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Based on document review and interview it was determined for 2 of 2 (Pt #1 and 11) clinical records reviewed of patients with self destructive (behavioral) restraint usage, the Hospital failed to ensure the patients were informed in writing of a restriction of rights, when placed in the restraint devices.

Findings include:

1. Hospital policy entitled, "Restraint Management," (approval 9/20/2013) required, "...Violent, Self-destructive...A Restriction of Rights form for each patient must be completed for each restraint...episode..."

2. The clinical record of Pt #1 was reviewed on 12/8/15. Pt #1 was a 34 year old male that presented to the Hospital's ED on 9/28/15 with diagnoses of depression and suicidal thoughts. Nursing documentation included that Pt #1 was placed in 4 point restraints at 1:46 PM for 4 hours with a continuation order at 5:40 PM. Pt #1's clinical record lacked documentation of a Restriction of Rights form.

3. The Assistant Vice President of Quality and Safety stated during an interview on 12/8/15 at approximately 1:00 PM that the patient's clinical record lacked a restriction of rights form and should have been completed.

4. The clinical record of Pt #11 was reviewed on 12/11/15. Pt #11 was a 27 year old male admitted on 9/24/15 with a diagnosis of bipolar disorder. Pt #11's clinical record contained a physician's order dated 9/24/15 for the application of 4 point velcro restraints to prevent harm. The record included that Pt #11 was in restraints on 9/25/15 from 3:45 PM until 4:52 PM. Pt #11's clinical record lacked documentation of a Restriction of Rights form.

5. During an interview on 12/11/15 at approximately 10:00 AM the Interim Director of Nursing stated that a restriction of rights form could not be found for the patient (Pt #11).

Based document review and interview, it was determined that for 2 of 3 (Pt #2 and 3) open clinical records reviewed with orders for psychotropic medication, the Hospital failed to ensure the patients were informed and agreed to the usage of the medications.

Findings include:

1. Hospital policy entitled, "Medication Management on the Behavioral Health Unit," (approval date 10/22/15) required, "Procedure: I. Obtaining Consent: a. The physician and/or designee shall advise the patient...of the side effects, risks, and benefits of prescribed psychotropic medication(s). b. The physician and/or designee shall obtain a written consent on the 'Patient Consent/Notification for Psychotropic Medications' (form #902276)..."

2. The Hospital's 2013 Formulary, (approval 10/22/15) was reviewed on 12/9/15. The formulary contained the following medications listed as antidepressants and antipsychotics: Haldol; Haldol Deconate; Lithium; Zyprexa; Ativan;Tegretol; and Luvox. The Director of Nursing for Behavioral Health (E #2) stated that the Hospital does not have a paper list of psychotropic medications. The medications are flagged by the computer system as psychotropic medications when they are entered by the nurse who then adds them to the psychotropic consent.

3. The Hospital's pharmacist stated during an interview on 12/9/15 at approximately 1:00 PM that other medications such as Tegretol (listed as an anticonvulsant) may be used as a psychotropic medication.

4. The "Patient Consent/Notification for Psychotropic Medications," (form #902276, dated 10/07) reviewed on 12/9/15 required, "Patient/Parent/Guardian: By signing below for each psychotropic medication prescribed, I acknowledge that my physician or designee has advised me in writing of the side effects...I voluntarily agree to take the medication as prescribed and ... Physician: By signing below the attending physician attests for each psychotropic medication prescribe: 1. The physician or their designee have advised the patient...in writing of the side effects, risks and benefits of the medications, as well as..."

5. The clinical record of Pt #2 was reviewed on 12/9/15. Pt #2 was a 37 year old male admitted on 12/5/15 with a diagnosis of bipolar disorder. Pt #2's clinical record contained physician's orders dated 12/5/15 for the following medications: Haldol and on 12/6/15 physician's orders for the following: Tegrotol, Luvox, and Trazodone. The clinical record of Pt #2 contained a "Patient Consent/Notification for Psychotropic Medications" that included Tegretol, Luvox, Zyprexia, Trazodone, Cogentin, Haldol, and Ativan. The form was unsigned by the patient and the physician. Pt #2's medication administration record (MAR) was reviewed for the dates 12/6, 12/7, and 12/8/15. The record included the psychotropic medications had been administered as ordered.

