HospitalInspections.org

Based on a review of documentation and interview, the facility failed to protect and promote each patient's rights, as evidenced by issues with restraints at the facility as well as general patient monitoring and assessment for fall risks. There was risk of patient harm due to inconsistency in documentation, monitoring, obtaining orders for restraint, and complete one hour face to face assessments at the facility.
* Fall risk assessments were not completed correctly for 4 of 10 patients, inconsistent with facility policy. 5 of 10 patients experienced falls during their stay at the facility. 10 of 10 patients were not observed at the monitoring level ordered by their physician throughout their stay, inconsistent with facility policy. Please refer to A0144.

* The facility failed to ensure that staff members were trained and demonstrated competence accordingly, as evidence by failing to ensure agency nurses were properly trained before initiating restraints. Without proper training and demonstrated competency it cannot be ensured that the use of restraint and/or seclusion were applied appropriately, placing patients and staff members at risk of injury from improper technique and applications. The facility also failed to ensure that the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques, as evidence by failing to ensure that patients in restraint or seclusion were appropriately monitored. Failure to properly monitor patients in restraint and/or seclusion increases the potential for injury and even death of patients in restraint. Please refer to A0167.

* The facility failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed practitioner. Please refer to A0168.

* The facility failed to ensure that when restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention by registered nurse who has been trained to conduct 1-hour face to face evaluations. Please refer to A0178.

An immediate jeopardy was identified at the facility on 08/10/22, related to the restraint issues noted above. The facility was able to enact plans of correction which included the immediate
education of staff and development of audit tools for compliance. The facility abated the immediate jeopardy on 08/10/22, however, the condition level findings remained.

Based on a review of documentation and clinical records, the facility failed to provide the patients with a humane treatment environment to ensure protection from harm, as evidenced by the following:
* fall risk assessments were scored incorrectly for 4 of 10 patients
* observation and precaution levels ordered by the treating physician were not followed for 10 of 10 patients

Findings were:

Patient #1 experienced a fall at the facility at 12:45 pm on 7-2-22. A Fall Risk Assessment performed at 5:00 pm was scored inaccurately, as the area addressing "History of Falls" stated that she had no history of falls.

Patient #7 experienced falls at the facility on 7-13-22 at 9:45 pm and again on 7-17-22 at 4:50 pm. Fall risk assessments performed on 7-17-22 and again on 7-22-22 were scored inaccurately, as the area addressing "History of Falls" on both assessments stated that she had no history of falls.

Patient #8 experienced a fall at the facility on 7-15-22. Her fall risk assessments performed 7-5-22, 7-9-22, 7-17-22 and 7-21-22 were all scored inaccurately, as the patient was admitted to the facility with a colostomy to her right lower quadrant and the assessments were not scored to reflect that fact. Following her fall on 7-15-22, fall risk assessments performed 7-17-22 and 7-21-22 were both also scored inaccurately, as the area addressing "History of Falls" stated that she had no history of falls.

Patient #9 experienced falls at the facility on 6-22-22, 6-29-22 and 7-1-22. Fall risk assessments performed 6-25-22, 7-2-22 and 7-8-22 were all scored inaccurately, as the area addressing "History of Falls" on all 3 assessments stated that the patient had no history of falls.

Facility policy AS-12 titled "Fall Assessment/Re-Assessment and Precautions" states, in part:
"Purpose:
To screen patient's potential for falling and decrease the risk of injury.
Policy:
Inpatient:
1. All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the tie of their initial nursing assessment, immediate after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls".
2. In the event of a fall occurrence, patients will be re-assessed and additional fall prevention interventions will be implemented.
3. The Registered Nurse (RN) utilizing the Fall Risk criteria on the Fall Risk Assessment Tool will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated.
...
Procedure:
Inpatient:
1. The admitting RN shall complete an initial assessment within 8 hours of patient's admission, evaluates patient's ambulatory status and completes Fall Risk criteria. If a Fall Risk Score indicates the patient is "at risk for falls", the immediate initiation of fall precautions will occur.
2. If a patient scores as "at risk for falls" during the initial nursing assessment, a Treatment Plan to address the risk for falls will be initiated by the RN.
...
4. The patient shall be re-assessed by the RN for fall risk at a minimum of every 7 days, immediately after a fall, and as needed based on patient's condition.
5. Interventions shall include:
* Mandatory fall precautions - interventions for patients "at risk for falls" (must implement all below)
* Apply yellow fall risk arm band
* Provide nonskid slipper socks or ensure appropriate skid-proof footwear is used
* Provide patient education
* Obtain fall precautions order and indicate on daily close observation forms
* Initial Fall Risk treatment plan
...
6. Post fall interventions shall include:
* Rn physical assessment of the patient
* Obtain vital signs including pain assessment
* Initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury
* Notify physician/non-physician practitioner (NPP) and obtain further orders as needed"


