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Based on observation of the behavioral health unit (BHU) and record reviews on March 8, 2017, it was determined that hospital was out of compliance with the condition of Patient Rights. The two patients on the BHU who were restrained and/or secluded in November 2016 and January 2017 were kept in seclusion/restraint based on unordered understandings between the psychiatrists and the nurses that the patients would stay in seclusion all night. These decisions were apparently made based on historic behavior and prior to concurrent observations of violent, destructive, or self-injurious behavior. In addition, one patient (#2) was kept in the seclusion area with the doors open, allowing patient #2 to run around the unit at least five times trying to self-injure. Each of these episodes led to patient #2 being placed in restraints and seclusion.

See A167

The hospital also failed to institute a QAPI process robust enough to capture care issues surrounding the use of restraints and seclusion. The concurrent documentation review for patient #2 did not identify a gap in physician orders for seclusion of eight hours; nor did it capture inconsistencies related to the timing of the earliest possible release of restraints and whether patient #2 was in seclusion with the doors locked or open. The hospital-wide QAPI committee reviews restraints and seclusion for violent behavior annually.

See Tag A-283

Based on a review on March 8, 2017 of the medical records of two patients secluded on the behavioral health unit (BHU), it was determined that both patients had notes indicating that they were to stay in seclusion overnight. These decisions had been made prior to concurrent assessments of violent and self-destructive behavior. In addition, one of the two patients (#2) had been kept in the seclusion area with the doors open, allowing the patient to run around the unit while trying to self-injure.

Patient no. 1 was placed in seclusion at approximately 2145 on an evening in November 2016. Patient #1 had been exhibiting violent, resistant, and destructive behaviors. Notes indicate the patient was refusing medications, throwing water on the floor, and tried to overflow a sink in another patient's bathroom. Within 40 minutes of being placed in seclusion, the nursing documentation indicated the patient was "fidgety, restless; flipped mattress over and sitting on the floor." When the physician came to perform the face-to-face assessment after 50 minutes in seclusion, the nurse noted, under the "reason to continue seclusion," that patient #1 was "unable to engage in meaningful discussion of what is happening (reason for seclusion, behaviors exhibited)" and that "Dr. ___ concurs with seclusion room for tonight." Even though patient #1 was not exhibiting violent behavior at the time of the face to face evaluation, the order was written to continue seclusion and the nursing documentation indicated the intention to keep patient #1 in seclusion all night.

After about five hours in seclusion the doors were opened and the patient was allowed to continue sleeping.

The seclusion area on the BHU consists of two lockable seclusion rooms with an outer area containing a bathroom. The entire suite is then separated from the general milieu with another lockable door.

Patient #2 was admitted in January with thoughts of suicide and self-harming behavior. Shortly after admission, patient #2 was found by a mental health counselor attempting to hang self. Patient #2 was placed in the seclusion area, apparently with the doors open as the documentation indicated that patient #2 almost immediately ran from the room and jumped on the desk of the nurses station, yelling and threatening self-harm. Patient #2 was then taken back to the seclusion area at 1948 and placed in restraints on each limb (4-point).

For the next eight hours, patient #2 was on a 1:1 with a RN posted at the door to the seclusion room. Documentation indicated that patient #2 continued to verbalize intent to self-harm and was trying to hit head on the bed rail and bite self. By 0320, the RN noted that the patient was sleeping but struggling against the restraints.

The restraints were removed at 0745 but the patient remained in the seclusion area, apparently with the doors open. Documentation from the nurse at 0922, 1326, and 1450 indicated that the patient remained in the seclusion room with 1:1, arms-length, observation. The seclusion order was renewed at 1300.

Then at 1450, nursing documentation stated that the patient again ran out of the seclusion suite and pulled the fire alarm in the nurse's station. Patient #2 was documented as bouncing on a bed and struggling with staff and was again placed in 4-point restraints with 1:1 observation in the seclusion room.

The documentation was unclear as to the time, but at some point, patient #2 was taken out of restraints and kept in the seclusion area with the doors open and 1:1 observation. At 1944 the documentation indicated that patient #2 ran out into the hall and went into the kitchen area, where patient #2 started trying to eat a plastic cup. Patient #2 was documented as head-banging on a window and scratching and swinging at staff. A new order for 4-point restraints was entered by the physician.

Nursing documentation at 2004 stated that the patient continues to scream "I just want to kill myself." Documentation entered at 2207 stated "will continue on restraints until sure patient is asleep. Per MD request will keep in locked seclusion d/t [due to] imminent risk to self and staff."

The seclusion order was renewed by the physician at 2342 and noted that the patient was not restrained at that time.

Nursing documentation at 0004 stated that "Dr. states to either be in seclusion or restraints all night d/t pt. tried to harm self several times since arrival." This statement was repeated every 30 minutes to one hour until 0911.

At 0911, the nurse documented that the patient was "unpredictable to harm self when awakens" [sic] but was apparently in the seclusion area with the doors open because the note written at 1104 stated "patient willing to stay in seclusion."

At 1145, patient #2 again ran out of the seclusion area and was noted to be pushing staff, threatening staff, jumping, and banging head. 4-point restraints were again applied in the seclusion room with a new order and were removed at 1455.

The seclusion orders were renewed at 1457, 1847, and 2250 on that day and 0250, 0654, 1016, and 1330 the following day. Documentation from the nurse stated that at 0145 the patient was at the hallway door "very loud, hyperverbal and not following instructions" and again ran around the hallway and was very unpredictable. Patient #2 was placed back in seclusion.

Later that morning, at 0950, patient #2 was placed back in 4-point restraints in seclusion after throwing a bedpan at the nurse. The restraint order was discontinued at 1330 but at 1342, an order was written to transfer the patient in 4-point restraints. At the same time, the every-15 minute checks document that the patient is in the dayroom watching TV, or walking in the halls. Patient #2 went to a group and had dinner. Patient #2 was transferred to an involuntary unit at 1725 for further care.

The documentation consistently indicated that patient #2 was unpredictable and intent on self-harming. Failure to properly seclude patient #2 meant that patient #2 had numerous opportunities to harm self or others. Failure to properly seclude patient #2 also led to episodes where four-point restraints had to be applied due to violent and self-harming behavior.

Based on a review of QAPI data on March 8, 2017, it was determined that the hospital's QAPI committee reviews and reports out on the use of restraints for violent behavior once a year. The Behavioral Health Unit (BHU) staff confirmed, in an interview on March 8, that they perform a concurrent review of documentation for each episode of restraints or seclusion used for violent behavior, but these reviews did not catch obvious deficient documentation and care issues with patients #1 and #2. Restraint and seclusion use is a high-risk procedure with patient rights and safety implications and failure to review associated factors more frequently than once a year may lead to missed opportunities for improvement.