop Comprehensive Master Treatment plans for 8 of 8 active sample patients. (1, 2, 3, 4, 5, 6, 7 and 8). Plans listed the patient's admitting diagnosis rather than delineating patient problems in behavioral terms (Refer to B119). There were no long-term goals, and short-term goals were not individualized and measurable (Refer to B121). Interventions on plans included the routine, generic nursing functions inappropriately listed as individualized interventions, and lacked physician and social work interventions on any plan (Refer to B122). These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach of multidisciplinary treatment team.

II. The hospital failed to ensure a safe, therapeutic environment for patients that is free of risk of physical, and in some instances psychological, harm for all patients on the ward. Staff at the facility routinely request or allow armed city police to restrain or assist in the restraint of patients on the unit. During one restraint episode observed by the surveyors, non-sample patient (10) was subjected to physical and psychological abuse by city police without intervention by the staff. Record review of Patient 10's records revealed police involvement with another episode of restraint of non-sample patient 10 at a previous hospitalization, and review of incident reports revealed police involvement in the restraint of one of the five discharged patients in the sample discharged patient (D7). Staff fail to follow facility policy by allowing police to have weapons on the unit. Interview revealed it is common practice to allow armed police to assist in restraint of inpatients. (Refer to B125, Section I).

III. The hospital failed to appropriately utilize and document seclusion/restraints as external controls of violence toward self and others for 1 of 8 active sample patients (Patient 5), 1 non-sample patient (Patient 10) and 1 discharged patient (D7) for whom the use of seclusion/restraint was reported on incident forms. For Patients 5, 10 and D7, seclusion/restraints were continued without documented justification. For Patient 5, two seclusion/restraint orders were not countersigned, and for Patients 10 and D7, the face-to-face assessment within one hour of the initiation of seclusion/restraints was inadequate, not timed and/or late. These failures exposed patients to potential harm from unnecessary restraint. (Refer to B125, Section II)

IV. The hospital failed to develop and implement a policy for seclusion and restraint to include the definition of a physical hold, and the necessity for medical authorization and monitoring for physical holds.

This failure resulted in improper documentation for the use of a physical hold without documented justification and review for 1 patient (D8). (Refer to B125, Section III).

Based on record review and staff interview, it was determined that in 8 of 8 active records
reviewed (1, 2, 3, 4, 5, 6, 7, and 8) a neurological examination including gross testing of cranial nerves II through XII was not documented. This failure to perform and record detailed neurological findings could result in the overlooking of treatable neurological conditions and/or the inability to document changes from baseline status during patients' hospital stay. This failure makes it impossible to ascertain progression/worsening of the patient's condition on subsequent re-examination.

Findings include:

A. Record Review

1. Patient 1 had a physical examination completed on 2/5/11. Neurological examination (which was part of this physical examination) stated, "Cranial nerves 2-12 are intact."

2. Patient 2 had a physical examination completed on 2/5/11 which stated: "cranial nerves 2-12 are intact."

3. Patient 3 had a physical examination completed on 1/27/11 which stated: "Cranial nerves II through XII are grossly intact."

4. Patient 4 had a physical examination completed on 2/7/11 which stated: "cranial nerves 2-12 are intact."

5. Patient 5 had no neurological examination noted on the physical examination as per the report of physical examination completed on 1/10/11.

6. Patient 6 had a physical examination done on 2/3/11 which stated: "cranial nerves II through XII were reported to be grossly intact."

7. Patient 7 had a physical examination completed on 1/20/11 which reported "cranial nerves II-XII grossly intact."

8. Patient 8 had a physical examination completed on 1/12/11 which stated: "Cranial nerves II-XII were tested and are intact."

B. Staff Interview

In a phone interview on 2/8/11 at 1:30pm with the Medical Director, the Medical director stated, "I know cranial nerves needed to be tested individually. I take the blame, I should have monitored it."

Based on record review and staff interview, the facility failed to ensure that memory functioning was tested in 8 of 8 active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). This failure to test memory functioning results in a lack of baseline data from which future assessments can be measured.

Findings include:

A. Record review

1. Patient 1 had a mental status examination done as part of an "Inpatient Evaluation" (facility's term for psychiatric evaluation) completed on 2/6/11. Mental status examination did not include testing of memory function.

2. Patient 2 had an Inpatient Evaluation completed on 2/6/11. Memory testing was not recorded as part of this mental status examination.

