HospitalInspections.org

Based on the scope and severity of Patient Rights deficiencies, the facility failed to substantially comply with this condition.

Based on observation, interviews and document review, it was determined hospital staff failed to provide care in a safe setting by:

a) failing to complete environment of care risk assessments for all areas assessable to patients,

b) failing to conduct fifteen (15) minute safety checks as required on the geriatric psychiatric unit, and;

c) failing to ensure inpatient psychiatric patients were admitted to units acting within the scope of the unit's license. (A - 0144)


Based on review of video footage,clinical record review, and during the course of a complaint investigation, it was determined hospital staff failed to accurately document the seclusion of one (1) of one (1) patient included in the sample for seclusion. (A - 0162)

Based on observation, interviews and document review, it was determined hospital staff failed to provide care in a safes setting by:

a) failing to complete environment of care risk assessments for all areas assessable to patients,

b) failing to conduct fifteen (15) minute safety checks as required on the geriatric psychiatric unit, and;

c) failing to ensure inpatient psychiatric patients were admitted to units acting within the scope of the unit's license.

The findings include:

a) During the survey, the surveyor asked for and was provided with the environment of care facility risk assessment for each of the two hospitals (Hospital A and Hospital B) covered under the provider number. A review of the provided documents for Hospital B found multiple areas of the hospital had not received a ligature risk assessment. On 8/8/19 the surveyor again asked Staff Member (SM) #4 to provide the ligature risk assessment for those areas (Mother/Baby, Birthing Center, Acute Rehab and the Medical Surgical Intermediate Unit).

The afternoon of 8/9/19, SM #4 acknowledged to the surveyor that the aforementioned areas had not been included in Hospital B's environment of care risk assessment and agreed the assessment should have been completed for those areas. Prior to the survey team's exit on 8/9/19, SM #4 presented the surveyor with environment of care risk assessments that had been completed after the surveyor had requested the documents.

b) As a part of the surveyor's investigation, recorded video was reviewed for all psychiatric units (Adult, Child and Adolescent and Geriatric) to determine if 15 minute safety checks were being completed. Video was reviewed for multiple dates, times and shifts. A review of video footage for July 1, 2019 on the Adult Unit found safety checks not being completed within the required time (15 minutes). Video review revealed 8 (eight) safety checks were completed during 4 hours and 28 minutes (there should have been 18 safety checks completed during this time) with only 1 (one) safety check within the required time, times for other safety checks ranged from 30 to 55 minutes. (Note there was no safety check education provided to the Adult unit staff).

c) Upon entering the hospital on 7/2/19, the surveyor asked to tour the hospital's behavioral health units. Hospital B has 3 behavioral health units which are: Geriatric Psychiatry (ages 65+), Adult Psychiatry (ages 18-64) and Children and Adolescents (ages 5-17). The surveyor was accompanied on the tour by SM #5, the Vice President of Behavioral Health. During the tour, the surveyor asked general information questions about the units. When asking about the ages of patients on each unit, SM #5 stated the Child and Adolescent unit accepted patients age 5 to 17, but a waiver was obtained from the licensing agency (Department of Behavior Health and Developmental Services (DBHDS)) and a 17 year old may be housed on the Adult Psychiatry Unit (APU) if certain conditions were met i.e. is married, attends college, has children, etc. SM #5 went on to say 18 year olds may be placed on the Child and Adolescent Unit (C&A) if it were determined it would be a better placement. On 7/9/19 while the surveyor was making observations on the C&A unit, it was discovered a 4 year old had been admitted to the unit on 7/8/19. The surveyor was assured the 4 year old had a private room and 1 to 1 supervision by staff. The surveyor was told there was a licensing variance allowing the admission of a 4 year old.

When interviewed, SM #1 and SM #8 (unit managers) also stated there was a variance issued by DBHDS that allowed some flexibility in the placement of 17 and 18 year old patients. The surveyor was told by SM #5, SM #1 and SM #8 they had always been told there was a variance in place. A surveyor review of the license issued by DBHDS found no evidence of a variance to the license. DBHDS personal had been on site and addressed this licensure regulatory issue with the hospital management.

