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Based on observation and interviews, the facility failed to provide the necessary oversight to ensure a safe setting for all patients in the Mental Health Unit. The required 15-minute checks on patients conducted by the Mental Health Technicians (MHT's) failed to be random in their implementation. The facility also failed to have more than one staff member on 15-minute rounding for 15 patients during observation. Nursing staff also failed to have a clear understanding for implementing 1:1 (one on one) monitoring of patients which has the potential of affecting all patients requiring this level of care. At the time of survey 10 of 15 patients were on suicidal precautions. The facility census was 244.

Findings included:

1. Record review of the facility's policy titled, "Observation of the patient through 1:1, close observation and 15-minute checks" revised 06/2011, showed the following direction to staff:
- On admission, all inpatients will be placed on a minimum of 15-minute checks for safety unless otherwise ordered by physician or indicated by medical status.
PROCEDURE:
- Fifteen (15) minute checks: Ordered for a patient who verbalizes thoughts of suicide without a plan or immediate threat to self, engaged in non-life threatening/self-damaging behaviors, expresses anger and/or thoughts of harming others without intent to act;
- Close Observation: Ordered on patients who present a serious risk of harm to self and/or others (suicidal thoughts but not actively seeking ways to harm self in hospital. Close observation may also be ordered for those with moderate inability to care for themselves, and/or those whose cognitive abilities are insufficient to recognize dangers and follow simple instructions. Staff will maintain visual contact of the patient at all times unless the patient is directly monitored by audio-visual equipment. When the patient is being observed on the monitors, a staff member will be within line of sight of the monitor, and the audio component will remain on and audible;
- 1:1 Observation: Ordered on a patient who is at immediate risk of harm to self and/or others (unable to contract for safety and actively seeking ways to harm self). Staff will be in close proximity to the patient, and the patient will be visible to staff at all times. No patient is to be left unattended while on 1:1 status.

Record review of the facility's policy titled, "Management of patients Displaying hypersexual or sexually inappropriate behavior towards one another" dated 01/2012, gave the following direction:
Process: Staff needs to be aware that sexual acts between patients can occur in between 15-minute checks. All patients shall be monitored on 15-minute checks or more often, as ordered by their physician. The order of completing the 15-minute checks shall be varied so that patients cannot predict the time of return of staff.

2. During an interview on 02/28/12 at 10:12 AM, Staff B, MHT, stated that he always does the 15-minute rounding by starting in the Dayroom (designated common room for group therapy, dining and relaxation) and working his way down the female hall and back to the Dayroom.

During an interview on 02/28/12 at 10:35 AM, Staff C, MHT, stated that he always does the 15-minute rounding the same way starting at room 7101 and working his way around the unit and back.

During an interview on 02/29/12 at 9:00 AM, Staff H, MHT, stated that she always starts the 15-minute rounding at the front first room and works her way to the back.

During an interview on 02/28/12 at 10:55 AM, Staff D, RN, Charge Nurse, stated that 15-minute checks should be varied and should never have a pattern because the patients' can plan when the monitors are coming to find them.

During an interview on 02/28/12 at 1:33 PM, Staff E, RN, stated that 15-minute checks should never be conducted in the same way because the patients can figure them out and potentially give them more time if they want to plan something.

During an interview on 02/28/12 at 1:55 PM, Staff F, RN, stated that 15-minute checks are supposed to be changed around so the patients won't get used to the pattern and be able to avoid the monitors.

During an interview on 02/28/12 at 3:40 PM, Staff I, RN, stated that 15-minute checks must not be carried out in the same manner because the patients will recognize that and could plan for 15 or more minutes without supervision.

During an interview on 02/29/12 at 9:25 AM, Staff G, RN, Mental Health Nurse Manager, stated that she had just trained the staff on 15-minute rounding and that it should never have a pattern and should always be varied to ensure patient safety.

3. Observation on 02/28/12 at 10:00 AM showed the Mental Health Unit on 7 West designed in an oval shape with the nursing station located at one end and the day room located at the other end. There were two inpatient halls, each hall had patient rooms on either side - one hall houses male patients and the other hall houses female patients. The halls cannot be viewed at the same time and cannot be seen from behind the nurses' station. There were three Registered Nurses (RN's) and two MHT's staffed for 15 current patients. Patient #19 required 1:1 monitoring for safety and Staff B, MHT, was assigned to her room leaving one MHT, Staff C, to conduct the 15-minute checks by himself.

During an interview on 02/28/12 at 10:12 AM, Staff B, MHT, stated that it was difficult to conduct the 15-minute checks by himself. He stated that the nurses forget to tell them [MHTs] if a patient has been taken off the unit for some reason like tests and we spend a lot of time looking for them.