* Patient #1 was admitted to the facility on 6-17-22 through 7-8-22 and placed on a q-15 minute monitoring level with special precautions for violence, falls, bleeding and elopement. None of the special precautions wree discontinued during the stay. A review of her monitoring sheets revealed the following discrepancies:
*6-18-22 at 5:00 pm; the patient's location was not checked by a registered nurse
*6-25-22 at 4:00 am; the direct-care staff did not initial the sheet to confirm that the check had been performed
*6-27-22 from 4:15 am to 6:45 am, the direct-care staff did not initial the sheet to confirm that the check had been performed
*6-27-22 from 7:00 am to 7:15 am, there was no behavior or location noted and no initials by the direct-care staff
*6-27-22 at 9:45 am; no behavior or location was noted
*6-30-22 at 9:30 am and 9:45 am; the direct-care staff did not initial the sheet to confirm that the check had been performed
*7-1-22 from 4:00 am through 6:45 am; the direct care staff did not initial the sheet to confirm that the check had been performed

None of patient #1's special precautions (which included fall precautions) were noted on her observation sheets. The patient fell at the facility on 7-2-22 and sustained a head injury.

* Patient #2 was admitted to the facility on 5-9-22 through 6-9-22 and placed on a q-15 minute monitoring level with special precautions for violence, falls and elopement. None of the special precautions were discontinued during the stay. A review of his monitoring sheets revealed the following discrepancies:
*5-5-22; observation sheet did not note that the patient was to be observed at a q-15 monitoring level
*5-22-22; observation sheet did not note that the patient was to be observed at a q-15 monitoring level
*5-24-22; observation sheet did not note that the patient was to be observed at a q-15 monitoring level
*5-28-22; observation sheet did not note that the patient was to be observed at a q-15 monitoring level
*6-1-22; observation sheet did not note that the patient was to be observed at a q-15 monitoring level
*5-9-22 at 6:45 pm (time of admission) until 5-10-22 at 7:00 am; no documentation of any observation of the patient
*5-15-22 at 7:00 pm, 9:00 pm & 11:00 pm; the patient's location was not checked by a registered nurse
*5-16-22 at 1:00 am, 3:00 am & 5:00 am; the patient's location was not checked by a registered nurse
5-24-22 at 5:00 pm; the patient's location was not checked by a registered nurse
5-26-22 at 7:00 am, 9:00 am, 11:00 am, 1:00 pm, 3:00 pm and 5:00 pm; the patient's location was not checked by a registered nurse

None of patient #2's special precautions were noted on his observation sheets.

* Patient #3 was admitted to the facility on 7-4-22 through 7-11-22 and placed on a q-15 minute monitoring level with special precautions for violence, falls and elopement. None of the special precautions were discontinued during the stay. A review of his monitoring sheets revealed the following discrepancies:
*7-10-22 at 7:00 pm, 9:00 pm and 11:00 pm; the patient's location was not checked by a registered nurse
*7-11-22 at 1:00 am, 3:00 am and 5:00 am; the patient's location was not checked by a registered nurse

None of patient #3's special precautions were noted on his observation sheets.

* Patient #4 was admitted to the facility on 6-24-22 through 7-12-22 and placed on a q-15 minute monitoring level with special precautions for violence and elopement. None of the special precautions were discontinued during the stay. A review of his monitoring sheets revealed the following discrepancies:
*6-28-22 at 5:00 pm; the patient's location was not checked by a registered nurse
*7-1-22 at 1:00 am; the patient's location was not checked by a registered nurse
*7-4-22 at 9:15 am; the direct-care staff did not initial the sheet to confirm that the check had been performed
*7-10-22 at 7:00 pm; the patient's location was not checked by a registered nurse
*7-10-22 at 9:00 pm; no documentation of any observation of the patient
*7-10-22 at 11:00 pm; the patient's location was not checked by a registered nurse
*7-11-22 at 1:00 am, 3:00 am, 5:00 am, 7:00 pm, 9:00 pm and 11:00 pm; the patient's location was not checked by a registered nurse
*7-12-22 at 1:00 am; the patient's location was not checked by a registered nurse

None of patient #4's special precautions were noted on his observation sheets.

* Patient #5 was admitted to the facility on 7-28-22 and was still inpatient during the surveyors' visit from 8-8-22 to 8-10-22. He was placed on a q-15 minute monitoring level with special precautions for suicide, violence, seizure and elopement. None of the special precautions had been discontinued at the time of the survey. A review of his monitoring sheets revealed the following discrepancies:
*7-31-22 at 5:00 pm; the patient's location was not checked by a registered nurse
*8-2-11 at 3:00 pm; the patient's location was not checked by a registered nurse
*8-4-22 at 5:00 pm; the patient's location was not checked by a registered nurse
*8-6-22 at 7:00 pm; the patient's location was not checked by a registered nurse

None of patient #5's special precautions were noted on his observation sheets.

