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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on observations, interviews and document review the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items which a patient could harm themselves or others were not accessible to patients in the inpatient psychiatric unit. Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items, which pose a safety risk to patients or others, were not accessible to patients in the inpatient psychiatric units.

A-0174 Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Based on interviews and document review, the facility failed to discontinue seclusion at the earliest possible time, when the patient's behavior was not threatening to the patient, staff or others, in two of three seclusion medical records reviewed (Patient #2 and #5).

A-0175 The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. Based on document review and interviews, the facility failed to ensure staff accurately and timely monitored the physical condition and cognitive status of Patient #5, one of four patients placed in seclusion during their admission.

Based on the manner and degree of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM was out of compliance.

A-0286 -(a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities .....
(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Based on interviews, document review and record review, the facility's quality management committee failed to analyze adverse patient events in order to identify contributing factors and implement preventive actions in contraband events and three of four seclusion events reviewed (Patient #2 and #5). (Cross-reference A144, A0174 and A0175)

Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items, which pose a safety risk to patients or others, were not accessible to patients in the inpatient psychiatric units.

Findings include:

Facility policy:

According to the policy, Search for Contraband, in order to keep everyone safe, the environment of care (EOC) in which our patients are being treated will be routinely and regularly searched for contraband. EOC rounds are performed a minimum of once per shift and any time a member of the clinical team believes there is an environmental safety issue within the milieu. This includes searching patient rooms and any programming areas. Contraband is defined as items specifically identified to pose a potential risk to patients, teams, and/or visitors.

The policy then listed items, including, but not limited to, drugs, knives and guns.

1. The facility failed to ensure plastic pieces, pens and metal from facemask's were not accessible to patients in the inpatient psychiatric units.

Observations conducted in three of the three inpatient psychiatric units on 6/23/20 and 6/24/20 revealed pens, plastic pieces from a staff member's badge and metal strips in facemask's were accessible on the inpatient psychiatric units.

a. Observations conducted on 6/23/20 revealed plastic pieces were located in a patient's room in the adolescent inpatient psychiatric unit (Unit 600).

i. On 6/23/20 at 8:45 a.m. observations of a patient's room (601) was conducted with Mental Health Technician (MHT) #18. Observations revealed two black pieces of plastic approximately one inch square located in the shower.

ii. Review of the Staff Reporting Tool revealed the patient in room 601 was on physician-ordered suicide, assault and elopement precautions.

iii. MHT #18 identified the plastic pieces as contraband from a staff member's badge. MHT #18 stated the patient had taken a staff member's badge on 6/22/20 around 7:00 p.m. MHT #18 stated she was unsure how long the patient had the contraband in his possession and why it had not been found previously.

iv. Review of the overnight duty checks revealed two room searches were documented as completed by two separate MHTs on 6/22/20 of room 601 after the patient had obtained the staff members badge.

v. Per interviews with MHTs who were responsible for room searches, the searches were completed to ensure patients did not have any contraband hidden which could be used for patient or staff harm. Staff stated it took approximately three to five minutes to perform a room check and included, but was not limited to, lifting up mattresses, checking the sides of mattresses, checking patient belongings and cubies, checking the bathroom, including the toilet paper holder, shower, soap dispenser and mirror for any loose or contraband objects.

vi. Review of the camera footage provided by facility leadership for room 601 from 6/22/20 at 7:00 p.m. until 6/23/20 at 7:00 a.m., revealed only one staff member had entered room 601 and the staff member remained in the room for less than one minute.

vii. On 6/26/20 at 11:23 a.m., the Medical Director (Provider #13) was interviewed. Provider #13 stated any objects the patient could use for staff or self-harm was considered contraband. Provider #13 stated staff had a responsibility to ensure patients remained safe while at the facility. He stated, through monitoring and searches for contraband, staff could provide a safe environment for the patients. Provider #13 stated it was of enormous importance to look at environmental risks when caring for unpredictable patients who could intentionally or unknowingly harm themselves.

On review of the plastic pieces found in room 601's shower, Provider #13 stated the patient could have used the pieces for staff or self-harm; he stated the plastic piece could be used as a razor or could be swallowed, either of which could cause severe injuries. Provider #13 said the pieces of plastic should have been found during the room searches that should have occurred on the 6/22/20 night shift.

viii. On 6/26/20 at 10:05 a.m., Chief Nursing Officer (CNO) #12 was interviewed. CNO #12 stated staff should have checked the patient in room 601's skin, clothing, room and bathroom after he obtained a staff badge to ensure he did not have contraband. CNO #12 stated she was unaware the room checks were documented as completed, but were not performed. She stated she did not know why staff would document things as done when they had not been done. She stated she had reviewed the video of the incident involving the patient in room 601 to see what happened, but did not review to see if staff had followed the policy for monitoring and checks.

CNO #12 stated after review of the signed room check document, the staff signature was a new employee on orientation. She stated there were two lead MHTs who trained new hires. She stated as the nurse educator, she did not know how new hires were trained on searching patients or rooms, nor did she verify new hire competencies. CNO #12 stated the previous CNO was working on creating a competency binder, but she was unable to locate the binder or any staff training on room checks.

CNO #12 stated there had been no process changes or education of staff after contraband was found in room 601.

b. Observation conducted on 6/23/20 and 6/24/20 on the 400 unit and the 500 unit respectively, revealed pens were accessible to patients.

i. Observations conducted on 6/23/20 at 8:22 a.m. with the CNO #12 on the adult 400 psychiatric unit revealed pens in patient room 403 and 408. CNO #12 stated patients were permitted to have pens in their rooms unmonitored because pens were not listed as contraband in the policy.
However, see above; the policy defined contraband as items specifically identified to pose a potential risk to patients, teams, and/or visitors.

ii. Review of the Staff Reporting Tool revealed both patients with unmonitored pens in their rooms were on physician-ordered suicide precautions.

iii. Observations conducted on 6/24/20 at 10:56 a.m. of the 500 unit revealed MHTs were unable to account for all pens on the unit. When asked which patients had pens, the two MHTs on the unit stated all pens were accounted for and no patient had a pen. However, observations of the pen carousel revealed a pen was in the slot for room 502, which indicated the pen for that room was not in use. Further observations of room 502 revealed a patient with a pen in her room.

iv. According to interviews with patient care staff, there was no consistent process for staff to monitor, supervise and account for the pens used by patients. Multiple interviews with different staff, including registered nurses (RNs) and MHTs, revealed all staff identified a pen as an object patients could use to harm staff, others or themselves. But, when asked how the pens were monitored and accounted for, staff had no consistent answer on what the process was and staff interviews revealed each unit had a different process.

v. On 6/26/20 at 12:50 p.m., an interview was conducted with the Director of Quality (Director #14). Director #14 stated the pens and pencils were removed from the contraband list due to previously cited deficiencies by the regulatory agency involving pencils. Director #14 was unable to provide any documentation or evidence how it was determined the pens had been reviewed for patient safety and did not meet the contraband list criteria. Director #14 stated after receiving the deficiencies, the facility did not include in its plan of correction that staff would monitor or track pens and, therefore, pens were not tracked or monitored on the inpatient units.

vi. Review of the Safety Risk and Mitigation Plan provided by leadership revealed pens had not been identified as a safety risk and no mitigation plan was listed.

vii. On 6/26/20 at 12:50 p.m., the Chief Executive Officer (CEO) #15 was interviewed. CEO #15 stated when the facility replaced pencils with pens for patient use, the facility no longer considered pens contraband and allowed patients to keep them. She stated "everyone" concluded patients were allowed to keep the pens but could provide no evidence how the facility came to this determination. CEO #15 then stated contraband could be anything a patient could harm themselves with.

viii. On 6/26/20 at 10:05 a.m., CNO #12 was interviewed. CNO #12 stated, again, since pens were not listed in the contraband policy, they were allowed unsupervised on the unit and most recently, due to COVID-19, in patient rooms.

