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Based on document review and interview, the facility failed to obtain an order for behavioral restraints for 1 of 4 (#17) patients resulting in the potential for a loss of the patients' rights. A total of 4 (four) records were reviewed for use of restraints from a total universe of 49 (forty-nine) records that were reviewed during the survey. Findings include:

On 04/06/2015 at 1430 during review of the electronic medical record with staff I, for patient #17, revealed that the patient was placed into seclusion for "aggressive or destructive behavior" on 03/10/2015 at 1415. The first physician's order was for seclusion and was obtained at 1432. The seclusion order was good for up to four hours. At 1730 a second order was obtained to continue the seclusion for up to another four hours. Per the medical record restraint documentation, the patient then remained in seclusion until 1815 at which time the documentation then has him in "4-point 'hard restraints' for 'physical abuse and verbally threatening.'" On 03/10/2015 at 2243 the first order for restraints was obtained. Patient #17 then remained in the restraints until 03/11/2015 at 0045. At 0045 on 03/11/2015, the patient was released from the four-point restraints and was then kept in seclusion until 0117 at which time he was released.

In an interview with staff I on 04/06/2015 at 1430, during review of the medical record for patient #17, when queried if staff are allowed to put the patient in restraints if the order was for seclusion, she stated, "NO, it should be for what the order was written for." When staff I was queried if she could locate an order for the restraints that were applied at 1815, she stated, "I cannot."

On 04/07/2015 at 0800, review of the facility's policy titled, "Restraint and Seclusion, (no policy #), Revised on: 03/25/2015," stated, "II. Behavioral Management Restraint/Seclusion, B. Restraint/Seclusion Decision: After determining that the least restrictive methods and any appropriate alternatives have been tried, and the assessment indicates that the patient requires restraint or seclusion, the attending physician will be contacted (if not assessed by attending physician already) to obtain an order prior to applying restraints/initiating seclusion."

Based on document review and interview, the facility failed to get restraint release at the earliest possible time for 1 of 4 (#17) patients resulting in the potential for a loss of the patient's rights. A total of 4 (four) records were reviewed for use of restraints within a total universe of 49 (forty-nine) records that were reviewed during the survey. Findings include:

On 04/06/2015 at 1430 during review of the electronic medical record with staff I, for patient #17, revealed that the patient was placed into seclusion for "aggressive or destructive behavior" on 03/10/2015 at 1415. The first physician's order was for seclusion and was obtained at 1432. The seclusion order was good for up to four hours. At 1730 a second order was obtained to continue the seclusion for up to another four hours. Per the medical record restraint documentation, the patient then remained in seclusion until 1815 at which time the documentation then has him in "4-point 'hard restraints' for 'physical abuse and verbally threatening.'" On 03/10/2015 at 2243 the first order for restraints was obtained. Patient #17 then remained in the restraints until 03/11/2015 at 0045. At 0045 on 03/11/2015, the patient was released from the four point restraints and was then kept in seclusion. At 0100 the documentation stated that the patient was "Quiet and Cooperative." The patient was then released from seclusion at 0117.

In an interview with staff I on 04/06/2015 at 1430, during review of the medical record for patient #17, when queried as to why the patient was taken out of restraints but kept in seclusion for another 32 minutes, she stated, "We just wanted to make sure he remained calm." When staff I was queried if the patient meets the criteria to be released from restraints or seclusion are they not supposed to be released, she stated, "They are, but we usually wait a little while just to make sure they are going to remain calm."

On 04/07/2015 at 0800, review of the facility's policy titled, "Restraint and Seclusion, (no policy #), Revised on: 03/25/2015," stated, "II. Behavioral Management Restraint/Seclusion, C. Time Limits: Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order."

Based on document review and interview, the facility failed to complete a debriefing for 2 of 2 (#13, #17) patients on the behavioral health unit who required the use of restraint/seclusion for violent behavior(s) resulting in the potential for missed/un-identified alternatives to the use of restraint/seclusion. A total of four (4) medical records were reviewed for the use of restraints/seclusion within a total universe of forty-nine (49) medical records reviewed. Findings include:

On 04/06/2015 at 1430 during review of the medical record for patient #17, revealed that the patient was in restraint/seclusion on 03/10/2015 at 1415 until 03/11/2015 at 0117. The record lacked documentation of a debriefing with the staff and patient after the patient was released regarding what lead up to the incident and what may need to occur to prevent the incident from happening again.

In an interview with staff I on 04/06/2015 at 1445, when queried if debriefing was suppose to occur after the use of restraint/seclusion, she stated, "Yes, a debriefing is supposed to take place." When queried if the debriefing was documented in the patient's medical record, she stated, "It is supposed to be." When queried if she could locate documentation of a debriefing for patient #17's restraint/seclusion episode, she stated, "I don't see one." When staff I was queried about how the debriefing was supposed to occur, she stated, "First, there needs to an order put in for the debriefing and then after the restraints/seclusion are discontinued the staff and the patient are suppose to discuss what occurred, why the restraint or seclusion was used and see if there are alternatives that could prevent this from occurring again."

On 04/06/2015 at 1500 during review of the medical record for patient #13 with staff I, revealed that on 02/17/2015 at 1600 the patient required the use of seclusion for impulsive and physically abusive behavior(s). The documentation after the discontinuation of the seclusion lacked evidence of a debriefing with staff and the patient. When staff I was queried about the lack of documentation of a debriefing, she stated, "It does not look like one was ordered and I don't see where one was documented as being completed."

On 04/07/2015 at 088 during review of the facility's policy titled, "Restraint and Seclusion, (no policy #), Revised On : 03/25/2015, read, "II. Behavioral Management Restraint/Seclusion, H. 1. Following the use of restraint/seclusion in the Behavioral Health settings, a debriefing will be initiated by the clinical manager or designee at the time restraint/seclusion removal or within 24 hours of discontinuation. 2. Staff and patient (and family if applicable) will participate in a debriefing about the use of restraints/seclusion. The purpose of the debriefing is to: Identify what led to the use of restraints/seclusion, what could have been handled differently, and future alternatives; Ascertain that the patient's physical well-being, psychological comfort, and right to privacy were addressed; Evaluate with the patient (and/or family) when appropriate, to identify any trauma that may have resulted from the restraint/seclusion; and When indicated, modify the patient's treatment plan. 3. The clinical manager will review the debriefing results and assess whether further action is needed."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include:

See the individually and below cited K-tags dated April 9, 2015:
K-0018
K-0025
K-0027
K-0029
K-0050
K-0051
K-0071
K-0076
K-0144