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Based on record review and interviews, the facility failed to:

I. Assure that 1 of 7 active sample patients (A5) whose records were reviewed for facility restraint policy and procedure compliance, was released from 5-point restraints after she regained control of her behavior. This failure results in a violation of patient rights to be free from the restrictive nature of restraints as soon as possible.

II. Assure that physicians performing the face to face evaluations within one hour of the initiation of restraints for 6 of 7 patients whose records were reviewed for facility policy and procedure compliance (active sample patient B6 and non-sample patients D1, D2, D3, D4, and D5), documented the details of their individual findings from the assessments in the patients' records. Instead, the physicians signed a form ("Order for Restraint or Seclusion - Mental Health") that included a routine pre-printed statement about the assessment. This failure results in clinical staff not having access to the details of physicians' assessments regarding patients' mental and physical health status at the time of restraint initiation.

Findings include:

I. Failure to release Patient A5 from restraints as soon as possible

A. Record Review

1. Facility policy titled "Use of Restraint and Seclusion (commitment in mental health facilities)," ID: MSO.00.045, last revised 8/24/10, is used to document seclusion and restraint procedures. The nurse obtaining the verbal order for the procedure fills out the form. This pre-printed form requires the nurse to fill in the blank spaces and/or put check marks next to the desired information. The nurse then fills in the name of the doctor who was called for the order. The nurse then signs and dates the form in the appropriate spaces. In the area of patient release, the policy states: "The individual will be told specifically he or she will be released as soon as the release criteria are met."

2. Active sample patient A5 was placed in 5-point restraints on 9/23/10 at 9:35a.m. The facility's "Order for Restraint or Seclusion for Mental Health" form, dated 9/23/10 at 9:35a.m., described the patient as "highly agitated. Attacking staff & [and] peers. Cont. [sic] [continued] to threaten to harm others." The length of time and justification was "up to 2 hours, allow sufficient amount of time to calm down and regain control of self."
The release criteria stated: "1 hour calm & quiet. Will follow simple request & cooperate with staff." The rationale for the justification and criteria was "per policy & procedure." The "Restraint/Seclusion" flow sheet, started 9/23/10 at 9:35a.m., listed the patient as being in restraints from 9:35a.m. to 11:25a.m.-one hour and forty minutes. From 10:15a.m. to 11:15a.m., when the patient was released from restraints, the patient's behavior was documented as being "quiet", "calm", "cooperative", and "no behaviors."

B. Interviews

1. In an interview on 10/18/10 around 12:15p.m. RN #1 (who initiated the restraint and obtained the doctor's order) was asked why the patient had been kept in restraints for an hour after she had calmed down. She first said it was because the release criteria stated 1 hour. When asked who determined the release criteria, she said: "I did." She then stated that it was also because patient A5 had a history of unpredictable acting out behavior and she felt an hour of the patient being quiet would give the nursing staff time to assess whether the patient was ready to be released from restraints.

2. In an interview with the Nursing Director on 10/19/10 at 12:10p.m., the one hour prolonged stay of patient A5's restraints was discussed. The DON stated "It's [allowance of time for patients in restraint/seclusion to calm down] usually a half hour." When told that the facility policy does not state a specific time frame for releasing patients from restraints after they calm down, she stated "That's a valid point."

3. In an interview on 10/19/10 at 12:45p.m., RN #2 was asked how long a patient should be kept in restraints after calming down. RN #2 stated "If they are calm in 15 minutes, they should be released." When asked where she obtained this information since the facility's policy did not list a specific time for patient release, she said "That's just my opinion."

II. Physician failure to write a detailed description of the face to face evaluation

A. Record Review

1. Facility policy titled: "Use of Restraint and Seclusion [containment] in Mental Health facilities", ID: MSO.00.045, last revised 8/24/10, does not state what the face to face assessment should include. It merely states that "a physician must personally examine the individual patient and complete a written order within one (1) hour of the initial implementation of restraints."

2. The facility's "Order for Restraint and Seclusion - Mental Health" form has the following statement at the bottom of the form: "I have personally examined the individual within one hour of the initiation of restraints or seclusion. It is my assessment that such application did not pose undue risk to the individual's health in light of the individual's physical or mental condition." Following this statement is a line for the physician's signature - including date, and time of signature.