As a part of the investigation into the placement of 17 and 18 year olds outside of the licensing guidelines, the surveyor reviewed the admission data on 17 and 18 year old patients for the last 2 years and found 29 instances where a 18 year old patient was admitted to the C&A unit and 2 occasions where a 17 year old was admitted to the adult unit. A sample of records were reviewed with emphasis placed on the age of the roommate, and any adverse events identified for those patients placed inappropriately. The clinical records did not contain evidence of harm.

The surveyor interviewed Risk Management, Quality and Accreditation staff members, non of whom had an explanation of how the failure to obtain variances for licensure (resulting in the inappropriate placing of 17 and 18 year old patients) had not been identified and corrected.

Based on review of video footage,clinical record review and during the course of a complaint investigation, it was determined hospital staff failed to accurately document the seclusion of a patient. For one (1) of one (1) patients included in the sample for seclusion.

The findings are:

On 7/30/19 during review of video related to the completion of 15-minute safety checks, the surveyor was able to observe the initiation of seclusion for Patient #9. After alternative interventions failed, staff accompanied Patient #9 to the seclusion room at 8:13 a.m. on 7/27/19. The door to the seclusion room remained open but staff were standing in the doorway actively preventing Patient #9 from leaving the room. At 8:40 a.m. the door to the seclusion room was closed with staff remaining just outside the door. Patient #9 was observed appearing to bite his/her forearms and was noted to bang his/her head on the door to the seclusion room. Patient #9 was released from seclusion at 8:59 a.m.

A review of the clinical record for Patient #9 found documentation of seclusion beginning at 8:41 a.m., approximately when the door was closed. Staff Member (SM) #25 failed to recognize the seclusion began when the patient was prevented from leaving the room at 8:13 a.m.

A review of hospital policy CLIN.01.02.11 last reviewed 4/24/2017 reads in part as follows: "Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving."

The above information was shared with SM #5 who stated it appeared staff needed some training related to the initiation of seclusion.

Based on interview, observations and document review, it was determined hospital staff failed to implement and maintain an effective quality assessment program to include all areas of the hospital. Due to the pervasive and serious nature of the deficiencies this is a condition level finding.

The findings are:

Hospital staff failed to ensure ligature risk assessments were completed for all patient assessable areas. (A-0286)

Hospital staff failed to ensure behavioral health patients were admitted to appropriate units based on licensing guidelines. (A-0286)

Hospital staff failed to measure, analyze and track emergent transfers out of the hospital's behavioral health units. (A-0286)

Hospital staff failed to fully implement action plans for identified problems in the Geriatric Psychiatry Unit. (A-0283)

Hospital staff failed to fully implement an action plan to ensure high-level disinfection of semi-critical medical equipment. (A-283)

Based on interview and document review, it was determined hospital staff failed to:

a) fully implement action plans for identified problems in the Geriatric Psychiatry Unit, and;

b) implement and track measures related to high level disinfection/sterilization to ensure that improvements are sustained.

The findings are:

a) Patient #1 was admitted to the GPU (Geriatric Psychiatry Unit) on 12/18/18. The night of 1/2/19, Patient #1's condition deteriorated rapidly and the emergency response team was notified and responded at 7:55 a.m. and assumed care of Patient #1. Patient #1 was transferred to the ED (emergency department). ED documentation reveals Patient #1 deteriorated further and went into cardiac arrest. Patient #1 stabilized and was accepted for admission to MICU (medical intensive care). En route to the MICU, a CT of the abdomen and head were obtained. The patient had a third cardiac arrest in the CT scanner. CPR was performed but unfortunately the patient expired. Time of death was called at 12:18 p.m. .

Hospital staff's investigation of this event determined 15-minute patient safety checks were not being completed but were being documented. Documentation of the 15 minute safety checks as required by facility policy were reviewed for the night of 01/02/19 and were documented as completed. Hospital policy CLIN.20.05.28 Safety Precautions: Level of Supervision reads in part as follows: "All patients receive 15-minute checks" and "Unit staff will observe the patient at least every 15 minutes to ensure that the patient is safe and in no apparent physical distress (i.e. respiratory, cardiac) and document each check on the fifteen-minute check form." Video footage for the night of 01/02/19 was not available but had been reviewed by SM #8 and SM #1 and SM #23 as a part of the hospital investigation. SM # 8 stated in an interview on 7/16/19 that video footage of the other units (Adult and Child and Adolescent) were reviewed and it was decided the failure to complete 15-minute patient safety checks was only a problem on the Geriatric unit. Education related to completing the safety checks was confined only to Geriatric Psychiatry staff. When asked how compliance was monitored SM #8 responded that he/she was doing random checks, but there was no documentation available. SM #8 confirmed for the surveyor that the action plan for the problem was not fully developed.

