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Based on patient records reviewed, facility policy and procedure review and staff interviews, the facility failed to ensure they honored patients rights while in restraints for 9 (Patients #2, #22, #23, #24, #25, #26, #27, #28 and #29) of 9 patients sampled for restraints. The facility did not discontinue the restraints at the earliest possible time (A154, A174), failed to ensure the physicians wrote the restraint orders according to the regulation (A168), the facility failed to monitor these patients according to their policy (A175), the facility failed to train their physicians on their restraint policy and regulations (A176), they failed to complete a face-to-face with the patients within one hour of being in the restraint (A179) and the staff did not consult the physicians concerning these face-to-face evaluations (A182) and there was no rational for the continued use of some of these restraints (A188).

Based on record review for patients with restraints and facility staff interviews, the facility failed to discontinue restraints for 4 (Patients #22, #23, #25 and #26) of 9 patients when they met the criteria for the restraints to be discontinued.

The findings included:

1. A review of Patient #22's closed record showed there was a physician order for seclusion on 2/26/17. On this order the condition for the restraint to be released was for the patient to be calm for 15 minutes and verbalize he would come to the staff if he was feeling aggressive. A review of the "Restraint Record" for Patient #22 showed he was withdrawn from 10:45-11:15 a.m. There was no documentation showing the patient verbalized he would go to the staff when feeling aggressive. He was released from his restraint after 30 minutes instead of 15 minutes.

2. A review of Patient #23's closed record showed a physician order for restraints dated 7/29/16. On this order the condition to be released from this restraint was Patient #23 was to be calm for 15 minutes and say he did not want to hurt himself. A review of the "Restraint Record" for Patient #23 showed he was sleeping in the restraints from 9:15 a.m. through 12:00 p.m. Patient #23 was not released from the restraints after showing he was calm after 15 minutes.

3. A review of Patient #25's closed record showed a physician order for restraints dated 9/16/16. On this order the condition to be released from this restraint was Patient #25 was to be calm for 15 minutes, be redirected and to put her clothes on. A review of the "Restraint Record" showed Patient #25 was "calming" at 10:00 a.m., "calming down" at 10:15 a.m. and "sleeping from 10:30 a.m. to 11:15 a.m. Patient #25 was released from the restraints at 11:15 a.m. There was no documentation she was able to be redirected and to put her clothes on. However, Patient #25 was restrained from 10:00 a.m. through 11:15 a.m. while being calm and was not released within 15 minutes.

4. A review of Patient #26's closed record showed a physician order for restraints dated 12/17/16. On this order the condition to be released from this restraint was Patient #26 was to be calm for 15 minutes and agree to go to bed. A review of the "Restraint Record" showed Patient #26 was "quiet from 6:45 p.m. to 7:45 p.m. There is no documentation showing Patient #26 agreed to go to bed, but was released from the restraint at 7:45 p.m. Patient #26 was not released from this restraint after being calm for 15 minutes.

5. On 3/9/17 at 9:00 a.m., the Risk Manager and Chief Nursing Officer reviewed the above patient records and said the patients should have been released from their restraints when the patients' displayed calming behavior.
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Based on record review of patients with restraints, review of facility policy and staff interviews, the facility failed to ensure physician orders were written according to their policy for 2 (Patients #24 and #26) of 9 patients reviewed.

The findings included:

1. A review of the facility's "Seclusion & Restraint" policy showed: "Restraints are used upon the written or verbal order of a physician" and the restraint order should specify the length of time for the restraint, purpose of the restraint and the criteria for discontinuing the restraint.

A review of Patient #26's closed record showed a physician order dated 12/14/16, to "Put pt (patient) in seclusion." This physician order did not show the length of time for the restraint, the purpose for the restraint and the criteria for discontinuing the restraint. A review of the "Restraint Record" dated 12/16/16 showed Patient #26 was in restraints. Further review of Patient #26's record showed there was no physician order for this restraint.

2. A review of the facility's "Seclusion & Restraint" policy showed the restraint order form must be signed within 24 hours by the physician.

A review of Patient #24's closed record showed on 8/21/16 at 12:45 p.m., she was put in restraints. However, the physician did not sign this order until 8/24/16 at 11:45 a.m.

3. On 3/9/17 at 9:00 a.m., the Risk Manager and Chief Nursing Officer agreed Patient #26's physician order was not written appropriately and Patient #24's order should have been signed within 24 hours of the application of the restraint.
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Based on record review of patients who had restraints and facility staff interviews, the facility failed to discontinue restraints for 4 (Patients #22, #23, #25 and #26) of 9 patients sampled, when they met the criteria for the restraints to be discontinued.

