HospitalInspections.org

Based on policy review, record review, and staff interview, it was determined the facility staff failed to protect and promote patient's rights in the area of seclusion. The facility failed to ensure all staff used the least restrictive interventions for violent behaviors, obtain correct physician orders for ongoing seclusion, and discontinue the seclusion after the patient had stabilized for 1 (#2) of 5 patients reviewed. Findings include:

The facility failed to use the least restrictive interventions for one patient after a violent episode and the patient had stabilized. See A154.

The facility failed to discontinue the seclusion for one patient after the patient had stabilized and was no longer violent. See A162.

The facility failed to utilize the least restrictive interventions, and failed to determine less restrictive interventions were ineffective, after initiating seclusion. See. A164.

The facility failed to indicate that the use of seclusion was the least restrictive interventions. See A165.

The facility failed to ensure an order for seclusion from the physician identified the length of time a patient would be in seclusion. See A168.

The facility failed to obtain ongoing physician orders for seclusion for one patient. See A171.

The facility medical provider failed to assess the patient in seclusion after 24 hours and before writing another order for seclusion. See A172.

The facility failed to ensure that seclusion was discontinued at the earliest possible time. See A174.

The facility failed to document the rationale for continued use of seclusion. See. A188.

Based on observation, record review, and interview, the facility failed to properly discontinue the use of seclusion for 1 (#2) of 5 patients whose medical records were reviewed to ensure the patient was free from seclusion imposed as a means of coercion, discipline, convenience or retaliation by staff. Findings include:

During an observation and interview on 7/8/21 at 1:00 p.m., on the Grasslands unit, the special care area and the seclusion rooms were observed. There were no patients in the seclusion rooms or the special care area at the time, pictures were taken. The area had two exits to the main unit, and both were locked and required a staff badge to get out. There was no bathroom and no furniture in the special care area. Staff member C stated the patient would need to ask the staff to go to the bathroom if they were in the special care area, the quiet room, or the seclusion rooms. There was a window in the hall that you could see the nursing station and staff. The special care area was referred to by staff as the quiet area, quiet room, or the special care area. There were two separate rooms in another locked area that were labeled QR (quiet room) on the top of the door way. Staff member C stated the two rooms were the seclusion rooms. There was no furniture in the rooms. Staff member C stated there were cameras to see the patients in the special care area and the quite/seclusion rooms.

Record review for patient #2 showed, the patient was placed by facility staff in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., "this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly ... staff quickly intervene and he was restrained and secluded. Consultation with nursing staff to develop safety plan and he will remain in the staging area over the weekend. He is to have no contact with peers ... A police report was completed and charges may be pressed as this patient was injured...".

Review of patient #2's nursing note, dated and timed 4/9/21 at 6:24 p.m., showed the patient was escorted to the QR (quiet room) where he was secluded at 12:55 p.m., due to unprovoked assault to a peer and unpredictable threats of violence.

Review of patient #2's nursing note, dated and timed 4/10/21 at 6:11 a.m., showed the patient appeared to sleep through the NOC (nocturnal/night) without difficulty in the special care area.

Review of patient #2's nursing note, dated and timed 4/10/21 at 1:49 p.m., showed the patient had not attended any scheduled programming due to being based out of the safety care area. Patient #2 was provided alternative activities to complete in the QR staging area.

Review of patient #2's nursing note, dated and timed 4/11/21 at 2:19 p.m., showed the patient remained in the special care area.

Review of patient #2's nursing note, dated and timed 4/12/21 at 2:57 p.m., showed the patient remained in the QR specialty area.

Review of patient #2's nursing note, dated and timed 4/13/21 at 3:42 p.m., showed the patient was to remain in the specialty area until further notice. Patient #2 wanted to be let out of the specialty area so he could attack someone again and the concern was he would attempt to attack staff so two staff were required.

Review of patient #2's nursing note, dated and timed 4/14/21 at 10:13 p.m., showed the patient remained in the special care area.

