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Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1. Failure to ensure locked seclusion was used for the management of violent or self-destructive behavior as evidenced by placing 5 (#1, #2, #3, #4, #5) of 5 discharged adolescent ED patients and 1 (#6) current adolescent ED patient into locked seclusion while they were not exhibiting violent or self-destructive behaviors that jeopardized the immediate physical safety of the patient, the staff member or others. (See findings at tag A-0162);

2. Failure to ensure less restrictive interventions were attempted before placing patients into locked seclusion for 5 (#1, #2, #3, #4, #5) of 5 discharged adolescent ED patients sampled and 1(#6) current adolescent ED patient. ( See findings at tag A-0164);

3. Failure to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient, authorized to order restraint or seclusion by hospital policy in accordance with State law as evidenced by the RN writing seclusion orders every 2 hours without obtaining a verbal order from the physician every 2 hours for 1 (#2) of 1 patients reviewed from a total patient sample of 5 discharged adolescent ED patients (#1-#5) and 1 current sampled adolescent ED patient (#6) (See findings at tag A-0168); and

4. Failure to ensure seclusion was discontinued at the earliest possible time as evidenced by 5 (#1, #2. #3, #4, #5) of 5 sampled adolescent ED patients that presented with psychiatric problems being placed into locked seclusion and not being released despite no documented behaviors of being a threat to themselves, staff members or others (See findings at tag A-0174).


30364

Based on record reviews, observation, and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by:
1) Failing to ensure nursing staff observed PEC/CEC patients that had been placed in locked seclusion every 15 minutes according to Physician's Orders and hospital policy for 1 (#2) of 2 (#2,#6) sampled patients observed from a total patient sample of 6 (#1- #6); and
2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients being treated for being a danger to self or others in the hospital's ED (emergency department).


Findings:

1) Failing to ensure nursing staff observed PEC/CEC patients every 15 minutes that had been placed in locked seclusion according to Physician's Orders and hospital policy.

Review of the hospital policy titled, "Restraint Policy" revealed in part:
C. Observation/Monitoring of the patient in Restraint or Seclusion
1. In this hospital an RN will perform the initial assessments. A trained staff member, who is assigned to perform uninterrupted observation of the patient, may perform ongoing 15 minute assessment of the patient with RN oversight.

Review of Patient #2's medical record revealed the patient was a 10 year old male who had arrived in the ED on 9/23/18 at 4:50 p.m. The patient's reported chief complaint was face tingling, itching nose, and dizziness. Further review revealed the patient also had co-morbid diagnoses of Autism and ADD/ADHD.

Review of Patient #2's physician documentation revealed an assessment performed on 9/23/18 at 7:58 p.m. by S12NP. Further review revealed the following, in part: Mother reports that child has been complaining of tingling to his entire face, off and on since yesterday. She also states for the last several days he has been very emotional, he seems to be depressed, and sometimes he is having outbursts. Mother reports to me that the child reported to her husband yesterday that he wanted to kill himself and grabbed a kitchen knife.

Review of Patient #2's legal status revealed the patient had been PEC'd on 9/23/18 at 11:00 p.m. due to being currently suicidal, dangerous to self, unable to seek voluntary admission. Further review revealed the patient had been CEC'd on 9/25/18 at 5:30 p.m., due to being currently suicidal, dangerous to self and unable to seek voluntary admission.

Review of Patient #2's medical record revealed the patient had been placed on ordered seclusion from 9/23/18 at 11:00 p.m. until 3:00 p.m. on 9/28/18 when he was discharged home status post psychiatric evaluation by S6Psych.

On 10/30/18 beginning at 1:20 p.m., a video recording of Patient #2's seclusion room was observed with S2QADir and S13QAAsst. The time interval was from 10:28 p.m. on 9/24/18 to 2:00 a.m. on 9/25/18 (a total of 2 hours and 32 minutes). The observation was compared to the documentation by S7RN. The following was observed: S7RN documented an assessment of Patient #2 every 15 minutes which included skin and circulation checks although these assessments were not observed on the video. The blinds to the only window in Patient #2's room were visibly closed blocking view from the exterior hallway.

S2QADir, confirmed in interview, during review of the recorded footage, that the every 15 minute documentation recorded in Patient #2's record did not correlate with the observed video footage. S2QADir also confirmed the patient's skin and circulation had not been assessed by S7RN for 2 hours and 30 minutes as documented in the patient's record.

On 10/31/18 at 8:30 a.m. the surveyor was informed by S1EDNurDir that attempts at contacting S7RN to schedule an interview on 10/31/18 had been unsuccessful. S7RN had not been available for interview, to discuss observed findings, prior to survey team exit on 10/31/18.

