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Based on record review and interview, the hospital failed to ensure the use of restraints, was the least restrictive restraint intervention for 4 Patients (#7, #8, #9 and #22) out of a total sample of 30 patients. Findings include:

Review of the Hospital's policy and procedure for Mechanical Restraints, Seclusion, Physical Restraint, Medication Restraint on an Adult Inpatient Unit, dated and last revised on 10/15/15, indicated the following:

The Hospital's indicated the purpose of the policy was to provide guidance to staff regarding the appropriate use of restraints and the Hospital's commitment to the prevention and minimal use of restraints.

The Hospital's definition of a behavioral restraint included medication restraint, mechanical restraint and physical restraint. Restraint means bodily physical restriction, mechanical devices, or medication that unreasonably limits freedom of movement.

The policy indicated that medication restraints occur when an individual is given medication involuntarily for the purpose of restraining the individual; and a medication restraint can only be ordered by a physician who is present at the time and has examined the patient. The policy indicated that it was prohibited for staff to administer a medication restraint without the physician on-site.

The policy indicated a commitment to the prevention and minimal use of restraints as a facility, but does not provide specific policy to what constitutes least restrictive uses of restraints and least amount of time in restraints.

During interview on 5/9/18 at 11:30 A. M, the Director of Nurses and Compliance Officer said their understanding of chemical restraints required the refusal by the patient to take the medications. They said that if a Patient voluntarily accepted medications ordered to chemically restrain them it was not restraint. The Compliance Officer confirmed that this was included in their education with staff and followed as a standard.

1. For Patient #7, the Hospital staff failed to use least restrictive restraint intervention when restraints were required and instead used both physical and chemical restraints together.

Patient #7 was admitted to the hospital in 5/2018 and had diagnoses that included depression, anxiety and mood disorder.

Review of the clinical record indicated the Patient was a new admission and her behaviors included unprovoked assault towards others, had poor insight judgement and poor impulse control.

The plan included monitoring and assess patient's mental status and monitor for safety

Review of the nursing notes of 5/5/18, indicated throughout the day the Patient had been pacing and exhibited agitation. The notes indicated that the Patient's agitation increased when staff attempted to redirect or when they were unable to meet her needs. The notes indicated by 6:00 P.M., the Patient was asked to go to her room for quiet time. The Patient responded by throwing a water bottle at the Staff.

The nursing note indicated on 5/5/18 at 6:00 P.M., a physician written order was obtained to initiate a physical restraints, 4 point mechanical restraint (leather restraints applied to both wrists and ankles) and a medication restraint.

The medication order included Haldol (an antipsychotic) 5 mg, IM (intramuscular), Benadryl (an anti-histamine which causes sleepiness) 50 mg, IM, and Ativan (benzodiazepine/anti-anxiety) 2 mg, IM.

The Patient was placed in the restraints and immediately administered the chemical restraints.

The nursing documentation indicated from 5/5/18 - 5/8/18 at 1:00 P.M., the Patient continued to exhibit agitation and was impulsive. The Patient refused treatment including medication ordered as needed for agitation and redirection. The nursing progress notes indicated the Patient was frustrated and indicated she felt unsafe. The only plan remained monitoring and redirection (which had been ineffective).

On 5/8/18 at 1:00 A.M., the nurse documented Patient #7 became agitated and verbally abusive towards staff while attempting to get the keys from the nurses station to leave. The note indicated the Patient grabbed the phone from nurse and threw the phone. The nurse indicated she contacted the doctor for a telephone order for a physical and chemical restraint. The rationale for the multiple restraint use was the Patient was agitated, loud, talking about leaving and threw the phone. The note indicated the Patient was unable to follow redirections.

The note indicated the Patient was held physically for 5 minutes and released after the Staff administered the IM medications that included Haldol, Benadryl and Ativan.

The least restrictive restraint would have been to initiate only the physical restraints ( 4 point restraint) first and evaluate to see if this calmed the patient first before intervening with chemical restraints (medications) which remain in the body and cannot be removed as a physical restraint can. Chemical restraints can produce undesired side effects and cannot be recalled once administered.

2. For Patient #8, the Hospital staff failed to use least restrictive restraint intervention when restraints were required instead used both physical and chemical restraints together.

Patient #8 was admitted to the hospital in 12/2017 and had diagnoses that included bipolar, personality disorder and cannibis dependency.

Review of the medical record indicated the staff used medication and/or physical restraints to treat the Patient's behavior on 7 occasions without trying the use of less restrictive interventions. The Patient was restrained on 12/14/17, 12/17/17, 12/22/17, 12/23/17, 12/25/17, 12/31/17 and 3/1/18.

According to the clinical record the Patient admitted for psychiatric treatment following a criminal event. The Patient was identified to have delusional thoughts, mood labile, hypersexual behavior, loud and pressured speech, lack of insight and aggressive behaviors towards others.

Prior to the initial completion of his formal treatment plan, the Patient was restrained on 12/14/18 at 4:00 P.M. The nursing note summarized the Patient's day and identified behaviors including wandering, bizarre behavior and conversation, hypersexual behaviors towards a specific female patient and aggression.

The notes indicated the Patient was monitored for safety and maintained on the routine 15 minute safety checks. The Staff did not identify other interventions.

During an incident with the female Patient that Patient #8 was focused on and was exhibiting sexual and protective behaviors towards, Patient #8 became agitated when staff had an altercation with this patient. During the incident the Staff were unable to de-escalate the incident and restrained Patient #8 to prevent his/her becoming involved in the incident. The progress notes indicated the Patient (#8) was agitated, combative and threatened to assault the staff while trying to help the other patient.

During the incident the Hospital Staff called for additional staff for a what was identified as a "show of support." The show of support included the unit staff, a doctor, the nurse coordinator and the campus security to assist in de-escalation of behaviors.