3. Patient 3 had an Inpatient evaluation which was completed on 1/27/11 which listed memory functioning as "impairment to Recent, Impairment to long-term." There was no description of the actual tests which were used to come to this conclusion.

4. Patient 4 had an Inpatient Evaluation completed on 2/7/11; the mental status examination in this report did not include testing of memory function.

5. Patient 5 had an Inpatient Evaluation completed on 1/13/11. Mental status examination in this report did not include any description for the testing of memory function.

6. Patient 6 had an Inpatient Evaluation completed on 1/28/11 which did not show any evidence of testing for memory function in its mental status examination.

7. Patient 7 had an Inpatient Evaluation completed on 2/7/11. Mental status examination in this report did not include any description for the testing of memory function.

8. Patient 8 had an Inpatient Evaluation completed on 2/7/11. Memory function was not listed as part of this patient's mental status examination.

B. Staff interview

In a phone interview on 2/8/11 at 1:30pm with the Medical Director, these findings were shared, and she agreed that memory functioning needed to be included in the mental status examination.

Based on record review and staff interview, the facility failed to address in the master treatment plan which specific problems would be treated during the patient's hospitalization for 7 of 8 active sample patients.(2, 3, 4, 5, 6, 7 and 8). Rather than identifying and describing the problem behavior, patient's admitting diagnosis was used as the patient's problem. This failure results in a lack of a specific identifiable focus upon which treatment planning can be based.

Findings include:

A. Record Review

1. Patient 2: In a master treatment plan dated 2/7/2011, "major depression" was listed as the patient's problem.

2. Patient 3: In a master treatment plan dated 1/28/2011, the patient's problem was listed as "schizoaffective disorder."

3. Patient 4: In a master treatment plan dated 2/7/11, the patient's problem was listed as "schizoaffective disorder."

4. Patient 5: In a master treatment plan dated1/1/2011, the patient's problem was listed as "schizoaffective disorder."

5. Patient 6: In a master treatment plan dated 1/28/11, "schizophrenia, paranoid type" was listed as the patient's problem.

6. Patient 7: In a master treatment plan dated 1/20/2011, "Major Depressive Disorder" as the patient's problem.

7. Patient 8: In a master treatment plan dated 2/7/11, "schizoaffective disorder" was listed as the patient's problem.

B. Staff interview

In a telephone interview on 2/28/11 at 1.30pm with the medical director, s/he agreed with that the problems needed to be stated in behavioral terms rather than listing the diagnosis of the patient.

Based on record review and staff interview, the facility failed to establish short-term and long-term goals for 8 of 8 active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). Instead the facility used only short-term objectives which were generic and non-specific, and could not be observed or measured. This failure to establish individualized objectives which are observable and measurable hinders the ability of the treating team to measure change in the patient as a result of treatment interventions and may prolong the hospital stay beyond the resolution of the behaviors requiring admission.

Findings include:

A. Record Review

1. Patient 1: In a master treatment plan completed on 2/4/11, the objectives that were listed included: "patient will detox without incident;" "patient will understand the role of substance usage in life situation," and "will meet the discharge criteria."

2. Patient 2: In a master treatment plan completed on 2/4/11, the objectives that were listed included: "Establish a working alliance with client;" "decrease in depressive symptoms;" "client will achieve and maintain environmental stability" "client will maintain mental health stability;" "client will successfully handle crisis situations;" "successful independent living in the community;" "maintain mental health stability" and "meet discharge criteria."

3. Patient 3: In a master treatment plan dated 1/28/11, the following objectives were included: "Staff and patient will work together to return patient to previous functioning;" "to determine/address physical health issues that may impact patient's psychiatric treatment;" "psychotic behaviors will be controlled or eliminated" and "meet discharge criteria."

4. Patient 4: In a master treatment plan completed on 2/7/11, the objectives listed included: "staff and patient will work together to return patient to previous level of functioning;" "To determine/address physical health issues that may impact patient's psychiatric treatment;" "Psychotic behaviors will be controlled or eliminated" and "meet discharge criteria."

5. Patient 5: In a master treatment plan completed on1/11/11, the following objectives were included: "staff and patient will work together to return patient to previous level of functioning;" "to determine/address the physical health issues that may impact psychiatric treatment;" "psychotic behaviors will be controlled or eliminated", and "meet discharge criteria."

