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Based on review of 6 open and 6 closed medical records, hospital policies and procedures, and other pertinent documents, it was determined that the hospital denied 2 of 12 patients the opportunity to be involved in care, as evidenced by failure to allow Patients #11 and #8 to participate in the treatment and discharge planning, or timely certify their lack of capacity to make health care decisions.

Surveyors reviewed the hospital policy titled "Consent to Treatment (Informed Consent)" which stated: "F. Decision to refuse medical treatment: (1) competent adults generally have the right to accept or reject medical treatment for themselves. G. Special considerations: 1. Capacity (a.) an adult has the right to consent or to refuse medical treatment. An adult is presumed to have capacity unless (two) physician(s) have deemed the patient incapable of making an informed decision regarding the treatment. (iii) When authorization is sought for treatment of a mental illness, the second physician may not be otherwise involved in the treatment of the patient assessed".

Patient #11 (P11) was a 50+ year old patient who was brought to the Emergency Department (ED) for evaluation of a psychiatric condition. The nursing staff documented that P11 was "alert and agitated" on arrival to the ED and requested several times over the subsequent 12 hours to be discharged home.

The initial assessment documented by the ED physician determined that P11 was alert and oriented and capable of making their own decisions. An evaluation completed by the Mental Health (MH) provider stated that P11 was alert and oriented to person, place, time, and situation, was in the ED voluntarily and "displayed cognitive ability to understand what this means". The same MH provider also documented that two other physicians involved in P11's care were in agreement with this plan.

During the course of the ED stay, P11 voiced on 3 separate occasions that they wanted to "leave and go home". The documentation by nursing staff regarding these requests included "security called", "IM (intramuscular) medications given with brief physical hold", and "MD aware, medications ordered". A physician note following one of these events stated that the patient required "medications to control [patient's] behavior". Another nursing note stated "patient refusing to take scheduled medications". No documentation was found to support that the patient agreed to either the administration of the IM medications or the continued stay in the ED.

P11 was transferred to another facility after 20+ hours in the ED. Around the time of transfer to the receiving facility, P11's status was changed to "involuntary" and the certification by two physicians was placed in the record. No documentation was found to support that any discussion took place with P11 regarding the change from voluntary to involuntary status or why the change was or was not appropriate.

In summary, the hospital staff precluded P11 from being involved in their care planning and treatment, including exercising the right to refuse medications and treatment, on several occasions prior to completion of the certification for involuntary admission.

Patient #8 (P8) was a 75+ year old sent by nursing facility to emergency department due to aggressive behavior. The ED provider note on the day arrival indicated that the patient was positive for behavior problems and suicidal ideation. Assessment findings also indicated twice in the same provider's note that P8 was oriented to person, place, and time. The patient was cleared medically and was awaiting a mental health evaluation. Per record review, P8 did not have a medical or mental health advanced directive on file.

On day two, the Initial Mental Health Evaluation (IMHE) was performed. It was determined that P8 lacked orientation to time, place, and situation during the evaluation. The IMHE contained a robust amount of information gathered from the patient, observations, interviews with hospital staff, nursing facility staff, and multiple family members. The plan within the IMHE indicated a possibility that the patient may require involuntary certification for treatment, but that the patient was currently voluntary. There was no documentation found in the medical record of P8 being certified by two physicians to lack capacity to make decisions regarding their admission and care. In the absence of this certification, there was also no evidence that P8 was in agreement or aware of the plan for voluntary or involuntary admission, as the results of IMHE and plan of care were discussed with P8's adult children, and not the patient.

The hospital failed to ensure that P8 was appropriately evaluated and, if warranted, documented by two physicians to lack capacity for medical decision making and be placed in involuntary status. In the absence of this documentation, it appeared that P8 was precluded from making informed decisions about their plan of treatment and transfer.

Based on review of medical records, a hospital policy, and other pertinent documents, it was determined that the hospital failed to provide 1 of 12 patients the right to be free from restraints as a means of coercion, discipline and/or convenience by staff.

Surveyors reviewed the hospital's "Policy for Restraint" (dated 8/2018) which stated: "1. Restraint (b) a drug or medication when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement".