An observation was made with S2QADir and S13QAAst of the video recording of Patient #2's room from 3:00 p.m. - 5:00 p.m. on 9/25/18 (a total of 2 hours) and compared to the documentation of S8RN. The observation revealed the following: A total of 2 hours was observed and no assessment of Patient #2 by S8RN was observed for the duration of the video recording review for that time interval. The blinds in the glass window of the room were observed to be open and at no time during the observation was staff observed viewing the patient through the glass window. Review of the documentation by S8RN revealed the following assessment was recorded every 15 minutes for the duration of the observed time interval referenced above: Patient behavior: Patient is calm, cooperative. Care provided: Observed by ED staff, respirations even, non-labored, airway patent, no immediate needs determined.

S2QADir, confirmed in interview, during review of the recoded footage, that the every 15 minute documentation recorded in Patient #2's record did not correlate with the observed video footage. S2QADir also confirmed Patient #2 had not been assessed by S8RN for 2 hours despite having had every 15 minute assessments documented in the patient's record from 3:00 p.m. -5:00 p.m. on 9/25/18.

In an interview on 10/31/18 at 9:11 a.m. with S9RN, he reported he remembered Patient #2. S9RN confirmed it is the expectation that PEC/CEC'd patients in locked seclusion in the ED were to be assessed and documented on every 15 minutes. S9RN further reported the every 15 minute assessments did not include any questions regarding whether the patients had any thoughts of self-harm/harm of others. S9RN indicated realistically the nursing staff could not have been in the room every 15 minutes. He confirmed PEC/CEC psychiatric patients boarded in locked seclusion in the ED were assigned to nursing staff but care of emergency patients treated in the ED with a higher acuity would have taken priority.

In an interview on 10/31/18 at 11:20 a.m. with S8RN, he reported he remembered Patient #2 and confirmed he had been assigned to care for the patient. S8RN reported the expectation by administration was for staff to assess and document every 15 minute checks/rounds on patients in locked seclusion, but that expectation was unrealistic. S8RN indicated he was documenting every 15 minutes, but the checks were not always being performed every 15 minutes as documented. He reiterated there is no way to do checks every 15 minutes on patients in the ED. He also said no nurse in the ED observed patients in seclusion every 15 minutes and took care of other patients because it was impossible.


2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients being treated for being a danger to self or others in the hospital's ED.

On 10/29/18 between 3:30 p.m. and 4:15 p.m. an observation of the 6 bathrooms and the shower room in the ED that were used by patients identified as being at risk for harm to themselves and/or others, without direct visualization by staff at all times, revealed the following safety concerns:

1. Bathrooms #1, #2, #3, #4, #5, and #6:
a. Gooseneck faucets with flanged handles;
b. Exposed plumbing under the sink;
c. Fluorescent bulbs in light fixtures accessible to patients (could be broken and used for self-harm);
d. Grab bars along the walls that were not flush to the wall - potential ligature anchor points;
e. Glass mirrors accessible to patients (could be broken and used for self-harm);
f. Exposed toilet plumbing - potential ligature anchor points;
g. Interior door with a protruding handle - potential ligature anchor point;
h. Plastic bags in garbage cans- potentially used for suffocation;
i. Protruding bathroom entry door hinge, located on the inside of the bathroom- potential ligature anchor point.
j. Bathroom entry doors that were lockable from the inside which could allow the patient to barricade themselves from staff, potentially allowing for self- injury.

S1EDNurDir confirmed, during the observation, that the charge nurse had the key to unlock the bathroom and agreed there could be a potential delay in opening the bathroom if a patient had locked themselves in the bathroom.

2. Shower room:
a. Shower water faucet that protruded providing a potential ligature anchor point;
b. Shower head that protruded providing a potential ligature anchor point;
c. Call light with a long cord - could be used for potential ligature;
d. Protruding bathroom entry door hinge, located on the inside of the bathroom- potential ligature anchor point; and
e. Bathroom entry doors that were lockable from the inside which could allow the patient to barricade themselves from staff, potentially allowing for self- injury.

S1EDNurDir and S2QADir confirmed, during the observations on 10/29/18, that patients identified as being at risk for harm to themselves and/or others could use the above referenced bathrooms and shower room without direct visualization by staff at all times. S1EDNurDir reported the PEC/CEC'd patients, including suicidal patients, were allowed to go into the bathroom unattended by staff to maintain the patients' privacy. He further reported the staff stood outside of the closed door and they would check on the patients if they had been in the bathroom "for a while."

30984


Based on record review and interview, the hospital failed to ensure locked seclusion was used for the management of violent or self-destructive behavior. This deficient practice was evidenced by placing 5 (#1, #2, #3, #4, #5) of 5 sampled discharged adolescent ED patients in locked seclusion and 1 (#6) current adolescent ED patient in locked seclusion while they were not exhibiting violent or self-destructive behaviors that jeopardized the immediate physical safety of the patient, the staff member or others.

Findings:

Review of the hospital policy titled, "Restraint Policy" revealed in part:
The physician orders restraint or seclusion only when less restrictive measures have been found to be ineffective to protect the patient or others from harm.

