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Based on document review and interview, it was determined the Hospital failed to promote and protect the rights of the patients. As a result, the Condition of Participation of Patient Rights, 42 CFR 482.13, was not met. This has the potential to affect all Inpatients (average daily census of 37 patients), all Emergency Department patients (average daily census of 257 patients), and all other Outpatients (excluding ED) serviced by the Hospital.

Findings include:

1. The Hospital failed to ensure its Grievance policy was followed. See A-118.

2. The Hospital failed to ensure it's Workplace Violence policy was followed. See A-145.

3. The Hospital failed to ensure physician orders for the initiation of the restraint or seclusion were obtained. See A-168A.

4. The Hospital failed to ensure the appropriate medical director was informed of the active orders for violent behavior and follow up was conducted in accordance with its policy. A-168B.

5. The Hospital failed to ensure orders to continue restraints was written in accordance with its policy. See A-173.

6. The Hospital failed to ensure restrained patients were monitored in accordance with its policy. See A-175.

7. The Hospital failed to ensure Medical Doctors ordering restraint and/or seclusion had a working knowledge of the Hospital's policy. See A-176.

8. The Hospital failed to ensure training to identify staff and patient behaviors, events, and environment factors that may trigger circumstances that require the use of a restraint or seclusion. See A-199.

Based on document review and interview, it was determined for 1 of 1 (Pt #2) behavioral health patient who reported an allegation of professional misconduct, the Hospital failed to ensure its Grievance policy was followed. This has the potential to affect all inpatients and outpatients serviced by the Hospital with an average daily census of 37 patients and 257 patients respectively.

Findings include:

1. The Hospital policy titled "9000-033... Customer Complaint/Grievance Management" (effective May 20, 2016) was reviewed on 5/16/17 at approximately 1:00 PM. The policy stated "Definitions:... Grievance: A formal or informal; written or verbal complaint that is made by a patient, or the patients' representative, regarding the patient's care that is not resolved in a timely manner. Verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance as defined by the Centers for Medicare and Medicaid Services) Hospital Conditions of Participation are considered grievances... Grievance Management: A. Grievances will be managed through the GPE (Great Patient Experience) Department..." and went on to say the GPE was to be notified as soon as possible and that a GPE representative "upon receipt of the grievance, is responsible to handle the grievance and document its receipt into the SENSOR Event Reporting System." The policy proceeded to state who would be alerted and what documentation was to be completed and entered into the SENSOR System and timeframes to be followed through resolution of the grievance.

2. The Hospital policy titled "Policy Number: 9000-105... SENSOR Event Reporting" (effective date February 9, 2016) was reviewed on 5/17/17 at approximately 1:00 PM. The policy stated "I. Reporting an Event... 3. After clicking on the "SENSOR" link, the user is directed to the Icon Wall where they can select the most appropriate event type... o. Professional Conduct...II. Review and Investigation of Reported Events...d. Professional Conduct Events and Narcotic Discrepancy Events shall be investigated within 3 business days..."

3. An interview was conducted with the Nurse Manager Behavioral Health (E#1), the Clinical Director (E#2), and the Chief Executive Officer (E#3) on 5/16/17 at approximately 9:35 AM. E#1 stated being aware of one complaint and stated it centered around a patient's (Pt #2) discharge. E#1 stated the complaint was related to the Behavioral Health Social Worker (E#7) and stated that Pt #2 stated E#7 had "put hands on (Pt #2) and (Pt #2) felt uncomfortable." E#1 stated "I investigated it myself and didn't find anything." All present stated knowledge of the allegation/event. There was no documentation of Pt #2's complaint/grievance being entered into the SENSOR Event Reporting System, any documentation of an investigation, and/or any resolution in accordance with Hospital policy.