The findings included:

1. A review of Patient #22's closed record showed there was a physician order for seclusion on 2/26/17. On this order the condition for the restraint to be released was for the patient to be calm for 15 minutes and verbalize he would come to the staff if he was feeling aggressive. A review of the "Restraint Record" for Patient #22 showed he was withdrawn from 10:45-11:15 a.m. There was no documentation showing the patient verbalized he would go to the staff when feeling aggressive. He was released from his restraint after 30 minutes instead of 15 minutes.

2. A review of Patient #23's closed record showed a physician order for restraints dated 7/29/16. On this order the condition to be released from this restraint was Patient #23 was to be calm for 15 minutes and say he did not want to hurt himself. A review of the "Restraint Record" for Patient #23 showed he was sleeping in the restraints from 9:15 a.m. through 12:00 p.m. Patient #23 was not released from the restraints after showing he was calm after 15 minutes.

3. A review of Patient #25's closed record showed a physician order for restraints dated 9/16/16. On this order the condition to be released from this restraint was Patient #25 was to be calm for 15 minutes, be redirected and to put her clothes on. A review of the "Restraint Record" showed Patient #25 was "calming" at 10:00 a.m., "calming down" at 10:15 a.m. and "sleeping from 10:30 a.m. to 11:15 a.m. Patient #25 was released from the restraints at 11:15 a.m. There was no documentation she was able to be redirected and to put her clothes on. However, Patient #25 was restrained from 10:00 a.m. through 11:15 a.m. while being calm and was not released within 15 minutes.

4. A review of Patient #26's closed record showed a physician order for restraints dated 12/17/16. On this order the condition to be released from this restraint was Patient #26 was to be calm for 15 minutes and agree to go to bed. A review of the "Restraint Record" showed Patient #26 was "quiet from 6:45 p.m. to 7:45 p.m. There is no documentation showing Patient #26 agreed to go to bed, but was released from the restraint at 7:45 p.m. Patient #26 was not released from this restraint after being calm for 15 minutes.

5. On 3/9/17 at 9:00 a.m., the Risk Manager and Chief Nursing Officer reviewed the above patient records and said the patients should have been released from their restraints when the patients' displayed calming behavior.
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Based on record review of patients who had restraints, review of the facility policy for restraints and staff interviews, the facility failed to ensure 4 (Patients #23, #24, #25 and #26) of 9 patients sampled were being monitored while in restraints.

The findings included:

A review of the facility's policy on "Seclusion & Restraints" showed while a patient was in restraints the facility staff were to monitor the patient while they were in restraints. Staff were to document blood pressure, respirations, and pulse every hour or as indicated while in seclusion. If the patient was in 4-point restraints, staff were to document blood pressure, respiration, pulse and circulation every hour and ambulate the patient every two hours.

1. Closed record review of Patient #23's "Restraint Record" form showed he was in 4-point restraints on 7/29/16 from 9:00 a.m. through 12:00 p.m. There is no documentation his blood pressure, respiration, pulse and circulation were being monitored every hour nor was he ambulated during that time frame.

2. Closed record review of Patient #24's "Restraint Record" form showed she was in 4-point restraints from 5:00 through 6:00 (no data showing a.m. or p.m. and no date). There was no documentation showing she was being monitored for her blood pressure, respiration, pulse and circulation. Another "Restraint Record" form dated "8/ /16" showed she was in 4-point restraints from 12:45 p.m. through 4:00 p.m. There was no documentation showing her blood pressure, respiration, pulse and circulation were being monitored every hour and no documentation showing Patient #24 was being ambulated every two hours. Her blood pressure, pulse and respiration was not documented until she was taken out of the restraints.

3. Closed record review of Patient #25's "Restraint Record" form showed she was in 4-point restraints from 9:30 a.m. through 11:15 a.m. on 9/6/16. There was no documentation showing her blood pressure, respiration, pulse and circulation were being monitored each hour.

4. Closed record review of Patient #26's "Restraint Record" form showed he was in seclusion on 12/16/16 from 4:45 p.m. through 7:15 p.m. There is no documentation showing he was being monitored for blood pressure, pulse, and respiration while in seclusion. Another "Restraint Record" form showed on 12/17/16 he was in 4-point restraints from 5:45 p.m. through 7:45 p.m. There is no documentation he was being monitored for blood pressure, pulse, respiration and circulation every hour. There was no documentation showing he was ambulated within 2 hours of being in the 4-point restraints.