As a part of the surveyor's investigation, recorded video was reviewed for all psychiatric units (Adult, Child and Adolescent and Geriatric) to determine if 15 minute safety checks were being completed. Video was reviewed for multiple dates, times and shifts. A review of video footage for July 1, 2019 on the Adult Unit found safety checks not being completed within the required time (15 minutes). Video review revealed 8 (eight) safety checks were completed during 4 hours and 28 minutes (there should have been 18 safety checks completed during this time) with only 1 (one) safety check within the required time, times for other safety checks ranged from 30 to 55 minutes. (Note there was no safety check education provided to the Adult unit staff). A review of video footage for GPU and Child & Adolescent units found safety checks were completed as required with only minutes variation from the 15 minute guideline.

The surveyor discussed with SM #5 and SM #8 the need to consider all areas that may be completing the 15-min safety checks when determining a course of action to correct a problem. The surveyor's observation of the Adult Psychiatric Unit staff's failure to complete the safety checks as required by policy confirmed the need to educate all units.

The surveyor was provided with Behavioral Health action plan to provide mandatory education that needs to be completed before any staff can begin a shift on all 3 behavioral health units. Education rolled out to staff on 7/15/19, with all staff to be completed by 7/29/19.

b) Tours of the ED on 8/4/19 at 1:05 p.m., and on 8/5/19 between 1:35 p.m. and 2:15 p.m., interviews with nursing staff , and an audit of the Cysto cart housed in the ED, revealed that staff were not familiar with the pre-cleaning processes put into place as a result of the High Level/Disinfection/Sterilization Meetings.

A discussion was held with SM #30, Infection Prevention (IP) Director, on 8/5/19 at 1:15 p.m. related to high level disinfection and pre-cleaning of scopes; SM #30 stated "I have been working on high level disinfection for years. I pulled an ad-hock team together to standardize treatment across the system. When we were meeting, the ad-hock team, it came to my attention that the pre-cleaning was not documented. The carts can go anywhere, but probably the ED (emergency department) would be the most prevalent place. A nursing bulletin alert was issued in August 2018 about the change in process to notify SPD (sterile processing department) to come do cleaning ongoing with high level disinfection. In August 2018 we decided SPD would take ownership of precleaning, then it changed, I'm not sure when it changed. I think it changed due to a handoff in leadership and I'm not sure who knew what and when...".

The surveyor was given an email written by SM #30, dated August 30, 2018, and sent to multiple recipients with the subject "Urology and ENT Cart Process Change", with an attachment titled "Nurse Alert-Effective Immediately: Point of Care pre-cleaning requirement ENT and urology carts. The email, in part stated "In addition to the sign on the carts, to help with nursing staff communication, see attached nurse alert that can be sent out to LGH/VBH nursing staff so they are aware prior to need of the cart. If you want to draft something different, please do so. I just wanted to lend a helping hand".
The Nurse Alert included the following information: 1. The Sterile Processing Department (SPD) will be responsible for delivery and pick-up of all ENT and Urology Carts. 2. All endoscopes are to undergo point of care pre-cleaning immediately after use: *Cystocope requires flushing of the channel and external wipe down at the end of the procedure *ENT scope requires external wipe down at the end of the procedure *First Step kit of enzymatic detergent and water will be used to perform pre-cleaning at the point of use. 3. SPD staff will be responsible for point of care pre-cleaning after use. 4. Nursing staff responsible for notifying SPD at the end of the beside {sic} procedure. Immediately after use of ENT or Urology Carts notify SPD at 200-3200 for proper pre-cleaning at point of use". SM #30 told the surveyor that the email went to Unit Directors who were responsible for disseminating information to their employees.

The hospital developed and enacted a corrective action plan related to pre-cleaning of ENT and cystocope as a step in high-level disinfection prior to the start of the survey on 7/02/19; however, survey observations and interviews indicated improper infection control practices were present.

