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Based on a review of medical records, a review of policy and procedures, a review of personnel files and interviews with staff it was determined that the facility failed to ensure that patients received care in a safe setting specifically:
1. One (P#1) of nine patients reviewed was placed in seclusion without a physician order.
2. One (P#1) of nine patients reviewed was not assessed by a qualified staff member within one hour of being placed in seclusion.
3. Three (RN FF, RN GG, and RN KK) of ten personnel files reviewed failed to contain documentation of current emergency safety intervention training.

Findings include:
Cross reference to A0168 as it relates to the facility's failure to ensure that seclusion was initiated with a physician's order.

Cross reference to A0179 as it relates to the facility's failure to ensure that a qualified staff member assessed patients within one hour of the initiation of seclusion.

Cross reference to A0194 as it relates to the facility's failure to ensure that staff working on the Behavioral Health Unit have current emergency safety intervention training.

Based on a review of medical records, a review of policy and procedures and interviews with staff it was determined that the facility failed to ensure that the use of restraints or seclusion was in accordance with a provider's order when one (P#1) of nine sampled patients was placed in seclusion without an accompanying order on 9/7/22, 9/8/22, 9/11/22, 9/12/22, and 9/22/22.

Findings include:

A review of P#1's medical record included the following:

The 'Seclusion/Restraint 15 Minutes and RN Hourly Rounding' sheet revealed that P#1 was in seclusion on 9/7/22 from 5:00 p.m. until 9:30 p.m. without a corresponding physician order.

The 'Special Precautions Patient Observation' revealed that P#1 was in seclusion on 9/8/22 from 4:15 p.m. to 5:15 p.m. without a corresponding physician order.

The 'Special Precautions Patient Observation' revealed that P#1 was in seclusion on 9/11/22 from 7:15 a.m. to 8:45 a.m. without a corresponding physician order.

The 'Special Precautions Patient Observation' revealed that P#1 was in seclusion on 9/12/22 from 2:15 p.m. to 3:45 p.m. without a corresponding physician order.

A review of 'Patient Progress Notes' on 9/22/22 at 6:30 a.m. revealed that P#1 was placed in seclusion for striking staff member. P#1 was removed from seclusion at 8:35 a.m. The record failed to include a physician order for the seclusion on 9/22/22.

A review of the facility's 'Use of Seclusion/Restraint' policy no. 02.27.01, effective 11/15/2021, revealed that the use of restraint and seclusion poses an inherent risk to the physical safety and psychological well-being of the individual served and staff. Therefore, restraint and seclusion are used only in an emergency when there is an imminent risk of an individual served physically harming herself or himself or others, including staff. Nonphysical interventions are the first choice unless safety demands an immediate physical response.

POLICY/GENERAL GUIDELINES
The Behavioral Health Unit follows related hospital policies and accreditation standards such as TJC (The Joint Commission), Healthcare Facilities Accreditation Program (HFAP), and DNV (Det Norske VERITAS).

PROCEDURE
The practices outlined in this protocol provide further guidance in effectively managing restraint and seclusion episodes.
Ordering of Seclusion or Restraints
1. A licensed independent practitioner (LIP) orders the use of restraints or seclusion. For purposes of this protocol, LIP refers to physicians and advance practice nurses.
a) In an emergency when a physician is not immediately available, the use of restraint and/or seclusion may be initiated by a Registered Nurse.
(1) A verbal/telephone order is to be obtained during restraint application or immediately after the restraint is applied.
b) If a physician is not the person who ordered the restraints, she/he shall be notified that restraints were applied (e.g., through review of the restraint order).
c) A physician must sign the seclusion/restraint order within 24 hours of the initiation of the seclusion or restraint episode.

During an interview with Quality Director (QD) LL in the Board Room on 6/28/23 at 1:00 p.m. she confirmed that she had researched the records for P#1 through P#13 and provided all documentation of restraints, seclusion, social work, discharge planning, and activities therapy. QD LL does chart audits and acknowledged that documentation is a problem, and it was identified on 12/14/22. She stated that a Quality action plan had been initiated about seclusion documentation a few months ago with a 90-day completion date of 3/13/23.

Based on a review of medical records, a review of policy and procedures and interviews with staff it was determined that the facility failed to ensure that patients in seclusion for the management of violent behavior were assessed face to face by a qualified person within one hour after initiation of the intervention when one (P#1) of nine sampled records failed to include the 'Seclusion/Restraint 15 Minutes and RN Hourly Rounding' documentation for seclusion incidents on 9/7/22, 9/10/22, 9/12/22, 9/13/22, 9/14/22, 9/15/22, and 9/22/22.

