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Based on record review, staff interview, policy review, and review of the Florida Administrative Code 65E-5.180(7), the facility failed to protect clients rights regarding restraints for 4 of 4 patients sampled for seclusion and restraint review (#3, 13, 16 and 21). The facility failed to release patients from seclusion or restraint at the earliest possible time, failed to provide rationale for continued restraint usage or recommend staff retraining during their restraint review process. The facility failed to
have a restraint policy and procedure that was in accordance with Florida Administrative Code 65E-5.180(7) regarding the physician order, the release from restraints, the debriefing process, and the review process. The culmination of these failures resulted in a determination of non-compliance with the Condition of Participation of Patient Rights.

The findings:

Cross Reference A0154: Based on record review and staff interview, the facility failed to discontinue seclusion and/or restraint usage at the earliest possible time for 3 of 4 sampled clients who were secluded and/or restrained (#3, #13 and #21). The facility facility failed to document patient clinical condition which supported the continued use of restraints after calm or asleep behavior was observed. The facility failed to obtain release criteria from the ordering physician in accordance with State Law. The facility failed to identify concerns with release times during review of the restraint and seclusion events.

Cross Reference A0167: Based on record review, staff interview and policy review, the facility failed to have a restraint policy and procedure that was in accordance with Florida Administrative Code 65E-5.180(7)(f) regarding the release from restraints and a debriefing process. This affected 4 of 4 patients sampled for seclusion and restraint review (#3, 13, 16 and 21).

Cross Reference A0174: Based on record review and staff interview, the facility failed to discontinue seclusion and/or restraint usage at the earliest possible time for 3 of 4 sampled patients who were secluded and/or restrained (#3, #13 and #21).

Cross Reference A0184: Based on record review and staff interview, the facility failed to clearly document the 1-hour face-to-face medical and behavioral evaluation. It was unclear from documentation which discipline was conducting the 1-hour face-to-face evaluation.

Cross Reference A0204: Based on record review and staff interview, the facility failed to have a training program which trained staff on identifying behavioral changes that indicate restraint or seclusion is no longer necessary so that restraints were released at the earliest possible moment. This affected 3 of 4 patients sampled for seclusion and restraint review, #3, #13 and #21.

Based on record review and staff interview, the facility failed to discontinue seclusion and/or restraint usage at the earliest possible time for 3 of 4 sampled clients who were secluded and/or restrained (#3, #13 and #21). The facility failed to document patient clinical condition which supported the continued use of restraints after calm or asleep behavior was observed. The facility failed to obtain release criteria from the ordering physician in accordance with State Law. The facility failed to identify concerns with release times during review of the restraint and seclusion events.

The findings:

A record review of 'Seclusion / Restraint / Hold Placement' forms, 'Continual In-Person Observation and Safety Check' forms, Progress notes, Physician orders and 'Seclusion / Restraint / ETO (emergency treatment order) Hold Review' forms was conducted for Patients #3, #13 and #21.

Patient #13:

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am for a total of 2 hours. Every 15 minutes staff documented the patients behaviors. Patient #13 was documented as calm or asleep beginning at 6:35am. Patient #13 remained clam or asleep until he was released at 8:05am for 1.5 hours of calm behavior. The release criteria was documented as "Verbalize ability to: Remain in control and No longer threaten".

The Progress Notes were reviewed for restraint-related entries for Patient #13. On 8/25/13 at 6:30am, a nurse documented that Patient #13 was observed on the unit attempting to throw punches at other clients and following them. Staff were unable to redirect client. An ETO (Emergency Treatment Order) injection of Thorazine and Benadryl was given, and Patient #13 "began to kick and hit at staff. The on-call physician was notified, client placed in four point restraints. Will continue to monitor". There were no further nursing notes documented on the Progress Note. There was no documentation to show why Patient #13 remained in restraints for 1.5 hours after start of calm behavior.

The physician orders were reviewed. Patient #13 had a physician order for 4 point restraints on 8/25/13 at 6:10am. The order stated, "place client in 4 point restraints, up to 4 hours." The order did not specify the release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #13, dated 8/27/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

Patient #3:

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am for a total of 3.25 hours. Every 15 minutes staff documented the patients behaviors. Patient #3 was documented as calm or asleep for an hour from 4:30am to 5:30am. At 5:45 he was documented as yelling. He was documented as being asleep for the rest of the seclusion time (1.5 hours) of 6:00am until 7:30am. The release criteria was documented as "Verbalize ability to: Remain in control; No longer harm others; No longer threaten; Talk to staff; and Able to follow instructions and cooperate with staff".

The Progress Notes were reviewed for seclusion-related entries for Patient #3. There was only one entry made, and it was at the initiation of seclusion. On 5/28/13 at 4:15am, a nurse documented that Patient #3 was escorted to the seclusion room for agitation, threatening staff and delusional paranoia. Per physician order the client will remain in seclusion for up to 4 hours until able to follow instruction. Will monitor and assess every 15 minutes for "self-aware and understanding before letting client out". There was no documentation to show why Patient #3 remained in seclusion for 1.5 hours after start of calm behavior.

Patient #3 had a physician order for seclusion on 5/28/13 at 4:00am. The order stated, "put client on seclusion for up to 4 hours for agitation and danger to others". The order did not specify release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #3, dated 6/25/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

Patient #3 was again placed in seclusion on 5/30/13 from 12:55am until 1:45pm for a total of 50 minutes. Every 15 minutes staff documented the patients behaviors. Patient #3 was documented as calm for 30 minutes from 1:15pm until 1:45pm. The release criteria was documented as "Verbalize ability to: Remain in control; No longer harm self; No longer harm others; No longer threaten; Talk to staff".

The Progress Notes were reviewed for seclusion-related entries for Patient #3. At 12:50pm a nurse documented the patient's behavior that necessitated seclusion. No release criteria was specified in the narrative note. There was no documentation to show why Patient #3 remained in seclusion for 30 minutes after start of calm behavior.

Patient #3 had a physician order for seclusion on 5/30/13 at 12:50pm. The order stated "may use seclusion and hold for ETO (emergency treatment order) x 4 hours." The behavior was documented as aggressive and agitation. The order did not specify release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #3, dated 6/25/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

Patient #21:

Patient #21 was placed in 4 point restraints on 8/17/13 from 8:35am until 9:30am (55 minutes). Patient #21 was documented as calm beginning at 9:05am. Patient #21 remained clam until released at 9:30am for 25 minutes of calm behavior. The release criteria was documented as "Verbalize ability to: Remain in control and No longer harm self".

The Progress Notes were reviewed for seclusion-related entries for Patient #21. There was only one entry regarding the restraint episode written on 8/17/13 at 11:00pm. The entry stated that release criteria was explained and the patient verbalized understanding. The release criteria was not specified in the progress note, nor was the rationale for continued restraints for 25 minutes of calm behavior.

Patient #21 had a physician order for 4 point restraints on 8/17/13 at 8:45pm. The order stated, "4 point restraints due to SIB (self-injurious behavior). Max 4 hours." The order did not specify release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #21, dated 8/20/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

On 8/28/13 at approximately 2:30pm, an interview was conducted with Staff Development. The staff member confirmed that she taught restraints and seclusion, but the patient care liaison does the hands on training. She stated that only the physician or registered nurse (RN) can give the directive as to when the patient was released. The criteria for release was "as soon as safely possible." The staff training plan does not contain specific criteria regarding the length of time calm behavior is exhibited prior to release.

The 'Use of Seclusion or Restraint' policy, #500-27, dated August 2011, was reviewed. The section for Discontinuation states:
1. As early as feasible in the restraint or seclusion process, the client shall be made aware of the rationale for restraint or seclusion and the behavior criteria for its discontinuation. Examples of behavior criteria shall include the ability of the client to contract for safety, whether a client is oriented to the environment, and/or cessation of verbal threats.
2. Restraint or seclusion shall be discontinued as soon as the client meets his or her behavior criteria.
3. The decision to release the client from a seclusion/restraint order shall be made only upon physician approval or by the Charge Nurse.

The information required in a physicians' restraint or seclusion order is specified in Florida Administrative Code (FAC):
FAC 65E-5.180(7)(d)5: The order shall include the specific behavior prompting the use of seclusion or restraint, the time limit for seclusion or restraint, and the behavior necessary for the person's release. Additionally, for restraint, the order shall contain the type of restraint ordered and the positioning of the person, including possibly elevating the person's head for respiratory and other medical safety considerations. Consideration shall be given to
age, physical fragility, and physical disability when ordering
restraint type.