5. On 3/9/17 at 9:00 a.m., the Risk Manager and Chief Nursing Officer said the vital signs were to be monitored hourly for anyone in restraints and confirmed there is no documentation showing that was done for these patients.
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Based on physician personnel records and staff interview, the facility did not train physicians in the facility's restraint policy for 5 (Staff O, Staff P, Staff Y, Staff MM and the Medical Director) of 5 physicians who prescribed restraints.

The findings included:

1. A review of Staff O and Staff P's personnel records showed there was no documentation they had received training in the facility's policy on "Seclusion & Restraints."

2. On 3/9/17 at 10:40 a.m., the Risk Manager said these two staff are the facility's physicians who write orders for restraints. She said the Medical Director and two contracted physicians also did not have training on the facility's policy on "Seclusion & Restraints." She verified these three physicians write orders for restraints. The personnel records were reviewed for the Medical Director, Staff Y and Staff MM and no training documentation was found.
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Based on record review of patients who had restraints, facility policy review and staff interviews, the facility failed to evaluate 5 (Patients #2, #24, #25, #26 and #29) of 9 patients within one hour after being in restraints.

The findings included:

A review of the facility's "Seclusion & Restraint" policy showed a physician, registered nurse or licensed independent practitioner "must see and evaluate the need for restraint or seclusion within 1 hour after initiation of interventions even if the patient is no longer in restraints or seclusion..."

1. A review of Patient #24's closed record showed she was in seclusion on 8/16/16. A review of the "One Hour Face To Face Evaluation" form showed there was no date and time of the face to face evaluation or information if this was done within one hour of the patient being in seclusion.

2. A review of Patient #25's closed record showed she was in 4-point restraints on 9/6/16. A review of the "One Hour Face To Face Evaluation" form showed there was no time of day of the face to face evaluation.

4. A review of Patient #26's closed record showed he was in seclusion on 12/16/16. There is no "One Hour Face To Face Evaluation" form for this restrain. On 12/17/17 Patient #26 was in 4-point restraints. A review of the "One Hour Face To Face Evaluation" form did not show the time this evaluation was conducted.

5. A review of Patient #29's closed records showed he was in 4-point restraints on 2/27/17. The physician's order, "Restraint Record" form and "One Hour Face To Face Evaluation" form showed he was placed in this restraint at 1458. The "One Hour Face To Face Evaluation" form showed this evaluation was done at "1430."

On 3/9/17 at 9:00 a.m., the Risk Manager and Chief Nursing Officer reviewed the patient records' and confirmed the nurses were not following the restraint policy by not filling out this form appropriately.


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6. A review of the clinical record for Patient #2 revealed the patient was placed in seclusion two times on 12/1/16.
On 12/10/16 at 1:00 a.m., Patient #2 was physically and chemically restrained, and placed in seclusion. On 12/11/16 at 10:25 a.m., Patient #2 was placed in seclusion.

Both "One Hour Face to Face" forms did not document the times of initiation of the seclusion, or when the seclusion was discontinued. Both "One Hour Face to Face Evaluation" forms failed to show the time the evaluations were completed. A check box on the form was checked to indicate the face to face evaluation was not done within 1 hour for one of the forms and was unchecked for the other.

On 3/9/17 at 2:11 p.m., the Risk Manager confirmed the restraint documentation for Patient #2 was incomplete.

Based on record review of patients who had restraints and staff interview, the facility failed to consult the physicians for 4 (Patients #2, #24, #25 and #28) of 9 patients sampled after each completion of the one hour face to face evaluations.

The findings included:

1. A review of Patient #24's closed record showed she was in seclusion on 8/16/16. A "One Hour Face To Face Evaluation" was done with no date or time, and no documentation showing Patient #24's physician was notified of this evaluation. Another "One Hour Face To Face Evaluation was completed for a restraint applied on 8/21/16 with no date or time on this form. There is no documentation showing her physician was notified of this evaluation.

2. A review of Patient #25's closed record showed she was in 4-point restraints on 9/6/16. The "One Hour Face To Face Evaluation" was done on 9/6/16, however, there is no documentation showing her physician was notified of this evaluation.

3. A review of Patient #28 closed record showed he was in seclusion on 1/26/17. The "One Hour Face To Face Evaluation" was completed on 9/6/16. There is no documentation showing his physician was notified of this evaluation.

