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Based on review of 8 open and 7 closed medical records, inclusive of three violent restraint records from the behavioral health unit, it was determined that the medical and nursing staff failed to obtain a seclusion order for patient #3 and failed to obtain an order as soon as possible after the restraint and seclusion episode initiated for patient #8 .

Patient #8 was an adult patient who was voluntarily admitted to the behavioral health unit from an outside emergency department (ED) for suicidal ideations and delusions. On the 16th day of admission, patient #8 was held for an intramuscular injection and placed in locked-door seclusion for threatening behavior at 1115.

Per the document titled "Violent Restraint and Seclusion Management Order Flowsheet," the order was signed by the provider at 1230, over an hour after initiation of the restraint episode.

Patient #3 presented to the Emergency Department (ED) with acute psychosis and suicidal thoughts including threats of self-harm. Patient #3 was admitted to the behavioral health unit and a treatment plan was initiated. Review of patient's medical record revealed several incidents of violent restraints. Additionally, on separate dates, two clinicians documented patient #3 "has had episodes where [patient #3] has been in seclusion" and "[Patient #3] was diverted to seclusion for increased observation". No evidence was found in patient's medical record of a physician order for seclusion.

This tag has been cited in two previous surveys in August 2017 and January 2018 for the same issue of obtaining late orders.

Based on review of 8 open and 7 closed medical records, inclusive of three patient records from the behavioral health unit, it was determined that the medical staff failed to adequately document all of the components of the face-to-face assessments for all three behavioral health patients and obtain a face-to-face within an hour for 1 of 3 patients.

For all three behavioral health patient records reviewed, a face-to-face document was found titled "Restraint and Seclusion Physician Face-to-Face Evaluation." On this form, under the "One Hour Face-to-Face Evaluation," there were four check boxes with pre-printed assumptions, of which 3 out of 4 did not meet the criteria of a face-to-face.

The assumptions include: "The interventions attempted to modify the patient's behavior as documented on the flowsheet necessitates seclusion/restraints since attempts to modify risky behaviors were unsuccessful." This does not describe an actual real-time assessment of the immediate patient situation.

"The medical and behavioral condition is stable and safe." This only generally describes the actual patient medical and behavioral condition and does not clearly describe the patient's current behavior.

"Restraint/seclusion needs to be terminated as soon as patient is safe." This does not address the real-time question of whether the patient may be released or should be in continued in restraints.

Patient #8 was an adult patient who was voluntarily admitted to the behavioral health unit from an outside emergency department for suicidal ideations and delusions. Per the restraint order sheet, on the 16th day of admission patient #8 was held for an intramuscular injection and placed in lock door seclusion for threatening behavior at 1115. Patient #8 was released from seclusion at 1203. Per the face-to-face documentation, the narrative below the checked boxes did not address the patient's immediate situation or the medical and behavioral condition at the time of the face-to-face. On the same form, the provider checked the check box off that the patient needed "to continue use of restraint/seclusions" after the patient was no longer in seclusion. The face-to-face was signed at 1230, over an hour late from restraint initiation.

Patient #2 was an adult patient who was voluntarily admitted to the behavioral health unit after presenting to the ED with symptoms of manic behavior. On patient's 3rd day of admission, patient #2 was placed in locked door seclusion for combative behavior at 0210. Per the face-to-face documentation at 0244, the narrative below the checked boxes did not address the patient's immediate situation or the medical and behavioral condition at the time of the face-to-face.

Patient #3 presented to the Emergency Department (ED) with acute psychosis and suicidal thoughts, including threats of self-harm. patient # 3 was admitted to the behavioral health unit and a treatment plan was initiated. Review of patient #3's medical record revealed three incidents of violent restraint, one physical hold event and two 4-point episodes.

On day nine of admission, patient #3 was exhibiting active self-injurious behavior and staff documented that attempts to re-direct the patient were unsuccessful. The treating provider ordered 4-point violent restraints to prevent self-harm. Based on the review, it was determined the hospital failed to provide complete documentation of the face-to- face evaluation, including a description of the four conditions required, by the ordering provider.

Due to active self-injurious behavior, patient #3 required a physical hold for the administration of emergency medication on day 13th of admission. Patient #3 was "biting and scratching" at self. Staff documented multiple attempts to de-escalate the patient were unsuccessful and patient #3 refused oral medications. The face-to-face assessment documentation completed by the ordering provider did not include a detailed narrative of the four conditions required.

On day 17th of admission, patient #3 was threatening staff and exhibiting active self-injurious behavior. Per the patient record, all attempts to calm and redirect patient #3 were unsuccessful. The provider ordered 4-point violent restraints to protect the patient and staff from injury. The face-to-face assessment documentation completed by the provider did not include a detailed narrative of the four conditions required.

In summary, the hospital's face-to-face process failed to conduct real-time, objective assessments and document all four components of a face-to-face. This is a repeat deficiency from a survey in August 2017.