6. Patient 6: In a master treatment plan completed on 1/28/11, the objectives that were listed included: "staff and patient will work together to return patient to previous level of functioning;" "psychotic behaviors will be controlled or eliminated" and "meet discharge criteria."

7. Patient 7: In a master treatment plan completed on 1/20/11, the objectives that were noted included: "establish a working alliance with patient;" "decrease in depressive symptoms;" "client will achieve and maintain emotional and environmental stability;" "client will successfully handle crisis situation;" "maintain mental health stability" and "meet discharge criteria."

8. Patient 8: In a master treatment plan completed on 2/7/11, the objectives that were noted included: "staff and patient will work together to return patient to previous level of functioning;" "to determine/address physical health issues that may impact patient's psychiatric treatment;" "psychotic behaviors will be controlled/eliminated .and "meet discharge criteria."

B. Staff interview

In a phone interview on 2/8/11 at 1:30pm with the Medical Director, the Medical Director agreed that the objectives were not individualized and measurable.

Based on record review and staff interviews, the facility failed to develop master treatment plans which identified interventions for psychiatry and social work in 8 of 8 active sample patients. (1, 2, 3, 4, 5, 6, 7 and 8). The resultant master treatment plans thus lacked a comprehensive, integrated and individualized approach. This deficient practice results in a failure to ensure focused treatment that can be easily measureable of a patient's progress toward his/her treatment objectives. In addition, the nursing interventions listed on the master treatment plan included routine, generic discipline functions listed as individualized interventions for 8 of 8 active sample patients (1, 2, 3, 4, 5, 6, 7 and 8).

Findings include:

I. Record Review

A. Lack of Psychiatric Interventions and Social Work Interventions

1. Patient 1: In a master treatment plan dated 2/7/11, there were no psychiatric interventions. There also were no interventions for social work.

2. Patient 2: In a master treatment plan dated 2/7/11, there were no interventions for the treating psychiatrist. There also were no interventions included for the social worker.

3. Patient 3: A master treatment plan dated 1/28/11 did not include psychiatric interventions. There were also no interventions for the social worker.

4. Patient 4: In a master treatment plan dated 2/7/11, there were no interventions for either the treating psychiatrist or the social worker.

5. Patient 5: In a master treatment plan dated 1/11/11, there were no interventions included for the treating psychiatrist or social worker.

6. Patient 6: In a master treatment plan dated 1/27/11, there were no interventions noted for the treating psychiatrist and social worker.

7. Patient 7: In a master treatment plan dated 1/20/11, there were no interventions for the treating psychiatrist and social worker.

8. Patient 8: In a master treatment plan dated 2/7/11, there were no interventions for the treating psychiatrist and social worker.

B. Nursing Interventions.

1. Patient 1: In a master treatment plan dated 2/7/11, interventions that were listed for nursing staff included activities which were routine, generic, discipline functions listed as interventions. The interventions that were noted included; "monitor vital signs;" "monitor dietary intake;" "supervise/assist in patient's completion of ADLs."

2. Patient 2: In a master treatment plan dated 2/7/11, the nursing interventions were noted as: "establish a working relationship with patient;" "gather information and complete exams to determine current health status;" "decrease in positive symptoms of illness;" "decrease in negative symptoms of illness;" "Re-establish and maintain reality based orientation."

3. Patient 3: In a master treatment plan dated1/28/11, the nursing interventions that were listed included: "establish a working relationship with patient;" "decrease in positive symptoms of illness;" "re-establish and maintain reality based orientation" and "decrease in negative symptoms of illness."

4. Patient 4: In a master treatment plan dated 2/7/11, the nursing interventions were noted as follows: "establish a working relationship with patient;" "gather information and complete exams to determine current health status;" "decrease in positive symptoms;" "decrease in negative symptoms;" "Re-establish and maintain reality based orientation."

5. Patient 5: In a master treatment plan dated 1/11/11, the nursing interventions were listed as follows: "establish a working relationship with patient;" "decrease in positive symptoms of illness;" "decrease in negative symptoms of illness;" "Re-establish and maintain reality orientation."

6. Patient 6: In a master treatment plan dated 1/28/11, the nursing interventions noted on the master treatment plan included: "establish a working relationship with patient;" "gather information and complete exam to determine current health issues(sic);" "decrease in positive symptoms;" "decrease in negative symptoms."