After discussion of the observations from 6/24/20 on the 500 unit, CNO #12 stated the MHTs should have been able to account for all the pens on the unit.

CNO #12 was unable to provide any documentation related to the procedures regarding pens, including staff training, policy or procedures to account for pens, and pens were not listed on the Safety Risk and Mitigation Plan for the facility.

ix. On 6/26/20 at 11:23 a.m., Provider #13 was interviewed. Provider #13 had not seen the pens the facility was using. He was shown the pen and after review, Provider #13 stated he considered the pens to be contraband. He stated the pen could be modified and used as a weapon for patients to harm themselves or others. Provider #13 stated if pens were unaccounted for, a patient could put more than one together and the pen would be stronger and more of a risk for harm. Provider #13 stated if the patient had the pen, the patient must be monitored by staff to ensure the pen was being used for its intended purpose only and once done, must be collected by staff to ensure a safe patient environment.

c. Review of the facility incident report revealed an incident occurred on 6/3/20 in which a patient had obtained and hidden the metal from the face mask.

Observations on 6/24/20 at 10:56 a.m. of the 500 unit revealed three of the four patients on the 500 unit had facemask's containing metal nose pieces.

i. Observations of room 503 revealed a patient sleeping in the room. Noted on the desk near the room entrance was an unmonitored facemask with the metal nose piece still in the mask.

Observations of the group room revealed the patient from room 502 wearing her facemask with the metal nose piece intact.

Observations of the patient in room 507 revealed his facemask was stored in the supply closet for use when he left his room. Inspection of his facemask revealed the metal nose piece still in the mask.

ii. According to unit staff, all patients on the unit were on suicidal precautions due to the risk of self-harm.

iii. On 6/24/20 at 11:50 a.m., an interview was conducted with RN #9, who was the RN for the 500 unit. RN #9 stated patients were supposed to wear a mask when they were out of their room. Once the patient decided they were going to spend a period of time in their room, the mask was stored in a bag with their name on it in the supply closet. RN #9 stated when she was working, the MHTs would bring her a mask and she would remove the metal piece. She stated it was important to remove the metal piece as a safety precaution because the patient could use the metal for all sorts of things to include harming themselves or others. RN #9 stated she had never checked the masks used by patients on the unit for metal because she thought everyone removed the metal piece like she did. RN #9 stated she was unaware patients had masks with metal in them on her unit.

iv. On 6/26/20 at 11:23 a.m., Provider #13 was interviewed. Provider #13 stated the patients' masks should not contain metal as it could be used for staff or self-harm. Furthermore, Provider #13 stated masks should not be unmonitored in a patient's room because a patient could collect several masks and make a rope which would be dangerous for both patients and staff.

v. On 6/26/20 at 10:05 a.m., CNO #12 was interviewed. CNO #12 stated the facility did not have a policy related to mask use for patients. She explained the staff were supposed to remove the metal piece from the mask prior to issuing the mask to each patient. The patients were supposed to wear the mask when in common areas and when out of their rooms, and the masks should be collected and stored when the patients were in their rooms. CNO #12 stated the process was created because patients could harm themselves or others with the metal nose piece from the mask. Additionally, she stated masks unsupervised in a patient room could be a ligature risk and should never occur. This conflicted with the observations above conducted 6/24/20 on the inpatient psychiatric unit.

CNO #12 stated no formal ligature risk and mitigation plan that included an assessment of mask use was done, but stated the process she described was the mitigation plan. However, CNO #12 was unable to provide any evidence staff had been educated on the process she described.

CNO #12 stated after surveyors found masks in the patient rooms and masks with the metal nose piece, leadership had started performing rounds to look for masks in patient rooms and to ensure the metal pieces had been removed. She stated these rounds had not been completed prior to the survey.

vi. On 6/26/20 at 12:50 p.m., CEO #15 was interviewed. CEO #15 stated masks were introduced after the facility had a COVID-19 diagnosed patient. She stated the safety plan was for staff to remove the metal piece and for patients to not keep the masks in their rooms. CEO #15 stated patients could harm themselves with the metal in the masks. CEO #15 stated she did not think the plan for masks was official or approved when put in place. She stated leadership did EOC rounds and during rounds, she had removed masks from patient rooms and performed in the moment teaching to staff and later notified the respective department of the teaching she had conducted. CEO #15 was unable to provide evidence staff had been educated on the process she described for safely managing patients' masks.

Based on interviews and document review, the facility failed to discontinue seclusion at the earliest possible time, when the patient's behavior was not threatening to the patient, staff or others, in two of three seclusion medical records reviewed (Patient #2 and #5).

Findings include:

Facility policies:

Seclusion and Restraint

The Seclusion and Restraint policy read, seclusion is the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving. Seclusion may only be used for the management of imminent threat of violent or self-destructive behavior which jeopardizes the safety of the patient, a staff member, or others. Each patient has the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation. Restraint or seclusion shall be a last resort in circumstances in which a patient cannot be deescalated using evidenced based de-escalation training and poses a risk of imminent harm to themselves or others. Any use of Restraint and/or Seclusion require clinical justification and must have a physician's order. The RN shall inform the psychiatrist/physician of the patient's current condition. The psychiatrist/physician will decide whether to continue the restraint or seclusion.

The condition of the patient who is restricted is monitored by a registered nurse (RN) and/or trained staff. All restraint or seclusion will be documented by a qualified registered nurse in the patient's medical record and will reflect justification, implementation, and outcome of procedure (to include behavior at time of release) and shall address the failure of less restraint or seclusion. Each occurrence of restraint or seclusion will be documented by the RN in the patient's medical record and will include antecedents, less restraint or seclusion, crisis intervention techniques, clinical justification, implementation, and outcome of procedure. Restraint or seclusion is to be discontinued as soon as the patient meets his or her behavior criteria.

Nursing Staffing

The Nursing Staffing Policy and Procedure read, the Director of Nursing (DON) will be responsible for assessing and evaluating the nursing staffing needs of all units. Staffing needs will be based on patient-nurse ratio, acuity, safety concerns, staff mix and availability. During off shift, the Charge Nurse will be responsible, and will provide notice to the Administrator-On-Call. The designated staffing person will be responsible for calling in and off staff. Current Patient to Nurse Ratios: Adult/Geriatric is 6:1.

Provision of Care

The Staffing Plan for Provision of Care read, to identify nursing care needs of the patient using the nursing process. Specifically, registered nurses shall use the assessment skills initially and on an ongoing basis to determine the level of care; necessary interventions will be evaluated for effectiveness and target positive patient outcome as criteria. Modifications shall be made in treatment strategies based on the nurse's evaluation of the patient's response to interventions; thus, ensuring the delivery of care is representative of the patient's individualized needs.

