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Based on record review and interview, the facility failed to ensure that all long term goals and short term goals/objectives specified in the Master Treatment Plans (MTPs) of 8 of 8 active sample patients (A10, A17, B22, C20, F19, G1, H9 and I20) were stated as measurable patient outcome behaviors. In addition, some of the goals for sample patients' F19 and G1 were stated as staff goals for patient participation in treatment modalities (instead of expected behavioral outcomes for the patients), and some of the goals for patients G1 and I20 were written as staff interventions. These failures can hamper staffs' ability to provide goal-directed care and measure patients' responses to treatment, potentially resulting in prolonged hospitalizations.

Findings include:

A. Record Review

1. Patient A10 (MTP update = 9/16/10). For Problem #1 "Legal [Issues]", the long-term goal was, "[Patient] will be returned to court as competent to stand trial..." For Problem 32 "Discharge [needs]," the long-term goal was "[Patient] will be discharged from SBH into the community meeting the requirements for the restraining order." As stated, these goals were not behavioral outcomes for the patient to achieve.

2. Patient A17 (MTP update = 9/2/10). For Problem #2 "Educational Needs," the long-term goal was "[Patient] will improve his basic reading, math, and science skills as well as learning basic computer skills." This goal is not measurable as stated. For problem #3 "Discharge Planning," the long-term goal was [Patient] will be released to the community with an appropriate living situation and proper community supports in place." As stated, this goal is not a measurable behavior for the patient to achieve.

3. Patient B22 (MTP update = 9/7/10). For Problem #1 "[Need for] Discharge Planning," the long-term goal was "[Patient] will be released to the court or back to the community with needs identified and resources in place to support his recovery in the community." For Problem #2 "RTC [Return to Competency status], the long-term goal was "[Patient] will be returned to court with the opinion of competent to stand trial and be able to move forward with his court proceedings." As stated, these goals are not measurable behavioral outcomes to be achieved by the patient. For Problem #5 "Dental [problems]," the long-term goal was "[Patient's] dental problems will be resolved or referred for ongoing management." This goal also is not a measurable patient behavior.

4. Patient C20 (MTP date = 9/14/10). For Problem #2 "Thought Disorder," the long-term goal was "[Patient's] symptoms of paranoia, disorganized thoughts (including severe agitation/acting out) will decrease such that he can function in a less restrictive environment." As stated, this goal is not measurable.

5. Patient F19 (MTP date = 9/12/10). For Problem #1 "Schizoaffective Disorder," the long-term goal was "[Patient] will experience a decrease in paranoia, suspiciousness and depression..." This goal was not measurable as stated. For Problem #2 "[Patient] needs...to develop a discharge plan," the long-term goal was "[Patient] will identify needs and resources needed to support his recovery in the community." This was not measurable. The short-term goal for Problem #2 was "[Patient] will actively participate in groups, treatment team meetings and discussions with his social worker, psychiatrist and case manager to identify his needs and appropriate resources..." This goal was a staff goal for patient participation in treatment, not a measurable patient health status outcome behavior.

6. Patient G1 (MTP update =9/7/10). For Problem #1 "Psychotic Disorder...paranoid type...," the long-term goal was "[Patient] will no longer exhibit paranoid ideation and avoidant, withdrawn behavior..." The short-term goal (objective) was "[Patient] will...interact with peers and staff without interference from psychotic symptoms and reduce the amount of time that he spends withdrawn, avoidant and isolated from others." These goals/objectives were not measurable as stated. For Problem #2 "[Patient] has been diagnosed with and has a history of hypertension," the long-term goal was "[Patient] will comply with treatment to maintain his blood pressure within normal limits." The short-term goal (objective was "[Patient] will comply with medical treatment including remaining on proper medications for his hypertension." These goals/objectives were not measurable as stated. They also were staff goals for patient participation in treatment, not patient outcomes that could be used to determine the effectiveness of treatment. For Problem #4 "[Patient] requires reconnection with Case Management...understanding of the importance of compliance...maintaining compliance with court-related treatment expectations," the long-term goal was "[Patient] will be assisted by [name] LSW and Centerpoint Case Manager...in identifying housing and treatment services..." This was a staff intervention, not a patient goal. For Problem #5 "...dental problems...," the long-term goal was "[Patient] will comply with customary treatment to manage decaying teeth." This goal was not measurable as stated.

7. Patient H9. (MTP update = 8/16/10). For Problem #1 "Discharge Issuses [sic]," the long-term goal was "[Patient] will have appropriate structured housing placement...in place in order to support successful community re-entry." For Problem #3 "Medical Issue[s]," the long-term goal was "Progression of cells [sic] will be identified early enough to achieve optimal treatment outcome." As stated, these goals were not measurable behaviors for the patient to achieve.

8. Patient I20 (MTP update = 8/17/10). For Problem #1 "Discharge Plan," the short-term goal was "[Staff Name] LSW will meet with case manager, guardian, help [patient] to identify housing options and aftercare programs to support his recovery in the community." This was a staff intervention, not a measurable patient behavior. For Problem #2 "[Patient] is unaware of the interaction between alcohol/drugs of abuse with his thought disorder and/or mood disorder...," the long-term goal was "[Staff Name] LICDC will establish a working alliance and engage with [patient]..." The short-term goal was "[Staff Name] LICDC will engage [patient] in conversation relative to his current and past...substance use." These were staff interventions, not patient goals/objectives. For Problem #3 "[Patient] has a perceptual disorder with symptoms including paranoid and grandiose ideations...," the short-term goal (objective) was "[Patient] will be able to speak in reality based statements, and not behave in an intrusive manner." This goal/objective was not measurable as stated. For Problem #4 "GERD (Gastric Esophogeal Reflux Disease)," the goal was "[Patient] will have improvement or resolution of symptoms..." This goal was not measurable as stated. For Problem # 5 "Symptoms of stiffness and/or movement problems from medications" and Problem #6 "History of hyperlipidemia (high cholesterol levels)," the short-term goals (objectives) were written as staff interventions instead of behaviors for the patient to achieve. These were [Problem #5]: "[Patient] has been referred for specialized examination and testing relevant to the endocrine condition" and [Problem #6]: "[Patient] will receive medical treatment to manage hyperlipidemia."