Findings include:

A review of P#1's medical record revealed that he was placed in seclusion on 9/7/22 at 5:00 p.m. and the first RN assessment was at 9:30 p.m.
A review of P#1's medical record revealed that he was placed in seclusion on 9/10/22 at 11:59 p.m. and the first RN assessment was at 4:28 a.m.
A review of P#1's medical record revealed that he was placed in seclusion on 9/12/22 at 2:21 p.m. and the first RN assessment was at 5:00 p.m.
A review of P#1's medical record revealed that he was placed in seclusion on 9/14/22 at 7:45 p.m. and the record failed to include documentation by an RN during seclusion.
A review of P#1's medical record revealed that he was placed in seclusion on 9/15/22 at 8:40 a.m. and the first RN assessment was at 10:20 a.m.
A review of P#1's medical record revealed that he was placed in seclusion on 922/22 at 6:30 a.m. and the first RN assessment was at 8:35 a.m.

A review of the facility's 'Use of Seclusion/Restraint' policy no. 02.27.01, effective 11/15/2021, revealed that the use of restraint and seclusion poses an inherent risk to the physical safety and psychological well-being of the individual served and staff. Therefore, restraint and seclusion are used only in an emergency when there is an imminent risk of an individual served physically harming herself or himself or others, including staff. Nonphysical interventions are the first choice unless safety demands an immediate physical response.

POLICY/GENERAL GUIDELINES

The Behavioral Health Unit follows related hospital policies and accreditation standards such as TJC (The Joint Commission), Healthcare Facilities Accreditation Program (HFAP), and DNV (Det Norske VERITAS).

PROCEDURE
The practices outlined in this protocol provide further guidance in effectively managing restraint and seclusion episodes.
Monitoring of Individual in Restraints or Seclusion
1. Individuals in seclusion or restraints are monitored. Monitoring of individuals in restraint or seclusion is done through continuous in-person observation by an assigned staff member.
a) Individual in restraints - Assigned staff will be with patient at all times and within arm's length.
b) Individual in seclusion - Assigned staff will have patient within eyesight at all times.
c) Monitoring of individuals in restraints or seclusion is documented on the Behavioral Restraints/Seclusion (Violent/Self-Destructive Behavior) Monitoring Record as well as on the individual's Department of Behavioral Health Observation Sheet
(1) The back of the Observation Sheet is used to document specific behaviors that occur during the 15-minute monitoring checks.
(2) Hourly vital signs and those taken at release are recorded on Behavioral Restraints/Seclusion (Violent/Self-Destructive Behavior) Monitoring Record and then updated to the patient's vital sign sheet.
d) The Nurse Manager, or the nurse in charge of the patient if the Nurse Manager is off-site, will perform a reassessment of the patient at each hour after application of restraints or seclusion.
K. Documentation of the Seclusion or Restraint Episode
1. The clinical record contains documentation of the use of restraints or seclusion. Documentation in the clinical record includes but is not limited to:
a) Nursing/Clinician Assessment: De-escalation Preferences
(1) Any pre-existing medical conditions or any physical disabilities that would place the individual served at greater risk during restraint and/or seclusion.
(2) Any history of sexual or physical abuse that would place the individual at greater psychological risk during restraint and/or seclusion.
b) Behavioral Restraints/Seclusion Orders for Management of Violent/Self Destructive Behavior
(1) Each episode of restraint and/or seclusion
(2) The circumstances that led to the use of restraints and/or seclusion
(3) Consideration or failure of nonphysical interventions
(4) Written orders for the use of restraints and/or seclusion
(5) Each verbal order received from a licensed independent practitioner.
(6) Each in-person evaluation and reevaluation of the individual served.
c) Behavioral Restraints/Seclusion (Violent/Self-Destructive Behavior) Monitoring Record
(1) Each 15-minute assessment of the status of the individual served
(2) Continuous monitoring of the individual served
(3) Reassessment of patient's physical and psychological condition.
(4) Behavior criteria for discontinuing restraint and/or seclusion.
d) Patient Debriefing Form
(7) That the individual served was informed of the behavior criteria he or she needed to meet in order for restraint and/or seclusion to be discontinued.
(8) Assistance provided to the individual served to help him or her meet the behavior criteria for discontinuing the use of restraints and/or seclusion, including medications.
(9) Debriefing the individual served with staff following an episode of restraint and/or seclusion.
(e) Treatment Plan of Care
(10) The Plan of Care will be updated by the nurse in the event of a seclusion or restraint episode to reflect that the event occurred and to identify the associated treatment goals, objectives, and interventions for the patient.
(a) The Plan of Care is updated every time a seclusion or restraint episode occurs.
(f) Progress Notes (if warranted)
(1) May include information related to any of the above information such as what led up to and occurred during and after the episode may be read and understood by other staff and internal and external reviewers.
(2) Any injuries the individual served sustained and the treatment for these injuries.
(3) The death of the individual served while in restraint or seclusion.

During an interview with Quality Director (QD) LL in the Board Room on 6/28/23 at 1:00 p.m. she confirmed that she had researched the records for P#1 through P#13 and provided all documentation of restraints, seclusion, social work, discharge planning, and activities therapy. QD LL does chart audits and acknowledged that documentation is a problem, and it was identified on 12/14/22. She stated that a Quality action plan had been initiated about seclusion documentation a few months ago with a 90-day completion date of 3/13/23.