Patient #1
Review of Patient #1's medical record revealed he was a 12 year old boy that arrived at the Emergency Department on 5/16/18 at 7:50 p.m. for a psychiatric evaluation. Further review revealed Patient #1 had broken a window and struck a family member in the face.

Review of Patient #1's medical record revealed an entry by S3MD on 5/16/18 at 8:20 p.m. that Patient #1 stated he was currently feeling calm and was in a better mood. Further review revealed at 8:42 p.m. S3MD documented Patient #1's behavior and mood was cooperative, affect was calm and had no thoughts or intent to hurt himself or others. No documentation was provided of Patient #1's behaviors being violent or self-destructive when he was placed into locked seclusion on 5/16/18 at 8:30 p.m.

Patient #2
Review of Patient #2's medical record revealed the patient was a 10 year old child who had arrived in the ED on 9/23/18 at 4:50 p.m. The patient's reported chief complaint was face tingling, itching nose, and dizziness.

Review of Patient #2's physician documentation revealed an assessment performed on 9/23/18 at 7:58 p.m. by S12NP. Further review revealed the following, in part: 10 year old well appearing male presents to emergency room has a past medical history of autism and ADHD. Mother also states for the last several days pt. has been very emotional, he seems to be depressed, and sometimes he is having outbursts. Mother reports to me that the child reported to her husband yesterday that he wanted to kill himself and grabbed a kitchen knife. Mother states child has a local psychiatrist; however he has never had any suicidal thoughts or ideations previously. Currently child has no complaints.

Review of Patient #2's medical record revealed no documentation of Patient #2's behaviors being violent or self-destructive when he was placed into locked seclusion on 9/23/18 at 11:00 p.m.

Patient #3
Review of Patient #3's medical record revealed he was a 9 year old boy that had presented to the ED on 8/28/18 at 12:44 a.m. Further review revealed Patient #3 had threatened to kill himself and harm a teacher at school.

Review of Patient #3's medical record revealed no documentation of Patient #3's behaviors being violent or self-destructive when he was placed into locked seclusion on 8/28/18 at 1:00 a.m.

Patient #4
Review of Patient #4's medical record revealed the patient was a 9 year old male that arrived at the ED on 10/1/18 at 3:31 p.m. with the presenting complaint of acting out against his mother and pushing her around.

Review of Patient #4's medical record revealed the patient had been placed into locked seclusion on 10/1/18 at 6:00 p.m. Seclusion was last ordered on 10/8/18 at 8:00 p.m. (122 hours).

Review of Patient #4's medical record revealed no documentation of least restrictive interventions attempted before placing the patient into locked seclusion.

Patient #5
Review of Patient #5's medical record revealed she was an 8 year old girl that arrived at the ED on 10/4/18 at 10:46 a.m. with the presenting complaint of attempting to stab herself in the chest with a pencil.

Review of S14MD's physician's notes dated 10/4/18 at 3:45 p.m. revealed he had assessed Patient #5's behavior and mood as pleasant and cooperative with a calm affect. S14MD also documented Patient #5 had no thoughts to harm self or others. Further review of Patient #5's medical record revealed no documentation of Patient #5's behaviors being violent or self-destructive when she was placed into locked seclusion on 10/4/18 at 4:00 p.m.

Patient #6
Review of Patient #6's medical record revealed the patient was a 16 year old male that arrived at the ED on 10/30/18 at 11:28 a.m. with the presenting complaint of being suicidal (self-admitted by patient) and positive for homicidal ideations toward "anybody."

Review of Patient #6's medical record revealed the patient had been placed into locked seclusion on 10/30/18 at 1:00 p.m.

Further review of Patient #6's medical record revealed no documentation of Patient #6's behaviors being violent or self-destructive when he was placed into locked seclusion on 10/30/18 at 1:00 p.m.

In an interview on 10/30/18 at 10:08 a.m. with S1EDNurDir, he said as long as 1 of the 4 seclusion rooms were available, PEC'd patients in the ED were placed in locked seclusion and remained in locked seclusion until transferred.

In an interview on 10/30/18 at 3:30 p.m. with S3MD (Emergency Medicine), he reported placing PEC/CEC'd patients in the ED in locked seclusion is the hospital's standard practice. S3MD further reported there were no specific reason for patients to be placed in locked seclusion except for being monitored constantly and for patient safety. S3MD reported the reality is that placing PEC/CEC'd patients in the ED in locked seclusion has to do with staffing.

In an interview on 10/31/18 at 8:11 a.m. with S4MedDir (Medical Director of ED), he confirmed all adolescent psychaitric patients were placed in locked seclusion while awaiting placement at an inpatient psychiatric facility.
S4MedDir reported placing the patients in locked seclusion was about utilization of man power that they have because they are under-manned. S4MedDir reported if patients were in ordered locked seclusion there should be a valid need for seclusion. S4MedDir indicated the goal was to get PEC/CEC'd patients to a higher level of care. S4MedDir further reported, "The PEC/CEC'd patients being held in the ED awaiting placement were put in captivity." S4MedDir also verified the hospital did not do anything for patient to address their psychiatric problems, didn't adjust their medications, and didn't initiate any type of management of their psychiatric care because they do not have a pediatric/adolescent psychiatrist at the hospital.

