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Based on document review and interview, it was determined for 1 of 1 (Pt #6) psychiatric seclusion patient, the Hospital failed to ensure post-seclusion debriefings were conducted in accordance with its policy. This has the potential to affect all patients who require seclusion in the Hospital.

Findings include:

1. The PolicyStat ID: 5586278 Restraint/Seclusion policy (last approved by the Hospital 12/2018) was reviewed on 2/21/19 at approximately 3:45 PM. Under "Behavioral Health Special Considerations", on page 7, the policy stated, "3. Post-Restraint/Seclusion Debriefing... a. A psychiatric RN (Registered Nurse) will lead the debriefing on APS (Adult Psychiatric Services)... b. The debriefing occurs as soon as possible and must be documented. c. Debriefing is used to..."

2. Pt #6 Admission date: 2/9/19 Diagnosis: Psychosis.
Pt #6's record was reviewed on 2/21/19 at approximately 12:05 PM. Pt #6's nursing note dated 2/11/19, stated that Pt #6 was placed in seclusion from 10:00 AM-11:04 AM. The record lacked a post-seclusion debriefing.

3. On 2/21/19 at approximately 2:00 PM, an interview was conducted with the Psychiatric Nursing Manager (E#11) with the Director of Nursing Psychiatric Services (E#5) present. E#11 verbally agreed that Pt #6's record lacked a debriefing for the 2/11/19 seclusion event.

A. Based on document review and interview, it was determined for 1 of 1 (Pt #2) child/adolescent behavioral health patient, whom required the "Independent Day Program (IDP)" for behavioral management, the Hospital failed to ensure its IDP policy was followed. This has the potential to affect all child/adolescent behavioral health patients serviced by the Hospital, with an average daily census of nine patients.

Findings include:

1. The Hospital policy titled, "PolicyStat ID: 5941430 Independent Day Program (IDP) for CAS (Child and Adolescent Services)" (last approved by the Hospital on 01/2019) was reviewed on 2/21/19 at approximately 10:00 AM. The policy defined IDP as an "intense, individualized therapeutic intervention used to address specific behaviors or symptoms that cannot be adequately addressed or controlled in the general behavioral program environment... Procedure: 1. The RN (Registered Nurse) will place a patient who is unable to interact/function... 2. The RN will immediately notify the physician for direction/orders. The IDP may be ended after four hours of appropriate behavior at the RN's and/or physician's discretion.

2. Pt #2 Admitted: 1/10/19 Diagnoses: Depression and Suicidal Thoughts.
Pt #2's record was reviewed on 2/21/19 at approximately 9:10 AM. Documentation stated the following:
a. On 1/14/19 at 2:42 PM, the Psychiatric Technician (E#9) documented that Pt #2 was "redirected multiple times to complete tx (treatment) work and was "advised (Pt #2) would receive a timeout or IDP if (Pt #2) did not focus on tx work... Pt placed in IDP at 2:40 PM. Pt threw tx work on the ground..." E#9 was not a RN.
b. On 1/14/19 at 2:44 PM, RN (E#8) documented that, "Pt w as (how typed in record) placed on group side of dayroom w with (how typed in record) curtain pulled for IDP. Pt making noises to be attention seeking and distracting..."
c. On 1/14/19 at 3:29 PM, RN (E#8) documented that, "Pt to serve 1 hr (hour) IDP and moved from dayroom to multipurpose room for IDP".
d. On 1/14/19 at 3:41 PM, a "Call/Page Contact Note" stated the nurse contacted the physician Psychiatrist-E#10) "Reason for Call...informed the physician (E#10) of Pt #2's behaviors, to serve 1 hour IDP, continued behaviors, and escorted to recovery room to continue IDP. "Orders received for PRNs (as needed medications) at this time."
e. On 1/14/19 at 4:00 PM, RN documented that, "Patient has continued to yell... refusing to do tx (treatment) and act out..."
f. On 1/14/19 at 4:10 PM, RN documented that, "Pt continues to escalate..."
g. The record lacked physician notification immediately after Pt #2 was placed in IDP and a physician order for the IDP.

3. An interview was conducted with the Director of Nursing Psychiatric Services (E#5) on 2/21/19 at approximately 10:10 AM. E#5 reviewed Pt #2's record and verbally agreed the RN did not contact the physician until 3:41 PM, which was approximately 1 hour after Pt #2 was placed in a one hour IDP. E #5 stated, "No, it doesn't look like they (the nurse) wrote the order after talking to the physician either."

4. On 2/21/19 at approximately 11:00 AM, an interview was conducted with the RN (E#8). The Director of Nursing Psychiatric Services (E#5) was present. E#8 had reviewed Pt #2's record and stated, "I only remember what was charted." E#8 verbally agreed the record lacked a physician order for the IDP.

5. On 2/22/19 at approximately 1:00 PM, an interview was conducted with the Psychiatric Technician (E#9). E#9 stated E #9 remembered Pt #2 and the use of time-out and IDP. E#9 stated, "The IDP rules are written and posted at the nurses station (on the unit). They were written by (the Psychiatrist- E#10) for the floor to follow. Verbal warnings are given and then a patient can get three times outs. After three time outs, the fourth time out is a one hour IDP. If another time out, the IDP time increases. We can't go any higher than a four hour IDP. The Psych Techs (Psychiatric Technicians), the Nurse, the Doctor, or the Therapists can send a patient to time-out and IDP. We chart it in the Progress Summary (area of the chart) like I did (with Pt 2)."

