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Based on record review and interview the facility failed to ensure that a face-to-face evaluation/assessment was done within 1 hour of restraint initiation for 5 (P[patient]1, P3, P5, P6, P8) out of 10 patients reviewed for restraint use while admitted for Psychiatric Care. This deficiency could lead to patient's being left at risk for serious medical or psychological harm without a focused assessment being done.

The findings are:

A. Record review of facility's policy titled "Use of Restraint or Seclusion for Management of Violent or Self-Destructive Behavior" dated 12/09/2022 on page 7, under "Documentation" it states, "Documentation in the electronic medical record must include the following: i. The one (1) hour face-to-face medical and behavioral evaluation."\

B. Findings for P1 are:
a. Record review of the "Order Sheet" revealed an order for "BH [Behavioral Health] Peds [Pediatric] Restraint" on 01/14/2023 at 2123 (9:23 PM). The order states "A Physician or other LIP [Licensed Independent Practitioner], or an appropriately trained Registered Nurse, conducts a face-to-face assessment within one hour after the initiation of restraint or seclusion."
b. Record review of document titled "BH [Behavioral Health] Child Inpt [Inpatient] Nurse Note" reveals that a nursing face-to-face was done on 01/15/2023 at 0139 (1:39 AM). There was no evidence found that a face-to-face was done closer to the time of restraint initiation.

C. Findings for P3 are:
a. Record review of the restraint documentation in the "Interactive View" for date 01/12/2023 reveals that patient was restrained at 1729 (5:29 PM).
b. No evidence of a restraint order was found for date 01/12/2023.
c. No evidence of a 1-hour face-to-face assessment was found for 01/12/2023.

D. Findings for P5 are:
a. Record review of the "Order Sheet" revealed an order for "BH Peds Seclusion" on 01/15/2023 at 1821 (6:21 PM). The order states "A physician or other LIP, or an appropriately trained Registered Nurse, conducts a face-to-face assessment within one hour after the initiation of restraint or seclusion."
b. No evidence of a 1-hour face-to-face assessment was found for 01/15/2023.

E. Findings for P6 are:
a. Record review of the "Order Sheet" revealed an order for "BH Peds Restraint" on 01/10/2023 at 2013 (8:13 PM). The order states "A physician or other LIP, or an appropriately trained Registered Nurse, conducts a face-to-face assessment within one hour after the initiation of restraint or seclusion."
b. No evidence of a 1-hour face-to-face assessment was found for 01/10/2023.

F. Findings for P8 are:
a. Record review of the "Order Sheet" revealed an order for "BH Peds Seclusion" on 01/12/2023 at 1723 (5:23 PM). The order states "A physician or other LIP, or an appropriately trained Registered Nurse, conducts a face-to-face assessment within one hour after the initiation of restraint or seclusion."
b. No evidence of a 1-hour face-to-face assessment was found for 01/12/2023.

G. In an interview with S(Staff)2, Unit Director on 01/18/2023 at 12:09 PM it was confirmed that patients should have a face-to-face every time they are restrained or placed in seclusion. It was asked if there is any reason a face-to-face evaluation would not be done? It was stated, "Maybe if we did not have one trained but that's not the case in these patients."

H. In an interview with S8, Executive Director on 01/18/2023 at 2:57 PM it was confirmed that the face-to-face evaluation should be done within the hour of restraint initiation or "as soon as possible".

Based on record review and interview the facility failed to ensure proper documentation of the intervention used for 3 (P[patient]1, P2, P6) out of 10 patients reviewed for restraint use while admitted for psychiatric care. This deficiency results in inaccuracies in the medical record and could lead to a violation of patient's rights.

The findings are:

A. Record review of the facility's policy titled "Use of Restraint or Seclusion for Management of Violent of Self-Destructive Behavior" dated 12/09/2022 on page 7, under "Documentation" it states, ". . . b. Documentation in the electronic medical record must include the following: . . . x. Restraint or seclusion order, including date and time obtained, and type of intervention."

B. Findings for P1 are:
a. Record review of facility document titled "Support Team Seclusion and Restraint Log" dated 01/14/2023 reveals that P1 was placed in "Mechanical Restraint" at 2115 (9:15 PM), 2159 (9:59 PM), and 2259 (10:59 PM).
b. Record review of the "Order Sheet" revealed an order for "BH [Behavioral Health] Peds [Pediatric] Restraint" on 01/14/2023 for the following times:
1. At 2123 (9:23 PM) the "Restraint Method" is "Physical. This order includes "Orders comments: mechanical."
2. At 2159 (9:59 PM) the "Restraint Method" is "Physical". There is no evidence of comments or specific type of restraint in this order.
3. At 2259 (10:59 PM) the "Restraint Method" is "Physical". There is no evidence of comments or specific type of restraint in this order.
c. Record review of the restraint documentation in the "Interactive View" for date 01/14/2023 revealed:
1. From 2320 (11:20 PM) - 2355 (11:55 PM) the "Restraint Intervention Type" is "MOAB" and the "MOAB Intervention Type" is "Basic".
2. From 2300 (11:00 PM) - 2315 (11:15 PM) the "Restraint Intervention Type" is "MOAB" and the "MOAB Intervention Type" is "Basic".
3. From 2155 (9:55 PM) the "Restraint Intervention Type" is "MOAB" and the "MOAB Intervention Type" is "Basic".
d. Review of document titled "Text-Behavioral Health Form" dated 01/15/2023 at 0547 (5:47 AM) on page 4 the "Progress Note" states ". . . 2055 [8:55 pm] pt [patient] started hitting and kicking staff. Called for arms one. to help. [sic] Pt refused PRN [as needed medication]. Pt 2100 [9:00 PM] team called. Pt taken to the floor. [S17, MD] notified of [restraint] 2100 [9:00 PM] Pt struggling unable to contractfor [sic] safety and refusing PRN;S [sic]. 2114 [9:14 PM] pt able to report she could be safe sat up and [immediately] started kicking restrained again. 2123 [9:23 PM] transferred to bed [restraint bed].. [sic] remains struggling. 2130 [9:30 PM] remains struggling 2139 [9:39 PM] pt gave Zyprexa 5 mg given IM in R [right] gluteus. 2145 [9:45 PM] Not able to contractfor safety. 2156 [9:56 PM] released from bed. Pt [assisted] to room. Pt again attacking staff. 2159 [9:59 PM] Pt put back in restraint bed.@2207 [10:07 PM] . . ."

