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Based on record reviews, interviews, and review of the hospital's policy, titled, "Restraint and Seclusion", the hospital staff failed to ensure the Responsible Party for Patient #4 who was 1 of 2 patients reviewed for use of a Restraint Chair had received information on admission about the potential use of emergency measures such as restraint or seclusion. The hospital's form , titled, "Authorization to Share Information With Family and Others Form" had not been signed and was blank.

The findings included:

On 9/29/22 at 12:00 PM, review of Patient #4's chart revealed there was no documentation of the patient's (Date of Birth 6/12/2006) and/or Responsible Party (RP) acknowledgement on admission of the possible use of Seclusion/Restraint procedures. The hospital's form, titled, "SCDMH (South Carolina Department of Mental Health) TO OUR PATIENTS: A word about the use of seclusion and restraints" was blank and had not been signed by staff or the Patient/Guardian. During an interview on 9/29/22 at 12:23 PM, Performance Improvement Liaison #1 verified the M204 form, titled, "A Word About Use of Seclusion and Restraints" and the form titled, "Authorization to Share Information With Family and Others", was blank and had not been signed or completed on admission.

On 9/29/22 at 1:00 PM, review of the policy, provided by the hospital, entitled, "Restraint and Seclusion", revealed, "...The patient and/or family are informed of the DIS (Division of Inpatient Services) philosophy and policy on the use of restraint and seclusion to the extent that such information is not clinically contraindicated. The role of the family is discussed with the patient and, as appropriate, the patient's family." The information sheet, entitled, "To Our Patients: A Word About the Use of Seclusion and Restraints" (SCDMH form M208) contained information regarding the DIS philosophy and policy, the telephone number and mailing address of the SC Protection and Advocacy for the Handicapped, Inc. This document is discussed with the patient and/or family significant other, as appropriate by the social worker or intake counselor, as soon as is feasible after admission. The signed form is placed in the medical record. If it is not feasible to obtain the signature of the patient or family member, this is noted on the form by the social worker or intake counselor. If the parent or guardian of patients under sixteen (16) was informed of the seclusion/restraint policy by phone this information should be recorded on the form and the parent/guardian should sign the form at the first available opportunity. Notification of any patient's family is done in conjunction with the patient's right to confidentiality and as Indicated on the "Authorization to Share Information With Family and Others form" (M-450J rev 2010). Patient consent is required in some cases and for certain patient populations...".

Based on record reviews, interview, and review of the hospital's policy, titled, "Abuse, Neglect or Exploitation of Patients and Clients Prohibited", the hospital failed to ensure abuse training had been provided for 1 of 1 Behavioral Health Assistants (BHAs) reviewed for training.

The findings are:

On 9/29/22 at 10:11 AM, review of the hospital's grievance log and an Occurrence Report revealed Patient #1 had been the alleged victim of physical aggression by another patient on 9/6/22 and the incident was reported to a physician and a patient rights representative. Documentation revealed revealed Patient #1 alleged that BHA #10 did not intervene and had laughed during the incident. On 9/29/22 at 12:00 PM, review of BHA(Behavioral Health Assistant) #10's education and training records revealed there was no evidence of training on abuse and neglect. The finding was verified by Patient Advocate #1 who stated she/he would check and see if there was any documentation of abuse/neglect training for BHA #10. There was no documentation of abuse and neglect training for BHA #10 provided.

On 9/29/22 at 12:30 PM, review of the hospital's policy provided by the hospital, entitled, "Abuse, Neglect or Exploitation of Patients and Clients Prohibited", revealed under Knowledge and Training, "Each Facility Director and Center Director shall ensure that all employees review this directive and that all direct care employees receive sufficient training regarding actions which may constitute conduct prohibited by this directive and the procedures for reporting such conduct prior to the employee's assuming responsibility for the care and treatment of patients and clients...".

Based on record reviews, interview, and review of the hospital's policy, titled, "Restraint and Seclusion", the hospital staff failed to ensure physician orders for restraint or seclusion were documented for one of two patients reviewed with use of the Restraint Chair (Patient #4) and failed to document circulation checks every 30 minutes for 1 of 1 patient. (Patient #2)

The findings included:

On 9/29/22 at 12:30 PM, review of a nurse note dated 6/26/22 at 8:58 PM revealed Patient #4 had been in seclusion. There was no physician order for seclusion for that day. The finding was verified with Performance Improvement Liaison #2 during an interview on 9/29/22 at 12:15 PM.

