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Based on review of 13 medical records, inclusive of 3 records of restrained patients, hospital policies and procedures, and other pertinent documentation, it was determined that the hospital failed to meet the Condition of Participation for Patient Rights, as evidenced by:

1. Failure to provide Patient #9, a hearing impaired patient, with an interpreter consistently, to ensure their understanding of the plan of care, procedures, and discharge information (see tag A-0130);
2. Failure to allow Patient #12 to sign out Against Medical Advice (AMA) without certifying the patient's incapacity for making decisions, and failure to perform an incapacity evaluation and certification of Patient #4 before allowing a general consent forms to be signed by a spouse (see tag A-0131);
3. Failure to enter an appropriate restraint order by a physician for Patients #11 and #13 (see tag A-0168);
4. Failure to renew a violent restraint order for Patient #13 (see tag A-171);
5. Failure to release Patients #11 and #13 from restraints at the earliest possible time;
6. Failure to conduct a Face-to-Face assessment for Patient #13 within one hours of restraint application (see tag A-0178).

Based on review of 13 medical records, hospital policies, and other pertinent documentation, it was determined that the hospital failed to uphold the right to participate in development and implementation of the care plan for 1 of 13 patients, as evidenced by failure to provide Patient #9, a hearing impaired patient, with an interpreter consistently, to ensure their understanding of the plan of care, procedures, and discharge information.

The surveyors reviewed the policy, titled "Communication Challenged Patients", dated 7/2019. Under the section titled "Procedure", the policy stated: "Interpreter services should be provided in any situation where a significant clinical change occurs. Examples include but are not limited to: initial evaluation by the provider, obtaining informed consent or permission for treatment, explanations of medical procedures and treatment plans, discharge instructions and teaching". Under the section "Hearing impaired person", the following communication methods were found: "Methods: Deaftalk, Teletypwriter (TTY), Mercy certified interpreter or closed caption on televisions". The policy further stated that family members should not be used as interpreters.

P9 was a 55+ year old patient who presented to the Emergency Department (ED) with a chief complaint of difficulty swallowing. The patient was documented as being deaf and in need of interpreter services for communication. P9 was evaluated and admitted for further treatment.

Physician notes from the presenting day determined that the patient had some difficulty with the video interpreter services that were initially provided. Statements such as, "family member requesting in-person interpreter. Patient knows minimal sign language" and "originally said the year was 2006, however may have been misinterpretation with the interpreter as patient then said the correct year". There was also a physician note which listed possible differential diagnoses based on the patient's signs and symptoms with a note stating, "Unclear given limited history by language barrier".

During the patient's 14+ day inpatient stay, evaluations and treatments were ordered for physical therapy, nutrition, and speech therapy. The majority of the notations from those staff members stated that the patient was "using a white/board" or "pad and pen" to communicate. On at least three separate occasions, it was noted that the video interpreter system or 'deaf talk' was not working properly and could not be used. In some of those cases, documentation supported that the family members were used to assist with interpreting for the patient. In one case, it was documented that a "student assisted with translation".

Per medical record review, P9's family members consistently requested an on-site interpreter due to the inconsistency of the availability of the video interpreter. It was documented by more than one staff member that they would inform a physician or charge nurse of the family's and patient's wishes. On day six of the patient's two week inpatient stay, it was noted that an on-site interpreter would be available but for only two hours during each day. No clarification was given to the family as to which two hours the interpreter would be present. According to documentation, an onsite interpreter was used for two hours a day for three consecutive days. After those three days, it was noted that the staff went back to using the white board for all communication needs until discharge.

During P9's two week inpatient stay, it was documented that the patient was 'frustrated' and 'anxious' regarding the lack of communication regarding their care. No evidence was found that any staff members communicated to the patient or family members why an on-site interpreter would not be made available during the first week of the patient's stay.

The hospital violated P9's right to participate in the meaningful development and implementation of their treatment plan as the limited or malfunctioning interpreter services provided to the patient interfered with the patient's ability to receive information about the plan of care, procedures, and discharge information in the format best understood by the patient.

Based on review of 13 medical records, hospital policies and procedures, and other pertinent documents, it was determined that the hospital failed to uphold the right to make informed decisions about care and disposition for 2 of 13 patients, as evidenced by 1) failing to allow Patient #12 (P12) to sign out Against Medical Advice (AMA) without certifying the patient's incapacity for making decisions, and 2) obtaining consent for multiple procedures from a family member of Patient #4 (P4) without completing the evaluation and certification of incapacity.

