HospitalInspections.org

Based on medical record review, staff interview, and review of policies and procedures, it was determined the facility failed to ensure all behavioral seclusion and restraint requirements were met. There was evidence a staff member was abusive to one patient (A145). There was evidence the hospital did not protect the confidentiality of medical records (A146). The facility did not ensure plans of care were modified to address all types of restraint use (A166). There was evidence one physician wrote a PRN (as needed) order for a papoose restraint (A169). There lacked adequate evidence the facility performed a complete one hour face-to-face evaluation (A179). The cumulative effect of these systems failures resulted in the inability of the facility to ensure patient rights to confidentiality and being free from abuse, and that use of seclusion and restraint interventions were implemented appropriately.

Based on staff interview, medical record review, and review of the patient "Bill of Rights," the facility failed to ensure 1 (#13) of 16 sample patients were protected from abuse. The findings were:

Review of the medical record for patient #13 showed s/he was admitted on 10/10/09 with multiple psychiatric and medical diagnoses. Interview with certified nurse aide (CNA) #1 on 4/15/10 at 10:30 AM revealed this patient was in the day room and was exhibiting "scary" behaviors which frightened the other patients. The CNA said she asked the patient to leave and return to his/her room but the patient did not do so. The CNA stated she then used both of her hands, with palms open, to "escort" the patient out of the dayroom. The CNA described "escort" as using her hands to physically turn the patient around and pushing him/her in the direction the CNA wanted the patient to go. The CNA said she used this procedure to escort the patient back to his/her room. The CNA said the patient reported her to her supervisor as being abusive. The CNA said the next day the patient apologized to the CNA for reporting her to her supervisor. The CNA said she told the patient that she (CNA) did not accept the patient's apology because s/he almost cost the CNA her job. Interview with the director of clinical services on 4/15/10 at 11 AM revealed the CNA should have used the "Handle With Care" technique as she was taught and should not have pushed the patient along to his/her room. Review of the patient "Bill of Rights" (2007) showed "A patient has the right to....be safe from physical....and mental abuse.

Based on staff interview and medical record review, the hospital failed to ensure confidentiality of medical records was maintained for 1 (#12) of 16 sample patients. The findings were:

During an interview with an education staff member on 4/15/10 at 4:30 PM, she acknowledged that she had mailed a copy of the psychiatric evaluation, history and physical, and discharge summary for patient #12 to the wrong school. She said the school she mailed it to returned it and the records were then sent to the correct school. Review of the medical record revealed the appropriate release of information form was completed for the requesting school. Interview with Health Information Management staff on 4/15/10 at 9:10 AM revealed all information mailed outside the facility should be reported to the Health Information Management department. She said she was unaware of this breach of confidentiality.

Based on staff interview, medical record review, and review of the hospital seclusion and restraint policy and procedure, the hospital failed to ensure the care plan was modified after seclusion and/or restraints were implemented for 5 (#1, #11,#12, #14, #16) of 6 sample patients who required these measures. The findings were:

1. Review of the medical record for six year old patient #16 revealed s/he was placed in seclusion and a papoose restraint on 3/12/10 at 9 PM. Further review showed the patient was placed in seclusion on 3/16/10 at 2:45 PM, on 3/17/10 at 2:15 PM, and again on 3/17/10 at 6:20 PM for assaultive behaviors. Review of the care plan showed the care plan was not modified to address the implementation of the papoose restraint or seclusion.

2. Medical record review for patient #1 showed s/he was placed in seclusion on 1/4/10 at 1:40 PM and again on 1/11/10 at 8:55 PM due to self-injurious behaviors. Review of the care plan showed the care plan was not modified to address the implementation of seclusion.

3. Medical record review for six year old patient #12 showed s/he was placed in seclusion on 1/3/10 at 2:30 PM for biting and hitting a staff member. Review of the care plan showed the care plan was not modified to address the implementation of seclusion.

4. Review of the medical review for 10 year old patient #11 showed s/he was placed in seclusion on 1/3/10 at 10:40 PM for physical and verbal abuse to staff, hitting, kicking, stomping on toes, spitting, and head butting the registered nurse. Review of the care plan showed the care plan was not modified to address the implementation of seclusion.

5. Medical record review for 11 year old patient #14 showed s/he required seclusion on 2/7/10 at 2:40 PM due to assaultive behaviors towards staff, kicking, pushing, throwing an object, screaming, yelling, and refusing to follow directions. Review of the care plan showed the care plan was not modified to address the implementation of seclusion.

6. Interview with the director of clinical services and director of nursing on 4/15/10 at 3:45 PM revealed the care plan should be modified when seclusion and/or restraints were implemented. Review of the hospital policy and procedure #1000.66, revised 3/10, showed the following instructions: "Master treatment plan revisions following the episode of seclusion or restraints. The treatment plan revision will include interventions to prevent future use."

