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Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to meet the Medicare Conditions of Participation for Acute Care Hospitals 42 CFR 482.13 Patients Rights as evidenced by failure to:

a. identify and investigate grievances;

b. respond to grievances in writing, to include all information as required by federal regulations;

c. obtain informed consent for admission to an in-patient psychiatric unit;

d. perform restraint and seclusion in a safe manner;

e. use restraint and seclusion in an appropriate manner;

f. attempt the use of less restrictive interventions before the use of restraint and seclusion;

g. document detailed assessments of the patient's physical and mental status including behaviors and environmental factors, that may have contributed to the need for restraint and seclusion;

h. document details of less restrictive alternatives and all interventions attempted before the use of restraint and seclusion; and

i. failed to document a detailed description of the patient's condition and symptoms that warranted the use of physical restraint and seclusion.

See A Tags 0118, 0123, 0131, 0142, 0154, 0164, 0185, 0186 and 0187.

Based on review of the hospital's grievance, complaint and variance manual and interviews with hospital staff, the hospital did not follow its grievance process. Three of four complaints (Complaints #2, 3, and 4) reviewed, that were not resolved at the time of the complaint, were not identified as grievances and processed through the hospital's grievance process.

Findings:

1. The hospital's grievance policy, correctly identifies that complaints that are not resolved at the time are identified as grievances and processed through the hospital's grievance program.

2. Three of four complaints (Complaints #2, 3, and 4) reviewed did not show investigation and evidence a written response, with the required information, had been sent to the complainants.

3. On the afternoon of 09/25/2012, staff confirmed there were no notes of investigation for three of the complaints and verified that no written response had been sent/provided to the complainants.

Based on review of the hospital's grievance, complaint and variance manual and interviews with hospital staff, the hospital did not follow its grievance process. For three of four complaints reviewed, that were not resolved at the time of the complaint, the complainants were not provided a written response with the required information.

Findings:

1. The hospital's grievance policy, correctly identifies that complaints that are not resolved at the time are identified as grievances and processed through the hospital's grievance program with a written response with the all required information on investigation, resolution and contact information.

2. Three of four complaints (Complaints #2, 3, and 4) reviewed did not show evidence a written response, with the required information, had been sent to the complainants.

3. On the afternoon of 09/25/2012, staff confirmed no written response had been sent/provided to the complainants.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to obtain informed consent for admission to an in-patient psychiatric unit. Findings:

Patient #1 was admitted to the hospital behavioral health unit on 06/01/12 at approximately 11:15 a.m.. The demographic information documented the patient's legal status as "competent". The form also documented the patient was his own guardian.

A hospital Admission Agreements form included the following: consent for treatment, release of information, medical and nursing care, advanced directive, organ tissue donor and patient rights.

The form was not signed by the patient. The signature line documented, "... Pt. unable to sign due to physical & mental condition..." This statement was signed by two behavioral health staff members.

The staff members were asked why the patient was unable to sign. They stated he was agitated and out of control. A review of the clinical record indicated the patient was calm and in control at the time of admission. The record documented he attended occupational therapy and then had lunch. The record indicated he allowed his fingernails to be trimmed.

The staff were asked if there was an opportunity to obtain informed consent. They stated, "Possibly." They were asked if there was a hospital policy that addressed obtaining consent for admission to the behavioral health unit. They stated there was not.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the patient's safety during a restraint and seclusion procedure. Findings:

A Patient's Bill of Rights form documented, "... The patient has a right to:... Receive treatment that is appropriate and that complies with acceptable standards... Be treated by all personnel with consideration and respect, and in a safe environment that is free from all forms of abuse or harassment..."

Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission. There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's behavior after admission. The clinical record documented the patient attended occupational therapy, allowed his fingernails to be trimmed and had lunch immediately after admission.

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

Other than the physician's order, there was no documentation of the patient's behavior. There was no documentation of what was communicated to the physician.

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction. There was no documentation any medications were administered.

