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Based on document reviews and interviews, the hospital failed to provide evidence that patients were offered to have the patient's Primary Care Physician notified of an admission to the hospital for two (2) of ten (10) patients reviewed (Patient #1 and #8).

Findings:

The hospitals policy "Patient Notification Rights on Admission", last revised 11/29/2022 states in part, "Registration will ask the patient if the PCP [Primary Care Physician] is to be notified that the patient has been admitted and will indicate the answer in the appropriate field in the Registration conversation".

On 7/19/2023 at 2:20 PM, ten (10) patient records were reviewed. This review indicated the following in the medical records:
- Patient #1 and Patient #8 had no documented evidence that they were asked by Registration about their right to have the Primary Care Physician notified; and
- Patient #1 and Patient #8 had no documented evidence that the Primary Care Physician was notified of their admission.

On 7/21/2023 at 12:29 PM, the Regulatory and Licensing Compliance Officer confirmed that there was no documented evidence that the Primary Care Physicians were notified of the patients admission.

Based on document reviews and interviews, the hospital failed to ensure that the hospital's policy for restraints and seclusion, related to the documenting of less restrictive measures tried before providing restraints, was implemented for one (1) of six (6) restrained patients (Patient 5R).

Findings:

The hospitals policy "Restraint and Seclusion", last revised 2/1/2023 states in part, "Each episode of restraint use is documented in the patient's medical record. Documentation will include but is not limited to: ... Consideration or failure of non-physical interventions ... Documentation is accomplished in a manner (such as a restraint log) that allows for the collection and analysis if data for performance improvement activities".

On 7/17/2023 at 12:15 PM, six (6) records were reviewed. This review revealed the following:

Documentation in Patient 5R's record indicated:
- Registered Nurse ("RN") #1 documented that Patient 5R was in a physical hold between 4:27 PM and 4:29 PM;
- RN #1 documented that Patient 5R was given a chemical restraint, involving two (2) intra-muscular medications;
- RN #1 documented that Patient 5R was placed in seclusion from 4:30 PM to 5:12 PM; and
- There was no documented evidence on the Restraint or Seclusion Flow sheet or in the medical record that would show that less restrictive measures were attempted for the chemical restraint or the seclusion.

On 7/19/2023 at 11:44 AM, the above findings were confirmed during a second review of the record with the Nurse Manager of the Emergency Department.

Based on document reviews and interviews, the hospital failed to ensure a physician's order was obtained for two (2) of six (6) patients that were restrained (Patient 5R and 6R).

Findings:

The hospitals policy "Restraint and Seclusion", last revised 2/1/2023 states in part, "The initial restraint order may be done via written order, or telephone with read-back, following assessment of the patient by the provider or trained RN. It should be entered into the EMR [Electronic Medical Record] as soon as patient safety is ensured or during the telephone process. The order for the restraint will include: a. Type of restraint b. Starting date and time c. Indications for use ... The use of chemical restraint follows all the requirements of ordering, assessment and documentation as does the application of violent physical restraint with the following additions: a. Administration of the medication to restrain is often involuntary on the part of the patient. An order for a Physical Hold may be required. b. Vital signs must be assessed following medication administration: i. on administration ii. at 30-minute intervals x3 ... Seclusion is categorized as a 'Violent Restraint'. All the elements of order entry, assessment and timing for Violent Restraints apply to Seclusion. Physical Holds, while short in duration, follow the same ordering and assessment requirements as Violent Restraints".

On 7/17/2023 at 12:15 PM, six (6) records were reviewed. This review revealed the following:

1. Documentation in Patient 5R's record indicated the following:
- On 6/10/2023 at 4:24 PM, Doctor of Osteopathy ("DO") #1 ordered two (2) intra-muscular medications;
- On 6/10/2023 at 4:27 PM, Patient 5R required a physical hold to provide a chemical restraint;
- On 6/10/2023 at approximately 4:27 PM, Patient 5R was given a chemical restraint;
- On 6/10/2023 at 4:30 PM, Patient 5R was placed in seclusion until, which ended on 6/10/2023 at 5:12 PM;
- On 6/10/2023 at approximately 4:30 PM, DO #1 documented, "[Patient 5R] has been placed in ED [Emergency Department] observation with plan for further psychiatric evaluation once [Patient 5R] is awake after his chemical restraint"; and
- There was no evidence in the medical record of a physician's order for the chemical restraint or the seclusion.

On 7/19/2023 at 11:44 AM, a second review of the record was conducted with the Nurse Manager of the Emergency Department and the above findings were confirmed.

2. Documentation in Patient 6R's record indicated the following:
- On 5/22/2021 at 7:50 PM, Patient 6R required a physical hold;
- Five (5) security personnel maintained a physical hold until 7:53 PM; and
- There was no evidence in the medical record of a physician's order for the physical hold.

On 7/24/2023 at 2:01 PM, a second review of the record was conducted with the Nurse Manager of the Emergency Department and the above findings were confirmed.

Based on record reviews and interviews, the hospital failed to ensure the condition of patients, who were in restraints, were monitored in accordance with hospital policy for one (1) of six (6) patients reviewed (Patient 5R).

Findings:

The hospital's "Restraint and Seclusion" Policy, last revised on 2/1/2023, states in part, "When chemical restraints are administered via IM [Intra-Muscular] route, vital signs must be checked at 30-minute intervals a minimum of THREE (3) times after administration to evaluate for over-sedation or unstable vital signs (i.e. hypotension, decreased/shallow respirations)".