B. Staff Interviews

1. In an interview on 9/14/10 at approximately 11:15AM, after reviewing some sample patients' treatment plans, the Director of Nursing (DON) acknowledged that some of the patient goals and objectives on the MTPs were not measurable. She also agreed that some of the goals were written as staff goals for patients or staff interventions. She commented "Staff have all received the training (on treatment plan documentations), but it is a learning curve to get everything right."

2. In an interview on 9/14/10 at approximately 2:30 PM, MD X, the attending psychiatrist for Patient G1 acknowledged that the MTP goals for Patient G1 were not all written as measurable patient behaviors.

Based on record review and interview, the facility failed to ensure that policies and procedures related to Seclusion or Restraint (S/R) of patients were followed. A review of all S/R episodes from 6/15/10 to 9/12/10 showed that there were 40 different patients listed for a total of 165 episodes. Two patients non-sample patients SR1 and SR 2) that had a total of 75 episodes, accounting for nearly 50% of the total episodes were chosen for in-depth reviews of the episodes. Document review and interviews revealed that the facility failed to:

(A) ensure that physician orders included the time of the initial order for seclusion and/or restraint (S/R) on 5 occasions for the 2 non-sample patients; (B) ensure that 1 of the 2 non-sample patients reviewed (SR2) was released by clinical staff from seclusion at the earliest possible time on three occasions; (C) ensure that nursing staff documented the "Readiness for Release Criteria" on the S/R forms for the 2 non-sample patients on 7 occasions; (D) ensure that physicians completed one hour face-to-face evaluations for the 2 non-sample patients on 4 separate occasions; and (E) ensure that medical and nursing staff completed all sections on Seclusion or Restraint Records (including signatures) for the 2 non-sample patients on two occasions. These failures result in restrictions of patient's rights without adequate documented justification and place patients at risk for future restriction of the right to be free of restraint.

Findings include:

A. Record Review

1. Patient SR1

a. Patient SR1 was placed in seclusion on 6/16/10 at 7:30PM. The Seclusion or Restraint Order form did not include documentation of the type of order (written or telephone) and did not have an RN signature. In addition, the physician's initial order was neither dated nor timed.

b. Patient SR1 was placed in seclusion and 4-point restraint on 6/24/10 at 8:35PM. The Seclusion or Restraint Order form did not include documentation of the time of the verbal order by the physician.

c. Patient SR1 was placed in seclusion and 4-point restraint on 7/8/10 at 3:53PM. The RN failed to document "Readiness for Release Criteria" on the Seclusion or Restraint Record form. However, on the same page of the form, the RN noted that the patient was assessed for release criteria every 15 minutes from 4:15PM to 5:45PM.

d. Patient SR1 was placed in seclusion on 7/12/10 at 7:30PM. The Seclusion or Restraint Order form did not document the time of the verbal order by the physician.

e. Patient SR1 was placed in seclusion on 7/17/10 at 5:10PM. The Seclusion or Restraint Record failed to document "Readiness for Release Criteria" and did not document any nursing assessment for release from 5:10PM to 5:45PM. (The actual time of release was not noted on the form.)

f. Patient SR1 was placed in 4-point restraint on 8/11/10 at 1:12PM. The Seclusion or Restraint Record failed to document "Readiness for Release Criteria." In the section "Readiness for Release Reviewed" the nurse had the notation "N/A" at 15 intervals between 1:13PM and 3:00 PM. (The actual release time was not noted on the form.) On 9/15/10 at 10:15AM. RN3 stated that the "N/A" meant "not assessed."

g. Patient SR1 was placed in 4-point restraint on 8/12/10 at 9:56AM. The Seclusion or Restraint Record [S/R Record] failed to document "Readiness for Release Criteria." Nursing documentations on the same page of the S/R Record stated that the patient was assessed for "Readiness for Release" every 15 minutes between 10:10AM and 10:55AM. There were no notations for the release criteria assessments from 11:10AM to 11:40AM. The Seclusion or Restraint Order form indicated that the patient initially had an "up to one hour" order that was renewed at 10:56AM for an additional two hours. In both instances, the physician failed to complete the one hour face-to-face evaluation in a timely manner; the form as signed (by the physician) at 3:26PM (8/12/10) for the 9:56AM incident and at 3:15PM (8/12/10) for the 10:56AM update order.

h. Patient SR1 was placed in 4-point restraint on 8/13/10 at 5:10AM. The Seclusion or Restraint Record failed to document "Readiness for Release Criteria." Nursing staff documentations on the same page of the S/R Record noted that "Readiness for Release Reviewed" was performed at 5:25AM. (The time at which the patient was released was not noted, so that it was not possible to ascertain if release criteria assessments were required after the 5:25 entry or not.)

i. Patient SR1 was placed in 4-point restraint on 8/17/10 at 8:39AM (noted on the Seclusion or Restraint Order form). The physician failed to sign the initial order.

j. Patient SR1 had another Seclusion or Restraint Record form dated 8/30/10 at 9:25PM. Nursing failed to complete any other part of the form including "Readiness for Release Criteria," "Vital Signs"; "Hygiene measures": "nursing assessments"; and "circulation checks." The second page of the form had two handwritten "R"'s written in by the "circulation check" boxes indicating "Patient Refused." There was no information about the time or date of the evaluation on the form. There was a nurse's signature on the bottom of the second page, again undated and untimed.