There was no documentation a staff person was involved in an unprovoked attack by the patient.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It also documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was preformed (sic) correctly: CNA attempted 2 person cape hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling. Leg splinted with a pillow, taped secure. Pt. placed on slide board and transferred to gurney for transfer/evaluation in ER...

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open... Physiological / Medical condition of the patient: Patient is awake. Patient is non-verbal by history. Patient has a bloody nose and swelling to right lower leg... The following must be assessed: respiratory status, circulatory status, skin integrity, vital signs, injuries, arousal..."

There was no documentation of nursing assessment of circulatory status, skin integrity, vital signs or level of arousal.

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed by the registered nurse.

The form documented the registered nurse notified the attending physician of the restraint and seclusion event at 1:45 p.m.

There was no narrative documentation of this event in the clinical record. There was no physician's order to transfer the patient to the emergency room.

An emergency room physician's record, dated 06/01/12 at 1:27 p.m. documented, "... Unsure of story but was told (pt) very agitated and had a fall backwards and staff noticed leg twisted... Psych: Behavior/mood is pleasant, affect is flat, oriented to person..."

An emergency room nursing record, dated 06/01/12 at 1:29 p.m., documented, "... Presenting complaint: Pt. brought from (behavioral health unit) for possible TIB/FIB fracture right leg. Pt. also has bleeding from nose where pt fell and hit face on floor... Mechanism of injury: (left blank)..."

At 1:45 p.m., the emergency room nursing record documented, "... Unsure exactly what events led to injury. Was told that pt became agitated and 'took two men to try and contain him.' Nurse was concerned about possible aspiration. Pt was taken to seclusion room. Unsure of events after that... Assessment:... Pt appears sedated... dried blood under right nares; no swelling noted. Small amount of swelling noted above right eye..."

The emergency room clinical record included an x-ray report, dated 06/01/12 at 3:37 p.m. The radiologist documented, "... There is a comminuted fracture of the mid shaft of the RIGHT tibia... with comminuted fractures of the proximal and distal shaft of the fibula... These fracture fragments are displaced..."

Staff were asked to provide documentation of investigation of the incident and the findings. The surveyors were given copies of written statements provided by some of the personnel involved. Not everyone who was directly involved, or those who may have witnessed the events were asked to provide statements. There was no evidence all participants and witnesses were interviewed.

A hand-written statement by staff B on 06/01/12, documented, "... I walked down the hall to the patient with his linens and asked him to come to his room for a nap. The patient struck me very forcefully in the left arm to pectoral region. I then proceeded to cape the patient. Patient and I came to [the] floor and I restrained him... Then [two staff names deleted] assisted me in a 3 person transfer to the seclusion room where [we] placed him in the floor. We let go and he came back at us. I grabbed and turned him and myself and we both hit the ground hard. The wind was knocked out of me and the patient's nose started bleeding... Nurse observed that the patient's leg was broken..."

There was no documentation in the statement as to how or why the patient's leg may have been broken.

Staff C documented in a typed statement, "... I went to the back to help [staff name deleted] with a pt. We went to pick him up and he went to trying to kick so we took him to the seclusion room where after we got him put back down, we went to exit the room and the pt went back after [staff name deleted]. [Staff name deleted] cape the pt again. That is when I got the other arm and we was holding him... we were told by the RN to scoot the pt back where the RN could check him. That is when [staff name deleted] seen the pt.'s leg and brought it to our attention..."

There was no documentation in this written statement as to how or why the patient's leg may have been broken.

Staff G documented in a typed statement, "... I jumped up and ran to the back and [staff names deleted] had the patient on the ground holding him down and he was kicking so I caped his legs until [nurse name deleted] advised (sic) us to transport him to the seclusion room... The patient was kicking and fighting them and then the patient went back to the ground. I then went to cape his legs again to help transport him that way... [staff names deleted] picked him back up and so I let go of his leg... They then got him in the seclusion room and put him there and then he got back up and I did not see what the patient did at that point... Then I seen [staff name deleted] attempt to cape him then they went to the ground hard... [nurse name deleted] started checking the patient out and advised someone to get supplies to clean him up. He was bleeding. She... advised the boys to ease up and she told us to back him so he would be away from the wall and give him some breathing room. So I leaned up and attempted to cape his upper legs and we scooted him back. When I leaned back down to cape his legs that's when I seen his poor leg looking very deformed..."