In an interview on 10/31/18 at 9:43 a.m. with S5MD, (Emergency Medicine), he reported all patients being held on PEC were held in locked rooms in order to monitor ingress and egress into/out of the room. S5MD reported the locked rooms were used for staffing and security purposes. He reported the rooms were designed for psychiatric patients.

30984


Based on record review and interview, the hospital failed to ensure less restrictive interventions were attempted before placing patients into locked seclusion for 5 (#1, #2, #3, #4, #5) of 5 sampled discharged adolescent ED patients placed in seclusion and 1(#6) current sampled adolescent ED patient placed in seclusion.

Findings:

Review of the hospital policy titled Restraint Policy revealed in part:
The physician orders restraint or seclusion only when less restrictive measures have been found to be ineffective to protect the patient or others from harm.

Patient #1
Review of Patient #1's medical record revealed he was a 12 year old boy that arrived at the Emergency Department on 5/16/18 at 7:50 p.m. for a psychiatric evaluation. Further review revealed Patient #1 had broken a window and struck a family member in the face.

Review of Patient #1's medical record revealed he had been placed into locked seclusion in the ED on 5/16/18 at 8:30 p.m. and not released until he was transferred on 5/19/18 at 8:41 p.m. (72 hours and 11 minutes).

Review of Patient #1's medical record revealed no documentation of least restrictive interventions attempted before placing him into locked seclusion.

Patient #2
Review of Patient #2's medical record revealed the patient was a 10 year old child who had arrived in the ED on 9/23/18 at 4:50 p.m. The patient's reported chief complaint was face tingling, itching nose, and dizziness. Further review revealed the patient also had co-morbid diagnoses of Autism and ADD/ADHD.

Review of Patient #2's physician documentation revealed an assessment performed on 9/23/18 at 7:58 p.m. by S12NP. Further review revealed the following, in part: 10 year old well appearing male presents emergency room has a past medical history of autism and ADHD. Mother also states for the last several days pt. has been very emotional, he seems to be depressed, and sometimes he is having outbursts. Mother reports to me that the child reported to her husband yesterday that he wanted to kill himself and grabbed a kitchen knife. Mother states child has a local psychiatrist; however he has never had any suicidal thoughts or ideations previously. Currently child has no complaints. Additional review revealed Review of Systems: Psych: Positive for depression and suicide gesture.

Review of Patient #2's medical record revealed the patient had been placed on ordered, locked seclusion from 9/23/18 at 11:00 p.m. until the last q 2 hour seclusion renewal had been ordered at 1:00 p.m. on 9/28/18 (110 hours). The patient was discharged home status post psychiatric evaluation by S6Psych on 9/28/18 at 1:35 p.m.

Review of Patient #2's medical record revealed no documentation of least restrictive interventions having been attempted before placing the patient into locked seclusion.

Patient #3
Review of Patient #3's medical record revealed he was a 9 year old boy that had presented to the ED on 8/28/18 at 12:44 a.m. Further review revealed Patient #3 had threatened to kill himself and harm a teacher at school.

Review of Patient #3's medical record revealed he was placed into locked seclusion on 8/28/18 at 1:00 a.m. and not released until his transfer on 9/4/18 at 1:58 p.m. (181 hours and 14 minutes).

Review of Patient #3's medical record revealed no documentation of least restrictive interventions attempted before placing him into locked seclusion.

Patient #4
Review of Patient #4's medical record revealed the patient was a 9 year old male that arrived at the ED on 10/1/18 at 3:31 p.m. with the presenting complaint of acting out against his mother and pushing her around.

Review of Patient #4's medical record revealed the patient had been placed into locked seclusion on 10/1/18 at 6:00 p.m. Seclusion was last ordered on 10/8/18 at 8:00 p.m. (122 hours).

Review of Patient #4's medical record revealed no documentation of least restrictive interventions attempted before placing the patient into locked seclusion.

Patient #5
Review of Patient #5's medical record revealed she was an 8 year old girl that arrived at the ED on 10/4/18 at 10:46 a.m. with the presenting complaint of attempting to stab herself in the chest with a pencil.

Review of Patient #5's medical record revealed she was placed into locked seclusion on 10/4/18 at 4:00 p.m. Seclusion was last ordered on 10/8/18 at 9:00 a.m. (101 hours).

Review of Patient #5's medical record revealed no documentation of least restrictive interventions attempted before placing her into locked seclusion.

Patient #6
Review of Patient #6's medical record revealed the patient was a 16 year old male that arrived at the ED on 10/30/18 at 11:28 a.m. with the presenting complaint of being suicidal (self admitted by patient) and positive for homicidal ideations toward "anybody."

Review of Patient #6's medical record revealed the patient had been placed into locked seclusion on 10/30/18 at 1:00 p.m.