Patient Bill of Rights

The Patient Bill of Rights read, the patient has the right to be free from restraints or seclusion imposed as a means of coercion, discipline, convenience or retaliation by staff.

1. The facility failed to discontinue seclusion at the earliest possible time, when Patient #2 and Patient #5 no longer exhibited behaviors threatening to themselves, staff or others.

A. Document review

Document review revealed Patient #2 and #5's incidents of seclusion conflicted regulation, the facility's seclusion policy and the patients' bill of rights, all of which limited seclusion to the management of imminent threat of violent or self-destructive behavior which jeopardizes the safety of the patient, a staff member or others.

1. A facility incident report for Patient #2 read, Patient #2 was placed in seclusion on 5/23/20 at 8:54 p.m. until 5/24/20 at 7:00 a.m., a total of 606 minutes. Record review revealed the Patient #2 was not released from seclusion when he no longer met the criteria for seclusion.

a. Review of the report revealed Registered Nurse (RN) #1 wrote at 8:54 p.m., Patient #2 cornered two mental health technicians (MHT), yelled and made threatening gestures and verbal threats to staff. Four additional staff assisted Patient #2 in seclusion.

At 12:27 a.m., RN #1 documented Patient #2 was calm. RN #1 told Patient #2 he would stay in the seclusion room until the next shift arrived at 7:00 a.m. She stated it was for his safety and the safety of the staff and other patients because his behavior was unpredictable earlier in the shift.

At 12:51 a.m., Patient #2 was given a dose of Zyprexa (an antipsychotic medication to treat mental disorders) and was calm and cooperative.

At 1:00 a.m., Patient #2 asked what he needed to do to get out of seclusion and RN #1 reinforced he would stay in seclusion until the day shift arrived at 7:00 a.m. Also at 1:00 a.m., RN #1 explained to the former medical director (Provider #17) that due to staffing on the unit, it was unsafe to release Patient #2 onto the unit and she would like to continue Patient #2 in seclusion until the day shift arrived. Provider #17 agreed and the seclusion order was renewed.

b. Patient #2's medical record was reviewed. It revealed no documentation Patient #2 exhibited self-harming or threatening behaviors from 1:00 a.m. to 7:00 a.m. Rather, at 1:00 a.m., RN #1 documented Patient #2 was not exhibiting self-injurious behavior and was alert and oriented. The RN documented Patient #2's behavior as restless but calm; he was no longer throwing items and was no longer verbally aggressive toward staff. From 1:00 a.m. to 7:00 a.m., Patient #2's behavior was documented as calm, eating or sleeping.

Patient #2's continued seclusion from 1:00 a.m. until 7:00 a.m. conflicted regulation, the facility's seclusion policy and the patients' bill of rights (see above).

2. Another facility incident report, for a second patient, Patient #5, was reviewed. It revealed Patient #5 was placed in seclusion on two separate occasions. The first incident of seclusion occurred on 6/6/20 from 12:32 p.m. until 8:38 p.m. The patient was in seclusion for 486 minutes. The second incident of seclusion occurred on 6/7/20 from 10:39 a.m. until 4:35 p.m. Patient #5 was in seclusion for 356 minutes. Record review revealed Patient #5 was not released from seclusion when she no longer met the criteria for seclusion.

a. A review of Patient #5's medical record revealed a Nursing Progress Note on 6/6/2020 at 8:26 a.m. which read, Patient #5's son/medical power of attorney (POA) had a discussion with the admitting RN. The note read the son stated the patient had been more distant with a slow decline over the past two weeks, a direct result of being confined to her room in the assisted living facility due to COVID-19 precautions. He stated she had been confused, walking into other patients' rooms, calling them his (son's) name and refusing to leave their rooms.

After the above 6/6/20 Progress Note was written, Patient #5 was placed in seclusion on 6/6/20 and then again the next day on 6/7/20.

i. On 6/6/20, Patient #5's seclusion documentation revealed RN #11 documented Patient #5 was in seclusion from 1:30 p.m. until 6:30 p.m. because she continued to attempt to push through staff to gain access to another patient's room. RN #11 documented the patient exhibited this behavior (wandering and pushing through staff) every hour from 1:30 p.m. until 6:30 p.m.

However, the Mental Health Technician (MHT), who was the staff member in the seclusion area with Patient #5, documented Patient #5's behaviors as lying, sitting, standing, pacing and walking. For over seven hours, from 12:40 p.m. to 8:20 p.m., the MHT documented Patient #5 exhibited only two episodes of agitation, each lasting less than five minutes.

Patient #5 was not released from seclusion until 8:40 p.m. when she was transferred to the emergency department for a decline in her physical condition. Patient #5's seclusion for ten hours on 6/6/20 conflicted with regulation, the facility's seclusion policy and its bill of rights (see above).

ii. On 6/7/20, Patient #5's seclusion documentation revealed she was placed in seclusion a second time from 10:39 a.m. until 4:35 p.m. Patient #5 was in seclusion for 356 minutes due to attempting to sit on the floor because she thought another patient was her son. From 10:40 a.m. to 3:55 p.m., the MHT documented Patient #5's behaviors as lying, sitting, awake or standing. Patient #5's seclusion for over five hours on 6/7/20 conflicted with regulation, the facility's seclusion policy and its bill of rights (see above).

B. Interviews

Interviews with staff revealed both Patient #2 and Patient #5 met criteria to be released from seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) earlier than their actual release.

1. On 6/24/20 at 6:33 a.m., MHT #5 was interviewed. MHT #5 stated once a patient was able to control their emotions and demonstrate appropriate behavior, such as not yelling or threatening, the patient should be released from seclusion.

MHT #5 stated when a patient was in seclusion, one staff member was required to hold the door closed and monitor the patient. She stated some seclusion and restraint episodes took five staff members to manage. This would require the MHT from another unit to respond, leaving the RN as the only person on the unit. MHT #5 stated this occurred each time there only was one MHT scheduled on a unit and another unit called for staff assistance.

MHT #5 stated a seclusion or restraint episode was different on the night shift because the only extra staff to assist was the house supervisor, whereas on day shift, administration staff were available to assist. MHT #5 stated the night shift was frequently staffed with only one MHT per unit which limited response assistance. Additionally, MHT #5 stated the staff on night shift were all females and most were diminutive in stature, making seclusion episodes difficult.

2. On 6/24/20 at 2:12 p.m., RN #1 was interviewed. RN #1 stated seclusion was when a patient was prevented from leaving an area to prevent harm to him or herself or others. She stated criteria for release from seclusion was not to be a harm to oneself or others. RN #1 stated she determined a patient was not at risk for harm by having a verbal agreement from the patient that he or she would not exhibit harmful behaviors.

RN #1 stated she was the nurse on the 500 unit the night shift of 5/23/20 when Patient #2 remained in seclusion. She stated Patient #2 was a very large patient and there were not enough staff on the 500 unit to hold Patient #2 if he exhibited harmful behavior. She explained that evening and overnight she was working as both the 500 unit nurse and the house supervisor, meaning she was supervising all the units in the facility. RN #1 stated when she worked both positions, she was limited in her ability to perform house supervisor duties, such as assisting other units with lunch breaks, medication administration and patient care including seclusion.

