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Based on review of six open and four closed medical records, it was determined the hospital failed to inform Patient #5 of the voluntary nature of an open door seclusion room he/she was placed in by not providing interpretive services at the time.

Patient #5 was a Spanish-speaking patient who required interpreter services. Per nursing progress note at 2033 for restraint episode #2 on 8/21/17, Patient #5 was "escorted to the quiet room by staff and given intramuscular (medication)." Review of record revealed the door to the room was not locked but no documentation indicated that the use of interpreter services to inform Patient #5 why they received the intramuscular (IM) injection medication. Additionally, there was no indication that patient #5 was in the open door seclusion room on a voluntary bases or that he/she was informed that he/she could leave the open seclusion room.

Based on review of six open and four closed medical records, inclusive of four patients from the behavioral health unit, it was determined that the hospital failed to 1) keep 1 out of 10 patient's free from seclusion and; 2) use appropriate release criteria from seclusion for 2 out of 9 restraint episodes, affecting two behavioral health patients.

1. Review of Patient #5's record revealed patient was a Spanish-speaking patient who required interpreter services. Per nursing progress note at 2033 for restraint episode #2 on 8/21/17 at 1922, Patient #5 was "escorted to the quiet room by staff and given intramuscular (medication)." Review of record revealed the door to the room was not locked but there was no documentation to indicate the use of interpreter services to inform Patient #5 why they received the intramuscular (IM) injection medication. Additionally, there was no indication that patient #5 was in the open door seclusion room on a voluntary bases or that he/she was informed that he/she could leave the open seclusion room. It was documented on the patient's "24 Hour Record" that Patient #5 was in the open seclusion room from 1930 to 0745 of the following day. During that time, Patient #5 was observed as either laying or sleeping.

The observation note of that morning, 8/22/17, had documented the patient was in the hallway attempting to elope at 0800 and was again taken back to the open seclusion room at 0830 for IM medication administration. Patient #5 remained in the open seclusion room until 1200. While a RN note of 1644 revealed in part, "An interpreter was present at the time," the note failed to indicate when that time was, and again, if Patient #5 was made aware of the voluntary nature of the open seclusion room.

In summary, when nursing failed to inform Patient #5 of the voluntary nature of the open door seclusion room.

2. Review of Patient #4, episode #1 on 6/25/17 revealed the nursing criteria for release from seclusion was stated as "Pt will refrain from behavior which excites peers and induced threatening behavior." Based on the fact that patients are only responsible for their own behaviors, the use of this criterion was not realistic and could not be met by Patient #4.

Review of Patient #7, episode #2 on 7/30/17 revealed nursing criteria to be released from seclusion was stated as, "Pt is calm and can say (she/he) can be safe with (him/herself) and others. (She/he) can verbalize that (she/he) can follow directions and stay away from exits."

In summary, the hospital used inappropriate criteria for release from seclusion, where the only criterion is the cessation of the dangerous behavior which necessitated the intervention.

Based on review of six open and four closed medical records and other documentation, inclusive of four patients from the behavioral health unit, it was determined that the medical and nursing staff failed to 1) obtain a restraint/seclusion order as soon as possible after episode was initiated for two out of nine restraint episodes 2) specify/ include all types of restraints ordered for three out nine episodes reviewed and 3) provide an order for two out of nine restraint episodes, affecting two behavioral patients.

Patient #4 had two restraint episodes reviewed. Review of restraint episode #1's record revealed that on 06/25/17 patient was placed in seclusion. The order from a provider was done 71 minutes after initiation of seclusion on the form titled "Violent Restraint & Seclusion Management Flowsheet/Order" (VRSMFO).

Review of Patient #5's record revealed patient had four restraint episodes. An order was not obtained from a provider for restraint episode #1 that occurred on 8/20/17 until one hour after initiation of restraint.

2. Patient #7 had three restraints reviewed. For episode #1 on 7/25/17, the VRSMFO form failed to specify the type of restraint in the "type of restraint" section which was left blank. It was documented patient was "throwing objects forcefully across room, threatening, aggressively kicking and slamming door, wailing with clenched fists, refusing PO medication." There is no indication that patient #7 accepted the injection voluntarily, indicating a physical hold was required.

The VRSMFO form for Patient #5, episode #2 on 8/21/17 did not have an order for a physical hold. Patient "was assisted to quiet room" and received an IM injection for threatening behavior. No documentation indicated that Patient #5, who had documented violent behavior, went voluntarily to the open seclusion room, nor that the patient took the IM on a voluntary basis. Therefore, staff would have necessarily had to have held patient #5 for which there was no order for a physical hold.

Likewise, a face-to-face documentation for Patient #5, restraint episode # 4 on 8/23/17 states "Pt declined redirection PO PRN Mediations. Pt required manual assist to the quiet room and was escorted. Pt received IM medication ..." The VRSMFO form did not include an order for a physical hold.

3. Per face-to-face documentation for restraint episode #3 on 8/22/17 for Patient #5, "Pt declined PO as needed medications and redirection. Security was called pt was escorted to the quite room and received IM medications..." No order form was found for the physical hold or the physical escort when Patient #5 was given an IM injection.