On 7/17/2023 at 12:15 PM, six (6) records were reviewed. This review revealed the following:

1. Documentation in Patient 5R's record indicated the following:
- On 6/10/2023 at 4:24 PM, Doctor of Osteopathy ("DO") #1 ordered two (2) intra-muscular medications;
- On 6/10/2023 at 4:27 PM, Patient 5R required a physical hold to provide a chemical restraint;
- On 6/10/2023 at approximately 4:27 PM, Patient 5R was given a chemical restraint;
- On 6/10/2023 at 4:30 PM, Patient 5R was placed in seclusion until, which ended on 6/10/2023 at 5:12 PM;
- On 6/10/2023 at approximately 4:30 PM, DO #1 documented, "[Patient 5R] has been placed in ED [Emergency Department] observation with plan for further psychiatric evaluation once [he/she] is awake after [his/her] chemical restraint"; and
- Nursing documentation in the medical record indicated that the first set of vitals after receiving the chemical restraint at approximately 4:27 PM on 6/10/2023 was at 5:18 PM on 6/10/2023 (a duration of 51 minutes), instead of at the required thirty (30) minutes.

On 7/19/2023 at 11:44 AM, a second review of the record was conducted with the Nurse Manager of the Emergency Department and the above findings were confirmed.

Based on document reviews and interviews, the hospital failed to ensure that restrained patients received an evaluation within one (1) hour of restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint for two (2) of six (6) patients (Patient 5R and 6R).

Findings:

The hospital's "Restraint and Seclusion" Policy, last revised on 2/1/2023, states in part, "Any medication given without the patient's consent during a behavioral emergency as a chemical restraint (when the patient is exhibiting behaviors that are immediately dangerous to their self or others) is subject to all standards of the restraint use guidelines ... When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a Physician or other licensed independent practitioner ... The physician/provider must assess AND document: - the patient's condition; - the patient's reaction to the intervention; - the patient's medical and behavioral condition; and - the need to continue or terminate the restraint or seclusion ... . ".

On 7/17/2023 at 12:15 PM, six (6) records were reviewed. This review revealed the following:

1. Patient 5R
- On 6/10/2023 at 4:27 PM, Patient 5R required a physical hold to provide a chemical restraint;
- On 6/10/2023 at approximately 4:27 PM, Patient 5R was given a chemical restraint, involving two (2) intra-muscular medications;
- On 6/10/2023 at 4:30 PM, Patient 5R was placed in seclusion until 5:12 PM; and
- There was no evidence of a face-to-face evaluation for all three (3) restraints by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

On 7/19/2023 at 11:44 AM, a second review of the record was conducted with the Nurse Manager of the Emergency Department and the above findings were confirmed.

2. Patient 6R
- On 5/22/2021 at 7:50 PM, Patient 6R required a physical hold;
- Five (5) security personnel maintained a physical hold until 7:53 PM; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

On 7/24/2023 at 2:01 PM, a second review of the record was conducted with the Nurse Manager of the Emergency Department and the above findings were confirmed.

Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for two (2) of six (6) patients that were restrained (Patient 5R and 6R).

Findings:

The hospital's "Restraint and Seclusion" Policy, last revised on 2/1/2023, states in part, "Any medication given without the patient's consent during a behavioral emergency as a chemical restraint (when the patient is exhibiting behaviors that are immediately dangerous to their self or others) is subject to all standards of the restraint use guidelines ... When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a Physician or other licensed independent practitioner ... ".

On 7/17/2023 at 12:15 PM, six (6) records were reviewed. This review revealed the following:

1. Patient 5R
- On 6/10/2023 at 4:27 PM, Patient 5R required a physical hold to provide a chemical restraint;
- On 6/10/2023 at approximately 4:27 PM, Patient 5R was given a chemical restraint, involving two (2) intra-muscular medications;
- On 6/10/2023 at 4:30 PM, Patient 5R was placed in seclusion until 5:12 PM; and
- There was no documented evidence of a face-to-face evaluation for all three (3) restraints by a provider within one (1) hour of the restraint initiation.

On 7/19/2023 at 11:44 AM, a second review of the record was conducted with the Nurse Manager of the Emergency Department and the above findings were confirmed.

2. Patient 6R
- On 5/22/2021 at 7:50 PM, Patient 6R required a physical hold;
- Five (5) security personnel maintained a physical hold until 7:53 PM; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

On 7/24/2023 at 2:01 PM, a second review of the record was conducted with the Nurse Manager of the Emergency Department and the above findings were confirmed.

Based on document reviews and interviews, the hospital failed to ensure staff completed initial restraint training and the documentation was contained in the staff member's personnel record for one (1) of nine (9) physicians reviewed who had been involved in a patient restraint (Medical Doctor #1).

Findings:

The hospital's "Restraint and Seclusion" Policy, last revised on 2/1/2023, states in part, "Physicians and other AHP's [Advanced Health Practitioners] will be provided education in order to maintain a working knowledge of this policy and appropriate order sets ... Initial training contains: a. Review of related policies b. iCare module for direct and non-direct patient care staff ... ".

1. Medical Doctor ("MD") #1 was involved in the care of the following patient who was restrained:
- On 5/22/2021 at 7:00 PM, MD #1 assumed care of Patient 6R;
- On 5/22/2021 at 7:50 PM, Patient 6R required a physical hold; and
- Five (5) security personnel maintained a physical hold until 7:53 PM.

The surveyor requested to review MD #1's training records.

MD #1 was hired in 7/2020 and until 11/9/2022, there was no evidence provided to the surveyor that indicated MD #1 had completed any training on restraints.

On 7/26/2023 at 12:19 PM, the Regulatory and Licensing Compliance Officer confirmed the above findings.