2. Patient SR2

a. Patient SR2 was placed in 4-point restraint on 7/12/10 at 5:45PM. The Seclusion or Restraint Record included no "Readiness for Release Criteria." However, the "Readiness for Release Reviewed" section of the form was completed at 15 minute intervals between 5:45PM and 7:20PM. (The time of release was not noted on the form.)

b. Patient SR2 was placed in 4-point restraint on 7/18/10 at 8:35PM. The Seclusion or Restraint Record did not include the "Readiness for Release Criteria." However, the record documented that the "Readiness for Release Reviewed" had occurred at 9:00PM.

c. Patient SR2 was placed in 4-point restraint on 7/18/10 at 9:35PM. The Seclusion or Restraint Order form did not have a physician signature for the initial order and did not contain any evidence that a 1 hour face-to-face evaluation had been performed by a physician. (The entire area of the form for the physician was left blank)

d. Patient SR2 was placed in 4-point restraint on 7/19/10 at 5:20PM. The physician's order form documented that the release criteria was "patient is calm." Review of the "Seclusion or Restraint Observation Note" form revealed the following notations:

7/19/10 at 5:35 PM.: "Pt resting quietly in seclusion room with eyes closed."
7/19/10 at 5:50 PM.: "Pt continues to rest quietly with eyes closed."
7/19/10 at 6:05 PM.: "Pt lying down in seclusion room talking with writer about his family."
7/19/10 at 6:20 PM.: "Pt lying in seclusion room talking with writer about being in his 50's."
7/19/10 at 6:35 PM.: "Pt came out of hand restraints at this time and had to be readjusted [sic] and put back in. Pt resting quietly."
7/19/10 at 6:50 PM.: "Pt lying quietly with eyes closed."
7/19/10 at 7:05 PM.: "Pt out of restraints, still in seclusion room, using restroom."
7/19/10 at 7:13 PM.: "Pt out of seclusion room"

e. Patient SR2 was placed in 4-point restraint on 7/31/10 at 8:10PM. The physician's order stated that that release criteria was "Patient is calm." A review of the "Seclusion or Restraint Observation Note" form revealed the following notations:

7/31/10 at 8:40 PM.: "Pt being seen by doctor at this time. Pt demanding to be released. Dr. explained that his behavior will determine when he will come out of the restraints."
7/31/10 at 8:55 PM.: "Pt asked for water. Pt given water and now resting quietly."
7/31/10 at 9:25 PM.: "Pt resting quietly at this time. Pt appears to be asleep."
7/31/10 at 9:40 PM.: "Pt sleeping at this time. Charge nurse assessed pt, however he would not contract for safety."
7/31/10 at 9:55 PM.: "Pt continues to sleep."
7/31/10 at 10:20 PM.: "Pt resting quietly."
7/31/10 at 10:45 PM.: "Pt removed from restraints by writer and charge nurse at this time."

f. Patient SR2 was placed in 4-point restraint on 8/11/10 at 8:10PM. The physician's order form included the release criteria "Patient is calm." Review of the Seclusion or Restraint Observation Note form revealed the following notations:

8/11/10 at 8:25 PM.: "Resting quietly c (with) ou (both eyes) closed."
8/11/10 at 8:40 PM.: "Resting quietly c ou closed."
8/11/10 at 8:55 PM.: "Resting quietly c ou open."
8/11/10 at 9:10 PM.: "Client is resting quietly."
8/11/10 at 9:25 PM.: "Client is resting quietly."
8/11/10 at 9:40 PM.: "Client is resting quietly."
8/11/10 at 9:45 PM.: "Client is resting quietly."
8/11/10 at 10:45 PM.: "Client remains quiet in restraints."
Seclusion and restraint were discontinued at 11:00PM. on 8/11/10.

g. Patient SR2 was placed in 4-point restraint on 8/12/10 at 12:16PM. The physician's order was written for "up to 1 hour." The physician completed the one hour face-to-face evaluation at 1:25PM. (9 minutes after the original order expired).

B. Policy Review

Facility BHO Policy: CLIN-104B "Emergency Intervention Related to Patient Care (Restraint and/or Seclusion) effective date: 6/6/08" states the following:

Section IV: Philosophy: "If restraint or seclusion must be used to maintain the safety of the patient and/or others, then the use of restraint or seclusion is discontinued as soon as the patient has regained control of him/herself and the emergency situation has passed."

Section VII: Procedures: 2(a) "The physician must order seclusion and restraint separately. Each order shall be documented on the Physician's Seclusion or Restraint Order form."
"Before co-signing the telephone order, the physician shall personally examine the patient."

2(e)iv: "The physician shall conduct a face-to-face evaluation of the patient and document the findings in the patient's chart on the Physician's Seclusion or Restraint Progress Note [on S/R form] within one hour of the initiation of the intervention."
3(e): "The RN will assess readiness for release from restraint or seclusion every 15 minutes based on information provided by the trained staff member monitoring the patient 1:1, by personal observation, or both and will assess the potential for decreasing points of restraint to the least number of points possible and document on the Seclusion and Restraint Record."
3(g): "Restraint or seclusion is discontinued as soon as the patient meets his/her behavioral criteria for discontinuation."

C. Staff Interviews

1. In an interview on 9/14/10 at 11:15AM, the Clinical Director and Assistant Clinical Director were shown the records for SR1 and SR2. After reviewing the Seclusion/Restraint documentations, they acknowledged the surveyor's findings noted above. The Clinical Director stated, "We need to do a better job of documenting."

2. In an interview on 9/14/10 at 1:15PM, the Director of Nursing and the Assistant CEO were shown the records noted above. They both acknowledged the surveyor's findings. The DON said, "The Peer Review Nurse should have caught these."

D. Patient Interviews

1. In an interview on 9/14/10 at 2:45PM, Patient SR1 stated "The nurses don't talk to me when I'm in seclusion; they (nurses) just let me out whenever."

2. In an interview on 9/15/10 at 10:30AM, Patient SR2 stated "I fall asleep all the time in restraint because of the shots (medications)."

