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Based on interview and record review the facility failed to ensure patients are free of restraints, including escort hold, for 1 of 9 (#7) patients.

Findings:

1. A review of the medical record revealed patient #7 signed an Application for Voluntary Admission of an Adult on 07/20/2012. On the Consent for treatment and conditions of admissions: 12) she initialed that use of reasonable interventions (may include restraints, seclusion, protective hold, medication) may be used for management of behavioral psychiatric emergencies if the symptoms warrant, in order to protect the patient from harming herself or others. A review of the incident log revealedpatient #7 was physically and chemically restrained on 07/21/2012, and no injury involved. Patient was out of control, classified as acute. On 07/25/2012 the patient was also chemically/ physically restrained. Patient out of control. Acute.
A review of the nurses notes revealed on 07/23/2012 the patient was sent to the hospital for hyperventilation and restlessness. The physician was notified and an order was given to send the patient to the Emergency Department for evaluation.
A review of the records for patient #7 revealed the physical examination on 07/20/2012 showed the skin was warm and dry. Intact, without active dermatosis.
The Psychiatric evaluation on 07/20/2012 revealed she was admitted for Mood disorder, problems with primary support group. The history and physical revealed a medical impression/plan: Anxiety/sleep intolerance. The Integrated Assessment on 07/20/2012 by the therapist revealed she was a voluntary patient. A review of the records revealed the physician gave a telephone order for CPI hold to return patient to the Adult Unit. Dated 07/23/2012. The Psychiatry daily progress note on 07/23/2012 at 1615 revealed "CPI hold needed to return patient to the facility".
A review of the Seclusion and Restraint one hour/post intervention face to face revealed on 07/23/2012 at 0710: The patient was agitated in parents car, refusing to get out of the car. Patient must return to the adult unit to discontinue restraint. The parents requested staff to assist patient out of car. CPI hold with 2 person escort used to assist patient out o car and return to unit. Patient passively resident to CPI hold. Patient refusing to get out of parents car. CPI hold less than 5 minutes. A review of the Seclusion and Restraint one hour /post intervention face to face revealed on 07/23/2012 at 0810: Patient has multiple small, medium size bruises on arms and torso. Not occurring from this episode. Patient was anxious, fearful, refusing to speak.
A review of the Discharge Summary on 07/25/2012 revealed the patient was placed under suicide precautions and every 15 minute checks. She was prescribed Trazadone and Vistaril. Approximately 1/2 hour after arrival, she became acutely agitated and was unable to be deescalated by other measures, so she received an emergency treatment order for Ativan 2 mg IM. On that same day she was prescribed Ativan 3 times daily for anxiety, Celexa 20 mg for depression, and Remeron. She continued to be suspicious and uncooperative with medication so was sent to the emergency department for medical clearance. On 07/25/2012 she was discharged to her parents.

The Seclusion/Restraint Patient Debriefing revealed the patients family requested intervention.
A review of the Determination of Voluntary/Involuntary Evaluation/Admission Procedure/Baker Act revealed:
Psychiatrist: decides if client/patient requires Involuntary Placement within 24 hours of arrival.
Documents whether client/patient is competent to consent for Voluntary Admission in client/patient's clinical record.
If client/patient is deemed competent to be a Voluntary, will write order for client/patient to sign voluntary Admission.

2. On 10/30/2012 at 8:53 AM an interview with the Registered Nurse (RN B) revealed she went to the car when the patient was returned the same day from the hospital by her parents. The supervisor directed staff to bring patient #7 into the building. The Mental Health Techs coaxed her out of the car and escorted her back in. She was put into the shower with tech. RN "B"helped her get undressed, saw bruising.
The RN further revealed the Restraint policy is only used if the patient is a danger of hurting themselves or others. Restraint includes the escort hold (CPI Crisis Prevention Institute).

