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Based on document review, interview and observation, the facility failed to ensure patient privacy by requiring patients to wear transparent gowns (Tag 143), failed to ensure safety while on 1:1 (tag 144), failed to ensure patients were free from seclusion as a means of discipline (tag 154), failed to ensure less restrictive hold or restraint was utilized prior to initiating 6 point restraint (tag 164), failed to modify the patients care plan when restraint and/or seclusion were utilized (tag 166), failed failed to obtain orders for seclusion (tag 168), and kept patients in seclusion for extended periods of time (tag 174).

The cumulative effects of the above prevented the facility from protecting and promoting patient rights.

Based on document review, interview and observation, the facility failed to ensure patient privacy by requiring patients to wear transparent gowns for 2 of 11 patients (patients #1 and #9).

Findings include;

1. Facility policy titled "A Handbook for Patients, Relatives, and Friends" which included patient rights last reviewed/revised 5/17 states on page 3 of 10: "YOUR RIGHTS AS A PATIENT.....Constitutional Rights, guaranteed rights that cannot be taken away.....Be treat with consideration, dignity, and respect....."

2. Review of patient #1 medical record indicated the following:
(A) Per the Psychiatric Initial Assessment form, the patient was admitted to the facility on 8/4/16 for "Worsening depression and suicidal thoughts.....".
(B) The patient took an overdose of medication while on a leave and returned to the facility after a hospital stay on 4/2/17. Per nurses notes at 2149 hours on 4/2/17, upon arrival to the facility at approximately 1600 hours the patient was placed in a hospital gown. Nurses notes at 0229 hours on 4/3/17 indicated the patient remained in quiet room wearing a hospital gown.
(C) On 4/8/17 at 1945 hours, the patient was behind the nurses station to make a call and picked up a AA battery and swallowed it as well as a piece of plastic. An order was written at 2000 hours on 4/8/17 to place patient in a yellow gown. Nurses notes on 4/9/17 at 0120 indicated that the patient returned from facility #2 and was placed in quiet room with gown and underwear and no bra. Nurses notes on 4/9/17 at 0500 hours indicated that the patient remained in the quiet room in gown and underwear with the light on for Suicidal ideations and self injurious behavior. Nurses notes on 4/10/17 at 0420 hours indicated the patient remained in the quiet room with gown and underwear and the lights were on in the room.
(D) On 4/12/17 at 0015 hours, the patient swallowed a spork and was hitting and kicking staff trying to prevent the behavior. The patient was sent out to facility #2 for evaluation. An order was written on 4/12/17 at 0540 hours for patient to be placed on 2:1 24/7 papergown with underwear and no bra, nothing in room, contraband check every shift and prn (as needed), no blankets or sheets until further review. An order was written on 4/14/17 at 0900 hours for patient to remain on 2:1 24/7, paper gown only with no ties, no personal items, no blanket, no sheet and no clothing. The restrictions continued through 4/15/17.
(E) Nurses notes on 4/16/17 at 2200 hours indicated the patient was restarted on Suicidal ideation (SI) and Self injurious behavior (SIB) precautions for attempting to swallow a piece of a Styrofoam cup. The patient was sent to facility #2 on this date for test to evaluate battery that had been ingested earlier. The note indicated the patient remained on a 2:1 in the quiet room at all times.
(F) Nurses notes on 4/18/17 at 1315 hours indicated the patient remained on a 2:1, in paper gown and in quiet room. Nurses notes on 4/18/17 at 2208 indicated the patient remained in the quiet room. Nurses notes on 4/19/17 at 2235 indicated the patient remained on a 2:1 24/7, paper gown and quiet room at all times. Nurses notes on 4/20/17 at 1440 hours indicated the patient remained on a 2:1 in the quiet room but was allowed to wear hospital blues vs the paper gown.
(G) Nurses notes on 5/29/17 at 2150 hours indicated the patient was oppositional and defiant with staff and his/her room was stripped of all belongings.

