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Based on document review and interview the facility failed to protect patients' rights resulting in the potential for loss of the patients' rights to be free from either restrains or seclusion. Findings include:

This CONDITION is not met based on:
---the facility failed to ensure that staff did not use seclusion as a form of discipline (See A-154),
---the facility failed to ensure that staff followed physician orders for seclusion (See A-168),
---the facility failed to ensure that 2 of 3 security staff (N, P) had received annual training for "Non-Violent Crisis Intervention Training (CPI)" (See A-200).

Based on document review and interview, the facility failed to ensure that staff did not use seclusion as a form of discipline for one of three patients (#4) patients on the behavioral health unit that required behavioral restraints resulting in the potential for the loss of rights for all patient's receiving treatment on the behavioral health unit. A total universe of four records were reviewed for restraints, three records were reviewed for behavioral restraints and one for medical restraints. Findings include:

On 03/18/2015 at 1400, during review of the medical record for patient #4 revealed that he had been admitted to the hospital's behavioral health unit on 02/11/2015 due to "Psychosis, Agitation, Aggression, Hallucinations, Delusions and non-compliance with treatment." On 02/25/2015 at 1730, he required 4 point leather restraints due to being "Out of control, broke property." He remained in the restraints for a total of two and a half hours (150 minutes) at which time he was able to calm down and the restraints were removed. Then on 03/02/2015 at 0855 the patient again became aggressive and he aggressed on the psychiatrist injuring him to the point where he required treatment in the Emergency Department. At this time the patient was again placed into restraints for four hours with the order expiring at 1300. The documentation supports that at 1300 the patient was removed from the four point leather restraints and placed into seclusion. On 03/02/2015 at 1300, the face to face evaluation completed by the psychiatrist read, "No physical exam due to violent threat. Sleeping, No internal complaints of pain, No overt evidence of illness or injury." The RN (Registered Nurse) documented on 03/02/2015 at 1300, "Explanation given to patient regarding need for patient to be in seclusion room for safety reasons. patient cooperative with staying in room as security left. 1330 patient lying on bed, awake, 1345 Security here. Patient cooperative with vitals. At 1415, Security here. patient used urinal. Asking when he can come out. At 1515, Continues to pace in seclusion room. Security here. patient given food. States he is not mad at staff. 'I'm just mad at the doctor.'" On 03/02/2015 at 1700 the physician performed another face to face evaluation of the patient. The evaluation stated, "Checked on patient. Observed through window. Appeared to be sleeping in no distress." The patient was to remain in seclusion for the next four hours. Also on 03/02/2015 at 1700 an RN documented "Debriefing/COPING: C=Patient is relatively calm and willing to talk. O= patient relates he got upset with the doctor when he told him something he felt was a lie so 'I just lost it.' P= Patient relates he just looses control when he gets upset. I Explored what he might do differently next time, patient did not have any ideas except to say 'I'll try not to loose it.' N= Suggested patient might try to focus on expressing his feelings in a non violent fashion. G= Support and encouragement given, but patient continues to lack insight and motivation." Documentation on 03/02/2015 at 1900 read, "Patient resting in seclusion. Color good, respirations regular and euphenic. Patient remains unpredictable." At 2100 on 03/02/2015, the physician did another face to face evaluation for another four hour continuation of seclusion. The physician documented, "Patient observed through monitoring window. Appears to be sleeping in bed in no distress. No complaints from nursing staff that has been monitoring him. Will follow in four hours." On 03/02/2015 at 2300 the RN documented, "Patient remains in seclusion due to unpredictable behavior and threat to others. No physical distress. On 03/03/2015 at 0059 the RN documented, "Hospitalist contacted by this staff. Discussed situation of patient and obtained order for continuation of patient 4 hour seclusion." At 0100 a RN documented the following, "C=Control Is the patient calm, rational, in control? Yes, he is not aggressive. Is polite and asking for a snack." On 03/03/2015 at 0135 the physician conducted another face to face evaluation on the patient and documented, "Observed patient from observing window. Appears to be eating meal of cereal. In no distress. No complaints form nursing staff. Continued seclusion for assault on medical staff earlier today." Documentation on 03/03/2015 at 0300 read, "Patient resting in bed in quiet room with eyes closed. Respirations even and non-labored. No acute distress noted. 1:1 continued." At 0456 the RN documented, "Patient resting quietly with eyes closed in bed in seclusion. Breathing non-labored. No acute distress observed. Continue 1:1 monitoring. Hospitalist was contacted and discussed continuation of seclusion order." At 0500 the physician completed the face to face evaluation and documented, "patient observed through observation window. appears to be sleeping in no distress. No concerns form nursing staff. Patient to remain in seclusion for assault on MD (Medical Doctor) earlier today." On 03/03/2015 at 0800 the RN documented, "Patient continues to be delusional irrational, Flexing his muscles. Patient denies hallucinations. Rates anxiety as 2/10. Stated he did not want a particular nurse to care for him. Patient continues to talk verbally aggressive toward the doctor." On 03/03/2015 at 1000 the physician completed a face to face evaluation and the patient was to remain in the seclusion room for another four hours. The physician documented, "Violent behavior, transfer to state psychiatric facility pending." On 03/03/2015 at 0914 the physician documented a plan that stated, "He is going to be kept in seclusion area as he is very unpredictable." The documentation supports that the patient remained in the seclusion room until the time of his discharge on 03/04/2015 at 0925 to the county jail.