7. Patient 7: In a master treatment plan dated 1/20/11, the nursing interventions were listed as: "assist client in identifying needs to be met;" "work with client on future planning;" "develop a plan to structure day;" "develop and implement a crisis plan;" "support client in assuring that mental illness symptoms are controlled."

8. Patient 8: In a master treatment plan dated 2/7/11, the nursing interventions that were listed included: "establish a working relationship with patient;" "gather information and complete exam to determine current health status.(sic);" "decrease in positive symptoms of illness;" "decrease in negative symptoms of illness;" "re-establish and maintain reality orientation."

B. Staff interviews

1. In a telephone interview on 2/8/2011 at 1:30p.m. with the Medical Director, the Medical Director agreed that the master treatment plans were not comprehensive and individualized.

2. In an interview on 2/8/11 at 2:15PM with the Director of Social Work, s/he agreed that there were no interventions listed for the social worker on the master treatment plans.

Based on observation, interview and document review, the facility failed to:

I. Ensure a safe, therapeutic environment for patients that is free of risk of physical, and in some instances psychological, harm for all patients on the ward. Staff at the facility routinely request or allow armed city police to restrain or assist in the restraint of patients on the unit. During one restraint episode observed by the surveyors, non-sample patient (10) was subjected to physical and psychological abuse by city police without intervention by the staff. Interview revealed it is common practice to allow armed police to assist in restraint of inpatients. Record review revealed police involvement with another episode of restraint of non-sample patient 10 at a previous hospitalization, and in the restraint of one of the five discharged patients in the sample, discharged patient (D7). In addition, staff interview and policy review revealed the facility failed to follow the hospital policy on "Calling Police on Inpatient for Assistance." These failures compromise the safety of all patients and staff and resulted in psychological/physical abuse of patient #10.

II. Appropriately utilize and document seclusion/restraints as external controls of violence toward self and others for 1 of 8 sample patients (Patient 5), 1 non-sample patient (Patient 10) and 1 of 5 discharged patients (D7) for whom the use of seclusion/restraint was reported on incident forms. For Patients 5, 10 and D7, seclusion/restraints were continued without documented justification. For Patient 5, two seclusion/restraint orders were not countersigned by a physician/LIP and for Patients 10 and D7, the face-to-face assessment within one hour of the initiation of seclusion/restraints was inadequate, not timed and/or late. These failures exposed patients to potential harm from unnecessary restraint.

III. Develop and implement a policy for seclusion and restraint to include the definition of a physical hold, and the necessity for medical authorization and monitoring for physical holds.
This failure resulted in improper documentation for the use of a physical hold without documented justification and review for 1 patient (D8).

Findings include:

I. Findings related to law enforcement personnel involved in clinical care:

A. Patient observation

On February 7, 2011 at 12:00p.m., a surveyor observed a patient (non-sample Patient #10) standing at the nursing station on the In-Patient Unit with his hands behind his back in metal handcuffs. Patient 10 was surrounded by 3 policemen in uniform who had brought him to the unit in handcuffs. At that time Patient 10 was escorted down the ward hallway to the seclusion room by 2 staff members (including RN 2) and the 3 policemen. At times, the policemen had their hands on the patient. When the patient reached the seclusion room, the staff members (2 RNs and 1 Technician) encouraged the patient to take oral medications. During this period of time the policemen were standing between the patient in the room and the doorway of the seclusion room; 2 of the policemen had tasers in their hands, that were held behind their backs or at their sides, aiming the taser guns at the floor. The taser red beam light reflection could be seen on floor, indicating the tasers were powered on; the light beam reflections would have been visible to the patient.

Physician 1 entered the room at about 12:10p.m. and related the reason for the medication, telling the patient, "You have been court-ordered to the hospital because you refused to take your medications." Following that, 2 of the policemen were arguing with the patient, telling him that he was "going to take the medicine and like it." One policeman had his hand over his holstered gun on his hip and the other policeman had his taser held by his side which was clearly visible to the patient. One of the policemen told Patient 10 that they would taser him if necessary, that he (the policeman) was older than him (Patient 10) and was not going to fight with him (patient). During the interchanges between the policemen and the patient, staff did not intervene on the patient's behalf. Both of these policemen continued to argue and one physically threatened Patient 10 by telling him, "It is our job to bring you here and I will see that the law is enforced." Patient 10 refused to follow staff and police direction to sit down on the bed in the seclusion room; one of the policemen then walked over and stood face-to-face with the patient. When Patient 10 continued to stand, the policeman kneed Patient 10 in his knee, thereby physically forcing the patient to sit on the bed. Throughout this interchange, the patient complained about treatment by the police: he told the staff and police that his back was hurting from the police take-down performed on him that day prior to his coming into the facility, and that he had blood on his wrist from the handcuffs applied during that take-down. At 12:15p.m. the metal handcuffs were removed from Patient 10's wrists by 2 of the policemen.