Patient # 11 (P11) was a 50+ year old patient who was brought to the Emergency Department (ED) for evaluation of a psychiatric condition. The nursing staff documented that P11 was "alert and agitated" on arrival to the ED and requested several times over the subsequent 12 hours to be discharged home.

The initial assessment documented by the ED physician determined that P11 was alert and oriented and capable of making their own decisions. An evaluation completed by the Mental Health (MH) provider also determined that P11 was in the ED voluntarily and "displayed cognitive ability to understand what this means".

During the 20+ hours in the ED, P11 stated "I just want to go home", "I'm not staying here" and "I'm gonna walk right out the door, I want my own bed". Nursing documentation stated that P11 was yelling at the staff and trying to leave the unit. There were 3 documented episodes of the patient verbalizing they wanted to leave. In each episode, security was called, and P11 was placed in a physical hold while nursing staff administered intramuscular (IM) medications. No documentation was found to support that the patient was displaying any violent or self-destructive behaviors that would jeopardize the immediate physical safety of themselves or the staff, or that the patient agreed to these IMs. Further review of the medical records revealed a physician note that stated, "Patient did initially receive medications to control their behavior".

In summary, P11 was evaluated and determined to be alert, oriented, and remaining voluntarily at the hospital, and, consequently, had the right to make decisions regarding their care and discharge. The hospital staff utilized security presence, physical holds, and administration of medications that could have a sedative effect as a means to control P11 and to keep them from leaving the hospital. In addition, the physical and chemical restraints were performed by staff in the absence of emergency behaviors that could pose an immediate threat to P11 or staff.

Based on review of medical records, hospital policy, and other pertinent documents, it was determined that the hospital failed to document multiple restraint orders for 3 of 3 patients reviewed for restraints and seclusion.

Surveyors reviewed the hospital's "Policy for Restraints" (dated 8/2018) which stated: "2. Physical hold for forced medications - the use of force in order to medicate a patient, as with other restraints, must have a medical staff member and/or house staff's order prior to the application of the restraint".

Patient #11 (P11) was a 50+ year old patient who was brought to the Emergency Department (ED) for evaluation of a psychiatric condition. The nursing staff documented that P11 was "alert and agitated" and wanted to leave the hospital.

P11 remained in the ED for 20+ hours and during that time it was documented on 3 separate occasions that a physical hold with medication administration was required for the patient. Review of P11's medical record determined that no physical hold orders were found for the first or second episodes. An order was present for the third episode; however, it was dated and timed 2 hours after the physical hold took place.

Patient #12 (P12) was a 10+ year old patient who was brought to the ED for evaluation of aggressive behaviors caused by a chronic cognitive disorder. The patient was non-verbal and had a history of aggression.

Review of P12's medical record determined that, during the first 5 days in the ED, there were 7 documented episodes of a "brief physical hold" for administration of IM (intramuscular) medications. Of those 7 episodes, 4 were documented in nursing notes and 3 were documented by a physician on the behavioral flowsheet. While reviewing the order section of the record, it was noted that only one order existed for a physical hold; therefore, 6 of 7 episodes lacked an order by a physician during or after the episode.

Patient #8 (P8), a 75+ year old, was sent by a nursing facility to the ED due to aggressive behavior. At 8:35 AM, the nurse documented that P8 was given an antipsychotic medication via an intramuscular (IM) injection with a brief hold needed in order to safely administer the medication. There was no order found in the medical record for the holding of P8 to administer the medication.

Without an order by the physician, it was unclear whether there was clinical oversight for each of the restraint events that lacked an order.

Based on review of restraint and seclusion records, hospital policy, and other pertinent documents, it was determined that the hospital failed to complete the one hour face-to-face evaluations after multiple restraint episodes for Patients #11 and #12.

Surveyors reviewed "Policy for Restraint" (dated 8/2018) which stated: "IV. Physical hold for forced medications - C. Evaluation 1. Medical staff member who has received face to face assessment training conducts an in person, face to face evaluation of the patient within one hour of the initiation to include an evaluation of the immediate situation, the patient's medical and behavioral condition, the patient's reaction to the intervention and the need to continue or terminate the restraint. D. Documentation - 2. Detailed documentation of the situation/event is required."

