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Based on interview and document review, the Community Behavioral Health Hospital (CBHH) failed to obtain a physician order for use of restraints for 1 of 5 patients (P23) reviewed, and failed to obtain a physician order in a timely manner for 2 of 5 patients (P21, P22) reviewed for restraint use.

Findings include:
P23's Seclusion/Restraint record indicated the use of a manual restraint on 8/8/15, the record indicted a start time of 2:00 p.m. and an end time of 2:16 p.m., however did not include evidence a physician's order had been obtained for the use of the manual restraint.
P21's Seclusion/Restraint record indicated the patient had been placed in a manual restraint on 1/20/16. The seclusion/restraint record indicted a start time of 6:51 p.m. and an end time of 6:52 p.m. However, an order for the use of the manual restraint was not provided until 8:28 p.m. when an order was received from a certified nurse practitioner. On 1/27/16 at 1:26 p.m. registered nurse (RN)-C verified the manual restraint use for P21 on 1/20/16 had been started at 6:51 p.m., but no order had been received until 8:28 p.m. (1 hour and thirty-seven minutes after implementation of the restraint).
P22's Seclusion/Restraint record indicated the patient had been placed into a manual restraint on 8/8/15. The seclusion/restraint record indicted a start time of 1:40 p.m. and an end time of 1:45 p.m. However, an order for the use of the manual restraint was not provided until a physician provided an order at 5:29 p.m.
P22 had been placed into Velcro restraints to the wrist and ankle on 8/8/15, the seclusion/restraint record indicted a start time of 1:41 p.m. and an end time of 1:45 p.m. An order for the use of the Velcro restraint was completed at 5:35 p.m. by the physician.
P22 was placed into the restraint chair on 8/8/15, the seclusion/restraint record indicted a start time of 1:45 p.m. and an end time of 4:29 p.m. The order for the use of the restraint chair was completed at 5:38 p.m. by the physician.
P22 was placed into seclusion on 8/8/15, the seclusion/restraint record indicted a start time of 4:29 p.m. and an end time of 4:45 p.m. The order for the use seclusion was completed at 5:41 p.m. by the physician.
On 1/27/16, at 1:50 p.m. RN-C verified the manual restraint was started at 1:40 p.m. and the order was written at 5:24 p.m. or 3 hours and forty-three minutes after the restraint was implemented. RN-C verified the Velcro restraint was started at 1:41 p.m. and the order was written at 5:25 p.m. or 3 hours and forty-four minutes after the restraint was implemented. RN-C verified the restraint chair was started at 1:45 p.m. and the order was written at 5:28 p.m. or 3 hours and fifty-three minutes after the restraint was implemented. RN-C verified seclusion was started at 4:29 p.m. and the order was written at 5:41 p.m. or 1 hour and twelve minutes after the restraint was implemented.
On 1/27/16, at 2:17 p.m. RN-C stated a physician order must be obtained for the use of restraints and stated physician orders should be obtained as soon a possible after the implementation of restraints. RN-C verified there was no documented restraint order for P23, and the restraint orders for P21 and P22 were not obtained in a timely manner.
On 1/27/16, at 4:03 p.m. the administrator stated she expected facility staff to follow the policy and procedure on restraints, however verified the policy did not indicate a timeframe for obtaining the order. The administrator stated she expected an order for a restraint to be obtained within an hour of the restraint implementation and stated an order must be obtained for use of any restraint.
The Seclusion or Restraint policy dated 9/25/15 indicated, "Obtains LIP [licensed independent practitioner] order to authorize the application of seclusion or restraint as soon as possible."

Based on interview and document review the Community Behavioral Health Hospital (CBHH) failed to complete a face to face evaluation within one hour of restraint implementation for 1 of 5 patients (P21) reviewed for restraint use. This had the potential to affect all future patients who may need restraints to control behavior.
Finding Include:
P21 was placed into a manual restraint on 1/20/16. The Seclusion/Restraint record indicted a start time of 6:51 p.m. on 1/20/16, and an end time of 6:52 p.m. on 1/20/16. A face to face evaluation was documented as having been completed at 9:50 p.m. by a registered nurse (RN). RN-C was interviewed at 1:26 p.m. on 1/27/16, and stated face to face evaluations were to be completed within an hour of restraint application, and verified the face to face evaluation for P21 had not been completed until two hours and fifty-nine minutes after the implementation of restraint for P21 on 1/20/16.
The Seclusion/ Restraint policy dated 9/25/15, was reviewed and did not include a timeframe for completion of the face to face evaluation
On 1/27/16, at 4:03 p.m. the administrator confirmed a face to face evaluation should be completed per the guidelines in these regulations. The administrator verified the time frame for completion of the face to face evaluation was not included in their facility policy and stated it should have been included in the policy.

Based on observation, interview and document review, the hospital was found to be out of compliance with Life Safety Code requirements. These findings had the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code deficiencies cited at K-0154 and K-0155 for additional information.

Based on interview and document review, the facility failed to ensure their policies were implemented for notification to the Organ Procurement Organization (OPO) for 1 of 1 patient (P24) reviewed for whose death was imminent.

Findings include:

P4's medical record was reviewed and indicated the patient had died at 12:35 p.m. on 6/17/15. There was no documentation in the record to indicated the OPO, Life Source, had been notified regarding P4's death.

The facility's Adult Mental Health Organ, Tissue and Eye Procurement Policy dated July 17, 2015, included: "Timely Referral: Notification to LifeSource within one hour of the patient meeting the clinical trigger criteria for imminent death...With respect to cardiac death, timely notification means notification to LifeSource within one hour of cardiac death."

On 1/27/16, at 3:00 p.m. the administrator verified during interview that Life Source had not been notified regarding P4's death. The administrator also verified the hospital policy indicated LifeSource should be notified within one hour of death, and that the policy had not been implemented at the time of P4's death.