The documentation was not clear if the extra staff was called because of Patient #8's behaviors or the whole event. The nursing note indicated Patient #8 was offered oral medications (Haldol, Ativan and Benadryl). The Patient refused the medication and was subsequently placed in a physical hold, brought to a quiet room, placed in 4 point mechanical restraints and given IM Haldol, Ativan and Benadryl.

The Patient remained in the restraints for 1 hour and documentation indicated that the Patient refused any assessments and was agitated for the hour.

Review of the nursing progress notes and restraint event notes dated 12/17/17 at 4:00 P.M., included a summary of the day which indicated Patient #8 had been agitated, (he/she) had informed the Staff he/she had not been sleeping well and wanted to leave the Hospital. The Patient was offered oral medication (Haldol, Ativan and Benadryl) and refused. The Staff indicated they provided education, 15 safety checks and monitoring for support. The note indicated that the Patient was watching television and threw a chair at another patient.

The physician was called and ordered the patient be restrained for threatening to assault a staff. The Patient was placed in a physical hold, then placed in 5 point mechanical restraint and administered the 3 IM medications. The documentation indicated the Patient refused staff assessment and was in full restraints including the 5 point restraints for 1 hour and 45 minutes (when he became calm).

The nursing note dated 12/20/17, indicated the Patient had remained agitated, continued in pursuing another patient and making sexual comments to the other patient (a behavior identified with the other patient since 12/14/17). The nursing note indicated Patient #8 threatened to choke the other patient. The intervention was to call the physician for an order to administer an additional dose of (telephone order) of 100 mg of Benadryl, (oral) to treat the agitation. The nursing staff administered both the 1 time order of Benadryl and the PRN/as needed dose of Benadryl 100 mg at 8:00 P.M., which totaled 200 mg of medication.

The clinical record indicated the Patient's behavior was treated with sedating medication.

Review of the nursing progress and restraint notes, the Hospital Staff used medications, physical holds and mechanical restraints to treat the Patient's behavior on 12/22/17 and 12/23/17.

The clinical record indicated on 12/22/17 at 5:00 P.M., the Patient was agitated and displaying verbal aggression and inappropriate sexual behaviors. The staff called the physician and he ordered a one time dose of Haldol 10 mg, Benadryl 100 mg and Ativan 2 mg by mouth (PO).

The clinical record indicated on 12/22/17 at 9:30 P.M., the physician ordered the Patient be placed in 5 point mechanical restraint and to give IM medications included IM Haldol 10 mg, Ativan 2 mg and Benadryl 100 mg.

The Patient was displaying violent destructive behavior towards others and staff were not able to de-escalate the Patient to place him in the 5 point physical restraints and to give the medication. The Staff called for a show of support and this increased the Patient's aggression and he took out a toothbrush and threatened to stab staff with it. The Hospital staff contacted law enforcement to assist and the presence of law enforcement increased the Patient's agitation. The documentation was not clear, but in order to apply the restraints, the law enforcement official subdued the Patient with a tazer.

The physician assessed the Patient after ordering the physical and medication restraints at 11:45 A.M. on 12/22/17, not prior to the orders for multiple restraints including medication.

According to the clinical record the Patient was placed in 5 point restraints and administered the IM medications at 12:45 A.M. on 12/23/17. The documentation indicated the Patient was in 5 point restraints until 2:00 A.M., after refusing interventions and assessments.

The nursing progress notes dated 12/23/17 at 1:00 P.M. indicated that the Patient had interrupted a group activity and attempted to block the door. The Patient was offered oral medication (telephone orders) to treat his behavior and after refusing was given IM medications (Haldol, Ativan and Benadryl) and placed in 4 point restraints.

The Patient remained in 4 point restraints until 5:00 P.M. for agitation and threatening behavior. A renewal order was obtained at 3:00 P.M. to continue to use of 4 point restraints.

The physician did not assess the Patient until 4:30 P.M., after the Patient was given the medications.

Review of the nursing noted on 12/25/17 at 1:30 P.M., Patient #8 was involved in an patient to patient altercation. The staff called a "show of support" and offered oral medications. The Patient was observed pocketing the medications and spitting them out. The telephone order was changed from oral to IM and the Patient was administered IM Haldol 10 mg, Ativan 2 mg and Benadryl 100 mg, one time dose. The order did not include the medication as a restraint and the physician did not assess the Patient prior to the medication being given.

Review of the 12/29/17 treatment plan indicated that during the Staff's review, they had identified that the Patient required "at least 5 physical/medication restraints" since his admission. The incidents are outlined and and indicated that the Patient required the restraints. There is no evidence the least restrictive type of restraints were used.

Review of the nursing progress notes and restraint note dated 12/31/17 at 10:50 A.M., indicated the Patient had an altercation with another patient, made verbal threats that included threatening to pull the television off the wall. The staff obtained a telephone order to restrain the Patient by applying a physical restraint and giving medication.

During the physical hold and while giving the medications, the Patient sustained a laceration on his/her left eye lid. The Patient was administered Haldol 10 mg, Ativan 2 mg and Benadryl 100 mg orally and released after 2 minutes from the hold.

The physician's assessment the Patient on 12/23/17 at 11:45 A.M., after having ordered the restraints, the physician assessed the Patient's injury.

Review of the nursing progress notes dated 3/1/18 at 10:15 A.M. indicated the Patient had a verbal altercation with another patient. The Patient hit the other patient with chair. The interventions and treatment consisted of placing the Patient in 4 point restraints and administered medication restraints (IM Haldol, Ativan and Benadryl). The Patient remained in 4 point restraints for 1 hour and 45 minutes. The documentation indicated the Patient remained agitated for the time period restrained.

The least restrictive restraint could have been to initiate only the physical restraints (4 point restraint) first and evaluate to see if this calmed the patient first before intervening with chemical restraints (medications) which remain in the body and cannot be removed as a physical restraint can. Chemical restraints can produce undesired side effects and cannot be recalled once administered.