There was no documentation in this statement as to how or why the patient's leg was broken.

Staff A documented in a typed statement, "... I was called to the hallway for a patient that was exhibiting aggressive physical behaviors. When I reached the... hallway, [the patient] was being escorted toward the quiet room by [two staff names deleted]. The patient was kicking and attempting to hit staff... Patient was escorted into the seclusion room for a time out period to decelerate his behaviors. The patient continued hitting and kicking at staff and I instructed staff to leave the patient in the seclusion room and I was going to lock the door making this a restraint and seclusion event. Upon attempting to let go of the patient and exit the room, the patient lunged toward the window and twisted toward the door. The [techs] then took the patient by his arms in an attempt to restrain him for his safety. At this time it appeared that the patient and 1 [tech] fell to the floor. I dropped to the floor at the head of the patient and saw blood coming from his facial area... The patient continued to kick and thrash about with staff attempting to verbally and physically calm his actions. I was notified that his leg looked abnormal... I then splinted the lower extremity... Patient was sitting up at this time with the staff assisting him for comfort..."

This staff person did not document how and why the patient's leg may been broken.

Staff F was asked if there were any witnesses to the initial altercation between the patient and the technician. She stated there were not.

She was asked about her conclusions after the investigation. She stated, "We think the patient's rubber sandal may have caught on the rubber floor mat in the seclusion room. So when the tech and the patient lost their footing, the patient's leg twisted and the leg was broken in a twisting manner when they both fell."

She was asked if the restraint and seclusion had been done in a safe manner. She stated, "Both techs were re-trained in CAPE procedures." She was asked if re-training was done because the evidence showed incorrect interventions were taken with the patient. She stated, "They needed a refresher on CAPE."

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the appropriate use of physical restraint and seclusion. Findings:

A Patient's Bill of Rights form documented, "... The patient has a right to:... Remain free from seclusion or restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. Restraints can only be used when less restrictive interventions have been determined to be ineffective and only to improve the patient's well-being..."

Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission. There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

The clinical record documented from approximately 11:30 a.m. until 12:30 p.m. the patient attended occupational therapy, had his fingernails trimmed and had lunch.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's behavior after admission.

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction. There was no documentation any medications were administered.

There was no documentation of failed attempts at less restrictive interventions. There was no documentation of what information was communicated to the physician.

There was no documentation a staff person was involved in an unprovoked attack by the patient.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was performed correctly: CNA attempted 2 person CAPE hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling...

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open... Physiological / Medical condition of the patient: Patient is awake. Patient is non-verbal by history. Patient has a bloody nose and swelling to right lower leg... The following must be assessed: respiratory status, circulatory status, skin integrity, vital signs, injuries, arousal..."

There was no documentation of nursing assessment of circulatory status, skin integrity, vital signs or level of arousal.

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed by the registered nurse.

The form documented the registered nurse notified the attending physician of the restraint and seclusion event at 1:45 p.m.

There was no narrative documentation of this event in the clinical record.

Staff F was asked why the patient was restrained and placed in seclusion. She stated the patient struck a male psych tech without warning. She was asked if this information was documented in the clinical record. She stated it was not.

She was asked if there were any witnesses to the initial altercation between the patient and the technician. She stated there were not.

She was asked if the registered nurse or the psych tech documented a narrative description of what happened before, during and after the restraint and seclusion. She stated they did not.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the use of less restrictive interventions before the use of physical restraint and seclusion. Findings:

A Patient's Bill of Rights form documented, "... The patient has a right to:... Remain free from seclusion or restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. Restraints can only be used when less restrictive interventions have been determined to be ineffective and only to improve the patient's well-being..."

Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission. There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

The clinical record documented from approximately 11:30 a.m. until 12:30 p.m. the patient attended occupational therapy, had his fingernails trimmed and had lunch.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's behavior after admission.

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction. There was no documentation any medications were administered.

There was no documentation of failed attempts at less restrictive interventions. There was no documentation of what information was communicated to the physician.

There was no documentation a staff person was involved in an unprovoked attack by the patient.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was performed correctly: CNA attempted 2 person CAPE hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling...

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open... Physiological / Medical condition of the patient: Patient is awake. Patient is non-verbal by history. Patient has a bloody nose and swelling to right lower leg... The following must be assessed: respiratory status, circulatory status, skin integrity, vital signs, injuries, arousal..."

There was no documentation of nursing assessment of circulatory status, skin integrity, vital signs or level of arousal.

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed by the registered nurse.

The form documented the registered nurse notified the attending physician of the restraint and seclusion event at 1:45 p.m.

There was no narrative documentation of this event in the clinical record.

Staff F was asked why the patient was restrained and placed in seclusion. She stated the patient struck a male psych tech without warning. She was asked if this information was documented in the clinical record. She stated it was not.

She stated, "This patient had been admitted here before and he had exhibited unpredictable, aggressive behavior." She was asked if the staff knew what triggered the patient. She stated she didn't know. She stated, "We just know that he was known to just strike out at people."

She was asked if he was known to strike out at other patients. She stated, "It's usually just staff."

She was asked if there were any witnesses to the initial altercation between the patient and the technician. She stated there were not. She was asked if she had investigated a possible cause for the patient's physical aggression. She stated she had not.

She was asked if the registered nurse on duty or any of the psych techs documented a narrative description of what happened before, during and after the restraint and seclusion. She stated they did not.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the clinical record documented a clear and detailed description of the patient's physical and mental status, including behaviors and environmental factors, that may have contributed to the need for the use of physical restraint and seclusion. Findings:

A hospital policy titled, "Seclusion and Restraint Use," documented, "... Each episode of seclusion and/or restraint requires documented information in the patient's medical record. This includes: Circumstances leading up to seclusion and restraint use;
Alternatives to seclusion and restraint attempted; Rationale for type of restraint selected... In-person evaluation and re-evaluation of patient..."

Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission. There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

The clinical record documented from approximately 11:30 a.m. until 12:30 p.m. the patient attended occupational therapy, had his fingernails trimmed and had lunch.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's behavior after admission.

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction.

There was no detailed documentation of failed attempts at less restrictive interventions prior to the initiation of restraint and seclusion.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was performed correctly: CNA attempted 2 person CAPE hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling. Leg splinted with a pillow, taped secure. Pt. placed on slide board and transferred to gurney for transfer/evaluation in ER...

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open... Physiological / Medical condition of the patient: Patient is awake. Patient is non-verbal by history. Patient has a bloody nose and swelling to right lower leg... The following must be assessed: respiratory status, circulatory status, skin integrity, vital signs, injuries, arousal..."

There was no documentation of nursing assessment of circulatory status, skin integrity, vital signs or level of arousal.

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed by the registered nurse.

There was no detailed narrative documentation of the restraint procedure in the clinical record.

Staff F was asked why the patient was restrained and placed in seclusion. She stated the patient struck a male psych tech without warning. She stated the psych tech used a CAPE hold on the patient and then "took him to the floor in the hallway."

She stated another male psych tech came to assist and the patient was taken to the seclusion room. She stated when they attempted to release the patient in the seclusion room, he began trying to kick and bite the techs as they were leaving the room.

She stated one psych tech tried again to place the patient in a CAPE hold. The psych tech fell on top of the patient and the patient's leg was broken.

