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Based on interview and record review, the facility failed to recognize seclusion for 3 (#1, 2, 13) of 3 secluded patients according to regulatory requirements and facility policy resulting in the potential loss of patient rights for all patients who may be secluded in the facility. Findings include:

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A-154 Failure to recognize and implement seclusion

Based on interview and record review, the facility failed to recognize and implement seclusion consistent with regulatory requirements and facility policy for 3 (#1, 2, 13) of 3 patients resulting in the potential for unnecessary restriction and patient distress. Findings include:

Review of Patient #1's medical record on 8/30/2022 at 1453 revealed he was a 45-year-old male who was admitted to the facility for schizophrenia on 8/9/2022. Past medical history included: history of suicide attempt, ETOH (alcohol) abuse, homelessness, hypertension (high blood pressure), masturbation, noncompliance with medication regimen, psychiatric illness, schizoaffective disorder (a mental health disorder that includes schizophrenia and mood disorder symptoms), and sexually offensive behavior.

Review of Patient #2's medical record on 8/30/2022 at 1417 revealed he was a 33-year-old male who had been in and out of treatment multiple times since April 2022 (4/19/2022-5/19/2022, 5/21/2022-5/23/2022, 5/24/2022-7/11/2022, and 7/21/2022-present) with paranoid delusions, hallucinations, and homicidal ideation (HI). Patient #2 had a history of serving as a bodyguard to a cult leader in another state. He was expressing the desire to kill an unknown person in another state that was allegedly threatening the cult leader, in the process, assaulted both of his parents on separate occasions when attempting to steal their vehicles. Past medical history included: concussion and delusional disorders. He was petitioned, and a clinical certificate was completed by the ED staff. He was admitted with the diagnoses of concussion and delusional disorders. In past admissions, Patient #2 had assaulted multiple staff members during his admission of 5/24/2022-7/11/2022 and had a history of thinking patients were people he knew outside of the hospital setting that he knew and/or disliked. Patient #2 was not on any elevated monitoring due to his past assaultive history.

On 8/30/2022 at 1130, review of security reports, facility incident reports for Patients #1 and #2 (reviewed 8/30/2022 at 1200), and the medical records for both patients revealed Patient #2 went into Patient #1's room, climbed on top of Patient #1 who was sleeping on his stomach, choked him and put a pillow over the back of his head. As a result, both patients were placed on hallway restrictions (had to remain on the hallway where their bedroom was and were not permitted to attend groups or go out to the patio).

Further review of the security reports, incident reports, and medical records revealed on 8/28/2022 Patient #1 went into Patient #2's bedroom and assaulted him.

On 8/31/2022 at 1019, Registered Nurse (RN) Staff O stated she saw Patient #1 "slip into (Patient #2's) room" and "attack (Patient #2) on his bed." Staff O further stated after the two patients were separated, Patient #1 told a mental health technician his attack was "premeditated" and told another nurse it was "payback" for the assault that had occurred on 8/22/2022.

On 8/31/2022 at 1140, RN Staff R explained "sequestering" was used for patients with "unpredictable behavior" or who were assaultive toward another patient or staff. She stated the back of Hall A "has double doors that can be locked." Staff R confirmed there were no patients or staff present with the patient being "sequestered" and the patient was checked periodically for their safety. Staff R was also able to recall two other patients (#2 and #13) that had been "sequestered" bedsides Patient #1.

Resident Staff T stated on 8/31/2022 at 1238 security had voiced concerns that what had happened between Patients #1 and #2 was not over and "sequestering" Patient #1 was "the most appropriate" thing to do. She explained that 1:1 monitoring was not chosen as it was "inappropriate" due to his mental illness of masturbating in front of staff and inappropriately touching staff. "We are just trying to keep everyone safe." When queried as to the differences between "sequestering" and seclusion, Staff T stated the seclusion room "has nothing in it. With sequestering, he had the ability to access the phone, sit in a chair, have more space and had his own bed." She stated she was not "real familiar' with seclusion at this facility; however, "sequestering" was "temporary to keep everyone safe now. It is not a permanent fix." She further stated had there been concern that Patient #1 was suicidal or would "self harm" the safety plan would have been different.

Physician Staff U stated on 8/31/2022 at 1317 after speaking with Patient #1 following the 8/28/2022 assault that Patient #1 was "sequestered to the back of Hall A." He explained there was an area at the end of the hallway that could be closed off by locking double doors. By "sequestering" the patient, they had "no access to the general milieu." Staff U confirmed that all of the doors in the "sequestering" area were locked except for the patient's bedroom which included a bathroom and there were no staff or patients present in the "sequestered" area. When queried as to how "sequestering" was different from seclusion, Staff U stated, "It is not seclusion. It is not a seclusion room. It is not complete isolation. The patient is able to interact with staff by knocking on the nurse's station door... (The patient) has access to their own bedroom and bathroom and can walk in the hallway..."

On 8/31/2022 at 1300, a targeted review of Patient #2's medical record revealed orders for "sequestering" on 5/27/2022, 6/4/2022, and 6/22/2022.

On 8/31/2022 at 1330, a targeted review of Patient #13's medical record revealed orders for "sequestering" twice on 11/19/2021 and being "sequestered" on 11/22/2021, 12/1/2021, 12/27/2021, 2/4/2022, and 2/15/2022.

Review of facility policy #215 dated January 2022, and titled "Patient-Restraint and Seclusion on 1 East" states, "Seclusion The involuntary confinement of a person in a room or an area where the person is physically prevented from leaving by any means... Seclusion may only be used for the management of violent behavior..."

Requests were made for a policy regarding "sequestering" in the behavioral health setting on 8/30/2022 and 8/31/2022; however, no document was found. This was confirmed by Regulatory Liaison Staff B on 8/31/2022 at 1215.