Based on record review, policy review and interview, it was determined that the Clinical Director failed to adequately monitor and assure the quality of medical practice. Specifically, the Clinical Director failed to:

I. Assure that medical staff had sufficient monitoring for the appropriate use of seclusion and/or restraint. The medical staff failed to document initial S/R orders for 2 of 2 non-sample patients (SR1 and SR2), and failed to complete one hour face-to-face evaluations in a timely manner for 2 of 2 non-sample patients (SR1 and SR2). Failure to closely supervise physicians can lead to inappropriate use of seclusion and restraint. (Refer to B125)

II. Assure timely completion of administrative reviews of Seclusion/Restraint events for Patients SR1 and SR2 who had multiple and frequent S/R incidents during July/August, 2010. Failure to complete and document administrative reviews can result in deficient practices not being detected and corrected, potentially leading to unsafe situations for patients.

Findings include:

A. Policy Review

Facility BHO Policy: CLIN-104B "Emergency Intervention Related to Patient Care (Restraint and/or Seclusion) effective date: 6/6/08" states the following under "VII. Procedures, Section 4. Monitoring and Quality Improvement Requirements, (c):"

"SBH CCO (Summit Behavioral Health Chief Clinical Officer) or designee and the Director of Nursing or designee shall review daily all uses of seclusion or restraint. Special attention is given to the following situations: i. Patients in over 8 hours in one episode of restraint or seclusion, ii. Number of episodes per patient, iii.2 episodes of restraint or seclusion by 1 patient within 8 hours, iv. 3 episodes of restraint or seclusion by 1 patient within any rolling 30 day period, and v. Use of psychoactive medications as an alternative for or to enable discontinuation of restraint or seclusion [sic]."

B. Record Review

1. The facility's Restraint and Seclusion Logs from June 15, 2010 to September 12, 2010 documented the following S/R events:

a. Patient SR1: Between 7/5/10 and 8/4/10, Patient SR1 had 26 episodes of seclusion and/or restraint. Several of the days included multiple episodes including: 7/5/10, 7/8/10, 7/9/10, 7/10/10, 7/11/10, 7/12/10, 7/18/10, 7/20/10 and 7/25/10.

b. Patient SR2: Between 7/15/10 and 8/12/10, Patient SR2 had 19 episodes of seclusion and/or restraint. Several of the days included multiple episodes including: 7/15/10, 7/16/10, 7/18/10, 7/31/10, 8/11/10 and 8/12/10.

2. The facility did not produce any documentation that administrative review had occurred for the episodes of seclusion and/or restraint for either patient (SR1 and SR2).

C. Interview

In an interview on 9/14/10 at 11:15AM. with the Clinical Director (CCO) and the Assistant Clinical Director, the information noted above was discussed. Both Directors acknowledged the surveyor's findings. The Clinical Director stated "We talk about it (seclusion and restraint) in our morning meeting but we don't formally write anything about the incidents."

III. Ensure that review of seclusion and restraint is appropriately monitored. The current review process does not clearly lead to remedial actions where deficient practices are found, nor does it show that the Chief Clinical Officer (Medical Director) is involved in the administrative review process. This procedure may lead to medical staff continuing deficient medical practices without adequate administrative review and direction.

Findings Include:

A. Record Review

1. Patient SR1 was placed in 4-point restraint on 8/12/10 at 9:56AM. The Seclusion or Restraint Record [S/R Record] failed to document "Readiness for Release Criteria" which the physician involved in the S&R assessment and orders was to specify. The Seclusion or Restraint Order form indicated that the patient initially had an "up to one hour" order that was renewed at 10:56AM for an additional two hours. In both instances, the physician failed to complete the one hour face-to-face evaluation in a timely manner; the form as signed (by the physician) at 3:26PM (8/12/10) for the 9:56AM incident and at 3:15PM (8/12/10) for the 10:56AM update order.

2. Patient SR1 was placed in 4-point restraint on 8/17/10 at 8:39AM (noted on the Seclusion or Restraint Order form). The physician failed to sign the initial order.

3. Patient SR2 was placed in 4-point restraint on 7/18/10 at 9:35PM. The Seclusion or Restraint Order form did not have a physician signature for the initial order and did not contain any evidence that a 1 hour face-to-face evaluation had been performed by a physician. (The entire area of the form for the physician was left blank)

4. Patient SR2 was placed in 4-point restraint on 8/12/10 at 12:16PM. The physician's order was written for "up to 1 hour." The physician completed the one hour face-to-face evaluation at 1:25 PM. (9 minutes after the original order expired).

B. Policy Review

Facility BHO Policy: CLIN-104B "Emergency Intervention Related to Patient Care (Restraint and/or Seclusion) effective date: 6/6/08" includes the following statement under "VII. Procedures, Section 4. Monitoring and Quality Improvement Requirements, (c):"

"SBH CCO (Summit Behavioral Health Chief Clinical Officer) or designee and the Director of Nursing or designee shall review daily all uses of seclusion or restraint. Special attention is given to the following situations: i.Patients in over 8 hours in one episode of restraint or seclusion, ii. Number of episodes per patient, iii. 2 episodes of restraint or seclusion by 1 patient within 8 hours, iv. 3 episodes of restraint or seclusion by 1 patient within any rolling 30 day period, and v. Use of psychoactive medications as an alternative for or to enable discontinuation of restraint or seclusion.[sic]"

C. Staff Interviews

1. In an interview on 9/14/10 at approximately 3:00PM, the DON and the surveyor reviewed the missing and inconsistent documentations on the S/R Record for Patient SR2 with the Director of Quality Improvement. In response to the enquiry about the inconsistent times documented on the S/R Record, the Director of Quality Improvement stated that these might occur because "the physician might order S/R for a patient, but the S/R might not be implemented until later because the physician might try to "calm the patient" or "talk the patient down" after the initial order is written. The Director of Quality Improvement also stated that the physician might write an order on the MD order sheet, but it might not "show up" on the other notes (referring to the S/R Record). She also stated that a physician writing an S/R order might see a patient within an hour after initiation of the S/R event but might not document it until a later time.