Based on staff interview, medical record review, and review of hospital policy and procedure, the hospital failed to ensure an order for restraint was not written as a PRN (as needed) order for 1 (#16) of 1 sample patients who required restraints. The findings were:

Review of the medical record for six year old patient #16 revealed s/he was placed in seclusion and a papoose restraint on 3/12/10 at 9 PM for assaulting multiple staff and refusing to take PRN (as needed) medication to calm down. "It was determined that [s/he] must be put in restraints for the safety of the staff." Review of the physician's admission orders written on 2/25/10 at 10:04 AM showed an order was written for PRN (as needed) use of a papoose board (restraint). Interview with the director of nursing and director of clinical services on 4/15/10 at 4 PM confirmed the papoose board was a restraint and that PRN orders were forbidden. Interview with the director of clinical services on 4/27/10 at 3:30 PM revealed the PRN papoose order was supposed to be for laboratory blood draws according to the physician who wrote the order. However, that was not how the order was written. Review of the hospital policy and procedure #1000.66, revised 3/10, showed the following instructions: "PRN orders....for patients with primary behavioral health needs is prohibited!"

Based on staff interview, medical record review, review of incident reports, and review of the seclusion/restraint log, the hospital failed to ensure the required elements for placement in seclusion and/or restraints were followed for 5 of 6 (#1, #11, #12, #14, #16) sample patients who requirement implementation of these measures. The findings were:

1. Review of the medical record for six year old patient #16 revealed s/he was placed in seclusion and a papoose restraint on 3/12/10 at 9 PM for assaulting multiple staff and refusing to take PRN (as needed) medication to calm down. "It was determined that [s/he] must be put in restraints for the safety of the staff." The following concerns were identified:
a. Review of the physician's admission orders written on 2/25/10 at 10:04 AM showed an order was written for PRN (as needed) use of a papoose board (restraint). Interview with the director of nursing and director of clincal services on 4/15/10 at 4 PM confirmed the papoose board was a restraint. Review of the "seclusion/restraint orders" flowsheet revealed the family or guardian was not notified, and the one hour face-to-face evaluation failed to include a review of systems assessment.
b. Review of the "seclusion/restraint orders" flowsheet also showed the patient sustained an injury while restrained. The patient banged his/her head on the floor while in the papoose restraint and stated, "It hurts." Review of the incident reports showed the injury was not noted, assessed, or monitored. The includent report only included a notation that the patient required restraints/seclusion. There was no evidence in the medical record that an assessment, or monitoring of the patient's injury, was performed.
c. Review of the medical record revealed the patient was again placed in seclusion on 3/16/10 at 2:45 PM because/she was highly assaultive towards multiple staff, was unable to process, was destructive (throwing chairs) and threatening to others. Review of the "seclusion/restraint orders" flowsheet showed the one hour face-to-face evaluation lacked a review of systems assessment.
d. Review of the "seclusion/restraint" flowsheet showed the patient was placed in seclusion on 3/17/10 at 2:15 PM and again on 3/17/10 at 6:20 PM for assaulting staff. Further review of the two flowsheets showed the one hour face-to-face evaluations failed to include a systems review assessment.

2. Medical record review for patient #1 showed s/he was placed in seclusion on 1/4/10 at 1:40 PM and again on 1/11/10 at 8:55 PM due to self-injurious behaviors. Review of the documentation including the "seclusion/restraint flow sheets" and "face to face evaluation review" showed the one hour face-to-face evaluations failed to include the patient's reaction to the intervention, complete review of systems assessment and justification of termination of the seclusion. During an interview on 4/15/10 at 4:50 PM the director of clinical services verified both face-to-face evaluations as documented.

3. Medical record review for six year old patient #12 showed s/he was placed in seclusion on 1/3/10 at 2:30 PM for biting and hitting a staff member. Review of the "seclusion/restraint orders" flowsheet showed the one hour face-to-face evaluation lacked a review of systems assessment.

4. Review of the medical review for 10 year old patient #11 showed s/he was placed in seclusion on 1/3/10 at 10:40 PM for physical and verbal abuse to staff, hitting, kicking, stomping on toes, spitting, and head butting the registered nurse. Review of the "seclusion/restraint orders" flowsheet showed the one hour face-to-face evaluation did not include a complete review of systems assessment.

5. Medical record review for 11 year old patient #14 showed s/he required seclusion on 2/7/10 at 2:40 PM due to assaultive behaviors towards staff, kicking, pushing, throwing an object, screaming, yelling, and refusing to follow directions. Review of the "seclusion/restraint orders" flowsheet showed the one hour face-to-face evaluation did not include a complete review of systems assessment.

