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Based on record review and staff interview, the facility failed to assess patient intellectual functioning and orientation for 2 of 8 active sample patients (A3 and A4). This deficiency makes it impossible to follow the changes of these parameters and adjust treatment accordingly.

Findings include:

A. Record Review

1. The psychiatric evaluation for patient A3 (dated 7/22/11) had no intellectual functioning or orientation included.

2. The psychiatric evaluation for patient A4 (dated 7/22/11) had no intellectual functioning or orientation included.

B. Interviews

In an interview on 7/26/11 at 11a.m. the Medical Director acknowledged the findings.

Based on record review and interview, the facility failed to include group therapy interventions on 3 of 8 active sample patients' master treatment plans [MTP] (A2, A4, and A7). The interventions on these treatment plans did not include any of the group therapies. Failure to include all treatment interventions may result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings include:

A. Record Review

1. For patient A2, the MTP, dated 7/15/11, did not include group therapy interventions.

2. For patient A4, the MTP, dated 7/23/11, did not include group therapy interventions.

3. For patient A7, the MTP, dated 7/19/11, did not include group therapy interventions.

B. Interview

1. In an interview on 7/26/11 at 9a.m., the Director of Social Work agreed with the findings and stated "We usually include groups on the interventions, but I don't know how we missed it on these 3 charts."

2. In an interview on7/26/11 at 11:10a.m., the Medical Director agreed with the findings.

Based on record review and interview, the facility failed to assure that alternative methods of helping the patient were provided before placement in seclusion and restraint at the patient's request for 1 of 2 seclusion/restraint incidents reviewed (S1). The patient requested seclusion and restraint in order to feel safer. The lack of staff interventions before placing the patient in seclusion and restraint at his request is a violation of the patient's right to less restrictive therapeutic intervention.

Findings include:

A. Record Review

The following documentation of the restrictive procedures for patient S1, who was admitted on 5/04/11 and voluntarily placed in seclusion and 4 point [wrists and ankles] restraints on 5/7/11 for 3 1/2 hours, included:

1. A nursing note on 5/7/11 at 7:30p.m., stated: "Patient is in 4 point restraints per request due to thinking of harm to self..."

2. On a form titled "PHYSICIAN EVALUATION OF RESTRAINT OR SELUSION" dated 5/7/11 at 7:30p.m., a check list was marked "NO" for the item "RESTRAINT OR SECLUSION WAS APPROPRIATE AND NECESSARY FOR THIS PATIENT BECAUSE FAILURE TO RESTRAIN OR SECLUDE THE PATIENT WOULD LIKELY HAVE RESULTED IN SERIOUS HARM TO THE PATIENT, PATIENTS [sic] AND/OR STAFF."

3. On a form titled "DENIAL OF PATIENT RIGHTS," dated 5/7/11, the item on a check list, "EXPLANATION OF 'GOOD CAUSE' FOR DENIAL OF RIGHTS, PLACEMENT IN SECLUSION, OR RESTRAINTS" was completed by a written note: "Patient requested S/R due to thoughts of harming himself & not being able to contract not to harm himself despite less restrictive measures offered. High risk of committing suicide." This form was signed by a physician on 5/8/11.

B. Interview

In an interview on 7/25/11 at 1:40p.m., the Director of Quality Improvement stated "We had some concerns about that [the voluntary restraint and seclusion] when we did the debriefing-because other methods were not tried."

C. Policy Review

The facility's "Seclusion/Violent Restraints [sic]" policy includes the following statement on page 1: "POLICY...The confinement of patients through the use of restraints is a high-risk treatment and will only be used when such measures are necessary to ensure the immediate safety of the patient, a staff member or others and only when alternative measures are not sufficient to assure the patient's safety."

Based on observation, record review and interview, the Medical Director failed to adequately ensure the quality and appropriateness of services provided by the medical staff. Specifically, the Medical Director failed to:

I. Ensure that intellectual functioning and orientation was assessed for 2 of 8 active sample patients (A3 and A4). This deficiency makes it difficult to follow changes in these parameters and adjust treatment accordingly.

Findings include:

A. Record Review

1. The psychiatric evaluation for patient A3 (dated 7/22/11) had no intellectual functioning or orientation included.

2. The psychiatric evaluation for patient A4 (dated 7/22/11) had no intellectual functioning or orientation included.

B. Interviews

1. In an interview on 7/26/11 at 11a.m. the Medical Director acknowledged the findings.

II. Ensure that the facility included group therapy interventions on 3 of 8 active sample master treatment plans [MTP] reviewed (A2, A4, and A7). The interventions on these treatment plans did not include any of the group therapies. The failure to include all treatment interventions may result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings include:

A. Record Review

1. For patient A2, the MTP, dated 7/15/11, did not include group therapy interventions.

2. For patient A4, the MTP, dated 7/23/11, did not include group therapy interventions.

3. For patient A7, the MTP, dated 7/19/11, did not include group therapy interventions.

B. Interview

1. In an interview on 7/26/11 at 9a.m., the Director of Social Work agreed with the findings and stated "We usually include groups on the interventions, but I don't know how we missed it on these 3 charts."