During interview with Unit Manager (Nurse #2) on 5/8/18 at 1:00 P.M. she that that the administration of the medications and/or combinations of drugs (Haldol, Ativan and Benadryl) was not a chemical or a medical restraint if the patient took the medication voluntarily.

3. Patient #9 was admitted in 4/2018 with diagnoses that included anxiety, schizoaffective disorder and substance abuse.

Review of the medical record indicated the Patient had a long psychiatric history and he had poor insight into his illness. The Patient had problems with anger, was delusional and has been incarcerated and maintained mostly in solitary confinement for the past year.

The progress notes from 4/24/18 - 4/28/18 indicated the Patient was accepting prescribed medications as ordered and was monitored for safety. The Patient was found with smoking contraband on 4/25/18 and on 4/28/18, threatening and yelling someone on the phone. The staff's plan was to monitor for further episodes.

The initial treatment plan, dated 5/1/18, identified problems with alteration in thought process and substance abuse.

Review of the nursing notes, physician orders for 5/4/18 at 3:00 P.M. indicated Patient #9 was agitated, pacing, frustrated and combative. The Patient became aggressive towards staff and made verbal threats to murder staff. The staff called for a "show of support" and upon arrival of the security officers the Patient ran towards them and they placed the Patient in a physical hold, placed on a stretcher, the Patient was carried to the seclusion room, placed in 4 point restraints and given IM medications (Ativan, Haldol and Benadryl). The Patient remained in 4 point restraints for 2 hours.

The Patient's treatment plan remained unchanged and there was no evidence that staff implemented treatments that would less restrictive.

The least restrictive restraint could have been to initiate only the physical restraints ( 4 point restraint) first with seclusion and evaluate to see if this calmed the patient first before intervening with chemical restraints (medications) which remain in the body and cannot be removed as a physical restraint can. Chemical restraints can produce undesired side effects and cannot be recalled once administered.

4. For Patient #22, the hospital failed to use least restrictive alternative before chemically restraining the patient to alter the patient's behavior.

Patient #22 was admitted in 5/2018 with diagnoses that included Bipolar Disorder and substance abuse.

Review of the clinical record on 5/9/18 indicated that on 4/22/18 Patient #22 was shoving paper towels and cups down the toilet multiple times, was very aggressive and intrusive, wearing dirty, stained underwear over his/her sweat pants and refusing to adhere to the rules. The Patient also pushed the nurse in the chest.

The documented treatment intervention included that the Psychiatrist ordered sedative medication including Lorazepam 3 mg, Benadryl 100 mg and Haldol 10 mg intramuscularly, which was given in the Patient's bilateral upper forearms. It was documented that the Patient stayed overnight in the unit quiet room. Further nursing documentation indicated that the patient was monitored every 15 minutes but refused to have his/her vitals check as per hospital protocol.

The Unit Manager (Nurse #9) was interviewed on 5/9/18 at 2:30 P.M. and reviewed the procedure of administering medication when a Patient is agitated and that the Patient was monitored every 15 minutes, but that the Patient refused to have his/her vitals checked per the hospital protocol. Nurse #9 said that the administration of the medication was not a chemical or a medical restraint because the patient took the medication voluntarily.

Because the patient accepted the medications and it did not require any physical interventions to take or administer the medications, the facility did not consider the medications a chemical restraint. The staff obtained one time orders and did not implement changes in the plan of care to prevent the use (convenience) giving medications to treat the Patient's escalating behaviors.

During interview with the Director of Nursing and the Compliance Officer on 5/9/18 at 11:30 A.M., they said that the Hospital was trying to prevent the use of and promote the least restrictive use of of restraints. The Director and Compliance Officer reviewed the Hospital policy and confirmed that the Policy and procedure did not include the use of medications that were used for restraining and treating behaviors. They said that if the Patient voluntarily accepts a drug or medication it was not a restraint and confirmed that the medication was being used to stop behaviors and not part of the active treatment plan. They said they were reviewing the documentation following restraint events and addressing missing documentation to ensure restraints are being used appropriately. They said they were aware there was problems with documentation related to medication restraints and the use of multiple restraints. They said that they were educating staff to number the restraint used in order. For example if a physical hold was used, the staff placed a 1 next to that restraint. They could not explain how this process prevented and decreased the use of restraints or determining which would be considered the least restrictive. In addition, the Director of Nurse confirmed that use of multiple restraints, whether they were voluntarily or involuntarily given, could not be judged least restrictive without some evidence that staff implemented changes in treatment to ensure the least restricted restraints are used. The Director agreed that the information lead to the judgement that restraints of all types are being used not as a least restrictive measure.

Based on record review, review of the Hospital's policy for restraints, the Hospital failed to implement the use of medication restraints in accordance with their policy. The Hospital indicated that medication restraints can only be ordered by a physician who is present at the time and has examined the patient. The policy indicated that it was prohibited for staff to administer a medication restraint without the physician on-site for 3 patients (#7, #8 and #9) out of 30 sampled patients.

Findings include:

Review of the Hospital's policy and procedure for Mechanical Restraints, Seclusion, Physical Restraint, Medication Restraint on an Adult Inpatient Unit, dated and last revised on 10/15/15, indicated that medication restraints occur when an individual is given medication involuntarily for the purpose of restraining the individual; and a medication restraint can only be ordered by a physician who is present at the time and has examined the patient. The policy indicated that it was prohibited for staff to administer a medication restraint without the physician on-site.

1. For Patient #7, the Hospital staff gave medications as a restraint without a physician on-site at the time the medication was ordered.

Patient #7 was admitted to the hospital in 5/2018 and had diagnoses that included depression, anxiety and mood disorder.

Review of the clinical record indicated the Patient was placed in the restraints and given a chemical restraint on 5/5/18 at 6:00 P.M.

The medication order included Haldol (an antipsychotic) 5 mg, IM (intramuscular), Benadryl (an anti-histamine which causes sleepiness) 50 mg, IM, and Ativan (benzodiazepine/anti-anxiety) 2 mg, IM.