6. Interview with the director of clinical services and the director of nursing on 4/15/10 at 4:10 PM revealed they were unaware a complete review of systems was required for placement in seclusion and/or restraints.

Based on staff interview, medical record review, and review of nursing policies and procedures, it was determined the hospital failed to ensure all nursing requirements were met. There lacked evidence nursing staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate pain management and appropriate nursing treatment of clinical events (A395). The hospital did not ensure plans for care were modified to address patient needs as they changed and new interventions were put in place (A396). The combined results of these systems failures resulted in the inability of the hospital to ensure nursing assessments, monitoring, and nursing measures were adequately and appropriately provided for all patients.

Based on staff interview, medical record review, and review of the patient "Bill of Rights," the hospital failed to ensure staff provided adequate pain management, and adequate assessing, monitoring and nursing management for 1 (#13) of 2 sample patients who experienced pain and exhibited clinical events. The findings were:

Review of the admission face sheet for patient #13 showed s/he was admitted with multiple psychiatric and medical problems. The following concerns were identified:

1. During review of the pain scale log for patient #13, the following concerns were identified:
a. Review showed the patient had back pain rated 6 on a scale of 1 to 10 (1/10) with 10 being the worst pain and a headache rated 9/10 at 7:57 AM on 10/11/09. Review of the physician's orders showed no PRN (as needed) pain medication was ordered until 10/14/09 at 8 PM. At that time Tylenol 650 milligrams (mg) was ordered PRN every four hours for pain. Review of the nursing notes showed nursing staff did not address the patient's pain by notifying the physician to request an intervention. Again, on 10/12/09 at 11:12 AM, the patient complained of a headache and back pain rated 9/10. On 10/14/09 at 7:47 AM the patient complained of pain rated 6/10 and still, there was no PRN pain medication ordered for this patient. In addition, there was no evidence nonpharmacologic measures were attempted to relieve the patient's complaint of back pain and headache.
b. Review of the 10/15/09 pain scale showed that at 7:45 AM the patient had a headache rated 5/10. On 10/17/09 at 7:03 AM the patient complained of pain in his/her whole body rated 5/10. Review of the nursing notes and medication administration record (MAR) showed no evidence the patient received any PRN medications for these complaints of pain.
c. Review of the pain scale log revealed on 10/21/09 the patient complained of a headache rated 7/10 at 8:21 AM. However, review of the MAR and nursing notes showed the patient did not receive a PRN pain medication until 9 PM that evening, 13 hours later. In addition, there was no evidence nonpharmacologic measures were attempted to relieve the patient's complaint of pain.
d. Review of the patient "Bill of Rights" (2007) showed "This right includes the following: Have your pain assessed and managed. Your pain should be at a minimum level."

2. Review of the physician progress notes and orders for this patient showed on 10/11/09 at 9 AM the physician asked for verification of an order for Plavix. According to the nurse on the unit on 4/13/10 at 10 AM, the patient was unsure if s/he was on this medication or not but thought s/he might be. Review of the physician progress notes and orders for 10/17/09 written at 10:45 AM, showed the physician again asked for verification of the Plavix order. Finally, review of the 10/20/09 physician progress notes and orders written at 1:20 PM showed the physician again requested verification of the Plavix order. Review of the physician orders written on 10/21/09 at 1 PM, 10 days after the physician first requested verification of the Plavix order, showed the physician ordered Plavix 75 mg daily for stroke risk. Interview with the director of nursing (DON) on 4/15/10 at 10:15 AM revealed 10 days was too long to wait for verification of a medication order.

3. Review of the 10/11/09 physician orders written at 9 AM showed an order to perform a finger stick blood sugar before breakfast and dinner. Review of the MAR showed the times indicated for testing were 6:30 AM and 4 PM. Review of the medical record showed the scheduled 4 PM testing was not performed on 10/15, 10/16, 10/17, 10/20, and 10/22/09. Interview with the DON on 4/15/10 at 2 PM revealed she, too, was unable to find evidence the testing was performed on these dates and times.

4. Review of the 10/20/09 occupational therapy (OT) notes showed the patient was observed with his/her head lowered and had stopped the activity s/he was performing. At that time it was noted the patient was slurring his/her words and was unable to communicate with the occupational therapist. Review of the same note revealed the patient was unable to get his/her left side to cooperate. Review of the OT notes showed the nurse on duty was notified of this episode. Review of the 10/21/09 OT notes showed the occupational therapist observed the patient was again not using the left side of the body. The patient said the activity hurt his/her head. The occupational therapist observed the patient was unable to use both sides of the body and required assistance. Review of the nursing notes showed neither of these episodes were assessed or monitored by nursing staff. Interview with the DON on 4/22/10 at 2 PM revealed both episodes should "certainly" have been assessed and monitored by nursing.