4. An interview was conducted with the Chief Nursing Officer (E#6) on 5/16/17 at approximately 1:10 PM. E#6 stated "The patient (Pt #2) never actually complained to us. He (Pt #2) went to (an outlying Mental Health Provider) and made a comment about what they said they saw and heard. They (the provider) wanted to give us a 'heads up' that they were notifying the Office of Advocacy. That's when we checked this out (the video) and did the investigation. I instructed (E#1) to put it into SENSOR and to write everything down. I agree there isn't anything in writing. It wasn't put into the SENSOR System and should have been. There isn't anything documented that says who was interviewed, no staff or patient statements, nothing. We didn't follow our policy."

Based on document review and interview, it was determined for 1 of 1 (Pt #2) behavioral health patient who reported an allegation of professional misconduct, the Hospital failed to ensure it's Workplace Violence policy was followed. This has the potential to affect all Behavioral Health patients serviced by the Hospital with an average daily census of 8 patients.

Findings include:

1. The Hospital policy titled "Workplace Violence Procedures Policy #9100-068a" (effective June 1, 2016) was reviewed on 5/17/17 at approximately 2:00 PM. The policy stated "Employees Exhibiting Threatening Behaviors: a. Leader immediately investigates allegations of workplace violence. b. Leader documents the workplace violence event in the Workplace Violence Incident Report... e. Leader submits a completed Workplace Violence Incident Report to Human Resources."

2. Internal documentation (no date) was presented and reviewed on 5/17/17 at approximately 12:00 PM. The document stated Pt #2 had called the Manager of Behavioral Health (E#1) on 4/19/17 with complaints related to discharge and "made allegations of professional misconduct about... (the Behavioral Health Social Worker- E#7)... put hands on (Pt #2) and called (Pt #2) a 'dumb shit'." There was no documentation of a Workplace Violence Report being initiated and/or completed.

3. E#7's personnel file was reviewed on 5/17/17 at approximately 3:30 PM with the Interim Human Resources Manager (E#18). There was no documentation of a Workplace Violence Report being initiated and/or completed in E#7's file.

4. An interview was conducted with E#18 on 5/17/17 at approximately 3:30 PM. E#18 stated if there was an allegation of professional misconduct, there would be documentation in the involved employees file.

A. Based on document review and interview, it was determined for 2 of 4 (Pts #4 and #13) patients in which mechanical restraints for either violent or non-violent behavior were utilized, the Hospital failed to ensure physician orders for the initiation of the restraint or seclusion were obtained. This has the potential to affect all Inpatients and Emergency Department (ED) patients serviced by the Hospital with an average daily census of 37 patients and 257 patients respectively.

Findings include:

1. The policies titled "Policy Number: 9000-035B ... Restraints for Non-Violent Behaviors" (Effective June 10, 2016) and "Policy Number: 9000-035A ... Restraints and/or Seclusion for Violent Behaviors" (Effective June 10, 2016 were reviewed on 5/17/17 at approximately 2:00 PM. The Non-Violent addressed "restraints". The Violent addressed both "restraint and/or seclusion". Both policies stated "restraints" or "restraints and/or seclusion" required "an order from a physician or Allied Health Professional..." Both stated if the" restraint" or "restraint and/or seclusion" were discontinued for a patient, a new order was required before reinitiating the "restraint" or "restraint and/or seclusion".

2. Pt #4's record was reviewed on 5/17/17 at approximately 1:00 PM. Pt #4 was admitted to the ED on 4/15/17 with the Chief Complaint of Evaluation of Drug-Induced Psychosis admitted to Behavioral Health Unit with diagnoses of Suicidal Ideations and Acute Psychosis. Pt #4's record indicated the following:
a. Pt #4 was placed in mechanical restraints on 5/10/17 at 9:57 AM.
b. Pt was removed from mechanical restraints and placed in seclusion on 5/10/17 at 11:35 AM.
c. Pt #4 was placed back into mechanical restraints on 5/10/17 at 11:55 AM.
d. Pt was removed from mechanical restraints and placed in seclusion on 5/10/17 at 3:10 PM and was released from seclusion on 5/10/17 at 4:07 PM.
e. Pt #4 was placed in mechanical restraints on 5/13/17 at 7:45 AM and was released on 5/13/17 at 8:45 AM.
The record lacked orders for any of the restraint or seclusion events.

