HospitalInspections.org

Based on document review and staff interviews, the acute care hospital's (ACH) administrative staff failed to ensure the identified Behavioral Health (BH) staff were separated from all dependent adults once the hospital received notification of an allegation of abuse. The cumulative effect of this failure and deficient practice resulted in the hospital staff failing to ensure all patients had the right to be free from abuse. The hospital's administrative staff identified a census of 23 inpatients in the Behavioral Health at the start of the investigation.

1. Separate an alleged abuser from all patients, investigate an allegation of dependent adult abuse, and report an allegation of dependent adult abuse. Please see A-0145.

2. Ensure seclusion was discontinued at the earliest possible time. Please see A-0174.

3. Ensure a face to face physical and behavioral assessment was documented prior to the continuation of seclusion. Please see A-0179.

4. Ensure provider (Physician or Advanced Registered Nurse Practitioner) notification of the results of the face to face physical and behavioral assessment prior to the continuation of seclusion. Please see A-0182.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure all patients' rights were protected.

5. The survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient's Rights (42 CFR 482.13). The SA notified the administrative staff on 10/18/22. The hospital failed to separate an alleged abuser from all patients, investigate and report allegations of dependent adult abuse. The hospital's administrative staff removed the immediacy prior to the survey team exiting on 10/24/22 when the administrative staff took the following actions:

a. The hospital implemented measures to educate, separate, report, and investigate allegations of abuse.

b. The hospital updated the debriefing policy. Leadership, when immediately available, will assist/observe all seclusion events, direct the immediate debrief, and evaluate actions taken, post event. When Leadership is not immediately available, the House Supervisor will be notified, lead the debriefing, and evaluate actions taken. If Leadership and the House Supervisor are unavailable, the Seclusion Debriefing Form will be completed as soon as possible post seclusion event and submitted to Leadership for review within 24 hours.

c. Upon review of the Seclusion Briefing Form, within 48 hours, Leadership will review video footage, when available, for all seclusion events in which Leadership did not assist and/or observe event Leadership will record observations in the event management technology solution system. Any additional questions will be followed up with the Team Members involved upon Leadership post video footage review.

d. The Leadership will take appropriate action necessary to remove team members from patient care until the investigation is completed.

e. The hospital updated the Seclusion Debriefing Form. Leadership will track completion of education until all current Team Members are trained.

f. The Director of Behavioral Health sent algorithm, which outlines the steps and expectations in reporting abuse. Education started immediately on the algorithm.

g. For all seclusion events, Leadership will review all incidents reported within the event reporting system and validate the process as outlined above is working as intended. In the event re-education is warranted Leadership with provide such education and document completion.

h. Leadership will review all incident reports since 7/1/2022 until current to identify any events that should have been reported that were not reported. If any events were not reported, but should have been reported, Leadership will immediately report such event to DIA/DHS (whichever is appropriate), will immediately remove involved Team Members from patient care, and investigate the incident following the Just Culture framework.

Based on document review and staff interview, the acute care hospital's administrative staff failed to follow their policy and separate an alleged abuser from all patients, investigate an allegation of dependent adult abuse, and report an allegation of dependent adult abuse for 1 of 5 patients (Patient #2). Failure to remove alleged abuser from all patients, investigate the incident, and report the incident to the Department of Inspections and Appeals (DIA) resulted in the alleged abuser continuing to work with all patients after potentially committing dependent adult abuse. The hospital identified an average daily census of 527 and an average daily census of 46 in the Behavioral Health units.

Findings include:

1. Review of policy, "Reporting Suspected Child/Dependent Adult Abuse", dated 06/22, revealed in part: "...If a [hospital] team member suspects abuse of any kind, they will immediately report it to their direct Supervisor, or in their absence, the House Supervisor or the AOD [Administrator on Duty]. If the suspected abuser is a team member, the direct Supervisor (or in their absence the House Supervisor or AOD), must be notified immediately in order to remove the team member from patient care to keep all patients safe. Suspected abuse must be reported to the appropriate regulatory body within 24 hours...Any team member can report suspected abuse to the appropriate regulatory body. The team member's direct supervisor should be made aware of any suspected abuse or
reports filed. Any time a team member is involved in an abuse situation where there is an internal
and/or external investigation, the team member is to be removed from patient care until
the internal and/or external investigation is complete..." Policy also directs a team member to fill out an occurrence report when possible abuse is identified.

2. On 7/13/22 at 11:21 PM, RN A documented that Patient #2 had become agitated and was actively hallucinating. Patient #2 was running and pounding on doors, yelling that they were looking for Donald Trump. Patient #2 attempted to forcibly enter the nurse's station and other patient rooms. Patient #2 was walked to the seclusion room but once in the doorway Patient #2 turned and became physically aggressive with staff and attempted to run through staff. A physical hold (a brief physical restraint which restricts the patient's voluntary movement) was used at 11:09 PM, and Patient #2 was brought into the seclusion room where they continued to thrash and wrapped their legs around staff's legs until staff were able to exit the room and secure Patient #2 in seclusion.

3. Review of email provided by hospital dated 7/15/22 from RN B to RN Supervisor G and RN Supervisor H revealed RN B had witnessed Patient #2 being "drug" into the seclusion room, a Patient Care Tech (PCT) had grabbed Patient #2's legs and pulled them. RN B noted this occurred on 7/13/22 at 11:00 PM, and requested RN Nursing Supervisor G view the videotape

4. During an interview on 10/13/22 at 1:30 PM, RN B recalled that on 7/13/22 RN A and PCT C were pulling Patient #2 by their arms as Patient #2 was splaying out their legs to stop the movement, recalled RN A got a hold of one of Patient #2's legs and Patient #2 was hopping. Patient #2 was standing and they were pulling Patient #2 into the seclusion room. RN B stated their interpretation was Patient #2 was dragged, if Patient #2 had been on dirt or sand they would have left drag marks with their feet as they were pulled. RN B did not think it was abusive until they heard that word related to this incident, they thought there had to be a physical injury to a patient to meet the definition of abuse. RN B confirmed they sent an email to their supervisors on 7/15/22 (two days after the incident) and did have follow up from them, was told that they would have all staff receive additional training.