The documentation failed to indicate that the physician was onsite to assess and order the medication prior to the Staff giving the medication during the restraint event.

On 5/8/18 at 1:00 A.M., the nurse documented Patient #7 became agitated and verbally abusive towards staff while attempting to get the keys from the nurses station to leave. The note indicated the Patient grabbed the phone from nurse and threw the phone. The nurse indicated she contacted the doctor for a telephone order for a physical and chemical restraint.

The progress notes indicated the Patient was held physically for 5 minutes and released after the Staff administered the IM medications that included Haldol, Benadryl and Ativan.

The Patient was not assessed by the physician prior or at the time the chemical restraint was ordered and given.

2. Patient #8 was admitted to the hospital in 12/2017 and had diagnoses that included bipolar, personality disorder and cannibis dependency.

Review of the nursing progress notes and restraint event notes dated 12/17/17 at 4:00 P.M., indicated Patient #8 had been agitated and had informed the Staff he/she had not been sleeping well and wanted to leave the Hospital. The Patient was offered oral medication (Haldol, Ativan and Benadryl) and refused. The Staff indicated they provided education, 15 safety checks and monitoring for support. The note indicated that the Patient was watching television and threw a chair at another patient.

The Staff called the physician and obtained a telephone order to restrain the patient. The Staff placed the Patient in a physical hold, then placed in 5 point mechanical restraint and administered the 3 intramuscular (IM) medications. The documentation indicated the physician did not assess the patient and was not present when the medications were administered at 4:00 P.M.

The clinical record indicated on 12/22/17 at 5:00 P.M., the Patient was agitated and displaying verbal aggression and inappropriate sexual behaviors. The staff called the physician and he ordered a one time dose of Haldol 10 mg, Benadryl 100 mg and Ativan 2 mg by mouth (PO).

The Patient was administered the medication and there was no documentation indicating that the physician assessed the patient or that he was present when the medications were administered at 5:00 P.M.

The nursing progress notes dated 12/23/17 at 1:00 P.M. indicated that the Patient had interrupted a group activity and attempted to block the door. The Patient was offered oral medication (telephone orders) to treat his behavior and after refusing was given IM medications (Haldol, Ativan and Benadryl) and placed in 4 point restraints.

The Patient remained in 4 point restraints until 5:00 P.M. for agitation and threatening behavior. A renewal order was obtained at 3:00 P.M. to continue to use of 4 point restraints.

The physician did not assess the Patient until 4:30 P.M. on 12/23/17, after the Patient was given the medications nor was there any evidence that the physician was onsite when the medications were administered per policy.

Review of the nursing noted on 12/25/17 at 1:30 P.M., Patient #8 was involved in an patient to patient altercation. The staff called a "show of support" and offered oral medications. The Patient was observed pocketing the medications and spitting them out. The telephone order was changed from oral to IM and the Patient was administered IM Haldol 10 mg, Ativan 2 mg and Benadryl 100 mg, one time dose. The order did not include the medication as a restraint and the documentation did not support that the physician was onsite when the medication was given nor that the physician had assessed the patient prior to administration of the medications per policy.

Review of the nursing progress notes dated 3/1/18 at 10:15 A.M. indicated the Patient had a verbal altercation with another patient. The Patient hit the other patient with chair. The interventions and treatment consisted of placing the Patient in 4 point restraints and administered medication restraints (IM Haldol, Ativan and Benadryl). The Patient remained in 4 point restraints for 1 hour and 45 minutes. The documentation indicated the Patient remained agitated for the time period restrained.

There was no evidence that the physician was onsite when the medication was administered or that the physician had assessed the patient prior to ordering the chemical restraints per policy.

3. Patient #9 was admitted in 4/2018 with diagnoses that included anxiety, schizoaffective disorder and substance abuse.

Record review indicated that the Patient was agitated on 5/1/18 at 5:30 P.M. The nursing note indicated the Patient was aggressive during dinner. The note indicated the Patient's treatment plan was reviewed with him, but this intervention was ineffective. The nursing staff called for a "show of support" and with the support of staff including security was able to give the Patient Ativan 2 mg. Haldol 5 mg and Benadryl 50 mg (PO), which was ordered as a one dose via a telephone order. There was no evidence in the clinical record that the physician assessed the patient prior to the medications given.

The nursing notes indicated on 5/3/18 at 3:00 P.M., a telephone order was obtained for a "stat" order for Haldol, Ativan and Benadryl, as the Patient was being confrontational with another patient. The stat medication was not identified as a restraint and was administered orally.

The physician did not assess the Patient prior to ordering the medications.

During interview with the Director of Nursing and the Compliance Officer on 5/9/18 at 11:30 A.M., they said that the Hospital was trying to prevent the use of and promote the least restrictive use of of restraints. The Director and Compliance Officer reviewed the Hospital policy and confirmed that the Policy indicated that the Hospital relied on determining chemical restraints based on whether the Patient accepted or voluntarily accepted the given medication. The Director said that without ensuring chemicals being administered were or were not defined as a restraint was difficult to ascertain based on the restraint events and documentation associated with restraint events. The Director said she was aware that during restraint events that there was missing documentation (including the physician assessment prior to medications given during restraint events).

Based on review of facility reports and interviews, the hospital did not tak actions at performance improvement and set priorities for its performance improvement activities that focused on high risk and high volume areas that affected patient safety. Findings include:

1. Review of the Hospital's Patient Safety Plan, Critical Incidents, Occurrences,Complaints, Abuse, 10 Day Fact Finding incidents, Administrative Resolution incidents and Grievances policies, procedures, logs and reports, indicated that the Hospital objective was to improve patient safety by identifying high risk occurrences, practices and conducting internal reporting of problems and taking action to prevent further occurrences. The Hospital's objective was to prevent occurrences and eliminate risks of potential or actual harm by educating staff, integrating patient-safety activities with an identified focus on accountability within the hospital.