* Patient #6 was admitted to the facility on 6-24-22 through 7-14-22 and was placed on a q-15 minute monitoring level with special precautions for violence and elopement. None of the special precautions were discontinued during the stay. A review of her monitoring sheets revealed the following discrepancies:
*6-27-22 from 4:00 am through 6:30 am; the direct care staff did not initial the sheet to confirm that the checks had been performed
*6-27-22 from 6:45 am until 7:15 am; there was no documentation of the patients location or behavior (although a registered nurse had initialed the missing entries)
*7-1-22 from 4:00 am until 7:00 am; the direct care staff did not initial the sheet to confirm that the checks had been performed
*7-6-22 at 7:00 am, 9:00 am, 11:00 am, 1:00 pm, 3:00 pm and 5:00 pm; the patient's location was not checked by a registered nurse
*7-10-22 at 11:00 pm; the patient's location was not checked by a registered nurse
*7-11-22 at 3:00 pm and 5:00 pm; the patient's location was not checked by a registered nurse
*7-12-22 at 5:00 pm; the patient's location was not checked by a registered nurse
*7-13-22 at 11:00 pm; the patient's location was not checked by a registered nurse
*7-14-22 at 1:00 pm and 3:00 pm; the patient's location was not checked by a registered nurse

None of patient #6's special precautions were noted on her observation sheets.

* Patient #7 was admitted to the facility on 7-8-22 through 7-25-22 and was placed on a q-15 minute monitoring level with special precautions for violence, falls and elopement. None of the special precautions were discontinued during the stay. A review of her monitoring sheets revealed the following discrepancies:
*7-20-22 from 9:15 am to 10:00 am; there was no documentation of the patient's location or behavior

None of patient #7's special precautions were noted on her observation sheets. The patient fell twice during her stay, sustaining a head injury.

* Patient #8 was admitted to the facility on 7-6-22 through 7-21-22 and was placed on a q-15 monitoring level with special precautions for violence. The special precaution was not discontinued during the stay. A review of her monitoring sheets revealed the following discrepancies:
*7-8-22 from 7:00 pm until 8:00 pm; the direct care staff did not initial the sheet to confirm that the checks had been performed
*7-8-22 at 7:00 pm; the patient's location was not checked by a registered nurse
*7-11-22 at 5:00 am, 3:00 pm and 5:00 pm; the patient's location was not checked by a registered nurse
*7-20-22 from 9:30 am to 10:00 am; there was no documentation of the patient's location or behavior
*7-20-22 at 11:00 am; the patient's location was not checked by a registered nurse

Patient #8's special precaution was not noted on her observation sheets. The patient fell during her stay, sustaining a head injury.

* Patient #9 was admitted to the facility on 6-22-22 through 7-8-22 and was placed on a q-15 minute monitoring level with special precautions for violence and elopement. The special precautions were not discontinued during the stay. A review of the patient's monitoring sheets revealed the following discrepancies:
*6-27-22 from 4:00 am to 7:00 am; the direct care staff did not initial the sheet to confirm that the checks had been performed
*6-27-22 from 7:00 am to 7:15 am; there was no documentation of the patient's location or behavior
*6-27-22 from 9:45 am to 10:00 am; there was no documentation of the patient's location or behavior
*7-1-22 from 4:00 am to 7:00 am; the direct care staff did not initial the sheet to confirm that the checks had been performed
*7-3-22 at 7:00 am; the patient's location was not checked by a registered nurse

Patient #9's special precautions were not noted on his observation sheets and he was never placed on fall precautions per facility policy. The patient fell 3 times during his stay, sustaining head injuries.

* Patient #10 was admitted to the facility on 7-6-22 through 7-27-22 and was placed on a q-15 minute monitoring level with special precautions for violence, falls and elopement. The special precautions were not discontinued during the stay. A reviwe of the patient's monitoring sheets revealed the following discrepancies:
*7-6-22 from 4:00 pm to 7:00 pm; the patient's location was not checked by a registered nurse
*7-10-22 at 11:00 pm; the patient's location was not checked by a registered nurse
*7-11-22 at 3:00 pm and 5:00 pm; the patient's location was not checked by a registered nurse
*7-19-22 from 9:00 pm to 9:30 pm; there was no documentation of the patient's location or behavior
*7-24-22 at 3:00 am & 5:00 am; the patient's location was not checked by a registered nurse
*7-26-22 at 7:00 pm to 7-27-22 at 7:00 am (12-hour span); no documentation of the patient's location or behavior.