B. Interviews

1. During an interview on 2/7/11 at 12:25p.m. in a ward conference room, the lead policeman reported that the Marion City Policemen delivered patients to the facility, often assisting in seclusion/restraint of patients, about 1 time per week.

2. During an interview on 2/7/11 at 12:30p.m. Physician 1 agreed there was a safety risk that resulted from having guns on the ward. S/he also agreed that the patient may have experienced the policemen's actions as an emotional/psychological threat.

3. During an interview on 2/7/11 at 2:30p.m., the COO stated that she could see how the guns on the ward would be a safety risk. She stated that Patient 10 was a patient at the time that he was brought to the ward, and therefore facility staff were responsible for his care, as well as for ward safety. She added that in previous years, law enforcement officers had locked their weapons in their vehicles before entering the facility. In an additional interview on 2/8/11 at 10:30a.m., the COO reported that prior to 2002, there was a hospital policy that prevented guns from being brought into the patient building, but was not sure of the exact date that this policy had been changed. She added that the policemen are currently called to help ward staff in the behavioral control of patients when additional physical assistance is needed.

4. During an interview on 2/7/11 at 3:10p.m., Patient 10 showed the surveyor where his wrists were swollen and abraded from the metal handcuffs.

C. Additional Patient Findings

1. Patient 10:

Review of an incident form (10/11/10 during previous hospitalization) and medical record RN progress notes (10/11/10) revealed that Marion City Policemen were called to assist staff to move Patient 10 from the downstairs admission office to the In-Patient Unit located on the second floor of the building where the police assisted in placing Patient 10 in 4-point restraints. The face-to-face assessment completed by an RN on 10/11/10 (time not documented) stated, "2 MPD [Marion City Police] officers and 4 staff members held (patient) down on bed while IM [intramuscular] was given and restraints were applied."

2. Patient D7:

Review of an incident form (1/3/11) and medical record RN progress notes (1/3/11) revealed that a sheriff's officer, who was present on the ward because of admitting another patient, was asked to assist staff in secluding Patient D7 for threatening behavior.

D. Policy Review

Policy titled "Calling Police on Inpatient for assistance (dated 10/88 with 5/02 review)," stated:

1. "The receptionist will accompany the officers to the area where all hand weapons can be stored and locked, or ask them to lock their weapon in the trunk of their squad car...The RN in charge is responsible to insure no officer brings a gun to the Inpatient Unit."

The above facility policy requirement was not currently being enforced by facility staff.

2. "RN or designee will push the panic button which will result in Automatic calls to Center staff who will report to the need for assistance. If additional back (sic) is required, the Marion Police Department (MPD) will be notified."

The above facility policy requirement allowing policemen to be called to assist in the control of patients was currently being utilized.

II. Findings related to the use of seclusion/restraint:

A. Patient Findings

1. Patient 5:

As documented on restraint/seclusion forms and in nursing progress notes, during his prior hospitalization active sample Patient 5 was secluded or restrained from 12:20p.m. on 1/5/11 until 11:00a.m. on 1/7/11 for "high risk of injury to self" and "high risk of injury to others," for "running up to the door [supply room] + [and] grabbed a bottle of hand sanitizer. He was trying to drink it. Staff knocked it out of his hands." Interventions attempted before seclusion were listed as "Client had been walking around the unit. Cooperative."

This patient was escorted to the general hospital for medical evaluation two times while he was in seclusion. "High risk of elopement" was added as justification for restraining Patient 5 to a wheelchair to escort him to a general hospital. The patient was returned to seclusion each time without documentation of an imminent danger to self/others. A nursing progress note (1/5/11 at 8:32p.m.) stated, "Arrived on IPU [Inpatient Unit] at 2010 in wheelchair accompanied by MPD [Marion Police Department]. Client had a very big smile on his face. He was returned to locked seclusion for his own safety."