5. During an interview on 10/11/22 at 1:45 PM, RN A recalled the incident after reviewing the note. Patient #2 was
psychotic and a fall risk, was put on a 1:1 to mitigate fall risk but that seemed to agitate Patient #2. On 7/13/22 staff had tried to get Patient #2 to go into a seclusion room, Patient #2 had walked with them but RN A remembered that Patient #2 had turned around and tried to shove RN A. RN A was trying to keep Patient #2 from falling and used a physical hold to walk with them into the seclusion room. They were trying to get Patient #2 to sit down on the mattress. RN A fell onto the floor and does not really remember what happened after that. RN A stated that it was possible that someone had pulled on Patient #2's legs but that was not something they specifically remembered. RN A did not recall any follow up related to the incident, RN A's main concern was someone could have gotten hurt in that moment.

6. During an interview on 10/11/22 at 2:00 PM, PCT C recalled Patient #2 and stated they had been involved in multiple restraint or seclusion events with them. Recalled an incident where Patient #2 was fighting, kicking and hitting and they were just trying to grab ankles and arms and limbs to get Patient #2 into safety. PCT C denied dragging Patient #2. PCT C did not recall any follow up of an incident by hospital administrative staff.

7. During an interview on 10/11/22 at 2:10 PM, PCT D did not recall any follow up of an incident by hospital administrative staff.

8. During an interview on 10/11/22 at 1:18 PM, PCT E did not recall any follow up of an incident by hospital administrative staff.

9. During an interview on 10/11/22 at 1:35 PM, PCT F did not recall any follow up of an incident by hospital administrative staff.

10. During an interview on 10/11/22 at 8:00 AM, RN Supervisor G stated RN B had emailed both RN Supervisor G and RN Supervisor H on 7/15/22 related to an incident with Patient #2 on 7/13/22. RN B had conveyed, among other issues, that Patient #2 had been dragged. Nursing Supervisor G and Nursing Supervisor H met with RN B to discuss the incident on 7/22/22 (nine days after the alleged abuse, seven days after email was sent from RN B) and RN B had conveyed they were concerned about how the team had escorted Patient #2 from point A to point B and thought staff needed additional training. RN Supervisor G also spoke with RN A who was caring for Patient #2 when the alleged abuse occurred and RN A had shared it was a violent seclusion but did not mention any type of dragging. RN Supervisor G confirmed that they did not review available video or speak to any other involved staff members, did not remove any staff member from patient care, and did not report the alleged abuse.

11. During an interview on 10/11/22 at 8:15 AM, RN Supervisor H recalled a situation where Patient #2 had a seclusion event did not go well, but did not recall there was any allegation of abuse. Confirmed that RN B had sent an email on 7/15/22 around 7:30 AM and RN B did write that they saw Patient #2 being dragged. RN Supervisor H and RN Supervisor G met with RN B on 7/22/22 (a week later) where RN B conveyed that when staff moved Patient #2 it did end up being a bit more like dragging than carrying. RN Supervisor H did not have any concerns about abuse, said they knew RN Supervisor G was going to follow up on this incident and they never heard anything more about it.

12. Review of hospital occurrence reports 4/1/22 to 10/4/22 revealed hospital failed to file an occurrence report related to this incident.

13. Review of Kronos timekeeper records revealed RN A had worked with patients approximately 570 hours after hospital administrative staff received an email on 7/15/22 with an allegation of abuse.

14. Review of Kronos timekeeper records revealed PCT C had worked with patients approximately 474 hours after hospital administrative staff received an email on 7/15/22 with an allegation of abuse.

15. During an interview on 10/10/22 at 3:45 PM, Behavioral Health Director denied having any knowledge of an event on 7/13/22 that involved an allegation of abuse. Confirmed that no occurrence report was filed. Behavioral Health Director explained that video tape from the Behavioral Health Unit is only kept for 7 days so would be unable to go back and view this event.

Based on document review and staff interviews the acute care hospital's (ACH) staff failed to follow the ACH's policy and ensure that each seclusion event for 1 of 5 patients reviewed (Patient #1) was based on an identified patient need and not the patient's history of dangerous behavior. Failure to ensure that each seclusion event was based on an identified patient need and not a history of dangerous behavior resulted in Patient #1 being in seclusion for long periods of time without documented clinical reasons to continue seclusion, which may have resulted in adverse physical or psychological consequences for Patient #1. The hospital identified and average daily census of 527 and an average daily census of 46 in Behavioral Health units.

Findings include:

1. Review of policy, "Restraint and Seclusion Use", revealed in part, "The use of restraint or seclusion is not based on the patient's history of seclusion or restraint use or solely on a history of dangerous behavior. The use of restraint or seclusion intervention is a collaborative function of the nursing and medical staff in response to an assessed patient need."