Review of the Hospital's grievance process including logs and recorded incidents/occurrences (that included critical, non-critical, 10 Day Fact Finding and Administrative Resolution) indicated that staff recorded the occurrence and then the information was then placed into a category (critical, non-critical, 10 Day Fact Finding, etc). Incidents other than Administrative Resolution and 10 Day Fact Finding were forwarded to an external Hospital official. Once the Hospital staff forward the report, they take no action, The Hospital does not do a onsite investigation or attempt to implement staff standard practices. The Hospital staff acknowledged that they take no additional accountability once these occurrences are forwarded to the outside Hospital official, until they receive a report from them.

The internal occurrences are reviewed by the Hospital staff. The procedure indicated staff fact find and then subsequently resolve the occurrence. However, review of the individual incident/occurrence reports failed to indicate how the Hospital investigated the incident/occurrence and there was no indication of the action that was taken to ensure safety for the patients that were potentially affected by occurrences and practices considered to be potential risk to patients and others. Furthermore, the Hospital policy for investigation of an incident/occurrence had limited procedural guidance for the staff to follow that in turn would lend the staff to develop and implement a patient safe environment.

Review of the Hospital's incident/occurrence reports from 1/2018 through 4/2018, indicated that following:

*Reports were identified as either critical (injury during occurrence), non-critical (no injury), 10 Day Fact Finding and Administrative Resolution.

*The reports were identified as internal investigations and resolved.

*The reports indicated that there were 39 critical incidents of patient to patient assaults, 15 non-critical incidents patient to patient assaults, 15 incidents of patients having contraband (non-critical), that included a knife in a package on 1/18/18, a fire burning in a basket on 3/25/18 and on 4/29/18, a visitor gave a patient a utility knife, 6 incidents of sexual behavior (patient to patient) and 1 incident of a patient (#15), who had identified to have high risk behaviors, delivered a baby without staff knowledge of the occurrence.

*The Hospital action towards these incidents indicated that the the Patients physician was notified of the occurrence , treatment team will address the incident and/or nursing will monitor and assess. There was no defined action plan to ensure a decrease in the occurrence of these types of incidents.

During interview on 5/7/18 at 1:30 P.M., with the Director of Quality and the Risk Coordinator, the incidents and investigations were reviewed. The Director of Quality and the Risk Coordinator said that the Hospital follows a procedure for investigating and reporting. They said the Human Rights Officer follows up on grievances and that critical incidents are reported to their chief operating department. They said that they "fact find" for 10 Day Fact Finding and Administrative Resolution complaints.

During the interview, the Director of Quality and the Risk Coordinator, they provided data that identified high risk safety occurrences, but failed to provide supporting evidence that their fact finding process was completed and that with the data they had developed and implemented an action plan(s) to prevent a reoccurrences and provide a safe environment (other than a generic individual treatment plan).

2. ) According to the incident reports, the Hospital identified that there had been 39 critical incidents of patient to patient assaults and 15 non-critical incidents patient to patient assaults. The Director of Risk was asked about a plan to prevent the assaults, on 5/7/18 at 1:30 P.M., she said that the Hospital had noticed through the data collection that their had been an increase in the number of patient to patient altercations. She said the Hospital changed the category and added an additional category to include the labeling of 2 areas, patient to patient if they hit each and patient to victim. The change in category failed to identify how the Hospital could prevent altercations between patients and keep them safe.

3.) Review of the incidents had indicated that there were 15 incidents (1/2018-4/2018) of patients having contraband (non-critical), that included a knife in a package on 1/18/18, a fire burning in a basket on 3/25/18 and on 4/29/18, a visitor gave a patient a utility knife.

The Hospital policy indicated that sharps and hazardous items were not allowed inpatient to ensure a safe and therapeutic environment. The policy indicated on admission, the staff check all belongings for harmful objects that can include, but not limited to brushes combs toothbrushes, glasses and knifes, etc. The restriction of sharp or hazardous items is assessed for potential harmfulness and items are restricted if pose risk or safety concerns.

The policy includes supervision of the use of sharps and hazardous items, visitors who bring packages have to have the packages searched prior to giving the patient the package. The policy indicates that staff are ultimately responsible for maintaining individual safety.

The Hospital is smoke free and not smoking contraband was to be maintained by patients.

Review of clinical records indicated that on admission the nursing staff consistently check for sharps and contraband by checking a box on an assessment form. However, there was no additional monitoring following the completion of the admission assessment.

Nurse #3 said on 5/8/18 at 10:00 A.M., that there is some frequency of contraband including smoking paraphernalia found and being used by patients. She said that usually the patient will give up the contraband and are educated by staff. She said that there was no consequence to the patient following an incident.

Nurse #1 was interviewed on 5/9/18 at 11:00 A.M., she said that her staff was lucky they had seen the visitor pass the utility knife to the patient. She said that other than on admission Patients are not regularly searched for contraband and that visitors are not required to be searched. She said she had notified everyone about the utility knife, but had not heard what the plan was for safety improvement following the event.

Review of the incidents of contraband and specifically the utility knife and smoking indicated that the staff addressed the immediate incident and then followed notifying the physician and team of the occurrence. The Hospital staff indicated the Patient with the utility knife had his visitors stopped for a period of time.

The Director of Safety and the Administrator were interviewed on 5/9/18 at 2:00 P.M. about Patient Safety and the number of occurrences identified in their reports. Both the Administrator and the Director of Safety indicated that they were aware of occurrences including the knife and prolific contraband on the units. The Director of Safety said that he was discussing changes for safety and contraband provided by others or accessed by patients, but had not implemented anything. The Administrator confirmed that the Hospital should have some level of monitoring for occurrence that pose a safety risk and assessment of the interventions.