1) The surveyors reviewed the policy titled "Release of Patients Against Medical Advice - Competent Adults", dated 10/18. Section II of the policy stated:
" - A physician should discuss with the patient the reasons for seeking discharge from the hospital. The provider should also ascertain if the adult patient clearly understands the risks of leaving and the benefits of remaining in the hospital. If there is a question of competency or if
the patient is a minor, further assessment must be completed.
- When a competent patient clearly understands the risks of leaving against medical advice and the benefits of remaining in the hospital and still insists on being discharged, a Statement of Patient Leaving Medical Center Against Medical Advice form must be completed, and the patient should be discharged. This policy should be followed even when the risks of discharge include further injury or death.
- Medical, nursing or other personnel should not physically restrain an adult patient whom the provider has deemed competent and fully understands the risks of leaving against medical advice."

Patient #12 (P12) was a 25+ year old patient who presented to the emergency department (ED) complaining of swelling and redness of the left hand and arm. A medical screening exam was performed and it was determined that the patient had an infection and was started on intravenous antibiotics. The patient also stated they were having symptoms of withdrawal after recent drug use and requested medications for those symptoms. It was documented that P12 was alert and oriented x3 (person, place and situation).

A nursing note 12+ hours later stated that P12 "became annoyed at the situation". The note further stated that the patient said they "should have just killed themselves rather than come to the hospital" due to the fact that no one was addressing the withdrawal symptoms. P12 was ordered a sitter for suicidal statements and a psychiatric evaluation. This psychiatric evaluation was not performed until 7+ hours later. The psychiatrist note stated, "Strongly doubt any intentional suicide intentions". It was also documented that the patient wanted information on an outpatient rehabilitation treatment center.

For the next five hours, P12 made multiple statements indicating that they wanted to leave. The physician and nursing staff documented that the patient wanted to sign out Against Medical Advice (AMA). Documentation stated, "The patient then became agitated, verbally abusive and attempting to roam the hallway". The physician documented, "patient not allowed to leave AMA due to endorsing suicidal ideations yesterday". Additional physician notes stated, "ordered a B52 (a term for 3 drugs given to a behavioral patient) to prevent the patient from leaving AMA" and "if patient is combative and attempting to leave, may require security for assistance, restraints".

The following morning, nursing progress notes stated that the patient was fully dressed and demanding to leave. At this time, the physician was called to the bedside, and the patient continued to explain that they were "never suicidal, just angry due to their withdrawal symptoms not being treated". The patient was allowed to sign out AMA at this time.

No evidence was found in P12's medical record to support that P12 was deemed to be incapable of making decisions regarding their care or disposition. Several times, it was clarified by the patient and also documented by the psychiatrist that P12 was not suicidal; however, the patient was kept in the hospital for 12+ hours after expressing the desire to leave. Furthermore, based on documentation, case management was not notified that the patient was being released; therefore, no follow-up information regarding outpatient rehabilitation was given to the patient on discharge.

2) The surveyors reviewed the policy "Informed Consent", dated 01/2019. Under the section "Definitions", the policy stated: "3. Not incapacitated - means able to understand or to evaluate treatment issues and to communicate a decision about treatment". Section "D. Process of Obtaining Consent" of the policy further stated: "3. Obtaining consent - the treatment or procedure may not be performed without the express consent of the appropriate consenter to that particular treatment or procedure".

P4 was an 80+ year old patient who presented to the Emergency Department (ED) for leg pain and urinary complaints. Review of the medical record showed that P4 was admitted to the hospital for approximately 11 days. Nursing notes stated that the patient was 'alert and oriented X 3' on multiple occasions during their inpatient stay. While inpatient, P4 had multiple procedures, and all consent forms, including anesthesia and blood transfusion consents, were signed by the patient's spouse.

No documentation was found to support that P4 was evaluated and certified as incapable of making their own decisions or signing the consent forms. Without a Certification of Incapacity completed by two members of the medical staff, it could not be determined whether P4, an otherwise alert and oriented patient, was included in the plan of care or that they were provided the information necessary to give informed consent for care provided.

Based on review of 3 medical records involving restraints or seclusion, hospital policies and procedures, and other pertinent documentation, it was determined that hospital failed to enter appropriate restraint orders for 2 of 3 restrained patient reviewed.

Surveyors reviewed the policy titled "Restraints, Seclusions, Non-violent/Non-self-destructive, Violent/self-destructive". Under the section VII, v. 1., the policy stated, "Provider orders must be obtained within one hour of initiating restraint/seclusion protocol'.

Patient #13 (P13) was a 20+ year old patient who presented to the Emergency Department (ED) via EMS for a suspected drug overdose. Per physician and nursing documentation, P13 was placed in 4-point hard restraints (on all 4 extremities) to control verbal and physical aggression toward medical staff. Review of restraint documentation showed that the patient remained in restraints for a total of 4.5 hours.

