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Based on interview, medical record, document and video review, the facility does not ensure the application, monitoring and documentation of restraints and seclusion is carried out in accordance with facility policy. Failure to follow facility policies places both patients and staff at risk for an adverse event.

See findings under Tag #167, #184, #196 and #206.

Based on policy review, medical record review and interview, nursing staff did not follow facility policy related to the assessment and documentation of restraint/seclusion use for 2 of 13 patients (Patient #1 and #2). Failure to follow facility policy potentially places patients at risk for an adverse patient outcome.

Findings include:

Review on 06/30/17 of policy "Restraints: Violent/Self Destructive" last revised 03/15/15 indicates the registered nurse (RN) must complete an initial assessment for each episode of restraint or seclusion which includes the time the restraint was initiated, the time the order expires and behavioral criteria for release. Monitoring of the patient is continuous and findings are documented every 15 minutes. The RN obtains vital signs every hour for patients in restraints only. A separate "Violent/Self-destructive Restraint/Seclusion Monitoring" form will be filled out for each order/episode with initials and titles of all staff who document on the form, a description of how the patient was restrained, every 15 minute monitoring and restraint teaching provided. The patient is to be evaluated by the RN within 1 hour of the intervention.

Review on 06/30/17 of policy "Restraint or Seclusion: A-111" last revised 03/15 indicates patients in restraints/seclusion will be under continuous monitoring by healthcare staff. Vital signs will be taken at least hourly. If a patient is not able to cooperate, monitoring of appearance, airway and circulation to restrained limbs will be conducted every 15 minutes and documented on the "Violent/Self-destructive Restraint/Seclusion Monitoring" form (BEH0711). For seclusion, a secure room is to be used devoid of furniture or fixtures that may be a danger to the patient and the bathroom is locked. The condition of the person must be continually monitored and re-evaluated by healthcare staff. Observation will be done through a window for the first hour and either via window or closed circuit monitoring thereafter. Patient monitoring during seclusion includes assessment of behavior, environment, personal needs including bathroom and hygiene, response to medication and medical needs/health status according to the "Violent/Self-destructive Restraint/Seclusion Monitoring" form (BEH0711) which will be utilized for each seclusion order/episode. Following an episode of restraint/seclusion, a debriefing meeting will be held for the patient, family, staff and other patients if needed. The meeting will be documented on the Mental Health Debriefing Tool.

Review of the Emergency Department (ED) medical record for Patient #1 dated 5/30/17 revealed a physician order for 4 point restraints was obtained at 5:31pm as the patient was becoming increasingly violent. Nursing documentation at 6:12pm and 6:34pm revealed the patient remained in restraints. Vital signs were documented at 6:00pm and at 6:12pm there is a notation "maintaining airway". At 8:20pm the patient is noted to be roaming the halls and at 9:10pm the patient was transferred to the inpatient psychiatric unit.There is no documentation to indicate when the restraint was applied, when it was released, the behavioral criteria for release, teaching provided or the ongoing monitoring of the patient's condition, including appearance, airway and circulation during the restraint episode.

Review of video footage dated 4/7/17 revealed Patient #2 being placed in room 126 at 1:15pm. Furniture was not removed and the bathroom door remained unlocked. Review of the ED nursing notes dated 4/7/17 at 1:55pm revealed the patient was lying on the ground, shouting throughout the ED that she needed to be seen by a doctor. A verbal order for seclusion in room 126 was obtained. Other than the video recording, there is no documentation of ongoing patient assessment, including behavior, environment or personal needs including bathroom and hygiene. Review of the physician assessment dated 4/7/17 at 3:56pm does not address the implementation of seclusion. At 5:41pm the patient was transferred to the inpatient psychiatric unit.

Interview on 7/7/17 at 1:00pm with Staff (B), VP of Nursing verified these findings.

Based on medical record review, policy review and interview, there is no evidence to indicate a one hour face to face medical and behavioral evaluation was conducted on Patient #1 following the application of restraints. Lack of assessment could potentially lead to an adverse patient event.

Finding include:

Review of the facility's RN Restraint/Seclusion Checklist (3M & 3S) indicates a physician, nurse practitioner or physician assistant completes the face to face with a patient within 30 minutes of the restraint/seclusion and documents findings.