Patient #10's special precautions were not noted on his observation sheets. The patient fell 3 times during his stay, sustaining head injuries.

Facility policy AS-12 titled "Fall Assessment/Re-Assessment and Precautions" states, in part:
"Purpose:
To screen patient's potential for falling and decrease the risk of injury.
Policy:
Inpatient:
1. All patients will be assessed and identified for the potential o f being at risk for falls within the first 8 hours of admission at the tie of their initial nursing assessment, immediate after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls".
2. In the event of a fall occurrence, patients will be re-assessed and additional fall prevention interventions will be implemented.
3. The Registered Nurse (RN) utilizing the Fall Risk criteria on the Fall Risk Assessment Tool will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated.
...
Procedure:
Inpatient:
1. The admitting RN shall complete an initial assessment within 8 hours of patient's admission, evaluates patient's ambulatory status and completes Fall Risk criteria. If a Fall Risk Score indicates the patient is "at risk for falls", the immediate initiation of fall precautions will occur.
2. If a patient scores as "at risk for falls" during the initial nursing assessment, a Treatment Plan to address the risk for falls will be initiated by the RN.
...
4. The patient shall be re-assessed by the RN for fall risk at a minimum of every 7 days, immediately after a fall, and as needed based on patient's condition.
5. Interventions shall include:
* Mandatory fall precautions - interventions for patients "at risk for falls" (must implement all below)
* Apply yellow fall risk arm band
* Provide nonskid slipper socks or ensure appropriate skid-proof footwear is used
* Provide patient education
* Obtain fall precautions order and indicate on daily close observation forms
* Initial Fall Risk treatment plan
...
6. Post fall interventions shall include:
* RN physical assessment of the patient
* Obtain vital signs including pain assessment
* Initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury
* Notify physician/non-physician practitioner (NPP) and obtain further orders as needed"

Facility policy CS-23 titled "Level of Observations" states, in part:
"Purpose:
To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety.
Policy:
Two levels of observation are utilized: every 15-minute (q 15 minute) observation and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order.
Observation levels:
* Every 15 minutes - the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression and unsafe activities.
...
Procedure:
1. The initial patient observation level is determined and ordered by the physician up on patient admission. The decision to utilize one of the observation levels is made based on the patient's needs and presenting symptomology. The following are considered when the decision for an observation level is made:
* Suicidal ideation
* Violence/aggressive threats
* Poor judgment
* Poor impulse control
* Actively psychotic
* High fall risk
* Manic behavior
* Intrusive behavior placing patient, hospital employees and/or peers at risk.
2. The physician and treatment team members are charged with the responsibility of accurately assessing each patient's needs. A patient's observation level should be increased or decreased in intensity base on ongoing assessment findings.
3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. Additional information regarding activities are included on the form when relevant (i.e. water offered, activities of daily living). The observing staff initials the d15-minute increments on the form to indicate the patient was observed. This form will also be utilized for 1:1 monitoring when a stricter level of monitoring is ordered and will notated(sic) as such on top of form.
The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The Registered Nurse (RNO will conduct routine patient safety and observation rounds at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form.
4. All staff conducting q15 or 1:1 observation must formally hand off their patient assignments to another staff member prior to taking their breaks. All staff must be allowed scheduled meals and breaks the charge nurse will be responsible for ensuring proper hand-off to other available staff. Frequency of breaks and rotating of staff assignments will be based on the charge nurse's judgment and needs of the unit. All staff assigned to one-to-one observation should be provided a break at least every four hours.
Every 15 minute observation:
* Physician/NPP provides order for observation level. Considers patient's individual needs and risks. Note: The Charge Nurse may utilize clinical judgment to increase the intensity of observation when the patient's need indicates it. Will notify the Physician/NPP for order and notify Director of Nursing for staffing considerations.
* RN assigns staff members to q 15-minute observations or one-to-one observation based on physician/NPP orders and assigns breaks and meal-time relief.
* RN makes observations at least every 2 hours during the shift and initials the RN observations on the close observation sheet.

Assigned Nursing Staff (Mental Health Technician) performs the following:
* Indicates the type of specialty observation on the form (Q15, 1:1) according to observation level ordered per physician/NPP order.
* Indicates the type of specialty precautions on the form (fall, suicide, elopement etc.) according to the specific precautions ordered per physician/NPP order.
* Physically walks to find each patient on q 15-minute observation.
* Documents patient's location and reports identified risk to RN when indicated.
* Documents the location on the close observation form and documents the activity when indicated, e.g., water offered, and etc.
* Initials the form every 15 minutes.
* Notifies the Charge nurse immediately of any patient who cannot be observed or located."