Even though there was no documentation of behaviors reflecting harm to self/others after 1:15p.m. on 1/5/11, Patient 5 was retained in either seclusion and/or restraint until 1/7/11 at 11:00a.m. resulting in a total of 45 hours and 45 minutes without documented clinical justification.

During the episodes of seclusion/restraint, 2 of the LIP renewal orders (1/6/11 at 4:00 and 8:00 a.m.) were not countersigned by a LIP or a physician.

2. Patient 10:

As documented on restraint/seclusion forms and nursing progress notes, during his prior hospitalization Patient 10 was restrained at 3:15p.m. on 10/11/10 for "high risk of injury to self" and "high risk of injury to others," for "yelling, running about shouting in peoples faces (sic), asking + [and] demanding men and women to kiss and marry him. Out of control behavior." The RN face-to-face assessment documented on 10/11/10 (time not given) failed to clearly address the need to continue or terminate the restraint. He was taken out of restraints on 10/11/10 at 5:30pm., but was maintained in seclusion. Patient 10 was retained in seclusion until 11:45a.m. on 10/12/10 resulting in a total of 18 hours and 15 minutes without documented clinical justification.

3. Patient D7:

As documented in restraint/seclusion forms and nursing progress notes, Patient D7 was secluded at 7:20p.m. on 1/3/11 for "yelling, slapping self in head-accusing charge nurse of starting a fight while posuring (sic) in threatening way." The RN face-to-face assessment documented on 1/3/11 at 10:00p.m. (late by 1 hour and 40 minutes) failed to clearly address the need to continue or terminate the restraint. A nursing note on 1/3/11 at 11:05p.m. stated, "She shouted and paced in the seclusion room for about 40 minutes before laying (sic) down on the bed. She has been laying (sic) quietly. Pt [Patient] took her bedtime medications when delivered to her. She is now resting quietly. She will remain in locked seclusion for safety of herself and others on the unit. Pt [Patient] will be reevaluated periodically per procedure." Even though there was no documentation of behaviors reflecting harm to self/others after 7:45p.m. on 1/3/11, Patient D7 was retained in seclusion until 3:35p.m. on 1/4/11 resulting in a total of 19 hours and 50 minutes without documented clinical justification.

B. Policy Review

Review of policies, "Restraint (8/07)" and "Seclusion (8/07)," revealed failure to address the roles of the LIP (Advanced Nurse Practitioner) in the use of seclusion/restraint (orders and clinical follow-up) and the Registered Nurse in conducting the face-to-face patient assessments.

C. Interview

During an interview on 2/8/11 at 1:30p.m. with the Clinical Director, and on the afternoon of 2/8/11 with the Chief Operating Officer and the Director of Nursing, the above documented findings were reviewed. The Director of Nursing verified the findings and stated that the facility policy had not been revised to reflect that the face-to-face assessments are to be completed by RNs.

III. Findings related to physical (manual) holds:

A. Patient Findings

As documented on an incident form (10/25/10), Patient D8 "was angry he (sic) became combative with his contact person began (sic) spitting and hitting. He was taken to 218 (quiet/seclusion/restraint room) for time out." A nursing progress note (10/25/10 at 4:48p.m. stated, "Staff...held pt [patient] while giving Ativan 1 mg IM...would not stop spitting and scratching. It was several minutes before it was safe for staff to let go of him." A review of the medical record failed to reveal a physician's order, face-to-face assessment or behavioral monitoring documentation.

B. Policy Review

Review of policy, "Restraints dated 8/07," failed to address the use of physical (manual) holds with patients.

C. Interview

During interview on 2/8/11, the CEO and the Director of Nursing stated that they were unaware that physical holds were viewed as restraints.