Review of Patient #6's medical record revealed no documentation of least restrictive interventions attempted before placing the patient into locked seclusion.

In an interview on 10/30/18 at 10:08 a.m. with S1EDNurDir, he said as long as 1 of the 4 seclusion rooms were available, PEC'd patients in the ED were placed in locked seclusion and remained in locked seclusion until transferred.

In an interview on 10/30/18 at 2:48 p.m., S13QAAsst stated she had reviewed the medical records for Patient's #1-#5. She verified the review revealed less restrictive measures were not documented as having been done before placing the patients into locked seclusion but should have been.

Based on record review and interview, the hospital failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice was evidenced by the RN writing seclusion orders every 2 hours without obtaining a verbal order from the physician every 2 hours for 1 (#2) of 1 sampled patients reviewed from a total patient sample of 5 discharged adolescent ED patients placed in seclusion (#1-#5) and 1 current sampled adolescent ED patient placed in seclusion (#6).

Findings:

Review of the hospital policy titled,"Restraint Policy", Policy Number: PC-080, revealed in part: Purpose: To provide guidelines regarding appropriate restraint use for the medical well-being of non-violent medical/surgical patients and unanticipated severely aggressive or destructive behavior that places the patient or others in danger. This policy will also outline the hospital's philosophy regarding implementation of restraints or seclusion and the protection of patients' rights. Section 1A. Definitions: 3. Seclusion: It is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving. Section 2 B. Authorization and Ordering of Restraint or Seclusion: 1. The physician orders restraint or seclusion only when less restrictive measures have been found to be ineffective to protect patient or others from harm 7. Orders for or restraint are time limited. The physician determines the duration of the restraint order. The order can be less than the following lengths of time, but cannot exceed: 2 hours for children and adolescents ages 9-17. 9. The physician conducts an in-person re-evaluation at least every 4 hours for patients ages 17 and younger. 10. Contents of a seclusion/restrsaint order will include: b. The maximum length of time restraint or seclusion may be utilized; c. The specific behaviors that present a danger to the patient or others which require the use of seclusion or restraint; and d. The specific measureable behaviors which must be exhibited by the patient in order for the seclusion or restraint to be discontinued. G. Staff responsibilities: 1. Registered Nurse: 4. Receiving orders from physician.

Review of Patient #2's medical record revealed the patient was a 10 year old child who had arrived in the ED on 9/23/18 at 4:50 p.m. The patient's reported chief complaint was face tingling, itching nose, and dizziness.

Review of Patient #2's physician documentation revealed an assessment performed on 9/23/18 at 7:58 p.m. by S12NP. Further review revealed the following, in part: 10 year old well appearing male presents to emergency room has a past medical history of autism and ADHD. Mother also states for the last several days pt. has been very emotional, he seems to be depressed, and sometimes he is having outbursts. Mother reports to me that the child reported to her husband yesterday that he wanted to kill himself and grabbed a kitchen knife. Mother states child has a local psychiatrist; however he has never had any suicidal thoughts or ideations previously. Currently child has no complaints.

Review of Patient #2's medical record revealed the patient had been placed on ordered seclusion from 9/23/18 at 11:00 p.m. until the last every 2 hour seclusion renewal had been ordered at 1:00 p.m. on 9/28/18 (110 hours). The seclusion orders had been re-ordered every 2 hours as per hospital policy for adolescent patients 9-17 years of age by the nursing staff. There was no documented evidence that verbal orders for the every 2 hour seclusion renewal had been obtained from the MD/LIP caring for the patient. Further review revealed no documentation of violent or self-destructive behaviors that warranted the continued use of seclusion because of being a threat to himself, staff members or others while in the locked seclusion.

In an interview on 10/31/18 at 8:11 a.m. with S4MedDir, Medical Director of ED, he reported the nurses were entering the every 2 hour seclusion renewal orders and the nurses assigned the MD to the orders entered. S4MedDir reported sometime during their shift the assigned MDs should go in and sign the orders off before the end of the shift.


In an interview on 10/31/18 at 9:11 a.m. with S9RN, he reported the nurses re-order the seclusion renewal orders every 2 hours. S9RN indicated the nurses input the orders into the system and the assigned MD goes back later to approve them. S9RN reported the seclusion renewal orders were like a standing order. S9RN reported child/adolescent PEC/CEC'd patients boarded in the ED, awaiting placement in an inpatient psychiatric facility, would have had seclusion orders re-ordered/renewed every 2 hours.


In an interview on 10/31/18 at 9:35 a.m. with S10RN, she indicated nurses enter the orders for renewal of seclusion orders every 2 hours. S10RN reported the orders go into the que and the assigned MDs signed off on the orders at at the end of the shift.

In an interview on 10/31/18 at 9:43 a.m. with S5MD, he reported the patient's nurse puts in the orders for renewal of seclusion orders every 2 hours. S5MD reported the orders for seclusion were entered automatically by the nursing staff and they were signed off later by the MD/LIP. S5MD confirmed the nursing staff does not obtain a verbal order from the MD/LIP for renewal of seclusion orders every 2 hours.