Patient #11 (P11) was a 50+ year old patient who was brought to the Emergency Department (ED) for evaluation of a psychiatric condition. The nursing staff documented that P11 was "alert and agitated" on arrival to ED and wanted to leave the hospital.

P11 remained in the ED for 20+ hours and during that time it was documented on 3 separate occasions that a physical hold with medication administration was required for P11. During one episode, the face-to-face evaluation was documented one hour before the physical hold and medication administration took place. No documentation was found that another face-to-face evaluation took place after the actual hold was completed. No documentation of a face-to-face evaluation was found for the second physical hold episode. A face-to-face evaluation was found for the third physical hold episode; however, it was documented almost 2 hours after the restraint episode was completed.

Patient #12 (P12) was a 10+ year old patient who was brought to the ED for evaluation of aggressive behaviors caused by a chronic cognitive disorder. P12 was non-verbal and had a history of aggression.

Review of P12's medical record determined that, during the first 5 days in the ED, there were 7 documented episodes of a 'brief physical hold' for administration of IM (intramuscular) medications. The 5 of 7 episodes either did not have a face-to-face evaluation documented during or after the episode, or the evaluation was not documented within the required time frame. In the first episode, the face-to-face evaluation was documented 4+ hours after the restraint took place. In the second episode, the evaluation was documented 2 hours after the restraint. In the third episode, the face-to-face evaluation was documented almost an hour before the restraint took place. In the final 2 episodes, no documentation of a face-to-face evaluation was found during or after the restraint episodes.

Based on review of 3 closed behavioral health patient records, it was determined that registered nurse (RN) staff lacked awareness of patients' behavior and condition for 1 of 3 reviewed records, as evidenced by lapses in documentation of 15 minute Patient Safety checks which were delegated by RN staff to unlicensed personnel.

Patient #8's (P8) medical record was reviewed by surveyors and was found to lack consistent documentation of Patient Safety checks. In one episode, no Patient Safety checks were documented for over 14 hours, although documentation of patient's situation and behavior were to be performed by a Safety Attendant every 15 minutes.

Patient #8, a 75+ year old, was sent by a nursing facility to the Emergency Department due to aggressive behavior. In the first two hours of P8's arrival, the nurse noted at 7:51 PM that P8's behavior was aggressive and P8 was verbalizing a suicidal ideation. At 8:00 PM, a Safety Attendant (SA) was placed at the patient's bedside; however, no documentation by the SA of P8's behavior, location, or treatment interventions appeared in the medical record for greater than 4 hours.

The day prior to transfer, the second lapse in safety documentation for P8's occurred and exceeded 14 hours. There was no documentation from the SA for P8 from 4:15 PM until the following day at 7:00 AM.

The assigned RN staff performed and documented various assessments and checks on P8 during the above-described episodes; however, these assessments fell short of the frequency of Patient Safety checks that should have been provided/documented by the Safety Attendant to meet the needs of P8.

The RN staff caring for P8 failed to supervise the delegated task of Patient Safety checks and ensure that the SA's assessments were being performed and documented. Based on the lack of awareness of patient's condition, behavior, and needs by the RN staff during the times when Patient Safety checks were not performed/documented appropriately, the assigned RN staff could not perform a comprehensive evaluation of P8's plan of care.

Based on review of patient medical records, it was determined that the hospital failed to maintain an accurate medical record for 1 of 12 patients.

Patient #8 (P8) was a 75+ year old sent by nursing facility to emergency department due to aggressive behavior. Review of P8's medical record determined that the sending physician failed to appropriately and accurately document P8's condition and status upon transfer to another hospital. P8's transfer form lacked completion of critical areas of the form including: 1) sending physician's certification of need for transfer, 2) receiving physician's name and contact information, and 3) patient's and/or patient's representative signature.

There was no evidence found in the record of P8 being certified by two physicians to lack capacity to make health care decisions or physicians completing an application for involuntary admission; however, the transfer form stated that the patient was " involuntary". This contradicted the Initial Mental Health Evaluation note documented on day 2 of the ED stay which stated P8 was in "voluntary" status.

Inaccurate and incomplete medical records, at a minimum, could lead to misdiagnosis, mistreatment, and medication errors putting patients at risk for negative outcomes.