The above was confirmed by the Director of Quality on 8-10-22

Based on a review of personnel files, documentation, and interview, the facility failed to ensure that staff members were trained and demonstrated competence accordingly, as evidence by failing to ensure agency nurses were properly trained before initiating restraints. Without proper training and demonstrated competency it cannot be ensured that the use of restraint and/or seclusion were applied appropriately, placing patients and staff members at risk of injury from improper technique and applications.

The facility also failed to ensure that the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques, as evidence by failing to ensure that patients in restraint or seclusion were appropriately monitored. Failure to properly monitor patients in restraint and/or seclusion increases the potential for injury and even death of patients in restraint.
Findings included:
Facility based policy entitled "SECLUSION AND RESTRAINTS" Policy Number: NSG-71 stated in part,
"Staff Training:
All employees are trained in verbal de-escalation and application of physical holds as part of validated industry recognized de-escalation and aggression management program. They shall demonstrate competency in the application of such restraints and implementation of seclusion.
All direct-care employees [Registered Nurse (RN), Licensed Practical Vocational Nurse (LPN/LVN), Mental Health Tech (MHT), Therapy, Activity/Recreational staff] are additionally trained in the monitoring and provision of care for a patient in restraint or seclusion. RNs are trained and able to demonstrate competency in assessment and performing the 1-hour face-to-face evaluation ...
All training and competency evaluations are conducted as part of new-hire orientation, before employees are allowed to perform any of the actions specified in this policy, and on an annual basis ..."
Review of medical records revealed that 3 of 4 restraint episodes (Patients #3, 4, and 5) that occurred in July 2022 had documentation present from agency nursing staff members with did not have evidence of proper restraint training or demonstrated competency.
* Patient #3 had a 4-point restraint on 07/06/22 from 0725 to 0759. Documentation of this restraint episode revealed it was initiated and documented on by staff member #6 (an agency nurse).
* Patient #4 had a 4-point restraint episode on 07/01/22 from 0720-0840. Documentation of this restraint episode revealed it was initiated and documented on by staff member #6 (an agency nurse).
* Patient #5 had a 4-point restraint episode on 07/29/22 from 1847-2230. Documentation of this restraint episode revealed it was initiated and documented on by staff member #3 (an agency nurse).

In interview on 08/09/22, the Director of Nursing, verified the above documentation and signatures, on the restraint records for Patients #3, 4, and 5, were from agency nurses (staff members #3 and 6). On 08/10/22, the hospital administrator provided 2 signed statements to the survey staff that indicating that staff members #3 and 6 are contracted as agency nurses at the facility and began working at the facility in May of 2022.

Review of personnel files for 2 of 2 agency nurses involved in restraint episodes indicated above revealed the following:
* Staff member #3 (agency nurse) had no SAMA (Satori Alternatives for Managing Aggression) training present in their personnel file. The only restraint training present in this personnel file was for facility Ocean TIDE (Therapeutic Intervention De-escalation Education) Bridge Orientation and training which was completed on 05/20/22.
* Staff member #6 (agency nurse) had no SAMA (Satori Alternatives for Managing Aggression) training present their personnel file. This agency nurse also had the facility Ocean TIDE (Therapeutic Intervention De-escalation Education) Bridge Orientation and training which was completed on 05/10/22. A Behavioral Health RN checklist completed on 05/02/22 with a staffing agency checklist included, "Assessment, management, and interpretation of: ...Use of restraints". It appears this checklist does not reflect any kind of demonstration or competency for restraint application.

The Oceans Behavioral Hospital TIDE Bridge Orientation statement signed by both agency nurses (staff members #3 and 6) stated, "I [employee name] have reviewed Oceans T.I D.E. Bridge and understand that if there is a situation, I should inform an Oceans employee promptly. If there if there no Oceans employee in the vicinity, I should talk to the patient calmly until an Oceans employee can help to handle the situation." This TIDE training and orientation appeared to only be written test based with no demonstration or competency in restraint application demonstrated.

In interview on 08/09/22 at 2:00 PM, the Director of Nursing (DON), verified that the 2 agency nurses involved in restraint episodes at the facility did not have SAMA training or any kind of physical de-escalation demonstration competency, or return demonstration of appropriate restraint technique present in their personnel files. Staff member #1, stated that, "The agency told us that they [agency nurses] had CPI or SAMA, a de-escalation type training done before they come to us". Staff member #1 verified they were unable to find any such de-escalation/restraint training in the personnel records for the two agency nurses (#3 and 6) that per documentation were involved in 3 of 4 restraint episodes at the facility in July 2022. The DON also verified for surveyors the facility wide designated restraint and de-escalation training program used at the facility is SAMA.