Based on review of policy and procedures, review of personnel files and interviews with staff it was determined that the facility failed to ensure that all staff assigned to the Behavioral Health Unit (BHU) had completed mandatory emergency safety intervention training when three (RN FF, RN GG, and RN KK) of ten reviewed personnel files failed to include evidence of current CPI training.

Findings included:

A review of the facility's policy no. 01.13.01 titled 'Staffing' effective 11/15/21 revealed that staff were supervised by the Program Director and hospital leadership. The supervisor ensured a proper patient staff ratio for safe quality care and treatment. Continued review revealed that procedures included that staff was competent to completed their assigned duty and responsibilities and competencies were assessed annually. Human Resources assisted in the monitoring of licensed staff for expiration. All staff were to present to their supervisor or HR any certifications or recertifications in relation to their position.

A review of the facility's policy no. 03.01.01 titled 'Staff Qualification and Competency', effective 11/15/2021 revealed that the purpose was to establish a means of ensuring qualified competent staff provide care, treatment and services to the Behavioral Health Unit patients. The organization has in place a system to ensure that the licensure, registration and certification required for patient care staff is continually maintained. Along with policies to ensure that all employees are qualified and competent in accordance with local, state and federal laws and regulations. It is the policy of the Behavioral Health Unit to ensure all staff members meet the qualifications and competency requirements established by the hospital so they can provide patient care.

This process is ongoing from their initial employment, continuous observation education and annual in-service training. Their observation, training, continuing education and annual evaluations are overseen by the Program Director (or organization's equivalent) and Human Resource Department.

II. Human Resource Initial Employment- Program Director (or organization's equivalent)
A. Job descriptions-
1. Explanations and performance expectations during the interview and orientation.

B. Initial verification of Professional License. (copies)
1. Professional License Personnel- shall have licensure and certification verified.
a) Have an Active State License or is in the process of obtaining a state license.
C. Initial verification of Certifications as required by the job description and via primary source verification,
1. Or are in the process of getting the certification- (such as CPR, CPI, etc.)
D. Initial assessment of competencies-
1. Will be assessed during the orientation process prior to the employee providing care or services.
2. Independent or joint responsibility between the specific department, Orientation (if Organization/Hospital has a separate Department) and Human Resources.

III. Unit Specific Orientation upon employment.
A. Unit -Co Workers
B. Unit- Work Area/Unit Tour
C. Overview of the Unit
D. Unit Mission, Vision and Values
E. Unit Policies and Procedures
1. Age Specific Competencies
2. Infection Control - Hand Washing
3. Safety and the Environment
a) Seclusion/Restraint
b) Electrical Safety
c) Disaster Plan
d) Fire Safety
4. Annual Evaluation/Orientation & Annual Re-Orientation (hospital)
5. Age Specific Competencies
6. CPR Certification
7. Code Blue Review
8. CPI or other equivalent
9. Patient Abuse & Neglect
10. Patient Rights and the complaint process
11. Confidentiality/HIPPA

IV. New Staff Supervision:
A. New staff members will have direct supervision for a designated period of time during their orientation.
B. Once the new staff member has demonstrated competence in performing the skills required for their position and met the orientation criteria he/she will be approved to perform their role independently.

V. Members Mandatory Annual in-services
A. All employees will attend the Hospital Wide Annual In-service or go online to complete the specified in-service assignments as directed by HR.
B. BHU staff members will attend all mandatory in-services that are required for the Behavioral Health Unit which are Unit Specific. (These may be offered online and will need to be completed).

A review of the facility's PowerPoint Presentation titled 'Geri-Psych Orientation', no date, revealed that all staff were trained in CPI non-violent crisis intervention techniques. Staff were certified upon hire and re-certified annually.

A review of ten (NP AA, LPN BB, RN CC, CNA EE, RN FF, RN GG, AC HH, SW II, CNA JJ, and RN KK) personnel files revealed that three (RN GG, RN FF, and RN KK) failed to include current CPI training.

An interview was conducted with Manager of Behavioral Health (Mgr) AA on 6/27/23 at 10:30 AM in The Board Room. She has been employed on the behavioral unit since 11/21. Mgr AA explained that she functioned as the manager and as the Psychiatric Nurse Practitioner. She assessed all patients daily. During the incident with P#2, it was determined that RN FF did not have Crisis Prevention Institute (CPI) training. RN FF obtained CPI training after the incident. They have since remodeled the orientation training for agency nurses. Mgr AA explained that all BHU staff were required to complete CPI training. The training was presented by one of the consultant staff who was a certified instructor. She further explained that RN FF was no longer in a contract with the facility. RN GG, had also been a contract nurse did complete CPI after it was determined that the agency staff did not have it, RN GG was terminated on 5/20/23.

During an interview with Quality Director (QD) LL in the Board Room on 6/28/23 at 1:00 p.m. she confirmed that RN FF and RN GG had worked on the BHU prior to obtaining CPI certification. QD LL explained that the facility had issues with maintenance of personnel files and that they were in the process of working to get all files updated.