6. An untitled, undated written notice was presented by E#6 and E#5 on 2/22/19 at approximately 1:50 PM. The notice was reviewed, along with a concurrent interview. The notice outlined the reasons for an immediate time-out, when an IDP would be performed, and the following steps thereafter for repeated time-outs/IDPs. The process would repeat each day. E #5 and E #6 stated that, "the plan was put into place 'about a year ago' because the Day Room was becoming chaotic. (The Psychiatrist- E#10) met with the treatment team (therapists and nurses) and we put together this plan. (E#10) spoke with all the patients present and explained it to them. We've done it ever since." E #5 and E #6 verbally agreed the IDP policy did not include any mention of this "plan". Both stated that it was their understanding that only nurses would "officially" call the time-out or IDP and the RN would contact the Dr. for an order. E #5 and E #6 stated that patient records were not reviewed for the use of time-out/IDP and for the physician orders. E#6 stated, "It may very well be that staff aren't aware (that the RN needs to be the one to put patients into time-out and/or IDP and the RN is to contact the Dr. and the RN is to write an order- as in Pt #2). We will have to do some training on this. We never really thought about it before, but we see that it's definitely something we need to look at now."

B. Based on document review and interview, it was determined for 1 of 1 (Pt #6) seclusion patient, the Hospital failed to ensure seclusion orders were obtained, in accordance with its policy. This has the potential to affect all patients who require seclusion in the Hospital.

Findings include:

1. The PolicyStat ID: 5586278 Restraint/Seclusion policy (last approved by the Hospital 12/2018) was reviewed on 2/21/19 at approximately 3:45 PM. On page 1, the policy stated, "An order is required... If restraint or seclusion needs to continue beyond the expiration of the time-limited order based on an evaluation, a new order is obtained... If a patient was recently released from restraint or seclusion and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order would be required...Licensed Independent Professional (Physician, Clinical Psychologist...) conducts a face to face in person assessment of the patient with in one hour of the initiation of restraint or seclusion..."

2. Pt #6 Admission date: 2/9/19 Diagnosis: Psychosis.
Pt #6's record was reviewed on 2/21/19 at approximately 12:05 PM. The following deficiencies were identified related to seclusion:
a. On 2/9/19, nursing documentation stated that, Pt #6 was placed in seclusion 4:50 PM-8:10 PM. (three hours and twenty minutes) Pt #6's record lacked a Physician's order for the seclusion. The "Violent/ Self-Destructive/ Seclusion Face to Face" form was not signed by the physician until 2/10/19 at 2:44 PM.
b. On 2/11/19, nursing documentation stated that, Pt #6 was placed in seclusion 10:00 AM-11:04 AM. Pt #6's record lacked a Physician's order for the seclusion and a Physician's signature on the "Violent/ Self-Destructive/ Seclusion Face to Face" form.

3. On 2/21/19 at approximately 2:00 PM, an interview was conducted with the Psychiatric Nursing Manager (E#11). The Director of Nursing Psychiatric Services (E#5) was present. E#11 stated the restraint/seclusion orders have two parts: one is the electronic order which has the timeframe and one is the "Violent/ Self-Destructive/ Seclusion Face to Face" form, which the physician is required to sign also. Both verbally agreed with the the above mentioned issues with the lack of a Physician's order for Pt #6's seclusion events and the "Violent/ Self-Destructive/ Seclusion Face to Face" forms.

Based on document review and interview, it was determined for 1 of 1 (E#12) security personnel, who may respond to and/or assist with restraint/seclusion, the Hospital failed to ensure all direct care staff were certified in cardio-pulmonary resuscitation. This has the potential to affect all patients who require the use of restraint and/or seclusion.

Findings include:

1. The PolicyStat ID: 5586278 Restraint/Seclusion policy (last approved by the Hospital 12/2018) was reviewed on 2/21/19 at approximately 3:45 PM. On page 7, under "Staff Training & Competency", the policy stated, "All direct care staff are trained to perform cardio-pulmonary resuscitation (CPR)..."

2. The personnel file of security personnel (E#12) was conducted on 2/22/19 at approximately 9:10 AM. E#12's file lacked CPR certification.

4. The "Restraint Committee Meeting" minutes, dated October 19, 2018 and November 2, 2019, were reviewed on 2/22/19 at approximately 1:50 PM. The minutes stated the following:
a. On 10/19/18, the minutes stated, "According to CMS (Centers for Medicare and Medicaid Services) requirements; anyone who assists with restraints must have CPR... This would include Maintenance, EVS (environmental services) and Security... What we are currently doing for education is not sufficient for First Aide requirements... see how many of their staff are available to be certified in CPR..."
b. On 11/2/18, the minutes state, "According to CMS requirements; anyone who assists with restraints must have CPR and First Aide training... They agree to have their staff trained in CPR..."
c. As of 2/22/19 at approximately 2:30 PM, there were no timeframe's for the training of Security in CPR.


3. An interview was conducted with the Administrative Director Psychiatric Services (E#6), the Administrative Coordinator Regulatory Compliance (E#7), and the Educational Supervisor (E#13) on 2/22/19 at approximately 10:15 AM. E#7 stated the training process for restraint and seclusion had been reviewed in October/November 2018 and it was identified by the Restraint Committee; that the Hospital needed to look at the CPR training of Security "since they respond to and may assist in restraint and seclusion". We (the Hospital) have not set up a timeframe, at this time (for CPR training of Security). It is still in the planning phase."