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Based on document review and interview, in 2 of 5 (Patient #1 and Patient #2) grievances reviewed, the facility did not ensure that two verbal complaints alleging abuse were treated as grievances. This could lead to lack of resolution of the grievance to the complainant.

Findings include:

-- Per review of the hospital's policy and procedure (P&P) titled "Complaint and Grievance Management," dated 11/14/17, a grievance is a written or verbal complaint by a patient (his/her representative) regarding care, abuse, neglect, etc. It also indicated a grievance requires that the patient (representative) be provided with a written notice that contains the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance investigation, and the date of completion.

-- Per review of the Complaint/Grievance File for Patient #1, a verbal grievance alleging abuse was submitted on 10/16/17 with a request for follow up. As of 10/27/17, when the grievance was closed, the file lacked documentation indicating a written notice was sent to the complainant.

-- Per review of the Complaint/Grievance File for Patient #2, a verbal grievance alleging abuse was submitted on 10/10/17 with a request for a copy of any video taping of the incident. The complaint was closed the same day via a phone conversation with Patient #2 indicating there was no video taping. The file lacked documentation of the hospital's investigation or any written correspondence with Patient #2.

-- Per interview of Staff A (Patient Relations Coordinator) on 2/13/18 at 3:30 pm, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, the hospital's policies and procedures (P&P) for restraint and seclusion did not employ a definition or description of what constitutes the use of drugs or medications as a restraint that is consistent with this regulation. The facility did not recognize STAT (to be given immediately) intramuscular (IM) medications given to patients in emergency situations to control behavior as chemical restraints. This was evident in 4 of 4 MRs reviewed for patients who received STAT IM medications. This lack of recognition of medications used as chemical restraints could lead to lack of appropriate patient monitoring and untoward patient outcomes.

Findings include:

-- Review of the hospital's P&P titled "Restraint and Seclusion'" last revised 7/2017 and "Violent/Self - Destructive Restraint and Seclusion (CPEP [Comprehensive Psychiatric Emergency Program] and Psychiatric Inpatient Units)," last revised 10/2014, indicated the following: Drug or medication restraint is when it is used as a restriction to manage the patient's behavior or restrict the patients freedom of movement and is not standard treatment or dosage for the patient's new or continuing medical or behavioral condition. It is this organization's policy to only use medications that are standard treatment for the patient's ongoing or newly emerging conditions. Therefore, drug or medication restraint is not used in this organization.

-- Review of Patient #2's MR indicated he presented to the hospital on 10/8/17 with chief complaint of chest pain and Seroquel overdose (Seroquel is a drug used to treat the symptoms of schizophrenia, bipolar disorder and major depressive disorder.) Patient #2 was evaluated and it was determined that inpatient psychiatric treatment was needed. The patient was told that he was being involuntarily admitted to the hospital. He became verbally agitated, uncooperative and postured towards the exit, requiring redirection by hospital security. The Emergency Department (ED) Registered Nurse (RN) administered Ativan 2 milligrams (mg) (a benzodiazepine medication for used to treat anxiety and has sedative effects) and Geodon 20 mg (medication intended for short term control of severe occurrences of agitation) IM STAT per order of the ED physician.

-- Per interview of Staff B (Crisis Evaluator CPEP) on 2/13/18 at 8:50 am, he/she was present during this event and indicated hospital security attempted to stop Patient #2 from leaving the ED by verbal deescalation. However, the patient became more aggressive which resulted in the 3 security officers having to physically restrain the patient. They all ended up on the floor. The nurse administered Ativan 2 mg and Geodon 20 mg IM STAT per order of the ED physician.

-- Review of Patient #3's MR indicated on 2/6/18 at 2:38 pm he was brought to the ED by police after he became violent towards his family and threatened violence towards a police officer. Documentation by the ED physician at 4:51 pm indicated, Patient #3 attempted to charge at staff before security intervened. He was aggressive, combative and was placed in 4 point restraints. Geodon 20 mg, Ativan 2 mg IM STAT were administered per order of the ED physician.

-- Review of Patient #1's MR indicated on 10/13/17 at 3:17 am, he/she presented to the ED after self mutilation behavior. After evaluation it was determined the patient needed inpatient psychiatric care. The patient was advised that he was being admitted. He called Staff C (ED Physician) to the bedside and began verbally assaulting him/her, spitting and attempting to strike him/her. Security was called, Patient #1 was put in 4 point restraints and the ED nurse administered Geodon 20 mg and Ativan 2 mg IM STAT per order of the ED physician.

