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Based on review of documents and interviews with staff, the facility Governing Body failed to be responsible for the conduct of the hospital, as services furnished in the hospital did not comply with all applicable Conditions of Participation and Standards. The rights of patient #1 were violated, as medical and nursing staff did not follow proper procedures in ordering and monitoring physical restraint of the patient during 2 inpatient admissions in January 2012, and the facility did not protect the right of the patient to refuse treatment. Additionally, the patient did not receive IV fluids as ordered..

Findings were:

Review of the medical records of patient #1 revealed that the patient was admitted to the facility on 1/2/12 - 1/12/12 and again 1/14/12 - 1/20/12. The medical records for both stays reported that patient #1 had self-inflicted an abdominal stab wound the previous July and subsequently underwent a laparotomy and a colon resection. Both January admissions were due to the patient's tearing open the abdominal incision and probing with fingers and other instruments, creating infection. During both admissions, the patient was physically restrained for violent, self-harming behavior. The patient expired during a 3rd inpatient admission, 2/2/12 - 2/3/12.

1. Review of the patient ' s record for the admission 1/2/12 - 1/12/12 revealed that only 2 physician orders were written for physical restraints over a total of 7 days that the patient was in restraints. During the admission 1/14/12 - 1/20/12, only 2 orders were written for physical restraints for patient #1 over a total of 7 days the patient was restrained. Restraint policy states that orders for patients in restraints for violent, self-harming behavior must be renewed every 4 hours up to 24 hours, then a new order must be obtained. The physicians did not order restraints per facility policy, entitled Use of Restraint Policy, last approved by the facility governing body in June of 2009, and did not exhibit a working knowledge of the restraint policy and procedure. Cross refer to tags A0171 and A0176 for additional information.

2. Review of the patient ' s record for the admission 1/2/12 - 1/12/12 revealed that the nursing staff did not monitor the patient while in restraints according to facility policy. For example, on 1/8/2012, Patient #1 was in physical restraints and a nursing assessment was performed at 9:17am. The next restraint assessment was performed approximately 4 hours later, at 1:25pm. During the admission 1/14/12 - 1/20/12, patient #1 was placed in physical restraints on 1/14/2012 at 7:39pm; the order stated it was for Behavioral Emergency. Progress notes revealed patient #1' restraint was first assessed by a registered nurse on 1/15/2012 at 6:00am, 9 ? hours after the patient was restrained. The next restraint assessment was on 1/15/2012 at 7:45pm. Facility policy, entitled Use of Restraint Policy, last approved by the facility governing body in June of 2009, states that patients in restraint for violent, self-harming behavior must be monitored every 15-30 minutes. Cross refer to tag A0175 for additional information.

3. Patient #1 requested to leave against medical advice (AMA), and was not allowed to leave. There is no further documentation that the hospital explained the risks of leaving AMA.Cross refer to tag A0131 for additional information.

4. The facility utilizes a form entitled REPORT OF DEATH. This form contains sections to be filled out if the patient died in restraints or within 24 hours of restraint. The forms for patients #1-#12 were reviewed; these 12 patients all died in restraint or within 24 hours of restraint. None of these patients' deaths were reported to CMS. Cross refer to tag A0214 for additional information.

5. Patient #1 did not receive IV fluids as ordered by the physician on 1/15/12. Cross refer to tag 0405 for additional information.

Based on review of documents and interviews with staff, the facility failed to be protect and promote the rights of patient #1, as medical and nursing staff did not follow proper procedures in ordering and monitoring physical restraint of the patient and the facility did not protect the right of the patient to refuse treatment.

Findings were:

Review of the medical records of patient #1 revealed that the patient was admitted to the facility on 1/2/12 - 1/12/12 and again 1/14/12 - 1/20/12. The medical records for both stays reported that patient #1 had self-inflicted an abdominal stab wound the previous July and subsequently underwent a laparotomy and a colon resection. Both January admissions were due to the patient's tearing open the abdominal incision and probing with fingers and other instruments, creating infection. During both admissions, the patient was physically restrained for violent, self-harming behavior. The patient expired during a 3rd inpatient admission, 2/2/12 - 2/3/12.