Based on record review, staff interview and policy review, the facility failed to have a restraint policy and procedure that was in accordance with Florida Administrative Code 65E-5.180(7) regarding the release from restraints, the debriefing process, and the review process. This affected 4 of 4 patients sampled for seclusion and restraint review (#3, 13, 16 and 21). The facility failed to release patients from seclusion or restraint as soon as the person no longer appeared to present an imminent danger to themselves or others (#3, 13 and 21). The facility failed to conduct a debriefing within 24 hours following seclusion or restraint (#3, 16 and 21). The facility failed to ensure that when the debriefing was conducted, it was conducted with either the recovery team or another preferred staff member (#3 and 13). The facility failed to review the incident with all staff involved as soon as possible after the event (#3, #13, #16 and #21). The review of the seclusion and/or restraint procedure failed to identify that patients were not being released as soon as safely possible (#3, 13, and 21).

The findings:

1. The facility policy was not in accordance with State law and the facility failed to release patients from seclusion or restraint as soon as the person no longer appeared to present an imminent danger to themselves or others (#3, 13 and 21).

Florida Administrative Code 65E-5.180(7)(a)11 states, "11. The person shall be released from seclusion or restraint as soon as he or she is no longer an imminent danger to self or others. "

Florida Administrative Code 65E-5.180(7)(f) states,1. Release from seclusion or restraint shall occur as soon as the person no longer appears to present an imminent danger to themselves or others. Upon release from seclusion or restraint, the person's physical condition shall be observed, evaluated, and documented by trained staff. Documentation shall also include: the name and title of the staff releasing the person; and the date and time of release.

A record review was conducted of policy #500-27 entitled, 'Use of Seclusion or Restraint', dated August 2011. The section for Discontinuation states:
1. As early as feasible in the restraint or seclusion process, the client shall be made aware of the rationale for restraint or seclusion and the behavior criteria for its discontinuation. Examples of behavior criteria shall include the ability of the client to contract for safety, whether a client is oriented to the environment, and/or cessation of verbal threats.
2. Restraint or seclusion shall be discontinued as soon as the client meets his or her behavior criteria.
3. The decision to release the client from a seclusion/restraint order shall be made only upon physician approval or by the Charge Nurse.

The procedure for Restraints dated April 2012 was reviewed. The Procedure was entitled, 'Apalachee Center Procedure Inpatient Services - Use of Restraints'. The release of restraints part of the procedure was not in accordance with the hospital policy or the law. Page 10 talks about 'Releasing Patients from Restraints'. The Procedure states, "The decision to release should be based upon the behavioral criteria established and previously explained to the client, and the RN (registered nurse) and/or physician's assessment of the continued risk of harm to the client or others. When the client is able to meet the behavioral criteria for a continuous 30 minutes, the RN and /or physician should consider release."

The procedure component of "30 continuous minutes" was not in accordance with state or federal law. Release times should be individualized, and according to the law, "shall occur as soon as the person no longer appears to present an imminent danger to themselves or others."

A record review of 'Seclusion / Restraint / Hold Placement' forms and 'Continual In-Person Observation and Safety Check' forms was conducted for Patients #3, #13 and #21. None of the patients had an individualized, specific release criteria with a timeframe developed for them.

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am for a total of 2 hours. Patient #13 was documented as calm or asleep beginning at 6:35am. Patient #13 remained clam or asleep until he was released at 8:05am for 1.5 hours of calm behavior.

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am for a total of 3.25 hours. Patient #3 was documented as calm or asleep for an hour from 4:30am to 5:30am. At 5:45 he was documented as yelling. He was documented as being asleep for the rest of the restraint time (1.5 hours) of 6:00am until released at 7:30am.

Patient #3 was placed in seclusion on 5/30/13 from 12:55am until 1:45pm for a total of 50 minutes. Patient #3 was documented as calm for 30 minutes from 1:15pm until 1:45pm.

Patient #21 was placed in 4 point restraints on 8/17/13 from 8:35am until 9:30am (55 minutes). Patient #21 was documented as calm for 25 minutes from 9:05am until released at 9:30am.

On 8/28/13 at approximately 2:30pm, an interview was conducted with Staff Development. The staff member confirmed that she taught restraints and seclusion, but the patient care liaison does the hands on training. She stated that only the physician or registered nurse (RN) can give the directive as to when the patient was released. The criteria for release was "as soon as safely possible." The staff training plan does not contain specific criteria regarding the length of time calm behavior is exhibited prior to release.

2. The facility failed to conduct a debriefing within 24 hours following seclusion or restraint for patients #3, 16 and 21.

Florida Administrative Code 65E-5.180(7)(f) states: 2. After a seclusion or restraint event, a debriefing process shall take place to decrease the likelihood of a future seclusion or restraint event for the person and to provide support.
a. Each facility shall develop policies to address: (I) A review of the incident with the person who was secluded or restrained. The person shall be given the opportunity to process the seclusion or restraint event as soon as possible but no longer than within 24 hours of release. This debriefing discussion shall take place between the person and either the recovery team or another preferred staff member.

A record review was conducted of the 'Seclusion / Restraint / Hold Debriefing' form for Patients #3, 16 and 21.

Patient #3 was placed in seclusion on 5/30/13. A debriefing was not done.

Patient #21 was placed in 4 point restraints on 8/17/13. A debriefing was not done.

Patient #16 was placed in 4 point restraints on 8/23/13. A debriefing was not done.

The 'Use of Seclusion or Restraint' policy, 500-27, dated August 2011, was reviewed. The Debriefing section stated: "1. The client and, if appropriate, the (patent's) family, shall participate with staff members who were not involved in the episode and who are available in a debriefing about each episode of restraint or seclusion. 2. The debriefing shall occur as soon as possible and appropriate, but not longer than 24 hours after the episode."

On 8/28/13 at approximately 3:25pm, an interview was conducted with the Risk Manager. The Risk Manager stated that Performance Improvement had identified debriefing not being completed within 24 hours as a concern. They had developed an action plan. The Risk Manager was unable to provide further details of the action plan. The Performance Improvement coordinator was unavailable for interview.

3. The facility failed to ensure that when the debriefing was conducted, it was conducted with either the recovery team or another preferred staff member for patients #3 and 13.

A record review was conducted of the 'Seclusion / Restraint / Hold Debriefing' form for Patients #3 and 13.

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am. A debriefing was documented as completed at the time of release (7:30am) by the same nurse involved in the seclusion procedure. There was no indication that the recovery team was involved in the debriefing, or that the patient had chosen to have alternate staff conduct the debriefing.

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am. A debriefing was documented as completed immediately following release from restraints (8:15am) by one of the nurses involved in the procedure. There was no indication that the recovery team was involved in the debriefing, or that the patient had chosen to have alternate staff conduct the debriefing.

The 'Use of Seclusion or Restraint' policy, 500-27, dated August 2011, was reviewed. The Debriefing section stated: "1. The client and, if appropriate, the (patent's) family, shall participate with staff members who were not involved in the episode and who are available in a debriefing about each episode of restraint or seclusion. 2. The debriefing shall occur as soon as possible and appropriate, but not longer than 24 hours after the episode."

Under the policy section for Performance Improvement, part 5, the policy states, "Each seclusion or restraint placement must be retrospectively reviewed by the treatment team on a daily basis to assess the appropriateness and effectiveness of the placement, and review treatment pan consideration. The completed debriefing forms should be reviewed and discussed. "

On 8/28/13 at approximately 3:25pm, an interview was conducted with the Risk Manager. The Risk Manager stated that Performance Improvement had identified debriefing not being completed within 24 hours as a concern. They had developed an action plan. The Risk Manager was unable to provide further details of the action plan. The Performance Improvement coordinator was unavailable for interview.

4. The facility failed to review the incident with all staff involved as soon as possible after the event for patients #3, #13, #16 and #21.

Florida Administrative Code states: 65E-5.180(7)(f)2(II) A review of the incident with all staff involved in the event and supervisors or administrators. This review shall be conducted as soon as possible after the event and shall address: the circumstances leading to the event, the nature of de-escalation efforts and alternatives to seclusion and restraint attempted, staff response to the incident, and ways to effectively support the person's constructive coping in the future and avoid the need for future seclusion or restraint. The outcomes of this review should be documented by the facility for purposes of continuous performance improvement and monitoring.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for patients #3, 13, 16 and 21.

Patient #3 was placed in seclusion on 5/28/13. The review was conducted almost a month later on 6/25/13. The form does not indicate that the incident was reviewed with involved staff.

Patient #3 was placed in seclusion on 5/30/13. The review was conducted almost a month later on 6/25/13. The form only indicates that a review was conducted with nursing staff, it does not indicate that the incident was reviewed with all involved staff.

Patient #21 was placed in 4 point restraints on 8/17/13. The review form dated 8/20/13 does not indicate that the incident was reviewed with involved staff.

Patient #13 was placed in 4 point restraints on 8/25/13. The review form dated 8/27/13 indicates that a review was conducted with nursing staff, it does not indicate that the incident was reviewed with all involved staff.

Patient #16 was placed in 4 point restraints on 8/23/13. The review form dated 8/26/13 indicates that a review was conducted with nursing staff, it does not indicate that the incident was reviewed with all involved staff.