3. On 10/30/2012 at 10:51 AM an interview conducted with the Mental Health Tech, (A) revealed he was directed by the nursing supervisor to bring the patient into the building. He asked about voluntary status, and was told the mother wanted her to come back to the facility. After coaxing her to come to the car door he reached under her arm, and assisted her out of the car. He had his arm under hers, and the other male was holding the other arm. She walked okay to the step, then she pushed with her foot against the step and pushed back. She was saying, " No, no " . She leaned against him while pushing back. She did not fall, she pushed back and both were holding her because she was leaning back. She pushed back and both were holding her because she was leaning. Once inside she was turned over to the nurses. He said he saw bruises on her before she went to the hospital. She used to take her bed apart. He saw marks on her neck/shoulder area when she came back from the hospital and pointed it out to the nurse. He saw bruises on her wrists before she left. He said he reported it to the nursing staff, but he did no documentation.

4. On 10/30/2012 at 11:40 AM an interview with MHT (B) revealed she had completed the body observation on patient #7 on 07/20/2012 and noted marks on the lower extremities that were not bruises, more like birthmarks. There were no red marks or bruising.

5. A review of the Admission Procedure for Ambulatory/Non Ambulatory Client/Patients dated 03/09 revealed: All arriving client/patients are to come in through the facility's front lobby entrance with the exception of clients/patients Baker Acted by the police.

Based on record review and interview, the facility failed to follow their own policies and procedures regarding medical screening and treatment of 1 of 9 (#2) sampled patients prior to discharging them from the facility.

Findings:


A review of the medical records revealed patient #2 was admitted with suicidal ideations on 09/20/2012. The orders by the admitting physician on 09/20/2012 at 5 PM revealed: Suicidal precautions. On 09/21/2012 at 9:20 AM orders were taken to discharge the patient. The therapist called the police department to advise them the patient was being discharged. Registered Nurse "B" did the discharge assessment and gave discharge instructions to the patient. A review of the medical record for patient #2 also revealed there was no order to discontinue suicide precautions. Review of the facility ' s " Short Stay Summary " for Patient #2 revealed under the Mental Status Examination section, " A mental status examination was not performed as the police apparently decided to take him to jail instead of leaving him for psychiatric evaluation. He was released from this hospital and apparently taken to jail before [Patient #2] could be seen by the psychiatrist. " Review of the Hospital Course section revealed, " He was not started on medication until the planned psychiatric evaluation; however, as noted above, he was removed to be incarcerated prior to being seen by the psychiatrist. " Review of the, Condition at time of discharge section revealed, " As noted above, [Patient #2] had not been seen by the psychiatrist prior to being delivered into the custody of the [named city] Police Department. The nurse indicated that he was on no medications and that he denied suicidal ideation. " Review of the Plan of care section revealed, " None was arranged, as he was being taken to jail. Either he will be returned from jail if he gives cause to the officers and can be set up for follow-up should he be discharged home or the jail can set up a referral for him upon his release. "

The Vines Hospital Nursing Assessment Summary of Assessment by the RN revealed the patient stated " I will not last here for 72 hours, I need to go now " . He told the RN that he told the police he was going to kill himself because he did not want to go to jail.

10/30/2012 at 10:10 AM the psychiatrist stated he did not interview the patient. He further stated he discharged patient #2 when he was told the police were here to pick up the patient. He stated the MSE (Mental Status Exam) was not done. He stated he had not had the opportunity to evaluate the patient before he was discharged to the police. He stated he did not discontinue the suicide precautions because he did not do a psychiatric evaluation on the patient.

An interview with registered nurse (RN) "B" on 10/30/2012 at 3:40 PM revealed that the treatment team on 09/21/2012 included the psychiatrist and the therapist. The meeting included talk about expected discharge date for the patient. The therapist contacted the police to inform them the patient was being discharged. RN "B" called the psychiatrist for the discharge orders after the police arrived to pick patient #2 up. She further stated she thought the patient had been evaluated by the psychiatrist. She informed the patient of the discharge. She walked him to the front waiting area where police were waiting for him. She stated she did not tell the police about the suicide precautions. She assumed they knew he was a Baker Act since the police had brought him in. She stated the patient denied suicidal ideations to her. She also stated the doctor must see the patient before discharge, and the therapist must also do an assessment.