1. Review of the patient's record for the admission 1/2/12 - 1/12/12 revealed that only 2 physician orders were written for physical restraints over a total of 7 days that the patient was in restraints. During the admission 1/14/12 - 1/20/12, only 2 orders were written for physical restraints for patient #1 over a total of 7 days the patient was restrained. Restraint policy, entitled Use of Restraint Policy, last approved by the facility governing body in June of 2009, states that orders for patients in restraints for violent, self-harming behavior must be renewed every 4 hours up to 24 hours, then a new order must be obtained. The physicians did not order restraints per facility policy and did not exhibit a working knowledge of restraint policy and procedure. Cross refer to tags A0171 and A0176 for additional information.

2. Review of the patient's record for the admission 1/2/12 - 1/12/12 revealed that the nursing staff did not monitor the patient while in restraints according to facility policy. For example, on 1/8/2012, Patient #1 was in physical restraints and a nursing assessment was performed at 9:17am. The next restraint assessment was performed approximately 4 hours later, at 1:25pm. During the admission 1/14/12 - 1/20/12, patient #1 was placed in physical restraints on 1/14/2012 at 7:39pm; the order stated it was for Behavioral Emergency. Progress notes revealed patient #1's restraint was first assessed by a registered nurse on 1/15/2012 at 6:00am, 9 ? hours after the patient was restrained. The next restraint assessment was on 1/15/2012 at 7:45pm. Restraint policy states that patients in restraint for violent, self-harming behavior must be monitored every 15-30 minutes. Cross refer to tag A0175 for additional information.

3. Patient #1 requested to leave against medical advice (AMA), and was not allowed to leave. There is no further documentation that the hospital explained the risks of leaving AMA.Cross refer to tag A0131 for additional information.

4. The facility utilizes a form entitled REPORT OF DEATH. This form contains sections to be filled out if the patient died in restraints or within 24 hours of restraint. The forms for patients #1-#12 were reviewed; these 12 patients all died in restraint or within 24 hours of restraint. None of these patients' deaths were reported to CMS. Cross refer to tag A0214 for additional information.

Based on review of documents and interview with staff, the facility failed to ensure the right to refuse treatment for 1 of 1 patient whose record was reviewed. Patient #1 requested to leave against medical advice (AMA), and was not allowed to leave.

Findings were:

The facility policy entitled PATIENT RIGHTS AND RESPONSIBILITIES states under section PATIENT RIGHTS #6 that the patient has the right to refuse treatment as permitted by law and regulations, and if the treatment is refused the patient will receive other needed and available care.

Review of the medical record for patient #1 revealed that the patient was admitted to the facility on 1/14/12 and discharged 1/20/12. Physician progress notes written 1/15/2012 stated that the patient wanted to leave against medical advice but the facility would not grant him that privilege unless they had a court order or a directive from the state hospital. There is no further documentation that the hospital explained the risks of leaving AMA or contacted staff at NTSH.
These findings were confirmed in a telephonic interview conducted on 5/18/12 with staff #12, facility Patient Safety Coordinator.

Based on review of documents and interview with staff, the facility did not ensure that the orders for physical restraint were in accordance with the required limits for 1 of 1 patient whose records were reviewed. Patient #1 was physically restrained during 2 inpatient stays for violent and self-destructive behavior, and the orders for restraint were only written 4 times; the patient remained in restraints a total of 14 days throughout the inpatient stays.

Findings were:

Review of the medical record for the first January 2012 admission revealed that patient #1, age 36, was admitted to the facility on 1/2/2012 at 11:51pm and was discharged 1/12/2012 at 8:25pm. Review of the patient's History & Physical (H&P) dated 1/2/2012 indicated the patient was a resident of a state facility for people with mental illness. The report also stated patient #1 self-inflicted an abdominal stab wound the previous July and subsequently underwent a laparotomy and a colon resection. This admission on 1/2/2012 was due to the patient's tearing open the incision and probing with fingers and other instruments, creating infection. The H&P also stated the physician's assessment was sepsis, anterior abdominal wound infection, cellulitis, campylobacter infection, borderline personality disorder, and history of multiple self inflicted abdominal stab wounds. The H&P also reported patient #1 had factitious disorder, the psychiatric condition in which a patient deliberately produces or falsifies symptoms of illness for the sole purpose of assuming the sick role. Patient #1 was placed in restraints 1/6/12 due to violence and intent for self-harm, not only for medical reasons, such as pulling tubes. For example, on 1/8/2012 at 7:01am, the nurse documented the patient stabbed the abdominal wound with a toothbrush. Also on 1/8/2012 at 5:45pm, the nurse documented that patient #1 had removed the wrist restraints and was agitated with "fists balled up" yelling at the sitter "Touch me, so I can knock the shit out of you!!" The nurse documented on 1/8/2012 at 10:30pm patient #1 became very agitated, clenching fists, and security was called. Patient #1 had to have a procedure to remove the toothbrush from the abdomen. Additionally the nurse documented on 1/9/2012 at 8:36 pm that the patient was angry, combative, and belligerent; was medicated with Ativan and Benadryl, and was in 4 point restraints (both upper and lower extremities). On 1/10/2012 at 1:20am, the nurse documented the patient was given Ativan and Benadryl for agitation and was in 4 point restraints. Further review revealed the nurse documented on 1/10/2012 at 6:51am, the patient was agitated, belligerent and combative when awake. The nurse also documented "4 point restraints maintained with prn (as needed) meds."