C. Findings for P2 are:
a. Record review of facility document titled "Support Team Seclusion and Restraint Log" dated 01/14/2023 reveals that P2 was placed in "Mechanical Restraint" at 0928 (9:28 AM).
b. Record review of the "Order Sheet" revealed an order for "BH Peds Restraint" on 01/14/2023 at 0931 (9:31 AM). The "Restraint Method" is "Physical". There is no evidence of comments or specific type of restraint in this order.
c. Record review of the restraint documentation in the "Interactive View" for date 01/14/2023 at 0928 (9:28 AM) the "Restraint Intervention Type" is "MOAB" and the "MOAB Intervention Type" is "Basic".
d. Record review of a note titled "BH Child Seclusion/Restraint Note" on page 2 it states, "c. . . . Contraband found on person before she was transferred to the mechanical bed. . ."

D. Findings for P6 are:
a. Record review of facility document titled "Support Team Seclusion and Restraint Log" dated 01/14/2023 reveals that P6 was placed in "Mechanical Restraint" at 1540 (3:40 PM), and 1552 (3:52 PM).
b. Record review of the "Order Sheet" revealed an order for "BH Peds Restraint" on 01/14/2023 at 1552 (3:52 PM). The "Restraint Method" is "Physical". There is no evidence of comments or specific type of restraint in this order.
c. Record review of the restraint documentation in the "Interactive View" for date 01/14/2023 revealed:
1. At 1550 (3:50 PM) there is no evidence of documentation under "Restraint Intervention Type".
2. At 1552 (3:52 PM) the "Restraint Intervention Type" is "MOAB" and the "MOAB Intervention Type" is "Basic".
d. Review of document titled "Text-Behavioral Health Form" dated 01/14/2023 at 1743 (5:43 PM) the "Progress Note" states ". . .Pt [patient] continued to ram staff and was put into restraints at 1540 [3:40 PM]. Pt given pm [evening] zyprexa 10mg [milligram] ODT [oral dissolving tablet] at 1545 [3:45 PM]. Pt reported he would be safe and wanted to be released. Pt released at 1550 [3:50 PM]. Once released patient rolled around on the floor and crawled towards a specific staff to try to grab or hit Staff tried to redirect patient away from staff and if the behavior is to continue, trying to hit or grab staff that he would end up back in restraints because he is being unsafe. Pt refused to stop and continued to attack staff. Pt put into additional restraint at 1552 [3:52 PM]. Pt given IM [intramuscular] benadryl 50mg at 1600 [4:00 PM]. Nursing gave patient time to try to calm down and let medications take effect When patient continued to show no signs of calming down an additional 10mg ofzyprexa [sic] IM given at 1630 [4:30 PM]. Pt able to calm down at 1636 [4:36 PM], and released at 1636 [4:36 PM]."

E. In an interview with S(Staff)8, Executive Director on 01/18/2023 at 2:57 PM it was confirmed that the type of restraint is expected to be documented by staff. During interview it was also shown that in the electronic health record's "Interactive View" under "Restraint Intervention Type" there is a "Mechanical" option.

Based on record review and interview the facility failed to train Mental Health Technicians in how to recognize and respond to signs of physical and psychological distress of patients while in restraint and seclusion for all admitted patients. This deficient practice could lead to injury, harm, impairment or death of all patients admitted to the facility who experience restraint or seclusion.

The findings are:

A. Record review of facility policy titled Use of Restraint or Seclusion for Management of Violent or Self-Destructive Behavior. Effective date 12/09/2022 states in section 2.B.i "MHTs (Mental Health Technicians) ... may monitor the patient while in restraint or seclusion. The monitoring is continuous and includes but is not limited to: ...3. Integument or skin integrity and condition of extremities. 4. Signs of physical distress or injury. 5. Signs of psychological distress ... 7. Respiratory and circulatory status. 8. Fluid and nutritional needs. 9. Hygiene and toileting needs."

B. Record review of undated training curriculum titled "Support Team Roles & Responsibilities and Hands on Application of Mechanical Restraint" does not mention how to assess and recognize issues with Integument or skin integrity and condition of extremities, signs of physical distress or injury, signs of psychological distress, respiratory and circulatory status, fluid and nutritional needs, or hygiene and toileting needs.

C. Record review of undated training curriculum titled "Seclusion or Restraint for Violent or Self Destructive Behavior" mentions on slide 7: "Risks: Physical Injury, broken bones, bruises, cuts. Psychological Trauma. Death, asphyxiation, cardiac arrest, blunt trauma, drug overdose and interactions, chocking." There is no mention in the training about how MHT's should recognize and respond to these risks.

D. In an interview with S(staff)8, Executive Director of Behavioral Health, on 1/19/23 at 10:56 am when asked if there is any other training for training for MHT's about identifying signs of physical and psychological distress while in restraint stated "This is covered in the in-person class, but it goes off the slides [refer to findings B and C] I already gave you. We will create more specific slides and make sure that this is explicit in the check off list"