Based on staff interviews and clinical record review the facility failed to obtain informed consent from the Rogers Guardian, as required, prior to the administration of an anti-psychotic medication, and failed to follow Rogers Treatment plan for one Resident (#16) in a total sample of 30

Findings include:

For Resident #16, the facility failed to to follow current Rogers Treatment plan which did not include the use of Zyprexa.

Resident #16 was admitted to the facility on 4/22/2016 with diagnosis including schizo-affective disorder (bipolar type), history of alcohol and Intravenous drug use, borderline personality disorder and a history of assaultive,volatile and aggressive behavior.

The Resident was admitted to the facility with a Rogers Guardianship in place. The current Rogers Treatment plan, with a next review date of 6/12/18, indicated the following court orders for the Patient's antipsychotic medication use.

Primary antipsychotic medications:

-Haldol Deconate (long acting) 100 milligrams (mg) Intramuscularly (IM) every two weeks. Dose range is 0-200 mg IM every 2 weeks

-Seroquel 150 mg per day: Dose range 0-900 mg per day.

Alternate antipsychotic medications:

-Trilafon 0-64 mg per day

-Risperidone 0 to 8 mg per day: Consta (long acting) 0-50 mg every 2 weeks

-Invega 0-12 mg per day Sustenna (long acting) 0-234 mg IM every 1 to 4 weeks: Trinza 0-818 mg IM every 3 months

On 6/13/17 the Rogers Treatment Plan had been amended and the physician at the time requested that the Haldol (by mouth), Zyprexa and Abilify be removed and the Invega be added to the treatment plan. This amended treatment plan went into effect 6/13/17.

Clinical record review indicated that the patient had been receiving/had a current physician's orders for Zyprexa 5 mg at bedtime: Zyprexa 2.5 mg every 4 hours as needed for agitation.

Further clinical record review indicated that multiple times the patient had also received Zyprexa 10 mg IM for agitation/aggression.

The patient was receiving and had received the Zyprexa outside of the current Rogers Treatment plan.

On 5/10/18 at 11:00 A.M. Registered Nurse #9 and the Nurse Practioner #1 confirmed that the facility was unable to provide any evidence that the hospital had pursued court orders for the administration of Zyprexia.

Based on observation, staff interview and record review, the Nutrition Services Department failed to accurately monitor the concentration of the chemical sanitizer in the dish machine and maintain a sanitary work environment including work surfaces, cooking equipment and dishware to reduce the potential of food borne illness for a high risk population.

Finding include:

During an observation of the main kitchen dish machine on 5/9/18 at 9:30 A.M., the Nutrition Services General Manager identified to the Surveyor that the dish machine was a low temperature machine and used a chemical sanitizer to sanitize dishware, trays, pots and pans. The Surveyor asked the Nutrition Services General Manager to check the concentration of the chemical sanitizer in the dish machine. The Nutrition Services General Manager made three attempts to check the concentration, however each time the chemical did not register on the test strips. The Surveyor check the package of test stripes and observed that the test stripes had expired in March 2018. The Nutrition Services General Manager retrieved a new package of test stripes from the office and checked the concentration which registered 50 PPM (parts per million). He also said that he prefers that concentration range from 75-100 PPM. The Nutrition Services General Manager said that he would contact the Maintenance Provider to evaluate the dish machine to ensure that the proper amount of chemical sanitizer was being dispensed in the dish machine.

Review of the 5/2018 "Low Temperature Dish Machine Log" indicated that the dish machine was tested three times a day prior to each service. The staff documented that the chlorine concentration registered 75-100 PPM each time, however the Nutrition Services General Manager could not identify to the Surveyor how long the expired test stripes were being utilized by staff and therefore could not assure that the documented concentrations were accurate.

On 5/10/18 at 9:30 A.M. the Nutrition Services General Manager was again interviewed and provided the Surveyor with the Food Service Policy on Sanitation. The Nutrition General Manager identified to the Surveyor that he found that the test stripes used to check the concentration of the chemical sanitizer in the sanitizing buckets (used with cleaning towels to wipe counter tops and equipment) had also expired and could not identify how long the expired stripes were being utilized by the staff. The Nutrition General Manager again could not assure that the concentration of the chemical sanitizer was adequate to reduce food borne pathogens.

Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patients' psychiatric condition for seven (7) of eight (8) active sample patients (1, 2, 3, 4, 5, 7, and 8). Many of the goals were either not measurable or were staff goals (what the staff wanted the patient to achieve) rather than an outline of mental status or functional status level to be obtained. Without a set of defined goals against which to measure progress, it is difficult to judge the effectiveness of treatment and implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. In patient's 1's Master Treatment Plan (MTP), dated 4/25/18, the staff goal for the identified problem " ...long standing and persistent paranoid and persecute only delusions of being raped, assaulted, having both male and female genitals, impairing [his/her] ability to process reality based interactions and frequently resulting in violence" was: "[Name of patient] will accept all psychiatric medications as prescribed daily, and complete required lab work required for any medication dosage." A difficult to measure goal was: "[Name of patient] will be able to identify one symptom of mental illness that is managed by medication compliance."

2. In patient 2's MTP, dated 5/3/18, the staff goals for the problem "Overcoming barriers to stated goal of living in the community as evidenced by: "Current commitment on legal status 7 & 8," "history of multiple psychiatric hospitalizations; history of substance use; history of legal charges and incarceration" was: "[Name of patient] will attend substance abuse groups offered on the unit at least once per week and to discuss how substance use has impaired his/her life and verbalize 2 strategies to prevent relapse." The difficult to measure goal was: "[Name of patient] will be able to identify 2 symptoms of his/her mental illness with no more than 4 cues."

3. In patient 3's MTP, dated 4/10/18, the difficult to measure goal for the problem: "Overcoming barriers which may prevent [name of patient] from living a productive life in the community in the context of mental health concerns and legal charges as evidenced by: "Charges and dates of alleged offenses - assault and battery on a person over 60. Strangulation or suffocation - allegedly on 5/23, punched [his/her] mother several times in the shoulder and tried to strangle [him/her]," the difficult to measure goal was: "[Name of patient] will be able to independently verbalize symptoms of [his/her] mental illness."
A staff goal was: "[Name of patient] will attend The Understanding Court Group once per week with no more than 2 cues."