A physician restraint order dated 1/6/2012 at 9:12am stated "Acute Med/Surg, bilateral hands, monitor at least every 2 hours, mittens due to patient having the feeling to hurt himself." Further review revealed a restraint order dated on 1/8/2012 at 7:22am for "Acute Med/Surg, monitor at least every 2 hours." The reason for the restraints was "High Risk: causing significant disruption of treatment (tubes, lines), stabbing himself." The restraint order did not specify the type of restraints to use and did not specify the extremities to be restrained. There were no further physician orders for restraint during this hospitalization, although restraints were documented by nursing and medical staff daily through the date of discharge, 1/12/2012.

Patient #1 was readmitted to the facility on 1/14/12, due to tearing at the abdominal incision while at his residence. The patient was discharged on 1/20/2012. The admitting physician documented in the History and Physical (H&P) report that the patient had a "24cm incision wound extending from umbilicus to the left side of the abdomen. It is extremely tender with purulent discharge."

Patient #1 was placed in physical restraints per physician staff # 8 on 1/14/2012 at 7:39pm; the order stated it was for Behavioral Emergency, as the patient was considered a high risk of injury to self or others. The physician documented the behavior that led to the restraints was "self inflicted wound at abdomen." The restraint type was both upper and lower extremities. There was no documented renewal of the restraint order. The patient was in restraints 1/15, 1/16, 1/17 with no order. On 1/18/2012 at 11:18am, physician staff #13 ordered restraints for "Acute Med/Surg," to be monitored every 2 hours for the significant disruption of treatment (tubes, lines). The restraint order included mittens bilaterally. Nursing and medical progress notes continue to indicate that patient #1 was still in restraints for behavioral issues. For example, physician progress notes dated 1/15/2012 at 1:00am state that the physician informed the patient that restraints were needed at all times to prevent further self-inflicted damage to the abdominal wound. Additionally, in the Restraint Documentation portion of the medical record, the nurse stated "both upper extremities; wrist/ankle, agitated, protection of lines, protection of abdominal dressing, violence/self harm potential-close obs (observation) required."

The hospital policy regarding use of restraint, entitled Use of Restraint Policy, last approved by the facility governing body in June of 2009 outlines the requirements for physician intervention in the use of restraints. Under the section, entitled ORDERING OF RESTRAINT FOR VIOLENT OR SELF DESTRUCTIVE BEHAVIOR, the policy states that each order for restraint used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient may only be obtained and renewed in accordance with the following limits up to a total of 24 hours: Up to four (4) hours for adults age 18 and older. The policy states that " if restraint is discontinued prior to the expiration of the original order, a new order must be obtained prior to reinstating the use of restraint. At the end of the time frame, if the continued use of restraint to manage violent or self-destructive behavior is deemed necessary based on an individualized patient assessment, another order is required. When the original order is about to expire, a Registered Nurse (RN) must contact the physician or other LIP, report the results of his or her most recent assessment and request that the original order be renewed. Whether or not an onsite assessment is necessary prior to renewing the order is left to the discretion of the physician or other LIP in conjunction with a discussion with the RN who is overseeing the care of the patient.

In an in-person interview on 5/8/2012 at 11:05am, physician staff # 8 stated patient #1 had been admitted multiple times to the facility. Physician staff # 8 recalled that patient #1 would place different items in the abdominal wound which caused sepsis.The physician stated restraints were ordered on 1/14/2012 for behavioral emergency, but the intent was to order the "regular" restraint because the patient was manipulating the wound. Physican staff # 8 did not know there was a difference between the Behavioral restraint order and the Acute Med/Surg restraint order.