Review of patient #2's nursing note, dated and timed 4/15/21 at 5:36 a.m., showed the patient appeared to sleep through the NOC without difficulty in the special care area.

Review of patient #2's nursing note, dated and timed 4/16/21 at 10:12 p.m., showed the patient had not attended groups due to an ongoing order to not be around peers.

Review of patient #2's nursing note, dated and timed 4/17/21 at 5:30 a.m., showed the patient remained in the special care area.

Review of patient #2's nursing note, dated and timed 4/18/21 at 1:51 p.m., showed the patient remained the specialty area.

Review of patient #2's nursing note, dated and timed 4/19/21 at 5:49 p.m., showed the patient remained in the specialty area, then a note timed 10:32 p.m., showed remained in special care area this evening per patient request.

Review of patient #2's nursing note, dated and timed 4/20/21 at 3:53 p.m., showed the patient remained in specialty area. Patient #2 stated "maybe tomorrow", when asked if he wanted to go to his room.

Review of patient #2's nursing note, dated and timed 4/21/21 at 12:26 p.m., showed the patient remained in the special care area. At 2:28 p.m., the noted showed patient #2 chose to remain in the special care area.

Review of the facility forms for patient #2 titled ACUTE: Specialist Observation Sheet for 4/9/21 through 4/21/21 showed fifteen-minute checks were performed by staff. There were no seclusion observation forms in the medical record.

Review of the facility Special Care Area information from the Operations Manual showed ... If the patient requires involuntary separation or isolation due to agitation resulting in loss of self-control, then a seclusion may be indicated. (Refer to the Restraint and Seclusion Policy)...

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed:

- Restraint (physical holding) or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff members or others and must be discontinued at the earliest possible time....

- In the section titled Policy, Staffing and Training, showed ... staff will be trained and able to demonstrate competency in the application of restraints (physical holding), implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint (physical holding) or seclusion before performing any of these procedures and as part of their initial hospital orientation and subsequently on an annual basis.....

- In the section titled Physician Orders for Restraint (physical holding), Seclusion, and Evaluation showed ... Seclusion- Orders for seclusion (initial and renewal) may not exceed one (1) hour, regardless of the age of the child....

Review of the facility seclusion log did not show patient #2 on the log for 4/9/21 through 4/21/21.

During an interview on 7/7/21 at 2:25 p.m., staff member C stated the staff would need a physician order for seclusion. She stated if a patient was in the quiet room that information would be on the treatment plan. Staff member C stated a patient could ask to go to the quiet room and throw the ball around, and the quiet room door would not be locked then but the information would be on the treatment plan.

During an interview on 7/7/21 at 3:45 p.m., staff member H stated staff would need to obtain a physician order to place a patient in the quiet room with the door shut. She stated if the patient is put in there for safety, staff still needed a physician order and it has to be renewed at different times. Staff member H stated the patient would be on fifteen minute checks or maybe even three to four minute checks.

During an interview on 7/8/21 at 11:05 a.m., staff member B stated patient #2 had assaulted another patient, was put in the special care area room for several days. She stated patient #2 had broken the other patient's orbital bones who had to be seen at the emergency room. Staff member B stated patient #2 was in the special care area for days and not allowed out of the area but he was not in seclusion.

During an interview on 7/8/21 at 11:25 a.m., staff member Q stated seclusion is when the patient is not allowed to leave an area; unless the physician orders seclusion, the patient needs to be able to come out of the area. She stated patient #2 informed staff on day nine that he wanted to stay in the special care area. Staff member Q stated the staff utilize the special care area that way. She stated once patient #2 stated he wanted to stay in the special care area she informed her supervisor, in order to get a plan in place to get the patient out of the special care area. Staff member Q further stated that patient #2 chose the date to come out of the special care area.

During an interview on 7/8/21 at 12:00 p.m., staff member S stated the special care area is different from the quiet room or the seclusion rooms which are locked and padded. She stated the special care area is more like an ICU (Intensive Care Unit) area and the staff see that area as a smaller unit of the unit. Staff member S stated the staff on the unit did not believe it was seclusion when patient #2 was in that area. She stated during that time the unit had other patients that needed the seclusion/quiet rooms, and could not have patient #2 roaming around the unit with the other patients.

