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Based on interviews, clinical record review and document review, it was determined facility staff failed to complete a face-to-face assessment within one (1) hour of the initiation of restraint or seclusion for two (2) of five (5) patients included in the sample who were restrained or secluded. (Patient #4 and Patient #5)

The findings include:

The clinical record for Patient #4 was reviewed on 10/16/18 with the assistance of a navigator provided by the facility (Staff Member (SM) #22). A review of restraint documentation for Patient #4 found the patient was admitted on 9/08/18 under a TDO (temporary detention order) with a diagnosis of "Unspecified Schizophrenia Spectrum and Other Psychotic Disorder along with Major Neurocognitive Disorder with Behavioral Disturbance". At 10:50 a.m. on 9/9/18, Patient #4 was placed in seclusion for throwing self onto furniture, screaming, yelling, increased risk of self injury--psychotic, not cooperative with redirection. SM #18 (a provider) had documented at 10:54 a.m. "aggressive in dayroom. Verbal altercation with another patient. Pushing chairs around dayroom. Would not redirect. Loud and agitated. Necessary to escort to seclusion. Will monitor and release as soon as behaviors improve." Patient #4 remained in seclusion until the patient fell at approximately 1:00 p.m. sustaining an injury that resulted in Patient #4 being transported by ambulance to the local hospital. The clinical record failed to provide evidence of a face-to-face assessment being completed within an hour of the initiation of the restraint. On 10/18/18 beginning at approximately 10:17 a.m., the survey team conducted an interview with SM #18 via telephone. During the course of the interview and discussion of the event occurring on 09/09/18, SM # 18 confirmed that he/she had not seen Patient #4 for a face-to-face assessment after the seclusion was initiated, but had seen the patient just prior to the initiation of seclusion.

The clinical record for Patient #5 was reviewed on 10/16/18 with the assistance of a navigator provided by the facility SM #22. A review of restraint documentation for Patient #5 found the patient was admitted on 6/16/18 under a TDO with a diagnosis of Intermittent explosive disorder. On 6/18/18 Patient #5 became upset after a court appearance and began throwing soap and water down the hallway of the living unit, pulling curtains off the windows and becoming aggressive towards staff. At 11:10 a.m., Patient #5 was placed in a restraint chair after less restrictive methods of calming the patient had failed. Patient #5 was released from the restraint chair at 12:45 p.m. The clinical record failed to provide evidence of a face-to-face assessment within 1 hour of the initiation of the restraint. At 18:36 p.m., Patient #5 was placed in seclusion after damaging property belonging to his/her roommate, hitting/pulling on roommate and becoming combative with nursing staff. Patient #5 remained in seclusion until 8:05 p.m. when he/she calmed and was released. The clinical record failed to provide evidence of a face-to-face assessment within 1 hour of the initiation of the seclusion.

Review of facility policy "Emergency Use of Seclusion or Restraint" effective date 08/01/17 reads in part as follows: "C. Within one hour of the initiation of seclusion or restraint, the Medical Professional Staff will conduct a face-to-face assessment of the individual, review the individual's physical and psychological status, evaluate the individual's response to the intervention, and document assessment in a physician's restraint note".

Facility staff's failure to complete a face-to-face assessment within one hour of initiation of restraint and/or seclusion as detailed above, was shared with SM #4 and SM #22 at the time of discovery and with the facility management team prior to exit on 10/18/18. No further information was provided to the survey team.