5. The review of the seclusion or restraint procedure failed to identify that patients were not being released as soon as safely possible.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for patients #3, 13, and 21.

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am for a total of 3.25 hours. Patient #3 was documented as calm or asleep for an hour from 4:30am to 5:30am. At 5:45 he was documented as yelling. He was documented as being asleep for the rest of the seclusion time (1.5 hours) of 6:00am until released at 7:30am. The review form dated 6/25/13 item #13 stated: "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" The reviewer marked "yes". There was no explanation how this was determined.

Patient #3 was placed in seclusion on 5/30/13 from 12:55am until 1:45pm for a total of 50 minutes. Patient #3 was documented as calm for 30 minutes from 1:15pm until 1:45pm. The review form dated 6/25/13 under item #13 stated: "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" The reviewer marked "yes". There was no explanation how this was determined.

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am for a total of 2 hours. Patient #13 was documented as calm or asleep beginning at 6:35am. Patient #13 remained clam or asleep until he was released at 8:05am for 1.5 hours of calm behavior. "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" The reviewer marked "yes". There was no explanation how this was determined.

Patient #21 was placed in 4 point restraints on 8/17/13 from 8:35am until 9:30am (55 minutes). Patient #21 was documented as calm for 25 minutes from 9:05am until released at 9:30am. There was no debriefing done. The review form was completed on 8/20/13. Under the section for "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" The reviewer marked "yes". Under the section for "12. Debriefing session conducted within 24 hours?" The reviewer mark "no". Under follow-up the reviewed marked "no action needed."

A record review was conducted of policy #500-27 entitled, 'Use of Seclusion or Restraint', dated August 2011. Under section O, Performance Improvement, part 6, the policy states, "The Director of Nursing (DON), or Program Administrator in the DON's absence, shall review each use of restraint or seclusion and investigate unusual or possible unwarranted instances or patterns or utilization."

Based on record review and staff interview, the facility failed to discontinue seclusion and/or restraint usage at the earliest possible time for 3 of 4 sampled patients who were secluded and/or restrained (#3, #13 and #21).

The findings:

A record review of Seclusion / Restraint / Hold Placement forms, Continual In-Person Observation and Safety Check forms, Progress notes, Physician orders and Seclusion / Restraint / ETO (emergency treatment order) Hold Review Forms was conducted for Patients #3, #13 and #21.

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am for a total of 2 hours. The Behavioral Objective for Release was documented as Verbalize ability to remain in control and no longer threaten. No timeframe was documented. Every 15 minutes staff documented the patients behaviors. Patient #13 was documented as calm or asleep beginning at 6:35am. Patient #13 remained clam or asleep until he was released at 8:05am for 1.5 hours of calm behavior. The physician order did not specify release criteria. Nursing notes did not indicate why Patient #13 remained in restraints for 1.5 hours after he demonstrated calm behavior. The review form indicated that the length of stay was appropriate, but did not specify how that was determined.

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am for a total of 3.25 hours. The Behavioral Objective for Release was documented as: Verbalize ability to remain in control, no longer harm others, no longer threaten, talk with staff and able to follow instructions and cooperate with staff. No timeframe was documented. Every 15 minutes staff documented the patients behaviors. Patient #3 was documented as calm or asleep for an hour from 4:30am to 5:30am. At 5:45 he was documented as yelling. He was documented as being asleep for the rest of the seclusion time (1.5 hours) of 6:00am until 7:30am. The physician order did not specify release criteria. Nursing notes did not indicate why Patient #3 remained in seclusion for 1 hour and then 1.5 hours after he demonstrated calm (asleep) behavior. The review form indicated that the length of stay was appropriate, but did not specify how that was determined.

Patient #3 was placed in seclusion on 5/30/13 from 12:55am until 1:45pm for a total of 50 minutes. The Behavioral Objective for Release was documented as: Verbalize ability to remain in control, no longer harm self, no longer harm others, no longer threaten, and talk with staff. No timeframe was documented. Every 15 minutes staff documented the patients behaviors. Patient #3 was documented as calm for 30 minutes from 1:15pm until 1:45pm. The physician order did not specify release criteria. Nursing notes did not indicate why Patient #3 remained in seclusion for 30 minutes after he demonstrated calm behavior. The review form indicated that the length of stay was appropriate, but did not specify how that was determined.

Patient #21 was placed in 4 point restraints on 8/17/13 from 8:35am until 9:30am (55 minutes). The Behavioral Objective for Release for Patient #21 was documented as: remain in control and no longer harm self. Patient #21 was documented as calm beginning at 9:05am. Patient #21 remained clam until released at 9:30am for 25 minutes of calm behavior. The physician order did not specify release criteria. Nursing notes did not indicate why Patient #21 remained in restraints for 25 minutes after she demonstrated calm behavior. The review form indicated that the length of stay was appropriate, but did not specify how that was determined.

On 8/28/13 at approximately 2:30pm, an interview was conducted with Staff Development. The staff member confirmed that she taught restraints and seclusion, but the patient care liaison does the hands on training. She stated that only the physician or registered nurse (RN) can give the directive as to when the patient was released. The criteria for release was "as soon as safely possible." The staff training plan does not contain specific criteria regarding the length of time calm behavior is exhibited prior to release.

The 'Use of Seclusion or Restraint' policy, #500-27, dated August 2011, was reviewed. The section for Discontinuation states:
1. As early as feasible in the restraint or seclusion process, the client shall be made aware of the rationale for restraint or seclusion and the behavior criteria for its discontinuation. Examples of behavior criteria shall include the ability of the client to contract for safety, whether a client is oriented to the environment, and/or cessation of verbal threats.
2. Restraint or seclusion shall be discontinued as soon as the client meets his or her behavior criteria.
3. The decision to release the client from a seclusion/restraint order shall be made only upon physician approval or by the Charge Nurse.

Based on record review and staff interview, the facility failed to clearly document the 1-hour face-to-face medical and behavioral evaluation. It was unclear from documentation which discipline was conducting the 1-hour face-to-face evaluation.

The findings:

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am. The 1 hour face-to-face was documented as completed at 7:30am. The form does not state what medical discipline conducted the exam. The exam was not signed, and there was no indication that the exam was discussed with or conducted by a physician.

Patient #3 was placed in seclusion on 5/30/13 from 12:55am until 1:45pm. The 1 hour face-to-face was documented as completed at 1:45pm. The form was not signed indicating who conducted the exam.

Patient #16 was placed in 4 point restraints on 8/23/13 from 6:05am until 8:00am. The 1 hour face-to-face was documented as completed at 6:05am (at the time restraints were applied). The form does not state what medical discipline conducted the exam. The exam was not signed, and there was no indication that the exam was discussed with or conducted by a physician. The staff conducting the face-to-face exam made no recommendation whether to continue or discontinue restraints.

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am. The 1 hour face-to-face was documented as completed at 7:00am. The form does not state what medical discipline conducted the exam. The exam was not signed, and there was no indication that the exam was discussed with or conducted by a physician. The staff conducting the face-to-face exam made no recommendation whether to continue or discontinue restraints.

The 'Apalachee Center Procedure Inpatient Services - Use of Restraints', dated April 2012 was reviewed. The 1 hour face-to-face exam was discussed on page 3. The procedure states:
5. The client must receive a face to face evaluation within 60 minutes of the client being placed in restraints by either a:
a. Physician or other licensed independent practitioner; or
b. Registered nurse who has received training as per the procedure "Seclusion/Restraint: Staff Competency."
6. At the time of the in person evaluation, the psychiatrist or registered nurse shall: Evaluate the client's immediate situation, the client's reaction to the intervention, the client's behavioral and medical condition, and the need to continue or terminate the restraint.

Based on record review and staff interview, the facility failed to have a training program which trained staff on identifying behavioral changes that indicate restraint or seclusion is no longer necessary so that restraints were released at the earliest possible moment. This affected 3 of 4 patients sampled for seclusion and restraint review, #3, #13 and #21.

The findings:

The staff training procedure entitled "Inpatient Services Seclusion / Restraint, Staff Competency" dated April 2012 was reviewed. The procedure states:
A. Within the first thirty days of assignment to an Inpatient position and annually thereafter, all clinical staff are to complete formal in-service training on the topic of "Performance-Based training in Seclusion / Restraint Interventions" which will include the following (course outline presented in Attachment 1):
1. Review of state laws and Joint Commission and Medicare guidelines pertaining to seclusion and restraint.
2. Review of Agency Policy 500-27 and Inpatient unit procedures addressing the use of time out, seclusion and restraint.
3. Review of less restrictive interventions and protective equipment which should first be considered and utilized....
4. Documentation requirements for seclusion / restraint events (placement, monitoring, release, etc).
5. Practice of safe methods of physical restraint and seclusion as to avoid risk of traumatization or retraumatization of client.
6. Registered ruses will be authorized to conduct the 1 hour face-to-face evaluation after completing additional training as outlined in Section IX of attachment 1.
7. Debriefing for clients and staff following seclusion / restraint....