During an interview on 7/8/21 at 12:53 p.m., staff member G stated the difference between the seclusion area and the special care area is a physician order. She stated in seclusion you have to physically observe the patient every five minutes. Staff member G stated if the provider decided the patient was not safe the patient could be there for more than a day.

Based on observation, record review, and interview, the facility failed to properly use seclusion (used only for the management of violent or self-destructive behavior for immediate needs) for 1 (#2) of 5 patients whose medical records were reviewed, and staff failed to identify the use of a room was seclusion as the patient was physically prevented from leaving the area. Findings include:

1.
a. During the initial tour of the facility on 7/7/21 at approximately 8:30 a.m., some of the patients on the Grasslands unit were in the dining room with staff, finishing breakfast, and the other patients were in the main area supervised by staff.

During an observation on 7/7/21 at 12:30 p.m., on the Grasslands unit, the patients had finished lunch, and were in the main area supervised by staff.

During an observation on 7/8/21 at 7:40 a.m., on the Grasslands unit, the patients were in the dining room, eating breakfast with staff supervision. At 8:00 a.m., the patients had finished breakfast and were getting prepared to take their showers, while two patients were in a line, in front of the medication room, waiting for their medications.

During an observation and interview on 7/8/21 at 1:00 p.m., on the Grasslands unit, the special care area and the seclusion rooms were observed. There were no patients in the seclusion rooms or the special care area at the time; pictures were taken at that time. The area had two exits to the main unit, and both were locked and required a staff badge to get out. There was no bathroom and no furniture in the special care area. Staff member C stated the patient would need to ask the staff to go to the bathroom if they were in the special care area, the quiet room, or the seclusion rooms. There was a window in the hall that you could see the nursing station and staff. The special care area was referred to by staff as the quiet area, quiet room, or the special care area. There were two separate rooms in another locked area that were labeled QR (quiet room) on the top of the door way. Staff member C stated the two rooms were the seclusion rooms. There was no furniture in the rooms. Staff member C stated there were cameras to see the patients in the special care area and the quite/seclusion rooms.

b. Review of patient #2's medical record showed that the patient was placed in the special care area by the facility staff from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., ... "this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly ... staff quickly intervene and he was restrained and secluded. Consultation with nursing staff to develop safety plan and he will remain in the staging area over the weekend. He is to have no contact with peers ... A police report was completed and charges may be pressed as this patient was injured...".

Review of patient #2's nursing note, dated and timed 4/9/21 at 6:24 p.m., showed the patient was escorted to the QR (quiet room) where he was secluded at 12:55 p.m., due to an unprovoked assault to a peer and unpredictable threats of violence.

Review of patient #2's nursing note, dated and timed 4/10/21 at 6:11 a.m., showed the patient appeared to sleep through the NOC (nocturnal/night) without difficulty in the special care area.

Review of patient #2's nursing note, dated and timed 4/10/21 at 1:49 p.m., showed the patient had not attended scheduled programming due to being based out of the safety care area. Patient #2 was provided alternative activities to complete in the QR staging area.

Review of patient #2's nursing note, dated and timed 4/11/21 at 2:19 p.m., showed the patient remained in the special care area.

Review of patient #2's nursing note, dated and timed 4/12/21 at 2:57 p.m., showed the patient remained in the QR specialty area.

Review of patient #2's nursing note, dated and timed 4/13/21 at 3:42 p.m., showed the patient was to remain in the specialty area until further notice. Patient #2 wanted to be let out of the specialty area so he could attack someone again and the concern was he would attempt to attack staff so two staff were required.

Review of patient #2's nursing note, dated and timed 4/14/21 at 10:13 p.m., showed the patient remained in the special care area.
Review of patient #2's nursing note, dated and timed 4/15/21 at 5:36 a.m., showed the patient appeared to sleep through the NOC without difficulty in the special care area.