For Patient #7, restraint episode #3 that occurred on 8/10/2017 the VRSMFO form was not signed by a provider, therefore there was no order for the restraint episode.

In summary, orders for physical holds to administer IMs or to forcibly escort a patient to the open door seclusion or seclusion room were not reflected on the order forms for three patients.

Based on review of six open and four closed medical records, inclusive of four patients from the behavioral health unit, it was determined that the medical staff failed to 1) adequately document all of the components of the face-to-face assessments for multiple restraint/seclusion episodes for three behavioral health patients and 2) obtain a face-to-face within an hour for one out of nine restraint episodes, affecting one behavioral health patient.

For each restraint/seclusion episode, a document was found titled "Restraint and Seclusion Physician Face-to-Face Evaluation." On this form, under the "One Hour Face-to-Face Evaluation," there were four check boxes with pre-printed assumptions, of which 3 out of 4 did not meet the criteria of a face-to-face. The assumptions include:

"The interventions attempted to modify the patient's behaviors as documented on the flowsheet necessitates seclusion/restraints since attempts to modify risky behaviors were unsuccessful."
This does not describe an actual real-time assessment of the immediate patient situation.

"The medical and behavioral condition is stable and safe."
This only generally describes the actual patient medical and behavioral condition and does not clearly describe the patient's current behavior.

"Restraint/seclusion needs to be terminated as soon as patient is safe."
This does not address the real-time question of whether the patient may be released or should be in continued restraint/seclusion.

The fact to face for three behavioral patients included the following deficient practices.

Patient #4 had two restraint/seclusion episodes. On 6/25/17 the patient was placed in seclusion for one hour and five minutes. The face-to-face for the seclusion episode was completed 71 minutes after initiation. On the face to face form the provider checked off that the patient needed "to continue use of restraint/seclusion" after the patient was no longer in seclusion. The same was true for the second restraint episode on 6/27/17 where the provider checked off the statement that the restraint/seclusion episode be continued even though the patient was not in restraints or seclusion at the time of the face to face.

Patient #5 had four restraint episodes. Episode #1 occurred on 8/20/17. The face to face didn't address the patient's current condition and the medical and behavioral condition. The box next to the statement, "I have personally evaluated this patient and determined the need to continue use of restraint/seclusion as specified by this order" was checked off even though the restraint episode was over at the time of the face-to-face.

Restraint episode #2 occurred on 8/21/17. The face-to-face for this episode did not address all components as it only provided a reason of why the patient required an IM injection in the narrative section. Restraint episode #3 on 8/22/17 had a face-to-face document that was partially answered. It did not address the need to continue or terminate the restraint episode. Restraint episode #4 on 8/23/17 did not address the medical and behavioral condition of the patient at the time the face-to-face was completed or the need to continue or terminate the restraint episode.

Patient #7 had three restraint episodes reviewed. Episode #1 occurred on 7/25/17. The face-to-face narrative mentions the medication the patient received and the behaviors that lead to an IM injection and presumed physical hold. The box next to the statement "I have personally evaluated this patient and determined the need to continue use of restraint/seclusion as specified by this order" was marked off even though the patient was not in restraint/seclusion at the time.

The face-to-face for episode #2 was for seclusion on 7/30/17. The face to face described the events that lead to patient's seclusion. It did not address the patient's immediate situation or the patient's medical and behavioral condition at the time the face-to-face was completed.

The face-to-face for episode #3 on 8/10/17 also did not address all components of a face-to-face. The provider described the medications that the patient was given and did not provide a real-time assessment.

In summary, the hospital's face-to-face process failed to conduct real-time, objective assessments to justify use of restraints/seclusion.

Based on a review of the documentation for nine restraint/seclusion episodes for three behavioral patients, it was determined that 5 of the 9 episodes failed to identify the type of intervention used.

See tag A-0168

Based on review of six open and four closed medical records, inclusive of four patients from the behavioral health unit, it was determined 1) that the behavioral health restraint order form had a pre-determined restraint duration and 2) that the staff on the behavioral health unit failed to have accurate documentation on a patient's observation record.

1. Review of three patients' (Patient #4, #5 and #7) restraint order forms for nine restraint episodes, revealed a pre-determined duration for restraints ordered. Under the section "Duration/ Termination of Restraint/ Seclusion:" there is a pre-checked box next to "4 hours for Adults Ages 18 Years and Older" irrespective of the type of restraint selected or continued violent behavior.

2. Review of Patient # 7's record revealed an observation sheet titled, "24 Hour Record." for restraint episode #3 on 8/10/17. Under "observation notes," it indicated patient #7 was in their bed room asleep between 0430 and 0500 during the time a restraint episode was also documented. The VRSMFO form on 8/10/17 at 0450, described in part "the pt attempted to leave the unit ...remained irate, attempted to climb over the nursing station. The pt was a danger to herself and staff." This did not match the documentation on the "24 Hour Record" form. As a result, the hospital failed to accurately document Patient #7's behavior for that time period.