No where in the outline does it discuss the training of staff in identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary.

The "Apalachee Center Education and Training Attachment 1 Program Overview for Performance-Based Seclusion / Restraint Inservice", dated September 2010, was reviewed. There inservice does discuss releasing from restraints in the following sections:
G. Staff interactions / directions to client: 4. Behavior criteria for release explained to client at time they are placed in time out, seclusion or restraints.
J. Release from seclusion / restraint: 1. Recognizing when client has met behavioral criteria for release.

The inservice does not discuss releasing the patient at the earliest possible time as per state law and Medicare guidelines.

Chapter 42 Code of Federal Regulation 482.13(e) states: Restraint or seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Florida Administrative Code, 65E-5.180(7), states: 11. The person shall be released from seclusion or restraint as soon as he or she is no longer an imminent danger to self or others.

This lack of training in release criteria affected 3 of 4 patients reviewed for seclusion and restraints, Patients #3, #13 and #21.

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am for a total of 2 hours. Patient #13 was documented as calm or asleep beginning at 6:35am. Patient #13 remained clam or asleep until he was released at 8:05am for 1.5 hours of calm behavior.

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am for a total of 3.25 hours. Patient #3 was documented as calm or asleep for an hour from 4:30am to 5:30am. At 5:45 he was documented as yelling. He was documented as being asleep for the rest of the seclusion time (1.5 hours) of 6:00am until 7:30am.

Patient #3 was placed in seclusion on 5/30/13 from 12:55am until 1:45pm for a total of 50 minutes. Patient #3 was documented as calm for 30 minutes from 1:15pm until 1:45pm.

Patient #21 was placed in 4 point restraints on 8/17/13 from 8:35am until 9:30am (55 minutes). Patient #21 was documented as calm beginning at 9:05am. Patient #21 remained clam until released at 9:30am for 25 minutes of calm behavior.

On 8/28/13 at approximately 2:30pm, an interview was conducted with Staff Development. The staff member confirmed that she taught restraints and seclusion, but the patient care liaison does the hands on training. She stated that only the physician or registered nurse (RN) can give the directive as to when the patient was released. The criteria for release was "as soon as safely possible." The staff training plan does not contain specific criteria regarding the length of time calm behavior is exhibited prior to release.

Based on record review, interviews and facility policy and procedure, the facility failed to ensure that physician orders were signed in a timely manner for 1 of 21 client records reviewed. (#14)

The finding include:

On 08/27/2013 at approximately 12:20pm a record review was conducted for Client #14. There were two physician orders received by telephone, dated for 08/22/2013 - the first order was for "7pm Ativan 2mg IM x 1 NOW ETO (Emergency Treatment Order) aggressive behavior toward others." The second order "Haldol 5mg IM x 1 NOW ETO for aggressive behavior - unable to follow direction." The orders were signed by the Staff RN. The order failed to be authenticated by the ordering physician.

On 08/27/2013 at approximately 12:23pm the Staff RN indicated that ETO are to be signed with 24 hours. She indicated that the ordering physician was a part time physician and she was not sure how she is notifed to sign her orders.

On 08/27/2013 at approximately 12:30pm, the Director of Nursing (DON), indicated that they usually have another physician sign the orders and indicated we just missed these (pointing to the orders in question). The DON indicated that the ordering physician (on-call) never comes up here, and stated she may go to medical records. A few minutes after this interview, the DON returned and indicated she spoke with the physician that is present on the unit, and he stated that if the order is on a weeked and it is more than 24 hours after he comes in to see them - he will not sgin the order because it is greater than 24 hours. The DON indicated the client's record would go to the Medical Record department and she would not sure how they would hand (signing of the orders).

A review of the facility's policy and procedure entitled "MEDICATION PRESCRIPTION ORDERS", Policy: 510-3 indicates "3. Procedures: ...... f. Inpatient and residential patient telephone orders must be signed, dated, and timed by the ordering practitioner or by another practitioner who is responsible for the client (i.e., "covering" physician) within 24 hours on the CSU/SRT and 48 hours on all of the units after giving the order."

Based on closed record review, Bylaw review and staff interview, the facility failed to complete a discharge summary for 2 of 10 sampled closed records (#3 and #4).

The findings:

A closed record review was conducted for Patient #3 on 8/27/13. Patient #3 was admitted on 6/15/13 and discharged on 7/5/13. There was no discharge summary in the record.

A closed record review was conducted for Patient #4 on 8/27/13. Patient #4 was admitted on 7/30/13 and discharged on 8/5/13. There was no discharge summary in the record.

A record review of the Apalachee Center Bylaws, Rules and Regulations of the Clinical Staff, dated August 2013, was reviewed. Beginning on Page 31 the document discussed discharge summaries. The document stated, "30. Within fifteen (15) days of inpatient unit discharge, a Discharge Summary (using the Apalachee Dictation Guidelines) must be dictated by the attending physician..."

On 8/28/13 at approximately 3:35pm, an interview was conducted with the Inpatient Medical Records Coordinator. The Coordinator stated that inpatient charts were returned to physicians within 15 days to complete any missing dictation. She stated she would frequently remind the physicians until the discharge summary was completed.

Based on observation, staff interviews and review of facility's policy and procedure, the facility failed to ensure Glucometers (blood glucose meter) were cleaned in accordance with accepted professional standards (Center for Disease Control and Prevention) for infection control and sanitary conditions were maintained between client use in the restraint room.

The findings include:

1. On 08/26/2013 at approximately 11:20am, while in the Hospital's Medication room, the Director of Nursing was asked if they had a Glucometer. She indicated they did and that it was cleaned after every use. She was not able to locate the Glucometer and sought assistance from the Geriatric Unit Registered Nurse. The R.N. indicated the Glucometer was cleaned after each use with alcohol. The DON was present.

On 08/26/2013 from 12:05pm to 12:30pm, 3 different patients (# ) were observed to have their blood glucose level checked by the R.N. on the Geriatric Unit. After each reading was obtained, the RN cleaned the "Assure 4 Glucose meter" with an alcohol wipe.

A review of the facility policy and procdure entitled "BLOOD GLUCOSE MONITORING", last revised March, 2011 indicates on page 4, Section "9. Preventive Maintenance/quality Control Checks.... A. For storage requirements and cleaning suggestions (See attachment 1, page14)." A review of Attachment 1 (copy of the operating manual for the Assure 4 Glucose Meter), page 14 under the heading of CLEANING indicates inside a gray box "Healthcare professionals should wear gloves when cleaning the Assure 4 meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggestion cleaning the meter between patients" in the paragraph below the box, "To clean the outside of your blood glucose meter, use a lint-free cloth dampened with soapy water or alcohol (70-85%). To disinfect the meter, dilute 1ml of household bleach (5%-6% sodium hypochlorite solution) in 9 mL of water to achieve a 1:10 dilution (final concentration of 0.5% - 0.6% sodium hypochlorite)."

The facility failed to following the manufacturers instructions regarding disinfecting the blood glucose meter. Bleach would be an acceptable method of cleaning and disinfecting, however, the facility's current method of cleaning/disinfection in between each patient use, does not prevent or decrease the risk of cross-contamination of blood borne pathogens.


2. On 8/26/13 at about 10:30am, an observation of the restraint room was conducted with the Inpatient Supervisor of Social Services. The room was vacant. The restraint bed in the room was observed to have a soiled sheet on it and there were 2 facial tissues on the floor bedside the bed. A follow-up observation was conducted on 8/27/13 at about 2:11pm with the Inpatient Supervisor of Social Services. The soiled sheet and the used facial tissue remained in the room.

An interview was conducted with the Director of Nursing (DON) on 8/27/13 at approximately 3:00pm. The DON stated that it was the responsibility of the Mental Health Associates to clean the room and change the sheets after a restraint episode. Housekeeping would also clean the room when notified

3. On 08/26/2013 beginning at 12:43pm, lunch-time dining observation was conducted for clients in the Geriatric Unit. There was one Certified Nursing Assist (CNA) and 1 Mental Health Aide (MHA) assisting clients with receiving meal trays and one client that required some prompting and assitance with feeding. Both the CNA and the MHA were wearing gloves while distrubting lunch tray. The CNA was observed to handles food trays, peel a banana, reposition a wheelchair, pick up napkin from floor and to handle a client's sandwich assisting to the client's mouth, with her gloved hands without ever changing her gloves. The CNA did change her gloves when she left the area and redonned gloves when she returned. The MHA was observed to pick up a napkin from the floor, wad it up and put into her pocket and then proceed to serve residents water.

Based on group therapy observation, staff interview and record review of group therapy documentation, the facility failed to maintain medical records which contained enough detail to permit a determination of the degree and intensity of the treatment provided to patients. The group therapy documentation was frequently omitted and/or incomplete. There was no documentation that the daily Counseling group or the evening Activity groups had been conducted. There was no documentation of a Therapeutic Group activity for 5 of 5 active patients sampled in the main hospital unit. The Health Management group was not conducted for 4 of 7 days between 8/21/13 and 8/27/13. The culmination of these failures resulted in a determination of non-compliance with the Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals.