In interview on 08/10/22 at 10:45 AM, Staff member #1 [DON] was shown the Oceans Behavioral Hospital TIDE Bridge Orientation statement signed by the agency nurses (#3 and 6) indicating they would wait for Oceans staff intervention in the case of a restraint (or T.I.D.E. Therapeutic Intervention De-escalation Education) situation. Staff member #1 indicated they were not aware of this statement and its contents. Staff member #1 again stated, "I understood they have some form of de-escalation of CPI or SAMA before coming here through their agency ...When they come here they get the TIDE on their short orientation." Staff member #1 indicated they had emailed the contracted nursing agency to obtain any documentation of restraint training but as of that morning (08/10/22) had received no evidence of restraint or de-escalation competencies provided by the nurse staffing agency. No evidence of any formal restraint training from the staff agency was provided to the surveyors at the time of the survey exit on 08/10/22.

In interview on 08/10/22 at 10:50 AM, Staff member # 8, was informed by the surveyor that it appears currently their agency nurses are initiating restraints at the facility without any documentation of demonstrated competency or training in safe restraint application. Staff member # 8 replied, "I agree".

Based on the above findings it appears that 2 of 2 agency nurses involved in restraints at the facility (application and monitoring) did not have evidence of appropriate training and/or demonstrated competency of restraint use. The two agency nurses (#3 and 6) had in fact signed a statement indicating they would wait for Oceans staff intervention if a T.I.D.E. (Therapeutic Intervention De-escalation Education) situation presented itself. Without evidence of sufficient training it cannot be established the 3 restraints (Patients 3,4, and 5) these agency nurses were involved with were applied appropriately. Without proper training and demonstrated competency it cannot be ensured the use of restraint and/or seclusion were applied appropriately, placing patients and staff members at risk of injury from improper technique and applications.

Facility based policy entitled "SECLUSION AND RESTRAINTS" Policy Number: NSG-71 stated in part,
"PROCEDURE: ...

7. Monitoring:
o The RN will assign a qualified, and trained staff member to continually ensure adequate respiration and circulation of the patient.
o The RN must assess the patient upon initiation of seclusion/restraint, after the first 15 minutes of seclusion/restraint, during the one-hour face-to-face assessment, every hour the patient remains in seclusion/restraint, and upon discontinuation of seclusion/restraint.
o At a minimum, respiratory status, circulation, and skin integrity will be documented as indicated on Seclusion/Restraint Flow Sheet every 15 minutes by assigned, qualified and trained staff member
o The assigned staff will also monitor for signs of injury associated with application and use of restraint and/or seclusion.
o The assigned staff will perform range of motion exercises for each extremity, one extremity at a time, for at least 5 minutes during every hour that a patient is in mechanical restraints.
o The assigned staff will provide care for patient as indicated on Seclusion/Restraint Flow Sheets for time(s) indicated.

2. Nursing Documentation: ...

o Restraint Flow Sheet:
o Date, ordering physician, start date and time, stop date and time, type of restraint, and reason for restraint written.
o Personal Care checks q2h and PRN.
o Observed Behaviors checks q2h and PRN.
o Visual Checks q 15 minutes.
o Nurse's signature and initial, or EMR authentication."

Review of medical records revealed that 1 of 4 restraint/seclusion episodes (Patients # 6) did not have Seclusion/Restraint Flow Sheet present in their medical record.
* Patient #6 had a restraint episode on 07/01/22 from 0958-1041 according the facility restraint log and a nursing narrative note [written by staff member #1] on 07/01/22 at 0945 which stated in part, "Pt cont to be violent with staff/pts, ER MD ordered per Dr. [name], given L glute with difficulty with 10 sec hold. Pt still combative after IM order, scratched, bit staff, pt placed in seclusion room @ 0958 per MD order ...Pt in day area being taken to table, swatted @ another pt to hit them, yelling @ times, Per Dr. [name} Ativan 2.0 given IM to R deltoid inj ...with 5 sec hold ..." There was no Seclusion/Restraint flowsheet in the medical record for this patient. This form is where staff members are to document their monitoring of the patient's physical well-being including their respiration and circulation status every 15 minutes.

In interview on 08/10/22, the Director of Nursing verified the only documentation for Patient #6 in the medical record to reflect the use of restraint was the above nursing narrative. The Director of Nursing stated they were unable to find a Seclusion/Restraint Flow Sheet for this patient.

With no Seclusion/Restraint Flow Sheet present for Patient #6, it cannot be established they were appropriately monitored, ensuring their respiratory and circulatory status were not comprised. Without monitoring documented, per policy and regulatory requirements, it cannot be established that the patient's safety and physical well-being were maintained.

Based on a review of the documentation and interview, the facility failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed practitioner.
Findings included:
Facility based policy entitled "SECLUSION AND RESTRAINTS" Policy Number: NSG-71 stated in part,
"PROCEDURE:

1. Initiation: ...

o The RN will document physician/NPP contact and physician order on Physician Order for Seclusion and Restraint Form. For facilities with electronic medical record (EMR), the physician or NPP will directly enter the physician's order into the EMR.
o The physician/NPP order must include the specific behaviors which constituted the behavioral emergency, specify the reason for restraint or seclusion, the type of restraint, and the duration of seclusion or restraint ...