6. The clinical record of Pt #3 was reviewed on 12/9/15. Pt #3 was a 45 year old female admitted on 12/2/15 with a diagnosis of schizophrenia. Pt #3's clinical record contained physician's orders dated 12/2/15 for the following medications: Tegretol, Haldol, Haldol Decanoate, Lithium and Ativan. The clinical record of Pt #3 contained a "Patient Consent/Notification for Psychotropic Medications" that included Carbamazepine, Haldol Decanoate, Haldol, Lithium and Ativan. The form was unsigned by the physician. Pt #3's medication administration record (MAR) was reviewed for the dates of 12/6, 12/7, and 12/8/15. The record included the psychotropic medications had been administered as ordered.

7. The Director of Nursing for Behavioral Health stated during an interview on 12/9/15 at approximately 10:00 AM that the psychotropic medication consents were not signed.

A. Based on document review and interview it was determined that for 1 of 2 (Pt #1) clinical record reviewed of patients with violent restraint (behavioral) usage, the Hospital failed to ensure assessments were completed every 15 minutes, as required.

Findings include:

1. Hospital policy entitled, "Restraint Management," (approval 9/20/2013) required, "...Violent, Self-destructive: ...2. The patient shall be monitored at regular intervals consistent with physician orders and/or patient condition...Restraint Management Addendum: Monitoring and Assessment/Ongoing Care: Violent/Self Destructive (behavioral) For patient that are displaying violent, self destructive behavior who are in restraints must be monitored and documentation of continuous monitoring will occur every 15 minutes..."

2. The clinical record of Pt #1 was reviewed on 12/8/15. Pt #1 was a 34 year old male that presented to the Hospital's ED on 9/28/15 with diagnoses of depression and suicidal thoughts. Pt #1's clinical record contained nursing documentation dated 9/28/15 that included Pt #1 was placed in 4 point restraints at 1:46 PM for 4 hours with a continuation order at 5:40 PM for four (4) additional hours. Nursing documentation lacked every 15 minute restraint assessments from 3:00 PM to 6:00 PM (3 hours) on 9/28/15.

3. The ED manager stated during an interview on 12/9/15 at approximately 1:00 PM that the every 15 minute checks were not completed.

B. Based on document review and interview it was determined that for 3 of 4 (Pt #7, 8, and 10) clinical records reviewed of patients with non violent restraint usage, the Hospital failed to ensure the patients were assessed every 2 hours to include "Patient Care" as required.

Findings include:

1. Hospital policy entitled, "Restraint Management," (approval 9/20/13) required, " Non-Violent, Non-self destructive: For the restraint applied for non-violent or non-self-destructive behavior: 1. The patient shall be monitored at regular intervals...Monitoring and Assessment /Ongoing Care: All patients in restraints shall be reassessed, monitored and reevaluated minimally every two (2) hours..."

2. The clinical record of Pt #7 was reviewed on 12/10/15. Pt #7 was a 64 year old male admitted on 9/4/15 with a diagnosis of seizure activity. Pt #7's clinical record contained a physician's order dated 9/15/15 to apply a vest restraint to prevent unintentional injury. From 8:00 AM on 9/17/15 to 12: 00 PM on 9/18/15 (28 hours), Pt #7's clinical record lacked assessments of hydration/elimination, nutrition/hydration, and repositioning/range of motion.

3. The clinical record of Pt #8 was reviewed on 12/10/15. Pt #8 was a 93 year old male admitted on 9/20/15 with a diagnosis of septic shock. From 12:00 AM on 9/24/15 to 4:00 PM on 9/24/15 (16 hours) Pt #8's clinical record lacked documentation that his hygiene/elimination, nutrition/hydration, and range of motion/positioning were assessed every 2 hours.

4. The clinical record of Pt #10 was reviewed on 12/10/15. Pt #10 was an 81 year old male admitted on 8/31/15 with a diagnosis of sepsis. Pt #10's clinical record contained a physician's order dated 9/31/15 for the application of a vest to prevent unintentional injury. Documentation included that Pt #10 remained in the restraint device from 8/31/15 at 8:00 PM until 2:00 PM on 9/2/15. Pt #10's clinical record lacked documentation of the reassessment every 2 hours on 9/1/15 from 4:00 PM to 8:00 PM. On 9/2/15 from 10:00 AM until 2:00 PM (4 hours) documentation lacked an assessment of Pt #10's hygiene/elimination.

5. On 12/10/15 at approximately 2:00 PM the Director of Accreditation for Glen Oaks stated the patients were not monitored as required.