In concurrent in-person interviews conducted on 5/7-8/2012, the facility Vice President of Nursing and Clinical Services, staff # 1 and the Director of Quality Management, staff #2 confirmed that patient #1's physicians failed to follow proper policies and procedures for restraint orders during both hospitalizations in January 2012..

Based on review of documents and interview with staff, the facility staff failed to monitor the condition of 1 of 1 restrained patient whose record was reviewed. Pt #1 was in physical restraints for violent self-harming behavior, but was not monitored at the interval determined by hospital policy.

Findings were:

The hospital's policy regarding use of restraint, entitled Use of Restraint Policy, last approved by the facility Governing Body in June of 2009, outlines the requirements for monitoring a patient placed in restraints for violent or self-destructive behavior. Under the section entitled ONGOING MONITORING AND ASSESSMENT OF A PATIENT IN RESTRAINT, each patient must be monitored every 15-30 minutes, including checking the patient's vital signs, hydration and circulation; the patient's level of distress and agitation; and skin integrity. This assessment shall also determine if the patient continues to require restraints. The staff training document entitled ADULT RESTRAINTS states on page 1 that patients in restraints for violent or self-destructive behavior should be monitored every 15-30 minutes.

Review of the medical record of patient #1 revealed that the patient was admitted to the facility on 1/2/12 - 1/12/12 and again 1/14/12 - 1/20/12. The patient was a resident of a state facility for people with mental illness. The history and physical (H&P) report also stated patient #1 had self-inflicted an abdominal stab wound the previous July and subsequently underwent a laparotomy and a colon resection. Both admissions were due to the patient's tearing open the abdominal incision and probing with fingers and other instruments, creating infection. During both admisions, the patient was physically restrained for violent, self-harming behavior.

During the first admission, patient #1's physician ordered physical restraints on 1/6/12 at 9:12 am. In the "Restraints" section of the medical record, the nurse documented on 1/8/2012 at 7:30am the patient was in both upper and lower restraints. Further review revealed the behavior requiring the restraints was "agitated; violence/self harm potential, close obs (observation) required." On 1/8/2012 a nursing assessment was performed at 9:17am and the next restraint assessment was performed approximately 4 hours later, at 1:25pm. The patient was monitored approximately every 2 hours while in restraints until 1/11/2012 at 6:00pm. The nurse did not reassess patient #1 while in restraints 1/11/2012 after 6:00pm; however, the medical record contained documentation in progress notes that the patient remained in restraints. The next reassessment of restraints was on 1/12/2012 at 8:00am. There was no documentation for the reason patient #1 was in restraints during the assessments of 8:00am, 10:00am, 12:00pm, 2:26pm, and 4:00pm. The last documented restraint assessment was done at 8:00pm prior to patient #1's discharge on 1/12/12 at 8:25pm. While there were medical interventions documented during the time patient #1 was in restraints, the assessment elements and the timeframe required for a patient in restraints for behavioral issues was not followed.
During the 2nd admission, patient #1 was placed in physical restraints per physician staff # 8 on 1/14/2012 at 7:39pm; the order stated it was for Behavioral Emergency. Progress notes revealed patient #1 was first assessed by a registered nurse on 1/15/2012 at 6:00am. The next assessment was on 1/15/2012 at 7:45pm. The nurse then reassessed the patient again at 11:00pm and documented 4 point restraints (both upper and lower extremities). Documentation in the medical record on 1/16/2012 indicated that the patient was reassessed at 12:00am, 2:12am, and 6:00am. Following this, the nurses reassessed the patient approximately every 2 hours and documented restraints until 1/18/2012 at 4:00am. The next reassessment was on 1/18/2012 at 8:00am, 4 hours later. The nurse documented on 1/18/2012 at 7:50pm the patient had "both upper extremities; secured/tied mitten; 4 point." The documentation indicated that the patient continued to remain in restraints and was reassessed approximately every 2 hours until 1/19/2012 at 4:30am. The patient was discharged 1/20/2012. While there were nursing interventions documented during the time patient #1 was in restraints, the assessment elements and the timeframe required for a patient in restraints for behavioral issues was not followed.

In concurrent in-person interviews conducted on 5/7-8/2012, the facility Vice President of Nursing and Clinical Services, staff #1 and the Director of Quality Management, staff #2 confirmed that nursing staff failed to follow proper policies and procedures for monitoring patient #1 while in restraints during both hospitalizations.