In an interview with staff E on 03/18/2015 at 1600, when queried about why the patient was kept in seclusion when at times the documentation stated that the patient was either calm, lying quiet or sleeping, he stated, "They felt that his behavior was unpredictable." When queried if most patients on the psychiatric units are unpredictable, he stated, "Yes, they are." When queried if he would then agree that most patients are not kept in seclusion for being unpredictable, he stated, "Yes, I agree with that."

On 03/19/2015 at 0745 a review of the facility's policy titled, "Restraint and Seclusion - Behavioral Management, #9127-0301, date Last Revision: 08/2014," read, "Purpose: The purpose of this policy is to provide guidelines for nursing and medical personnel on the use of restraint and seclusion. All restraint or seclusion in behavioral health units are subject to the guidelines for the care of the violent patient. At (Facility A), it is the expectation that restraint or seclusion be implemented as a last resort. Hence, restraint or seclusion use is only considered after assessment data yields information that supports that the use of non-restraint measures poses a greater risk to the safety of the patient or others. In addition, restraints or seclusion is never instituted based on a 'history' of dangerous behavior. Restraint or seclusion is never used for staff convenience, for patient discipline or punishment, as a means of coercion or retaliation, or as a substitute for treatment or adequate staffing. In clinical situations where restraint or seclusion is used, the least restrictive device will be considered, and the device(s) will be removed at the earliest possible time. Definitions: B. Seclusion-is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent, aggressive, or self destructive behavior. Procedure: A. 4. the use of restraint or seclusion is not based on an individual's history or past use, or on a history of dangerous behavior. A. 7. A restrained or secluded patient will be released from restraints or seclusion at the earliest possible time when the circumstance that justified their use ceases to exists regardless of the time allowed by the physician order. C. 4. A physician order for the use of restraints or seclusion will be obtained. ii. Prior to the completion of the initial order, the RN may reassess the patient and request a telephone order to extend the restraints or seclusion. This decision is based on current behavior and safety risks and NOT the behavior that led to the initial restraint or seclusion episode."

Based on document review and interview, the facility failed to ensure that staff followed physician orders for seclusion for 1 of 1 patients (#6) resulting in the loss of the patient's rights to be free from either restrains or seclusion. A total of three patient records were reviewed for behavioral restraints and one patient was reviewed for medical restraints. Findings include:

03/18/2015 at 1630 during review of the medical record for patient #6 revealed that the physician wrote an order on 01/08/2015 at 1534 for seclusion due to the patient being verbally assaultive to staff and the doctor. The documentation in the patients medical record showed that the patient was placed into "4 way locking" leather restraints.

On 03/18/2015 at 1630 during the review of the electronic medical record, staff J confirmed the findings. When staff J was queried as to why he patient was placed into restraints instead of seclusion, she stated, "I am not sure why, the order was written for seclusion but the documentation shows that she was placed into restraints. I will talk with the staff about it."

Based on document review and interview, the facility failed to ensure that 2 of 3 security staff (N, P) had received annual training for "Non-Violent Crisis Intervention Training (CPI) resulting in the potential for poor patient outcomes. Findings include:

On 03/19/2015 at 1000 during review of employee files for three hospital security officers revealed that staff N and P had not attended annual training in 2014 for Crisis Intervention.

In an interview with staff K on 03/19/2015 at 1015, when queried if his security staff responds to behavior calls on the psychiatric unit, he stated, "We do." When queried if staff are required to have crisis intervention training, he stated, "We do an initial eight hour course and are then required to complete a three hour refresher course annually." When queried if he was aware that the two staff had not completed the refresher course in 2014, he stated, "I was not aware of it until now, i don't know how those two got missed."

On 03/19/2014 at 1020, a review of the facility's policy titled, "Non-Violent Crisis Intervention Training (CPI), #L6000-305, Date 02/2014," revealed that "B. Refresher 3 hour training: Required yearly training for ALL direct care staff in the following departments: 3. Security Department."