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Based on interview and documentation review the Hospital failed to ensure that the Patient was informed of implementation of Section 12 status and the reasons for implementation of that status.

Findings included:

The medical record documentation, dated 6/27/10 to 6/28/10, indicated that the Patient episodically refused exams, blood testing, and medications. The Patient required reapproaching and reminders of the consequences of noncompliance. The Patient verbalized being unhappy with limited use of narcotics for the headaches. The physician had a long discussion with the Patient regarding refusal of medications and the reason for limited use of narcotics (due to a substance abuse history). The plan was to ask for a psychiatric consult to determine whether the Patient would benefit from a psychiatric inpatient stay due the likelihood of severe complications due to treatment noncompliance.

The medical record documentation, dated 6/29/10, 8:55 A.M., indicated that a psychiatric consult was performed and a Section 12 was implemented.

Psychiatric Clinical Nurse Specialist (PCNS) #1 was interviewed on 7/9/10 at 10:50 A.M. PCNS #1 reported discussing the Patient with the Attending Physician and both felt the Patient needed inpatient psychiatric treatment because the Patient was not taking care of self and was not stabilized on medications. PCNS #1 said if the Patient had not been a diabetic then inpatient treatment would not have been considered. PCNS said a crisis team who were responsible for authorizing inpatient treatment under the Patient's insurance was contacted and a Section 12 was initiated. PCNS #1 said the Patient was not informed of the Section 12 status.

The Attending Physician was interviewed on 7/9/10 at 3:00 P.M. The Attending Physician confirmed the Patient was deliberately not told of the Section 12 implementation.

The medical record documentation, dated 6/29/10, indicated that at approximately 7:00 P.M., an order was written to institute a sitter, and at approximately 10:55 P.M. an order was obtained to apply 4 point restraints for behavior management.

The Nurse assigned to the Patient (Nurse #1) was interviewed on 7/20/10 at 9:25 A.M. Nurse #1 said the Patient felt the pain was not being managed and wanted to sign out. Nurse #1 reported seeing the Section 12 form in the medical record and called the Attending Physician. Nurse #1 said the Attending Physician reported the Patient was not aware of the Section 12 and was not to be told. Nurse #1 reported spending much time with the Patient during the shift and administering pain medication as ordered. Nurse #1 said toward the end of the shift the Patient began to pack up the belongings and the Attending Physician was called. Nurse #1 reported asking for permission to inform the Patient about the Section 12 status and requesting permission to apply restraints if needed. Nurse #1 reported telling the Patient about the Section 12 status and telling the Patient attempts to leave would result in restraint application. Nurse #1 said the Patient became combative and was restrained.

The Security Officer who assisted in restraining the Patient (Security Officer #1) was interviewed on 7/9/10 at 9:20 A.M. Security Officer #1 said the Patient reported acting that way because the Patient had not been made aware of the Section 12 status.

The Consulting Risk Manager was interviewed on 7/9/10 at 11:00 A.M. The Risk Manager said the Patient reported attempting to leave because the Patient thought staff was kidding when they told the Patient a Section 12 had been implemented.

The Attending Physician and PCNS #1 failed to inform the Patient of changes in the Plan of Care and reasons for those changes.

Based on documentation review the Hospital failed to ensure that documentation of the Patient's response to restraints was documented in the medical record.

Findings included:

The medical record documentation indicated that on 6/29/10 the Patient attempted to leave the Hospital while under a Section 12 status. The Patient was placed 4-point restraints at approximately 11:00 P.M.

The Policy/Procedure titled Restraints indicated that the Restraint Flowsheet would be used for each incident of restraint use. Assessment and interventions during restraint use when restraints were used for behavioral purposes was to be documented every 15 minutes.

Review of the Patient's medical record indicated that a Restraint Flowsheet had not been implemented.

Based on interview and documentation review the Hospital failed to identify opportunities for improvement related to restraints and Section 12 implementation during the course of an investigation.

Findings included:

Please refer to A-0130 for medical record information.

The Director of Patient Services was interviewed intermittently throughout the survey. The Director said an investigation was conducted that focused on the actual event in that the Patient and witnesses were interviewed. The Director said restraint application and use was determined to be appropriate. The Director said the investigation did not include a chart review for documentation purposes.

The investigation did not identify that: 1:1 documentation was not implemented in a timely manner; a Restraint Flowsheet was not completed; there was no documentation as to when restraints were discontinued, and the Section 12 form was not dated/timed.

Based on documentation review the Hospital failed to ensure that: 1). one to one observations were documented for one of one patient (the Patient); 2). the Restraint Flowsheet was implemented; 3). discontinuation of the restraints was documented, and 4). the Section 12 form was dated/timed.

Findings included:

1). The Policy/Procedure titled Patient Safety Precautions/One-to-One Observations indicated that documentation would occur in the medical record using electronic or paper format. Hourly documentation on the Continuous Observation Form was required. More frequent documentation was required as warranted by the Patient's condition.

The Patient's medical record documentation, dated 6/29/10, indicated that a Section 12 was implemented. At approximately 7:00 P.M. an order for a sitter was written.

The Continuous Observation Documentation form was not implemented on 6/29/10 at 10:30 P.M.

2). The medical record documentation indicated that on 6/29/10 the Patient attempted to leave the Hospital while under a Section 12 status. The Patient was placed 4-point restraints at approximately 11:00 P.M.

The Policy/Procedure titled Restraints indicated that the Restraint Flowsheet would be used for each incident of restraint use. Assessment and interventions during restraint use when restraints were used for behavioral purposes was to be documented every 15 minutes.

Review of the Patient's medical record indicated that a Restraint Flowsheet had not been implemented.

3). The sitter assigned to the Patient while the Patient was restrained (Orderly #1) was interviewed on 7/9/10 at 2:00 P.M. Orderly #1 reported the Patient calmed after restraints were applied and Orderly #1 initiated removal of the restraints. Orderly #1 said the restraints were all removed by approximately 2:30 A.M.

Review of the medical record indicated that there was no documentation to indicate when the restraints were discontinued.

4). See A-0130

Review of the Patient's medical record indicated there was no order for the Section 12, no documentation by Phychiatric Clinical Nurse Specialist #1 or the Attending Physician regarding implementation of the Section 12, and the Section 12 form, completed by PCNS #1, was not date or/timed.