Review of patient #2's nursing note, dated and timed 4/16/21 at 10:12 p.m., showed the patient had not attended groups due to ongoing orders to not be around peers.

Review of patient #2's nursing note, dated and timed 4/17/21 at 5:30 a.m., showed the patient remained in the special care area.

Review of patient #2's nursing note, dated and timed 4/18/21 at 1:51 p.m., showed the patient remained the specialty area.

Review of patient #2's nursing note, dated and timed 4/19/21 at 5:49 p.m., showed the patient remained in the specialty area. Review of a note timed 10:32 p.m., showed the patient remained in special care area this evening per patient request.

Review of patient #2's nursing note, dated and timed 4/20/21 at 3:53 p.m., showed the patient remained in specialty area. Patient #2 stated "maybe tomorrow", when asked if he wanted to go to his room.

Review of patient #2's nursing note, dated and timed 4/21/21 at 12:26 p.m., showed the patient remained in the special care area. At 2:28 p.m. the patient chose to remain in the special care area.

c. Review of the facility forms for patient #2 titled ACUTE: Specialist Observation Sheet for 4/9/21 through 4/21/21 showed fifteen-minute checks were performed by staff. There were no seclusion observation forms in the medical record.

Review of the facility Special Care Area information from the Operations Manual showed ... If the patient requires involuntary separation or isolation due to agitation resulting in loss of self-control, then a seclusion may be indicated. (Refer to the Restraint and Seclusion Policy)....

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed:
- Restraint (physical holding) or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff members or others and must be discontinued at the earliest possible time....

- In the section titled Policy, Staffing and Training, showed ... staff will be trained and able to demonstrate competency in the application of restraints (physical holding), implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint (physical holding) or seclusion before performing any of these procedures and as part of their initial hospital orientation and subsequently on an annual basis.....

- In the section titled Physician Orders for Restraint (physical holding), Seclusion, and Evaluation showed ... Seclusion- Orders for seclusion (initial and renewal) may not exceed one (1) hour, regardless of the age of the child....

d. Review of the facility seclusion log did not show patient #2 on the log for 4/9/21 through 4/21/21.

e. During an interview on 7/7/21 at 2:25 p.m., staff member C stated the staff would need a physician order for seclusion. She stated if a patient was in the quiet room, that information would be on the treatment plan. Staff member C stated a patient could ask to go to the quiet room and throw the ball around, and the quiet room door would not be locked then but the information would be on the treatment plan.

During an interview on 7/7/21 at 3:45 p.m., staff member H stated staff would need to obtain a physician order to place a patient in the quiet room with the door shut. She stated if the patient is put in there for safety staff still need a physician order and it has to be renewed at different times. Staff member H stated the patient would be on fifteen minute checks or maybe even three to four minute checks.

During an interview on 7/8/21 at 11:05 a.m.., staff member B stated patient #2 had assaulted another patient, was put in the special care area room for several days. She stated patient #2 had broken the other patient's orbital bones and had to be seen at the emergency room. Staff member B stated patient #2 was in the special care area for days and not allowed out of the area but he was not in seclusion.

During an interview on 7/8/21 at 11:25 a.m., staff member Q stated seclusion is when the patient is not allowed to leave an area unless the physician orders seclusion the patient needs to be able to come out of the area. She stated patient #2 informed staff on day nine that he wanted to stay in the special care area. Staff member Q stated the staff utilize the special care area that way. She stated once patient #2 stated he wanted to stay in the special care area she informed her supervisor, in order to get a plan in place to get the patient out of the special care area. Staff member Q further stated that patient #2 chose the date to come out of the special care area.

During an interview on 7/8/21 at 12:00 p.m., staff member S stated the special care area is different from the quiet room or the seclusion rooms which are locked and padded. She stated the special care area is more like an ICU (Intensive Care Unit) area and staff see that area as a smaller unit of the unit. Staff member S stated the staff on the unit did not believe it was seclusion when patient #2 was in that area. She stated during that time the unit had other patients that needed the seclusion/quiet rooms, and could not have patient #2 roaming around the unit with the other patients.