During an interview on 02/28/12 at 10:35 AM, Staff C, MHT, stated that he was conducting the 15-minute checks by himself today. He stated that the nurses are supposed to help but they don't always have time. Staff C stated that sometimes a patient can't readily be located and the 15-minute checks are late. He stated that they will finally go to the nurses' station to find out that the patient was taken off the unit for some reason but by then we are already late. Staff C stated that they do not get another MHT to help with the 15-minute checks and an MHT has to do it by themselves if there is a patient requiring 1:1 monitoring.

During an interview on 02/28/12 at 10:55 AM, Staff D, RN, stated that everyone is responsible to complete the 15-minute checks and nursing is supposed to oversee the process.

During an interview on 02/28/12 at 1:33 PM, Staff E, RN, stated that he will occasionally help with the 15-minute checks but they are usually done by the MHTs.

4. Observation on 02/28/12 at 10:00 AM showed Staff B, MHT, sitting in Patient #19's room just inside the door sitting in a chair. Patient #19 was in bed covered up and out of arm's length range from the monitor, approximately six feet.

During an interview on 02/28/12 at 10:35 AM, Staff C, MHT, stated that he was not within arm's length of Patient #19 because she was asleep and he didn't want to bother her. He stated that the patient was on 1:1 for safety and if she woke up and needed help he was close enough to reach her in time.

During an interview on 02/28/12 at 10:55 AM, Staff D, RN, Charge Nurse, stated that 1:1 monitoring means a patient should be within arm's length. Staff D stated that it really depended upon the reason the patient was on 1:1; if the patient had a sexual problem then I would stand outside the bathroom door while they are showering or toileting, but if they were on 1:1 for suicide precaution then I would keep the door open and maybe even stand inside the bathroom.

During an interview on 02/29/12 at 9:25 AM, Staff G, RN, Mental Health Nurse Manager, stated that 1:1 means a patient should be within arm's length of patient and should be able to touch the patient at all times without exception.

Based on interviews, record reviews and policy review, the facility failed to ensure physician's orders for restraints were complete for six patients (#9, #15, #16, #17, #18, #24) and failed to ensure restraint orders were signed by the physician for two patients (#15 and #18) of six restraint records reviewed. The facility census was 244.

Findings included:

1. Record review of the facility's policy titled "Alternatives to Restraints," Policy #PC-304, revised 01/01/11, showed the following:
- The leadership of the facility believes that patients should receive treatment in an environment where health and safety is protected and their dignity, rights and well being are preserved.
- An order for restraint must be obtained from a physician who is responsible for the care of the patient prior to the application of restraint.
-The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.
-An order for restraint may not be written as a standing order, protocol or as needed (PRN) order.
-If a telephone order is required, the Registered Nurse (RN) must write down the order while the physician is on the phone and read-back the order to verify accuracy.
-When a physician is not available to issue a restraint order, an RN with demonstrated competency may initiate restraint use based upon face-to-face assessment of the patient.
-In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint is applied.

2. Record review of Patient #9's History and Physical (H & P) dated 02/14/12, showed the patient was admitted to the facility on that date with a diagnosis of acute respiratory distress, with intubation (placement of a flexible plastic or rubber tube into the trachea, or windpipe, to add or remove fluids or air). The patient also had diagnoses of septic shock, diabetes mellitus and bipolar disorder.

Record review of Patient #9's medical record showed the physician ordered a restraint for the patient on 02/24/12, but failed to time the order. The physician ordered the patient to have mitten(s) and soft wrist restraint, but the order did not identify whether the mitten(s) was for the right hand, left hand or bilateral (both). The order also did not reflect whether the soft wrist restraint was for the right wrist, left wrist or bilateral wrist.

Record review of the nurses' note dated 02/24/12 at 3:31 AM showed the nurse documented the patient had a non-violent type of restraint and it was a soft bilateral upper extremities (BUE) restraint.

Record review of Patient #9's medical record showed the physician ordered a restraint for the patient on 02/26/12, but failed to time the order. The physician ordered the patient to have soft wrist restraint, but the order did not identify whether the soft wrist restraint was for the right wrist, left wrist or bilateral wrists.

Record review of the nurses' note dated 02/26/12 at 5:30 AM showed the nurse documented the patient had a non-violent type of restraint and it was a soft bilateral upper extremities (BUE) restraint.

Record review of Patient #9's medical record showed the physician ordered a restraint for the patient on 02/27/12 at 7:30 AM. The order did not identify the following:
-Reason for Restraint
-Type of Restraint
-Criteria for Release
Record review of the nurses' note dated 02/27/12 at 6:14 AM showed the nurse documented the patient had a non-violent type of restraint and it was a soft bilateral upper extremities (BUE) restraint.