Review of policy "Restraint or Seclusion: A-111" last revised 03/15 indicates restraint is effected only after a written order of a physician, except in an emergency situation. If an emergency situation exists, the RN contacts the physician for a verbal order and the physician examines the patient within 30 minutes. The patient is seen face to face within one hour after initiation of restraint by a trained RN, during which an evaluation of the patient's immediate situation, reaction to intervention, medical and behavioral condition and the need to continue or terminate the restraint or seclusion is conducted.

Review of ED physician note dated 5/30/17 at 11:25am revealed the patient swings into hostile, verbally threatening behavior. Deliberately intimidating to get needs met. At 3:19pm a decision to admit was noted. At 5:31pm an order for 4 point restraints was given with no further documentation from the physician noted.

Review of ED nursing notes dated 5/30/17 at 4:19pm revealed the patient was "becoming violent" and at 6:12pm "remains in restraints" was noted. At 8:12pm the patient was noted to be "roaming the halls" and at 9:22pm the patient was transferred to the inpatient psychiatric unit. There is no documentation of an evaluation of the patient's immediate situation, reaction to intervention, medical and behavioral condition and the need to continue or terminate the restraint or seclusion within one hour of restraint application.

Interview on 07/07/17 at 01:00 PM with Staff (B), VP of Nursing verified these findings.

Based on interview, document and video review the hospital does not ensure that all staff who have direct care responsibilities, including contract/agency personnel, demonstrate competency for the use and care of the patient in restraint or seclusion. Lack of training has the potential to result in an adverse patient event.

Findings include:

Review on 06/30/17 of policy "Safety/Security Policy" dated 07/12/12 indicates education includes but is not limited to crisis management training and signs of escalation. Education will be provided to all new employees during orientation.

Review on 06/30/17 of policy "Restraint or Seclusion: A-111" last revised 03/15 indicates all staff are required to engage in training and demonstrate competency during orientation and on a periodic basis.

Review on 06/30/17 of video footage from 5/30/17 revealed that Staff (N), Security Officer, Staff (O), RN, Staff (Q), agency RN, Staff (R), ED Tech and Staff (S), Social Worker/RN were restraining Patient #1 on the floor and attempting to place him onto a backboard. Four unidentified people came into room and assisted hospital staff, lifting Patient #1 on to a gurney. One of the unidentified people applied the four point restraint to Patient #1's right wrist.

Review on 6/30/17 of the personnel file for Staff (Q), agency RN revealed a self attestation Emergency Room RN skills checklist from the staffing agency which indicates Staff (Q) has experience in the care of patients in restraints, however, no documentation of facility training and/or competency for the use of restraint and seclusion was found.

Telephone interview on 6/30/17 at 9:15am with Staff (Q), agency RN revealed that she is a contract nurse working 3 days a week for a 13 week assignment. On 5/30/17, while caring for Patient #1, she stated that this was the first time she had cared for psychiatric patients at this facility, but was assisted by another hospital RN working in the ED. She indicated that she was not familiar with all the hospital restraint and seclusion policies. She was not aware of the drop down box for restraint documentation in the electronic medical record.

Interview on 7/7/17 at 11:00am with Staff (B), VP of Nursing revealed the orientation for contract/traveler nurses consists of 4 hours of documentation review, 1 day with a preceptor with review of policy and procedures/care issues. However, no documentation of Staff (Q), agency RN's orientation was available.

Interview on 7/7/17 at 1:00pm with Staff (B), VP of Nursing verified these findings.

Based on personnel file review and interview, 1 of 2 Security Officer's (Staff T) did not have education and training in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation (CPR). Staff must be able to render the appropriate "first aid" required if a restrained or secluded patient is in distress or injured.

Findings include:

Review on 6/30/17 of personnel file for Staff (T), Security Officer, revealed no evidence of training for CPR or first aid.

Interview on 6/30/17 at 10:30am with Staff (T), Security Guard revealed he does not have CPR and/or first aid training despite assisting in the application of patient restraints.

Interview on 7/07/17 at 1:00 PM with Staff (B), VP of Nursing verified these findings.