Review of the facility ' s Policy and Procedure regarding Suicide Prevention, effective 07/09, revealed under the section Assessment of Risk, " 2. The MD/Psychiatrist will assess each patient during the initial psychiatric evaluation. 4. A Further consideration of risk will be given to patients presenting with general risk factors that apply across demographics: Presence of a plan for suicide. 7. All assessments shall be considered by the treatment team and incorporated into the patient ' s individualized treatment plan as outlined in the Treatment Planning Policy. " Further review of this policy revealed a section entitled, Reassessment of Risk. According to this section, " 6. Documentation of reassessments: Nursing-On Suicide Reassessment Form; MD-in progress notes; Masters Therapist/Social Worker-Psychosocial or Suicidal Reassessment Form " . Under the Discharge Planning portion of this policy, is a section entitled Pre Discharge Suicide Assessment. " According to this section: " 2. Prior to discharge the physician is to perform a comprehensive assessment of the patient ' s suicide risk. The assessment should include: current level of suicidality, presence or absence of a plan (including lethality if present), review of any significant self injurious or suicidal activity while at facility, presence of physician reviewed and approved suicide prevention/safety plan, justification for discontinuation of any current heightened levels of observation or suicide precautions, and clinical justification for discharge or transfer to a lower level of care. This assessment is to be documented in the MD Progress Notes or in the Discharge Summary. "

The Patient Rights policy dated 06/09 revealed:
The following rights are extended to each patient without reservation or limitations.
B. Right to quality treatment. Each patient shall receive treatment suited to his or her needs, which shall be administered skillfully, safely, and humanely.
C. The right to individual treatment, including the provision of an individualized treatment plan, active participation in the development of the treatment plan by the patient, with periodic review, implementation and supervision by professional staff. Any threat or talk of suicide is always taken very seriously. The patient will be placed on 1:1 observation.

Based on record review and interview, the facility failed to assess 1 of 9 (#2) appropriately for discharge. This failure resulted in patient #2 physically harming himself. For this reason the Condition of Participation for Discharge Planning was not met.

Findings:Reference A 0800: Based on record review and interview, the facility failed for 1 of 9 (#2) to identify a potential adverse consequence upon discharge if there was no adequate discharge planning. This failure resulted in patient #2 physically harming himself.

Reference A 0806: Based on record review and interview, the facility failed to provide 1 of 9 (#2) patients with discharge planning.

Reference A 0810: Based on record review and interviews, the facility failed to follow their own policies and procedures regarding conducting a discharge evaluation for 1 of 9 (#2) sampled patients.

Based on record review and interview, the facility failed for 1 of 9 (#2) to identify a potential adverse consequence upon discharge if there was no adequate discharge planning. This failure resulted in patient #2 physically harming himself.

Finding:

A review of the medical records revealed patient #2 was admitted with suicidal ideations on 09/20/2012. The orders by the admitting physician on 09/20/2012 at 5 PM revealed: Suicidal precautions. On 09/21/2012 at 9:20 AM orders were taken to discharge the patient. The therapist called the police department to advise them the patient was being discharged. Registered Nurse "B" did the discharge assessment and gave discharge instructions to the patient. A review of the medical record for patient #2 also revealed there was no order to discontinue suicide precautions. Review of the facility ' s " Short Stay Summary " for Patient #2 revealed under the Mental Status Examination section, " A mental status examination was not performed as the police apparently decided to take him to jail instead of leaving him for psychiatric evaluation. He was released from this hospital and apparently taken to jail before [Patient #2] could be seen by the psychiatrist. " Review of the, Condition at time of discharge section revealed, " As noted above, [Patient #2] had not been seen by the psychiatrist prior to being delivered into the custody of the Ocala Police Department. The nurse indicated that he was on no medications and that he denied suicidal ideation. " Review of the Plan of care section revealed, " None was arranged, as he was being taken to jail. Either he will be returned from jail if he gives cause to the officers and can be set up for follow-up should he be discharged home or the jail can set up a referral for him upon his release. "

Interview with the psychiatrist on 10/29/12 at 1:40 PM revealed he was totally surprised with patient #2's suicide. The psychiatrist indicated that the patient informed the nurse that he had only made the statement about hurting himself because he wanted the police to go easy on him.

