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Based on policy and procedure review, medical record review and staff interviews, hospital staff failed to obtain a physician order for seclusion in 1 of 2 restraint/seclusion patients reviewed (#4).
The findings included:

Review of a hospital policy titled "Physical Restraint and Seclusion", revised 05/07/2019, revealed "...Seclusion: Involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving....Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, a staff member, or others. V. INITIATION Each episode of restraint shall be initiated. A. Upon the order of a licensed independent practitioner who is responsible for the patient or B. By a trained registered nurse when he or she determines it necessary to protect the patient. An order from a licensed independent practitioner who is responsible for the patient shall be obtained as soon as clinically possible after such initiation, but no longer than one hour....VI. ORDERS A. Orders for restraint or seclusion applied to manage violent or self-destructive behavior that jeopardizes the immediate safety of the patient, a staff member or others shall remain in effect until the patient's behavior or situation is assessed to no longer require restraints or seclusion, but no longer than...4 hours for adults 18 years of age or older....2. Renewal orders may be given for the above durations if the indications for restraint or seclusion exist. ..."

Medical record review, on 08/18/2020, revealed Patient #4, a 51 year old, arrived to the Emergency Department (ED) by EMS (Emergency Medical Services, ambulance services) on 07/31/2020 at 1513. ED record review revealed Patient #4 was "found by a passerby laying on the side of the road and they called 911. ..." Review of Physician Documentation, dated 07/31/2020 at 1623 revealed "...Pt (patient) with hx (history) of Bipolar Disorder and Schizophrenia (mental health illnesses). ED record review revealed Patient #4 remained in the ED from 07/31/2020 to 08/14/2020. On 08/02/2020 at 0846, "Nurses Notes" review revealed "...Appears agitated. Appears angry. Appears combative. Violent and threatening staff and cussing, beating room and door, throwing mattress on floor, Demanding to see Dr (doctor) and demanding to leave." At 0859, documentation noted "Pt laying on floor, code gray called... ." Physician documentation review on 08/02/2020 at 0856 revealed Patient #4 was "...belligerent....yelling....pounding on the walls of his room....he states that I cannot calm down. ..." Review of a "BH (Behavioral Health) Observation Sheet" revealed on 08/02/2020 from 0900 through 1845 (9 hours, 45 minutes) an "Activity Code" of "N" was documented each 15 minutes throughout that time period. Review of the Activity Codes revealed "...N. Seclusion..." Record review did not reveal an order for seclusion and did not reveal documentation by the nurse or physician to indicate Patient #4 was placed in seclusion. On 08/09/2020 at 1039 Nurses Notes review revealed "Pt (patient) banging on window". Review of "BH Observation Sheets", on 08/09/2020 from 1000 to 1500 (5 hours), revealed activity codes that included "N" every 15 minutes throughout the 5 hour time period. Record review did not reveal Seclusion Orders or other documentation to indicate Patient #4 was secluded on 08/09/2020.

Interview on 08/20/2020 at 1515 with Sitter #5 revealed the Sitter was on duty on 08/02/2020 and 08/09/2020 and recorded Patient #4 was in seclusion on the observation sheets. Interview revealed Sitter #5 understood seclusion was when a patient was left in the room alone with the door all the way shut and not able to leave. Interview revealed Sitter #5 recalled the situations on 08/02/2020 and 08/09/2020 and stated the patient was placed in seclusion. Sitter #5 stated she was told to leave the door shut, to leave the patient in seclusion. The sitter further stated she did not know if there were orders for seclusion, and stated the "nurse would cover that".

Requests for interviews on 08/20/2020 with two RNs (Registered Nurse) and the physicians on duty during these two seclusion episodes revealed they were not available for interview.

Interview with the Chief Quality Officer on 08/20/2020 at 1600 revealed there was no evidence of seclusion orders in the medical record for 08/02/2020 or 08/09/2020. Interview revealed that based on the observation sheets and interview of Sitter #5, seclusion orders should have been obtained.

Based on hospital policy review, medical record review, and staff interviews, the facility staff failed to document nursing assessment and reassessments on patients in the emergency department (ED) for 4 of 11 patients (Patients #1, 2, 5, 7) and vital signs for 1 of 11 patients (Patient #10) in accordance with hospital policy.

The findings included:

1. Policy review on 08/18/2020 of "Assessment and Reassessment of Patients (5 Tier)" policy last revised 03/01/2018 revealed " ... II. Procedure A. Patients presenting to the ED will be assessed for physical, psychological and social status to identify patient's care needs ... C. Assessment of the ED patient will begin at triage ... M. Patient reassessments will be done in a time frame appropriate for the patient's condition ...Minimally, nursing reassessment will be done according to hospital policy:... 2. Level II - Every 30 minutes..."

a. Closed medical record review on 08/18/2020 of Patient #1 revealed a 73-year-old male who arrived in the ED on 02/28/2020 at 1606 with a chief complaint of chest pain. Review revealed the triage assessment was documented at 1633 with an acuity Level 2. Patient #1 discharged home at 1845. Review failed to reveal reassessments documented every 30 minutes according to hospital policy.

Interview on 08/18/2020 at 1044 during ED tour with RN #2 (Registered Nurse) revealed nursing reassessments should be done at least every 30 minutes.