Interviews were conducted with E#1 (Nurse Manager of Behavioral Health) and E #2 (Clinical Director) on 5/17/17 between 1:30 PM and 2:45 PM. E#1 and E #2 had reviewed Pt #4's record and verbally agreed Pt #4's record lacked orders for restraints and/or seclusion.



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3. Pt #13's record was reviewed on 5/18/17 at approximately 3:00 PM. Pt #13 presented to the ED on 3/21/17 with the Chief Complaint of Shortness of Breath. At 4:26 AM, ED nursing documentation stated "Pt pulled Bipap (a device that provides pressure support during non-invasive ventilation) mask off... Pt placed in soft wrist restraints." At 5:10 AM, "Soft restraints removed." The record lacked an order for the non-violent soft restraints.

An interview was conducted with the Chief Nursing Officer (E#6) on 5/19/17 at approximately 9:00 AM. E#6 had reviewed Pt #13's record and verbally agreed there was no order for the restraint.

B. Based on document review and interview, it was determined for 1 of 1 (Pt #4) patient, who required the use of violent restraint, the Hospital failed to ensure the appropriate medical director was informed of the active orders for violent behavior and follow up was conducted in accordance with its policy. This has the potential to affect all Inpatients and Emergency Department patients serviced by the Hospital with an average daily census of 37 patients and 257 patients respectively.

Findings include:

1. The Hospital policy titled "Policy Number: 9000-035A ... Restraints and/or Seclusion for Violent Behaviors" (Effective June 10, 2016 was reviewed on 5/17/17 at approximately 2:00 PM. The policy stated "Orders 7. On a daily basis, an appropriate medical director will be informed of active restraint/seclusion orders for violent behavior. The director reviews the appropriateness of orders."

2. The Behavioral Health "Restraint/Seclusion For Violent Behavior" orderset was reviewed on 5/17/17 at approximately 2:30 PM. The orderset stated "Notification of Clinical Leadership" and included "Medical Director of Behavior Health Unit reviewed restraint order and reason..."

3. Pt #4's record was reviewed on 5/17/17 at approximately 1:00 PM. Pt #4 was admitted to the ED on 4/15/17 with the Chief Complaint of Evaluation of Drug-Induced Psychosis admitted to Behavioral Health Unit with diagnoses of Suicidal Ideations and Acute Psychosis. Pt #4's record indicated the following:
a. Pt #4 was placed in mechanical restraints on 5/10/17 at 9:57 AM.
b. Pt was removed from mechanical restraints and placed in seclusion on 5/10/17 at 11:35 AM.
c. Pt #4 was placed back into mechanical restraints on 5/10/17 at 11:55 AM.
d. Pt was removed from mechanical restraints and placed in seclusion on 5/10/17 at 3:10 PM and was released from seclusion on 5/10/17 at 4:07 PM.
e. Pt #4 was placed in mechanical restraints on 5/13/17 at 7:45 AM and was released on 5/13/17 at 8:45 AM.
The record lacked documentation of the Medical Director of Behavioral Health being notified of the restraint/seclusion events and/or Medical Director review of Pt #4's record for orders.

4. An interview was conducted with the Chief Nursing Officer (E#6) on 5/19/17 at approximately 9:00 AM. E#6 stated "This is the only patient who has been restrained or secluded on that unit" and verbally agreed there wasn't any documentation the Medical Director of Behavioral Health had been notified of Pt #4's restraint/seclusion events and had reviewed the record for orders and reasons for the restraint/seclusion.

Based on document review and interview, it was determined for 3 of 3 (Pts #6, #13, and #14) patients, who required non-violent restraints beyond 24 hours, the Hospital failed to ensure orders to continue restraints was written in accordance with its policy. This has the potential to affect all Inpatients and Emergency Department (ED) patients serviced by the Hospital with an average daily census of 37 patients and 257 patients respectively.