4. In patient 4's MTP, dated 4/25/18, the staff goal for the problem: "Overcoming barriers to [name of patient] stated goal of living in the community in the context of charge of first degree murder and history of psychosis," was: "[Name of patient] will practice 5 ways [s/he] can improve [his/her] quality of life in the context of long-term hospitalization including keeping in touch with family and developing friendship."

5. In patient 5's MTP, dated 4/17/18, the difficult to measure short-term goal for the problem: "Alteration in though [sic] disturbed thought process" as evidenced by: "Difficulty living in a community setting based on six hospitalizations in 2012 as a result of inability to care for [him/herself] due to engaging in aggressive verbal and physical behaviors towards peers and staff in a supervised group living environment, and long-term ineffective response to medication treatment" was: "[Name of patient] will be able to engage in community access opportunity with 1:1 [1 to 1] staff and engage in appropriate behavior including no verbal or physical outbursts 50% of the time over the next 30 days."

6. In patient 6's MTP, dated 4/19/18, the staff goal for the problem: "Alteration in thought process" as evidenced by: "Verbalized non-sensical statements and delusional thought content. On 4/14/18, [s/he] was charged with breaking and entering, destruction of property, (2 counts of each)" was: "[Name of patient] will actively discuss [his/her] diagnosis of mental illness and need for treatment adherence in the community. [Name of patient] will identify 2 strategies [s/he] can use to live successfully in the community."

7. In patient 8's MTP, dated 4/28/18, the difficult to measure short-term goal for the problem: "Risk for self-directed or other-directed violence" as evidenced by: "[Name of patient] was referred by [name of court] for an evaluation of competency to stand trial and criminal responsibility. [His/her] charges include disturbing the peace, negligent operation of a motor vehicle, speeding, failure to stop, marked lanes violation, uninsured motor vehicle, operating motor vehicle w [with] suspended license, unregistered motor vehicle, failure to stop/yield, failure to stop for police officer" was: "[Name of patient] will be able to identify and utilize 2 positive coping skills (i.e. music and safe exercise to [sic] during period of stress and anxiety."


B. Interview

In an interview on 5/8/18 at 12:00 p.m., the difficult to measure and staff goals on the MTPs were discussed with the Nursing Director. She did not dispute the findings.

Based on record review and interview, it was determined that for seven (7) of eight (8) patients (Patients 1, 2, 3, 4, 5, 6, and 8) the Master Treatment Plans failed to describe the various staff members' interventions that were more than a description of generic discipline functions. This failure results in no description of the staff's efforts that would individualize these patient's treatment modalities.

Findings include:

A. Record Review:

1. Patient 1: The Master Treatment Plan (MTP), dated 4/25/18, had for this 36-year-old patient with the Problem "Longstanding and persistent paranoid and persecutory delusions of being raped, assaulted, having both male and female genitals, impairing his/her ability to process reality based interactions and frequently resulting in violence." The deficient interventions for this problem were----

a. Psychiatrist: "[OD 1] will meet with [Patient #1] once per week to assess mental status, prescribe medications if necessary, monitor for side effects and efficacy and educate Patient 1 about mental illness."

b. Social Work: "[LICSW1] will meet with [Patient #1] once per week for 15 minutes to identify symptoms of mental illness, discuss legal and housing situation and developed an aftercare plan."

c. Nursing: [RN1] and other nursing staff will meet with [Patient #1] for 10 minutes daily to assess mental status, encourage positive coping strategies during periods of agitation and emotional distress, and continue to monitor on 15 minute checks."

2. Patient2: The MTP, dated 5/3/18, had for the Problem "Overcoming barriers to stated goal of living in the community" had the following deficient interventions:

a. Psychiatry: "[APRN1(Advanced Practice Registered Nurse)] will meet with [Patient #2] twice a week for 15 minutes to assess mental status, provide education about the benefits of medication adherence, monitor for efficacy and side effects of medications."

b. Nursing: ["RN2] and/or other nursing staff will meet with [Patient #2] twice per day for 5 minutes to maintain a therapeutic rapport and assess his/her mental status. Will provide education regarding symptoms of mental illness as well as his/her prescribed medications and the benefits of being adherent. Will educate him/her about resources available on the unit to help him/her cope with stress, such as groups and activities, use of the Sensory Room, and 1:1 time with staff."

3. Patient 3: The MTP, dated 4/10/18, had for the Problem "Overcoming barriers which may prevent [Patient #3] from living a productive life in the community in the context of mental health concerns and legal issues." The following were deficient interventions:

a. Psychiatry: "[MD1] will meet with [Patient #3] for 15 minutes twice per week, to engage in psychiatric assessment, including providing education and treatment recommendations, including psychiatric medications."

b. Nursing: "[RN2] and/or other nursing staff will continue to meet with Patient#3 once per week for 5 minutes (or as tolerated) to engage him/her in conversation regarding symptoms of mental illness and ways in which [s/he] can manage [his/her] symptoms. Will provide education regarding the benefits of a long acting injectable medication."

c. Social Work: "[LICSW#2] will meet with [Patient #3] for 15 minutes twice a week, as tolerated to encourage verbalization of mental health symptoms."

4. Patient 4: The MTP, dated 4/25/18, stated for the Problem "Overcoming barriers to [Patient #4's] stated goal of living in the community in the context of charge of First Degree Murder and history of psychosis." The deficient interventions included:

a. Psychiatry: "[MD2] will meet with Patient#4 at least once a week for 15 minutes to help [him/her] identify ways he/she can improve [his/her] quality of life in the context of this long hospitalization."

b. Nursing: "[RN#4] and/or other nursing staff will continue to meet twice per week for 5 minutes to assist [him/her] in identifying two ways [s/he] would like to improve his/her life. Will encourage [him/her] to use meditation techniques [s/he] is working on with staff. Will assist [him/her] in managing weight by encouraging [him/her] to pace the unit and engage in healthy activities. Will assist [him/her] in communicating with family members outside of the hospital."

c. Social Work: "[SW3] will meet with [Patient #4] twice a week to aid him/her in identifying ways [s/he] can improve the quality of [his/her] life in the hospital. Will assist [Patient #4] in contacting his/her family and will encourage him/her to engage in activities that he/she enjoys on the unit."