2. Review of Patient #1's medical record from 9/22/22 revealed:

a. On 9/22/22 at 9:00 PM, RN J documented that Patient #1 was calm and listening to headphones while in seclusion
b. On 9/22/22 at 9:15 PM, PCT K documented that Patient #1 was calm and listening to headphones
c. On 9/22/22 at 9:30 PM, PCT K documented that Patient #1 was calm and listening to headphones
d. On 9/22/22 at 9:45 PM, PCT K documented that Patient #1 was calm.
e. On 9/22/22 at 10:00 PM, PCT K documented that Patient #1 was calm.
f. On 9/22/22 at 10:15 PM, PCT K documented that Patient #1 was asleep.
g. On 9/22/22 at 10:30 PM, PCT K documented that Patient #1 was calm.
h. On 9/22/22 at 10:41 PM, RN A documented a verbal order from DO I to continue seclusion even though it was documented that Patient #1 had been calm or asleep for over 90 minutes.
i. On 9/22/22 at 10:45 PM, PCT K documented that Patient #1 was calm.
j. On 9/22/22 at 11:00 PM, PCT K documented that Patient #1 was calm.
k. On 9/22/22 at 11:15 PM, PCT K documented that Patient #1 was calm.
l. On 9/22/22 at 11:30 PM, PCT K documented that Patient #1 was asleep.
m. On 9/22/22 at 11:45 PM, PCT K documented that Patient #1 was asleep.
n. On 9/23/22 at 12:00 AM, PCT K documented that Patient #1 was calm.
o. On 9/23/22 at 12:15 AM, PCT K documented that Patient #1 was calm.
p. On 9/23/22 at 12:30 AM, PCT K documented that Patient #1 was asleep.
q. On 9/23/22 at 12:45 AM, PCT K documented that Patient #1 was asleep.
r. On 9/23/22 at 1:01 AM, RN A discontinued Patient #1's seclusion. Patient #1 spent almost 4 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

3. Review of Patient #1's medical record from 9/23/22 revealed:

a. On 9/23/22 at 10:24 PM, RN W documented a verbal order from DO I for Patient #1 to remain in seclusion.
b. On 9/23/22 at 10:45 PM, Safety Tech L documented that Patient #1 was calm while in seclusion
c. On 9/23/22 at 11:00 PM, PCT M documented that Patient #1 was calm.
d. On 9/23/22 at 11:15 PM, PCT M documented that Patient #1 was calm.
e. On 9/23/22 at 11:30 PM, PCT M documented that Patient #1 was calm.
f. On 9/23/22 at 11:45 PM, PCT M documented that Patient #1 was calm.
g. On 9/24/22 at 12:00 AM, PCT M documented that Patient #1 was calm.
h. On 9/24/22 at 12:15 AM, PCT M documented that Patient #1 was calm.
i. On 9/24/22 at 12:30 AM, PCT M documented that Patient #1 was calm.
j. On 9/24/22 at 12:45 AM, PCT M documented that Patient #1 was asleep.
k. On 9/24/22 at 1:00 AM, PCT M documented that Patient #1 was asleep.
l. On 9/24/22 at 1:15 AM, PCT M documented that Patient #1 was calm.
m. On 9/24/22 at 1:30 AM, PCT M documented that Patient #1 was calm.
n. On 9/24/22 at 1:45 AM, PCT M documented that Patient #1 was calm.
o. On 9/24/22 at 2:03 PM, RN N discontinued Patient #1's seclusion. Patient #1 spent approximately 3.5 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

4. Review of Patient #1's medical record from 9/24/22 revealed:

a. On 9/24/22 at 11:10 PM, RN P documented a verbal order from MD O for Patient #1 to remain in seclusion.
b. On 9/25/22 at 12:15 AM, PCT M documented that Patient #1 was asleep while in seclusion.
c. On 9/25/22 at 12:30 AM, PCT M documented that Patient #1 was calm.
d. On 9/25/22 at 12:45 AM, PCT M documented that Patient #1 was calm.
e. On 9/25/22 at 1:00 AM, PCT M documented that Patient #1 was calm.
f. On 9/25/22 at 1:15 AM, PCT M documented that Patient #1 was calm.
g. On 9/25/22 at 1:30 AM, PCT M documented that Patient #1 was calm.
h. On 9/25/22 at 1:45 AM, PCT M documented that Patient #1 was asleep.
i. On 9/25/22 at 2:00 AM, PCT M documented that Patient #1 was asleep.
j. On 9/25/22 at 2:27 AM, RN P discontinued Patient #1's seclusion. Patient #1 spent over two hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