During an interview on 02/29/12 at 2:55 PM, Staff K, RN, Nurse Manager, stated that Patient #9 came to the Unit from the Intensive Care Unit (ICU) with restraint orders. She stated that the patient had restraint orders until she returned from surgery on 02/28/12 at 12:30 PM, at which time the order was discontinued.

3. Review of the facility census dated 02/28/12 showed Patient #15 was admitted for Sepsis (a severe illness in which the bloodstream is overwhelmed by bacteria) and renal (kidney) failure. Record review of nursing and physician restraint documentation for Patient #15 showed:
-On 02/11/12 the nurse documented a telephone order for restraints, but the time of the order was absent. The portion of the order as to the reason for the restraint was not completed. The order included mitten(s), but it failed to include to which hand the mitten was to be applied or if the mittens should be applied bilaterally (to both hands). The portion of the order that stated that the criteria for release of the restraint was not completed. The physician failed to date and time the order.
-On 02/12/12 the physician failed to complete areas on the order for the reason for the restraint and the criteria for release of the restraint. The order included mitten(s), but it failed to include to which hand the mitten was to be applied or if the mittens should be applied bilaterally (to both hands). The physician failed to time the order.
-On 02/13/12 the physician order included mitten(s), but it failed to include to which hand the mitten was to be applied or if the mittens should be applied bilaterally (to both hands). The physician failed to sign the order.
-Review of nursing documentation showed the patient had bilateral mitten restraints applied on the dates of 02/11/12, 02/12/12 and 02/13/12.

4. Review of the facility census dated 02/28/12 showed Patient #18 was admitted for altered mental status and was on the cardiac (heart) floor. Record review of nursing and physician restraint documentation for Patient
#18 showed:
-On 02/21/12 and 02/23/12, the physician restraint order failed to state if the left or right hand was to be placed in a mitten restraint or if the restraints were to be applied bilaterally;
-The telephone restraint order dated 02/25/12 at 6:00 AM failed to be authenticated with a signature, date, or time by the physician;
-Nursing documentation on 02/25/12 at 7:32 PM showed the patient was in a mitten restraint to the left hand. The facility failed to obtain a mitten restraint order for Patient #18's left hand on 02/25/12;
-The telephone restraint order dated 02/26/12 at 6:00 AM failed to be authenticated with a date or time of the physician signature;
-The telephone restraint order dated 02/27/12 at 6:00 AM failed to be authenticated with a date or time of the physician signature;
-Nursing documentation on 02/27/12 at 6:06 AM showed the patient was in a mitten restraint to the left hand.

During an interview on 02/28/12 at 3:15 PM, Staff N, Director of Risk Management confirmed the restraint findings for Patient #18.

5. Review of the facility census dated 02/28/12 showed Patient #16 was admitted for Sepsis and was in the Intensive Care Unit (ICU). Record review of nursing and physician restraint documentation for Patient #16 showed:
-Physician restraint orders dated 02/24/12 (the time is not legible) for Patient #16 showed an order for soft wrist restraints, but the order failed to state if the restraints were to be applied to the left or right wrist or applied to bilateral wrists. On 02/24/12 at 10:00 AM the nurse documented the patient was in bilateral soft upper extremity restraints;
- Physician restraint orders dated 02/26/12 at 8:30 AM for Patient #16 showed an order for soft wrist restraints, but the order failed to state if the restraints were to be applied to the left or right wrist or applied to bilateral wrists. On 02/26/12 at 10:00 AM the nurse documented the patient was in bilateral soft upper extremity restraints;
-Physician restraint orders dated 02/27/12 at 6:00 AM for Patient #16 showed an order for all bed rails to be up. On 02/27/12 at 8:00 AM the nurse documented the patient was in bilateral upper extremity soft restraints; The facility failed to obtain bilateral upper extremity soft restraint orders for 02/27/12;and
-Physician restraint orders dated 02/28/12 at 5:00 AM for Patient #16 showed an order for all bed rails to be up. On 02/28/12 at 10:00 AM the nurse documented the patient was in bilateral upper extremity soft restraints. The facility failed to obtain bilateral upper extremity soft restraint orders for 02/28/12.

6. Review of the facility census dated 02/28/12 showed Patient #17 was admitted for a pneumothorax (a collection of air or gas in the chest space that causes part or all of a lung to collapse) and was in the ICU. Record review of nursing and physician restraint documentation for Patient #17 showed:
-Physician restraint order dated 02/26/12 at 8:10 AM for Patient
#17 failed to be completed other than the physician signing, dating and timing a blank order form. On 02/26/12 at 10:00 AM the nurse documented the patient was in soft bilateral upper extremity restraints.
The facility failed to obtain bilateral upper extremity soft restraint orders for Patient #17 on 02/26/12.