Based on observation, interview and document review, the facility failed to assure that the Medical Director provided necessary leadership to ensure adequate neurological examinations, adequate psychiatric evaluations and the development of appropriate individualized comprehensive treatment plans to include physician interventions. These failures resulted in lack of creation of a baseline from which future treatment could be planned and hindered individualized comprehensive treatment. (Refer to B144, Sections I-III) In addition, the Medical Director failed to ensure a safe, therapeutic clinical environment and proper utilization and documentation of seclusion/restraints. These deficiencies can result in physical and emotional harm for patients as well as failure to treat patients in the least restrictive environment. (Refer to B144, Sections IV-VI)

The facility failed to provide a qualified Director of Nursing (B147) to assure adequate leadership to develop and implement policies and procedures and to monitor nursing services to ensure individualized nursing interventions on the treatment plans resulting in lack of direction for the provision of nursing care (B148, Section I); provision of appropriate, safe nursing care which resulted in a physical safety risk and psychological/physical abuse (B148, Section II); proper use and documentation of seclusion/restraints resulting in failure to ensure that patients were treated in the least restrictive environment (B148, Sections III-IV); and assure that RNs performing face-to-face-assessment upon initiation of seclusion/restraint received adequate training with documented proof of required competencies. (Refer to B148, Section V)

Based on record review, staff interview and policy review, the medical Director failed to ensure that:

I. The physical examination of 8 of 8 active sample patients (1, 2, 3, 4, 5, 6,7and 8) had a neurological examination done which documented gross testing of cranial nerves II through XII. This failure to perform and record detailed neurological findings could result in overlooking a treatable neurological condition and/or the inability to document changes from baseline status during patient's hospital stay. This makes it impossible to ascertain progression/worsening of the patient's condition on subsequent re-examination. (Refer to B109)

II. Memory functioning was tested in 8 of 8 active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). This failure to test memory functioning results in a lack of baseline data from which future assessments can be measured. (Refer to B116)

III. Comprehensive master treatment plans were developed based on patients' presenting needs for 8 of 8 active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). There was failure to identify specific problems to be treated during patient's hospitalization, long-term goals were not present, and short-term goals were not measurable. There were no identified interventions for physicians and social workers, and nursing interventions were generic or expected role functions. This failure resulted in master treatment plans that did not reflect a comprehensive, integrated, individualized approach of multidisciplinary treatment team. (Refer to B119, B121 and B122)

IV. Ensure a safe, therapeutic environment for patients that is free of risk of physical, and in some instances psychological, harm for all patients on the ward. Staff at the facility routinely request or allow armed city police to restrain or assist in the restraint of patients on the unit. During one restraint episode observed by the surveyors, non-sample patient (10) was subjected to physical and psychological abuse by city police without intervention by the staff. Interview revealed it is common practice to allow armed police to assist in restraint of inpatients. Record review revealed police involvement with another episode of restraint of non-sample patient 10 at a previous hospitalization, and in the restraint of one of the five discharged patients in the sample, discharged patient (D7). In addition, staff interview and policy review revealed the facility failed to follow the hospital policy on "Calling Police on Inpatient for Assistance." These failures compromise the safety of all patients and staff and resulted in psychological/physical abuse of patient #10. (Refer to B125, Section I)

V. Appropriately utilize and document seclusion/restraints as external controls of violence toward self and others for 1 of 8 sample patients (Patient 5), 1 non-sample patient (Patient 10) and 1 discharged patient (D7) for whom the use of seclusion/restraint was reported on incident forms. For Patients 5, 10 and D7, seclusion/restraints were continued without documented justification, for Patient 5, two seclusion/restraint orders were not countersigned and for Patients 10 and D7, the face-to-face assessment within one hour of the initiation of seclusion/restraints was inadequate, not timed and/or late. These failures exposed patients to potential harm from unnecessary restraint. (Refer to B125, Section II)

VI. Develop and implement a policy for seclusion and restraint to include the definition of a physical hold, and the necessity for medical authorization and monitoring for physical holds.
This failure resulted in improper documentation for the use of a physical hold without documented justification and review for 1 patient (D8). (Refer to B125, Section III)

Based on interview and document review, the facility failed to ensure that the Director of Nursing was qualified to develop and implement clinical care policies necessary to direct, monitor and take corrective action based on needs of the patients served by the facility. This failure results in lack of direction for nursing personnel in the provision of appropriate care to patients.

Findings include:

In an interview on 2/9/11 at 9:30a.m. with the Director of Nursing, a review of her personnel file revealed that she has an Associate Degree in Nursing. She has many years psychiatric experience, but no additional training to indicate keeping current in psychiatric nursing. She reported that on-going consultation with a Master's prepared psychiatric nurse does not occur. She also related that her only continuing education program during the last 12 months was a program (time length unknown) presented by a physician on medications. In interviews noted under B125, she was not aware of current patient rights regulations.

