HospitalInspections.org

Based on a review of the clinical record and a facility incident report, the use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

Findings were:

An incident reported dated 9-16-17 at 8:10 pm stated that patient #1 was restrained from 8:10 pm to 8:20 pm due to [patient #1] attacking staff. The area marked "Nursing Assessment" (where any patient injuries would have been documented" was not completed by the nurse. Additional documentation attached to the incident reported stated:

"Pt [patient #1] got upset due to another peer getting into trouble with staff. Pt came out of the AR [activity room] with peers and refused to go back in. staff redirected pt several times to go back into the AR. Pt sat in hallway with peers. Once the hallway doors opened up pt went up to the nurse's station verbal escalation failed numerous times. Pt kept stating 'this is fucked up'. Numerous times pt then got with peers and started being verbally and physically aggressive towards staff. Pt told staff numerous times 'this is fucked up'. Pt then physically hit and spit on staff. Pt was then physically restrained by staff. Pt got upset with staff again. Pt then went down to the nurse's station by latency and started yelling down the hallway at staff saying 'bitch do something'. Pt was redirected by staff several times to go to room. Pt then had clothes taken out of room and was given blue scrubs. Pt and peers ripped blue scrubs up and said 'Im(sic) not wearing this shit'. Pt then was redirected by staff. Pt refused to go to PR [patient's room]. Pt then went into another pts(sic) room and they refused to come out. Staff went into PR and pt became verbally aggressive toward staff. Pt then let staff give medication and pt then went to PR. Will cont [continue] to monitor."

A review of physician's orders for patient #1 revealed an order written on 9-16-17 at 8:40 pm for an emergency injection of Thorazine 50 mg [milligrams] and Benadryl 50 mg intramuscularly. No order was found for the physical restraint. No restraint documentation paperwork was found and the clinical record for patient #1 as a whole provided no indication that the patient had been restrained during patient #1's stay.

Facility policy 1000.44 titled "Physical Restraint" states, in part:
"All physical restraints (therapeutic hold or escort) require a physician's order.
...
Procedure:
...
7. Clinically Competent Registered Nurse's Responsibilities
7.2 The RN [registered nurse] must secure a Physician's Order whether in person, verbal or Telephone Order (with appropriate 'read back' procedures as per policy) from the physician as soon as possible following a restraint incident.
7.3 The RN will sign, date, time and complete the Physician's Orders.
7.4 The RN should complete the Restraint Documentation Form.
7.5 The RN should as certain appropriate 'Debriefing' of the restraint incident with the patient and staff involved in the episode as soon as possible with subsequent documentation in the Debriefing Progress Notes."

Facility documentation titled "Patient Rights" (signed by the patient's mother on 9-13-17) states, in part:
"Patient Rights:
...
Respect and Dignity
-To receive considerate and respectful care at all times and under all circumstances, with recognition of my personal dignity.
Personal Safety
-To expect reasonable safety in so far as the hospital practices and environment are concerned, including the right to be free from all forms of abuse or harassment.
Seclusion and Restraints
-To be free from seclusion and restraints of any form that are not medically necessary or are used by the staff as a means of coercion, discipline, convenience, or retaliation.
Basic Rights
1. You have the right to be treated with respect and dignity in a place that is clean and where you are protected from harm.
Care and Treatment
17. You have the right not to be physically restrained (restriction of movement of your body by person or by a device or by being locked in a room alone) unless your doctor says it is necessary. However, if there is a situation in which staff thinks you may hurt yourself or someone else if you aren't restrained right away, you can be restrained for up to an hour before the doctor's permission is given. Whenever you are restrained, staff has to tell you why you are being restrained, how long you'll be restrained, and what you need to do to be removed from restraint sooner."

The above was confirmed in an interview with the CEO and other administrative staff the afternoon of 12-7-17.

Based on a review of clinical records and facility documentation, the facility failed to have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service failed to be responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital.

Findings were:

Patient #1 was prescribed the following the following psychoactive medications during [patient #1's] stay:
" Latuda
" Zoloft
" Trileptal
" Vistaril
" Focalin XR
Telephone consent was obtained from the patient #1's mother for Latuda, Zoloft, Trileptal and Focalin XR. The psychoactive consent forms contained no documentation that the telephone consent had been witnessed by a second staff member.