According to RN #1, the 500 unit had a high acuity on 5/23/20 and was staffed with one RN and one MHT because one MHT was sitting 1:1 with a patient and could not leave that patient. Furthermore, RN #1 stated the unit was staffed with an all-female staff. RN #1 stated since there were no males working to assist with de-escalation of patients, she almost needed to call the police for additional assistance. She stated that although Patient #2 did not exhibit violent behavior, he was unpredictable earlier during the shift. RN #1 stated, for the safety of the staff, she notified the provider and the decision was made to keep Patient #2 in seclusion until 7:00 a.m. when day shift arrived, six hours past the time when the patient no longer exhibited criteria to be in seclusion.

RN #1 stated she had a phone conversation with the former Medical Director (Provider #17) and the Chief Nursing Officer (CNO #19) who, according to policy (see above), is responsible for staffing the needs of the unit based on patient to nurse ratio, acuity, safety concerns, staff mix and availability. RN #1 said she informed them of the staffing situation and her desire to keep Patient #2 in seclusion. She stated CNO #19 and Provider #17 agreed with the decision to keep Patient #2 in seclusion until more staff arrived with the day shift. RN #1 stated CNO #19 did not offer to come to the facility to assist but rather, told her to call the police if she needed additional assistance.

On 6/24/20, interviews with two house supervisors revealed they had never been trained on adjusting staffing related to acuity.

3. On 6/25/20 at 10:03 a.m., House Supervisor (Supervisor #20), who had worked 6/6/20 when Patient #5 was admitted, was interviewed. The interview included a review of Patient #5's record and seclusion incident. Supervisor #20 stated she was unable to get information about what would soothe her or calm Patient #5 down to de-escalate her. She said the patient was confused and unable to follow directions.

Supervisor #20 stated she remembered staff thought severe dehydration and a urinary tract infection were contributing to the patient's confusion. According to Supervisor #20, Patient #5 received a dose of Rocephin (an antibiotic) on 6/6/20 and did have some clarity afterwards.

Supervisor #20 reviewed a Progress Note from 6/6/20 at 3:33 p.m. and stated Patient #5 could not understand that the other patient was not her son. She said the patient was not able to be redirected to stay out of the other patient's room. She reviewed a Progress Note from 6/6/20 at 7:30 p.m., and stated Patient #5 was unable to understand teaching and was impulsive as she attempted to exit the seclusion room. She stated the other patient stated he would harm on Patient #5 if she continued to go into his room and that was why Patient #5 was placed in seclusion.

Supervisor #20 stated patients were assessed by the RN while in seclusion to determine if they were able to be released. She stated patients would be released if they were no longer trying to hurt themselves or other people by no longer yelling, screaming or pacing. After review of Patient #5's medical record, Supervisor #20 stated she did not know why Patient #5 remained in seclusion.

4. Leadership Interviews:

a. On 6/26/20 at 11:23 a.m., the Chief Medical Officer (Provider #13) was interviewed and reviewed Patient #2 and #5's records. Provider #13 stated a seclusion or restraint episode could be a traumatic event for a patient which took away a patients' rights and freedom and should be used only as a last resort for the shortest amount of time possible. Provider #13 stated no patient should remain in seclusion due to staffing issues.

Provider #13 further stated it was important to monitor a patient in seclusion. Provider #13 explained the rationale for a patient to be placed in seclusion was if the patient was a imminent danger to him or herself or others, making seclusion a dangerous situation. Provider #13 stated if a patient was not monitored correctly, the patient could have medical issues arise which could worsen the patient's condition.

He stated staff should monitor for self-harm behaviors along with any indicators the patient was experiencing a medical issue while the patient was in seclusion. He confirmed seclusion was to end as soon as the patient met the criteria for release. Provider #13 stated maintaining a patient in seclusion when they qualified for release could cause even more of an emotional disturbance.

b.. On 6/24/20 at 4:29 p.m. the Director of Compliance and Risk (Director #14) was interviewed. Director #14 stated she was aware of the seclusion incidents involving Patient #2 and Patient #5.

On review of Patient #2's seclusion incident, Director #14 stated she had a discussion with the previous CNO (CNO #19) regarding Patient #2's lengthy seclusion. Director #14 stated CNO #19 told her the staff were concerned about releasing the patient from seclusion because of the all-female staff and their ability to manage the patient. Director #14 stated staff had notified and received approval to keep the patient in seclusion from the CNO and the medical director.

Director #19 stated she was told by the CNO, the house supervisor they had tried unsuccessfully to get other staff to come in and work and there was not anyone else to assist the unit; therefore, the patient was kept in seclusion. Director #14 stated the CNO should have gone to the unit to provide staff support on 5/23/20.

Director #14 stated the facility did not have enough male staff members to manage patient behaviors on the night shift and there had been discussion among leadership to look at staffing makeup. According to Director #14, as of the exit of the survey (6/26/20), the staffing review had not been performed.

Director #14 stated unit 500 was a COVID-19 unit and 5/23/20 was the first shift the unit was open. She stated they were comfortably staffed for three units to be open, but not when they had to open the COVID-19 unit. She stated the COVID-19 unit needed a RN and MHT which was why the house supervisor had to be the RN on the unit on 5/23/20. Director #14 stated the emergency staffing policy would be to call people in.

On review of Patient #5's seclusion incident, Director #14 stated Patient #5 was sent out to the hospital two times and was ultimately admitted to an outside hospital to meet both her acute medical and psychological needs. Director #14 stated she had completed a review of this incident, as had CNO #19. Director #14 stated CNO #19 had no concerns after her review and Director #14 agreed there was no evidence staff were educated on the restraint and seclusion policy following the incident.

She said after surveyors entered the facility, however, a re-review was conducted and concerns about Patient #5's seclusion incidents were identified. Director #14 stated the RN and MHT documentation of Patient #5's behaviors did not align. She stated the RN documented vital signs within normal limits at 7:00 p.m., but when the RN actually performed an assessment of Patient #5, she identified abnormal vital signs and Patient #5 was transferred to an acute care hospital. Director #14 stated the review showed care from staff was not provided.

Director #14 could not identify any process changes to prevent similar incidents from reoccurring at the facility and did not refer to any staffing adjustments or staff education on regulatory requirements, the facility's restraint and seclusion policy or patient bill of rights.

c. On 6/26/20 at 8:41 a.m., the interim CNO (CNO #12) was interviewed. She stated she had been in her position for a week. She described duties of the CNO as including running the entire nursing department, ensuring staff training was appropriate, working on performance improvement and ensuring all staff documented correctly. She stated she was also the nurse educator and infection preventionist.

CNO #12 stated RNs were supposed to monitor patients in seclusion every 15 minutes to ensure the patients were safe, their needs met and their rights protected. She stated as the nurse educator and interim CNO, she had not performed audits of seclusion documentation. CNO #12 stated prior to the survey, she had never watched a seclusion video to ensure staff was providing care, evaluating patient behavior, and assessing whether seclusion needed to continue.

CNO #12 stated, after she reviewed Patient #5's seclusion events, she determined the RN did not monitor the patient as frequently as she should have. CNO #12 stated on the video, Patient #5 was lying in the bed, not pushing through the staff and alternatives to seclusion were not attempted for the patient. CNO #12 stated after her review, the patient's seclusion "was not appropriate."

