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Based on document review, observation and interview, it was determined that for 1 of 6 patients (Pt #4) reviewed for restraints, the Facility failed to ensure less restrictive interventions or alternative measures were implemented to protect a staff member from harm prior to restraint application.

Findings include:

1. On 5/2/2022, the Hospital's policy titled, "Interdisciplinary Treatment Planning" (revised 2/2/2022) was reviewed and required, "Appropriate, individualized treatment services shall be provided to each patient."

2. On 5/2/2022, the Hospital's "Order for Physical Hold, Mechanical Restraint or Seclusion" (undated) lists behavioral interventions used before physical hold, mechanical restraint or seclusion included personal safety plan intervention, redirection to new task, empathic listening, distraction, conflict resolution, voluntary time in room, reassurance, meds, verbal support, walk with staff and treatment plan intervention..."

3. On 5/2/2022, Pt #4's clinical record, dated 5/1/2022 to 5/2/2022, was reviewed and indicated:

-Pt #4 was admitted to the Hospital on 5/1/2022 with the diagnosis of schizophrenia (mental disorder characterized by not being based in reality).

-Physician orders, dated 5/1/2022, noted "frequent monitoring" (every 15 minutes).

-Nursing Initial Treatment Plan (dated 5/1/2022) was reviewed and indicated:

-Psychotic (not based in reality) Problem Statement - psychosis - responding to internal stimuli

-As evidenced by - paranoid with grandiose delusional thinking

-Short term goal - Pt #4 will have no incidents of violence for 10 days

-Interventions - Observation level every 15 minute to ensure patient safety.

-Order for Physical Hold, Mechanical Restraint or Seclusion, dated 5/2/2022 at 12:22 PM, noted - Behavioral Interventions used before a physical hold, mechanical restraint or seclusion - distraction - behavioral response to intervention - highly agitated - can't follow redirection & distraction.

4. On 5/2/2022 between 10:55 AM to 12:30 PM, observations were conducted in the main area of the psychiatric unit. Pt #4 was observed doing the following:

-11:05 AM - 11:45 AM - Pt #4 was observed in the main area refusing to eat his lunch. Pt #4 threw his food tray to the floor stating "They are trying to poison me." Pt #4 appeared agitated. There was no staff redirection, distraction, or intervention observed. Pt #4 was not given any prn (as needed) medication to reduce his agitation (according to Pt #4's medication administration record).

-11:45 AM to 12:15 PM - Pt #4 appeared agitated and psychotic and was dancing in the main area.

-12:16 PM - Pt #4 punched E #2 (Registered Nurse) in the face in the main area as E #2 walked toward Pt. #4. E #2 immediately fell to the floor after being punched by Pt #4. Pt #4 then kicked E #2 several times in E #2's back area. Security appeared and escorted Pt #4 to the restraint room and placed Pt #4 in bilateral ankle restraints and bilateral wrist restraints.

5. On 5/3/2022 at 10:00 AM, an interview was conducted with the Assistant Director of Nursing (E #1). E #1 stated that before a patient is placed in restraints, staff attempt redirection. E #1 stated that the situation with Pt #4 was an emergency so redirection/distraction was not possible after Pt #4 hit E #2. E #1 stated that Pt #4 was dancing before punching E #2. E #1 stated that Pt #4 seemed fine. E #1 stated that staff need to be aware of their surroundings with the patients.

Based on document review and interview, it was determined that for 2 of 6 patients (Pt's. #17 & #18) in violent restraints, the Hospital failed to ensure that orders for restraints used for the management of violent behavior that jeopardized the immediate physical safety of staff members included the duration of the restraints to ensure it did not exceed 4 hours for adults, 18 years of age or older.

Findings include:

1. On 5/3/2022, the Hospital's policy titled, "Use of Restraint and Seclusion (Containment) in Mental Health Facilities," revised 9/12/14, was reviewed. The policy required, "D. Mechanical Restraint and Seclusion Orders: 1. Mechanical Restraint and Seclusion may be used only on the written order of a physician... 6. Initial order for Mechanical Restraint or Seclusion for individual patients is valid as follows... (1) For not more than one hour for adults age eighteen years and older..."

2. On 5/3/2022, Pt. #17's clinical record was reviewed. Pt. #17 was admitted to the Hospital on 3/21/2022 with a diagnosis of schizoaffective disorder (mental disorder with delusions, hallucinations, and/or mood disorders). Pt. #17's physician's orders dated 3/21/2022 at 3:15 PM, included, "While talking with psychiatrist, patient suddenly invaded personal space of staff and verbalized, 'Bitch, I will hit you with this,' motioning to his psychiatrist with a phone..." The order included, "Seclusion/ Restraint Release Criteria: When calm or asleep for 30 minutes." Pt. #17's physician's restraint order did not include a time limit for the restraints.