3. Review of patient #9 medical record indicated the following:
(A) He/she was admitted on 10/6/16 and per Psychiatric Assessment, the patient had a history of physical abuse and was a victim of rape/sexual abuse or assault.
(B) An order was written at 1930 hours on 4/3/17 to place patient in paper gown and quiet room at all times with strict 15 minute checks. Nurses notes on 4/3/17 at 2148 hours indicated the patient was placed on precautions due to scratching self in arm with a broken zip tie and that the patient was placed in the quiet room at all times with a paper gown on. Per nurses notes, the patient remained in the paper gown and in the quiet room until 0950 hours on 4/6/17.
(C) Nurses notes dated 4/7/17 at 1018 indicated that there was contraband found in the patients room (pencil and eraser) and patient was placed back in paper gowns and quiet room per order. An order was written at 1000 on 4/8/17 to place patient in paper gown and quiet room with every 15 minute checks with door open and no interaction with peers or staff. An order was written at 2358 hours on 4/8/17 to continue a 1:1, 1 gown only with underwear, nothing in room (books, pencils) and contraband check every shift. An order was written on 4/14/17 at 1130 for patient to remain on 1:1, in paper gown until 4/17/17. Nurses notes on 4/12/17 at 1330 hours indicated the patient continued to be in paper gown and 1:1 but was moved "from restraint room back to pt room." The paper gown was discontinued on 4/17/17.
(D) Nurses notes dated 4/19/17 at 2230 hours indicated that several suicide notes had been found in the patients room and 1:1 was maintained and paper gown only implemented. An order was written on 4/19/17 at 1530 hours to place the patient on 1:1, put in paper gown and in quiet room. Nurses notes dated 4/20/17 at 1945 hours indicated that the patient remained in a paper gown. The patient was back among peers on 4/23/17.
(E) Nurses notes dated 5/2/17 at 1630 hours indicated that the patient attempted to swallow a plastic piece off of a toothpaste tube, however staff was able to get the piece from the patient. The notes indicated that staff told the patient that they would be placed in a papergown and the patient became upset and threw a brush at the staff member. The patient then tore a piece from the brush and attempted to place it in his/her mouth with staff intervening and removing the piece. The patient then ran from the staff and began cussing and screaming and punching the wall. An order was written on 5/2/17 at 1700 hours to place the patient in a paper gown, no toothbrush and to use wash cloth with toothpaste.
(F) Nurses notes dated 5/5/17 at 0442 hours indicated the patient remained in paper gowns. The paper gown was discontinued at 0930 on 5/8/17.
(G) Nursing documentation dated 5/9/17 at 1855 hours indicated that the patient had superficial cuts on his/her arms, had attempted to swallow an object (pen lid) and was assaultive toward staff. An order was written on 5/9/17 at 1930 hours for paper gown with no bra and 1 blanket. An order was written on 5/16/17 at 0915 hours to discontinue the paper gowns and precautions due to no behaviors x 7 days.
(H) Nursing documentation dated 5/20/17 indicated that the patient was found in their room with ear bud cord around neck and standing on a basket and also swallowed a zipper. An order was written on 5/20/17 at 2040 hours for papergown with no bra or shoes and may have 1 blanket, underwear and socks. The medical record indicated the patient remained in paper gown until 5/26/17.
(I) Nurses notes dated 5/21/17 at 2220 hours indicated the patient remained on a 1:1 and in a paper gown.
(J) Nurses notes dated 5/30/17 at 1930 hours indicated that staff noticed a crayon drawing signed by the patient on the wall. When questioning the patient, the patient responded with "I don't know" and "I wanted to". The note indicated the patient was placed back in paper gown. An order was written on 5/30/17 at 2000 hours to place patient in paper gowns due to behavior. The order was discontinued at 1015 on 5/31/17.

4. Staff member #3 (Unit Director) indicated the following in interview beginning at 1:15 p.m. on 6/8/17:
(A) Yellow gowns are used for safety of patients. Indicated that patient #1 swallowed a battery and was placed in yellow gown for safety. When asked how this would prevent it from happening again, he/she had no answer.
(B) He/she indicated that patients stay in their room when in yellow gown. Indicated that the patient can come out, but they do not.

5. Patient #8 indicated the following in interview beginning at 3:20 p.m. on 6/8/17:
(A) He/she was admitted from juvenile detention center and has been at the facility for 1 1/2 years.
(B) Patients are placed on a 1:1 when they self harm and are placed in a yellow gown. He/she has not been placed in a yellow gown, but 1 of the patients frequently has been.
(C) When a patient is in a yellow gown, the door to their room is left open and you can see in the room. The patients have to stay in their room if they are in the yellow gowns and staff make them stay in their room. The patients are half naked when in the gowns.
(D) Some males are assigned to 1:1 and female staff take the patient to the bathroom.
(E) If you try to hide something, you are placed in a yellow gown and no bra.

6. Staff member #6 (RN) indicated the following in interview beginning at 3:40 p.m. on 6/8/17:
(A) When patients are placed in paper gowns, they are kept in their rooms for privacy. Patients are given a sheet if they have to go out into the hall.
(B) Patient #1 was kept in room to prevent him/her from swallowing objects.
(C) Sometimes patients are placed on a 2:1 to prevent the patient from running out of room and getting something to swallow.

7. Review of staffing assignment sheets indicated that male staff members worked the unit when patients were in yellow gowns including, but not limited to 4/9/17, 4/13/17, and 5/21/17. A male tech was assigned to the 1:1 of patient #9 on 5/21/17.

8. Observation of the yellow hospital gowns used for patients with physician order for hospital gown indicated the gowns were completely transparent and all body parts would be visible under the gown.

Based on document review, the facility failed to ensure patient safety while on 1:1 watch for 1 of 11 patients (patient #9).

Findings include;

1. Facility policy titled "A Handbook for Patients, Relatives, and Friends" which included patient rights last reviewed/revised 5/17 states on page 3 of 10: "YOUR RIGHTS AS A PATIENT.....Constitutional Rights, guaranteed rights that cannot be taken away.....Humane care and protection from harm...."

2. Review of patient #9 medical record indicated the following:
(A) He/she was admitted on 10/6/16 and per Psychiatric Assessment, the patient had a history of physical abuse and was a victim of rape/sexual abuse or assault.
(B) Nursing documentation dated 5/9/17 at 1855 hours indicated that the patient had superficial cuts on his/her arms, had attempted to swallow an object (pen lid) and was assaultive toward staff. An order was written on 5/9/17 at 1930 hours for 1:1 24/7.
(C) Nurses notes dated 5/10/17 at 1330 hours indicated the patient attempted self harm with tongue depressor used for crushed medication that had been given to the patient at 1215. The medical record lacked documentation as to why a tongue depressor was left in the patients room or how the patient obtained the tongue depressor while on a 1:1.
(D) Nursing documentation dated 5/20/17, at 0845 hours indicated that the patient was found in their room with ear bud cord around neck and standing on a basket and also swallowed a zipper. An order was obtained for restraint chair for up to 2 hours and for patient to be placed in a paper gown. An order was written on 5/20/17 at 2040 hours for 1:1 observation.
(E) Nurses notes dated 5/21/17 at 2220 hours indicated the patient remained on a 1:1 and in a paper gown and was found with a paper clip and a plastic piece which were taken from the patient. The medical record lacked documentation of how the patient obtained the items while on a 1:1.