A review of facility documents evidenced that designated IP staff were aware of and discussed issues related to the pre-cleaning process for ENT (Ear, Nose, and Throat) and Cysto (Cystoscopes) in the High Level Disinfection/Sterilization Meetings on 3/6/19, 3/20/19, 4/6/19, and 5/1/19. However, Centra Council Committee Meeting minutes dated May 13, 2019 and June 10, 2019 lacked evidence of the discussion of issues related to high-level disinfection.

The facility's Healthcare Epidemiology and Infection Prevention Plan for 2019 was reviewed. The plan and risk assessment were reviewed at least annually and/or whenever significant changes occur in elements that affect risk. Goals are established for prioritized risks with consideration given to preventing transmission of infections associated with procedures, equipment, devices, and supplies. Surveillance data is reviewed quarterly to evaluate the effectiveness of the plan...Findings are reported back to the service leaders in these areas and included in our quarterly report to the Infection Prevention Work Group".
The risk assessment rated High level disinfection non-compliance-Central Services #13, and was considered a "priority focus area", and scored twelve or greater in the preparedness score in the risk assessment.

Concerns were discussed with SM's #1 and 2, Accreditation/Licensure Specialists, #7, RN Surgical floor, #30, IP Director, #80,Director of Supply Chain Logistics and #81, Director of Central Sterile at multiple times throughout the survey. Concerns were again discussed on 8/9/19 at 9:00 a.m. with SM's #1, 2, and 52, the facility's Chief Executive Officer.

Based on interview and document review, it was determined hospital staff failed to:

a) measure, analyze and track emergent transfers out of the hospital's behavioral health units,

b) failed to ensure ligature risk assessments were completed for at risk areas, and;

c) failed to ensure patients were being assigned bed placement according to licensing guidelines for the behavioral health units.

The findings are:

a) Upon entering the facility on 7/2/19 the surveyor asked to tour the hospital's behavioral health units. The facility has 3 behavioral health units which are: Geriatric Psychiatry (ages 65+), Adult Psychiatry (ages 18-64) and Children and Adolescents (ages 5-17). The surveyor was accompanied on the tour by Staff Member (SM) #5, the Vice President of Behavioral Health. During the tour, the surveyor asked general information questions about the units. The surveyor asked SM #5 if the number and type of Patient emergent transfers for treatment were being collected and analyzed, he/she stated they were not.

The surveyor then asked for information related to reporting of serious events to the Department of Behavioral Health and Developmental Services (DBHDS). SM #5 then stated it was brought to his/her attention by DBHDS that all required events were not being reported. SM #5 stated to the surveyor that he/she had understood the reporting requirement to be only for abuse and neglect and because of that understanding facility staff had not been reporting serious incidents to the Computerized Human Rights Information System (CHRIS). Unit managers stated the same understanding of the requirement to the surveyor in individual interviews. SM #5 stated all the events were probably not captured by the "Riskmaster" the hospital's event reporting system. He/she stated there was opportunity for training and improvement.

Serious adverse events are also tracked in the "Riskmaster" system. Facility Policy ORG.06.01.10 Riskmaster Event Reporting System last reviewed 2/4/2019 reads in part as follows: "Event reports are used to document unexpected occurrences, whether or not they lead to harm. These reports are used in ongoing monitoring, evaluation, and improvement activities related to patient care and safety."

b) During the survey the surveyor asked for and was provided with the environment of care facility risk assessment for each of the two hospitals (Hospital A and Hospital B) covered under the provider number. A review of the provided documents for Hospital B found multiple areas of the hospital had not received a ligature risk assessment. On 8/8/19 the surveyor again asked Staff Member (SM) #4 to provide the ligature risk assessment for those areas (Mother/Baby, Birthing Center, Acute Rehab and the Medical Surgical Intermediate Unit).

The afternoon of 8/9/19, SM #4 acknowledged to the surveyor that the aforementioned areas had not been included in Hospital B's environment of care risk assessment and agreed the assessment should have been completed for those areas. Prior to the survey team's exit on 8/9/19, SM #4 presented the surveyor with environment of care risk assessments that had been completed after the surveyor had requested the documents.