The findings:

Cross Reference B0118: Based on record review and staff interview, the facility failed to develop a treatment plan for 1 of 8 sampled active patients, #13.

Cross Reference B0122: Based on observation, staff interview and record review, the facility failed to develop Treatment Plans which were in accordance with the actual treatment offered for 4 of 5 sampled active patients in the main unit (#2, 6, 16 and 17). The group titles recommended on the Treatment Plan did not coincide with the title of groups currently being offered at the hospital.

Cross Reference B0124: Based on record review and staff interview, the facility failed to provide adequate documentation of group activities for 5 of 5 sampled active patients in the main unit (#2, 6, 13, 16 and 17). There was no documentation from the 10:00am Counseling group or the 7:00pm activity group. The documentation from the milieu groups was frequently vague and incomplete. Subjects being discussed or therapy provided during groups could not be determined from the documentation.

Cross Reference B0125: Based on record review and staff interview, the facility failed to document any therapeutic group activities for 5 of 5 sampled active patients in the main hospital unit (#2, 6, 13, 16 and 17). Therapeutic activities focus upon the development and maintenance of adaptive skills that will improve the patient's functioning and include subjects such as anger management and coping skills.

Cross Reference B0133: Based on closed record review, Bylaw review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of each patient's stay for 2 of 10 sampled closed records (#3 and #4).

Cross Reference B0134: Based on record review and staff interview, the facility failed to provide adequate recommendations concerning aftercare for 2 of 9 sampled closed records (#11 and #19).

Based on record review and staff interview, the facility failed to develop a treatment plan for 1 of 8 sampled active patients, #13.

The findings:

Patient #13 was admitted on 8/20/13. A record review of the clinical record was conducted on 8/27/13. No treatment plan was located.

An interview was conducted with the Director of Nursing on 8/27/13 at approximately 10:00am. The Director of Nursing was unable to locate a treatment plan. The Director of Nursing conferred with other staff. She stated that a Treatment Plan was not developed because Patient #13 was mute on admission, and his needs could not be fully assessed.

On 8/28/13 at approximately 1:00pm, an interview was conducted with the Risk Manager. The Risk Manager stated that the Treatment Plan must be developed by the end of the 3rd day after admission.

Based on observation, staff interview and record review, the facility failed to develop Treatment Plans which were in accordance with the actual treatment offered for 4 of 5 sampled active patients in the main unit (#2, 6, 16 and 17). The group titles recommended on the Treatment Plan did not coincide with the title of groups currently being offered at the hospital.

The findings:

A record review of the current Treatment Plans was conducted for Patients #2, 6, 16 and 17.

Patient #2 had a Treatment Plan developed on 8/21/13 which addressed Suicidal Ideations. The Treatment Plan recommended "Encourage participation in Milieu Groups relaxation and psycho-education."

Patient #6 had a Treatment Plan developed on 8/23/13 which addressed Suicidal Ideations and Anxiety. The Treatment Plan recommended "Encourage participation in Milieu Groups relaxation and psycho-education."

Patient #16 had a Treatment Plan developed on 8/20/13 which addressed Delusions and Hallucination. The Treatment Plan recommended "Encourage participation in Milieu Groups relaxation and psycho-education."

Patient #17 had a Treatment Plan developed on 8/22/13 which addressed Suicidal Ideations, Depression and Hallucinations. The Treatment Plan recommended "Milieu groups to address reality orientation and "Encourage participation in Milieu Groups relaxation and psycho-education."

The Milieu Group schedule was reviewed. Monday through Friday the offered groups included:
9:20am Stretch group
9:35am Community group
10:00am Counseling group
10:30am De-stress group
11:00am Health management
1:00pm Art/relaxation
7:00pm - Activity group

The weekend schedule showed:
9:20am Stretch group
10:15am De-stress group
10:35am Community group
11:15am Saturday chaplain
4:00pm Art/relaxation
4:30pm Medication / Health Management
7:00pm Activity group

No milieu groups entitled "reality orientation" or "psycho-education" were found.

On 8/27/13 at approximately 9:10am, an interview was conducted with the Inpatient Supervisor of Social Services. The Supervisor stated that the Psycho-education group - includes topics such as anger management, panic attack and anxiety management, depressive disorder and coping skills. Reality orientation includes topics such as hallucinations, date & time, and realistic expectations. These groups are typically conducted at 10:00am Monday - Friday during the Counseling Group.

Based on record review and staff interview, the facility failed to provide adequate documentation of group activities for 5 of 5 sampled active patients in the main unit (#2, 6, 13, 16 and 17). There was no documentation from the 10:00am Counseling group or the 7:00pm activity group. The documentation from the milieu groups was frequently vague and incomplete. Subjects being discussed or therapy provided during groups could not be determined from the documentation.

The findings:

The Milieu Group schedule was reviewed. Monday through Friday the offered groups included:
9:20am Stretch group
9:35am Community group
10:00am Counseling group
10:30am De-stress group
11:00am Health management
1:00pm Art/relaxation
7:00pm - Activity group

A record review of the 'Patient Education / Group Activities' documentation forms (blue sheets) was conducted for Patients #2, 6, 13, 16 and 17. The forms contained 5 groups: Stretch at 9:20am, Community Meeting at 9:35am, De-Stress at 10:30am, Health Management at 11:00am, and Art and Relaxation at 1:00pm. Neither the 10:00am Counseling group nor the 7:00pm activity group was recorded on the document.

According to the documentation, the Health Management group did not occur on 8/21/13, 8/22/13, 8/24/13 or 8/26/13.

The directions for completing the 'Patient Education / Group Activities' document stated to record "Content, taught, patient response, follow-up and staff signature." A review of the documents for Patients #2, 6, 13, 16 and 17 revealed that the content and taught portions were frequently omitted.

Patient #13: 8/21/13 De-Stress: Client came to De-Stress group, but did not participate in the group discussion. Art and Relaxation: Client attended group and participated in the game.
8/22/13 De-Stress: Client was present during group and was focused on group. But client kept his attention on other stuff. Art and Relaxation: Client attended and participated in group. Client was calm.
8/23/13 De-Stress: Client attended group but did not participate
8/24/13 Art and Relaxation: He enjoyed the activity and was calm.

Patient #16: 8/21/13 Art and Relaxation: Client attended group and participated in group. Won the game. 8/22/13 De-Stress: Client attended group but was being disruptive such as yelling. 8/24/13 De-Stress: He kept dozing off and then got up and left group. Art and Relaxation: He enjoyed the activity and seemed interested. 8/25/13 De-Stress: He participates for most of the group but walked out before the end.

Patient #17: 8/23/13 De-Stress: Client participated in group and did well. 8/25/13 De-Stress: She enjoyed the group and interacted well. 8/26/13 De-Stress: Client came to De-Stress group by playing a game and having fun.

Patient #6: 8/26/13 De-Stress: Client come to De-Stress group, by playing a great game and had fun. (Patient #6 refused to attend groups 8/24/13 - 8/25/13).

Patient #2: 8/26/13 De-Stress: Client did attend the last 10 minutes, but listened only. There was no topic. (Patient #2 refused to attend groups 8/22/13 - 8/25/13).

There was no documentation on any of the 5 charts regarding therapeutic activity groups such as anger management skills, coping skills, panic attack and anxiety management, or dealing with hallucinations.

On 8/27/13 at approximately 8:52am, an interview was conducted with the Director of Inpatient Services, Risk Manager, the Inpatient Supervisor of Social Services and the Director of Nursing. The staff agreed that the documentation of the milieu groups was vague and incomplete. The staff stated that Therapeutic group documentation (10:00am counseling group) was typically typed on a separate document. An example was provided. .

A record review for the (typed) therapeutic group documentation was conducted for Patients #2, 6, 13, 16 and 17. No notes were found.

Based on record review and staff interview, the facility failed to document any therapeutic group activities for 5 of 5 sampled active patients in the main hospital unit (#2, 6, 13, 16 and 17). Therapeutic activities focus upon the development and maintenance of adaptive skills that will improve the patient's functioning and include subjects such as anger management and coping skills.

The findings:

The Milieu Group schedule was reviewed. Monday through Friday the offered groups included:
9:20am Stretch group
9:35am Community group
10:00am Counseling group
10:30am De-stress group
11:00am Health management
1:00pm Art/relaxation
7:00pm - Activity group

On 8/26/13 at approximately 10:40am, an observation of the De-Stress group therapy class was conducted. Patients were attentive and responsive to the leader, the Patient Care Liaison. Patients were identifying words that had the word "corn" in them (such as Corn Flakes, corn meal etc).

