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Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for care planning, the Hospital failed to ensure that patient's representative participated in the development and implementation of the plan of care.

Findings include:

1. On 9/4/19 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on 8/10/19 with a diagnosis of disruptive mood dysregulation disorder (depressive disorder in the youth). The clinical record indicated that S1 (Pt. #1's mother) was Pt. #1's guardian and representative. The clinical record did not indicate concerns that would limit S1 being involved in Pt. #1's care.

2. On 9/5/19 at approximately 2:30 PM, the Hospital's Job Description for Registered Nurse (undated) was reviewed and included, " ...The Registered Nurse prescribes, coordinates ... nursing care utilizing the nursing process which is integrated into the multidisciplinary treatment plan of care. The Registered Nurse is accountable for assigned nursing care activities on a shift basis and is responsible for promoting and enhancing professional practice on the unit ..."

3. On 9/5/19 at approximately 3:00 PM, the Hospital's policy titled, "Patient Rights" (revised 9/2019) was reviewed and included, " ... (To receive individual evaluations and individual treatment based upon your needs and goals) ... To have medical treatment when it is necessary ..."

4. On 9/6/19 at approximately 1:30 PM The Hospital's policy titled, " Interdisciplinary Treatment Planning Process" (revised 2/2019) was reviewed and included, "Each patient admitted to the (Hospital) will have a written, individualized comprehensive treatment plan ...the treatment identifies what specific problems/disabilities will be treated during patient's hospitalization ...Patients, families and significant others are involved in the treatment planning process as deemed clinically appropriate."

5. On 9/4/19 at approximately 3:41 PM, an interview was conducted with E #3 (Registered Nurse). E #3 stated that S1 approached her (E #3) during visitation and told her (E #3) that Pt. #1 was complaining of pain on his (Pt. #1's) right shoulder. E #3 stated that prior to S1's visit, she (E #3) had already assessed Pt. #1 for pain, and that Pt. #1 did not complain of pain. However, E #3 stated that Pt. #1 would become non-verbal at times, keep quiet and not say anything. E #3 later said, "I should have documented (S1's) concern for pain, reassessed Pt. #1, and have notifed the physician." E #3 also stated that the care plan should have been updated.

6. The "Interdisciplinary Master Treatment Plan" dated 8/10/19 to 8/22/19 indicate that Pt. #1's care plan did not include pain management and participation of Pt. #1's mother (S1) in care plan development.

7. On 9/5/19 at approximately 4:10 PM, the Interim Director of Nursing (E #8) was interviewed. E #8 stated that it is the expectation that nurses to notify the physician of an incident, concern or issue that has been identified. E #8 added that the plan of care should be updated to reflect new issues or concerns.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #2) clinical records reviewed regarding utilization of restraint/seclusion, the Hospital failed to ensure that written modification to the patient's plan of care was completed, as required.

Findings include:

1. On 9/4/19 at approximately 11:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 7/6/19 with a diagnosis of major depressive disorder. The clinical record indicated that Pt. #2 was placed in restraint and/or seclusion on 8/18/19, 8/21/19, and 8/28/19. However, the clinical record lacked documentation that Pt. #2's treatment plan was modified, to indicate the use of restraint and/or seclusion.

2. On 9/4/19 at approximately 1:00 PM, the Hospital's policy titled, "Restraint and Seclusion" (5/2019) was reviewed and included, "... (The Hospital) is committed to preventing, reducing, and striving to eliminate the use of restraints and seclusion... Action Steps... 12. Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion were indicated, a review and modification of the treatment plan is indicated... the RN (Registered Nurse) or social worker shall review and update the treatment plan within 8 hours of completion of the restrictive intervention... The updated treatment plan shall reflect goals and interventions related to prevention of the further use of restraint/seclusion..."

3. On 9/4/19 at approximately 3:25 PM, an interview was conducted with E #2 (Registered Nurse/Nursing Supervisor). E #2 stated that care plan should be modified whenever a patient is placed in restraint.

4. On 9/5/19 at approximately 9:30 AM, findings were discussed with E #1 (Director of Risk Management and Performance Improvement). E #1 stated that Pt. #2's treatment plan was not modified to indicate use of restraint or seclusion.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #2) clinical records reviewed regarding utilization of restraint/seclusion, the Hospital failed to authenticate a telephone order, to ensure that the use of restraint or seclusion was in accordance with the order of a physician.

Findings include:


1. On 9/4/19 at approximately 11:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 7/6/19 with a diagnosis of major depressive disorder. The clinical record indicated that telephone orders were obtained on 8/18/19, 8/21/19 and 8/28/19 for Pt. #2 to be placed in restraint and/or seclusion. However, as of survey date 9/4/19, the telephone orders lacked the physician's signature.

2. On 9/4/19 at approximately 1:00 PM, the Hospital's policy titled, "Restraint and Seclusion" (revised 5/19) was reviewed and included, ""... (The Hospital) is committed to preventing, reducing, and striving to eliminate the use of restraints and seclusion... Action Steps... 4. Physician Orders... 1. Restraint or seclusion shall be used in emergency situation only and required an order from a physician... 4. A physician shall authenticate the telephone/verbal order within 48 hours..."

3. On 9/4/19 at approximately 11:30 AM, findings were discussed with E #1 (Director of Risk Management and Performance Improvement). E #1 stated that the telephone order should have been signed by the physician within 72 hours.

4. On 9/4/19 at approximately 3:25 PM, an interview was conducted with E #2 (Registered Nurse/Nursing Supervisor). E #2 stated that the telephone order should be signed by the physician "quickly." E #2 stated, "I am not sure of the time frame... (E #1) would know that."