CNO #12 stated it was important for the RN to assess the patient when in seclusion and explain to the patient the behaviors expected for him or her to be released from seclusion as soon as possible. CNO #12 stated Patient #5 had dementia, so she was unsure if she would have understood seclusion release criteria. However, she stated staff kept Patient #5 in seclusion because she was wandering in another patient's room and aggravated him; other interventions could have been implemented instead of seclusion, such as moving Patient #5 to another unit.

After reviewing Patient #5's seclusion video, CNO #12 stated she thought the CNO should review all seclusion videos to ensure policies and procedures were followed as well as documentation to ensure it was accurate. She stated she did not think CNOs or nurse educators reviewed seclusion and restraint videos prior to the survey to determine if what staff documented actually occurred. CNO #12 stated she had never reviewed seclusion videos as the nurse educator to identify education gaps and needs. She stated she knew staff needed additional seclusion and restraint training so staff knew what was expected of them minute by minute and what they should do to release patients. CNO #12 stated seclusion and restraint forms also should be reviewed, to ensure staff documented appropriately.

CNO #12 stated additional training should have occurred for the staff involved in the seclusion incidents involving Patient #2 and #5, and continued the patients' seclusion after the patients had met release criteria. She was unable to provide evidence the staff had received any such training or education after the incidents on 5/23/20 and 6/6 and 6/7/20.

CNO #12 stated she was not involved with Patient #2, but was aware the patient had been in seclusion for a long time. She confirmed Patient #2 was kept in seclusion for staffing concerns; the facility had to open another unit due to a patient diagnosed with COVID-19 and it was Memorial Day weekend.

CNO #12 stated if staff were unable to meet the needs of the patient, they would notify the house supervisor. The house supervisor would call everyone not working to see if they could come in to work. If no staff could come in, the administrator on call or someone in leadership would come in and take the role of the house supervisor. CNO #12 did not know why leadership did not assist staff on 5/23/20 when staff had concerns about their ability to manage Patient #2 and which led to the patient's for over six hours beyond the time he met criteria for release.

CNO #12 stated the ratio was one RN to 10 (1:10) patients and one MHT to eight (1:8) patients. She stated the nurse ratio would not change, but the facility could staff more MHTs if more staffing was needed. CNO #12 stated she began looking at the staff makeup on night shift when she became the interim CNO last week. She stated the night shift had all female staff and she wanted to hire more male staff. CNO #12 stated the staffing matrix had been 1:8, but the previous CEO changed the ratio to 1:10 in January of 2020. CNO #12 was unable to provide any documentation or facility approval for the change in the staff to patient ratio. CNO #12 did not know how the current ratio of 1:10 was determined or if it was evaluated for patient safety. CNO #12 reviewed the Nursing Staffing Policy and Procedure and stated the current ratio did not follow the staffing policy which stated the current nurse to patient ratio was 1:6 (see above).

Based on document review and interviews, the facility failed to ensure staff accurately and timely monitored the physical condition and cognitive status of Patient #5, one of four patients placed in seclusion during their admission.

Findings include:

Facility Policy:

The Seclusion and Restraint policy read, all staff placing patients in restraints will be trained in the use of these restraint devices, monitoring procedures and data collection during orientation and annual skill review. Continuous observations are documented every 5 minutes to include location of patient and present behaviors. The registered nurse (RN) must assess the patient in seclusion every hour or more frequently to include the patient's physical and psychological status, vital signs, patient care requirements, and determination of continued need for intervention. Full vital signs are taken at the frequency determined by the RN every hour unless contraindicated with documented justification assessment. RN documentation at least every 15 minutes for signs of injury or distress, patient's behavior, hydration and nutritional needs, skin integrity, and indicators of readiness for discontinuation of seclusion. The patient must be offered toileting and hydration at least every two hours.

1. The facility failed to ensure complete monitoring and assessment of Patient #5 while in seclusion, contrary to the facility restraint and seclusion policy.

A. Record review

Patient #5 was in seclusion on 6/6/20 for approximately eight hours. Review of the facility's monitoring and assessment forms revealed the facility utilized three different forms to monitor the physical and mental status of the patient in seclusion: Restraint/Seclusion RN Assessment, Restraint/Seclusion Patient Observation Form RN ONLY, and Restraint/Seclusion Patient Observation Form MHT/RN. Review of Patient #5's medical record revealed gaps and inconsistencies related to seclusion monitoring and assessments.

1. Staff failed to assess and record Patient #5's vital signs every one hour while in seclusion, as expected per the facility's restraint and seclusion policy.

a. Patient #5 was placed in seclusion on 6/6/20 from 12:30 p.m. to 8:38 p.m. Review of monitoring documentation revealed a full set vital signs, which included blood pressure (BP), pain level, heart rate (HR) and temperature (temp) was not completed or documented as "refused" by the patient.

i. On 6/6/20 at 9:02 a.m., prior to seclusion, Patient #5's vital signs were documented as BP 139/65, HR 91 beats per minute (bpm), zero pain and a temp of 98.6°.
The next set of vital signs was documented at 12:54 p.m., approximately 20 minutes after Patient #5's was placed in seclusion. Her documented vital signs documented were the exact same values documented at 9:02 a.m.

ii. According to the Restraint/Seclusion RN Assessment form (RN assessment), the RN is to assess pulse, respiration and color. Even though there was a set of vital signs obtained at 12:54 p.m., there was no assessment of the patient's respirations and color. While Patient #5 was in seclusion, the RN documented at 12:30 p.m., 1:30 p.m., 2:30 p.m., 3:30 p.m., 4:30 p.m., 5:30 p.m., 6:30 p.m. and 7:30 p.m. that the patient's vital signs "within normal limits (WNL)."

iii. Patient #5's vital signs at 8:07 p.m. and were documented as: BP 155/65, HR 91 bpm, zero pain. On review there was no actual measurement of the Patient #5's vital signs documented for approximately 7 hours.

iv. At 8:30 p.m., RN #7 documented on the RN Assessment: respirations 26 breaths per minute, HR 200 and 47 bpm, skin color was pale. Patient #5 was found nonresponsive with difficulty breathing. At 8:38 p.m., she was transferred from seclusion to a higher level of care.

b. Review of Patient #5's medical record also revealed inconsistencies in the behavior assessments, according to the seclusion monitoring documentation reviewed.

The RN assessment form, completed by RN #11, was reviewed for the hours of 12:30 p.m. to 8:30 p.m. on 6/6/20. The form was where the RN documented the hourly seclusion assessment which included, in addition to vital signs and skin color, the patient's current behaviors, mental status, efforts made by staff to assist the patient, and changes needed to the patient's care plan.

This review was compared to the Restraint/Seclusion Observation Form for MHT Mental Health Technicians (MHT)/RN (MHT assessment) that the MHT who was in seclusion with the patient completed every five minutes. It reflected the patient's restraint/seclusion status, location in the facility, and activity/behavior. Contradictory assessments between the MHT assessment and RN assessments were identified.

i. On 6/6/20 at 1:30 p.m., RN #11 charted that Patient #5's behavior was wandering aimlessly and pushing through staff. RN #11 documented the patient was reassured and encouraged to rest. In contrast, on 6/6/20 at 1:30 p.m., the MHT documented that Patient #5 was lying/sitting and resting quietly.

ii. On 6/6/20 at 2:30 p.m., RN #11 documented Patient #5 was wandering, pushing through staff, provided reassurance and rest was encouraged. The MHT documented Patient #5 was sleeping from 1:58 p.m. - 2:32 p.m.