On 3/9/17 at 9:00 a.m., the Risk Manager and Chief Nursing Officer reviewed the records and determined the nurses did not document if the physicians were notified of these evaluations.


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4. A review of the clinical record for Patient #2 revealed the patient was placed in seclusion on 12/1/16. The facility's "One Hour Face to Face Evaluation" form failed to document if the physician was notified. There was no explanation as to why the physician was not contacted.

On 3/9/17 at 2:11 p.m., the Risk Manager was unable to confirm if the physician was contacted or not.

Based on record review of patients who had restraints and staff interviews, the facility failed to document the rational for continued use of these restraints for 4 (Patients #22, #23, #25 and #26) of 9 patients sampled.

The findings included:

1. A review of Patient #22's closed record showed there was a physician order for seclusion on 2/26/17. On this order the condition for the restraint to be released was for the patient to be calm for 15 minutes and verbalize he would come to the staff if he was feeling aggressive. A review of the "Restraint Record" for Patient #22 showed he was restrained from 10:45 a.m. to 11:15 a.m. (30 minutes). There was no documentation showing the rational for continued use of this restraint after he was showing he was calm after 15 minutes.

2. A review of Patient #23's closed record showed a physician order for restraints dated 7/29/16. On this order the condition to be released from this restraint was for Patient #23 is to be calm for 15 minutes and say he does not want to hurt himself. A review of the "Restraint Record" for Patient #23 showed he was sleeping in the restraints from 9:15 a.m. through 12:00 p.m.. Patient #23 was not released from the restraints after showing he was calm after 15 minutes. There was no documentation showing the rational for the continued use of this restraint after he showed he was calm after 15 minutes.

3. A review of Patient #25's closed record showed a physician order for restraints dated 9/16/16. On this order the condition to be released from this was Patient #25 is to be calm for 15 minutes, be redirected and to put her clothes on. A review of the "Restraint Record" shows Patient #25 was "calming" at 10:00 a.m., "calming down" at 10:15 a.m. and "sleeping from 10:30 a.m. to 11:15 a.m. Patient #25 was released from the restraints at 11:15 a.m. Patient #25 was restrained from 10:00 a.m. through 11:15 a.m. while being calm and was not released within 15 minutes. There is no documentation in her record showing the rational to continue this restraint once she showed she was calm within 15 minutes of being in this restraint.

4. A review of Patient #26's closed record showed a physician order for restraints dated 12/17/16. On this order the condition to be released from this restraint was Patient #26 was to be calm for 15 minutes and agree to go to bed. A review of the "Restraint Record" shows Patient #26 was "quiet from 6:45 p.m. to 7:45 p.m. Patient #26 was released from the restraint at 7:45 p.m. Patient #26 was not released from this restraint after being calm for 15 minutes. There was no documentation showing the rational for continued use of this restraint after he was showing he was calm after 15 minutes.

5. on 3/9/17 at 9:00 a.m., the Risk Manager and Chief Nursing Officer reviewed these patient records and agreed there was no documentation supporting the continued use of these restraints.

Based on a review of 27 discharge charts and interview with administrative staff, the hospital failed to ensure discharge planning was assessed, evaluated, and ensured a safe discharge plan for patients. Patient #5 was discharged to an unlicensed facility and did not receive needed therapies after discharge. (Refer to A812) The patient failed to assess and reassess a discharge plan for Patient #39. (Refer to A821) The hospital failed to have a quality assurance program which assessed and evaluated discharges from the facility. (Refer to A843)

Based on a review of discharge charts, and interviews with discharge planning staffs, the hospital failed to ensure 1 (Patient #5) of 27 discharged patents was discharged to a licensed facility for living and receiving care after discharge.

429.08 Florida Statute Unlicensed facilities; referral of person for residency to unlicensed facility; penalties.-
(2) It is unlawful to knowingly refer a person for residency to an unlicensed assisted living facility; to an assisted living facility the license of which is under denial or has been suspended or revoked; or to an assisted living facility that has a moratorium pursuant to part II of chapter 408.

The findings included:

1. On 3/15/17 at 3:00 p.m. an interview with an Agency for Health Care Administration (AHCA) staff was conducted. The AHCA staff verified she had investigated a complaint for unlicensed activity in an Assisted Living Facility (ALF). The allegation was substantiated. During the investigation, it was found that Patient #5 had been discharged to the unlicensed facility directly from this hospital.