Based on staff interview and medical record review, the hospital failed to ensure the care plan was modified after seclusion and/or restraints were implemented for 5 (#1, #11, #12, #14, #16) of 6 sample patients who were in seclusion and/or restraints. The findings were

Refer to A166 for details regarding the lack of modification of the care plan after implementation of seclusion or restraints for patients #1, #11, #12, #14, and #16.

Based on staff interview, medical record review, and review of hospital policy and procedure, the hospital failed to ensure appropriate arrangements were made (A810) and that family members or interested persons were counseled to prepare them for post-hospital care prior to discharge (A822). The cumulative effect of these failures resulted in the inability of the facility to ensure adequate discharge planning.

Based on staff interview and medical record review, the hospital failed to ensure appropriate arrangements for post-hospital care were made before discharge for 1 (#12) of 9 sample patients whose discharge records were reviewed. The findings were:

Review of the discharge summary for patient #12 showed s/he was admitted for a psychiatric evaluation at the request of his/her school for aggressive and violent behaviors. Interview with the education staff on 4/15/10 at 4:30 PM revealed the patient was admitted for a two week evaluation. Review revealed the patient was physically and verbally aggressive towards others and sometimes went into a "blind rage." When angry s/he stated "I want to kill you" and once, when angry, the patient displaced a teacher's jaw. The patient tore and destroyed things, banged his/her head against the wall, and bit or hit him/herself. Review of the master treatment plan problem list developed by the treatment team included the following: Problem #1 danger to others with a discharge goal for not intentionally physically harming others for five consecutive days prior to discharge. Problem #2 danger to self with a discharge goal of not intentionally physically harming him/herself for five consecutive days prior to discharge. Problem #3 depressive symptoms as evidence by expressed worthlessness, tearfulness, consistent mood swings, irritability and decreased energy level. The discharge goal was s/he would show objective improvement of mood with a brighter affect and fewer symptoms of depression prior to discharge. The projected date of discharge was 1/10/10. According to the discharge planning notes, the planned discharge date was 1/10/10. However, the actual discharge date was 1/5/10 (5 days earlier). Review of the treatment plan update for 12/27/09 through 1/2/10 showed an adjusted length of stay to just seven days, instead of the originally planned fourteen days due to the patient's deterioration in the hospital environment. Review of the medical record revealed no evidence the patient's home school was notified of the earlier discharge date. Interview with the school personnel on 3/19/10 at 10:30 AM revealed because the school was unaware of the patient's early discharge, his/her one-on-one teacher was unavailable when the patient actually returned to school on 1/6/10. Interview with the hospital education staff member on 4/15/10 at 4:30 PM revealed she thought she had called the school to alert theme of the new discharge date but could not remember for certain if she did or did not.

Based on staff interview and medical record review, the hospital failed to ensure family members or interested persons were counseled to preprare them for post-hospital care before discharge for 1 (#12) of 9 sample patients whose discharge records were reviewed. The findings were:

Review of the discharge summary for patient #12 showed s/he was admitted for a psychiatric evaluation at the request of his/her school for aggressive and violent behaviors. Review of the master treatment plan showed a planned discharge date of 1/10/10. Review of the discharge summary showed an actual discharge date 5 days earlier on 1/5/10. Review of the treatment plan update for 12/27/09 through 1/2/10 showed an adjusted length of stay to just seven days, instead of the originally planned fourteen days due to the patient's deterioration in the hospital environment. The following concerns were identified:
a. Review of the medical record revealed no evidence the patient's home school was notified of the earlier discharge date. Interview with the school personnel on 3/19/10 at 10:30 AM revealed because the school was unaware of the patient's early discharge, his/her one on one teacher was unavailable when the patient actually returned to school on 1/6/10.
b. Review of the therapy note dated 1/5/10 at 5 PM showed the therapist called the patient's mother and explained to her that the patient was reacting to the high stimulus in the hospital. Continued review of the note revealed the mom said that if the patient was not thriving in the hospital environment, maybe she should take him/her home. The therapist told the mother that would be a good idea and recommended her to come pick her child up and take him/her home. The patient was discharged at 8:04 PM on that same day. There was no evidence the mother was counseled or prepared for the patient's post-hospital care and how to deal with his/her continued behavioral outbursts. Review of the discharge planning policy and procedure showed instructions: "Prepare the patient and family for the transition...address the patient's and family's need for instructions about continued treatment...include timely and direct communication with...information to other programs... that will be providing continuing care...the staff member makes the discharge plan available to the patient's home school..."
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