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Based on document review and interview, it was determined that for 2 of 3 (Pt #3 and #4) clinical records reviewed of patients that required restraint usage, the Hospital failed to ensure all patients and/or families were notified in writing when rights were restricted.

Findings include:

1. Hospital policy entitled, "Patient Rights," (reviewed 02/16) required, "Policy...10. Whenever a patient's rights are denied or restricted, a verbal and written notice of such restrictions shall be given to the recipient and/or his designee...Procedure...c. The following must be completed each time the Patient Rights are restricted: i. The patient is given a given a copy of the 'Notice Regarding Rights of Recipient' to read...iii. If yes, the staff member will contact the significant other to notify them that the patient's rights have been restricted..."

2. The clinical record of Pt #3 was reviewed on 7/5/17 at approximately 9:40 AM. Pt #3 was a 15 year old female admitted on 6/29/17 with a diagnosis of bipolar disorder. Pt #3's clinical record contained a "Physician Order: Behavioral Restraint/Seclusion" order dated 7/3/17 that included Pt #3 was in restraints from 2:00 PM until 2:30 PM. Pt #3's clinical record lacked documentation that the patient and/or family were notified of Pt #3's restriction of rights.

3. On 7/6/17 at approximately 12:30 PM the clinical record of Pt #4 was reviewed. Pt #4 was a 14 year old female admitted to the ABHU (Adolescent Behavioral Health Unit) on 5/13/17 with a diagnosis of bipolar disorder. Pt #4's clinical record contained documentation that on 5/23/17 at 7:45 PM Pt #4 was placed in a "therapeutic hold" for aggressive behavior on the unit. Pt #4's clinical record lacked documentation that the patient and/or family were notified of Pt #4's restriction of rights.

4. The ABHU Manager (E #1) stated, during interview on 7/5/17 at approximately 9:45 AM and 7/6/17 at approximately 12:30, that the restriction of rights forms were missing from the charts.

Based on document review and interview, it was determined that for 1 of 2 (Pt #3) clinical records reviewed for precautions, the Hospital failed to ensure safety precautions were monitored as required by a physician's order.

Findings include:

1. Hospital policy entitled, "Precaution System," (reviewed 02/15) required, "Policy...All precautions require a physician order to ...remove a patient from a precaution and/or level of observation..."

2. The clinical record of Pt #3 was reviewed on 7/5/17 at approximately 9:40 AM. Pt #3 was a 15 year old female admitted on 6/29/17 with a diagnosis of bipolar disorder. Pt #3's clinical record contained a physician's order dated 6/29/17 at 4:00 PM that required Pt #3 be placed on suicide precautions, elopement precautions, and assault precautions. Pt #3's clinical record contained ABHU (Adolescent Behavioral Health Unit) Observation Records dated 6/29/2017 to 7/5/2017. The Observation Records dated 7/3/2017, 7/4/2017, and 7/5/2017 lacked documentation that Pt #3 was monitored for suicide precautions.

3. The ABHU Manager (E #1) stated, during an interview on 7/5/17 at approximately 9:45 AM, that the order for suicide precautions has not been discontinued.

Based on document review and interview, it was determined that for 1 of 2 (Pt #3) clinical records reviewed of a patient that required restraint usage, the Hospital failed to ensure a completed physician's order for restraint usage to include the length of time a restraint may be applied.

Findings include:

1. Hospital policy entitled "Restraint, Seclusion, and the 1 Hour Face to Face," (effective 3/2017) required, "Procedure: Behavioral Restraint and Seclusion...A. Requirements for all Settings...2. The initial and all subsequent restraint orders shall expire in...2 hours for patients from 9 to 17 years ...3. The order shall include the following...Maximum length of time, time limited, not to exceed..."

2. The clinical record of Pt #3 was reviewed on 7/5/17 at approximately 9:40 AM. Pt #3 was a 15 year old female admitted on 6/29/17 with a diagnosis of bipolar disorder. Pt #3's clinical record contained a "Physician Order: Behavioral Restraint/Seclusion" order dated 7/3/17 that included Pt #3 was in restraints from 2:00 PM until 2:30 PM. The order lacked the duration of restraint usage.

3. The Adolescent Behavioral Health Unit (ABHU) Manager (E #1) stated, during an interview on 7/5/17 at approximately 9:45 AM, that the order was lacking the duration the restraint could be used.

Based on document review and interview, it was determined that for 1 of 3 (Pt #3) clinical records reviewed of patients that required restraint usage, the Hospital failed to ensure criteria for discontinuing the restraint device was included in the physician's order.

Findings include:

1. Hospital policy entitled, "Restraints, Seclusion and the 1 Hour Face to Face," (effective 03/2017) required, "Hospital policy entitled "Restraint, Seclusion, and the 1 Hour Face to Face," (effective 3/2017) required, "Procedure: Behavioral Restraint and Seclusion...A. Requirements for all Settings...3. The order shall include the following...The medical or behavioral criteria for discontinuation of the restraint..."