Based on interview, observation and document review, the Director of Nursing failed to establish policies and procedures, and provide leadership to the nursing staff in the provision of nursing care. Specifically there was failure to:

I. Ensure that treatment plans included specific nursing interventions to guide nursing personnel in caring for the identified needs of 8 of 8 sample patients (1, 2, 3, 4, 5, 6, 7 and 8). For all 8 patients, interventions were chosen from a computerized program that had not been individualized for each patient. All identified nursing interventions were stated as guidelines for treatment and/or expected role functions. This failure hampers nursing staff's ability to provide focused treatment. (Refer to B122)

II Ensure a safe, therapeutic environment for patients that is free of risk of physical, and in some instances psychological, harm for all patients on the ward. Staff at the facility routinely request or allow armed city police to restrain or assist in the restraint of patients on the unit. During one restraint episode observed by the surveyors, non-sample patient (10) was subjected to physical and psychological abuse by city police without intervention by the staff. Interview revealed it is common practice to allow armed police to assist in restraint of inpatients. Record review revealed police involvement with another episode of restraint of non-sample patient 10 at a previous hospitalization, and in the restraint of one of the five discharged patients in the sample, discharged patient (D7). In addition, staff interview and policy review revealed the facility failed to follow the hospital policy on "Calling Police on Inpatient for Assistance." These failures compromise the safety of all patients and staff and resulted in psychological/physical abuse of patient #10. (Refer to B125, Section I)

III. Appropriately utilize and document seclusion/restraints as external controls of violence toward self and others for 1 of 8 sample patients (Patient 5), 1 non-sample patient (Patient 10) and 1 discharged patient (D7) for whom the use of seclusion/restraint was reported on incident forms. Patients 5, 10 and D7, seclusion/restraints were continued without documented justification, for Patient 5, two seclusion/restraint orders were not countersigned and for Patients 10 and D7, the face-to-face assessment within one hour of the initiation of seclusion/restraints was inadequate, not timed and/or late. These failures exposed patients to potential harm from unnecessary restraint. (Refer to B125, Section II)

IV. Develop and implement a policy for seclusion and restraint to include the definition of a physical hold, and the necessity for medical authorization and monitoring for physical holds.
This failure resulted in improper documentation for the use of a physical hold that was implemented without documented justification and review for 1 discharged patient (D8). (Refer to B125 III)

V. Ensure proof of competency for Registered Nurses who conducted face-to-face assessments for the use of seclusion/restraints for 1 of 8 sample patients (Patient 5), 1 non-sample patient (Patient 10) and 2 discharged patients (D7 and D8) for whom the use of seclusion/restraint was reported on incident forms. There was failure to ensure that the RNs authorized to do the one hour face-to-face assessments performed them adequately and in a timely manner. For Patients 10 and D7, the face-to-face assessment within one hour of the initiation of seclusion/restraints was inadequate, not timed and/or late. This resulted in potential failure to identify significant physical and physiological problems during the use of restrictive procedures.

Findings include:

A. Document Review:

1. Medical record documentation related to the use of physical restraints and seclusion revealed that the face-to-face assessments for Patient 5 (1/5/11), Patient 10 (10/11/10) and Patient D7 (1/3/11) were performed by registered nurses.

2. Medical record documentation revealed:

a. The RN face-to-face assessment for Patient 10 on 10/11/10 failed to clearly address the need to continue or terminate the restraint. In addition, the time for this assessment entry was not documented.

b. The RN face-to-face assessment for Patient D7 on 1/3/11 failed to clearly address the need to continue or terminate the restraint. In addition, this assessment entry was documented 2 hours and 40 minutes (rather than within an hour) after the initiation of the restraint procedure.

c. Review of the "Competency Check List" for proof of training for RNs who conduct face-to-face assessments following initiation of seclusion/restraint procedures interviews revealed failure to include proof of specific competencies necessary to perform and document this assessment.

B. Interview

During an interview on the afternoon of 2/8/11, the Director of Nursing reported that even though all RNs currently on the staff at the facility had received training required to conduct face-to-face assessments related to initiation of seclusion/restraints, the content for this program was no longer available for review. She agreed that the current competency check list failed to show proof of specific competencies necessary to conduct these assessments.

C. Policy Review

Review of policies, "Restraint (8/07)" and "Seclusion (8/07)," revealed a failure to address the required training of the Registered Nurse in conducting the face-to-face patient assessments.