Based on document reveiw and observation, the facility failed to ensure patients were free from seclusion as a means of discipline for 1 of 11 patients (patient #9).

Findings include;

1. Facility policy titled "Seclusion and Restraint Policy" last reviewed/revised 7/15 states on page 3 of 15 under Procedures and Responsiblities: "A. CMS Standard 42 CFR 482
A hospital must protect and promote each patient's rights. (e) Standard: Restraint or seclusion..... All patients have the right to be free from restaint or seclusion, of any form, imposed as a means of coercion, discipline......"

2. Review of patient #9 medical record indicated the following:
(A) He/she was admitted on 10/6/16 and per Psychiatric Assessment, the patient had a history of physical abuse and was a victim of rape/sexual abuse or assault.
(B) Nurses notes dated 5/30/17 at 1930 hours indicated that staff noticed a crayon drawing signed by the patient on the wall. When questioning the patient, the patient responded with "I don't know" and "I wanted to". The note indicated the patient was placed back on 1:1 and paper gown. An order was written on 5/30/17 at 2000 hours to place patient on 1:1 observation 24/7 and paper gowns due to behavior. The order was discontinued at 1015 on 5/31/17.

3. Patient #8 indicated the following in interview beginning at 3:20 p.m. on 6/8/17:
(A) Patients are placed on a 1:1 when they self harm and are placed in a yellow gown.
(B) The patients have to stay in their room if they are in the yellow gowns and staff make them stay in their room. The patients are half naked when in the gowns.

4. Staff member #6 (RN) indicated the following in interview beginning at 3:40 p.m. on 6/8/17:
(A) When patients are placed in paper gowns, they are kept in their rooms for privacy.

5. Observation of the yellow hospital gowns used for patients with physician order indicated the gowns were completely transparent and all body parts would be visible under the gown.

Based on document review and interview, the facility failed to ensure less restrictive hold or restraint was utilized prior to initiating 6 point restraint for 3 of 11 patients (patient #1, 5 and 9)

Findings include;

1. Facility policy titled "Seclusion and Restraint Policy" last reviewed/revised 7/15 states on page 3 of 15 under Procedures and Responsibilities: "3. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patent, a staff member, or others from harm".

2. Review of patient #1 medical record indicated the following:
(A) Per the Psychiatric Initial Assessment form, the patient was admitted to the facility on 8/4/16 for "Worsening depression and suicidal thoughts.....".
(B) On 4/8/17 at 1945 hours, the patient was behind the nurses station to make a call and picked up a AA battery and swallowed it as well as a piece of plastic. The patient was placed in a hold and then in a restraint chair which is a 6 point restraint (shoulders, waist, bilateral wrist, and bilateral ankles). The medical record lacked evidence that an attempt was made to place the patient on a watch or make his/her environment free of objects that could be ingested prior to placing in a 6 point restraint.
(C) On 4/12/17 at 0015 hours, the patient swallowed a spork and was hitting and kicking staff who were trying to prevent the behavior. He/she was placed in the restraint chair per order. The medical record lacked evidence that least restrictive hold/restraint was utilized prior to the 6 point restraint.
(I) Nurses notes on 5/29/17 at 2150 hours indicated the patient was oppositional and defiant with staff and his/her room was stripped of all belongings.

3. Review of patient #5 medical record indicated the following:
(A) Per the Psychiatric Initial Assessment, the patient was admitted to the unit on 1/9/17 with anger issues and reason for hospitalization listed was as danger to self and others.
(B) The medical record indicated that the patient was tearing down ceiling and camera with peers present at 1740 hours on 5/25/17. The patient was placed in 6 point restraint chair per order. The seclusions/restraint form stated on page 2: "2) No time for interventions". The medical record lacked evidence that a least restrictive hold or restraint was attempted and had failed prior to initiating the 6 point restraint chair.
(C) The medical record indicated that the patient was displaying aggressive behavior at 1430 hours on 6/3/17. The narrative nursing progress notes indicated the patient was placed in hold to go directly to the restraint chair. The medical record lacked documentation that the staff allowed time to see if the hold would be effective prior to implementing a 6 point restraint.