Findings include:

1. The Hospital policy titled "Policy Number: 9000-035B...Restraints for Non-Violent Behaviors" (effective June 10, 2016) was reviewed on 5/17/17 at approximately 2:00 PM. The policy stated "Procedure: 4. F. The RN (Registered Nurse) will assess the patient's response to the restraint and if continued use is clinically justified beyond the first 24 hours, the order can be renewed by a physician, APN (Advance Practice Nurse), or PA (Physician Assistant). Such an order is issued no less often than once each calendar day."

2. Pt #6's record was reviewed on 5/17/17 at approximately 10:00 AM. Pt #6 was admitted to the ED on 4/28/17 with the Chief Complaint of Abdominal pain and admitted to ICU (Intensive Care Unit) with the diagnosis of Diverticulitis with Abscess. Pt #6's record indicated Pt #6 was placed in non-violent soft wrist restraints on 4/29/17 at 3:45 AM and remained in non-violent soft wrist restraints on 4/30/17 at 12:49 PM when Pt #6 was transferred to another facility. The record lacked an order for the continuation of the restraints for 4/30/17.

An interview was conducted on 5/19/17 at approximately 11:00 AM with the Clinical Director (E#2). E#2 reviewed Pt #6's record and verbally agreed Pt #6's record lacked an order to continue the restraints for 4/30/17.

2. Pt #13's record was reviewed on 5/18/17 at approximately 3:00 PM. Pt #13 was admitted to the Hospital on 3/21/17 with the diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. Nursing documentation stated Pt #13 required non-violent soft restraints from 3/21/17 thru 3/23/17. The record lacked an order for the continuation of the restraints for 3/22/17.

3. Pt #14's record was reviewed on 5/18/17 at approximately 3:30 PM. Pt #14 was admitted to the Hospital on 5/1/17 with the diagnosis of Peritonitis. Nursing documentation stated Pt #14 required non-violent soft restraints from 5/1/17 thru 5/4/17. The record lacked an order for the continuation of the restraints for 5/3/17.

4. An interview was conducted with the Chief Nursing Officer (E#6) on 5/19/17 at approximately 9:00 AM. E#6 had reviewed the records of Pts #13 and #14 and verbally agreed the records lacked orders for the continuation of restraints at least once every calendar day as per Hospital policy.

Based on document review and interview, it was determined for 2 of 3 (Pts #13 and #14) patients who required non-violent restraints, the Hospital failed to ensure restrained patients were monitored in accordance with its policy. This has the potential to affect all Inpatients and Emergency Department (ED) patients serviced by the Hospital with a current average daily census of 37 patients and 257 patients respectively.

Findings include:

1. The Hospital policy titled "Policy Number: 9000-035B...Restraints for Non-Violent Behaviors" (effective June 10, 2016) was reviewed on 5/17/17 at approximately 2:00 PM. The policy stated "Procedure: 5. Safe use of restraints will be achieved by: D. Patients are assessed and needs attended to minimally upon restraint initiation and every 2 hours. The following interventions/care are to be provided every 2 hours or more often... iii. Restraint removed & (and) reapplied... viii. Range of motion..."

2. Pt #13's record was reviewed on 5/18/17 at approximately 3:00 PM. Pt #13 was admitted to the Hospital on 3/21/17 with the diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. Nursing documentation stated Pt #13 required non-violent soft restraints from 3/21/17 10:15 AM thru 3/23/17 7:45 AM. The record lacked every 2 hour monitoring between 1:50 PM and 4:15 PM (two hours and twenty five minutes) on 3/21/17.

3. Pt #14's record was reviewed on 5/18/17 at approximately 3:30 PM. Pt #14 was admitted to the Hospital on 5/1/17 with the diagnosis of Peritonitis. Nursing documentation stated Pt #14 required non-violent soft restraints from 5/1/17 thru 5/4/17 at 8:00 AM. The record lacked the following:
a. Every 2 hour monitoring six times during this period ranging two hours and nineteen minutes to three hours and thirty one minutes.
b. Every 2 hour removal, reapplication, and range of motion on 5/2/17 from 6:19 AM to 8:00 PM and on 5/3/17 6:00 AM to 7:32 PM.