Documentation:
I. Physician's Documentation/Orders
o The Physicians orders shall include:
o The date and time of the physician's order.
o The patient's diagnosis should be noted.
o The specific type of restraint to be used must be indicated.
o Instructions for monitoring the patient must be written.
o The length of time that restraints may be used must be indicated.
o The rational for the use of seclusion/restraint
o Any special considerations for use of restraint must be noted.
o Removal of any personal items based on the individual patient risks
o Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be re-ordered in accordance with the following limits for up to a total of 24 hours:
o 4 hours for adults 18 years of age or older.
o 2 hours for children and adolescents 9- 17 years of age; or
o 1 hour for children under 9 years of age
o At the end of the time frame, if the continued use of restraint or seclusion to manage violent or self-destructive behavior is deemed necessary based on an individualized patient assessment, another order is required."

Review of medical records revealed that 2 of 4 restraint episodes (Patients #3 and 6) that occurred in July 2022 had no physician order present for the initiation of these restraints.
* Patient #3 had a 4-point restraint on 07/06/22 from 0725 to 0759, this was reflected on a facility Seclusion/Restraint Flow sheet in their medical record. There was no physician order present in the medical record for this use of restraint.
* Patient #6 had a restraint episode on 07/01/22 from 0958-1041 according the facility restraint log and a nursing narrative note [written by staff member #1] on 07/01/22 at 0945 which stated in part, "Pt cont to be violent with staff/pts, ER MD ordered per Dr. [name], given L glute with difficulty with 10 sec hold. Pt still combative after IM order, scratched, bit staff, pt placed in seclusion room @ 0958 per MD order ...Pt in day area being taken to table, swatted @ another pt to hit them, yelling @ times, Per Dr. [name] Ativan 2.0 given IM to R deltoid inj ...with 5 sec hold ...". There was no physician order present in the medical record for this use of seclusion or restraint (personal holds) X 2.

In interview on 08/10/22, the Director of Nursing, verified they were unable to locate a physician order in the medical record for Patients #3 and 6 for the use of restraint and seclusion that was indicated in the respective Seclusion/Restraint Flow sheet and narrative notes for the above patients.

Based on a review of the personnel files, documentation, and interview, the facility failed to ensure that when restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient was seen face-to-face within 1-hour after the initiation of the intervention by registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section.

Findings included:

Facility based policy entitled "SECLUSION AND RESTRAINTS" Policy Number: NSG-71 stated in part,
"All direct-care employees [Registered Nurse (RN), Licensed Practical Vocational Nurse (LPN/LVN), Mental Health Tech (MHT), Therapy, Activity/Recreational staff] are additionally trained in the monitoring and provision of care for a patient in restraint or seclusion. RNs are trained and able to demonstrate competency in assessment and performing the 1-hour face-to-face evaluation ...

All training and competency evaluations are conducted as part of new-hire orientation, before employees are allowed to perform any of the actions specified in this policy, and on an annual basis ...

PROCEDURE:

1. Initiation: ...

4. Face-to-Face Evaluation: A one-hour face-to-face patient evaluation must be conducted in person by a physician or other NPP, or trained RN (for Texas, this RN cannot be the RN who initiated the restraint or seclusion) in the absence of the physician or NPP. A telephone call or telemedicine methodology is not permitted.
o Conduct one hour face-to-face, if trained to do so, even if patient is no longer in
restraint/seclusion and physician is not present."

Review of medical records revealed that 3 of 4 restraint episodes (Patients #3, 4, and 5) that occurred in July 2022 had documentation present from agency nursing staff members (#3 and 6).
* Patient #3 had a 4-point restraint on 07/06/22 from 0725 to 0759. Documentation of this restraint episode revealed it was initiated and documented on by staff member #6 (an agency nurse).
* Patient #4 had a 4-point restraint episode on 07/01/22 from 0720-0840. Documentation of this restraint episode revealed it was initiated and documented on by staff member #6 (an agency nurse).
* Patient #5 had a 4-point restraint episode on 07/29/22 from 1847-2230. Documentation of this restraint episode revealed it was initiated and documented on by staff member #3 (an agency nurse).

In interview on 08/09/22, the Director of Nursing, verified the above documentation and signatures, on the restraint records for Patients #3, 4, and 5, were from agency nurses (staff members #3 and 6). On 08/10/22, the hospital administrator provided 2 signed statements to the survey staff that indicating that staff members #3 and 6 are contracted as agency nurses at the facility and began working at the facility in May of 2022.