Facility policy 1000.34 titled "Informed Consent for Treatment with Psychoactive Medication" states, in part:
"Procedure:
...
Nursing Responsibilities:
...
11. When parent(s) or LAR [legally authorized representative] are not physically available, telephone consent will be obtained.
11.1 When telephone consent is obtained the following shall occur:
11.1.1 Notation will be made in appropriate place on the medication consent form.
11.1.2 The nurse who supplied the information regarding prescribed medications will sign the statement.
11.1.3 A second staff member will witness the phone approval of the parent/LAR."

Patient #1 was admitted to the child/adolescent unit and placed on elopement and suicide precautions (which were continued throughout patient #1's stay).

The "Precaution/Observation Checklist" was reviewed for each of the 6 days patient #1 was at CC. None of the 6 sheets gave any indication that the patient was to be observed on either elopement or suicide precautions.

Facility policy 1000.17 titled "Observation/Precaution Levels" states, in part:
"Policy:
To ensure the safety of each patient, various levels of observation of monitoring will be utilized based on assessed individual patient acuity."

Facility policy 1000.31a titled "Elopement Precautions" states, in part:
"Policy:
Elopement prevention and management is a priority in Cedar Crest Hospital and RTC. Patients are placed in our care for treatment and it is important to their safety that adequate precautions are taken to prevent them from leaving the hospital unauthorized. Patients clinically identified as posing a risk for elopement shall be placed in a heightened observation level in order to prevent or significantly decrease their risk for elopement from the unit.
...
Precaution's(sic) Checklist: The following interventions may be implemented under the direction of the Charge RN:
...
8. Notate Elopement Precautions on the Observation Check Sheet and Treatment Plan."

Facility policy 900.50 titled "Suicide Risk Assessment/Precautions" states, in part:
"Policy:
Identification of individuals at risk for suicide during admission and while under the care of a staffed, round-the-clock setting, or following discharge from a high care organization is an important step in preventing suicide and protecting these high risk individuals. Cedar Crest assesses the patient for suicide risk during admission, while in care, and upon discharge from the treatment program. The privileged LIP [licensed independent provider] assigns a Level of Observation corresponding with the acuity of the SRA [suicide risk assessment].

Facility documentation titled "Patient Rights" (signed by the patient's mother on 9-13-17) states, in part:
"Patient Rights:
...
Personal Safety
-To expect reasonable safety in so far as the hospital practices and environment are concerned, including the right to be free from all forms of abuse or harassment.
Basic Rights
1. You have the right to be treated with respect and dignity in a place that is clean and where you are protected from harm."

The above was confirmed in an interview with the CEO and other administrative staff the afternoon of 12-7-17.

Based on a review of the clinical record and facility documentation, the director of nursing failed to demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

Findings were:

An incident reported dated 9-16-17 at 8:10 pm stated that patient #1 was restrained from 8:10 pm to 8:20 pm due to [patient #1] attacking staff. The area marked "Nursing Assessment" (where any patient injuries would have been documented" was not completed by the nurse. Additional documentation attached to the incident reported stated:

"Pt [patient #1] got upset due to another peer getting into trouble with staff. Pt came out of the AR [activity room] with peers and refused to go back in. staff redirected pt several times to go back into the AR. Pt sat in hallway with peers. Once the hallway doors opened up pt went up to the nurse's station verbal escalation failed numerous times. Pt kept stating 'this is fucked up'. Numerous times pt then got with peers and started being verbally and physically aggressive towards staff. Pt told staff numerous times 'this is fucked up'. Pt then physically hit and spit on staff. Pt was then physically restrained by staff. Pt got upset with staff again. Pt then went down to the nurse's station by latency and started yelling down the hallway at staff saying 'bitch do something'. Pt was redirected by staff several times to go to room. Pt then had clothes taken out of room and was given blue scrubs. Pt and peers ripped blue scrubs up and said 'Im(sic) not wearing this shit'. Pt then was redirected by staff. Pt refused to go to PR [patient's room]. Pt then went into another pts(sic) room and they refused to come out. Staff went into PR and pt became verbally aggressive toward staff. Pt then let staff give medication and pt then went to PR. Will cont [continue] to monitor."

A review of physician's orders for patient #1 revealed an order written on 9-16-17 at 8:40 pm for an emergency injection of Thorazine 50 mg [milligrams] and Benadryl 50 mg intramuscularly. No order was found for the physical restraint. No restraint documentation paperwork was found and the clinical record for patient #1 as a whole provided no indication that the patient had been restrained during patient #1's stay.