A physician note stated 'Patient was placed in a Posey vest (a type of medical restrain used to restrain a patient to a bed or chair) for their protection. Was able to get out of the Posey and was escalated to 4- point behavioral restraints'. No order was found for the Posey vest which is considered a restraint device when used to manage aggressive or violent behaviors or for violent 4-point restraints.

A physician order placed for this patient was for non-violent restraints. All nursing restraint documentation in P13's medical record was documented under violent or self-destructive restraints and it stated they were started due to aggressive behaviors. Therefore, this restraint episode lacked an appropriate order for violent restraints.

Approximately 3.5 hours after the initial restraints were placed, nursing staff placed a restraint order for the continuation of "violent or self-destructive restraints". However, as stated above, no initial order had been placed for 4-point violent restraints. When this order was placed, P13's behavior was documented as "quite; asleep". Furthermore, nursing documentation revealed that P13 had only 3 limbs restrained (LUE, LLE, RLE). No documentation was found to support that this order was signed by a physician.

Patient #11 (P11) was a 55+ year old patient who presented to the ED with symptoms of alcohol withdrawal. Within 30 minutes of arriving at the hospital, the patient was documented as having a seizure. Physician documentation noted that post-seizure, the patient became confused and combative. P11 was medicated and placed in 2-point wrist restraints for "safety" and being "uncooperative".

Approximately 2 ½ hours later, P11 was found on the floor out of the restraints and was placed in 4-point restraints (wrist/ankles). Physician documentation stated the patient remained in a 'postictal state (altered state of consciousness after a seizure), and was fairly uncooperative'. Nursing documentation stated the patient was combative and agitated; however, documentation was completed for non-violent restraints. No physician order was found in P11's record for either 2-point or 4-point restraints.

Without appropriate restraint orders by the physician, it could not be determined if clinical oversight by the medical staff was occurring during the above-mentioned episodes for P13 and P11.

Based on review of 3 medical records involving restraints or seclusion, hospital policies and procedures, and other pertinent documents, it was determined that hospital failed to appropriately renew a restraint order for 1 of 3 restrained patients reviewed.

The surveyors reviewed the policy titled, "Restraints, Seclusions, Non-violent/Non-self-destructive, Violent/self-destructive". Under the section "VII. Restraint use for violent or self-destructive behavior: v.2" the policy stated: "An order many be renewed in accordance with the following times for up to a total of 24 hours: a. 4 hours for adults 18 years of age and older".

P13 was a 20+ year old patient who presented to the Emergency Department (ED) via EMS for a suspected drug overdose. Per physician and nursing documentation, P13 was placed in 4-point hard restraints (on all 4 extremities) to control verbal and physical aggression toward medical staff. Review of restraint documentation showed that the patient remained in restraints for a total of 4.5 hours.

The initial physician order placed for this patient was for non-violent restraints. All restraint documentation in P13's medical record by nursing was documented under "violent or self-destructive restraints". Nursing restraint documentation stated 4-point hard restraints were started. No physician order was found for the use of violent or self-destructive restraints (see tag A-0168 for a related citation).

Approximately 3.5 hours after the initial restraints were placed, nursing staff placed a verbal order for the renewal of "violent or self-destructive restraints". However, as stated above, no initial order had been placed for violent restraints. No documentation was found in P13's medical record to support that this renewal order was signed by a physician.

P13 remained restrained for a total of 4.5 hours without evidence of the restraint order being properly renewed in excess of the maximum allowable time.

Based on review of 3 medical records involving restraints, hospital policies and procedures, and other pertinent documentation, it was determined that the hospital failed to release patients #13 and #11 from restraints at the earliest possible time. This was evident for 2 of the 3 restraint records reviewed.

The surveyors reviewed the policy, titled "Restraints, Seclusions, Non-violent/Non-self-destructive, Violent/self-destructive". Under the section "Purpose" the policy stated: "How to manage patient requiring restraints in order to maintain medical therapy (non-violent) and to protect the immediate safety of the patient, staff and others (violent)'. Under the section "V. Policy/procedure content", the policy further stated: "iii. Restraints will only be used when alternative less restrictive measures have been attempted and/or assessed to be ineffective... Xiii. Restraints/seclusion are discontinued at the earliest possible time".

P13 was a 20+ year old patient who presented to the Emergency Department (ED) via EMS for a suspected drug overdose. Per physician and nursing documentation, P13 was placed in 4-point hard restraints (all 4 extremities) to control verbal and physical aggression toward medical staff. Review of restraint documentation showed that the patient remained in restraints for a total of 4.5 hours.