She was asked if the registered nurse, the psych technician or any other person involved in the event documented a narrative description of what happened before, during and after the restraint and seclusion in the clinical record. She stated they did not.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the clinical record documented a clear and detailed description of alternatives or less restrictive interventions used before physical restraint and seclusion were implemented. Findings:

A hospital policy titled, "Seclusion and Restraint Use," documented, "... Each episode of seclusion and/or restraint requires documented information in the patient's medical record. This includes: Circumstances leading up to seclusion and restraint use;
Alternatives to seclusion and restraint attempted; Rationale for type of restraint selected... In-person evaluation and re-evaluation of patient..."

Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission. There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

The clinical record documented from approximately 11:30 a.m. until 12:30 p.m. the patient attended occupational therapy, had his fingernails trimmed and had lunch.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's behavior after admission.

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction.

There was no detailed documentation of failed attempts at less restrictive interventions prior to the initiation of restraint and seclusion.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was performed correctly: CNA attempted 2 person CAPE hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling. Leg splinted with a pillow, taped secure. Pt. placed on slide board and transferred to gurney for transfer/evaluation in ER...

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open..."

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed and documented by the registered nurse.

There was no detailed narrative documentation of the restraint procedure in the clinical record.

Staff F was asked why the patient was restrained and placed in seclusion. She stated the patient struck a male psych tech in the arm without warning. She stated the psych tech used a CAPE hold on the patient and then "took him to the floor in the hallway."

She stated another male psych tech came to assist and the patient was taken to the seclusion room. She stated when they attempted to release the patient in the seclusion room, he began trying to kick and bite the techs as they were leaving the room.

She stated one psych tech tried again to place the patient in a CAPE hold. The psych tech fell on top of the patient and the patient's leg was broken.

She was asked if the registered nurse, the psych technician or any other person involved in the event documented a narrative description of what happened before, during and after the restraint and seclusion in the clinical record. She stated they did not.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the clinical record documented a clear and detailed description of the patient's condition and symptoms that warranted the use of physical restraint and seclusion. Findings:

A hospital policy titled, "Seclusion and Restraint Use," documented, "... Each episode of seclusion and/or restraint requires documented information in the patient's medical record. This includes: Circumstances leading up to seclusion and restraint use;
Alternatives to seclusion and restraint attempted; Rationale for type of restraint selected... In-person evaluation and re-evaluation of patient..."

Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission. There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

The clinical record documented from approximately 11:30 a.m. until 12:30 p.m. the patient attended occupational therapy, had his fingernails trimmed and had lunch.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's behavior after admission.

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction.

There was no detailed documentation of failed attempts at less restrictive interventions prior to the initiation of restraint and seclusion.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was performed correctly: CNA attempted 2 person CAPE hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling..."

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open... Physiological / Medical condition of the patient: Patient is awake. Patient is non-verbal by history. Patient has a bloody nose and swelling to right lower leg... The following must be assessed: respiratory status, circulatory status, skin integrity, vital signs, injuries, arousal..."

There was no documentation of nursing assessment of circulatory status, skin integrity, vital signs or level of arousal.

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed by the registered nurse.

There was no detailed narrative documentation of the restraint procedure in the clinical record.

Staff F was asked why the patient was restrained and placed in seclusion. She stated the patient struck a male psych tech without warning. She stated the psych tech used a CAPE hold on the patient and then "took him to the floor in the hallway."

She stated another male psych tech came to assist and the patient was taken to the seclusion room. She stated when they attempted to release the patient in the seclusion room, he began trying to kick and bite the techs as they were leaving the room.

She stated one psych tech tried again to place the patient in a CAPE hold. The psych tech fell on top of the patient and the patient's leg was broken.

She was asked if the registered nurse, the psych technician or any other person involved in the event documented a narrative description in the clinical record of what happened before the restraint. She stated they had not.

Based on review of hospital documents and medical records and interviews with hospital staff, it was determined, the hospital's quality assessment and performance improvement program (QAPI) failed to review, analyze and develop restraints and seclusions on the psychiatric unit. For one of three psychiatric patient records reviewed (Patient #1) , the patient was restrained and suffered an adverse patient event requiring the patient to undergo surgery at another acute care facility.