Review of the hospital's Seclusion and Restraint Reports on 9/29/22 at 12:45 PM revealed the following:
On 7/30/22, a physical hold was used from 12:00 PM to 12:15 PM on Patient #4 to administer a medication. There was no physician order for the physical hold.

On 8/3/22, the restraint chair was used from 12:20 PM through 1:23 PM, but there was no physician order for the restraint chair use that day. The findings were verified by Performance Improvement Liaison #2 during an interview on 9/29/22 at 12:00 PM.

On 9/29/22 at 1:00 PM, review of the hospital's policy provided by the hospital, entitled, "Restraint and Seclusion" revealed "...Seclusion and Restraint are only ordered by a physician (SC Code of Laws Section 44-22-150) and are limited to emergency safety situations when non-physical interventions are ineffective or not viable...".


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On 09/29/2022 at 1:00 PM, review of the restraint monitoring logs for Patient #2 revealed there was no documentation of circulation checks while patient in the restraint chair on 8/01/2022. The findings were verified with the Performance Improvement Liaison #1 who showed the log sheets for the documentation of the continuous observation for Patient #2. There was an area to check off circulation checks, but no circulation checks were checked off on the restraint log daily sheets. Performance Improvement Liaison #1 stated, "Sometime the nurses chart their findings and interventions on a note on back of restraint log." No charting for circulation checks every 2 hours by nurses on the restraint logs for 8/01/2022.

Policy, "Restraint and Seclusion," reads, "The ordering physician or a LPP responsible for patient ' s ongoing care, treatment, and services conducts a face-to-face in person evaluation of the patient within one hour of the initiation of the restraint or seclusion. The face-to-face evaluation is documented in the appropriate section of the medical record." The Policy also states, "The continuous observation includes monitoring the following, as appropriate to restraint or seclusion: c. Circulation and range of motion in the extremities-circulation checks are carried out every 30 minutes for the patient in restraint. One limb at a time is released and range of motion is conducted at least every two (2) hours."

Based on record reviews, interview, and review of the "SoftGuard Safety Restraint Procedure for Use and Release", the hospital nursing staff failed to ensure appropriate monitoring for one of two patients reviewed with the use of a Restraint Chair. (Patient #4) Circulation checks were not documented as having been completed every 30 minutes while restrained in the restraint chair, and vital signs had not been documented after receiving As Needed (PRN) medication Intramuscularly (IM) for behaviors.

The findings are:

On 9/28/22 at 11:10 AM, review of the hospital's "Special Treatment Procedure Log" revealed Patient #4 was in the Restraint Chair on 8/1/22 at 2:00 PM, released at 4:00 PM to use the bathroom, and back in the chair at 4:13 PM. At 4:59 PM, the patient was released to eat dinner. At 5:15 PM, the patient was getting ready to shower. At 5:50 PM, the patient got back in the restraint chair. At 7:30 PM, the patient was released to go to bed.

On 8/2/22 at 9:35 AM, the patient was back in the restraint chair, out of the restraint chair at 10:32 AM to go to the bathroom, out of the restraint chair at 12:00 noon for lunch. On 8/2/22 at 12:41 PM, the restraint chair was in use, at 1:40 PM, the patient was out of the chair to use the bathroom. On 8/2/22 at 3:05 PM, the patient was out of restraint chair, back in the restraint chair at 3:30 PM, out of the restraint chair to eat dinner at 5:00 PM, taking a shower at 5:30 PM, and back in the restraint chair at 6:25 PM. Patient was released to go to bed at 7:30 PM.

On 8/3/22 at 12:20 PM, the patient was put back in restraint chair, and at 12:55 PM, the patient had to go to the restroom. At 12:58 PM the patient was put back in the restraint chair, and released at 1:23 PM.

During an interview on 9/29/22 at 1:30 PM, Performance Improvement Liaison #1 and #2 stated documentation of circulation checks while in restraints should be documented on the Special Treatment Procedure Log or in the nurse notes. They were unable to find documentation that the circulation checks had been completed by the nursing staff while Patient #4 had been in the restraint chair on 8/1/22, 8/2/22, or 8/3/22.