2. In the same interview as above, the Director of Quality Improvement stated "I do QA of the physician's part of the S&R, not the nursing part." When asked what she does when she finds missing pieces or inconsistencies on a patient's S/R Record, the Director of Quality Improvement stated that she goes to the staff member responsible for completing the S/R forms and lets them know about the problem. When asked if she documents these communications or does any follow-up to see if corrections are made, she said "No, I don't."

IV. Ensure that only clinical staff carry out clinical practice activities. Facility records and interviews documented the use of a police officer to "assist" with the administration of court-ordered medication for non-sample patient SR3. The facility had no policy and procedure that clearly specified the role of police officers when called by clinical staff to ensure safety on the treatment units. These failures potentially place patients at risk of intimidation by police officers, and may violate patient rights to treatment in a safe, non-threatening environment.

Findings include:

A. Record review

1. In a review of all Incident Reports for July and August 2010, an incident report dated 7/15/10 noted that "campus police came to the unit to talk to [Patient SR3] about unit rules."

2. A 72 hour RN Note dated 7/15/10 at 6:10AM stated "pt [referring to Patient SR3] was awake at start of shift. Pt needed redirection. Told the writer 'I want you to have my baby.' Also told male tpw (therapeutic psychiatric worker), 'Do you need boxing gloves?' when staff asked him to go to his room at 11:30PM. Campus Police came to the unit and talked to pt about unit rules. Pt did respond and sat up in his room." [sic]

3. A Nursing Supervisor Shift Report dated for 7/14/10 (3rd shift starting at 11:00 PM) noted the following: "[Patient SR3] delusional, making inappropriate remarks to female staff about having babies and asked male staff 'Do you need boxing gloves?' when directed to his room at 11:35PM. Campus Police were called to unit and spoke with patient and he went to his room."

4. A Psychiatric Progress Note for Patient SR3 dated 7/23/10 at 2:00PM noted "It was explained to the patient that due to his agitation he was felt in need of additional medication, pt refused. Campus Police came to unit to assist. Pt was given Haldol 10 mg. IM (intramuscular), Ativan 2 mg. IM and Benadryl 50 mg. IM in his room."

5. The facility's Daily Patrol Log for Campus Police, dated 7/23/10, noted the following:
"12:30PM: Officer 206 Employee Assist. On Unit A with [Patient SR3]. Patient was given 3 IM medications by RN."
"12:30PM: Officer 205 Called to Unit A with staff for [Patient SR3] who was acting out."
"12:40PM: Officer 102 Responded to Unit A to stand-by while staff gave meds to [Patient SR3]."
"12:54PM: Officer 205 Clear Unit A."

6. A Nursing Progress Note for Patient SR3 dated 8/10/10 at 9:00AM noted "Campus Police called to assist with medication administration."

7. The facility's Daily Patrol Log for Campus Police, dated 8/10/10, noted the following:
"8:00AM: Officer 104 Respond to Unit A for assistance."
"8:00AM: Officer 103 Med assist on Unit A, [Patient SR3] was given 2 IM's."
"8:01AM: Officer 102 Responded to Unit A, Standing by while staff gave meds to [Patient SR3]."
"8:20AM: Officer 103 Clear from Unit A."
"8:20AM: Officer 104 Clear Unit A."

B. Policy Review

1. Facility BHO Policy: CLIN-134, "Emergency Medication" effective 10/12/08 and BHO Policy: CLIN-135, "Procedures Governing Capacity Assessment and Court Authorized Medication of Inpatients." Effective 12/09/07 were reviewed

Neither policy/procedure protocols included any provision for the use of non-clinical staff, nor did they mention any approved use of police officers for assisting with medication delivery.

2. Facility BHO Policy: CLIN-104B "Emergency Intervention Related to Patient Care (Restraint and/or Seclusion) effective date: 6/6/08" has the following statement under "VI. Subject Content: Clinical Purposes for Seclusion and Restraint, Section 5(b):"

"SBH Police Officers shall implement restraint and assist in the use of restraint or seclusion when a patient's behavior is beyond the control of nursing or other direct care personnel only if they have successfully completed training programs on minimizing the use of restraint or seclusion and maximizing safety when using seclusion and/or restraint."

C. Interviews

1. In an interview on 9/15/10 at 9:45AM with the Assistant Clinical Director, the information noted above was discussed. The Assistant Clinical Director agreed with the findings. He also acknowledged the situations noted above regarding Patient SR3 and that these events did not meet the criteria noted in Policy CLIN-104B, VI.5 (b).

2. On 9/15/10 at 10:10AM, the Chief of Police was interviewed regarding the role of police officers in the facility and his department's administrative reporting structure. The Chief of Police stated that the role of police officers at the facility is "like any police department...to keep everyone safe." He clarified that the officers wear police uniforms with badges on the units but that they do not carry weapons. When asked if his officers take direction from the nursing staff, he stated that, "We do, because they do the clinical work, we just assist." He added "I tell them (police officers under his supervision) 'We are not clinicians and don't tell patients what they are to do...only touch a patient if the supervising RN requests it.' The Chief of Police added, "We do help apply restraints. All police officers receive the S/R training like all staff every year."

When shown documentations in Patient SR3's medical record progress notes (dates 7/15/10; 7/23/10; 8/10/10) that a police officer "helped with medication administration," the Chief of Police stated that the documentations were incorrect. He said "That is not written right; we don't give medicines...that's the nurse's job." He added "We usually stand-by with the nursing staff when giving court ordered medications."

When asked if he were aware of any policy that clarified the difference between "clinical" and "law enforcement" roles or that gives guidelines for how staff should document what a police officer does to "assist" the nursing staff, the Chief of Police stated that he was not aware of any such policy.

The Chief of Police explained that he reports directly to the CEO of SBH, and that he and the 12 other police officers at the facility are paid as state employees (Ohio Department of Mental Health). After the interview, the CEO confirmed that the Chief of Police only reports to her.

3. In an interview on 9/15/10 at 10:20AM with Nurse B on Unit A, the surveyor asked about the progress note for patient SR-3 dated 8/10/10. Nurse B stated "We call Campus Police to assist with forced medications as part of policy."