Findings:

1. On 06/01/2012, Patient #1 was restrained, fell and sustained a fractured tibia and fibula, as well as other injuries. The radiologist documented, "... There is a comminuted fracture of the mid shaft of the RIGHT tibia... with comminuted fractures of the proximal and distal shaft of the fibula... These fracture fragments are displaced..." The emergency room record also documented the patient had "dried blood under right nares; no swelling noted. Small amount of swelling noted above right eye..."

2. Hospital meeting minutes provided as QAPI meeting minutes did not reflect this adverse event had been reviewed and analyzed with implementation of preventive actions and alternatives to reduce the risk of negative/adverse outcomes.

3. Hospital meeting minutes provided as QAPI minutes did not contain evidence restraints and seclusions were reviewed and monitored through the QAPI process with analysis of the causes and implementation of preventive actions to ensure:
i. That restraint or seclusion are used only to ensure the physical safety of the patient, staff and others; ii. That the least restrictive method is used to ensure patient and staff safety; and
iii. That the hospital complies with the requirements and hospital policy when the use of restraint or seclusion is necessary.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure a registered nurse evaluated the care needs of the patient upon admission, failed to assess the patient's condition when there was a change in condition and failed to evaluate the patient's response to interventions. Findings:

A hospital policy, titled "Admission of a Patient", documented, "... Thoroughly document all pertinent patient information available on admission. Documented information establishes a baseline evaluation available to all members of the health care team... Interventions addressing any urgent health care... or safety needs shall be implemented as soon as possible..."

A hospital policy, titled, "Nursing Process Standards", had no documentation of a psychiatric technician within the nursing care team description of duties. The policy did not address the components of nursing care related to the nursing assessment of psychiatric patients.

The policy did not include guidance for nurses on the Initial Interview and Initial Physical Assessment for psychiatric patients. The "Interventions" section of the policy did not address interventions for a psychiatric patient population.

A hospital policy, titled, "Guidelines for Documentation", did not document when and how narrative details should be documented in the electronic medical record. The policy focused on the step by step instructions on how to input patient data. The guidelines had no instruction on how to document vital patient information that may not fit into the pre-determined computer program.

Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation the patient had been hospitalized in the behavioral unit the month before. There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission.

There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's mood and behavior after admission.

In the hour after admission, the clinical record documented the patient attended occupational therapy, allowed his fingernails to be trimmed and had lunch. There was no narrative description of the patient's mood or behaviors during these activities and his responses to them.

Staff F was asked about the details of the patient's admission. She stated he had been transported to the hospital by two staff members from a group home where he lived. She stated his behavior had become unmanageable and he needed re-hospitalization.

She stated he had been violent on the way to the hospital and one staff member was injured. She was asked if he had been violent upon admission to the behavioral health unit. She stated he had not. She stated she had offered him a coke and he was calm and cooperative.

She was asked if this information was documented in the clinical record. She stated, "It should have been."

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

Other than the physician's order, there was no documentation of the patient's behavior. There was no documentation of what was communicated to the physician.

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction. There was no documentation any medications were administered.

There was no documentation a staff person was involved in an unprovoked attack by the patient.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It also documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was preformed (sic) correctly: CNA attempted 2 person cape hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling. Leg splinted with a pillow, taped secure. Pt. placed on slide board and transferred to gurney for transfer/evaluation in ER...

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open... Physiological / Medical condition of the patient: Patient is awake. Patient is non-verbal by history. Patient has a bloody nose and swelling to right lower leg... The following must be assessed: respiratory status, circulatory status, skin integrity, vital signs, injuries, arousal..."

There was no documentation of nursing assessment of circulatory status, skin integrity, vital signs or level of arousal.

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed by the registered nurse.

There was no narrative documentation of this event in the clinical record. There was no documentation of the nurse's actions when the patient was restrained and secluded.