3. The records of the following 6 of 7 patients who had been placed in restraints were found deficient in documentation (date and time of restraint in parenthesis): B6 (10/7/10 at 10:40a.m.), D1 (9/5/10 at 8:47a.m.), D2 (10/12/10 at 6:00p.m.), D3 (9/3/10 at 3:20p.m.), D4 (8/27/10 at 9:15p.m.), and D5 (9/28/10 at 8:40p.m.). None of the above medical records had, in either the progress notes or on the seclusion/restraint form, any detailed individualized description of the one hour face to face evaluation by the physician performing the assessment.

B. Interview

In an interview with the Medical Director on 10/19/10 at 11:45a.m., the lack of an individualized description of a patient's face to face evaluation within the hour of the initiation of a restraint was discussed. The Medical Director did not dispute the findings.

Based on record review and interview, the Medical Director failed to:

I. Assure that 1 of 7 patients (active sample patient A5) whose records were reviewed for facility restraint policy and procedure compliance was released from 5-point restraints after she regained control of her behavior. This failure results in a violation of patient rights to be free from restraints as soon as possible. (Refer to B125-I.)

II. Assure that physicians performing the face to face evaluations within one hour of the initiation of restraints for 6 of 7 patients whose records were reviewed for facility policy and procedure compliance (active sample patient B6 and non-sample patients D1, D2, D3, D4 and D5) documented the details of their individual findings from the assessments in the patients' records. Instead, the physicians signed a form ("Order for Restraint or Seclusion - Mental Health") that includes a routine pre-printed statement about the assessment. This failure results in clinical staff not having access the details of physicians' assessments at the time of restraint initiation. (Refer to B125-II.)

In an interview on 10/19/10 at 11:45a.m., the Medical Director was shown the restraint documentation for active sample patient A5 who had been kept in restraints 1 hour after she had calmed down. When asked what he thought of that situation, he stated "That's a long time to be quiet." When the lack of detailed individualized descriptions of the face to face physician evaluations of patients within 1 hour of the initiation of the restraint was discussed, the Medical Director did not dispute the findings.

Based on record review and interview, the Nursing Director failed to assure that 1 (active sample patient A5) of 7 patients, whose records were reviewed for facility restraint policy and procedure compliance, was released from 5-point restraints as soon as possible after she regained control of her behavior. This failure results in a violation of patient rights to be free from the restrictive nature of restraints as soon as possible (Refer to B125-I.)

Findings include:

A. Record Review

1. Facility policy titled "Use of Restraint and Seclusion (commitment in mental health facilities)", ID: MSO.00.045, last revised 8/24/10, states "The individual will be told specifically he or she will be released as soon as the release criteria are met."

2. Active sample patient A5 was placed in 5-point restraints on 9/23/10 at 9:35a.m. The facility's "Order for Restraint or Seclusion for Mental Health" form, dated 9/23/10 at 9:35a.m., described the patient as "highly agitated. Attacking staff & [and] peers. Cont. [sic] [continued] to threaten to harm others." The length of time and justification was "up to 2 hours, allow sufficient amount of time to calm down and regain control of self." The release criteria stated "1 hour calm & quiet. Will follow simple request & cooperate with staff." The rationale for the justification and criteria was "per policy & procedure." The "Restraint/Seclusion" flow sheet, started 9/23/10 at 9:35a.m., listed the patient as being in restraints from 9:35a.m. to 11:25a.m. -one hour and forty minutes. From 10:15a.m. to 11:15a.m., when the patient was released from restraints, the patient's behavior was documented as being "quiet", "calm", "cooperative", and "no behaviors".

B. Interviews

1. In an interview on 10/18/10 around 12:15p.m., RN #1 who initiated the restraint and obtained the doctor's order was asked why the patient had been kept in restraints for an hour after she had calmed down. She first said that it was because the release criteria stated 1 hour. When asked who determined the release criteria, she said "I did." The nurse then stated that it was also because patient A5 had a history of unpredictable acting out behavior and she felt an hour of the patient being quiet would give the nursing staff time to assess whether the patient was ready to be released from restraints.

2. In an interview with the Nursing Director on 10/19/10 at 12:10p.m., the one hour prolonged stay of patient A5 in restraints was discussed. She stated "It's [allowance of time for patients in restraint/seclusion to calm down] usually a half hour." When told that the facility policy does not state a specific time frame for releasing patients from restraints after they calm down, she stated "That's a valid point."

3. In an interview on 10/19/10 at 12:45p.m., RN #2 was asked how long a patient should be kept in restraints after calming down. She stated "If they are calm in 15 minutes, they should be released." When asked where she obtained this information since the facility policy did not list a specific time for patient release, she said "That's just my opinion."