3. On 5/3/2022, Pt. #18's clinical record was reviewed. Pt. #18 was admitted to the Hospital on 4/17/2022 with a diagnosis of bipolar disorder (mood swings from manic high to depressive low). Pt. #18's physician's orders dated 4/18/2022 at 11:40 PM, included, "Patient highly psychotic, yelling, slamming doors... climbed on table and tried to grab exit sign... Patient is an imminent danger to self and others..." The order included, "Seclusion/ Restraint Release Criteria: When patient calms down, relaxed, cooperate with staff, and listen to them, able to contract for safety." Pt. #18's physician's restraint order did not include a time limit for the restraints.

4. On 5/3/2022 at 1:30 PM, an interview was conducted with the Director of Nursing (E #3). E #3 stated the Hospital's policy requires a restraint reassessment after 1 hour, but the orders do not include the time limit for restraints.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on May 2, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on May 2, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review and interview, it was determined that for 1 of 16 (Pt #5) clinical records reviewed for treatment plans, the Hospital failed to ensure that a nursing initial treatment plan had documented interventions, as required.

Findings include:

1. On 5/3/2022, the Hospital's policy titled, "Interdisciplinary Treatment Planning" (revised 2/2/2022) was reviewed and required, "The Initial Treatment Plan must be formulated within 72 hours of admission..."

2. On 5/3/2022, Pt #5's clinical record, dated 4/10/2022 to 5/3/2022, was reviewed and indicated:

-Pt #5 was admitted to the Hospital on 4/10/2022, with the diagnosis of schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis - not based in reality).

- Nursing Initial Treatment Plan, dated 4/10/2022, noted Pt #5's psychiatric problem - psychosis. Pt #5's nursing initial treatment plan did not have any documented interventions for the listed problem - psychosis.

3. On 5/3/2022 at 10:20 AM, an interview was conducted with the Assistant Director of Nursing (E #1). E #1 stated that interventions should be documented on the nursing initial treatment plan. E #1 stated that interventions should be documented within 72 hours of admission. E #1 stated that she is not sure why Pt #5's interventions were not documented.

B. Based on document review, observation and interview, it was determined that for 1 of 16 (Pt #5) clinical records reviewed for treatment plans, the Hospital failed to ensure that an individualized plan regarding group activities was implemented based on Pt #5's strengths and disabilities, as required.

Findings include:

1. On 5/3/2022, the Hospital's policy titled, "Interdisciplinary Treatment Planning" (revised 2/2/2022) was reviewed and required, "Appropriate, individualized treatment services shall be provided to each patient..."

2. On 5/3/2022, Pt #5's clinical record, dated 4/10/2022 to 5/3/2022, was reviewed and indicated:

-Pt #5 was admitted to the Hospital on 4/10/2022 with the diagnosis of schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis - not based in reality).

-Pt #5's Individualized Plan of Care, dated 4/12/2022, noted group activities - 1 x weekly - staff will provide Wellness Recovery Action Plan for 45 minutes, 1 x weekly -Staff will provide Work/Education & Recovery for 45 minutes and 1 x weekly -staff will provide Recovery Topics Group for 45 minutes.

-Pt #5's Group Progress Notes, dated 4/14/2022 to 5/2/2022, noted that Pt #5 has not attended any of the above group activities listed.

3. Observations were conducted on the psychiatric unit on the following dates and times:

- On 5/2/2022 from 10:45 AM to 12:30 PM and 1:00 to 2:45 PM, Pt #5 was observed walking in the halls. Pt #5 did not attend scheduled group activity Work Education & Recovery at 12:15 PM.

-On 5/3/2022 from 9:45 AM to 11:30 AM, Pt #5 was observed walking in the halls. Pt #5 did not attend the group activity Wellness Recovery Action Plan group at 10:15 AM.

4. On 5/2/2022 at 1:00 PM, an interview was conducted with Pt #5. Pt #5 stated that she does not attend groups.

5. On 5/2/2022 at 1:15 PM, an interview was conducted with the Assistant Director of Nursing (E #1). E #1 stated that Pt #5 is encouraged to attend groups, but Pt #5 does not want to attend the group activities.

6. On 5/4/2022 at 10:15 AM, an interview was conducted with the Director of Psychology (E #4). E #4 stated that when a patient does not attend group activities, usually the patient receives individual activities. E #4 stated that Pt #5 is not involved in individual activities at this time.