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Based on observations, record review and interview, the facility failed to ensure phone cords were not long enough for patients to use as ligatures (A144); facility failed to ensure physician orders were present when physical restraint or seclusion was used (A168); facility failed to ensure the patient was monitored every 15 minutes while in seclusion (A175); and failed to ensure a face-to-face evaluation was documented for patients that were physically restrained or secluded (A178). The cumulative effect of these systemic problems resulted in the facility's inability to ensure patients rights were protected and promoted.

Based on observation, record review, interview and risk assessment review, the facility failed to ensure the length of the telephone cords was short enough to prevent ligature risk. This had the potential to affect all patients receiving psychiatric services at the facility. The facility census was 44.

Findings include:

During observation on 12/06/21 at 2:20 P.M., telephone cords in the Recovery unit quiet room were approximately two and a half feet long. Observation from the nurse's station revealed that the phone in the back of the room could not be clearly viewed. During observation on the Revive unit a patient was using a wall mounted phone. No staff were observed in the area. These observations were verified by the Director of Quality at the time of the observation.

Review of the facility's undated "Proactive Risk Assessment" revealed wall mounted patient phones were listed on the item lines as a ligature risk. The documented mitigation stated "Phones have short cords and are vandal proof design. Phones are installed in front of the nurse station and patients are monitored. Phones have been secured in a locking cabinet."

There was no mention of the length of the telephone cords on the Recovery unit or a plan to correct the ligature risk.

Based on record review, interview and policy review, the facility failed to ensure a physician order was obtained prior to using a physical restraint or seclusion . This affected three (Patients #3, #5 and #6) of four medical records reviewed for restraints and seclusion. This had the potential to affect all patients receiving psychiatric services at the facility. The census was 44.

Findings include:

1. Review of the medical record for Patient #3 revealed an admission date of 11/05/21 with diagnoses including autism spectrum disorder, Munchausen syndrome, and borderline personality disorder.

A nursing note dated 11/08/21 at 6:30 P.M. documented Patient #3 began screaming and striking her head on the exit doors. Attempts were made to redirect Patient #3 several times. Patient #3 continued to strike herself. Patient #3 began thrashing, striking staff with a closed fist and kicking staff in the lower extremities. Patient #3 was moved to seclusion using a therapeutic hold. Patient #3 bit the nurse on the right forearm. Orders were received from the physician for Thorazine 50 milligrams (mg), Benadryl 50 mg, and Ativan 2 mg injections "now". Patient #3 took the brace off of her lower left extremity and swung at staff, hitting staff multiple times. Patient #3 was restrained for safety. The patient will remain in seclusion until patient has demonstrated calm behavior. If patient has not calmed down in four hours contact physician for new seclusion order.

Record review revealed no physician orders for the restraint or the seclusion. There was no documentation of a face-to-face evaluation completed within one hour of initiation of seclusion or restraint.



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2. Record review revealed Patient #5 was admitted to the facility on 09/07/21 with the primary diagnosis of schizoaffective disorder.

Review of the seclusion/restraint assessment dated 09/21/21 revealed the patient was placed in a hold, on the ground, and an injection was given. The patient was then fighting staff. The patient was placed in seclusion for four hours.

Review of the medical record revealed no documented evidence of a signed physician's order for the physical hold.


3. Record review revealed Patient #6 was admitted to the facility on 08/29/21 with the primary diagnosis of bipolar disorder.

Review of the patient's seclusion/restraint assessment revealed the patient was placed in seclusion on 09/02/21 from 5:30 AM to 10:00 AM.

Review of the medical record revealed no documented evidence of a signed physician's order for seclusion.

During interview on 12/07/21 at 3:00 P.M., Staff B confirmed the above findings for all three patients.

Review of the hospital policy titled, "Restraint and Seclusion", originally approved 02/2019 and last reviewed 02/21, revealed when the use of a restraint or seclusion is clinically indicated, it shall be used only in accordance with the order of a practitioner who has been credentialed by the medical staff with approval by the governing body.

Based on record review and interview, the facility failed to ensure a patient was monitored every 15 minutes while in seclusion. This affected one (Patient #5) of ten medical records reviewed. The the facility census was 44.

Findings include:

Record review revealed Patient #5 was admitted to the facility on 09/07/21 with the primary diagnosis of schizoaffective disorder.

Review of the seclusion/restraint assessment dated 09/21/21 revealed the patient was placed in a hold, on the ground, and an injection was given. The patient was then fighting staff. The patient was placed in seclusion for four hours.

Review of patient monitoring form revealed patient monitoring should be documented every 15 minutes. Documentation revealed the patient was in seclusion from 7:30 AM to 11:30 AM with monitoring every half hour.

During interview on 12/07/21 at 3:00 P.M., Staff B stated patients should be monitored every 15 minutes while in seclusion.

Based on record review, interview, and policy review, the facility failed to ensure a face-to-face evaluation was documented for patients that were physically restrained or secluded. This affected two (Patients #3 and #5) of four patients reviewed for restraints and seclusion. This had the potential to affect all patients receiving psychiatric services at the facility. The facility census was 44.

Findings include:

1. Record review revealed Patient #3 was admitted on 11/05/21 with diagnoses including autism spectrum disorder, Munchausen syndrome, and borderline personality disorder.

A nursing note dated 11/08/21 at 6:30 P.M. documented Patient #3 began screaming and striking her head on the exit doors. Attempts were made to redirect Patient #3 several times. Patient #3 continued to strike herself. Patient #3 began thrashing, striking staff with a closed fist and kicking staff in the lower extremities. Patient #3 was moved to seclusion using a therapeutic hold. Patient #3 bit the nurse on the right forearm. Orders were received from the physician for Thorazine 50 milligrams (mg), Benadryl 50 mg, and Ativan 2 mg injections "now". Patient #3 took the brace off of her lower left extremity and swung at staff, hitting staff multiple times. Patient #3 was restrained for safety. The patient will remain in seclusion until patient has demonstrated calm behavior. If patient has not calmed down in four hours contact physician for new seclusion order.

The medical record documented Patient #3 was placed into seclusion on 11/08/21 at 7:30 A.M. and again at 6:30 P.M. This documentation lacked a face-to-face evaluation completed within one hour of initiation of seclusion or restraint.


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2. Record review revealed Patient #5 was admitted to the facility on 09/07/21 with the primary diagnosis of schizoaffective disorder.

Review of the seclusion/restraint assessment dated 09/21/21 revealed the patient was placed in a hold on the ground and an injection was given. The patient was then fighting staff and was placed in seclusion from 7:30 A.M. to 11:30 A.M.

Review of the face to face assessment dated 09/21/21 revealed the staff member completed the assessment at 12:30 P.M. which was not within one hour of the initiation of the restraint.

During interview on 12/07/21 at 3:00 P.M., Staff B confirmed the above findings.

Review of the policy titled, "Restraint and Seclusion," orginally approved 02/2019 and last reviewed 02/21, revealed a practitioner shall conduct an in-person (face to face) evaluation of the patient within one hour of initiation of restraint or seclusion to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the physical restraint or seclusion has been discontinued prior to the in-person evaluation. A trained Registered Nurse may complete the assessment in lieu of a practitioner.