7. Review of the facility census dated 02/28/12 showed Patient #24 was admitted for pneumonia (a lung infection) and dehydration (excessive loss of water from the body) and was in the ICU. Review review of nursing and physician restraint documentation for Patient #24 showed:
-Physician restraint orders dated 02/26/12 at 9:30 PM, included orders for soft wrist restraints, but failed to include if the orders were for the right or left wrist or bilateral wrists. On 02/26/12 at 11:00 PM the nurse documented the patient was in bilateral upper extremity soft restraints.
-Physician orders dated 02/27/12 at 7:00 AM, included orders for soft wrist restraints, but failed to include if the orders were for the right or left wrist or bilateral wrists. On 02/27/12 at 10:00 AM the nurse documented the patient was in bilateral upper extremity soft restraints.

During an interview on 02/28/12 at 2:00 PM, Staff S, ICU Director, confirmed the survey restraint findings for ICU Patients #16 and #17, and #24, are correct. Staff S stated that the facility improved the restraint order form about two weeks ago and stated that this survey review showed outdated restraint order forms were still in use even after the use had been discontinued. Staff S stated that training has been provided to all nursing staff and failure to get complete restraint orders is not due to a lack of training, but is due to the lack of staff following policy regarding the use of the new restraint order form.







12943

Based on record review, policy review and interviews the facility failed to provide first aid training to staff regarding the use of first aid techniques to patient injuries acquired during the use of restraints in three (Staff B, Staff M and Staff O) of three staff records reviewed. The facility census was 244.

Findings included:

1. Record review on 02/29/12 of the facility policy titled, "Alternatives to Restraints," policy number: PC-304, new/or revised date: 01/01/11, "Appendix A: Training Requirements," showed the following direction:
- Direct Care Staff: Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff assist direct care staff, when requested in the application of restraint or seclusion, the security guards or other non-healthcare staff are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion.
- Training will occur:
1. Before performing restraint application, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion;
2. As part of orientation, and
3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients; and
4. The results of skills and knowledge assessment, new equipment or Quality Assurance Performance Improvement (QAPI) data may indicate a need for targeted training or more frequent or revised training.

The facility policy failed to include the requirement for first aid training related to the use of restraints.

2. Record review of three employee files (Staff B, Mental Health Technician, Staff M, Mental Health Unit Clerk, and Staff O, Mental Health Registered Nurse (RN)), for evidence of restraint first aid training showed no evidence of first aide training related to restraints.

3. During an interview on 02/29/12 at 9:20 AM, Staff N, RN, Director of Risk Management, stated that they were unaware this was a requirement and have not provided first aid training to nursing staff in regard to restraints.

During an interview on 02/29/12 at 9:49 AM, Staff Q, Performance Improvement Department Manager, stated that she was not aware of the requirement regarding staff having first aid technique training regarding injuries that may occur when restraints are used. Staff Q confirmed first aid training related to restraints has not been provided to staff. Staff Q is not aware of a facility policy that addresses first aide training related to the use of restraints.



27029

Based on record review and interview, the facility failed to notify the Centers for Medicare & Medicaid (CMS), by telephone, of patient deaths associated with the use of restraints for four patients (#20, #21, #22 and #23) of four restraint related death records reviewed. The facility census was 244.

Findings included:

1. Record review on 02/29/12 of the facility policy titled, "Alternatives to Restraints," policy number: PC-304, new/or revised date: 01/01/11, "Appendix C: Reporting Requirements," stated the following direction:
-A report of deaths associated with the use of restraint or seclusion will be submitted to the CMS Regional Office by telephone, no later than close of the next business day following the day in which the hospital knows of the death.

2. Record reviews on 02/29/12, showed the facility notified CMS of patient deaths while in restraints with a faxed form titled, "Hospital Restraint/Seclusion Death Report Worksheet," revised July 2008. The facility notified CMS of the following patient deaths via fax:
-Patient #20 on 10/03/11
-Patient #21 on 10/10/11;
-Patient #22 on 11/14/11; and
-Patient #23 on 12/27/11.
There is no documentation the facility notified CMS by phone regarding these deaths.

During an interview on 02/29/12 at 9:00 AM, Staff N, Director of Risk Management, stated that death reporting of patients while in restraints to CMS is done by fax not by phone. Staff N confirmed the facility policy does require the facility to call CMS to report patient deaths that occurred while in restraints, but the facility used faxes only for CMS notification.