5. Review of Patient #1's medical record from 9/25/22 revealed:

a. On 9/25/22 at 10:15 PM, PCT M documented that Patient #1 was calm, asleep while in seclusion.
b. On 9/25/22 at 10:30 PM, PCT M documented that Patient #1 was asleep.
c. On 9/25/22 at 10:45 PM, PCT M documented that Patient #1 was asleep.
d. On 9/25/22 at 10:46 PM, RN X documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for 45 minutes.
e. On 9/25/22 at 11:00 PM, PCT M documented that Patient #1 was asleep.
f. On 9/25/22 at 11:15 PM, PCT M documented that Patient #1 was calm.
g. On 9/25/22 at 11:30 PM, PCT M documented that Patient #1 was calm.
h. On 9/25/22 at 11:45 PM, PCT M documented that Patient #1 was calm.
i. On 9/26/22 at 12:00 AM, PCT M documented that Patient #1 was asleep.
j. On 9/26/22 at 12:15 AM, PCT M documented that Patient #1 was asleep.
k. On 9/26/22 at 12:45 AM, PCT M documented that Patient #1 was asleep.
l. On 9/26/22 at 1:00 AM, PCT M documented that Patient #1 was asleep.
m. On 9/26/22 at 1:15 AM, PCT M documented that Patient #1 was asleep.
n. On 9/26/22 at 1:30 AM, PCT M documented that Patient #1 was asleep.
o. On 9/26/22 at 1:45 AM, PCT M documented that Patient #1 was asleep.
p. On 9/26/22 at 2:00 AM, PCT M documented that Patient #1 was asleep.
q. On 9/26/22 at 2:15 AM, PCT M documented that Patient #1 was calm. RN X documented a verbal order from MD Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm or asleep the last four hours.
r. On 9/26/22 at 2:30 AM, PCT M documented that Patient #1 was calm.
s. On 9/26/22 at 2:45 AM, PCT M documented that Patient #1 was asleep.
t. On 9/26/22 at 3:00 AM, PCT M documented that Patient #1 was asleep.
u. On 9/26/22 at 3:15 AM, PCT M documented that Patient #1 was asleep.
v. On 9/26/22 at 3:30 AM, PCT M documented that Patient #1 was asleep.
w. On 9/26/22 at 3:45 AM, PCT M documented that Patient #1 was asleep.
x. On 9/26/22 at 4:00 AM, PCT M documented that Patient #1 was asleep.
y. On 9/26/22 at 4:15 AM, PCT M documented that Patient #1 was asleep.
z. On 9/26/22 at 4:30 AM, PCT M documented that Patient #1 was asleep.
aa. On 9/26/22 at 4:45 AM, PCT M documented that Patient #1 was calm.
bb. On 9/26/22 at 5:00 AM, PCT M documented that Patient #1 was asleep.
cc. On 9/26/22 at 5:15 AM, PCT M documented that Patient #1 was asleep.
dd. On 9/26/22 at 5:30 AM, PCT M documented that Patient #1 was asleep.
ee. On 9/26/22 at 5:45 AM, PCT M documented that Patient #1 was asleep.
ff. On 9/26/22 at 6:00 AM, PCT M documented that Patient #1 was asleep.
gg. On 9/26/22 at 6:15 AM, PCT M documented that Patient #1 was calm. Medical Director Q gave a verbal order to RN X for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm or asleep the last four hours.
hh. On 9/26/22 at 6:30 AM, PCT M documented that Patient #1 was asleep.
ii. On 9/26/22 at 6:45 AM, PCT M documented that Patient #1 was calm.
jj. On 9/26/22 at 7:00 AM, PCT M documented that Patient #1 was calm.
kk. On 9/26/22 at 7:15 AM, PCT M documented that Patient #1 was calm.
ll.On 9/26/22 at 7:30 AM, PCT M documented that Patient #1 was calm.
mm. On 9/26/22 at 7:45 AM, PCT M documented that Patient #1 was calm.
nn. On 9/26/22 at 8:15 AM, RN Y discontinued Patient #1's seclusion. Patient #1 spent approximately nine hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

6. Review of Patient #1's medical record from 9/30/22 revealed:

a. On 9/30/22 at 10:15 PM, LPN R documented that Patient #1 was calm while in seclusion.
b. On 9/30/22 at 10:30 PM, LPN R documented that Patient #1 was asleep.
c. On 9/30/22 at 10:45 PM, LPN R documented that Patient #1 was asleep.
d. On 9/30/22 at 11:00 PM, LPN R documented that Patient #1 was asleep.
e. On 9/30/22 at 11:15 PM, PCT M documented that Patient #1 was asleep.
f. On 9/30/22 at 11:30 PM, PCT M documented that Patient #1 was calm.
g. On 9/30/22 at 11:45 PM, PCT M documented that Patient #1 was calm.
h. On 10/1/22 at 12:00 AM, PCT M documented that Patient #1 was calm.
i. On 10/1/22 at 12:15 AM, PCT M documented that Patient #1 was asleep.
j. On 10/1/22 at 12:30 AM, PCT M documented that Patient #1 was calm.
k. On 10/1/22 at 12:45 AM, PCT M documented that Patient #1 was calm.
l. On 10/1/22 at 12:47 AM, RN Z documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm or asleep for over two hours.
m. On 10/1/22 at 1:00 AM, PCT M documented that Patient #1 was calm.
n. On 10/1/22 at 1:15 AM, PCT M documented that Patient #1 was asleep.
o. On 10/1/22 at 1:30 AM, PCT M documented that Patient #1 was asleep.
p. On 10/1/22 at 1:45 AM, PCT M documented that Patient #1 was asleep.
q. On 10/1/22 at 2:00 AM, PCT M documented that Patient #1 was asleep.
r. On 10/1/22 at 2:15 AM, PCT M documented that Patient #1 was asleep.
s. On 10/1/22 at 2:30 AM, PCT M documented that Patient #1 was asleep.
t. On 10/1/22 at 2:32 AM, RN Z discontinued Patient #1's seclusion. Patient #1 spent over four hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

7. Further review of Patient #1's medical record from 10/1/22 revealed:

a. On 10/1/22 at 10:30 AM. PCT S documented that Patient #1 was asleep while in seclusion.
b. On 10/1/22 at 10:45 AM, PCT S documented that Patient #1 was asleep.
c. On 10/1/22 at 11:00 PM, PCT S documented that Patient #1 was asleep.
d. On 10/1/22 at 11:15 AM, PCT S documented that Patient #1 was asleep.
e. On 10/1/22 at 11:30 AM, Safety Tech L documented that Patient #1 was calm.
f. On 10/1/22 at 11:45 AM, Safety Tech L documented that Patient #1 was calm.
g. On 10/2/22 at 12:00 AM, PCT M documented that Patient #1 was calm.
h. On 10/1/22 at 12:00 PM, Safety Tech L documented that Patient #1 was calm and seclusion was discontinued. Patient #1 spent approximately 1.5 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