-- Per interview of Staff C on 2/12/18 at 3:30 pm, he/she provided care to Patient #1. After the patient was told he was going to be admitted, he became agitated. Staff C was walking by Patient #1's room when he began yelling profanities and spitting while coming off the stretcher as if to attack him. Security was called and they responded immediately. Four-point restraints were applied and the patient was medicated with Ativan and Geodon IM. Patient #1's behavior was wild; he was trying to bite, kick and scratch.

-- Review of Patient #4's MR indicated on 2/4/18 at 7:15 am on the inpatient mental health unit, he was placed in 4 point restraints and administered Geodon 20 mg and Ativan 2 mg IM after demonstrating violent and aggressive behavior toward another patient and pushing a Mental Health Technician.

-- During interview with Staff D (Nurse Manager CPEP) on 2/12/18 at 9:15 am, he/she indicated they do not use chemical restraints at their facility and the medications used are to treat patient's mental health condition.

-- During interview with Staff E (ED Medical Director) on 2/13/18 at 12:45 pm, he/she indicated the facility does not use chemical restraints. The medications that are given do not make the patient unable to communicate, but are used to treat the patient during an acute event when symptoms are so severe they prevent a physician evaluation. Medications are used to treat an acute or new condition in order to obtain an adequate history and physical.

The hospital indicated they do not use chemical restraints. However, the administration of psychotropic medication in these situations described above met criteria for chemical restraint.

Also see findings in Tag 179.

Based on interview it was determined that the facility did not develop policies and procedures (P&P) specifically recognizing and addressing medications used as chemical restraints and therefore lacked guidance to staff on monitoring patients after administration of chemical restraint. This could place patients at risk for untoward outcomes.

Findings include:

-- During interview of Staff E (Administrative Director of Behavioral Health) on 2/12/18 at 1:30 pm, he/she indicated medications are ordered by the provider to reduce the severity of the patient's symptoms and regain behavioral control. Geodon and Ativan are used for severe agitation and have a calming affect, they are not considered chemical restraints.

-- See findings in Tag 160.

Based on medical record (MR) review, document review and interview, in 2 of 2 MRs reviewed for Patients #5 and Patient #6 who required application of a 4 point restraint, the qualified practitioner's face-to-face (FTF) evaluation did not include a physical assessment. This lack of physician evaluation puts the patient at risk for harm.

Findings include:

-- Per review of Patient #5's MR, she presented to the Emergency Department (ED) on 2/11/18 at 1:00 am due to a suicide attempt. At 1:02 am, Staff G (ED Physician) performed a medical screening examination (MSE) and ordered tests. At 2:00 am Staff H (ED Registered Nurse [RN]) inserted a temperature sensing indwelling Foley catheter. At 2:05 am, Patient #5 attempted to pull out catheter and was kicking at staff. Security was summoned to bedside and Staff H obtained a verbal order to apply 4 point restraints. Staff H documented monitoring of Patient #5 every 15 minutes. There is no physician documentation that a face to face evaluation was performed after the restraints were applied.

-- Per review of Patient #6's MR, she presented to the ED on 2/12/18 at 6:07 pm for suicidal thoughts. Suicide precautions were implemented which included continuous 1 to 1 supervision with a security officer at the bedside. At 9:17 pm the ED physician performed a MSE and cleared Patient #6 for admission to Comprehensive Psychiatric Emergency Program (CPEP). At 12:16 am Patient #6 attempted to barricade herself in her room and was fighting with staff. At 12:18 am Staff I (RN) obtained a verbal order for soft 4 point restraints and applied them. There is no physician documentation that a face to face evaluation was performed after the restraints were applied.

-- Per reivew of the facility's policy and procedure (P&P) titled "Violent/Self- Destructive Restraint or Seclusion (CPEP and Psychiatric Inpatient Units)," last revised 10/17/14, "Within 30 minutes of the initiation of restraint or seclusion, the responsible physician or his/her designee shall perform a face to face examination of the patient's physical and psychological condition."

-- During interview of Staff D (CPEP Nurse Manager) on 2/12/18 at 2:30 pm, he/she verified the above findings.