In an interview on 10/31/18 at 11:01 a.m. with S1EDNurDir., he confirmed nurses are inputting orders for seclusion renewal every 2 hours and MDs are signing the orders later. S1EDNurDir reported the every 2 hour seclusion renewals were considered protocol orders. S1EDNurDir confirmed the nurses were not obtaining verbal orders from MDs/LIPs every 2 hours to continue seclusion.

In an interview on 10/31/18 at 11:20 a.m. with S8RN, he confirmed he had entered the orders for renewal of seclusion for Patient #2 every 2 hours. S8RN also confirmed he had not obtained a verbal order for renewal of seclusion orders every 2 hours from the patient's managing MD/LIP. S8RN indicated he was not sure when the MDs/LIPs signed off on the orders.

30984


Based on record review and interview, the hospital failed to ensure seclusion was discontinued at the earliest possible time. This deficient practice is evidenced by 5 (#1, #2. #3, #4, #5) of 5 sampled adolescent ED patients that presented with psychiatric problems being placed into locked seclusion and not being released despite no documented behaviors of being a threat to themselves, staff members or others.

Findings:

Review of the hospital policy titled,"Restraint Policy", Policy Number: PC-080, revealed in part: Purpose: To provide guidelines regarding appropriate restraint use for the medical well-being of non-violent medical/surgical patients and unanticipated severely aggressive or destructive behavior that places the patient or others in danger. This policy will also outline the hospital's philosophy regarding implementation of restraints or seclusion and the protection of patients' rights. Policy: Through the establishment of guidelines the organization will limit the use of restraint to those situations with appropriate and adequate clinical justification and facilitate discontinuation of restraint or seclusion as soon as possible. Section 1A. Definitions: 3. Seclusion: It is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving. C. Patient Rights: 1. Restraint or seclusion shall be ended at the earliest possible time. Neither restraint nor seclusion shall be used for purposes such as coercion, discipline, convenience, or retaliation by staff. Any such use is strictly prohibited. Section 2 B. Authorization and Ordering of Restraint or Seclusion: 7. Orders for or restraint are time limited. The physician determines the duration of the restraint order. The order can be less than the following lengths of time, but cannot exceed: 2 hours for children and adolescents ages 9-17. 9. The physician conducts an in-person re-evaluation at least every 4 hours for patients ages 17 and younger. 10. Contents of a seclusion/restraint order will include: b. The maximum length of time restraint or seclusion may be utilized; c. The specific behaviors that present a danger to the patient or others which require the use of seclusion or restraint; and d. The specific measureable behaviors which must be exhibited by the patient in order for the seclusion or restraint to be discontinued.

Patient #1
Review of Patient #1's medical record revealed he was a 12 year old boy that arrived at the Emergency Department on 5/16/18 at 7:50 p.m. for a psychiatric evaluation. Further review revealed Patient #1 had broken a window and struck a family member in the face.

Review of Patient #1's medical record revealed he had been placed into locked seclusion in the ED on 5/16/18 at 8:30 p.m. and not released until he was transferred on 5/19/18 at 8:41 p.m. (72 hours and 11 minutes). Further review revealed no documentation of violent or self-destructive behaviors that warrented the continued use of seclusion because of being a threat to himself, staff members or others while in the locked seclusion.

Patient #2
Review of Patient #2's medical record revealed the patient was a 10 year old child who had arrived in the ED on 9/23/18 at 4:50 p.m. The patient's reported chief complaint was face tingling, itching nose, and dizziness.

Review of Patient #2's physician documentation revealed an assessment performed on 9/23/18 at 7:58 p.m. by S12NP. Further review revealed the following, in part: 10 year old well appearing male presents to emergency room, has a past medical history of Autism and ADHD. Mother also states for the last several days pt. has been very emotional, he seems to be depressed, and sometimes he is having outbursts. Mother reports to me that the child reported to her husband yesterday that he wanted to kill himself and grabbed a kitchen knife. Mother states child has a local psychiatrist, however he has never had any suicidal thoughts or ideations previously. Currently child has no complaints.

Review of Patient #2's medical record revealed the patient had been placed on ordered, locked seclusion from 9/23/18 at 11:00 p.m. until the last every 2 hour seclusion renewal had been ordered at 1:00 p.m. on 9/28/18 (110 hours). Further review revealed no documentation of violent or self-destructive behaviors that warranted the continued use of seclusion because of being a threat to himself, staff members or others while in locked seclusion. The patient was discharged home status post psychiatric evaluation by S6Psych on 9/28/18 at 1:35 p.m.

Patient #3
Review of Patient #3's medical record revealed he was a 9 year old boy that had presented to the ED on 8/28/18 at 12:44 a.m. Further review revealed Patient #3 had threatened to kill himself and harm a teacher at school.