During an interview on 7/8/21 at 12:53 p.m., staff member G stated the difference between the seclusion area and the special care area is a physician order. She stated in seclusion you have to physically observe the patient every five minutes. Staff member G stated if the provider decided the patient was not safe the patient could be there for more than a day.

During an interview on 7/8/21 at 2:20 p.m., staff member B stated the Special Care Area procedure from the Operating Policy Manual had not been approved.

The facility continued to keep patient #2 in seclusion after the initial violent episode and did not discontinue the seclusion when patient #2 was no longer violent. Patient #2 was not able to leave the locked room without staff coming to let him out of the room.

Based on record review, policy review, and staff interview it was determined the facility staff failed to utilize the least restrictive interventions, after initially implementing seclusion, and failed to identify that any less restrictive interventions were ineffective for 1 (#2) out of 5 patients. Findings include:

Record review for patient #2 showed, the patient was in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., "...this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly...staff quickly intervene and he was restrained and secluded. Consultation with nursing staff to develop safety plan and he will remain in the staging area over the weekend. He is to have no contact with peers... A police report was completed and charges may be pressed as this patient was injured...".

There was no documentation in the medical record that any other interventions were tried and ineffective in protecting others from harm prior to placing patient #2 in seclusion.

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed:

... Restraint (physical holding) or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm;...

During an interview on 7/8/21 at 12:00 p.m., staff member S stated the staff on the unit did not believe it was seclusion when patient #2 was in that area. She stated during that time the unit had other patients that needed the seclusion/quiet rooms, and could not have patient #2 roaming around the unit with the other patients.

Based on record review and staff interview, the facility records failed to indicate that the use of seclusion was the least restrictive intervention for 1 (#2) of 5 sampled patients. Findings include:

Record review for patient #2 showed, the patient was in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., "...this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly...staff quickly intervene and he was restrained and secluded. Consultation with nursing staff to develop safety plan and he will remain in the staging area over the weekend. He is to have no contact with peers...A police report was completed and charges may be pressed as this patient was injured...".

There was no documentation in the medical record that any interventions besides seclusion were tried prior to placing patient #2 in seclusion.

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed:

... Restraint (physical holding) or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm;...

During an interview on 7/8/21 at 12:00 p.m., staff member S stated the staff on the unit did not believe it was seclusion when patient #2 was in that area. She stated during that time the unit had other patients that needed the seclusion/quiet rooms, and could not have patient #2 roaming around the unit with the other patients.

Based on interview, record review, and policy review, it was determined the hospital staff implemented seclusion for 1 (#2) of 5 patients without a physician order for how long the seclusion was to continue. Findings include:

Record review for patient #2 showed, the patient was in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., "...this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly...staff quickly intervene and he was restrained and secluded..."

There was no physician order in the medical record to indicate the time frame patient #2 was to remain in seclusion.

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed :

- In the section titled Physician Orders for Restraint (physical holding), Seclusion, and Evaluation showed ... Seclusion- Orders for seclusion (initial and renewal) may not exceed one (1) hour, regardless of the age of the child....


During an interview on 7/7/21 at 3:45 p.m., staff member H stated staff would need to obtain a physician order to place a patient in the quiet room with the door shut. She stated if the patient is put in there for safety, staff still needed a physician order and it had to be renewed at different times. Staff member H stated the patient would be on fifteen minute checks or maybe even three to four minute checks.

During an interview won 7/8/21 at 11:25 a.m., staff member Q stated seclusion if when the patient is not allowed to leave an area unless the physician orders seclusion the patient needs to be able to come out of the area.