4. Review of patient #9 medical record indicated the following:
(A) He/she was admitted on 10/6/16 and per Psychiatric Assessment, the patient had a history of physical abuse and was a victim of rape/sexual abuse or assault.
(B) Nurses notes dated 4/18/17 at 1900 hours indicated the patient was running from staff, jumping on top of tables, and pulling things off of the ceiling. Per nurses note, the patient was placed in the restraint chair. The medical record lacked documentation that a hold or least restrictive restraint was attempted and failed prior to placing the patient in a 6 point restraint.
(C) Nurses notes dated 5/1/17 at 1400 hours indicated that the patient was started back on 1:1 and "is isolated to room" because the patient tried to run from the elevator and running and hiding from staff once back on the unit. An order was written on 5/1/17 at 1415 hours for 1:1 and restricted to bedroom. The medical record lacked documentation that least restrictive interventions were attempted and failed prior to the room restriction.
(D) Nurses notes dated 5/2/17 at 1630 hours indicated that the patient attempted to swallow a plastic piece off of a toothpaste tube, however staff was able to get the piece from the patient. The notes indicated that staff told the patient that they would be placed in a papergown and the patient became upset and threw a brush at the staff member. The patient then tore a piece from the brush and attempted to place it in his/her mouth with staff intervening and removing the piece. The patient then ran from the staff and began cussing and screaming and punching the wall. The patient was placed in the restraint chair. An order was written on 5/2/17 at 1658 hours to place the patient in the restraint chair. The medical record lacked documentation that a hold or less restrictive restraint was implemented and failed prior to placing the patient in a 6 point restraint.
(E) Nursing documentation dated 5/9/17 at 1855 hours indicated that the patient had superficial cuts on his/her arms, had attempted to swallow an object (pen lid) and was assaultive toward staff. The patient was placed in the restraint chair per order. The medical record lacked evidence of least restrictive hold/restraint implemented with failure prior to placing the patient in the 6 point restraint.
(F) Nursing documentation dated 5/20/17 indicated that the patient was found in their room with ear bud cord around neck and standing on a basket and also swallowed a zipper. The patient was placed in the restraint chair per order at 2015 hours on 5/20/17 due to behavior dangerous to self or others. The medical record lacked evidence of least restrictive hold/restraint implemented with failure prior to placing the patient in the 6 point restraint.

5. Staff member #1 (Director of Quality) indicated on 6/9/17 at 11:40 a.m. that there were no documentation that adequate interventions were attempted prior to placing patients in a restraint chair.

6. Staff member #6 (RN) indicated in interview at 3:40 p.m. on 6/8/17 that the restraint chair restrains bilateral arms, bilateral legs, waist and shoulder.

Based on document review and interview, the facility failed to modify the patients care plan when restraint and/or seclusion were utilized for 2 of 11 patients (#1 and #9).

Findings include;

1. Facility policy titled "Seclusion and Restraint Policy" last reviewed/revised 7/15 states on page 3 of 15 under Procedures and Responsibilities: ".....4. The use of restraint or seclusion must be--i. In accordance with a written modification to the patients plan of care;....."

2. Review of patient #1 medical record indicated the following:
(A) Per the Psychiatric Initial Assessment form, the patient was admitted to the facility on 8/4/16 for "Worsening depression and suicidal thoughts.....".
(B) The patient took an overdose of medication while on a leave and returned to the facility after a hospital stay on 4/2/17. Per nurses notes at 2149 hours on 4/2/17, upon arrival to the facility at approximately 1600 hours the patient was placed in a hospital gown, 1:1 24/7 and was to sleep in the quiet room at all times. Nurses notes at 0229 hours on 4/3/17 indicated the patient remained on 1:1 watch 24/7, in quiet room wearing a hospital gown.
(C) On 4/8/17 at 1945 hours, the patient was behind the nurses station to make a call and picked up a AA battery and swallowed it as well as a piece of plastic. The patient was placed in a hold and then in a restraint chair. Nurses notes on 4/9/17 at 0120 indicated that the patient returned from facility #2 and was placed on 1:1 24/7, placed in quiet room with gown and underwear and no bra. Nurses notes on 4/9/17 at 0500 hours indicated that the patient remained on a 1:1, was sleeping in the quiet room in gown and underwear with the light on for Suicidal ideations and self injurious behavior. Nurses notes on 4/10/17 at 0420 hours indicated the patient remained in the quiet room with gown and underwear, was on a 1:1 and the lights were on in the room.
(D) On 4/12/17 at 0015 hours, the patient swallowed a spork and was hitting and kicking staff trying to prevent the behavior. He/she was placed in the restraint chair per order. An order was written on 4/12/17 at 0540 hours for patient to be placed on 2:1 24/7 papergown with underwear and no bra, nothing in room, contraband check every shift and prn (as needed), no blankets or sheets until further review. An order was written on 4/14/17 at 0900 hours for patient to remain on 2:1 24/7, paper gown only with no ties, no personal items, no blanket, no sheet and no clothing. The restrictions continued through 4/15/17.
(E) Nurses notes on 4/16/17 at 2200 hours indicated the patient was restarted on Suicidal ideation (SI) and Self injurious behavior (SIB) precautions for attempting to swallow a piece of a Styrofoam cup. The note indicated the patient remained on a 2:1 in the quiet room at all times.
(F) Nurses notes on 4/18/17 at 1315 hours indicated the patient remained on a 2:1, in paper gown and in quiet room. Nurses notes on 4/18/17 at 2208 indicated the patient remained in the quiet room. Nurses notes on 4/19/17 at 2235 indicated the patient remained on a 2:1 24/7, paper gown and quiet room at all times. Nurses notes on 4/20/17 at 1440 hours indicated the patient remained on a 2:1 in the quiet room but was allowed to wear hospital blues vs the paper gown.
(G) Nurses notes on 4/21/17 at 1407 hours indicated the patient was changed to a 1:1 and remained in quiet room.
(H) The medical record lacked documentation of restraints and use of quiet room for seclusion being addressed in the treatment plan.