2. A review of Patient #5's record revealed there was an order for discharge planning dated 1/15/17 with orders to discharge in the morning pending psych assessment. The order further noted the patient would need home health for physical and occupational therapies (PT/OT), psychiatric nursing assessment, and social work assessment. The discharge planner was also to help with discharge to an assisted living facility (ALF) or family home care (adult family care home AFCH). The patient needed a family/friend meeting prior to discharge.

The social worker/discharge planner notes were dated on 1/17/17 the day after discharge. There were no notes about the patient's need for home health and no plan was made to provide these services. The social worker/discharge planner indicated a meeting with the patient who indicated she felt a different living situation would be better for her. She was currently living with a friend, but the friend could not assist with care as she worked. The friend also agreed a different living situation would be better for this patient. The patient expressed that she wanted placement in Cape Coral. The patient's income was not that high. The documentation reflected they were able to find a place to accept her. The notes from the social worker never said what placement had been made for this patient. The note did not reflect the name and telephone number of where the patient was placed.

On 3/6/17 at 2:15 p.m., an interview was conducted with Social Worker, Staff A about this discharge plan. Staff A stated the patient's friend could no longer assist this patient and felt the patient needed a higher level of care. She admitted she was unsure where the patient went and agreed there was no documentation about this in the record. Staff A said she did not do anything about the home health referral as the patient had Blue Cross/Blue Shield insurance and she did not think they would pay for any care so she did not refer it to anyone. (The patient had a Medicare exchange insurance through BC/BS and would have qualified for some care). She was unaware whether the place she sent this patient to had a license or not.
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Based on patient record review, and interview with administrative staff, the facility failed to ensure the discharge plan was assessed and reassessed when changes occurred in the plan for 1 (Patient #39) of 69 patients sampled for discharge planning.

The findings included:

Patient #39 was admitted to the hospital as a involuntary admission on 12/22/16. The undated admission nursing note indicated the patient was in a battered woman's shelter, was doing intra venous drugs, and overdose with the medication. She was transferred to an acute care hospital for immediate treatment and then from there was admitted to the psychiatric hospital as an involuntary admission.

There was a social work note dated 12/26/16 which indicated the social worker attempted to contact the patient's husband with no answer at 3:00 p.m. Another attempt was made with the same results at 3:42 p.m. On 12/29/16, the social worker made a 3rd attempt to contact the patient's husband with no success. On 12/28/16, the social worker made a 4th attempt at contact with no success. On 12/30/16, the social worker met with the patient about the discharge plan. The patient planned to return to her home and to be transported via taxi. The patient was instructed about follow up care with outpatient services including medication management with a physician. Appointments were made for these services. It was also recommended for the patient to attend Narcotics Anonymous meetings. The patient was noted to be oriented in all spheres and the patient's thought process revealed no psychotic features. The patient demonstrated no suicidal/homicidal ideation.

The patient was discharged on 12/30/16 at 11:35 a.m. There was no evaluation in any of the notes that demonstrated the patient going home might not be the best option as she had been living in a battered women's shelter even with the husband unavailable to discuss the discharge plan.
Patient #23's record contained an undated investigation completed after discharge. The patient took the taxi and instead of going home, the patient went to another hospital patient's home. The hospital received a call indicating Patient #23 had overdosed and died on 12/31/16.

On 3/10/17 at 1:30 p.m., the risk manager/quality manger said they had an investigation to determine what could be done better, but she felt the discharge planning for this patient was ok.

On 3/24/17 at 3 p.m., the social worker, Staff AA said this patient was in the shelter due to a stalker. The patient had apparently reported this to the police, but the social worker indicated the patient was not afraid of her home situation. Staff AA agreed there was no documented contact about the stalker, the report to the police or contact with the shelter where the patient had been staying prior to admission. Staff AA thought the transportation was arranged through insurance with a medical transport company, but documented the transport was both via a taxi and an ambulance. There was no documentation of any other efforts to determine if the spouse was still present in the area and was willing to allow the patient back into the household. There was no documentation about the home situation in the social worker note dated 12/30/16, showing an evaluation of the home situation other than this was where the patient was wanting to go.

Based on a review of quality assurance information, and interview with the risk manager/quality assurance manager, the hospital failed to ensure there was an assessment of the discharge planning process conducted on an ongoing basis to assure the hospital was responsive to patient's discharge needs.

The findings included:

A review of the quality assurance minutes provided by the risk manager/quality assurance manager revealed no evidence of discharge assessments noted in the minutes.

On 3/10/17 at 1:45 p.m., the risk manager/quality assurance manager confirmed there has been no assessment of the discharge planning process done for any of the patients.