4. In an interview on 9/15/10 at 10:25AM with MD B on Unit A, the surveyor asked about the progress note for patient SR3 dated 7/23/10. MD B stated "Campus Police is used all the time for forced meds."

5. In an interview on 9/15/10 at 10:35AM, Patient SR3 stated "I don't like medications; the police make sure I get them (Medications)."

V. Ensure that all long term goals and short term goals/objectives specified in the Master Treatment Plans (MTPs) of 8 of 8 active sample patients (A10, A17, B22, C20, F-19, G-1, H9 and I-20) were stated as measurable patient outcome behaviors. In addition, some of the goals for sample patients' F-19 and G-1 were stated as staff goals for patient participation in treatment modalities (instead of expected behavioral outcomes for the patients), and some of the goals for patients G-1 and I-20 were written as staff interventions. These failures hamper staffs' ability to provide goal-directed care and measure patients' responses to treatment, and potentially result in prolonged hospitalizations. (Refer to B121)

Based on record review; policy review and interview, it was determined that the Director of Nursing failed to monitor and ensure the proper use and documentation of Seclusion/Restraint procedures by nurses, and assure that timely administrative reviews of S/R events were completed and documented. The DON also failed to ensure that only clinical staff carried out nursing practice activities; documentations showed that police officers "assisted" with administration of court-ordered medications.

Specifically, the DON failed to:

I. Ensure that nursing staff completed all required documentations, including the "Readiness for Release Criteria" on the S/R Records of 2 of 2 non-sample patients (SR1 and SR2) reviewed for S& R procedure implementation, and documented the initial seclusion/restraint orders for 1 of the 2 non-sample patients reviewed. Nursing staff also failed to release non-sample patient SR2 from restraint when the physician-ordered release criteria were met. These failures violate patient rights to be free from restraint except for the immediate protection of self and others.

II. Assure timely completion of administrative reviews of Seclusion/Restraint events for Patients SR1 and SR2 who had multiple and frequent S/R incidents during July/August, 2010. Failure to complete and document administrative reviews can result in deficient practices not being detected and corrected, potentially leading to unsafe situations for patients.

III. Ensure that only clinical staff carry out nursing clinical practice activities. Facility records and interviews documented the use of police officers to "assist" with the administration of court-ordered medications for non sample patient SR3. The facility also had no policy and procedure that clearly specified the role of police officers when called by clinical staff to help ensure safety on the treatment units. These failures potentially place patients at risk of intimidation and may violate patient rights to treatment in a safe, non-threatening environment.

Findings include:

I. Failure to ensure proper use and documentation of S/R events

1. Patient SR1

a. Patient SR1 was placed in seclusion on 6/16/10 at 7:30PM. The Seclusion or Restraint Order form did not include documentation of the type of order (written or telephone) and did not have an RN signature.

b. Patient SR1 was placed in seclusion and 4-point restraint on 6/24/10 at 8:35PM. The Seclusion or Restraint Order form did not include documentation of the time of the physician's verbal order.

c. Patient SR1 was placed in seclusion and 4-point restraint on 7/8/10 at 3:53PM. The S/R Record did not include the "Readiness for Release Criteria." However, the nurse noted that the patient was assessed for release criteria every 15 minutes from 4:15PM to 5:45PM.

d. Patient SR1 was placed in seclusion on 7/17/10 at 5:10PM. The S/R Record did not include the "Readiness for Release Criteria" and did not document any nursing assessment for release from 5:10PM to 5:45PM.

e. Patient SR1 was placed in 4-point restraint on 8/11/10 at 1:12PM. The S/R Record did not include the "Readiness for Release Criteria." In the section of the form for "Readiness for Release Reviewed" the nurse wrote "N/A" at 15 intervals between 1:13PM and 3:00PM." RN3 stated on 9/15/10 at 10:15AM. that the "N/A" meant "not assessed."

f. Patient SR1 was placed in 4-point restraint on 8/12/10 at 9:56 AM. The S/R Record did not include the "Readiness for Release Criteria." Nursing documentations noted that the patient was assessed for "Readiness for Release" every 15 minutes between 10:10 AM and 10:55 AM. There were no notations for 11:10 AM and 11:40 AM.

g. Patient SR1 was placed in 4-point restraint on 8/13/10 at 5:10AM. The S/R Record did not include the "Readiness for Release Criteria," although the S/R Record noted that "Readiness for Release Reviewed" was performed at 5:25AM.

h. Patient SR1 had a Seclusion or Restraint Record form dated 8/30/10 at 9:25PM. Nursing failed to complete any part of the form including "Readiness for Release Criteria," "Vital Signs"; "Hygiene measures": "nursing assessments"; and "circulation checks." The second page of the form had two handwritten "R"s written in by the "circulation check" boxes indicating "Patient Refused." There was no information about the time or date of the evaluation on the form. There was a nurse's signature on the bottom of the second page, again undated and untimed.

2. Patient SR2

a. Patient SR2 was placed in 4-point restraint on 7/12/10 at 5:45PM. The S/R Record did not include the "Readiness for Release Criteria." However, the "Readiness for Release Reviewed" section of the form was completed for 15 minute intervals between 5:45PM and 7:20PM.

b. Patient SR2 was placed in 4-point restraint on 7/18/10 at 8:35PM. The S/R Record did not include the "Readiness for Release Criteria." The S/R Record noted that the "Readiness for Release Reviewed" had occurred at 9:00PM.

c. Patient SR2 was placed in 4-point restraint 7/19/10 at 5:20PM. The physician's order form documented that the release criteria was "patient is calm." According to the Seclusion or Restraint Record, a nurse had completed the "Readiness for Release Reviewed" between 5:35 PM and 7:05 PM. Review of the "Seclusion or Restraint Observation Note" revealed the following notations:

7/19/10 at 5:35PM: "Pt resting quietly in seclusion room with eyes closed."
7/19/10 at 5:50PM: "Pt continues to rest quietly with eyes closed."
7/19/10 at 6:05PM: "Pt lying down in seclusion room talking with writer about his family."
7/19/10 at 6:20PM: "Pt lying in seclusion room talking with writer about being in his 50's."
7/19/10 at 6:35PM: "Pt came out of hand restraints at this time and had to be readjusted [sic] and put back in. Pt resting quietly."
7/19/10 at 6:50 PM: "Pt lying quietly with eyes closed."
7/19/10 at 7:05 PM: "Pt out of restraints, still in seclusion room, using restroom."
7/19/10 at 7:13 PM: "Pt out of seclusion room"

d. Patient SR2 was placed in 4-point restraint on 7/31/10 at 8:10PM. The physician's order stated that that release criteria was "Patient is calm." A review of the "Seclusion or Restraint Observation Note" form revealed the following notations:

7/31/10 at 8:40 PM: "Pt being seen by doctor at this time. Pt demanding to be released. Dr. explained that his behavior will determine when he will come out of the restraints."
7/31/10 at 8:55 PM: "Pt asked for water. Pt given water and now resting quietly."
7/31/10 at 9:25 PM: "Pt resting quietly at this time. Pt appears to be asleep."
7/31/10 at 9:40 PM: "Pt sleeping at this time. Charge nurse assessed pt, however he would not contract for safety."
7/31/10 at 9:55 PM: "Pt continues to sleep."
7/31/10 at 10:20 PM: "Pt resting quietly."
7/31/10 at 10:45 PM: "Pt removed from restraints by writer and charge nurse at this time."

e. Patient SR2 was placed in 4-point restraint on 8/11/10 at 8:10PM. The physician's order form included the release criteria "Patient is calm." Review of the Seclusion or Restraint Observation Note form revealed the following notations:

8/11/10 at 8:25 PM: "Resting quietly c (with) ou (both eyes) closed."
8/11/10 at 8:40 PM: "Resting quietly c ou closed."
8/11/10 at 8:55 PM: "Resting quietly c ou open."
8/11/10 at 9:10 PM: "Client is resting quietly."
8/11/10 at 9:25 PM: "Client is resting quietly."
8/11/10 at 9:40 PM: "Client is resting quietly."
8/11/10 at 9:45 PM: "Client is resting quietly."
8/11/10 at 10:45 PM: "Client remains quiet in restraints."
Seclusion and restraint were discontinued at 11:00PM on 8/11/10.

B. Policy Review

Facility BHO Policy: CLIN-104B "Emergency Intervention Related to Patient Care" (Restraint and/or Seclusion) effective date: 6/6/08 states the following:

Section IV: Philosophy: "If restraint or seclusion must be used to maintain the safety of the patient and/or others, then the use of restraint or seclusion is discontinued as soon as the patient has regained control of him/herself and the emergency situation has passed."

Section VII: Procedures:
2(g): "Rationale for the release from seclusion or restraint shall be documented by the registered nurse or licensed practical nurse in the patient's medical record on the Seclusion or Restraint RN Progress Note."
3(e): "The RN will assess readiness for release from restraint or seclusion every 15 minutes based on information provided by the trained staff member monitoring the patient 1:1, by personal observation, or both and will assess the potential for decreasing points of restraint to the least number of points possible and document on the Seclusion and Restraint Record."
3(g): "Restraint or seclusion is discontinued as soon as the patient meets his/her behavioral criteria for discontinuation."

B. Interview

1. In an interview on 9/14/10 at 11:15AM, The Clinical Director and Assistant Clinical Director were shown the records for SR1 and SR2. After reviewing the Seclusion/Restraint documentations, they acknowledged the findings noted above. The Clinical Director stated, "We need to do a better job of documenting."

2. In an interview on 9/14/10 at 1:15PM, The Director of Nursing and the Assistant CEO were shown the records noted above. They both acknowledged the surveyor's findings.

II. Failure to ensure timely administrative reviews of S/R events

A. Policy Review

Facility BHO Policy: CLIN-104B "Emergency Intervention Related to Patient Care (Restraint and/or Seclusion) effective date: 6/6/08" includes the following statement under "VII. Procedures, Section 4. Monitoring and Quality Improvement Requirements, (c):"

"SBH CCO (Summit Behavioral Health Chief Clinical Officer) or designee and the Director of Nursing or designee shall review daily all uses of seclusion or restraint. Special attention is given to the following situations: i.Patients in over 8 hours in one episode of restraint or seclusion, ii. Number of episodes per patient, iii. 2 episodes of restraint or seclusion by 1 patient within 8 hours, iv. 3 episodes of restraint or seclusion by 1 patient within any rolling 30 day period, and v. Use of psychoactive medications as an alternative for or to enable discontinuation of restraint or seclusion.[sic]"

B. Record Review

1. Review of the facility's Restraint and Seclusion Logs from June 15, 2010 to September 12, 2010 revealed the following:

a. Patient SR1: Between 7/5/10 and 8/4/10, Patient SR1 had 26 episodes of seclusion and/or restraint; several of the days included multiple episodes including: 7/5/10, 7/8/10, 7/9/10, 7/10/10, 7/11/10, 7/12/10, 7/18/10, 7/20/10 and 7/25/10.

b. Patient SR2: Between 7/15/10 and 8/12/10, Patient SR2 had 19 episodes of seclusion and/or restraint: several of the days included multiple episodes including: 7/15/10, 7/16/10, 7/18/10, 7/31/10, 8/11/10 and 8/12/10.

2. The facility did not produce any documentation that administrative review had occurred for the multiple episodes of seclusion and/or restraint for either patient (SR1 and SR2).

C. Interview

1. In an interview on 9/14/10 at 11:15AM. with the Clinical Director (CCO) and the Assistant Clinical Director, the information noted above was discussed. Both Directors acknowledged the surveyor's findings. The Clinical Director stated, "We talk about it (seclusion and restraint) in our morning meeting but we don't formally write anything about the incidents."