c) Hospital B has 3 behavioral health units which are: Geriatric Psychiatry (ages 65+), Adult Psychiatry (ages 18-64) and Children and Adolescents (ages 5-17). The surveyor was accompanied on the tour by SM #5, the Vice President of Behavioral Health. During the tour, the surveyor asked general information questions about the units. When asking about the ages of patients on each unit, SM #5 stated the Child and Adolescent unit accepted patients age 5 to 17, but a waiver was obtained from the licensing agency (Department of Behavior Health and Developmental Services (DBHDS)) and a 17 year old may be housed on the Adult Psychiatry Unit (APU) if certain conditions were met i.e. is married, attends college, has children, etc. SM #5 went on to say 18 year olds may be placed on the Child and Adolescent Unit (C&A) if it were determined it would be a better placement. On 7/9/19 while the surveyor was making observations on the C&A unit, it was discovered a 4 year old had been admitted to the unit on 7/8/19. The surveyor was assured the 4 year old had a private room and 1 to 1 supervision by staff. The surveyor was told there was a licensing variance allowing the admission of a 4 year old.

When interviewed with SM #1 and SM #8 (unit managers) also stated there was a variance issued by DBHDS that allowed some flexibility in the placement of 17 and 18 year old patients. The surveyor was told by SM #5, SM #1 and SM #8 they had always been told there was a variance in place. Surveyor review of the license issued by DBHDS found no evidence of a variance to the license. DBHDS personal had been on site and addressed this licensure regulatory issue with the hospital management.

As a part of the investigation into the placement of 17 and 18 year olds outside of the licensing guidelines, the surveyor reviewed the admission data on 17 and 18 year old patients for the last 2 years and found 29 instances where a 18 year old patient was admitted to the C&A unit and 2 occasions where a 17 year old was admitted to the adult unit. A sample of records were reviewed with emphasis placed on the age of the roommate, and any adverse events identified for those patients placed inappropriately. The clinical records did not contain evidence of harm.

The surveyor interviewed Risk Management, Quality and Accreditation staff members, non of whom had an explanation of how the failure to obtain variances for licensure (resulting in the inappropriate placing of 17 and 18 year old patients) had not been identified and corrected..

The above concerns were shared with SM #5 as they were discovered and shared with the management team for a final time prior to exit on 8/9/19. No further information was provided to the survey team.

Based on observations, interviews and review of hospital documentation, it was determined the hospital governing body, medical staff and administrative officials failed to ensure an ongoing program for quality improvement and patient safety, was implemented and maintained.

Findings included:


Tours of the ED on 8/4/19 at 1:05 p.m., and on 8/5/19 between 1:35 p.m. and 2:15 p.m., interviews with nursing staff , and an audit of the Cysto cart housed in the ED, revealed that staff were not familiar with the pre-cleaning processes put into place as a result of the High Level/Disinfection/Sterilization Meetings.

A discussion was held with SM #30, Infection Prevention (IP) Director, on 8/5/19 at 1:15 p.m. related to high level disinfection and pre-cleaning of scopes; SM #30 stated "I have been working on high level disinfection for years. I pulled an ad-hock team together to standardize treatment across the system. When we were meeting, the ad-hock team, it came to my attention that the pre-cleaning was not documented. The carts can go anywhere, but probably the ED (emergency department) would be the most prevalent place. A nursing bulletin alert was issued in August 2018 about the change in process to notify SPD (sterile processing department) to come do cleaning ongoing with high level disinfection. In August 2018 we decided SPD would take ownership of precleaning, then it changed, I'm not sure when it changed. I think it changed due to a handoff in leadership and I'm not sure who knew what and when...".

The surveyor was given an email written by SM #30, dated August 30, 2018, and sent to multiple recipients with the subject "Urology and ENT Cart Process Change", with an attachment titled "Nurse Alert-Effective Immediately: Point of Care pre-cleaning requirement ENT and urology carts. The email, in part stated "In addition to the sign on the carts, to help with nursing staff communication, see attached nurse alert that can be sent out to LGH/VBH nursing staff so they are aware prior to need of the cart. If you want to draft something different, please do so. I just wanted to lend a helping hand". The Nurse Alert included the following information: 1. The Sterile Processing Department (SPD) will be responsible for delivery and pick-up of all ENT and Urology Carts. 2. All endoscopes are to undergo point of care pre-cleaning immediately after use: *Cystocope requires flushing of the channel and external wipe down at the end of the procedure *ENT scope requires external wipe down at the end of the procedure *First Step kit of enzymatic detergent and water will be used to perform pre-cleaning at the point of use. 3. SPD staff will be responsible for point of care pre-cleaning after use. 4. Nursing staff responsible for notifying SPD at the end of the beside {sic} procedure. Immediately after use of ENT or Urology Carts notify SPD at 200-3200 for proper pre-cleaning at point of use".