Based on review of documents and interview with staff, the facility failed to ensure that physicians and other licensed independent practitioners (LIP) have a working knowledge of the use of restraints for 1 of 1 patient whose record was reviewed. Patient #1's practitioners did not order physical restraints or perform evaluations as required for patients in restraints for behavioral issues.

Findings were:

The hospital's policy regarding use of restraint, entitled Use of Restraint Policy, last approved by the facility governing body in June of 2009, states in the section entitled, PHYSICIAN EDUCATION & TRAINING ON THE USE OF RESTRAINT, that at a minimum, physicians and other LIPs authorized to order restraint must have a working knowledge of this policy regarding the use of restraint. This training may include, but not necessarily be limited to, the following: a patient's rights regarding the use of restraint; prohibitions on such use; ordering requirements; requirements and time frames for patient assessment.

Review of the medical record of patient #1 revealed that the patient was admitted to the facility on 1/2/12 - 1/12/12 and again 1/14/12 - 1/20/12. The patient was a resident of a state facility for people with mental illness. The history and physical (H&P) report stated patient #1 had self-inflicted an abdominal stab wound the previous July and subsequently underwent a laparotomy and a colon resection. Both January 2012 admissions were due to the patient's tearing open the abdominal incision and probing with fingers and other instruments, creating infection. During both admissions, the patient was physically restrained for violent, self-harming behavior. Patient #1 was physically restrained during 2 inpatient stays for violent and self-destructive behavior, and the orders for restraint were only written 4 times; the patient remained in restraints a total of 14 days throughout the inpatient stays.

Further review of the medical record of patient #1 revealed that physician staff #8 was involved in the patient's care. In an in-person interview on 5/8/2012 at 11:05am, physician staff # 8 stated patient #1 had been admitted multiple times to the facility. Physician staff # 8 recalled that patient #1 would place different items in the abdominal wound which caused sepsis. The physician stated restraints were ordered on 1/14/2012 for behavioral emergency, but intended to be for the "regular restraint" because the patient was manipulating the wound. Physician staff # 8 did not know there was a difference between the Behavioral restraint order and the Acute Med/Surg restraint order.

In concurrent in-person interviews conducted on 5/7-8/2012, the facility Vice President of Nursing and Clinical Services, staff # 1 and the Director of Quality Management, staff #2 confirmed that patient #1's physicians failed to follow proper policies and procedures for restraint orders during both hospitalizations.

Based on review of documents and interview with staff, the facility failed to report to the Center for Medicare and Medicaid Services (CMS), deaths associated with the use of restraints, for 12 of 12 patients whose records were reviewed.

Findings were:

The hospital's policy regarding use of restraint, entitled Use of Restraint Policy, last approved by the facility governing body in June of 2009, includes a section entitled REPORTING OF DEATHS DUE TO USE OF RESTRAINT. In this section, the hospital states it must report to the Center for Medicare and Medicaid Services (CMS) each death that occurs while a patient is in restraints; each death that occurs within 24 hours after the patient has been removed from restraint; and each death known to the hospital that occurs within 1 week after restraint where it is reasonable to assume that the use of restraint contributed directly or indirectly to a patient's death. Each death must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient's death. Staff must document in the patient's medical record the date and time the death was reported to CMS."

The facility utilizes a form entitled REPORT OF DEATH. This form contains sections to be filled out if the patient died in restraints or within 24 hours of restraint. The forms for patients #1-#12 were reviewed; these 12 patients all died in restraint or within 24 hours of restraint. None of these patients' deaths were reported to CMS.

In concurrent in-person interviews conducted on 5/7-8/2012, the facility Vice President of Nursing and Clinical Services, staff #1 and the Director of Quality Management, staff #2 confirmed that CMS (Center for Medicare and Medicaid Services) was not notified of deaths associated with restraints for patients #1-#12

Based on review of records and interview with staff, the facility failed to ensure that drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the care of 1 of 1 patient whose record was reviewed. Patient #1 had orders for IV fluids on 1/15/2012; however did not receive the fluids that day.

Findings were:

Review of the medical record for patient #1 revealed a physician order dated 1/15/2012 at 6:37am for Dextrose 5% Water Infusion 1000 ml with IV Additives of Sodium Bicarbonate and Potassium Chloride. Per the Medication Administration Record (MAR), the nursing staff did not administer the IV fluids as ordered. This finding was confirmed in a telephonic interview with staff #12, the facility Patient Safety Coordinator the morning of 5/24/12.