The RN assessment continued to list Patient #5 as wandering, pushing through staff or pushing staff, with a mental status of anxious and confused at 3:30 p.m., 4:30 p.m., 5:30 p.m., and 6:30 p.m. However, the MHT documented Patient #5 as cooperative at 3:36 p.m., awake/alert with no other behaviors recorded at both 4:25 p.m. and 5:33 p.m., and sleeping from 6:23 p.m. to 7:26 p.m.

iii. On 6/6/20 at 7:25 p.m., on the next shift, RN #7 documented Patient #5's behaviors on the RN assessment as out of touch with reality, unable to follow directions, unable to remain safe in the milieu, high risk for assault and own poor safety awareness. The MHT, however, documented Patient #5's behaviors on the MHT assessment as lying/sitting and quietly resting at 7:26 p.m. and alert/awake at 7:38 p.m.

c. Review of Patient #5's medical record revealed no evidence the document titled Restraint/Seclusion Patient Observation for RN Only was completed on 6/6/20 for Patient #5's seclusion from 12:30 p.m. to 8:38 p.m. The form had space to record hourly vital signs and nursing 15 minute checks, including care interventions, explanation of reason for restraint/seclusion, food and fluids offered, toileting needs, hygiene, patient teaching and whether the interventions offered were accepted or refused.

B. Interviews

1. An interview was conducted on 6/25/20 at 1:27 p.m. with RN #11. RN #11 stated a face-to-face assessment needed to be conducted within the first hour of seclusion which included the ability of the patient to remain safe, and bathroom and nutrition needs. She stated a set of vital signs should be assessed or the RN should document the patient refused. RN #11 stated the RN should go into the seclusion room for frequent visual checks, but if the patient was exhibiting harmful behaviors, then the RN could assess respirations by looking through the window.

RN #11 stated there were multiple forms which needed to be completed by staff. The MHT recorded observations every five minutes on the Restraint/Seclusion Observation Form for MHT Form. She stated the RN completed the Restraint/Seclusion Patient Observation for RN ONLY form to document their observations of the patient and the Restraint/Seclusion form for every 15 minute assessments.

RN #11 stated Patient #5's behavior was aggressive towards staff, with consistent confusion and urinating in her clothing. RN #11 stated she did not remember taking vital signs and stated if the patient allowed vital signs to be taken, they would be recorded. RN#11 reviewed the medical record for Patient #5 and was unable to identify documented vital signs other than those recorded at 9:02 a.m. and 8:07 p.m. on 6/6/20. RN #11 stated she had concerns regarding Patient #5's decreased urine output, but RN #11 was unable to locate any documentation regarding Patient #5's intake and output or an evaluation of the patient's hydration status during seclusion. RN #11 stated she felt the MHT documented showed Patient #5 as more calm than she observed during Patient #5's time in seclusion which may have caused discrepancies in the seclusion monitoring documentation.

2. On 6/25/20 at 9:57 a.m., an interview was conducted with house supervisor (Supervisor #18). Supervisor #18 stated the restrained/secluded patient was to be monitored every five minutes for the first 15 minutes, then every 15 minutes thereafter. The patient was to remain on one-to-one observation monitoring. Supervisor #18 stated the RN and MHT were both responsible for the observation documentation which included food or water offered and consumed, the patient's behavior, and toileting needs.

c. On 6/26/20 at 8:40 a.m., an interview was conducted with the interim CNO (CNO #12). CNO#12 stated active monitoring of a patient in seclusion included a full set of hourly vital signs; documentation of the results was required. CNO #12 stated documentation of WNL was unacceptable and did not show any values; therefore, tracking and trending could not occur. CNO #12 further stated observation checks were required at least every five to 15 minutes by the MHT and RN. CNO #12 stated observations included the patient's behavior, food offerings, toileting needs and acceptance or refusal of interventions. CNO #12 reviewed the video footage of Patient #5 while she was in seclusion on 6/6/20 and stated there were gaps in staff assessment and observation of Patient #5 while she was in seclusion.

Based on interviews, document review and record review, the facility's quality management committee failed to analyze adverse patient events in order to identify contributing factors and implement preventive actions in contraband events and three of four seclusion events reviewed (Patient #2 and #5). (Cross-reference A144, A0174 and A0175)

Findings include:

Facility Policies:

The Risk Management Plan read, the Governing Board shall be the governing body responsible to establish, maintain and support the risk management program as an ongoing process. This function shall be delegated to the administration and Quality Council to monitor on a regular basis as part of the overall clinical service process. Implementation and monitoring shall be accomplished through collaboration of the hospital's administration and medical staff.

The ultimate purpose of risk management is to enhance the quality of patient care by preventing and/or decreasing the frequency and severity of undesirable or adverse patient care occurrences. The risk management program is designed to provide: Identification of areas which may represent actual or potential sources of patient injury. Development and utilization of an indicator database for identifying and evaluating undesirable or adverse patient care occurrences. Resolution of clinical problems identified through data evaluation. Ongoing education for all staff on approaches for reducing or eliminating potential sources of patient injury.

Goals and objectives: To support, maintain and enhance the quality of patient care delivery by: Systematic objective monitoring and evaluation of reports of injuries, accidents, patient safety issues, safety hazards and/or clinical services findings. Identification and assessment of general areas of actual or potential risk in the clinical aspects of the delivery of patient care and safety. Implementation of appropriate corrective actions, to the extent possible, to alleviate and resolve identified problems or concerns with patient safety issues. Evaluations and documentation of the effectiveness of actions implemented. Aggregation of data/information collected for integration in the formation of management systems and use in managerial decisions and operations.

The CEO (Chief Executive Officer) shares joint responsibility with the medical staff for operation of the risk management program and, through the risk manager, delegates overall responsibility for designing, implementing and coordinating to maximum effectiveness the risk management program which includes: Implementation and evaluation of appropriate corrective action, to the extent possible, to alleviate or resolve identified problems or concerns with patient safety issues. Reports of all risk management functions shall be reviewed by the Governing Board and Medical Staff. It is the responsibility of the Medical Director of his designee to present this information to the medical staff body.

The authority and responsibility of the risk manager is as follows: Supervise and support risk management activities. Request problem reports/incident reports and any follow-up information necessary. Perform or assign investigation of problems. Prioritize problems based upon the degree of impact of patient care, program management and facility management. Conduct review for facility-wide problems and trends. Investigate, plan and implement corrective action. Assess the appropriateness and effectiveness of corrective actions. Assure communication between departments, services and programs when problems or opportunities to improve patient care involve more than one (1) department. Integrate the findings of all risk management activities, as appropriate, with the clinical services program where there are opportunities to improve the quality of patient care.
Each department, service, unit, program or standing committee identifying the problem will attempt to implement corrective action when an actual or potential risk is identified. Any problem which cannot be resolved due to scope, lack of authority or other reason will be addressed by the Quality Council.