Review of Patient #3's medical record revealed he was placed into locked seclusion on 8/28/18 at 1:00 a.m. and not released until his transfer on 9/4/18 at 1:58 p.m. (181 hours and 14 minutes). Further review revealed no documentation of violent or self-destructive behaviors that warrented the continued use of seclusion because of being a threat to himself, staff members or others while in the locked seclusion.

Patient #4
Review of Patient #4's medical record revealed the patient was a 9 year old male that arrived at the ED on 10/1/18 at 3:31 p.m. with the presenting complaint of acting out against his mother and pushing her around.

Review of Patient #4's medical record revealed the patient had been placed into locked seclusion on 10/1/18 at 6:00 p.m. Seclusion was last ordered on 10/8/18 at 8:00 p.m. (122 hours). Further review revealed no documentation of violent or self-destructive behaviors that warranted the continued use of seclusion because of being a threat to himself, staff members or others while in the locked seclusion.

Patient #5
Review of Patient #5's medical record revealed she was an 8 year old girl that arrived at the ED on 10/4/18 at 10:46 a.m. with the presenting complaint of attempting to stab herself in the chest with a pencil.

Review of Patient #5's medical record revealed placed into locked seclusion on 10/4/18 at 4:00 p.m. Seclusion was last ordered on 10/8/18 at 9:00 a.m. (101 hours). Further review revealed no documentation of violent or self-destructive behaviors that warrented the continued use of seclusion because of being a threat to herself, staff members or others while in the locked seclusion.

In an interview on 10/30/18 at 10:08 a.m. with S1EDNurDir, he said as long as 1 of the 4 seclusion rooms were available, PEC'd patients in the ED were placed in locked seclusion and remained in locked seclusion until transferred.

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Based on record review and interview, the hospital failed to ensure secluded patients' conditions were monitored every 4 hours by a physician as per hospital policy for 5 (#1, #2, #3, #4, #5) for 5 sampled adolescents placed in locked seclusion in the hospital's ED.

Findings:

Review of the hospital policy titled,"Restraint Policy", Policy Number: PC-080, revealed in part: Purpose: To provide guidelines regarding appropriate restraint use for the medical well-being of non-violent medical/surgical patients and unanticipated severely aggressive or destructive behavior that places the patient or others in danger. This policy will also outline the hospital's philosophy regarding implementation of restraints or seclusion and the protection of patients' rights. Policy: Through the establishment of guidelines the organization will limit the use of restraint to those situations with appropriate and adequate clinical justification and facilitate discontinuation of restraint or seclusion as soon as possible. Section 1A. Definitions: 3. Seclusion: It is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving. C. Patient Rights: 1. Restraint or seclusion shall be ended at the earliest possible time. Neither restraint nor seclusion shall be used for purposes such as coercion, discipline, convenience, or retaliation by staff. Any such use is strictly prohibited. Section 2 B. Authorization and Ordering of Restraint or Seclusion: 7. Orders for or restraint are time limited. The physician determines the duration of the restraint order. The order can be less than the following lengths of time, but cannot exceed: 2 hours for children and adolescents ages 9-17. 9. The physician conducts an in-person re-evaluation at least every 4 hours for patients ages 17 and younger.

Patient #1
Review of Patient #1's medical record revealed he had been placed into locked seclusion in the ED on 5/16/18 at 8:30 p.m. and not released until he was transferred on 5/19/18 at 8:41 p.m. (72 hours and 11 minutes). Further review revealed a physician did not document an assessment every 4 hours.

Patient #2
Review of Patient #2's medical record revealed the patient had been placed into locked seclusion on 9/23/18 at 11:00 p.m. Seclusion was last ordered on 9/28/18 at 1:00 p.m. (110 hours). Further review revealed a physician did not assess Patient #2 every 4 hours to determine the continued need for seclusion.

Patient #3
Review of Patient #3's medical record revealed he was placed into locked seclusion on 8/28/18 at 1:00 a.m. and not released until his transfer on 9/4/18 at 1:58 p.m. (181 hours and 14 minutes). Further review revealed a physician did not document an assessment every 4 hours.

Patient #4
Review of Patient #4's medical record revealed the patient had been placed into locked seclusion on 10/1/18 at 6:00 p.m. Seclusion was last ordered on 10/8/18 at 8:00 p.m. (122 hours).
Review of Patient #4's medical record revealed the patient had been placed into locked seclusion on 10/1/18 at 6:00 p.m. Seclusion was last ordered on 10/8/18 at 8:00 p.m. (122 hours). Further review revealed a physician did not assess Patient #4 every 4 hours to determine the continued need for seclusion.

Patient #5
Review of Patient #5's medical record revealed she was placed into locked seclusion on 10/4/18 at 4:00 p.m. Seclusion was last ordered on 10/8/18 at 9:00 a.m. (101 hours). Further review revealed a physician did not document an assessment every 4 hours.