On 10/30/2012 at 10:10 AM the psychiatrist stated he did not interview the patient. He further stated he discharged patient #2 when he was told the police were here to pick up the patient. He stated the MSE (Mental Status Exam) was not done. He stated he had not had the opportunity to evaluate the patient before he was discharged to the police. He stated he did not discontinue the suicide precautions because he did not do a psychiatric evaluation on the patient.

An interview with registered nurse (RN) "B" on 10/30/2012 at 3:40 PM revealed that the treatment team on 09/21/2012 included the psychiatrist and the therapist. The meeting included talk about expected discharge date for the patient. The therapist contacted the police to inform them the patient was being discharged. RN "B" called the psychiatrist for the discharge orders after the police arrived to pick patient #2 up. She further stated she thought the patient had been evaluated by the psychiatrist. She informed the patient of the discharge. She walked him to the front waiting area where police were waiting for him. She stated she did not tell the police about the suicide precautions. She assumed they knew he was a Baker Act since the police had brought him in. She stated the patient denied suicidal ideations to her. She also stated the doctor must see the patient before discharge, and the therapist must also do an assessment.

Review of the facility's Policy and Procedure regarding Suicide Prevention, effective 07/09, revealed under the section Discharge Planning portion of this policy, is a section entitled Pre Discharge Suicide Assessment. According to this section, "2. Prior to discharge the physician is to perform a comprehensive assessment of the patient's suicide risk. The assessment should include: current level of suicidality, presence or absence of a plan (including lethality if present), review of any significant self injurious or suicidal activity while at facility, presence of physician reviewed and approved suicide prevention/safety plan, justification for discontinuation of any current heightened levels of observation or suicide precautions, and clinical justification for discharge or transfer to a lower level of care. This assessment is to be documented in the MD Progress Notes or in the Discharge Summary."

Based on record review and interview, the facility failed to provide 1 of 9 (#2) patients with discharge planning.

Findings:

A review of the medical records revealed patient #2 was admitted with suicidal ideations on 09/20/2012. The orders by the admitting physician on 09/20/2012 at 5 PM revealed: Suicidal precautions. On 09/21/2012 at 9:20 AM orders were taken to discharge the patient. The therapist called the police department to advise them the patient was being discharged. Registered Nurse "B" did the discharge assessment and gave discharge instructions to the patient. A review of the medical record for patient #2 also revealed there was no order to discontinue suicide precautions. Review of the facility ' s " Short Stay Summary " for Patient #2 revealed under the Mental Status Examination section, " A mental status examination was not performed as the police apparently decided to take him to jail instead of leaving him for psychiatric evaluation. He was released from this hospital and apparently taken to jail before [Patient #2] could be seen by the psychiatrist. " Review of the, Condition at time of discharge section revealed, " As noted above, [Patient #2] had not been seen by the psychiatrist prior to being delivered into the custody of the Ocala Police Department. The nurse indicated that he was on no medications and that he denied suicidal ideation. " Review of the Plan of care section revealed, " None was arranged, as he was being taken to jail. Either he will be returned from jail if he gives cause to the officers and can be set up for follow-up should he be discharged home or the jail can set up a referral for him upon his release. "

Interview with the psychiatrist on 10/29/12 at 1:40 PM revealed he was totally surprised with patient #2's suicide. The psychiatrist indicated that the patient informed the nurse that he had only made the statement about hurting himself because he wanted the police to go easy on him.

On 10/30/2012 at 10:10 AM the psychiatrist stated he did not interview the patient. He further stated he discharged patient #2 when he was told the police were here to pick up the patient. He stated the MSE (Mental Status Exam) was not done. He stated he had not had the opportunity to evaluate the patient before he was discharged to the police. He stated he did not discontinue the suicide precautions because he did not do a psychiatric evaluation on the patient.

An interview with registered nurse (RN) "B" on 10/30/2012 at 3:40 PM revealed that the treatment team on 09/21/2012 included the psychiatrist and the therapist. The meeting included talk about expected discharge date for the patient. The therapist contacted the police to inform them the patient was being discharged. RN "B" called the psychiatrist for the discharge orders after the police arrived to pick patient #2 up. She further stated she thought the patient had been evaluated by the psychiatrist. She informed the patient of the discharge. She walked him to the front waiting area where police were waiting for him. She stated she did not tell the police about the suicide precautions. She assumed they knew he was a Baker Act since the police had brought him in. She stated the patient denied suicidal ideations to her. She also stated the doctor must see the patient before discharge, and the therapist must also do an assessment.