2. In an interview on 7/26/11 at 11:10a.m., the Medical Director agreed with the findings.

III. Ensure that alternative, less restrictive methods of helping the patient were provided before placement in seclusion and restraint at the patient's request for 1 of 2 seclusion/restraint incidents reviewed (S1). The patient requested seclusion and restraint in order to feel safer. The lack of staff interventions before placing the patient in seclusion and restraint at his request is a violation of the patient's right to less restrictive therapeutic intervention.

Findings include:

A. Record Review

The following documentation of the restrictive procedures for patient S1, who was admitted on 5/04/11 and voluntarily placed in seclusion and 4 point [wrists and ankles] restraints on 5/7/11 for 31/2 hours, included:

1. A nursing note on 5/7/11 at 7:30p.m., stated: "Patient is in 4 point restraints per request due to thinking of harm to self..."

2. On a form titled "PHYSICIAN EVALUATION OF RESTRAINT OR SELUSION" dated 5/7/11 at7:30p.m., a check list was marked "NO" for the item "RESTRAINT OR SECLUSION WAS APPROPRIATE AND NECESSARY FOR THIS PATIENT BECAUSE FAILURE TO RESTRAIN OR SECLUDE THE PATIENT WOULD LIKELY HAVE RESULTED IN SERIOUS HARM TO THE PATIENT, PATIENTS [sic] AND/OR STAFF."

3. On a form titled "DENIAL OF PATIENT RIGHTS," dated 5/7/11, the item on a check list, "EXPLANATION OF 'GOOD CAUSE' FOR DENIAL OF RIGHTS, PLACEMENT IN SECLUSION, OR RESTRAINTS" was completed by a written note: "Patient requested S/R due to thoughts of harming himself & not being able to contract not to harm himself despite less restrictive measures offered. High risk of committing suicide." This form was signed by a physician on 5/8/11.

B. Interview

In an interview on 7/25/11 at 1:40p.m., the Director of Quality Improvement stated "We had some concerns about that [the voluntary restraint and seclusion] when we did the debriefing-because other methods were not tried."

C. Policy Review

The facility's "Seclusion/Violent Restraints [sic]" policy includes the following statement on page 1: "POLICY...The confinement of patients through the use of restraints is a high-risk treatment and will only be used when such measures are necessary to ensure the immediate safety of the patient, a staff member or others and only when alternative measures are not sufficient to assure the patient's safety."

Based on record review and interview, the Director of Nursing failed to assure that registered nurses (RN) were provided special training to do face to face physical and mental assessments of patients within one hour after initiation of a seclusion or restraint procedure for 2 of 2 patients reviewed for restrictive procedures (S1 and D1). The hospital did not have a one hour face to face assessment training program for RNs. The lack of training for RNs who do face to face assessments after a restrictive procedure may result in failure to identify and treat any adverse effects of the procedure.

Findings include:

A. Record Review

1. Patient S1, admitted 5/4/11 and discharged 5/17/11, was in placed in seclusion and 4 point restraints [wrists and ankles] on 5/7/11 at 7:30p.m. The "RN Assessment" on the seclusion/restraint documentation form, also at 7:30p.m., was signed by an RN who had not been trained to do one hour face to face assessments. A nursing note, also on 5/7/11 at 7:30p.m., describing the patient's vital signs, was signed by an RN who had not been trained to do one hour face to face assessments.

2. Patient D1, admitted 4/10/11 and discharged [death] 4/26/11, was placed in seclusion on 4/11/11 from 7:40 to 7:45a.m. and in 4 point restraints from 7:45 to 9:45a.m. The RN assessment on the seclusion/restraint form was not documented until 9:45a.m. and was signed by an RN who had not been trained to do one hour face to face assessments.

B. Interview

1. In an interview at 2:45p.m. on 7/25/11, the Director of Quality Improvement provided a document titled "Key Competency Checklist, Seclusion/Restraint" signed by an RN and the Director of Nursing which included the statement "Able to verbalize required documentation" for a "RN face to face assessment within 1hr...." She stated "this is all the documentation we have on the training; it is all verbal."

2. In an interview at 9:15a.m. on 7/26/11, the Director of Nursing stated that she agreed with the findings.