8. Review of Patient #1's medical record from 10/2/22 revealed:

a. On 10/2/22 at 12:00 AM, PCT M documented that Patient #1 was calm while in seclusion.
b. On 10/2/22 at 12:30 AM, PCT M documented that Patient #1 was asleep.
c. On 10/2/22 at 12:45 AM, PCT M documented that Patient #1 was asleep.
d. On 10/2/22 at 1:00 AM, PCT M documented that Patient #1 was asleep.
e. On 10/2/22 at 1:15 AM, PCT M documented that Patient #1 was asleep.
f. On 10/2/22 at 1:30 AM, PCT M documented that Patient #1 was asleep.
g. On 10/2/22 at 1:45 AM, PCT M documented that Patient #1 was asleep.
h. On 10/2/22 at 2:00 AM, PCT M documented that Patient #1 was asleep.
i. On 10/2/22 at 2:15 AM, PCT M documented that Patient #1 was asleep.
j. On 10/2/22 at 2:30 AM, RN J documented that Patient #1 was asleep.
k. On 10/2/22 at 2:45 AM, PCT M documented that Patient #1 was asleep.
l. On 10/2/22 at 3:00 AM, PCT M documented that Patient #1 was asleep.
m. On 10/2/22 at 3:15 AM, PCT M documented that Patient #1 was asleep.
n. On 10/2/22 at 3:17 AM, RN J documented a verbal order from DO T for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for almost three hours.
o. n 10/2/22 at 3:30 AM, PCT M documented that Patient #1 was asleep.
p. On 10/2/22 at 3:45 AM, PCT M documented that Patient #1 was asleep.
q. On 10/2/22 at 4:00 AM, PCT M documented that Patient #1 was asleep.
r. On 10/2/22 at 4:09 AM, RN J documented that Patient #1 was asleep.
s. On 10/2/22 at 4:15 AM, PCT M documented Patient #1 was asleep.
t. On 10/2/22 at 4:30 AM, PCT M documented that Patient #1 was asleep.
u. On 10/2/22 at 4:45 AM, PCT M documented that Patient #1 was asleep.
v. On 10/2/22 at 5:00 AM, PCT M documented that Patient #1 was asleep.
w. On 10/2/22 at 5:17 AM, RN J discontinued Patient #1's seclusion. Patient #1 spent over 5 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

9. Review of Patient #1's medical record from 10/2/22 revealed:

a. On 10/2/22 at 10:15 PM, RN V documented that Patient #1 was asleep while in seclusion.
b. On 10/2/22 at 10:30 PM, RN V documented that Patient #1 was asleep.
c. On 10/2/22 at 10:45 PM, RN V documented that Patient #1 was asleep.
d. On 10/2/22 at 10:00 PM, RN V documented that Patient #1 was asleep.
e. On 10/2/22 at 11:15 PM, PCT M documented that Patient #1 was asleep.
f. On 10/2/22 at 11:30 PM, PCT M documented that Patient #1 was calm.
g. On 10/2/22 at 11:45 PM, PCT M documented that Patient #1 was calm.
h. On 10/3/22 at 12:00 AM, PCT M documented that Patient #1 was calm.
j. On 10/3/22 at 12:15 AM, PCT M documented that Patient #1 was calm.
k. On 10/322 at 12:30 AM, PCT M documented that Patient #1 was calm.
l. On 10/3/22 at 12:45 AM, PCT M documented that Patient #1 was asleep.
m. On 10/3/22 at 12:57 AM, RN J documented a verbal order from ARNP U for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for approximately 90 minutes.
n. On 10/3/22 at 1:00 AM, PCT M documented that Patient #1 was calm, asleep.
o. On 10/3/22 at 1:15 AM, PCT M documented that Patient #1 was asleep.
p. On 10/3/22 at 1:30 AM, PCT M documented that Patient #1 was asleep.
q. On 10/3/22 at 1:45 AM, PCT M documented that Patient #1 was asleep.
r. On 10/3/22 at 2:00 AM, PCT M documented that Patient #1 was asleep.
s. On 10/3/22 at 2:15 AM, PCT M documented that Patient #1 was asleep.
t. On 10/3/22 at 2:30 AM, PCT M documented that Patient #1 was asleep.
u. On 10/3/22 at 2:45 AM, PCT M documented that Patient #1 was asleep.
v. On 10/3/22 at 3:00 AM, PCT M documented that Patient #1 was asleep.
w. On 10/3/22 at 3:15 AM, PCT M documented that Patient #1 was calm.
x. On 10/3/22 at 3:30 AM, PCT M documented that Patient #1 was asleep.
y. On 10/3/22 at 3:45 AM, PCT M documented that Patient #1 was asleep.
z. On 10/3/22 at 4:00 AM, PCT M documented that Patient #1 was asleep.
aa. On 10/3/22 at 4:15 AM, PCT M documented that Patient #1 was asleep.
bb. On 10/3/22 at 4:30 AM, PCT M documented that Patient #1 was asleep.
cc. On 10/3/22 at 4:45 AM, PCT M document that Patient #1 was asleep.
dd. On 10/3/22 at 5:00 AM, RN J documented a verbal order from ARNP U for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep or calm for the last four hours.
ee. On 10/3/22 at 5:00 AM, RN J documented that Patient #1 was asleep.
ff. On 10/3/22 at 5:15 AM, PCT M documented that Patient #1 was asleep.
gg. On 10/3/22 at 5:30 AM, PCT M documented that Patient #1 was asleep.
hh. On 10/3/22 at 5:45 AM, PCT M documented that Patient #1 was asleep.
ii. 10/3/22 at 6:00 AM, PCT M documented that Patient #1 was asleep.
jj. 10/3/22 at 6:15 AM, PCT M documented that Patient #1 was asleep.
kk. 10/3/22 at 6:30 AM, PCT M documented that Patient #1 was asleep.
ll. 10/3/22 at 6:45 AM, PCT M documented that Patient #1 was calm.
mm. 10/3/22 at 6:55 AM, PCT M documented that Patient #1 was calm.
nn. On 10/3/22 at 7:00 AM, PCT M documented that Patient #1 was calm and seclusion was discontinued. Patient #1 spent approximately nine hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

10. During an interview on 10/10/22 at 4:45 PM, RN J acknowledged that they should have taken Patient #1 out of seclusion when they were sleeping. RN J confessed that sometimes evening shift would tell RN J to keep Patient #1 in seclusion because you just didn't know what Patient #1 was going to do, and stated other night nurses had done that too.