Patient #17 was observed to attend and participate in the group. A record review was conducted of the group activity documentation for Patient #17 after the class. The instructions on the form stated to document "Content, Taught, Patient Response, Follow-up, Staff Signature". For the 10:30 am De-Stress class of 8/26/13 staff wrote, "Client came to De-Stress group, by playing a game and having fun."

On 8/26/13 beginning at approximately 1:45pm, an interview was conducted with the Patient Care Liaison, who was the staff member identified as being in charge of the group therapy. The Liaison stated that the groups are typically led by Mental Health Associates, but she also helps (MHAs). The goal of the majority of the groups is to take the patient's mind off of their problems and just interact with others. Our groups mainly focus on interaction, mingling, helping each other, and community meetings. They deal with their problems on a 1:1 basis with the social worker and the psychiatrist. The Community meetings are done with all the clients after exercise class. Community group goes over the rules and the policies, patient rights and responsibilities, what the meal is and anything that the patients would like to see done. The Counseling group at 10:00am is typically done by interns from the local university. The cover subjects such as anger management, self-esteem, and positive affirmations. When the students are off, we have classes in that time slot that keep the patients focused off of their problems. The Art and Relaxation group at 1:00pm has activities such as Bingo, word search puzzles, and scrabble. Everybody can do their own thing and relax. The MHAs will also work with coping skills such as breathing, counting to 10 and de-escalation tips. This is a short- term unit, 1 - 5 days is a typical stay.

According to the documentation, the Health Management group did not occur on 8/21/13, 8/22/13, 8/24/13 or 8/26/13.

On 8/27/13, a record review was conducted for therapeutic group activities for patients 2, 6, 13, 16 and 17. Therapeutic activity groups include such topics such as anger management skills, coping skills, panic attack and anxiety management, or dealing with hallucinations. Patient #2 was admitted 8/21/13; Patient # 6 was admitted on 8/23/13; Patient #13 was admitted 8/2/13; Patient #16 was admitted 8/20/13, and Patient #17 was admitted on 8/22/13. There was no documentation on any of the 5 charts regarding received Therapeutic activities.

On 8/27/13 at approximately 8:52am, an interview was conducted with the Director of Inpatient Services, Risk Manager, the Inpatient Supervisor of Social Services and the Director of Nursing. The group confirmed that the interns do run the 10:00am class when they are available. The class covers topics such as Anger Management, Panic Attack and Anxiety Management, Depressive disorder, Coping Skill, and coping with Hallucinations. They do not have interns all of the time. Nursing would take over the group when the interns are unavailable. Our main goal is Crisis intervention - getting the patient to pre-crisis conditions then link them up to outpatient assistance and resources. The staff stated that Therapeutic group documentation (10:00am counseling group) was typically typed on a separate document. An example was provided.

A record review for the (typed) therapeutic group documentation was conducted for Patients #2, 6, 13, 16 and 17. No notes were found.

Based on closed record review, Bylaw review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of each patient's stay for 2 of 10 sampled closed records (#3 and #4).

The findings:

A closed record review was conducted for Patient #3 on 8/27/13. Patient #3 was admitted on 6/15/13 and discharged on 7/5/13. There was no discharge summary in the record.

A closed record review was conducted for Patient #4 on 8/27/13. Patient #4 was admitted on 7/30/13 and discharged on 8/5/13. There was no discharge summary in the record.

A record review of the Apalachee Center Bylaws, Rules and Regulations of the Clinical Staff, dated August 2013, was reviewed. Beginning on Page 31 the document discussed discharge summaries. The document stated, "30. Within fifteen (15) days of inpatient unit discharge, a Discharge Summary (using the Apalachee Dictation Guidelines) must be dictated by the attending physician..."

On 8/28/13 at approximately 3:35pm, an interview was conducted with the Inpatient Medical Records Coordinator. The Coordinator stated that inpatient charts were returned to physicians within 15 days to complete any missing dictation. She stated she would frequently remind the physicians until the discharge summary was completed.

Based on record review and staff interview, the facility failed to provide adequate recommendations concerning aftercare for 2 of 9 sampled closed records (#11 and #19)

The findings:

A close record review for discharge planning was conducted for Patient #19. Patient #19 was admitted on 8/1/13 and discharged on 8/7/13. The Discharge form with patient instructions was reviewed. The Social Service section which contained the Recommended psychiatric follow-up / aftercare was blank except for the name of a county out-patient.

The progress notes were reviewed. On 8/7/13 the Admission Discharge Coordinator documented that the public defender was contacted to obtain a court order for compliance with outpatient treatment. This was discussed with the client and family. No actual follow-up appointments were documented.

A close record review for discharge planning was conducted for Patient #11. Patient #11 was admitted on 8/18/13 and discharged on 8/22/13. The Discharge form with patient instructions was reviewed. The Social Service section was blank. There was no information regarding Recommended psychiatric follow-up. There were no documented referrals or appointments. The Inpatient Coordination of Care Progress Note dated 8/9/13 was reviewed. The form stated that Patient #11 has no outpatient case manager at this time. The Admission Discharge Coordinator (ADC) documented on 8/23/13 and 8/24/13. No appointments made or aftercare referrals were documented.

An interview was conducted with the Inpatient Supervisor of Social Services on 8/28/13 at approximately 10:45am. The Supervisor reviewed both clinical records, and was unable to locate further information regarding aftercare referrals. In regards to Patient #11, the Supervisor stated that the ADC should have sent a fax with the referral. I'm not seeing a referral, or a copy of the fax requesting same that was sent. It can be difficult to get a referral on the weekend, but we can at lease send a fax, and they should get back to us on Monday with an appointment. In regards to Patient #19, the Supervisor stated that the discharge information is incomplete regarding aftercare services. This is unacceptable. The Supervisor stated that he would meet with his team and address the discharge concerns today.

Based on group observations, staff interview and record review, the facility failed to provide adequate numbers of qualified therapists to provide active treatment measures. The Health Managment class was not consistently conducted. When a local university was not in session, the daily 10:00 Counseling class did not consistently occur. This effected 5 of 5 sampled patients in the main hospital unit, (#2, 6, 13, 16, 17).

The findings:

An observation of group activities was conducted on 8/26/13 beginning at approximately 10:40am until 4:45pm. Only 2 group therapy classes were observed. Clients were observed to be in a group entitled De-Stress at 10:45am. The 11:00 class, Health management, was not conducted. From 1:00pm until 1:30pm patients were observed to play Bingo for their Art and Recreational class. After 1:30 clients were observed sitting around the day room and pacing.

On 8/27/13 observations of group therapy classes were again conducted begining at 9:25am with the Exercise class. When exercise ended, Community Discussion began. Staff introduced themselves, then discussed house rules, discharges, the lunch menu, snack times and courtyard times. The group ended at 9:38am, and the clients walked over to the day room and sat or walked around until 10:00 when Counseling group began. There was no intern available, so the Counseling group was conducted by the Mental Health Associates (MHA). (Mental Health Associates are direct care staff, and are only required to have a highschool education). MHA P appeared to be the group leader. A worksheet entitled, "Don't let them push your buttons" was passed out to each patient. Patients were instructed to complete the form, then they took turns reading their responses. There was minimal group discussion. The last question, "How could I have NOT let this person 'push my buttons?' was often skipped. Staff did not direct patients to think of different ways that the situation could have been handled, or provide suggestions for same. The class ended by 10:24am, and De-Stress started. At 11:07am, the MHAs were observed to run the Health Managment class which Nursing was supposed to run.

Nursing was unavailable on both 8/26/13 and 8/27/13 to conducted the Health Management class. A record review of the Health Management class going back 1 week to 8/20/13 was conducted. The class was not conducted on 8/21/13, 8/22/13, 8/24/13, or 8/26/13.

On 8/26/13 at approximately 2:00pm, an interview was conducted with Nurse A who was supposed to conduct the Health Management class. Nurse A stated that she got busy at 11:00, when the class was due, and was unable to conduct it.

According to the documentation, the Health Management group did not occur on 8/21/13, 8/22/13, 8/24/13 or 8/26/13.

On 8/26/13 beginning at approximately 1:45pm, an interview was conducted with the Patient Care Liaison, who was the staff member identified as being in charge of the group therapy. The Liaison stated that the groups are typically led by Mental Health Associates, but she also helps (MHAs). The Counseling group at 10:00am is typically done by interns from the local university. The cover subjects such as anger management, self-esteem, and positive affirmations. When the students are off, we have classes in that time slot that keep the patients focused off of their problems. The MHAs will also work with coping skills such as breathing, counting to 10 and de-escalation tips. This is a short- term unit, 1 - 5 days is a typical stay.

On 8/27/13, a record review was conducted for evidence that the Counseling group (scheduled for 10:00am) had been conducted for patients 2, 6, 13, 16 and 17. Patient #2 was admitted 8/21/13; Patient # 6 was admitted on 8/23/13; Patient #13 was admitted 8/2/13; Patient #16 was admitted 8/20/13, and Patient #17 was admitted on 8/22/13. There was no documentation that any of the 5 patients had the opportunity to attend Counseling group.