P13 was evaluated by the ED physician and was noted to be, 'intermittently agitated, thrashing about in the bed, unable to sit voluntarily, and failed verbal redirection by nursing staff and provider'. P13 was placed in a Posey vest (a type of medical restraint used to restrain a patient to a bed or chair) and ED provider documentation stated, "P13 was placed in a Posey vest for their protection. Patient was able to get out of the Posey and this was escalated to 4 point behavioral restraints".

Nursing notes revealed time frames when the patient was not physically aggressive toward staff. Nursing staff documented P13's behavior as "quiet, hard restraint R wrist discontinued" and noted "RUE (right upper extremity) restraint released per Dr. Elder. Patient calm and cooperative at present".

Fifteen minutes later, the nursing staff re-ordered violent restraints for LUE (left upper extremity), LLE (left lower extremity), RLE (right lower extremity) noting the patient's current behavior as "quiet; asleep". Additional nursing notes five minutes later stated: "Patient is restless but asleep". The same nursing staff modified P13's restraints, after obtaining a verbal order from the provider, by releasing one of the three restrained limbs. Nursing continued to document P13's behavior as "quiet, LLE and RLE hard restraints are still continued" and "patient resting comfortably and LLE restraint released due to patient complaining of pain in area of restraint". Patient's right lower extremity remained in the restraint.

P13's restraint documentation revealed all restraints as being discontinued via a verbal order from the ED provider after 4.5 hours due to stated behaviors of "calm and cooperative". Based on documentation in the medical record, P13's physical and verbally aggressive behaviors had ceased approximately three hours after being placed in restraints, at the same time as the nursing staff released one of the patient's extremities from the restraint.

The patient remained partially restrained even after the behaviors that caused the initiation of the restraints had ceased. Removing one restraint at a time could not be classified as releasing the patient from restraints at the earliest possible time.

Patient #11 (P11) was a 55+ year old patient who presented to the ED with symptoms of alcohol withdrawal. Within 30 minutes of arriving at the hospital, the patient was documented as having a seizure. Physician documentation noted that post-seizure, the patient became confused and combative. P11 was medicated and placed in 2-point wrist restraints for "safety" and being "uncooperative".

Approximately 2 ½ hours later, P11 was found on the floor out of the restraints and was placed in 4-point restraints (wrist/ankles). Physician documentation stated the patient remained in a "post-ictal state (altered state of consciousness after a seizure), and was fairly uncooperative". Nursing documentation stated the patient was combative and agitated; however, the documentation was completed for non-violent restraints.

P11 remained in 4-point restraints for 4 hours. Nursing restraint documentation listed the patient as 'asleep' less than 2 hours after switching to 4-point restraints; however, the patient remained in restraints for additional 2 ½ hours. No documentation was found after this entry describing the patient's behaviors that could support the continuation of restraints.

By failing to discontinue the restraints for P13 and P11 at the earliest possible time when the patients no longer posed an imminent threat to self or others, the hospital violated the patients' right to be free from restraint and seclusion.

Based on review of 3 medical records involving restraints or seclusion, hospital policies and procedures, and other pertinent documentation, it was determined that the hospital failed to perform a face-to-face assessment within one hour of the initiation of restraints for violent behaviors for 1 of 3 restrained patients reviewed.

The surveyors reviewed the policy titled "Restraints, Seclusions, Non-violent/Non-self-destructive, Violent/self-destructive". Under the section "VII. Restraint use for violent or self-destructive patients", the policy stated: "ii. The provider performs a face-to-face assessment of the patient within 1 hour and writes orders for the restraints. The evaluation includes: 1. Patient's immediate situation 2. Reaction to the intervention 3. Medical and behavioral condition 4. The need to continue or terminate the restraint".

P13 was a 20+ year old patient who presented to the Emergency Department (ED) via EMS for a suspected drug overdose. Per physician and nursing documentation, P13 was placed in 4-point hard restraints (on all 4 extremities) to control verbal and physical aggression toward medical staff. Review of restraint documentation showed that the patient remained in restraints for a total of 4.5 hours.

The initial physician order placed for this patient was for non-violent restraints. All restraint documentation in P13's medical record by nursing was documented under "violent or self-destructive restraints". Nursing restraint documentation stated 4-point hard restraints were started. No physician order was found for the use of violent or self-destructive restraints (see tag A-0168 for a related citation).

The ED provider documented a note approximately 1.5 hours after the initial restraint incident occurred and stated "Patient is intermittently agitated and thrashing about in the bed". Furthermore, the ED provider documented, "patient is unable to sit voluntarily despite verbal redirection from provider or nursing staff, patient was unable to control their movements and nearly fell ...fall precautions ordered".

No documentation containing the required 4 elements of the face-to-face assessment was found in P13's medical record to support that a face to face was completed by a provider within one hour of the patient being placed in violent restraints.