2. In an interview on 9/14/10 at approximately 3:00PM, the Director of Quality Improvement stated "I do QA of the physician's part of the S&R, not the nursing part." When asked who reviews the nursing documentations on the S/R forms, the Director of Quality Improvement replied that the unit nurse managers do these.

III. Ensure that only clinical staff carried out nursing clinical practice activities

A. Record review

1. In a review of all Incident Report from July and August 2010, an Incident Report dated 7/15/10 noted that "campus police came to the unit to talk to pt [Patient SR3] about unit rules."

2. A 72 hour RN Note dated 7/15/10 at 6:10 AM stated "pt" [referring to Patient SR3] was awake at start of shift. Pt needed redirection. Told the writer, 'I want you to have my baby.' Also told male tpw (therapeutic psychiatric worker), 'Do you need boxing gloves?' when staff asked him to go to his room at 11:30 PM. Campus Police came to the unit and talked to pt about unit rules. Pt did respond and sat up in his room."

3. The Nursing Supervisor Shift Report dated for 7/14/10 (3rd shift starting at 11:00PM) noted the following: "[Patient SR3] delusional, making inappropriate remarks to female staff about having babies and asked male staff 'Do you need boxing gloves?' when directed to his room at 11:35PM. Campus Police were called to unit and spoke with patient and he went to his room."

4. A "Psychiatric Progress Note" for Patient SR3 dated 7/23/10 at 2:00PM noted "It was explained to the patient that due to his agitation he was felt in need of additional medication, pt refused. Campus Police came to unit to assist. Pt was given Haldol 10 mg. IM (intramuscular), Ativan 2 mg. IM and Benadryl 50 mg. IM in his room."

5. The facility's "Daily Patrol Log" for Campus Police, dated 7/23/10, noted the following:
"12:30PM: Officer 206 Employee Assist. On Unit A with [Patient SR3]. Patient was given 3 IM medications by RN."
"12:30PM: Officer 205 Called to Unit A with staff for [Patient SR3] who was acting out."
"12:40PM: Officer 102 Responded to Unit A to stand-by while staff gave meds to [Patient SR3]."
"12:54PM: Officer 205 Clear Unit A."

6. A "Nursing Progress Note" for Patient SR3 dated 8/10/10 at 9:00AM noted "Campus Police called to assist with medication administration."

7. The facility's "Daily Patrol Log" for Campus Police, dated 8/10/10, noted the following:
"8:00AM: Officer 104 Respond to Unit A for assistance."
"8:00AM: Officer 103 Med assist on Unit A, [Patient SR3] was given 2 IM's."
"8:01AM: Officer 102 Responded to Unit A Standing by while staff gave meds to [Patient SR3]."
"8:20AM: Officer 103 Clear from Unit A."
"8:20AM: Officer 104 Clear Unit A."

B. Policy Review

1. Facility BHO Policy: CLIN-134, "Emergency Medication" effective 10/12/08 and BHO Policy: CLIN-135, "Procedures Governing Capacity Assessment and Court Authorized Medication of Inpatients." Effective 12/09/07.

Neither policy and procedure protocol included any provision for the use of non-clinical staff, nor did they mention any approved use of police officers for assisting with medication delivery.

2. Facility BHO Policy: CLIN-104B "Emergency Intervention Related to Patient Care (Restraint and/or Seclusion) effective date: 6/6/08 has the following statement under VI. Subject Content: Clinical Purposes for Seclusion and Restraint, Section 5(b):

"SBH Police Officers shall implement restraint and assist in the use of restraint or seclusion when a patient's behavior is beyond the control of nursing or other direct care personnel only if they have successfully completed training programs on minimizing the use of restraint or seclusion and maximizing safety when using seclusion and/or restraint."

C. Interviews

1. In an interview on 9/15/10 at 9:45AM with the Assistant Clinical Director the information noted above was discussed. The Assistant Clinical Director agreed with the surveyor's findings. He also acknowledged that the situations noted above regarding Patient SR3 did not meet the criteria noted in Policy CLIN-104B, VI.5 (b).

2. On 9/15/10 at 10:10AM, the Chief of Police was interviewed regarding the role of police officers in the facility and his department's administrative reporting structure. The Chief of Police stated that the role of police officers at the facility is "like any police department...to keep everyone safe." He clarified that the officers wear a police uniform with a badge on the units but that they do not carry weapons. When asked if his officers take direction from the nursing staff, he stated that "We do because they do the clinical work, we just assist." He added "I tell them (police officers under his supervision) 'We are not clinicians and don't tell patients what they are to do...only touch a patient if the supervising RN requests it.' The Chief of Police added "We do help apply restraints. All my (police officers) receive the S/R training like all staff every year.

When shown documentations in the medical record progress notes of Patient SR3 (dates 7/15/10; 7/23/10; 8/10/10) that a police officer "helped with medication administration," the Chief of Police stated that the documentations were incorrect. He said "That is not written right; we don't give medicines...that's the nurse's job." He added "We usually stand-by with the nursing staff when giving court ordered medications."

When asked if he were aware of any policy that clarified the difference between "clinical" and "law enforcement" roles or that gives guidelines for how staff should document what a police officer does to "assist" the nursing staff, the Chief of Police stated that he was not aware of any such policy.

The Chief of Police explained that he reports directly to the CEO of SBH, and that he and the 12 other police officers at the facility are paid as state employees (Ohio Department of Mental Health). After the interview, the CEO confirmed that the Chief of Police only reports to her.

3. In an interview on 9/15/10 at 10:20AM with Nurse B on Unit A, the surveyor asked about the progress note for patient SR-3 dated 8/10/10. Nurse B stated "We call Campus Police to assist with forced medications as part of policy."

4. In an interview on 9/15/10 at 10:25AM with MD B on Unit A, the surveyor asked about the progress note for patient SR-3 dated 7/23/10. MD B stated "Campus Police is used all the time for forced meds."

5. In an interview on 9/15/10 at 10:35AM, Patient SR3 stated "I don't like medications; the police make sure I get them (Medications)."