11. During an interview on 10/11/22 at 1:45 PM, RN A thought getting ongoing seclusion orders for Patient #1 had been kind of a gray area and they weren't always following the appropriate process because Patient #1 was secluded so often.

12. During an interview on 10/17/22 at 9:15 AM, Medical Director Q stated that the recent review of Patient #1 had helped them understand that the Behavioral Health Unit medical staff did not have a consistent practice, and providers were not always hearing about each and every seclusion episode, the details of what was happening to justify why Patient #1 would need seclusion, and questioning the RN before any order was authorized.

Medical Director Q was clear they were not defending the practice but believed the length of Patient #1's hospitalization had made them a bit numb about their seclusion and the staff got sloppy in their practice. Medical Director Q said this situation was an anomaly and was not how they practice.

Based on document review and staff interviews the acute care hospital's (ACH) staff failed to follow the ACH's policy and only seclude 1 of 5 patients reviewed (Patient #1) for violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others. Failure to only seclude patients for violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others resulted in Patient #1 being in seclusion for long periods of time without documented violent or self-destructive behavior that would warrant continued seclusion, which may have resulted in adverse physical or psychological consequences for Patient #1. The hospital identified and average daily census of 527 and an average daily census of 46 in Behavioral Health units.

Findings include:

1. Review of policy, "Restraint and Seclusion Use", revealed in part, Seclusion is defined as..."The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others."

2. During an interview on 10/6/22 at 11:00 AM, Medical Director Q explained that Patient #1 had been stabbed and was without oxygen for a significant period of time prior to resuscitation which left Patient #1 with a permanent major neuro-cognitive (lacking intellectual activity such as thinking, reasoning, or remembering) disorder. Patient #1 was incredibly impulsive, had difficulty engaging with people, had brief periods where they were playful like an infant but that was the extent of any positive social interaction with people. When Patient #1 was not doing well, they were unable to interact with people without attempting to harm them so they were frequently secluded. Medical Director Q acknowledged that they should not keep anyone who was sleeping was not a threat to self or others and should not be kept behind a locked door (secluded). Medical Director Q relayed that if they had been called for an order to continue seclusion and were told that Patient #1 was sleeping they would tell the RN they should unlock the door, but if staff had attempted to unlock the door and every time Patient #1 woke up they rushed staff then that would be different.

Based on document review and staff interviews the hospital's administrative staff failed to follow and document less restrictive interventions tried to avoid seclusion for 1 of 5 patients reviewed (Patient #1). Failure to document any less restrictive interventions tried to avoid seclusion resulted in Patient #1 being secluded for long periods of time which may have resulted in adverse physical or psychological consequences for Patient #1. The hospital identified and average daily census of 527 and an average daily census of 46 in Behavioral Health units.

Findings include:

1. Review of policy, "Restraint and Seclusion Use", revealed in part, "...Documentation related to each episode of...seclusion will focus on the patient and will include...consideration or failure of non-physical intervention..."

2. Review of Patient #1's medical record revealed:

On 9/22/22 at 10:41 PM, RN A documented a verbal order from DO I to continue seclusion even though it was documented that Patient #1 had been calm or asleep for over 90 minutes.

On 9/23/22 at 10:24 PM, RN W documented a verbal order from DO I for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm for approximately 90 minutes.

On 9/25/22 at 10:30 PM, RN X documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for 45 minutes.

On 9/26/22 at 4:27 AM, RN X documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm or asleep the past 4 hours.

On 10/1/22 at 12:47 AM, RN Z documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm or asleep for over 2 hours.

On 10/2/22 at 3:17 AM, RN J documented a verbal order from DO T for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for almost 3 hours.

On 10/3/22 at 1:00 AM, RN J documented a verbal order from ARNP U for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for approximately 90 minutes.

3. During an interview on 10/10/22 at 9:00 AM, DO T revealed that they usually get a secure text in the middle of the night saying why Patient #1 needed an order to remain in seclusion. DO T stated there would be no reason to order continued selusion if Patient #1 was sleeping.

4. During an interview on 10/17/22 at 9:00 AM, ARNP U confirmed that it would not be appropriate to authorize seclusion for any patients who were calm or sleeping. ARNP U was being told that Patient #1 was being threatening or some other similar reason. If Patient #1 was asleep, there would be no reason to continue seclusion and ARNP U would not give that order.

5. During an interview on 10/10/22 at 4:45 PM, RN J acknowledged Patient #1 should have been removed from seclusion when they were sleeping but unlocking their door might wake them up and Patient #1 was very unpredictable. Sometimes the evening shift RN would say to keep Patient #1 in seclusion because you didn't know what he was going to do.

6. During an interview on 10/10/22 at 1:30 PM, RN A explained that if Patient #1 was pretty quick to get up and get out of their room if they would wake up due to noise. If Patient #1 was calm and cooperative or if they were sleeping they would end the seclusion and would just keep an eye on Patient #1 to make sure he was not waking up and causing an altercation.