The form documented the registered nurse notified the attending physician of the restraint and seclusion event at 1:45 p.m. There was no physician's order to transfer the patient to the emergency room for evaluation of his injuries and no documentation the physician was notified the patient was injured.

Staff F was asked why the patient was restrained and secluded. She stated the patient had struck a male psych tech member. She was asked why the patient did that. She stated the patient was known to be physically aggressive in an unpredictable manner.

She stated the psych tech "took the patient down and another psych tech helped take him to the seclusion room." She was asked how many people were involved in the restraint and seclusion procedure. She stated she didn't know.

She was asked what happened when the patient was placed in seclusion. She stated she was told one psych tech and the patient fell to the floor and the patient had a broken leg and possibly hit his face on the floor.

She was asked if the clinical record included the details of events that led to the restraint and seclusion. She stated it did not. She was asked if it could be determined that the RN performed an accurate assessment of the patient at the time of admission and again at the time of the restraint and seclusion procedure. She stated it could not.

She was asked if there was evidence the registered nurse had assessed and responded to the patient's change in condition and had implemented appropriate interventions in response to the change in condition. She stated there was not.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the medical record was complete and accurately written. Findings:

1. A hospital policy, titled, "Guidelines for Documentation", did not document when and how narrative details should be documented in the electronic medical record. The policy focused on the step by step instructions on how to input patient data. The guidelines had no instruction on how to document vital patient information that may not fit into the pre-determined computer program.

2. Patient #1, a 27 year old male, who had been previously living in a group home, was admitted to the hospital's behavioral health unit on 06/01/12 at approximately 11:15 a.m..

There was no documentation the patient had been hospitalized in the behavioral unit the month before. There was no documentation by the nursing staff of the reason for admission on this date or of the patient's behavior immediately prior to admission.

There was no documentation the patient had a history of unprovoked aggression to himself or others.

A behavioral health initial physical assessment, dated 06/01/12 at 12:44 p.m., documented, "... Nurses Notes:... Patient is calm and cooperative at present time... No acute distress noted at present... Mood calm... Self-Harm: None assessed... Focal Behavior: Cooperative... Pt unable to follow commands... Skin:... Abrasions noted to upper back/shoulder... Activity: Walks frequently... Mobility: No limits..."

The initial assessment documented the patient was non-verbal except for an occasional "yes or no" nod of the head.

Other than the initial physical assessment, there was no documentation by the nursing staff of the patient's mood and behavior after admission.

In the hour after admission, the clinical record documented the patient attended occupational therapy, allowed his fingernails to be trimmed and had lunch. There was no narrative description of the patient's mood or behaviors during these activities and his responses to them.

Staff F was asked about the details of the patient's admission. She stated he had been transported to the hospital by two staff members from a group home where he lived. She stated his behavior had become unmanageable and he needed re-hospitalization.

She stated he had been violent on the way to the hospital and one staff member was injured. She was asked if he had been violent upon admission to the behavioral health unit. She stated he had not. She stated she had offered him a coke and he was calm and cooperative.

She was asked if this information was documented in the clinical record. She stated, "It should have been."

A physician's order, dated 06/01/12 at 1:05 p.m., documented, "... Restraint for up to 10 min for pts safety/ staff safety / kicking & biting..."

Other than the physician's order, there was no documentation of the patient's behavior. There was no documentation of what was communicated to the physician.

The clinical record had no narrative documentation of a precipitating incident that warranted an order for restraint. There was no documentation of escalating behavior and attempts at re-direction. There was no documentation any medications were administered.

There was no documentation a staff person was involved in an unprovoked attack by the patient.

A Restraint/Seclusion Form documented the patient was physically restrained from 1:05 p.m. to 1:15 p.m. It also documented, "... Options considered prior to restraint or seclusion: verbal intervention, quiet room, physical restraint... Patient response to less restrictive option: patient kicking, hitting and attempting to bite... Emergency event / pt behavior(s) that lead to restraint or seclusion: patient hitting, kicking and attempting to bite staff..."