3. Review of patient #9 medical record indicated the following:
(A) He/she was admitted on 10/6/16 and per Psychiatric Assessment, the patient had a history of physical abuse and was a victim of rape/sexual abuse or assault.
(B) An order was written at 1930 hours on 4/3/17 to place patient in paper gown and quiet room at all times with strict 15 minute checks. Nurses notes on 4/3/17 at 2148 hours indicated the patient was placed on precautions due to scratching self in arm with a broken zip tie and that the patient was placed in the quiet room at all times with a paper gown on. Per nurses notes, the patient remained in the paper gown and in the quiet room until 0950 hours on 4/6/17.
(C) Nurses notes dated 4/7/17 at 1018 indicated that there was contraband found in the patients room (pencil and eraser) and patient was placed back in paper gowns and quiet room per order. An order was written at 1000 on 4/8/17 to place patient in paper gown and quiet room with every 15 minute checks with door open and no interaction with peers or staff. An order was written at 2358 hours on 4/8/17 to continue a 1:1, 1 gown only with underwear, nothing in room (books, pencils) and contraband check every shift. An order was written on 4/14/17 at 1130 for patient to remain on 1:1, in paper gown until 4/17/17. Nurses notes on 4/12/17 at 1330 hours indicated the patient continued to be in paper gown and 1:1 but was moved "from restraint room back to pt room."
(D) Nurses notes dated 4/18/17 at 1900 hours indicated the patient was running from staff, jumping on top of tables, and pulling things off of the ceiling. Per nurses note, the patient was placed in the restraint chair.
(E) Nurses notes dated 4/19/17 at 2230 hours indicated that several suicide notes had been found in the patients room and 1:1 was maintained and paper gown only implemented. An order was written on 4/19/17 at 1530 hours to place the patient on 1:1, put in paper gown and in quiet room. Nurses notes dated 4/20/17 at 1945 hours indicated that the patient remained on 1:1, in a paper gown and "must stay in room besides hygiene daily".
(F) Nurses notes dated 5/1/17 at 1400 hours indicated that the patient was started back on 1:1 and "is isolated to room" because the patient tried to run from the elevator and running and hiding from staff once back on the unit. An order was written on 5/1/17 at 1415 hours for 1:1 and restricted to bedroom.
(G) Nurses notes dated 5/2/17 at 1630 hours indicated that the patient attempted to swallow a plastic piece off of a toothpaste tube, however staff was able to get the piece from the patient. The notes indicated that staff told the patient that they would be placed in a papergown and the patient became upset and threw a brush at the staff member. The patient then tore a piece from the brush and attempted to place it in his/her mouth with staff intervening and removing the piece. The patient then ran from the staff and began cussing and screaming and punching the wall. The patient was placed in the restraint chair. An order was written on 5/2/17 at 1658 hours to place the patient in the restraint chair and an order was written at 1700 hours on same date to place the patient in a paper gown.
(H) Nurses notes dated 5/5/17 at 0442 hours indicated the patient remained in paper gowns and was restricted to bedroom. The paper gown and 1:1 was discontinued at 0930 on 5/8/17.
(I) Nursing documentation dated 5/9/17 at 1855 hours indicated that the patient had superficial cuts on his/her arms, had attempted to swallow an object (pen lid) and was assaultive toward staff. The patient was placed in the restraint chair per order. An order was written on 5/9/17 at 1930 hours for 1:1 24/7, paper gown with no bra and 1 blanket.
(J) Nursing documentation dated 5/20/17 at 0845 hours (based on order review and restraint documentation review, possible this time should be 2045 hours and not a.m.) indicated that the patient was found in their room with ear bud cord around neck and standing on a basket and also swallowed a zipper. The patient was placed in the restraint chair per order at 2015 hours on 5/20/17 due to behavior dangerous to self or others. An order was written on 5/20/17 at 2040 hours for 1:1 observation 24/7, papergown with no bra or shoes and may have 1 blanket, underwear and socks.
(K) Nurses notes dated 5/21/17 at 2220 hours indicated the patient remained on a 1:1 and in a paper gown and was found with a paper clip and a plastic piece which were taken from the patient. The medical record indicated the patient remained in paper gown until 5/26/17.
(L) Nurses notes dated 5/30/17 at 1930 hours indicated that staff noticed a crayon drawing signed by the patient on the wall. When questioning the patient, the patient responded with "I don't know" and "I wanted to". The note indicated the patient was placed back on 1:1 and paper gown. An order was written on 5/30/17 at 2000 hours to place patient on 1:1 observation 24/7 and paper gowns due to behavior. The order was discontinued at 1015 on 5/31/17.
(M) The medical record lacked documentation that the care plan/treatment plan was updated to include use of restraints, seclusion and paper gowns.

4. Staff member #3 (Unit Director) indicated the following in interview beginning at 1:15 p.m. on 6/8/17:
(A) Yellow gowns are used for safety of patients.
(B) He/she indicated that patients stay in their room when in yellow gown. Indicated that the patient can come out, but they do not.

5. Patient #8 indicated the following in interview beginning at 3:20 p.m. on 6/8/17:
(A) Patients are placed on a 1:1 when they self harm and are placed in a yellow gown.
(B) The patients have to stay in their room if they are in the yellow gowns and staff make them stay in their room. The patients are half naked when in the gowns.

6. Staff member #6 (RN) indicated the following in interview beginning at 3:40 p.m. on 6/8/17:
(A) When patients are placed in paper gowns, they are kept in their rooms for privacy. Patients are given a sheet if they have to go out into the hall.
(B) Sometimes patients are placed on a 2:1 to prevent the patient from running out of the room.

7. Staff member #1 (Director of Quality) verified at 11:40 a.m. on 6/9/17 that there was no update to patients #1 and #9 care plan/treatment plan.