Based on document review and staff interviews the hospital's administrative staff failed to follow their policy and discontinue seclusion at the earliest possible time for 1 of 5 patients reviewed (Patient #1). Failure to discontinue seclusion at the earliest possible time resulted in Patient #1 being in seclusion for long periods of time without documented clinical reasons to continue seclusion, which may have resulted in adverse physical or psychological consequences for Patient #1. The hospital identified and average daily census of 527 and an average daily census of 46 in Behavioral Health units.

Findings include:

1. Review of Patient #1's medical record from 9/22/22 revealed:

On 9/23/22 at 1:01 AM, RN A discontinued Patient #1's. Patient #1 spent almost 4 hours in seclusion without documentation of behavior that would necessitate ongoing seclusion.

On 9/24/22 at 2:03 PM, RN N discontinued Patient #1's seclusion. Patient #1 spent approximately 3.5 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

on 9/25/22 at 10:15 PM, RN P discontinued Patient #1's seclusion. Patient #1 spent over 2 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

On 9/26/22 at 6:45 AM, RN Y discontinued Patient #1's seclusion. Patient #1 spent approximately nine hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

On 10/1/22 at 2:32 AM, RN Z discontinued Patient #1's seclusion. Patient #1 spent over 4 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

On 10/1/22 at 12:00 PM, Safety Tech L documented that Patient #1 was calm and seclusion was discontinued. Patient #1 spent approximately 1.5 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

On 10/2/22 at 5:17 AM, RN J discontinued Patient #1 seclusion. Patient #1 spent over 5 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

On 10/3/22 at 7:00 AM, PCT M documented that Patient #1 was calm and seclusion was discontinued. Patient #1 spent approximately 9 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

2. During an interview on 10/10/22 at 8:45 AM, PCT M confirmed that when Patient #1 was secluded they monitored them continuously via camera and then documented rounds every 15 minutes. PCT M confirmed that if Patient #1's eyes were closed they would consider that sleeping.

3. During an interview on 10/10/22 at 1:00 PM, PCT S also confirmed monitoring process during seclusion and stated they would report anything unusual to the RN, including that Patient #1 was sleeping. PCT S denied concerns related to Patient #1's seclusion, stated Patient #1 was in seclusion for a reason whether that be staff or patient safety. PCT S stated thought it was difficult to have a clear answer, was not their call to make.

4. During an interview on 10/10/22 at 2:30 PM, Safety Tech L reviewed monitoring process for a patient in seclusion and confirmed documentation of Patient #1's activities every 15 minutes. Safety Tech L said they were in constant contact with an RN who are also in the same nurse's station with them all times. Safety Tech L did not recall times when they would document Patient #1 was sleeping for a long period of time because when Patient #1 was sleeping they would unlock the seclusion door.

5. During an interview on 10/10/22 at 2:45 PM, LPN R explained monitoring process and acknowledged Patient #1 was violent sometimes but there were also times when they were in seclusion when asleep. LPN R stated the RN's were in the same nurse's station with them and were aware of the situation.

6. During an interview on 10/10/22 at 4:45 PM, RN J acknowledged that they should have taken Patient #1 out of seclusion when they were sleeping. RN J confessed that sometimes evening shift would tell RN J to keep Patient #1 in seclusion because you just didn't know what Patient #1 was going to do, and stated other night nurses had done that too.

7. During an interview on 10/10/22 at 3:00 PM, RN V stated that sometimes it was charted that Patient #1 was calm but they were always confused, and could be calm one moment and then pacing, taking their clothes off the next. RN V shared that they had been educated that Patient #1 should not be in seclusion when they were sleeping.

8. During an interview on 10/6/22 at 11:00 AM, Medical Director Q acknowledged that they should not put anyone who was sleeping behind a locked door (secluded). Medical Director Q relayed that if they had been called for an order to continue seclusion and were told that Patient #1 was sleeping they would tell the RN they should unlock the door, but if staff had attempted to unlock the door and every time Patient #1 woke up they rushed staff then that would be a different situation.

9. During an interview on 10/10/22 at 9:00 AM, DO T confirmed that if Patient #1 was sleeping there would be no reason to continue seclusion and they would not give the order.

10. During an interview on 10/10/22 at 8:30 AM, ARNP U explained that they would get a secure message telling them what was going on with Patient #1 and why they needed seclusion. ARNP U would call the RN back to get any needed information and then would authorize the order. ARNP U said RNs did not convey that Patient #1 was sleeping. ARNP U confirmed that it would not be appropriate to to authorize seclusion for any patient who was calm or sleeping.

Based on document review and staff interview, the acute care hospital's (ACH) administrative staff failed to follow the ACH's policy and ensure a face to face assessment was completed prior to continuing seclusion for 1 of 5 patients reviewed (Patient #1). Failure to perform a face to face assessment resulted in Patient #1 remaining in seclusion without documentation of the medical and behavioral conditions that would justify the need for ongoing seclusion which may have resulted in adverse physical or psychological consequences for Patient #1. The hospital identified and average daily census of 527 and an average daily census of 46 in Behavioral Health units.

Findings include:

1. Review of policy, "Restraint and Seclusion Use", revealed in part "...Documentation related to each episode of ...seclusion will focus on the patient and will include...the one-hour, face-to-face medical and behavioral evaluation by the...trained RN.

2. Review of Patient #1's medical record revealed:

On 10/2/22 at 3:17 AM, RN J documented they received a verbal order from DO T to continue Patient #1's seclusion. RN J failed to document a face to face medical and behavioral examination justifying the need for ongoing seclusion prior to documenting a verbal order to continue seclusion.