2. The clinical record of Pt #3 was reviewed on 7/5/17 at approximately 9:40 AM. Pt #3 was a 15 year old female admitted on 6/29/17 with a diagnosis of bipolar disorder. Pt #3's clinical record contained a "Physician Order: Behavioral Restraint/Seclusion" dated 7/3/17 that included Pt #3 was in restraints from 2:00 PM until 2:30 PM. The physician's order lacked the medical and/or criteria for discontinuation of the restraint.

3. The Adolescent Behavioral Health Unit (ABHU) Manager (E #1) stated during an interview on 7/5/17 at approximately 9:45 AM that the order was lacking the duration the restraint could be used.

A. Based on document review and interview, it was determined that for 3 of 7 (Pt. #1, #5, and #6) clinical records reviewed for ESI (Emergency Severity Index) rating, the Hospital failed to ensure appropriate ESI assessment as required by policy.

Findings include:

1. On 7/5/17 at approximately 10:00 AM, the Hospital's policy titled "Triage Protocol" (reviewed 4/17) was reviewed and required, "...Triage... using the ESI (Emergency Severity Index) levels 1 thru 5. Acuity is based on the patient's presentation to the Emergency Department... Procedure:... 4. Classify an ESI level... b. Level 2: Emergent/Immediate: Patients are high-risk, their condition can easily deteriorate or the condition requires time-sensitive treatment. Patients require immediate attention and are to be sent directly to the treatment area. Examples:... Suicidal or homicidal patients... c. Level 3: Urgent: Patients have conditions, which require many resources for treatment and may have abnormal vital signs..."

2. On 7/5/17 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 14 year old male who was brought to the Hospital's Emergency Room (ER) on 5/22/17 due to psychiatric complaint. On the RN (registered nurse) triage assessment, the stated complaint indicated, "(Pt. #1) said he wants to die, suicidal ideation..." However, the RN triage assessment was completed with an ESI score of 3 (rather than 2).

3. On 7/5/17 at approximately 1:00 PM, findings were discussed with E # 2 (ER Manager). E #2 stated that the ESI score should have been 2.

4. The clinical record of Pt #5 was reviewed on 7/6/17 at approximately 9:15 AM. Pt #5 was a 17 year old male who presented to the ED on 6/11/17 with complaints of "Wanting to harm self after argument with father." Pt #5 was triaged at 4:45 PM was a category 3 and with documented vital signs of: temperature (T) 98.4; pulse (P) 63; respirations (R) 18; and blood pressure (B/P) 101/86.

5. The clinical record of Pt #6 was reviewed on 7/6/17 at approximately 9:30 AM. Pt #6 was a 17 year old male who presented to the ED on 6/3/17 with complaints of "My voice told me to do it... desire to do self-harm." Pt #6 was triaged at 10:28 AM as a category 3 and with documented vital signs of: T 97.2; P 64; R 16; and B/P 141/64.

6. E #2 stated, during an interview on 7/6/17 at approximately 9:55 AM, that no psychiatric patient should be triaged as a level 5 and according to the policy the suicide ideation patients should have been categorized as a level 2.

B. Based on document review and interview, it was determined that for 3 of 7 (Pt. #1, #5, and #6) clinical records reviewed for ED nursing assessment, the Hospital failed to ensure assessment was conducted as required by policy.

Findings include:

1. On 7/5/17 at approximately 10:00 AM, the Hospital's policy titled "Assessment, Emergency Nursing" (reviewed 10/16) was reviewed and required, "... Procedure: A. Nursing assessment... 2. General Survey... c. Vital Signs... Frequency of Assessments:... 2. All patients will be assessed no less than evey 2 hours..."

2. On 7/5/17 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 14 year old male who was brought to the Hospital's Emergency Room (ER) on 5/22/17 due to a psychiatric complaint. The clinical record indicated that vital signs were not assessed on 5/22/17 between 4:10 PM and 8:01 PM (3 hours and 51 minutes).

3. The clinical record of Pt #5 was reviewed on 7/6/17 at approximately 9:15 AM. Pt #5 was a 17 year old male who presented to the ED on 6/11/17 with complaints of "Wanting to harm self after argument with father." Pt #5 was triaged at 4:45 PM and as reassessed at 7:30 PM, 11:09 PM (3:39 minutes) and again on 6/12/17 at 10:45 AM (11 hours 36 minutes).

4. The clinical record of Pt #6 was reviewed on 7/6/17 at approximately 9:30 AM. Pt #6 was a 17 year old male who presented to the ED on 6/3/17 with complaints of "My voice told me to do it... desire to do self-harm." Pt #6 was triaged at 10:28 AM and was reassessed at 12:10 PM, 4:10 PM (4 hours later), and at 5:53 PM.

5. On 7/5/17 at approximately 1:00 PM and 7/6/17 at approximately 11:00 AM, findings were discussed with E #2 (ER Manager). E #2 agreed that vital signs were not assessed every 2 hours. E #2 stated, "Patients are reassessed at least every 2 hours."