5. Patient#6: The MTP, dated 4/11/18, had for the Problem "Poor impulse control" and the following deficient interventions:

a. Psychiatry: "[MD3] will observe the patient on the unit, check in with the patient daily and adjust medications as need, be informed of behavioral data."

b. Nursing: "[RN5] will direct MHW [Mental Health Worker] and other nursing staff to monitor patient 1:1 on all three shifts due to [his/her] impulsive behaviors. Complete Behavioral Worksheet daily."

c. Social Work: "[SW4] will communicate with patient's guardian when he/she is ill or having issues, and will monitor [Patient #6's] overall care and behavioral data."

6. Patient#7: The MTP, dated 5/17/18, stated for the Problem "Alteration in thought process" and the following deficient interventions:

a. Psychiatry: "[MD3] will meet with the patient for 15 minutes twice a week to help patient identify strategies to live successfully in the community (work, avoid rehospitalization, school)"

b. Nursing: "[RN6] will work with [Patient #7] towards [his/her] goal of living in the community successfully by helping him/her understand [his/her] mental illness and need for adherence to his/her medication regimen."

c. Social Work: "[SW3] will meet with Patient #7 at least twice a week to provide psycho education {sic} and discuss importance of treatment adherence in the community."

7. Patient#8: The MTP, dated 4/24/18, stated for the Problem "Risk for self-directed or other-directed violence" and the following deficient interventions:

a. Psychiatry: "[APRN1] will meet with [Patient #8] at least once per week for 15 minutes to assess mental status, educate about appropriate use of coping skills, medication options and provide therapeutic support."

b. Nursing: "[RN7] and other nursing staff, will meet with Patient#8 for 10 minutes three time [sic] a week to encourage [him/her] identify [sic] [his/her] strengths and to use [his/her] coping skills positively."

c. Social Work: "[SW5] will meet with [Patient #8] 2-3 times a week for 15-20 minutes to assist [him/her] at implementing [his/her] coping skills effectively to demonstrate safe behaviors."


B. Staff Interview

On 5/8/18 at 12:00 p.m. the Director of Nursing was interviewed. A partial focus of the interview was the findings described in Section I, above. The Director did not dispute the findings.

Based on record review and interview, the clinical director failed to ensure that Master Treatment Plans for seven (7) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, and 8) described staff interventions that were more than generic discipline functions. These failures result in Master Treatment Plans that were uninformative, not behaviorally measurable, and were not individualized. (Refer to B122)

Based on record review and interview, the nursing director failed to ensure that Master Treatment Plans for five (5) of eight (8) active sample patients (1, 2, 3, 4, and 6) described staff interventions that were more generic nursing discipline functions.

Findings include:

A. Record review

1. Patient 1: The Master Treatment Plan (MTP), dated 4/25/18, had for this 36-year-old patient with the Problem "Longstanding and persistent paranoid and persecutory delusions of being raped, assaulted, having both male and female genitals, impairing his/her ability to process reality based interactions and frequently resulting in violence." The deficient nursing interventions for this problem was:

"[RN1] and other nursing staff will meet with [Patient #1] for 10 minutes daily to assess mental status, encourage positive coping strategies during periods of agitation and emotional distress, and continue to monitor on 15 minute checks."

2. Patient 2: The MTP, dated 5/3/18, had for the Problem "Overcoming barriers to stated goal of living in the community" had the following deficient nursing interventions:

"[RN2] and/or other nursing staff will meet with [Patient #2] twice per day for 5 minutes to maintain a therapeutic rapport and assess [his/her] mental status. Will provide education regarding symptoms of mental illness as well as [his/her] prescribed medications and the benefits of being adherent. Will educate [him/her] about resources available on the unit to help [him/her] cope with stress, such as groups and activities, use of the Sensory Room, and 1:1 time with staff."

3. Patient 4: The MTP, dated 4/25/18, stated for the Problem "Overcoming barriers to [Patient #4's] stated goal of living in the community in the context of charge of First Degree Murder and history of psychosis." The deficient nursing intervention included:

Nursing: "[RN5] will direct MHW (Mental Health Worker) and other nursing staff to monitor patient 1:1 on all three shifts due to his/her impulsive behaviors. Complete Behavioral Worksheet daily."


Interview

On 5/8/18 at 12:00 p.m. the Director of Nursing was interviewed. The generic nursing interventions were discussed with her. The Director did not dispute the findings.

Based on record review and staff interview it was determined that the Director of Social Work failed to ensure that Master Treatment Plans for seven (7) of eight (8) patients (Patients 1, 2, 3, 4, 5, 6, and 8) stated Social Work treatment interventions that were not generic discipline functions and were individualized. This failure results in no information about what patient specific endeavors might occur. (refer to B122)

Based on record review and interview, the facility failed to provide therapeutic activities by occupational and recreational therapists after 4:00 p.m. on the weekends for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, 7 and 8). This failure results in patients not receiving a full complement of therapies which could hinder their progress towards treatment goals.

Findings include:

A. Record Review

The weekend schedule for all three (3) patient units (4 East, 5 East, and 8 East) had no OT/RT groups listed after 4:00 p.m.

B. Interview

In an interview on 5/8/18 around 10:15 a.m. with OTL2, the lack of therapeutic groups after 4:00 p.m. on weekends was discussed. He did not dispute the findings and stated he would look into changing the schedule to include the evening hours on the weekend.