Review of personnel files for 2 of 2 agency nurses involved in restraint episodes indicated above revealed the following:
* Staff member #3 (agency nurse) had no Competency Evaluation for Registered Nurses Providing One Hour Face to Face Evaluation present in their personnel file.
* Staff member #6 (agency nurse) had no Competency Evaluation for Registered Nurses Providing One Hour Face to Face Evaluation present in their personnel file.

In interview on 08/09/22 at 2:00 PM, the Director of Nursing, verified that the 2 agency nurses involved in restraint episodes indicated above did not have evidence of Competency Evaluation for Registered Nurses Providing One Hour Face to Face Evaluation training in their personnel records. Training to conduct assessment and performing the 1-hour face-to-face evaluation is required for register nurses per regulations and facility policy.

Based on a review of the documentation, personnel records, and interview, the facility failed to ensure that a physician, physician assistant as provided in paragraph (3) of this subsection, or a registered nurse who is trained and has demonstrated competence in assessing medical and psychiatric stability, other than the registered nurse who initiated the use of restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.

Facility based policy entitled "SECLUSION AND RESTRAINTS" Policy Number: NSG-71 stated in part,
"4. Face-to-Face Evaluation: A one-hour face-to-face patient evaluation must be conducted in person by a physician or other NPP, or trained RN (for Texas, this RN cannot be the RN who initiated the restraint or seclusion) in the absence of the physician or NPP. A telephone call or telemedicine methodology is not permitted.
o Conduct one hour face-to-face, if trained to do so, even if patient is no longer in restraint/seclusion and physician is not present."

Review of medical records revealed that 3 of 4 restraint episodes (Patients #3, 5, and 6) that occurred in July 2022 did not have a one-hour face to face evaluations documented in their medical record. 1 of 4 patients (#4) had a one-hour face to face evaluation documented in their medical record, however the registered nurse (staff member #6) did not have one hour face to face training or competency present in their personnel record.
* Patient #3 had a 4-point restraint on 07/06/22 from 0725 to 0759. There was no 1-hour face to face nursing assessment completed for this restraint event.
* Patient #4 had a 4-point restraint episode on 07/01/22 from 0720-0840. The 1-hour face to face nursing assessment and debriefing were documented on this patient, however it was conducted by staff member #6, and agency nurse who did not have any "Competency Evaluation for Registered Nurses Providing One Hour Face to Face Evaluation" present in their personnel record.
* Patient #5 had a 4-point restraint episode on 07/29/22 from 1847-2230. There was no 1-hour face to face nursing assessment completed for this restraint event.
Patient #6 had a restraint episode on 07/01/22 from 0958-1041 according the facility restraint log and a nursing narrative note [written by staff member #1] on 07/01/22 at 0945 which stated in part, "Pt cont to be violent with staff/pts, ER MD ordered per Dr. [name], given L glute with difficulty with 10 sec hold. Pt still combative after IM order, scratched, bit staff, pt placed in seclusion room @ 0958 per MD order ...Pt in day area being taken to table, swatted @ another pt to hit them, yelling @ times, Per Dr. [name] Ativan 2.0 given IM to R deltoid inj ...with 5 sec hold ...". There was no 1-hour face to face assessment present in the medical record for this use of seclusion or restraint (personal holds X 2).


Review of personnel files for the agency nurses who documented the 1-hour face to face nursing assessment and debriefing for Patient # 4 reveled the following:
* Staff member #6 (agency nurse) had no Competency Evaluation for Registered Nurses Providing One Hour Face to Face Evaluation present in their personnel file.

In interview on 08/09/22 at 2:00 PM, the Director of Nursing, verified that the staff member #6 (agency nurse) did not have evidence of Competency Evaluation for Registered Nurses Providing One Hour Face to Face Evaluation training in their personnel records. Training to conduct assessment and performing the 1-hour face-to-face evaluation is required for register nurses per regulations and facility policy.

In interview on 08/10/22 the Director of Nursing verified the above patients did not have a one-hour face to face evaluations documented in their medical record, and in one case, a registered nurse (staff member #6) documented completing the one-hour face to face nursing assessment and debriefing, however this nurse did not have one hour face to face training or competency present in their personnel record.

Based on a review of documentation and an interview with staff, the governing body failed to ensure that there was an effective, ongoing, facility-wide, data-driven quality assurance program to evaluation the provision of patient care by tracking adverse patient events.

Findings were:

A review of the facility fall log for July 2022 revealed that patient #7 fell once during the month (exact date unknown, as staff #2 said that the reporting tool used does not capture the date effectively). A review of nursing notes in the clinical record for patient #7 revealed that the patient sustained a fall on 7-13-22 and another on 7-17-22.

Failure to accurately report data hinders the evaluation of patient care.

The above missing data was confirmed in an interview with staff #2 on 8-10-22.