On 8/27/13 at approximately 8:52am, an interview was conducted with the Director of Inpatient Services, Risk Manager, the Inpatient Supervisor of Social Services and the Director of Nursing. The group confirmed that the interns do run the 10:00am Counseling class when they are available. The hospital Social Services employees main focus is case managment and discharge planning. They do not conduct groups. They do not have interns all of the time. Nursing should take over the group when the interns are unavailable. (This was not observed on 8/27/13 - MHAs took over). Our main goal is Crisis intervention - getting the patient to pre-crisis conditions then link them up to outpatient assistance and resources. The staff stated that Therapeutic group documentation (10:00am counseling group) was typically typed on a separate document. An example was provided.

A record review for the (typed) therapeutic group documentation was conducted for Patients #2, 6, 13, 16 and 17. No notes were found.

Based on observation, record review and staff interview, the facility failed to consistently provide at least one daily group which focused on therapeutic activities for 5 of 5 sampled active patients in the main hospital unit (#2, 6, 13, 16 and 17). Therapeutic activities focus upon the development and maintenance of adaptive skills that will improve the patient's functioning.

The findings:

The Milieu Group schedule was reviewed. Monday through Friday the offered groups included:
9:20am Stretch group
9:35am Community group
10:00am Counseling group
10:30am De-stress group
11:00am Health management
1:00pm Art/relaxation
7:00pm - Activity group

An observation of group activities was conducted on 8/26/13 beginning at approximately 10:40am until 4:45pm. Only 2 group therapy classes were observed. Clients were observed to be in a group entitled De-Stress at 10:45am. The 11:00 class, Health management, was not conducted. From 1:00pm until 1:30pm patients were observed to play Bingo for their Art and Recreational class. After 1:30 clients were observed sitting around the day room and pacing.

On 8/26/13 beginning at approximately 1:45pm, an interview was conducted with the Patient Care Liaison, who was the staff member identified as being in charge of the group therapy. The Liaison stated that the groups are typically led by Mental Health Associates, but she also helps (MHAs). The goal of the majority of the groups is to take the patient's mind off of their problems and just interact with others. Our groups mainly focus on interaction, mingling, helping each other, and community meetings. They deal with their problems on a 1:1 basis with the social worker and the psychiatrist. The Community meetings are done with all the clients after exercise class. Community group goes over the rules and the policies, patient rights and responsibilities, what the meal is and anything that the patients would like to see done. The Counseling group at 10:00am is typically done by interns from the local university. The cover subjects such as anger management, self-esteem, and positive affirmations. When the students are off, we have classes in that time slot that keep the patients focused off of their problems. The Art and Relaxation group at 1:00pm has activities such as Bingo, word search puzzles, and scrabble. Everybody can do their own thing and relax. The MHAs will also work with coping skills such as breathing, counting to 10 and de-escalation tips. This is a short- term unit, 1 - 5 days is a typical stay.

On 8/27/13 observations of group therapy classes were again conducted beginning at 9:25am with the Exercise class. When exercise ended, Community Discussion began. Staff introduced themselves, then discussed house rules, discharges, the lunch menu, snack times and courtyard times. The group ended at 9:38am, and the clients walked over to the day room and sat or walked around until 10:00 when Counseling group began. There was no intern available, so the Counseling group was conducted by the Mental Health Associates (MHA). MHA P appeared to be the group leader. A worksheet entitled, "Don't let them push your buttons" was passed out to each patient. Patients were instructed to complete the form, then they took turns reading their responses. There was minimal group discussion. The last question, "How could I have NOT let this person 'push my buttons?' was often skipped. Staff did not direct patients to think of different ways that the situation could have been handled, or provide suggestions for same. The class ended by 10:24am, and De-Stress started. At 11:07am, the MHAs were observed to run the Health Management class which Nursing was supposed to run.

On 8/27/13 at approximately 8:52am, an interview was conducted with the Director of Inpatient Services, Risk Manager, the Inpatient Supervisor of Social Services and the Director of Nursing. The group confirmed that they get interns from the local universities when school is in session. The interns run the 10:00am class when they are available. The class covers topics such as Anger Management, Panic Attack and Anxiety Management, Depressive disorder, Coping Skill, Coping with Hallucinations etc. They do not have interns all of the time. Nursing should take over the group when the interns are unavailable. Our main goal is Crisis intervention - getting the patient to pre-crisis conditions then link them up to outpatient assistance and resources. The staff stated that Therapeutic group documentation (10:00am counseling group) was typically typed on a separate document. An example was provided.

On 8/27/13, a record review was conducted for therapeutic group activities for patients 2, 6, 13, 16 and 17. Therapeutic activity groups include such topics such as anger management skills, coping skills, panic attack and anxiety management, or dealing with hallucinations. Patient #2 was admitted 8/21/13; Patient # 6 was admitted on 8/23/13; Patient #13 was admitted 8/2/13; Patient #16 was admitted 8/20/13, and Patient #17 was admitted on 8/22/13. There was no documentation on any of the 5 charts regarding received Therapeutic activities.

Based on record review and staff interview, the facility failed to discontinue seclusion and/or restraint usage at the earliest possible time for 3 of 4 sampled clients who were secluded and/or restrained (#3, #13 and #21). The facility failed to document patient clinical condition which supported the continued use of restraints after calm or asleep behavior was observed. The facility failed to obtain release criteria from the ordering physician in accordance with State Law. The facility failed to identify concerns with release times during review of the restraint and seclusion events.

The findings:

A record review of 'Seclusion / Restraint / Hold Placement' forms, 'Continual In-Person Observation and Safety Check' forms, Progress notes, Physician orders and 'Seclusion / Restraint / ETO (emergency treatment order) Hold Review' forms was conducted for Patients #3, #13 and #21.

Patient #13:

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am for a total of 2 hours. Every 15 minutes staff documented the patients behaviors. Patient #13 was documented as calm or asleep beginning at 6:35am. Patient #13 remained clam or asleep until he was released at 8:05am for 1.5 hours of calm behavior. The release criteria was documented as "Verbalize ability to: Remain in control and No longer threaten".

The Progress Notes were reviewed for restraint-related entries for Patient #13. On 8/25/13 at 6:30am, a nurse documented that Patient #13 was observed on the unit attempting to throw punches at other clients and following them. Staff were unable to redirect client. An ETO (Emergency Treatment Order) injection of Thorazine and Benadryl was given, and Patient #13 "began to kick and hit at staff. The on-call physician was notified, client placed in four point restraints. Will continue to monitor". There were no further nursing notes documented on the Progress Note. There was no documentation to show why Patient #13 remained in restraints for 1.5 hours after start of calm behavior.

The physician orders were reviewed. Patient #13 had a physician order for 4 point restraints on 8/25/13 at 6:10am. The order stated, "place client in 4 point restraints, up to 4 hours." The order did not specify the release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #13, dated 8/27/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

Patient #3:

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am for a total of 3.25 hours. Every 15 minutes staff documented the patients behaviors. Patient #3 was documented as calm or asleep for an hour from 4:30am to 5:30am. At 5:45 he was documented as yelling. He was documented as being asleep for the rest of the seclusion time (1.5 hours) of 6:00am until 7:30am. The release criteria was documented as "Verbalize ability to: Remain in control; No longer harm others; No longer threaten; Talk to staff; and Able to follow instructions and cooperate with staff".

The Progress Notes were reviewed for seclusion-related entries for Patient #3. There was only one entry made, and it was at the initiation of seclusion. On 5/28/13 at 4:15am, a nurse documented that Patient #3 was escorted to the seclusion room for agitation, threatening staff and delusional paranoia. Per physician order the client will remain in seclusion for up to 4 hours until able to follow instruction. Will monitor and assess every 15 minutes for "self-aware and understanding before letting client out". There was no documentation to show why Patient #3 remained in seclusion for 1.5 hours after start of calm behavior.

Patient #3 had a physician order for seclusion on 5/28/13 at 4:00am. The order stated, "put client on seclusion for up to 4 hours for agitation and danger to others". The order did not specify release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #3, dated 6/25/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

Patient #3 was again placed in seclusion on 5/30/13 from 12:55am until 1:45pm for a total of 50 minutes. Every 15 minutes staff documented the patients behaviors. Patient #3 was documented as calm for 30 minutes from 1:15pm until 1:45pm. The release criteria was documented as "Verbalize ability to: Remain in control; No longer harm self; No longer harm others; No longer threaten; Talk to staff".

The Progress Notes were reviewed for seclusion-related entries for Patient #3. At 12:50pm a nurse documented the patient's behavior that necessitated seclusion. No release criteria was specified in the narrative note. There was no documentation to show why Patient #3 remained in seclusion for 30 minutes after start of calm behavior.