1. The facility failed to investigate and analyze adverse patient events, including seclusion incidents that extended well beyond the time the patient met criteria for release and the presence of contraband in inpatient psychiatric units, in order to identify causes and contributing factors to prevent reoccurrence. (Cross-reference 0144, 0174)

A. Leadership interviews

1. On 6/26/20 at 12:50 p.m., Director of Compliance and Risk (Director #14) was interviewed. Director #14 stated she was responsible for the quality program. Director #14 stated her hours were recently decreased and she did not have enough resources or time to perform her duties as the quality director. Director #14 stated she felt as though the facility had 50 "holes" (quality concerns), but she could only cover ten at a time.

Director #14 stated one of the tasks she transferred to the Chief Nursing Officer (CNO) due to the decrease in her hours was reviewing seclusion and restraint incidents. Director #14 stated the CNO was responsible for any actions based on issues the review identified, and she did not do any follow up on these incidents after the CNO.

Director #14 further stated it was difficult to perform her job as she supported other roles in the facility due to the high turnover rate in leadership positions, including the CNO, Chief Medical Officer (CMO), two case managers, and the clinical director. The facility also had a new medical provider.

2. On 6/26/20 at 12:50 p.m., Chief Executive Officer (CEO #15) was interviewed at the same time as Director #14. CEO #15 stated she was responsible for all activities within the facility.
CEO #15 said she was not aware Director #14 did not have enough resources to perform her role, yet she disputed that Director #14's hours had been decreased, and indicated the issue was one of time management. CEO #15 agreed, however, that the facility had constant turnover and change which made the quality program almost impossible.

B. Review of multiple incidents revealed the facility failed to analyze adverse patient events to identify causes and contributing factors to prevent reoccurrence.

According to the policy, patient incidents creating actual or potential risks in the delivery of patient care and safety should have been investigated and corrective actions implemented to prevent reoccurrence. Additionally, the appropriateness and effectiveness of corrective actions should have been assessed. Record review revealed and interviews confirmed, these steps had not been taken.

1. Seclusion incidents

a. Patient #2 remained in seclusion for six hours past the time he met criteria for release due to a lack of staffing at the facility. According to the facility restraint log, Patient #2 was placed in seclusion on 5/23/20 at 8:54 p.m. until 5/24/20 at 7:00 a.m., a total of 606 minutes.

Review of the facility incident report read Patient #2 cornered two mental health technicians (MHT), yelled and made threatening gestures and verbal threats to staff and was placed in seclusion at 8:54 p.m. At 12:27 a.m., RN #1 documented Patient #2 was calm. RN #1 told Patient #2 he would stay in the seclusion room until the next shift arrived at 7:00 a.m. She stated it was for his safety and the safety of the staff and other patients because his behavior was unpredictable earlier in the shift. At 12:51 a.m., Patient #2 received a dose of Zyprexa (an antipsychotic medication to treat mental disorders) and was noted as calm and cooperative.

Continued review of the incident report revealed, at 1:00 a.m., Patient #2 asked what he needed to do to get out of seclusion. RN #1 reinforced he would stay in seclusion until the day shift arrived at 7:00 a.m. RN #1 obtained a renewal of the patient's seclusion order at this time, explaining to the provider that due to staffing, it was unsafe to release Patient #2 onto the unit...

Per interviews with facility staff and facility policy, Patient #2 met criteria for release from seclusion at 1:00 a.m., but remained in seclusion for an additional six hours due to a concern that there was insufficient staff to manage the patient.

i. Review of the incident report follow up revealed a lack of investigation into the incident.

Under the section "supervisor review section of the incident report, if applicable, include additional information, evaluation and/or recommendations": the House Supervisor (Supervisor #4) wrote on 5/26/20 at 3:50 p.m., no injuries to staff or patient. Staff did not touch the patient. Patient able to calm and eventually was released from seclusion when he calmed. No evaluation of the extended seclusion or recommendations to prevent another similar incident were noted.

Under the section "to be completed by Director of Nursing,": the previous Chief Nursing Officer (CNO #19) wrote it read on 5/26/20 at 9:00 a.m., for her review, noted no injury to patient or staff. No hands on with hold.

Under the section "to be completed by Risk Manager": the Director of Compliance and Risk (Director #14) wrote for her review: Discussed with the CNO on 5/26/20 and in patient safety. CNO and Provider contacted regarding long seclusion plan. Due to patient voicing concerns and the patient's unpredictability and level of aggression plan supported by both. No harm to the patient or staff. Will follow up on whether meds were offered earlier in intervention. Follow up: PRN meds were offered. Weren't comfortable trying to restrain due to refusing PRN to give IM. Patient eventually requested PRN.

In summary, review of the incident report revealed no evidence the quality program reviewed the incident for causes or contributing factors and there was no evidence a change in processes was consider in order to prevent reoccurrence of the incident. Moreover, none of the follow up identified Patient #2 was secluded for six hours after he met release criteria due to the inability of the staffing matrix and staffing make-up to manage his acuity. There was no reference to staff needed education for not following the seclusion policy. Additionally, there was no discussion of how staff should escalate their needs to get additional staff assistance, or why the CNO, who was notified of the situation, did not respond for additional support.

ii. Interviews confirmed the lack of investigation, process review and corrective actions following Patient #2's extended seclusion.

On 6/26/20 at 12:50 p.m., Director #14 was interviewed. She stated both CNO #19 and Provider #17 gave staff permission to hold Patient #2 in seclusion for staffing needs, so there was no further investigation into the cause of the long seclusion. Director #14 stated a discussion of restraint and seclusion expectations for staff was on the June restraint and seclusion committee agenda but this discussion had yet to take place and she did not indicate it would relate to what steps the facility might take to address staffing in order to prevent a repeat incident.

iii. On 6/26/20 at 12:50 p.m., CEO #15 was interviewed at the same time as Director #14. CEO #15 stated she was the administrator on call the night Patient #2 was held in seclusion due to staffing issues. She stated the RN called her and said they were having issues. CEO #15 stated she did not know the house supervisor was also the unit RN for the shift. CEO #15 agreed it was not legal and did not align with regulatory standards to keep a patient in seclusion. She stated she reviewed the incident report and said what was written was not what she was told by staff.

CEO #15 stated the facility needed to do immediate training as it was never acceptable to keep a patient in seclusion unless they were trying to harm themselves or others.

b. Patient #5 was placed in seclusion on two separate occasions, 6/6/20 and the next day 6/7/20. On 6/6/20, Patient #5 remained in seclusion for eight hours. On 6/7/20, she remained in seclusion for over five hours. Review of supporting documentation and interviews revealed a lack of monitoring by staff, inconsistent documentation by staff and a lack of behaviors demonstrated by the patient to remain in seclusion. None of these issues had been identified or reviewed by the facility quality program to resolve the problem of lengthy seclusion when criteria have been met for release.

i. Patient #5 was in seclusion on 6/6/20 from 12:32 p.m. to 8:38 p.m. The Restraint/Seclusion RN Assessment form (RN assessment) was reviewed for the hours of 12:30 p.m. to 8:30 p.m. on 6/6/20. Review of Patient #5's seclusion documentation revealed RN #11 documented, from 1:30 p.m. to 6:30 p.m., the reason for Patient #5's seclusion was the patient continued to attempt to push through staff to gain access to another patient's room. However, the mental health technician (MHT) documented Patient #5's behaviors as lying, sitting, standing, pacing and walking and from 12:40 p.m. to 8:20 p.m., and documented only two episodes of agitation, lasting less than five minutes. Patient #5 was not released from seclusion when she met criteria for release and left seclusion for transport to the emergency department when her physical condition raised concerns.


ii. Patient #5 was placed in seclusion a second time on the following day, 6/7/20 from 10:39 a.m. until 4:35 p.m. Patient #5 was in seclusion for 356 minutes due to attempting to sit on the floor because she thought another patient was her son. Again, however, the MHT documented from 10:40 a.m. to 3:55 p.m., Patient #5's behaviors were lying, sitting, awake or standing.


iii. Review of the incident report follow up revealed a lack of investigation into the causes for the seclusion incidents involving Patient #5 as well as identification of appropriate corrective actions.