Patient #1 remained in seclusion while asleep from 10/2/22 at 12:00 AM to 10/2/22 at 5:17 AM when RN J discontinued Patient #1's seclusion.

On 10/3/22 at 12:57 AM, RN J documented a verbal order from ARNP U to continue Patient #1's seclusion. RN J failed to document a face to face medical and behavioral examination justifying the need for ongoing seclusion prior to documenting a verbal order to continue seclusion.

Patient #1 remained in seclusion while asleep or calm from 10/2/22 at 10:15 PM to 10/3/22 at 7:00 AM when Patient #1's seclusion was discontinued.

3. During an interview on 10/10/22 at 4:45 PM, RN J explained they did not do a face to face because they were taught that they could just renew a seclusion order in the middle of the night for Patient #1 without calling a provider. RN J couldn't recall who told them that or what other RNs were also engaging in this practice. RN J again verified that they were documenting they obtained a verbal order for seclusion when they were not actually contacting the provider, not providing a face to face updated assessment (including the need for continued seclusion), and not getting a verbal order from a physician or ARNP.

Based on document review and staff interview, the acute care hospital's (ACH) staff failed to:

1. Ensure RNs followed hospital policy regarding receving and documenting verbal orders from providers. The RNs failed to follow hospital policy and documented in the medical record, they obtained a verbal order from a provider (Physicians or Advanced Registered Nurse Practitioners -- ARNP) without speaking to the provider. Please see A-407

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure all patients received safe and appropriate nursing care.

Based on document review and staff interview, the acute care hospital's (ACH) staff failed to follow the ACH's policy regarding verbal orders for 1 of 5 patients (Patient #1). Failure to follow ACH's policy resulted in Patient #1 remaining in seclusion after RNs documented that they had obtained a verbal order to continue seclusion from a provider (Physician or Advanced Registered Nurse Practitioner -- ARNP) without speaking to the provider. The hospital identified an average daily census of 527 and an average daily census of 46 in the Behavioral Health units.

Findings include:

1. Review of policy, "Acceptance of Physician Orders", dated 12/2021, revealed in part: RNs "...are licensed...within their profession, or within their scope of practice...to accept [verbal orders]...The staff person accepting the verbal order should document the order and read it back to the practitioner...[who] should verbally confirm that the order is correct..."

2. Review of Patient #1's medical record revealed:

On 9/22/22 at 10:41 PM, RN A documented a verbal order from DO I to continue seclusion even though it was documented that Patient #1 had been calm or asleep for over 90 minutes.

On 9/23/22 at 1:01 AM, RN A discontinued Patient #1 seclusion. Patient #1 spent almost 4 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

On 9/24/22 at 2:03 AM, RN N discontinued Patient #1's seclusion. Patient #1 spent approximately 3.5 hours in seclusion without documentation of any behavior that would necessitate ongoing seclusion.

On 9/25/22 at 10:30 PM, RN X documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for 45 minutes.

On 9/26/22 at 2:15 AM, RN X documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm or asleep the last four hours.

On 10/1/22 at 12:47 AM, RN Z documented a verbal order from Medical Director Q for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been calm or asleep for over 2 hours.

On 10/2/22 at 3:17 AM, RN J documented a verbal order from DO T for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for almost 3 hours.

On 10/3/22 at 1:00 AM, RN J documented a verbal order from ARNP U for Patient #1 to remain in seclusion even though it was documented that Patient #1 had been asleep for approximately 90 minutes.

3. During an interview on 10/10/22 at 4:45 PM, RN J revealed that they were told by other staff that they could just renew a seclusion order in the middle of the night for Patient #1 without calling a provider. RN J revealed that other RN's did the same thing but could not recall who told them to do that, or what other RN's were also engaging in this practice. RN J explained they had taken care of Patient #1 a few times and verified that they had documented that they had obtained a verbal order to continue seclusion for Patient #1 without actually obtaining that order from a provider.

4. During an interview on 10/10/22 at 5:00 PM, RN Z also revealed they were told that they did not need to call a provider to get an order to continue seclusion at night for Patient #1 because the medical team was already aware of Patient #1 and their need for frequent seclusion. RN Z recalled taking care of Patient #1 twice, said they put in a significant note, and a verbal order for seclusion, but they were not actually calling the provider for the seclusion order. RN Z stated that they don't often work in the unit where Patient #1 resides, thought it would be difficult to name the person(s) who told them this information.

5. During an interview on 10/20/22 at 9:00 AM, RN P recalled a time when they were being told by the previous shift that there was no need to contact a provider to continue seclusion for Patient #1 during the night. RN P could not recall any further details.

6. During an interview on 10/11/22 at 1:45 PM, RN A thought getting ongoing seclusion orders for Patient #1 had been kind of a gray area and they weren't always following the appropriate process because Patient #1 was secluded so often.

7. During an interview on 10/20/22 at 12:20 PM, RN AA stated that RN's had been documenting verbal orders for seclusion for Patient #1 without actually talking to the provider. Recalled it was quite a long time ago when an evening RN told RN AA that Medical Director Q trusted the nurses so they should just renew the order for Patient #1 when needed. RN AA could not recall the RN, and offered that it was hearsay that Medical Director Q actually told the RN to do that.

8. During an interview on 10/20/22 at 4:30 PM, RN Y confirmed that they had never obtained a verbal order for restraint and seclusion without talking to a provider and actually receiving the order, but they did know that it had been an issue where physicians had said they didn't need to be contacted every single time Patient #1 was secluded. RN Y stated it was not the norm but that practice had happened with Patient #1.

9. During an interview on 10/17/22 at 9:15 AM, Medical Director Q shared that it may have happened that a nurse wrote an order to continue seclusion for Patient #1 without actually speaking to a provider.