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Based on interviews and document review, it was determined the facility staff failed to ensure a patient having restraints and/or seclusion utilized for violent behaviors was evaluated within the required time limits for one (1) of four (4) patients sampled for restraint review (Patient 9). Two (2) of the four (4) sampled patients had restraints implemented due to violent behaviors.

The findings include:

Patient #9's clinical documentation failed to provide evidence of the face-to-face assessment being completed within one (1) hour of the initiation of restraints and/or seclusion for violent behaviors. It was also identified that the facility's written policy and procedure incorrectly provided guidance to indicate a face-to-face was not required within the 1-hour time frame if the restraints and/or seclusion was discontinued prior to the completion of the 1-hour face-to-face assessment.

The following nursing documentation was dated 7/10/17 at 9:21 but the content of the documentation detailed events earlier the same day (prior to the initiation of restraints and seclusion): " ... (he/she) INITIALLY REFUSED TO COOPERATE WITH THE SKIN ASSESSMENT AND SAFETY SEARCH BUT FINALLY DID WITH MUCH ENCOURAGMENT AND SARCASM [sic]. (he/she) THEN STARTED TO BANG (his/her) HAND ON WINDOW AND SAID (he/she) WOULD MAKE (his/her) HANDS BLOODY. (He/She) THEN SAID (he/she) WOULD JUST FIND SOMETHINGIN THE BATHROOM TO HURT OR HANG (himself/herself) ..."

Patient #9's clinical documentation included the following nursing documentation dated 7/10/17 at 8:53AM: "Upon arrival to the unit, patient was noted to be increasingly agitated with staff and attempting to elope. Patient walked into the seclusion room, without hands-on interventions. CPI De-Escalation techniques (orientation, reassurance, offering of food/beverage) used to help de-escalate patient. At 0710, seclusion room door was locked to prevent patient from eloping and harming staff. Haldol 5 mg IM, Ativan 2 MG IM, and Benadryl 50 mg IM order [sic] and seclusion order obtained from (doctor's name omitted). This writer maintained constant observation of patient. Patient begin [sic] to head bang and door was unlocked at 0720. (RN name omitted) administered IM medications for patient. Patient accepted medication willingly. At this time, patient noted to still be agitated, stating <> [sic] and requested to leave. This writer contacted (name omitted) at (agency initials omitted) to have patient evaluated for TDO ..."

The following medication orders were found in Patient #9's clinical documentation: (1) on 7/10/17 at 6:59AM an order for Bendaryl 50mg IM (intramuscular injection) as a one-time dose; (2) on 7/10/17 at 6:59AM an order for Ativan 2mg IM as a one-time dose; and (3) on 7/10/17 at 6:59 Haldol 5mg IM as a one-time dose. Patient #9's clinical record also included orders for Seclusion documented as being entered on 7/10/17 at 7:25AM; this seclusion order was for the events documented in the aforementioned nursing documentation.

Patient #9's clinical documentation indicated on 7/10/17 the patient was placed in seclusion at 7:10AM and removed from seclusion at 7:20AM.

Documentation was not found in Patient #9's clinical record to indicate the 1-hour face-to-face assessment had been completed.

The following information was found in a facility policy and procedure provided to the survey team after the entrance conference; this policy and procedure was entitled "Restraints, Patient" (with an effective date and a last review date of 02/2016): "Face-to-face assessment by a Physician or LIP: 1. Face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will: a. Work with staff and patient to identify ways to help the patient regain control b. Evaluate the patient's immediate situation c. Evaluate the patient's reaction to the intervention d. Evaluate the patient's medical and behavioral condition e. Evaluate the need to continue or terminate the restraint or seclusion f. Revise the plan of care, treatment and services as needed Note: A telephone call or telemedicine methodology does not constitute face-to-face assessment. 2. When the 1-hour face-to-face is performed by a RN or physician assistant with demonstrated competence, the following must occur: a. The RN or physician assistant with demonstrated competence must consult the attending physician or LIP who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. ("As soon as possible" is to be as soon as the attending physician is able to be reached by phone or in-person.) A consultation that is not conducted prior to renewal of the order would not be consistent with the requirement "as soon as possible." b. The consultation should include, at a minimum, a discussion of the findings of the 1-hour face-to-face evaluation, the need for other treatments, and the need to continue or discontinue the use of restraint or seclusion. c. If a patient who is restrained or secluded for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the face-to-face assessment, the physician must still see the patient face-to-face to perform the assessment within 24 hours."

The following information was found in "APPENDIX D: DEFINITIONS" of the aforementioned
"Restraints, Patient" policy and procedure. This is part of the definition for "Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint. When medications are used as restraints, it is important to note that the decision as to whether they constitute restraint is not specific to the treatment setting, but to the situation the restraint is being used to address. A mediation that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint ..."

On 7/19/17 at 1:50PM, Staff Member (SM) #7 (a registered nurse (RN)) was interviewed with the facility's Quality Manager present. SM #7 was the RN that was responsible for the completion of 1-hour face-to-face assessment for the medications as restraints and seclusion utilized for Patient #9 on the morning of 7/10/17. SM #7 reported that he/she did see Patient #7 after the medications was administered and the patient was removed from seclusion. SM #7 acknowledged no assessment was documented and the physician wasn't contacted because the "medications changed the behaviors so (the patient) didn't need to be in seclusion".

On 7/20/17 at 9:25 during a survey team meeting with the facility's Vice-President of Quality and Risk, Chief Executive Officer (CEO), Quality Manager, and Chief Nursing Office (CNO), the failure of the facility staff to ensure a 1-hour face-to-face assessment was completed and documented, after Patient #9 was administered medication and placed in seclusion for 10 minutes on the morning of 7/10/17, in response to patient behaviors, was discussed.