SM #30 told the surveyor that the email went to Unit Directors who were responsible for disseminating information to their employees.

The hospital developed and enacted a corrective action plan related to pre-cleaning of ENT and cystocope as a step in high-level disinfection prior to the start of the survey on 7/02/19; however, survey observations and interviews indicated improper infection control practices were present.

A review of facility documents evidenced that designated IP staff were aware of and discussed issues related to the pre-cleaning process for ENT (Ear, Nose, and Throat) and Cysto (Cystoscopes) in the High Level Disinfection/Sterilization Meetings on 3/6/19, 3/20/19, 4/6/19, and 5/1/19. However, Centra Council Committee Meeting minutes dated May 13, 2019 and June 10, 2019 lacked evidence of the discussion of issues related to high-level disinfection.

The facility's Healthcare Epidemiology and Infection Prevention Plan for 2019 was reviewed. The plan and risk assessment were reviewed at least annually and/or whenever significant changes occur in elements that affect risk. Goals are established for prioritized risks with consideration given to preventing transmission of infections associated with procedures, equipment, devices, and supplies. Surveillance data is reviewed quarterly to evaluate the effectiveness of the plan...Findings are reported back to the service leaders in these areas and included in our quarterly report to the Infection Prevention Work Group".
The risk assessment rated High level disinfection non-compliance-Central Services #13, and was considered a "priority focus area", and scored twelve or greater in the preparedness score in the risk assessment.

The facility's "Organizational Performance Improvement Plan" was reviewed, and stated the following, in part: "...II. Governance, Leadership, and Organizational Structure: ...Centra Council Committee: (Centra Lynchburg) The Centra Council has local responsibility for all clinical services across the full continuum of care for the service area not governed by the Board of (facility name) or the Board of (facility name). As a subcommittee of the Centra Board of Directors, the Centra Council helps implement Board goals, set clinical and operational goals, monitor performance regarding clinical quality, patient safety, patient satisfaction, quality data analytics, process improvement, physician credentialing, and recruitment and physician relations."

Concerns were discussed with SM's #1 and 2, Accreditation/Licensure Specialists, #7, RN Surgical floor, #30, IP Director, #80,Director of Supply Chain Logistics and #81, Director of Central Sterile at multiple times throughout the survey. Concerns were again discussed on 8/9/19 at 9:00 a.m. with SM's #1, 2, and 52, the facility's Chief Executive Officer.

Based on observation, interview and document review, it was determine hospital staff failed to appropriately assess 2 of 15 patients included in the sample.

The findings include:

A review of the clinical record for Patient #10 found nursing note dated 7/12/19 at 5:23 p.m. documenting a fall in the shower. Staff Member #25 documented the patient was heard crying in the shower, when the door was opened, the Patient stated that he fell in the shower, SM #25 states there was a nurse there as well and states "at the time there was no physical signs of any bruising or redness".

The clinical record failed to provide evidence of a nursing assessment after the fall and failed to provide evidence of a falls assessment on admission. Patient #1 was seen by a provider for an unrelated issue on 7/14/19, the assessment found a small 2x1 cm eccymosis present on left upper buttock, mild tenderness to palpation." Patient #10 reported to provider that he/she fell while in the shower.

Hospital policy CLIN.20.05.69 last reviewed 3/04/2019 reads in part as follows: "Screening for fall risk will be done on admission and patients will be reassessed per unit protocol (see below) and prn as patient condition or location warrants."

The above information was discussed at the time of discovery with SM #1, who confirmed that "all patients" should get a fall risk assessment when admitted regardless of their age.

Patient #9 was placed in the seclusion room at 8:13 a.m. on 7/27/19. The door to the seclusion room remained open but staff were standing in doorway actively preventing Patient #9 from leaving the room. At 8:40 a.m. the door to the seclusion room was closed with staff remaining just outside the door. Patient #9 was observed appearing to bite his/her forearms and was noted to bang his/her head on the door to the seclusion room. Patient #9 was released from seclusion at 8:59 a.m.

The clinical record failed to provide evidence Patient #9 was assessed for injury related to head banging (however lightly staff found it to be) and failed to provide evidence of assessment of Patient #9's forearms for self-inflicted injury.