Based on document review, interview, and observation the facility failed to obtain orders for seclusion for 2 of 11 patients (#1 and 9).

Findings include;

1. Facility policy titled "Seclusion and Restraint Policy" last reviewed/revised 7/15 states on page 3 of 15 under Procedures and Responsibilities: "5. The use of restraint or seclusion must be in accordance with the order of a physician......"

2. Review of patient #1 medical record indicated the following:
(A) Per the Psychiatric Initial Assessment form, the patient was admitted to the facility on 8/4/16 for "Worsening depression and suicidal thoughts.....".
(B) The patient took an overdose of medication while on a leave and returned to the facility after a hospital stay on 4/2/17. Per nurses notes at 2149 hours on 4/2/17, upon arrival to the facility at approximately 1600 hours the patient was placed in a hospital gown, 1:1 24/7 and was to sleep in the quiet room at all times. Nurses notes at 0229 hours on 4/3/17 indicated the patient remained on 1:1 watch 24/7, in quiet room wearing a hospital gown. The 1:1 was discontinued at 1300 hours on 4/3/17. The medical record lacked documentation of an order for seclusion when the patient was required to remain in the quiet room after readmission to the facility on 4/2/17 until 4/3/17.
(C) On 4/8/17 at 1945 hours, the patient was behind the nurses station to make a call and picked up a AA battery and swallowed it as well as a piece of plastic. An order was written at 2000 hours on 4/8/17 to place patient in a yellow gown and to keep patient 1:1. Nurses notes on 4/9/17 at 0120 indicated that the patient was placed on 1:1 24/7, placed in quiet room with gown and underwear and no bra. Nurses notes on 4/9/17 at 0500 hours indicated that the patient remained on a 1:1, was sleeping in the quiet room in gown and underwear. Nurses notes on 4/10/17 at 0420 hours indicated the patient remained in the quiet room with gown and underwear. The medical record lacked documentation of an order for seclusion for patient placement in the quiet room beginning on 4/8/17.
(D) On 4/12/17 at 0015 hours, the patient swallowed a spork and was hitting and kicking staff trying to prevent the behavior. An order was written on 4/12/17 at 0540 hours for patient to be placed on 2:1 24/7 papergown with underwear. An order was written on 4/14/17 at 0900 hours for patient to remain on 2:1 24/7. The restrictions continued through 4/15/17. The medical record lacked documentation of an order for seclusion for patient after paper gowns were order which would require patient to stay in room beginning on 4/12/17.
(E) Nurses notes on 4/16/17 at 2200 hours indicated the patient was restarted on Suicidal ideation (SI) and Self injurious behavior (SIB) precautions for attempting to swallow a piece of a Styrofoam cup. The note indicated the patient remained on a 2:1 in the quiet room at all times which continued until 4/24/17.

3. Review of patient #9 medical record indicated the following:
(A) He/she was admitted on 10/6/16 and per Psychiatric Assessment, the patient had a history of physical abuse and was a victim of rape/sexual abuse or assault.
(B) An order was written at 1930 hours on 4/3/17 to place patient in paper gown and quiet room at all times with strict 15 minute checks. Nurses notes on 4/3/17 at 2148 hours indicated the patient was placed on precautions due to scratching self in arm with a broken zip tie and that the patient was placed in the quiet room at all times with a paper gown on. Per nurses notes, the patient remained in the paper gown and in the quiet room until 0950 hours on 4/6/17. The record lacked documentation of an order for seclusion from 4/3/17 to 4/6/17.
(C) Nurses notes dated 4/7/17 at 1018 indicated that there was contraband found in the patients room (pencil and eraser) and patient was placed back in paper gowns and quiet room per order. An order was written at 1000 on 4/8/17 to place patient in paper gown and quiet room with every 15 minute checks with door open and no interaction with peers or staff. An order was written at 2358 hours on 4/8/17 to continue a 1:1, 1 gown only with underwear. An order was written on 4/14/17 at 1130 for patient to remain on 1:1, in paper gown until 4/17/17. Nurses notes on 4/12/17 at 1330 hours indicated the patient continued to be in paper gown and 1:1 but was moved "from restraint room back to pt room." The patient had no further self injurious behavior and the 1:1 and paper gown was discontinued on 4/17/17.
(D) Nurses notes dated 4/19/17 at 2230 hours indicated that several suicide notes had been found in the patients room and 1:1 was maintained and paper gown only implemented. An order was written on 4/19/17 at 1530 hours to place the patient on 1:1, put in paper gown and in quiet room. Nurses notes dated 4/20/17 at 1945 hours indicated that the patient remained on 1:1, in a paper gown and "must stay in room besides hygiene daily". The medical record lacked documentation of an order for seclusion. The patient was back among peers on 4/23/17.
(E) Nurses notes dated 5/1/17 at 1400 hours indicated that the patient was started back on 1:1 and "is isolated to room" because the patient tried to run from the elevator and running and hiding from staff once back on the unit. An order was written on 5/1/17 at 1415 hours for 1:1 and restricted to bedroom. The medical record lacked documentation that an order for seclusion was obtained.
(F) Nurses notes dated 5/2/17 at 1630 hours indicated that the patient attempted to swallow a plastic piece off of a toothpaste tube, however staff was able to get the piece from the patient. The notes indicated that staff told the patient that they would be placed in a papergown and the patient became upset and threw a brush at the staff member. The patient then tore a piece from the brush and attempted to place it in his/her mouth with staff intervening and removing the piece. The patient then ran from the staff and began cussing and screaming and punching the wall. An order was written on 5/2/17 at 1658 hours to place the patient in the restraint chair and an order was written at 1700 hours on same date to place the patient in a paper gown. The medical record lacked documentation of an order for seclusion.
(G) Nurses notes dated 5/5/17 at 0442 hours indicated the patient remained in paper gowns and was restricted to bedroom. The paper gown and 1:1 was discontinued at 0930 on 5/8/17.
(H) Nursing documentation dated 5/9/17 at 1855 hours indicated that the patient had superficial cuts on his/her arms, had attempted to swallow an object (pen lid) and was assaultive toward staff. An order was written on 5/9/17 at 1930 hours for 1:1 24/7, paper gown with no bra and 1 blanket. The medical record lacked documentation of an order for seclusion.
(I) An order was written on 5/16/17 at 0915 hours to discontinue the paper gowns and precautions due to no behaviors x 7 days.
(J) Nursing documentation dated 5/20/17 at 0845 hours (based on order review and restraint documentation review, possible this time should be 2045 hours and not a.m.) indicated that the patient had been found in their room with ear bud cord around neck and standing on a basket and also swallowed a zipper. An order was written on 5/20/17 at 2040 hours for 1:1 observation 24/7, papergown with no bra. Nurses notes dated 5/21/17 at 2220 hours indicated the patient remained on a 1:1 and in a paper gown. The medical record indicated the patient remained in paper gown until 5/26/17.
(K) Nurses notes dated 5/30/17 at 1930 hours indicated that staff noticed a crayon drawing signed by the patient on the wall. When questioning the patient, the patient responded with "I don't know" and "I wanted to". The note indicated the patient was placed back on 1:1 and paper gown. An order was written on 5/30/17 at 2000 hours to place patient on 1:1 observation 24/7 and paper gowns due to behavior. The order was discontinued at 1015 on 5/31/17.