Interview on 08/19/2020 at 1300 with the Director of the ED revealed patients should be triaged and a secondary nursing assessment should be documented. Interview revealed reassessments should be completed based on a patient's acuity level.

b. Closed medical record review on 08/18/2020 of Patient #2 revealed a 47-year-old female who arrived in the ED on 07/31/2020 at 1654 with a chief complaint of sinus congestion/asthma attacks. Review revealed the triage assessment was documented at 1811 with an acuity Level 2. A respiratory reassessment was documented at 1940. Patient #2 discharged home at 1944. Review failed to reveal reassessments documented every 30 minutes according to hospital policy.

Interview on 08/18/2020 at 1044 during ED tour with RN #2 revealed nursing reassessments should be done at least every 30 minutes.

Interview on 08/19/2020 at 1300 with the Director of the ED revealed patients should be triaged and a secondary nursing assessment should be documented. Interview revealed reassessments should be completed based on a patient's acuity level.

c. Closed medical record review on 08/19/2020 of Patient #5 revealed a 21-year-old male who arrived in the ED on 07/21/2020 at 1842 with a chief complaint of chest pain. Review revealed the triage assessment was documented at 1856 with an acuity Level 2. A cardiovascular reassessment was documented at 1923. Patient #5 discharged home at 2043. Review failed to reveal reassessments documented every 30 minutes according to hospital policy.

Interview on 08/18/2020 at 1044 during ED tour with RN #2 revealed nursing reassessments should be done at least every 30 minutes.

Interview on 08/19/2020 at 1300 with the Director of the ED revealed patients should be triaged and a secondary nursing assessment should be documented. Interview revealed reassessments should be completed based on a patient's acuity level.

d. Closed medical record review on 08/18/2020 of Patient #7 revealed an 82-year-old female who arrived in the ED on 08/11/2020 at 1056 with a chief complaint of chest pain. Review revealed the triage assessment was documented at 1119 with an acuity Level 2. A reassessment was documented at 1140. A pain assessment and reassessment were documented at 1421 and 1538 respectively. Patient #7 discharged home at 1543. Review failed to reveal reassessments documented every 30 minutes according to hospital policy.

Interview on 08/18/2020 at 1044 during ED tour with RN #2 revealed nursing reassessments should be done at least every 30 minutes.

Interview on 08/19/2020 at 1300 with the Director of the ED revealed patients should be triaged and a secondary nursing assessment should be documented. Interview revealed reassessments were completed based on a patient's acuity level.

2. Policy review on 08/18/2020 of "Assessment and Reassessment of Patients (5 Tier)" policy last revised 3/1/2018 revealed " ...P... In addition, vital signs (blood pressure, pulse, respirations and temperature) will be monitored as follows:... 1. Vital signs will be obtained during initial assessment on all patients ...Vital signs will be taken on all patients upon discharge."

a. Open medical record review on 08/19/2020 of Patient #10 revealed a 3-year-old male who arrived at the ED on 08/18/2020 at 1052 with a chief complaint of head laceration. Acuity Level 4 assigned. Triage vital signs documented at 1119. Patient discharged home at 1207. Review failed to reveal discharge vital signs documented according to hospital policy.

Interview on 08/20/2020 with the Director of the ED revealed she recalled Patient #10 because she walked him and his family to the door. Interview revealed vital signs should be done at discharge and she did not know why they were not complete on Patient #10.

Based on review of employee files, Core Competency Assessment for Sitter, timesheets and staff interview, hospital staff failed to have a job description and competencies that were appropriate for the employee's position for 1 of 10 employee files reviewed (#10).

The findings included:

Review on 08/20/2020 of employee file #10 revealed the employee was a unit secretary and the job description stated "...The Unit Secretary coordinates clerical activities with those of other professional, general, and supportive systems. The Unit Secretary acts as the focal point of communication on the nursing unit. Performs other duties incidental to the work described health ..." Review revealed the job description was signed by the employee #10 on 06/02/2020. Review failed to reveal a sitter competency form for the employee.

Review on 08/20/2020 of the "Core Competency Assessment for Sitter" revealed competencies for staff who were sitters included: "...Verbalizes the admission process for screening items that trigger suicide precautions...2. Verbalizes the need for 1:1 or close observation in accordance with policy and procedure...SUICIDE PRECAUTIONS: 1. Verbalizes understanding that patient may not be left unmonitored...2. Verbalizes understanding that patient may not leave the unit unescorted. 3. Verbalizes list of prohibited items for patients on suicide precautions. Verbalizes understanding of patient search process..."

Review of the staffing timesheets for 08/11/2020 revealed employee #10 worked from 0655 to 1908. Review of the staffing code for employee #10 revealed code 1485 which was a sitter code.

Interview on 08/20/2020 at 1605 revealed employee #10 stated she normally worked as a Unit Secretary and was hired in June of 2020. Interview revealed employee #10 stated she did sometimes sit with psychiatric patients and document on the sitter flowsheet. Interview revealed employee #10 was no longer in orientation and she was trained by two of the other unit secretaries.

Interview on 08/20/2020 at 1545 with the Chief Quality Officer revealed employee #10 was the only Unit Secretary who was not a Certified Nursing Assistant and did not have sitter competencies.

NC00168230, NC00168094