Facility policy 1000.44 titled "Physical Restraint" states, in part:
"All physical restraints (therapeutic hold or escort) require a physician's order.
...
Procedure:
...
7. Clinically Competent Registered Nurse's Responsibilities
7.2 The RN [registered nurse] must secure a Physician's Order whether in person, verbal or Telephone Order (with appropriate 'read back' procedures as per policy) from the physician as soon as possible following a restraint incident.
7.3 The RN will sign, date, time and complete the Physician's Orders.
7.4 The RN should complete the Restraint Documentation Form.
7.5 The RN should as certain appropriate 'Debriefing' of the restraint incident with the patient and staff involved in the episode as soon as possible with subsequent documentation in the Debriefing Progress Notes.
...
12. Chief Nursing Officer (CNO) Responsibilities
13.1 The CNO will be responsible for the development and implementation of written policies and procedures consistent with licensing and accreditation standards-of-care concerning the use of physical restraints.
13.2 The CNO or designee will be responsible for tracking and trending all physical restraint episodes with the departmental intent and goal to reduce the use of physical restraints as much as possible and to ensure other less restrictive alternatives first attempted."

Patient #1 was admitted to the child/adolescent unit and placed on elopement and suicide precautions (which were continued throughout patient #1's stay).

The "Precaution/Observation Checklist" was reviewed for each of the 6 days patient #1 was at CC. None of the 6 sheets gave any indication that the patient was to be observed on either elopement or suicide precautions.

Facility policy 1000.17 titled "Observation/Precaution Levels" states, in part:
"Policy:
To ensure the safety of each patient, various levels of observation of monitoring will be utilized based on assessed individual patient acuity."

Facility policy 1000.31a titled "Elopement Precautions" states, in part:
"Policy:
Elopement prevention and management is a priority in Cedar Crest Hospital and RTC. Patients are placed in our care for treatment and it is important to their safety that adequate precautions are taken to prevent them from leaving the hospital unauthorized. Patients clinically identified as posing a risk for elopement shall be placed in a heightened observation level in order to prevent or significantly decrease their risk for elopement from the unit.
...
Precaution's(sic) Checklist: The following interventions may be implemented under the direction of the Charge RN:
...
8. Notate Elopement Precautions on the Observation Check Sheet and Treatment Plan."

Facility policy 900.50 titled "Suicide Risk Assessment/Precautions" states, in part:
"Policy:
Identification of individuals at risk for suicide during admission and while under the care of a staffed, round-the-clock setting, or following discharge from a high care organization is an important step in preventing suicide and protecting these high risk individuals. Cedar Crest assesses the patient for suicide risk during admission, while in care, and upon discharge from the treatment program. The privileged LIP [licensed independent provider] assigns a Level of Observation corresponding with the acuity of the SRA [suicide risk assessment].

Facility documentation titled "Patient Rights" (signed by the patient's mother on 9-13-17) states, in part:
"Patient Rights:
...
Personal Safety
-To expect reasonable safety in so far as the hospital practices and environment are concerned, including the right to be free from all forms of abuse or harassment.
Basic Rights
1. You have the right to be treated with respect and dignity in a place that is clean and where you are protected from harm."

Patient #1 was prescribed the following the following psychoactive medications during [patient #1's] stay:
" Latuda
" Zoloft
" Trileptal
" Vistaril
" Focalin XR
Telephone consent was obtained from the patient #1's mother for Latuda, Zoloft, Trileptal and Focalin XR. The psychoactive consent forms contained no documentation that the telephone consent had been witnessed by a second staff member.

Facility policy 1000.34 titled "Informed Consent for Treatment with Psychoactive Medication" states, in part:
"Procedure:
...
Nursing Responsibilities:
...
11. When parent(s) or LAR [legally authorized representative] are not physically available, telephone consent will be obtained.
11.1 When telephone consent is obtained the following shall occur:
11.1.1 Notation will be made in appropriate place on the medication consent form.
11.1.2 The nurse who supplied the information regarding prescribed medications will sign the statement.
11.1.3 A second staff member will witness the phone approval of the parent/LAR."

The above was confirmed in an interview with the CEO and other administrative staff the afternoon of 12-7-17.