Patient #3 had a physician order for seclusion on 5/30/13 at 12:50pm. The order stated "may use seclusion and hold for ETO (emergency treatment order) x 4 hours." The behavior was documented as aggressive and agitation. The order did not specify release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #3, dated 6/25/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

Patient #21:

Patient #21 was placed in 4 point restraints on 8/17/13 from 8:35am until 9:30am (55 minutes). Patient #21 was documented as calm beginning at 9:05am. Patient #21 remained clam until released at 9:30am for 25 minutes of calm behavior. The release criteria was documented as "Verbalize ability to: Remain in control and No longer harm self".

The Progress Notes were reviewed for seclusion-related entries for Patient #21. There was only one entry regarding the restraint episode written on 8/17/13 at 11:00pm. The entry stated that release criteria was explained and the patient verbalized understanding. The release criteria was not specified in the progress note, nor was the rationale for continued restraints for 25 minutes of calm behavior.

Patient #21 had a physician order for 4 point restraints on 8/17/13 at 8:45pm. The order stated, "4 point restraints due to SIB (self-injurious behavior). Max 4 hours." The order did not specify release criteria.

A record review was conducted of the "Seclusion / Restraint / ETO (emergency treatment order) Hold Review Form" for Patient #21, dated 8/20/13. The reviewer marked "yes" to the question, "Was Length of Stay / Hold appropriate (client released as soon as safely possible)?" There was no explanation how this was determined.

On 8/28/13 at approximately 2:30pm, an interview was conducted with Staff Development. The staff member confirmed that she taught restraints and seclusion, but the patient care liaison does the hands on training. She stated that only the physician or registered nurse (RN) can give the directive as to when the patient was released. The criteria for release was "as soon as safely possible." The staff training plan does not contain specific criteria regarding the length of time calm behavior is exhibited prior to release.

The 'Use of Seclusion or Restraint' policy, #500-27, dated August 2011, was reviewed. The section for Discontinuation states:
1. As early as feasible in the restraint or seclusion process, the client shall be made aware of the rationale for restraint or seclusion and the behavior criteria for its discontinuation. Examples of behavior criteria shall include the ability of the client to contract for safety, whether a client is oriented to the environment, and/or cessation of verbal threats.
2. Restraint or seclusion shall be discontinued as soon as the client meets his or her behavior criteria.
3. The decision to release the client from a seclusion/restraint order shall be made on

Based on record review, staff interview and policy review, the facility failed to have a restraint policy and procedure that was in accordance with Florida Administrative Code 65E-5.180(7) regarding the release from restraints, the debriefing process, and the review process. This affected 4 of 4 patients sampled for seclusion and restraint review (#3, 13, 16 and 21). The facility failed to release patients from seclusion or restraint as soon as the person no longer appeared to present an imminent danger to themselves or others (#3, 13 and 21). The facility failed to conduct a debriefing within 24 hours following seclusion or restraint (#3, 16 and 21). The facility failed to ensure that when the debriefing was conducted, it was conducted with either the recovery team or another preferred staff member (#3 and 13). The facility failed to review the incident with all staff involved as soon as possible after the event (#3, #13, #16 and #21). The review of the seclusion and/or restraint procedure failed to identify that patients were not being released as soon as safely possible (#3, 13, and 21).

The findings:

1. The facility policy was not in accordance with State law and the facility failed to release patients from seclusion or restraint as soon as the person no longer appeared to present an imminent danger to themselves or others (#3, 13 and 21).

Florida Administrative Code 65E-5.180(7)(a)11 states, "11. The person shall be released from seclusion or restraint as soon as he or she is no longer an imminent danger to self or others. "

Florida Administrative Code 65E-5.180(7)(f) states,1. Release from seclusion or restraint shall occur as soon as the person no longer appears to present an imminent danger to themselves or others. Upon release from seclusion or restraint, the person's physical condition shall be observed, evaluated, and documented by trained staff. Documentation shall also include: the name and title of the staff releasing the person; and the date and time of release.

A record review was conducted of policy #500-27 entitled, 'Use of Seclusion or Restraint', dated August 2011. The section for Discontinuation states:
1. As early as feasible in the restraint or seclusion process, the client shall be made aware of the rationale for restraint or seclusion and the behavior criteria for its discontinuation. Examples of behavior criteria shall include the ability of the client to contract for safety, whether a client is oriented to the environment, and/or cessation of verbal threats.
2. Restraint or seclusion shall be discontinued as soon as the client meets his or her behavior criteria.
3. The decision to release the client from a seclusion/restraint order shall be made only upon physician approval or by the Charge Nurse.

The procedure for Restraints dated April 2012 was reviewed. The Procedure was entitled, 'Apalachee Center Procedure Inpatient Services - Use of Restraints'. The release of restraints part of the procedure was not in accordance with the hospital policy or the law. Page 10 talks about 'Releasing Patients from Restraints'. The Procedure states, "The decision to release should be based upon the behavioral criteria established and previously explained to the client, and the RN (registered nurse) and/or physician's assessment of the continued risk of harm to the client or others. When the client is able to meet the behavioral criteria for a continuous 30 minutes, the RN and /or physician should consider release."

The procedure component of "30 continuous minutes" was not in accordance with state or federal law. Release times should be individualized, and according to the law, "shall occur as soon as the person no longer appears to present an imminent danger to themselves or others."

A record review of 'Seclusion / Restraint / Hold Placement' forms and 'Continual In-Person Observation and Safety Check' forms was conducted for Patients #3, #13 and #21. None of the patients had an individualized, specific release criteria with a timeframe developed for them.

Patient #13 was placed in 4 point restraints on 8/25/13 from 6:05am until 8:05am for a total of 2 hours. Patient #13 was documented as calm or asleep beginning at 6:35am. Patient #13 remained clam or asleep until he was released at 8:05am for 1.5 hours of calm behavior.

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am for a total of 3.25 hours. Patient #3 was documented as calm or asleep for an hour from 4:30am to 5:30am. At 5:45 he was documented as yelling. He was documented as being asleep for the rest of the restraint time (1.5 hours) of 6:00am until released at 7:30am.

Patient #3 was placed in seclusion on 5/30/13 from 12:55am until 1:45pm for a total of 50 minutes. Patient #3 was documented as calm for 30 minutes from 1:15pm until 1:45pm.

Patient #21 was placed in 4 point restraints on 8/17/13 from 8:35am until 9:30am (55 minutes). Patient #21 was documented as calm for 25 minutes from 9:05am until released at 9:30am.

On 8/28/13 at approximately 2:30pm, an interview was conducted with Staff Development. The staff member confirmed that she taught restraints and seclusion, but the patient care liaison does the hands on training. She stated that only the physician or registered nurse (RN) can give the directive as to when the patient was released. The criteria for release was "as soon as safely possible." The staff training plan does not contain specific criteria regarding the length of time calm behavior is exhibited prior to release.

2. The facility failed to conduct a debriefing within 24 hours following seclusion or restraint for patients #3, 16 and 21.

Florida Administrative Code 65E-5.180(7)(f) states: 2. After a seclusion or restraint event, a debriefing process shall take place to decrease the likelihood of a future seclusion or restraint event for the person and to provide support.
a. Each facility shall develop policies to address: (I) A review of the incident with the person who was secluded or restrained. The person shall be given the opportunity to process the seclusion or restraint event as soon as possible but no longer than within 24 hours of release. This debriefing discussion shall take place between the person and either the recovery team or another preferred staff member.

A record review was conducted of the 'Seclusion / Restraint / Hold Debriefing' form for Patients #3, 16 and 21.

Patient #3 was placed in seclusion on 5/30/13. A debriefing was not done.

Patient #21 was placed in 4 point restraints on 8/17/13. A debriefing was not done.

Patient #16 was placed in 4 point restraints on 8/23/13. A debriefing was not done.

The 'Use of Seclusion or Restraint' policy, 500-27, dated August 2011, was reviewed. The Debriefing section stated: "1. The client and, if appropriate, the (patent's) family, shall participate with staff members who were not involved in the episode and who are available in a debriefing about each episode of restraint or seclusion. 2. The debriefing shall occur as soon as possible and appropriate, but not longer than 24 hours after the episode."

On 8/28/13 at approximately 3:25pm, an interview was conducted with the Risk Manager. The Risk Manager stated that Performance Improvement had identified debriefing not being completed within 24 hours as a concern. They had developed an action plan. The Risk Manager was unable to provide further details of the action plan. The Performance Improvement coordinator was unavailable for interview.

3. The facility failed to ensure that when the debriefing was conducted, it was conducted with either the recovery team or another preferred staff member for patients #3 and 13.

A record review was conducted of the 'Seclusion / Restraint / Hold Debriefing' form for Patients #3 and 13.

Patient #3 was placed in seclusion on 5/28/13 from 4:15am until 7:30am. A debriefing was documented as completed at the time of release (7:30am) by the same nurse involved in the seclusion procedure. There was no indication that the recovery team was involved in the debriefing, or that the patient had chosen to have alternate staff conduct the debriefing.

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