4. An interview was conducted on 5/19/17 at approximately 9:00 AM. E#6 had reviewed the records of Pts #13 and #14 and verbally agreed both records lacked every 2 hour monitoring and Pt #14's record also lacked removal and reapplication of the restraints and range of motion every 2 hours.

Based on document review and interview, it was determined for 3 of 3 (MD- Medical Doctor #1, MD#2, and MD#3) physicians whom have the ability to order the use of violent and/or non-violent restraints, the Hospital failed to ensure MDs ordering restraint and/or seclusion had a working knowledge of the Hospital's policy. This has the potential to affect all inpatients and Emergency Department patients serviced by the Hospital with an average daily census of 37 and 85, respectively.

Findings include:

1. The Hospital policies titled "Restraints and/or Seclusion for Violent Behavior", Policy Number 9000-035A and "Restraints for Non-Violent Behaviors", Policy Number 9000-035B, (both effective June 10, 2016) were reviewed on 5/16/17 at approximately 10: AM. The policies both stated orders for "restraint and/or seclusion" and for "restraints" "require an order from a physician or Allied Health Professional... with competency in monitoring, assessment, and care of the restrained patient."

2. The physician (MD#1, MD#2, and MD#3) files were reviewed on 5/17/17 at approximately 1:40 PM with the Medical Staff Coordinator (E#12). The Clinical Director (E#2) was also present. The files lacked documentation the physicians had a working knowledge of the Hospital's restraint and/or seclusion policy and competence in ordering restraints, in accordance with the Hospital's policy.
MD#1- initial appointment 8/14/15 and reappointed 12/23/16.
MD#2- Initial appointment 12/18/14 and reappointed 12/23/16.
MD#3- Initial appointment 4/21/15 and reappointed 12/14/16.

3. An interview was conducted with the E#12 on 5/17/17 at approximately 1:40 PM. E#12 stated "The physicians and midlevel providers do not have any documented training in this (the Hospital's restraint/seclusion policy or competency in monitoring, assessment, and care of the restrained patient). E#12 stated "No training has been sent to these providers until today when I received an email from the Chief Medical Officer (E#13) to email all the providers with the link to the article on restraints. It doesn't include our policy or any competency things."

Based on document review and interview, it was determined for 1 of 2 (E#8) Behavioral Health Technicians, the Hospital failed to ensure training to identify staff and patient behaviors, events, and environment factors that may trigger circumstances that require the use of a restraint or seclusion. This has the potential to affect all patients serviced by the Behavioral Health Unit with an average daily census of 8 patients.

Findings include:

1. The Job Description titled "11005-6090 Inpatient Behavioral Tech (Technician)/Clerk" (Date: 3-2016) was reviewed on 5/17/17 at approximately 3:30 PM. The Job Description stated "Must complete crisis management training course within 90 days of employment."

2. An interview was conducted with the Nurse Manager of Behavioral Health (E#1) on 5/16/17 at approximately 2:00 PM. E#1 stated the crisis management training course used by the Hospital is the TEAM (Techniques For Effective Aggression Management).

3. The TEAM "Essentials Workbook" was reviewed on 5/17/17 at approximately 12:15 PM. The Workbook stated objectives such as: Identify the factors which contribute to the potential for violence. Recognize the characteristics of an aggressor. Discuss the management of aggressive behavior and demonstrate techniques to effectively manage aggressive behavior. Identify useful verbal techniques to de-escalate potential volatile situations, etc.

4. The personnel file of Behavioral Health Technician (E#8) was reviewed on 5/17/17 at approximately 3:30 PM with the Interim Human Resources Manager (E#18). E#8 was hired by the Hospital as a Clerk and transferred to the Behavioral Health Unit in August of 2016 as a Behavioral Health Technician/Clerk. The file lacked any documentation of TEAM training.

5. An interview was conducted with the Chief Nursing Officer (E#6) on 5/17/17 at approximately 4:00 PM. E#6 stated E#18 had conveyed that E#8 had not completed the TEAM training as of this date and time and should have.