4. Staff member #1 (Director of Quality) indicated on 6/9/17 at 11:40 a.m. that there were no seclusion orders written for patients #1 or #9.

5. Patient #8 indicated the following in interview beginning at 3:20 p.m. on 6/8/17:
(A) Patients are placed on a 1:1 when they self harm and are placed in a yellow gown. He/she has not been placed in a yellow gown, but 1 of the patients frequently has been.
(B) When a patient is in a yellow gown, the patients have to stay in their room and staff make them stay in their room. The patients are half naked when in the gowns.

6. Staff member #6 (RN) indicated the following in interview beginning at 3:40 p.m. on 6/8/17:
(A) When patients are placed in paper gowns, they are kept in their rooms for privacy.
(B) Sometimes patients are placed on a 2:1 to prevent the patient from running out of the room.

7. Observation of the yellow hospital gowns used for patients with physician order indicated the gowns were completely transparent and all body parts would be visible under the gown.

Based on document review and observation, the facility kept patients in seclusion for extended periods of time for 2 of 11 patients (patients #1 and 9).

Findings include;

1. Facility policy titled Seclusion and Restraint Policy last reviewed/revised 7/15 states on page 4 of 15: 1. Each order for restraint or seclusion used for the management of violent or self destructive behavior.....may only be renewed in accordance with the following limits for up to a total of 24 hours:.....b. 2 hours for children and adolescents 9 to 17 years of age....."

2. Review of patient #1 (adolescent) medical record indicated the following:
(A) Per the Psychiatric Initial Assessment form, the patient was admitted to the facility on 8/4/16 for "Worsening depression and suicidal thoughts.....".
(B) The patient took an overdose of medication while on a leave and returned to the facility after a hospital stay on 4/2/17. Per nurses notes at 2149 hours on 4/2/17, upon arrival to the facility at approximately 1600 hours the patient was placed in a hospital gown, 1:1 24/7 and was to sleep in the quiet room at all times. Nurses notes at 0229 hours on 4/3/17 indicated the patient remained on 1:1 watch 24/7, in quiet room wearing a hospital gown. The 1:1 was discontinued at 1300 hours on 4/3/17.
(C) On 4/8/17 at 1945 hours, the patient was behind the nurses station to make a call and picked up a AA battery and swallowed it as well as a piece of plastic. An order was written at 2000 hours on 4/8/17 to place the patient in the restraint chair for up to 2 hours, place patient in a yellow gown and to keep patient 1:1. Nurses notes on 4/9/17 at 0120 indicated that the patient was placed on 1:1 24/7, placed in quiet room with gown and underwear and no bra. Nurses notes on 4/9/17 at 0500 hours indicated that the patient remained on a 1:1, was sleeping in the quiet room in gown and underwear. Nurses notes on 4/10/17 at 0420 hours indicated the patient remained in the quiet room with gown and underwear, was on a 1:1.
(D) On 4/12/17 at 0015 hours, the patient swallowed a spork and was hitting and kicking staff trying to prevent the behavior. An order was written on 4/12/17 at 0540 hours for patient to be placed on 2:1 24/7 papergown with underwear and no bra. An order was written on 4/14/17 at 0900 hours for patient to remain on 2:1 24/7, paper gown only. The restrictions continued through 4/15/17.
(E) Nurses notes on 4/18/17 at 1315 hours indicated the patient remained on a 2:1, in paper gown and in quiet room. Nurses notes on 4/18/17 at 2208 indicated the patient remained in the quiet room. Nurses notes on 4/19/17 at 2235 indicated the patient remained on a 2:1 24/7, paper gown and quiet room at all times. Nurses notes on 4/20/17 at 1440 hours indicated the patient remained on a 2:1 in the quiet room but was allowed to wear hospital blues vs the paper gown.
(F) Nurses notes on 4/21/17 at 1407 hours indicated the patient was changed to a 1:1 and remained in quiet room.
(G) Nurses notes on 4/24/17 at 1330 hours indicated the patient was "off precautions".