Review of the facility's Policy and Procedure regarding Suicide Prevention, effective 07/09, revealed under the section Discharge Planning portion of this policy, is a section entitled Pre Discharge Suicide Assessment. According to this section, "2. Prior to discharge the physician is to perform a comprehensive assessment of the patient's suicide risk. The assessment should include: current level of suicidality, presence or absence of a plan (including lethality if present), review of any significant self injurious or suicidal activity while at facility, presence of physician reviewed and approved suicide prevention/safety plan, justification for discontinuation of any current heightened levels of observation or suicide precautions, and clinical justification for discharge or transfer to a lower level of care. This assessment is to be documented in the MD Progress Notes or in the Discharge Summary."

Based on record review and interviews, the facility failed to follow their own policies and procedures regarding conducting a discharge evaluation for 1 of 9 (#2) sampled patients.
Findings:Review of patient #2's record revealed the patient had been brought in by the local law enforcement for making suicidal comments with a plan on 09/20/12. The patient was Baker Acted and was to be treated and returned to law enforcement. Further review of the patient's record failed to reveal the patient had a medical screening, a treatment plan, or a discharge evaluation. Review of the patient's Short Stay Summary revealed, under the Mental Status Examination section, " A mental status examination was not performed as the police apparently decided to take him to jail instead of leaving him for psychiatric evaluation. He was released from this hospital and apparently taken to jail before [Patient #2] could be seen by the psychiatrist. " Review of the, Condition at time of discharge section revealed, " As noted above, [Patient #2] had not been seen by the psychiatrist prior to being delivered into the custody of the Ocala Police Department. The nurse indicated that he was on no medications and that he denied suicidal ideation. " Review of the Plan of care section revealed, " None was arranged, as he was being taken to jail. Either he will be returned from jail if he gives cause to the officers and can be set up for follow-up should he be discharged home or the jail can set up a referral for him upon his release. "

Interview with the psychiatrist on 10/29/12 at 1:40 PM revealed he was totally surprised with patient #2's suicide. The psychiatrist indicated that the patient informed the nurse that he had only made the statement about hurting himself because he wanted the police to go easy on him.

On 10/30/2012 at 10:10 AM the psychiatrist stated he did not interview the patient. He further stated he discharged patient #2 when he was told the police were here to pick up the patient. He stated the MSE (Mental Status Exam) was not done. He stated he had not had the opportunity to evaluate the patient before he was discharged to the police. He stated he did not discontinue the suicide precautions because he did not do a psychiatric evaluation on the patient.

An interview with registered nurse (RN) "B" on 10/30/2012 at 3:40 PM revealed that the treatment team on 09/21/2012 included the psychiatrist and the therapist. The meeting included talk about expected discharge date for the patient. The therapist contacted the police to inform them the patient was being discharged. RN "B" called the psychiatrist for the discharge orders after the police arrived to pick patient #2 up. She further stated she thought the patient had been evaluated by the psychiatrist. She informed the patient of the discharge. She walked him to the front waiting area where police were waiting for him. She stated she did not tell the police about the suicide precautions. She assumed they knew he was a Baker Act since the police had brought him in. She stated the patient denied suicidal ideations to her. She also stated the doctor must see the patient before discharge, and the therapist must also do an assessment.

Review of the facility ' s Policy and Procedure regarding Suicide Prevention, effective 07/09, revealed under the section Discharge Planning portion of this policy, is a section entitled Pre Discharge Suicide Assessment. According to this section, " 2. Prior to discharge the physician is to perform a comprehensive assessment of the patient ' s suicide risk. The assessment should include: current level of suicidality, presence or absence of a plan (including lethality if present), review of any significant self injurious or suicidal activity while at facility, presence of physician reviewed and approved suicide prevention/safety plan, justification for discontinuation of any current heightened levels of observation or suicide precautions, and clinical justification for discharge or transfer to a lower level of care. This assessment is to be documented in the MD Progress Notes or in the Discharge Summary. "