The form documented, "... Immediate assessment to ensure [restraint and seclusion] was preformed (sic) correctly: CNA attempted 2 person cape hold. Patient struggling and staff lost footing balance and fell to floor... List patient's physical condition, mental status & injury treatment: Lower leg with swelling. Leg splinted with a pillow, taped secure. Pt. placed on slide board and transferred to gurney for transfer/evaluation in ER...

Situation that lead to intervention: patient hitting, kicking and attempting to bite staff. Patient refuses to redirect to verbal instruction... Patient reaction to intervention: Patient calm in seclusion room with door open... Physiological / Medical condition of the patient: Patient is awake. Patient is non-verbal by history. Patient has a bloody nose and swelling to right lower leg... The following must be assessed: respiratory status, circulatory status, skin integrity, vital signs, injuries, arousal..."

There was no documentation of nursing assessment of circulatory status, skin integrity, vital signs or level of arousal.

The restraint / seclusion form also documented, "... Psychological / behavioral condition of the patient: (mental status) Patient is calm at present time. Respirations even and unlabored. The following must be assessed: hallucinations, suicidal, delusions, physical aggression, mania, verbal aggression, depression, catatonia, self injurious, delirium, homicidal, violence..."

None of these areas were assessed by the registered nurse.

The restraint/seclusion form had no narrative description of the restraint and seclusion procedure. There was no documentation of the nurse's actions when the patient was restrained and secluded.

The form documented the registered nurse notified the attending physician of the restraint and seclusion event at 1:45 p.m. There was no physician's order to transfer the patient to the emergency room for evaluation of his injuries and no documentation the physician was notified the patient was injured.

Staff F was asked why the patient was restrained and secluded. She stated the patient had struck a male psych tech member. She was asked why the patient did that. She stated the patient was known to be physically aggressive in an unpredictable manner.

She stated the psych tech "took the patient down and another psych tech helped take him to the seclusion room." She was asked how many people were involved in the restraint and seclusion procedure. She stated she didn't know.

She was asked what happened when the patient was placed in seclusion. She stated she was told one psych tech and the patient fell to the floor and the patient had a broken leg and possibly hit his face on the floor.

She was asked if the clinical record included the details of events that led to the restraint and seclusion. She stated it did not. She was asked if it could be determined that the RN performed an accurate assessment of the patient at the time of admission and again at the time of the restraint and seclusion procedure. She stated it could not.

She was asked if there was evidence the registered nurse had assessed and responded to the patient's change in condition and had implemented appropriate interventions in response to the change in condition. She stated there was not. She was asked if this information should be included in the clinical record. She stated it should.

The surveyors were told nursing entries were all documented electronically. The narrative documentation for Patient #1 recorded the patient had skin abrasions on his back, but did not documents any other skin problems and did not give a description of the abrasions. The computer generated patient drawing documented the patient had skin interruptions/abrasions on: right front upper arm; right knee; right shin; upper aspect of right foot; posterior right calf; and left thigh. The form did not give a description other than abrasion. When this discrepancy was reviewed with Staff F and K, Staff K returned with another drawing that showed three abrasions on the pack and one on the patient's right knee. Staff K stated it was a problem with the computer program that it printed different that what was shown on the computer screen and she would have to talk with someone to fix the problem.

3. Patient #3, a 55 year-old female - the medical record contain four copies of monitoring sheets for the time periods of 07/27/2012 from 1100 to 22245 and 07/27/2012 from 2300 to 07/28/2012 at 1045. All contained different information documented by different staff. When asked on the afternoon of 09/25/2012, Staff F and K stated that the staff must have entered the wrong date and time for three of the documents.

The chart also contained multiple monitoring sheets for the time periods of: 07/18/2012 from 1100 to 2245; 07/20/2012 from 1100 to 2245; 07/20/2012 from 2300 to 07/21/2012 at 1045; 07/21/2012 from 1100 to 2245; 07/21/2012 from 2300 to 07/22/2012 at 1045; and 07/26/2012 from 1100 to 2245.