On 9/28/22 at 2:30 PM, review of the "SoftGuard Safety Restraint Chair" procedure for use and release, and additional information to be considered by (Education, Training, and Research) ETR leadership revealed circulation checks are carried out every 30 minutes for the patient in restraint. Vital signs, blood pressure, pulse, and respirations are taken one (1) hour after IM (Intramuscular) medication is administered.

On 9/29/22 at 11:00 AM, review of Patient #4's chart revealed the patient received Intramuscular (IM) medications, but did not have a blood pressure, pulse, and respirations documented within 1 hour. Review of the patient's Medication Administration Record (MAR) documentation revealed Patient #4 received Thorazine 50 mgs (milligrams) IM and Benadryl 50 mg IM at 4:29 PM on 7/27/22. On 7/28/22, the patient received Thorazine 100 mgs IM and Benadryl 100 mgs IM at 10:57 AM. On 7/30/22 at 12:10 PM, the patient received Benadryl 100 mgs IM and Zyprexa 10 mgs IM. On 8/1/22 at 1:27 PM and 1:29 PM, the patient received Benadryl 100 mgs IM and Zyprexa 10 mgs IM. During an interview on 9/29/22 at 11:27 AM, Performance Improvement Liaison #2 verified that vital signs had not been documented within 1 hour of receiving the "As Needed" IM prn medications. There was no documentation of refusals of vital signs.

On 9/29/22 at 12:30 PM, review of a nurse note dated 6/26/22 at 8:58 PM revealed Patient #4 had been in seclusion. Benadryl 50 mgs (milligrams) had been administered IM with no vital signs/refusals documented within 1 hour of the medication administration. The finding was verified with Performance Improvement Liaison #2 during an interview on 9/29/22 at 12:15 PM.

Based on record reviews, interviews, and a review of the hospital's policy, titled, "Restraint and Seclusion", the hospital failed to ensure the ordering physician or LPP (Licensed Prescribing Practitioner) performed a face-to face in person evaluation for one of two patients reviewed who had been restrained in a Restraint Chair and within 1 hour of initiation of the restraint or seclusion. (Patient #4)

The findings included:

On 9/29/22 at 12:30 PM, review of a nurse note dated 6/26/22 at 8:58 PM revealed Patient #4 had been in seclusion. A physician had assessed the patient on 6/26/22 at 10:28 PM which was more than 1 hour into seclusion. The finding was verified with Performance Improvement Liaison #2 during an interview on 9/29/22 at 12:15 PM.

Review of the hospital's Seclusion and Restraint Reports on 9/29/22 at 12:45 PM revealed the restraint chair was used from 12:20 PM through 1:23 PM on 8/3/22, but there was no face-to-face assessment documented by the physician for 8/3/22. The findings were verified by Patient Liaison #2 during an interview on 9/29/22 at 12:00 Noon.

On 9/29/22 at 1:00 PM, review of the hospital's policy provided by the hospital, entitled, "Restraint and Seclusion" revealed under "Physician Initiated Restraint or Seclusion- The physician authorizes the use of restraint or seclusion by entering the order into the appropriate section of the medical record and by completing the Face-to Face Evaluation within one (1) hour of the seclusion/restraint episode...".

Based on record reviews and interview, the nursing staff failed to ensure an X-Ray was completed as ordered for one of one patients reviewed who required medical monitoring. (Patient #4)

The findings included:


On 9/29/22 at 1:58 PM, review of Patient #4's chart revealed a Physician Progress Note dated 6/30/22 that the patient swallowed at least 2 screws. The patient was sent to the Emergency Department (ED) on 6/30/22 with a KUB (Kidney Ureter Bladder) X-Ray having been completed that showed the screws passing through the digestive tract. There was a recommendation to do another KUB on 7/4/22 to reassess. A physician order dated 7/1/22 at 4:50 PM was documented for an Xray of the Abdomen to be completed on 7/4/22 "to see if screws she/he had swallowed are visible." A review of physician notes and nurse notes revealed no documentation that another X-Ray was completed. The finding was verified by Performance Improvement Liasion #2 during an interview on 9/29/22 at 2:50 PM.