3. Review of patient #9 (adolescent) medical record indicated the following:
(A) He/she was admitted on 10/6/16 and per Psychiatric Assessment, the patient had a history of physical abuse and was a victim of rape/sexual abuse or assault.
(B) An order was written at 1930 hours on 4/3/17 to place patient in paper gown and quiet room at all times with strict 15 minute checks. Nurses notes on 4/3/17 at 2148 hours indicated the patient was placed on precautions due to scratching self in arm with a broken zip tie and that the patient was placed in the quiet room at all times with a paper gown on. Per nurses notes, the patient remained in the paper gown and in the quiet room until 0950 hours on 4/6/17.
(C) Nurses notes dated 4/7/17 at 1018 indicated that there was contraband found in the patients room (pencil and eraser) and patient was placed back in paper gowns and quiet room per order. An order was written at 1000 on 4/8/17 to place patient in paper gown and quiet room. An order was written at 2358 hours on 4/8/17 to continue a 1:1, 1 gown only with underwear. An order was written on 4/14/17 at 1130 for patient to remain on 1:1, in paper gown until 4/17/17. Nurses notes on 4/12/17 at 1330 hours indicated the patient continued to be in paper gown and 1:1 but was moved "from restraint room back to pt room." The patient had no further self injurious behavior and the 1:1 and paper gown was discontinued on 4/17/17.
(D) Nurses notes dated 4/19/17 at 2230 hours indicated that several suicide notes had been found in the patients room and 1:1 was maintained and paper gown only implemented. An order was written on 4/19/17 at 1530 hours to place the patient on 1:1, put in paper gown and in quiet room. Nurses notes dated 4/20/17 at 1945 hours indicated that the patient remained on 1:1, in a paper gown and "must stay in room besides hygiene daily". The patient was out of quiet room and back among peers on 4/23/17.
(E) Nurses notes dated 5/1/17 at 1400 hours indicated that the patient was started back on 1:1 and "is isolated to room" because the patient tried to run from the elevator and running and hiding from staff once back on the unit. An order was written on 5/1/17 at 1415 hours for 1:1 and restricted to bedroom.
(G) Nurses notes dated 5/2/17 at 1630 hours indicated that the patient attempted to swallow a plastic piece off of a toothpaste tube, however staff was able to get the piece from the patient. The notes indicated that staff told the patient that they would be placed in a papergown and the patient became upset and threw a brush at the staff member. The patient then tore a piece from the brush and attempted to place it in his/her mouth with staff intervening and removing the piece. The patient then ran from the staff and began cussing and screaming and punching the wall. An order was written on 5/2/17 at 1700 hours to place the patient in a paper gown.
(H) Nurses notes dated 5/5/17 at 0442 hours indicated the patient remained in paper gowns and was restricted to bedroom. The paper gown and 1:1 was discontinued at 0930 on 5/8/17.
(I) Nursing documentation dated 5/9/17 at 1855 hours indicated that the patient had superficial cuts on his/her arms, had attempted to swallow an object (pen lid) and was assaultive toward staff. An order was written on 5/9/17 at 1930 hours for 1:1 24/7, paper gown with no bra and 1 blanket.
(J) An order was written on 5/16/17 at 0915 hours to discontinue the paper gowns and precautions due to no behaviors x 7 days.
(K) Nursing documentation dated 5/20/17 at 0845 hours (based on order review and restraint documentation review, possible this time should be 2045 hours and not a.m.) indicated that the patient had been found in their room with ear bud cord around neck and standing on a basket and also swallowed a zipper. An order was written on 5/20/17 at 2040 hours for 1:1 observation 24/7, papergown with no bra.
(L) Nurses notes dated 5/21/17 at 2220 hours indicated the patient remained on a 1:1 and in a paper gown and was found with a paper clip and a plastic piece which were taken from the patient. The medical record indicated the patient remained in paper gown until 5/26/17.
(M) Nurses notes dated 5/30/17 at 1930 hours indicated that staff noticed a crayon drawing signed by the patient on the wall. When questioning the patient, the patient responded with "I don't know" and "I wanted to". The note indicated the patient was placed back on 1:1 and paper gown. An order was written on 5/30/17 at 2000 hours to place patient on 1:1 observation 24/7 and paper gowns due to behavior. The order was discontinued at 1015 on 5/31/17.

4. Patient #8 indicated the following in interview beginning at 3:20 p.m. on 6/8/17:
(A) Patients are placed on a 1:1 when they self harm and are placed in a yellow gown.
(B) When a patient is in a yellow gown, the patients have to stay in their room and staff make them stay in their room. The patients are half naked when in the gowns.

5. Staff member #6 (RN) indicated the following in interview beginning at 3:40 p.m. on 6/8/17:
(A) When patients are placed in paper gowns, they are kept in their rooms for privacy.
(B) Sometimes patients are placed on a 2:1 to prevent the patient from running out the room.

6. Observation of the yellow hospital gowns used for patients with physician order indicated the gowns were completely transparent and all body parts would be visible under the gown.