The supervisor review section of the incident report completed on 6/6/20 at 6:54 p.m., by Supervisor #4 read no injury to staff. No injury to patient. Patient was attempting to enter a psychotic patient's room and was pushing staff to get in. There was no evidence the incident was evaluated or recommendations to correct the incident noted.

Under the section "to be completed by Director of Nursing", completed by CNO #19 on 6/8/20 at 1:00 p.m., read, meeting scheduled to investigate. However, there were no notes that the meeting took place, no findings regarding factors that contributed to the incident, no follow up with staff or processes and action items to prevent the extended seclusion from reoccurring.

Under the section "to be completed by Risk Manager," completed by Director #14 on 6/9/20 at 3:48 p.m., Director #14 wrote, Discussed with CNO and in patient safety committee. CNO to meet with staff to discuss patient and incidents from weekend. No injury to patient or staff, meeting scheduled 6/9/20. Patient discharged to acute hospital to address medical issues while on the psychiatric unit.

There was no documentation of an investigation or action items to prevent recurrence. There were similar findings for the review and follow up for Patient #5's 6/7/20 extended seclusion incident for which she did not meet criteria for continued seclusion.

An interview with Director #14 revealed that, even though she had concerns about the lengthy seclusion times, CNO #19 had completed the bulk of the review and had not indicated a concern with either the inconsistent documentation of Patient #5's behavior, assessment gaps and need for staff education.

iv. Interviews with staff, following their review of Patient #5's record, revealed they were unable to determine the reason Patient #5 remained in seclusion.

On 6/26/20 at 12:50 p.m., Director #14 was interviewed. She stated Patient #5's seclusion incidents were reviewed by her and CNO #19 but CNO #19 did the bulk of the documentation review. She stated she spoke with CNO #19 because she had concerns with the length of seclusion episodes and asked if the patient could have been transferred to another unit instead of secluded. Director #14 stated CNO #19 did not indicate a concern of documentation, assessment gaps and identify any need for staff education even though documentation indicated Patient #5 met release criteria on 6/6 and 6/7/20.

Director #14 stated CNO #19 performed all video reviews of seclusion events, but was unable to recall or provide evidence to show Patient #5's seclusion incidents were reviewed.

Director #14 stated she did have a discussion with CNO #19 of the need to review documentation with videos of staff performing actions, but stated it had not been completed. Director #14 stated she did track incidents even though CNO #19 did the review and stated the facility had identified in May an increase in restraint and seclusion so they responded with a committee; however, it was difficult to get staff to attend. She did not state whether the committee had met and if so, what had been discussed to correct the identified concern.

2. Contraband

a. Review of another facility incident report revealed a patient harmed herself with a pen. Review of supporting documentation revealed a lack of intervention by staff. An Apparent Cause Analysis (ACA) was performed, yet contributing factors were not identified. Therefore, the plan did not include actions and follow up to prevent a reoccurrence.

i. An Incident Report dated 4/27/20 at 12:00 p.m., read the patient placed a piece of plastic from a pen into an existing wound in her arm. She was sent to an acute care facility to have the piece removed. The report further read the patient had a pen cap she had obtained from another patient, which was identified as contraband for her.

ii. The ACA was reviewed and identified the patient was admitted on 4/23/20 for self-injurious behavior of placing a pen into her arm. There were no orders for the level of observation until 4/29/20 when the patient was ordered every five minute checks. And, observation sheets revealed the patient was placed on a 1:1 status all or part of the day on 4/24, 4/25, 4/26 and 4/27 due to restraint/seclusion episodes, need for emergency medication and her behavior, which was documented as aggressive towards others and herself.

On 4/26/20, assistance was called due to the patient taking another patient's belongings and scattering items throughout the day room. The patient then offered to clean the day room up which was observed by staff. Staff did not observe the patient pocket any items. The MHTs believed this might be when she obtained the pen even though she was monitored closely as she picked up the mess.
On 4/26, overnight into 4/27/20, the MHTs noticed the patient touched her breast pocket many times and they suspected she had a pen. MHT #5 requested to search, but the patient refused, so they continued to monitor. When the patient got up in the middle of the night, MHTs searched her bed and found a pen at the bottom of the bed and it was removed. No other contraband was found. A room search had been completed at the beginning of the shift.
On 4/27/20, the MHT reported the patient was sleeping under covers and when the patient woke up for the morning, the MHTs found blood on her sheets and identified she had put the pen cap in her wound. When the patient was asked if she had anything else, she reported yes, and gave another pen cap and a crayon from the pocket of her scrubs.
The facility identified what could have been performed differently was to have asked for assistance in searching the patient when she was suspected of having a pen. They identified if she had one piece of contraband, she may have had others due to her safety risk. MHT #5 reported they did not force a search because they did not want to upset the patient again and have it lead to another restraint/seclusion episode in the middle of the night. Each MHT involved emphasized the patient was a self-harmer and needed to be closely monitored and each was aware she was admitted for harm to self, due to stabbing her arms with pencils, cutting, scratching, etc. Post incident action was the room was stripped to allow only a pillow without a pillow case and a safety blanket.
The corrective action was to remove caps from all patient flexible pens to reduce the opportunity for the incident to occur again. It was to be completed by 5/1/20 and owned by the MHTs.

iii. There was no investigation that addressed the lack of an observation order from 4/23/20 to 4/29/20 or the reason staff did not perform a search on the patient on the night shift, even though they had a high suspicion of contraband. In addition, there was no investigation that addressed why the staff did not have the patient change her clothes when contraband was suspected in her clothes or how the patient had contraband even though staff documented a room search was performed.

Furthermore, while the action plan was to remove the pen caps and was owned by the MHTs, there was no evidence of any leadership oversight to ensure the correction had been made, or if removing the pen caps was an effective management of pens as contraband.

Observations on 6/23/20, revealed contraband in a resident's on the 600 unit which staff suspected was present; yet, staff did not perform room checks upon video review as they documented (cross-reference A0144).

The 6/23/20 incident may have been prevented had staff been educated and audited on their room search performance after the 4/27/20 incident. Further, observations throughout the facility on 6/23/20 and 6/24/20 (almost 2 months after the 4/27/20 incident) revealed staff did not understand the process to ensure patients received care in a safe setting by identifying contraband and effectively removing it. The action plan did not include an assessment of contraband in the facility and staff education.