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Based on policy review, record review, observation and staff interview it was determined the facility failed to honor the right of one (#3) of 11 sampled patients to inform the designated patient representative of changes in the patient's status.

Findings included:

The facility policy "Seclusion, Physical & Chemical Restraint", policy number NS1010, revised date 6/30/15 was reviewed on 8/11/16. Page 6 of the policy indicated the family and or significant other will be contacted about the seclusion, physical or chemical restraint episode if the patient has consented to have them informed.

The record for Patient #3 included the Psychosocial Assessment dated 6/18/16. Page 5 included a section indicating the facility will contact family members to provide updates on treatment with the patient's authorization. This was marked "yes". The designated area was filled in with the name and telephone number of the person the patient wanted updated regarding the patient's treatment.

The record for Patient #3 contained 11 Authorizations to Disclose Healthcare Information forms signed by the patient authorizing disclosure of information them. Among the 11 signed authorizations was one naming the same person as was indicated on Page 5 of the Psychosocial Assessment as being authorized by the patient to have access to the patient's privileged health information.

The record included documentation on 6/27/16 that Patient #3 was given a chemical restraint on an emergency basis. The record failed to reveal evidence the patient's designated person was notified of the use of the chemical restraint.

The Progress Notes dated 7/26/16 at 6:25 p.m. indicated Patient #3 was placed in seclusion for behavior for one hour. The record failed to reveal evidence the patient's designated person was notified of Patient #3 being placed in seclusion.

An interview was conducted with the Charge Nurse on Unit B at the time of the tours on 8/11/16 regarding policies and procedures related to the use of chemical restraints and seclusion. The Charge Nurse indicated her responsibilities included notifying the person designated as the emergency contact by the patient. A chart was selected at random from those on the unit. The Charge Nurse was asked to demonstrate how she would identify which person to notify if it were necessary for that patient. The Charge Nurse indicated she would check the Emergency Contact information on the Face Sheet. That area was observed to be blank. She then leafed through several pages of the record looking at the Authorization to Disclose Healthcare Information forms. She chose one of the three forms and indicated the person named on that form would be the one she notified. She indicated she did not know of a single designated area where the identity of the person identified by the patient as the person to notify was documented other than the Emergency Contact area on the Face Sheet of the record.

An interview and record review was conducted with Risk Manager on 8/11/16 at approximately 3:00 p.m. The Risk Manager confirmed the finding the facility failed to ensure the designated person was notified of the chemical restraint and seclusion events in compliance with facility policy.

Based on record review and staff interview it was determined the facility failed to ensure the staff provided care and services in a safe environment one (#3) of 11 sampled records.

Findings included:

1. The Progress Notes dated 7/11/16 at 7:45 p.m. indicated Patient #3 was found by the roommate hanging from a bathroom door by a sheet tied around the neck.

Orders dated 7/9/16 at 11:09 a.m. and signed by the nurse practitioner included directions to maintain Patient #3 on line of sight observation status.

An interview was conducted with the Risk Manager on 8/11/16 at 2:35 p.m. The Risk Manager indicated she reviewed video tapes showing Patient #3 on the evening of 7/11/16. The Risk Manager indicated there were no staff members within line of sight of Patient #3. She confirmed the finding the staff failed to ensure Patient #3 was maintained on line of sight observation status as ordered for safety.

2. The Orders dated 6/19/16 at 7:20 p.m. and signed by the nurse practitioner included Patient #3 was permitted to use their own shampoo and conditioner and be allowed to shave with supervision.

The Progress Notes dated 7/26/16 at 6:25 p.m. indicated Patient #3 had a razor in their personal belongings.

A request to provide the facility policy related to patient shaving supplies resulted in being informed the facility did not have such a policy.

Interviews were conducted with multiple Mental Health Technicians (MHTs) related to the facility practice regarding patient shaving supplies on 8/11/16 at the time of the tours. Each MHT included information the MHT was required to maintain 1:1 direct supervision of the patient throughout the shaving process and dispose of a disposable razor in the sharps container located in the nurse's station or secure the patient's personal razor in a locked cabinet.

An interview was conducted with the Risk Manager (RM) on 8/11/16 at 2:35 p.m. She stated patient #3 had indicated to her in an interview at the time of the event that (the patient) had obtained the razor from within the facility. She indicated she was unable to determine exactly how Patient #3 had come to be in possession of a razor. The Risk Manager confirmed the finding the staff failed to ensure appropriate supervision to Patient #3.