In an interview on 10/30/18 at 2:48 p.m., S13QAAsst stated she had reviewed the medical records for patient's #1-#5. She stated the review revealed the physician did not assess the patients within 4 hours of being placed into seclusion or every 4 hours.

In an interview on 10/30/18 at 3:30 p.m. with S3MD (Emergency Medicine), he reported placing PEC/CEC'd patients in the ED in locked seclusion is the hospital's standard practice. S3MD further reported the expectation for ED MDs to assess patients once a shift. He reported the ED MDs worked 10 hour shifts. S3MD also reported he did not wake patients to assess them if they were observed to be asleep.

In an interview on 10/31/18 at 8:11 a.m. with S4MedDir (Medical Director of ED), he confirmed all adolescent psychiatric patients were placed in locked seclusion while awaiting placement at an inpatient psychiatric facility. S4MedDir reported MDs should be assessing the patient's once a shift because that is best practice for them. S4MedDir reported if patients were in ordered locked seclusion there should be a valid need for seclusion. S4MedDir indicated the goal is to get PEC/CEC'd patients to a higher level of care. S4MedDir further reported, "The PEC/CEC'd patients being held in the ED awaiting placement were put in captivity." S4MedDir also verified the hospital did not do anything for patient to address their psychiatric problems, didn't adjust their medications, and didn't initiate any type of management of their psychiatric care because they do not have a pediatric/adolescent psychiatrist at the hospital.

Based on record review and interview, the hospital failed to ensure the prescribing practitioner responsible for the care of a patient had issued an order, consistent with hospital policy, permitting self-administration of the patient's home medications by the patient's caregiver. This deficient practice was evidenced by failure of the prescribing practitioner to write an order permitting self-admininstration of a home medication by the patient's care giver and failure to order identification and visual inspection of the home medication's integrity, by the physician, prescribing practitioner, pharmacist, or nurse, prior to administration (as per hospital policy) for 1(#2) of 1 patient reviewed for receiving home medications while hospitalized from a total patient sample of 5 discharged adolescent ED patients (#1-#5) and 1 current sampled adolescent ED patient (#6).

Findings:

Review of the hospital policy titled,"Medication Management", Policy number: MM-080, revealed in part: 12. Self- medication by the patient is permitted only on physician's order. 13. A patient may use their own supply of medications, if permitted, only on a physician's order. The drug must first be identified and it's integrity visually evaluated by the physician, prescribing practitioner, pharmacist, or nurse.

Review of the hospital's complaint investigation documentation regarding a complaint related to Patient #2's care during his hospital stay revealed the following, in part: Complainant alleged she was forced to leave ED to retrieve Patient #2's home medications because the hospital had not provided them. The complainant alleged she self-administered home medications with ED nurses knowledge; however none of the medications she administered were verified by hospital staff. According to the complainant the home medications included Adderall, Clonidine, and Prozac. Further review revealed the following response to the complainant's allegation: Adderall is not on the hospital's formulary, therefore it would not be available for patients and per policy MM-080, the patient can be asked to provide their home medications for those not on formulary. In this case, Adderall is a schedule II drug, and it would not have been readily available in a short time frame so the patient would have been asked to provide their home medication to ensure they received the medication prescribed.

Review of Patient #2's medical record revealed the patient arrived in the ED on 9/23/18 at 5:03 p.m. The patient's reported chief complaint was facial tingling (onset yesterday), itching nose, and dizziness. Further review revealed the patient also had co-morbid diagnoses of Autism and ADD/ADHD.

Additional review revealed on 9/23/18 at 5:06 p.m. a triage assessment had been performed and the patient's home medications were documented as follows: Adderall XR (extended release) 20 mg (milligrams) oral - 2 caps once daily, Fluoxitine (Prozac) 10 mg oral cap once daily, and Clonidine HCL 0.1 mg oral tab p.m.

Additional review of Patient's #2's medical record revealed the following nurses' note entry regarding medication administration:

9/25/18 8:29 p.m. Mother reports she gave pt. his normal daily dose of Adderall XR- 20 mg. Further review revealed no documented evidence that the home medication had been verified as the correct medication and no documentation of verification of integrity of the medication, by the nursing staff or medical staff, in the patient's medical record, prior to the medication administration.

Review of Patient #2's physician's orders revealed there was no order for approval of self- administration of home medications (Adderall), by the patient's caregiver, and no order for identification and visual inspection of the home medication's integrity, by the physician, prescibing practitioner, pharmacist, or nurse, prior to administration (as per hospital policy). Additional review revealed no order had been written to discontinue the patient's Adderall.

In an interview on 10/29/18 at 3:00 p.m. with S1EDNurDir, he verified there was no order for approval of self-administration of the patient's home medication (Adderall) in the patient's medical record. S1EDNurDir further verified there was no documented evidence in the patient's medical record to indicate the self- administered medication had been verified as the correct medication and no documentation of verification of integrity of the medication, by the nursing staff or medical staff, in the patient's medical record but should have been.