Based on record review and interview, the facility staff failed to renew the seclusion order every four hours up to a total of 24 hours for a self-destructive or violent behavior for 1 (#2) of 5 patients. Findings include:

1.
a. Record review for patient #2 showed, the patient was in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., ... "this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly ... staff quickly intervene and he was restrained and secluded. Consultation with nursing staff to develop safety plan and he will remain in the staging area over the weekend. He is to have no contact with peers ... A police report was completed and charges may be pressed as this patient was injured...".

b. Review of the facility forms for patient #2 titled ACUTE: Specialist Observation Sheet for 4/9/21 through 4/21/21 showed fifteen minute checks were performed by staff. There were no seclusion observation forms in the medical record. There were no orders in the medical record for continued seclusion for patient #2 from 4/9/21 through 4/21/21.

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed:

- Restraint (physical holding) or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff members or others and must be discontinued at the earliest possible time....

- In the section titled Physician Orders for Restraint (physical holding), Seclusion, and Evaluation showed ... Seclusion- Orders for seclusion (initial and renewal) may not exceed one (1) hour, regardless of the age of the child....

c. During an interview on 7/7/21 at 2:25 p.m., staff member C stated the staff would need a physician order for seclusion.

During an interview on 7/8/21 at 11:05 a.m.., staff member B stated patient #2 had assaulted another patient, was put in the special care area room for several days and not allowed out of the area, but he was not in seclusion.

During an interview won 7/8/21 at 11:25 a.m., staff member Q stated seclusion is when the patient is not allowed to leave an area unless the physician orders seclusion the patient needs to be able to come out of the area. She stated patient #2 informed staff on day nine that he wanted to stay in the special care area. Staff member Q stated that staff utilized the special care area that way. She stated once patient #2 stated he wanted to stay in the special care area she informed her supervisor, in order to get a plan in place to get the patient out of the special care area. Staff member Q further stated that patient #2 chose the date to come out of the special care area.

During an interview on 7/8/21 at 12:00 p.m., staff member S stated the special care area is different from the quiet room or the seclusion rooms which are locked and padded. She stated the special care area is more like an ICU (Intensive Care Unit) area and staff see that area as a smaller unit of the unit. Staff member S stated staff on the unit did not believe it was seclusion when patient #2 was in that area. She stated during that time the unit had other patients that needed the seclusion/quiet rooms, and could not have patient #2 roaming around the unit with the other patients.

The medical record lacked renewal orders every 4 hours for the first 24 hours of initiating the seclusion.

Based on record review and policy review, the medical provider failed to assess the patient in seclusion after 24 hours and before writing another seclusion order for 1 (# 2) of 5 patients. Findings include:

Record review for patient #2 showed, the patient was in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., "...this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly...staff quickly intervene and he was restrained and secluded..."

There was no documentation in the medical record that the provider had seen patient #2 twenty-four hours after patient #2 was placed in seclusion to assess patient #2 and write an order for the continued seclusion including for how long the seclusion was needed and why.

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Physician Orders for Restraint (physical holding), Seclusion, and Evaluation section showed:

... In conjunction with the patient's evaluation, a new written verbal order is given by the physician if the restraint (physical holding) or seclusion is to be continued...

Based on record and policy review, the facility failed to ensure that seclusion was discontinued at the earliest possible time for 1 (#2) of 5 patients. Findings include:

Record review for patient #2 showed, the patient was in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., "...this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly...staff quickly intervene and he was restrained and secluded. Consultation with nursing staff to develop safety plan and he will remain in the staging area over the weekend. He is to have no contact with peers..."

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed:

- Restraint (physical holding) or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff members or others and must be discontinued at the earliest possible time....

Patient #2 remained in seclusion for 12 days. There was no documentation in the medical record the staff or medical provider attempted to discontinue the seclusion.

Based on medical record review and the facility's policy review, the facility failed to document the rationale for continued use of seclusion for 1 (#2) of 5 patients. Finding include:

Record review for patient #2 showed, the patient was in the special care area from 4/9/21 through 4/21/21. The record showed staff member V documented on 4/9/21 at approximately 4:16 p.m., "...this provider meeting with another patient, I witnessed patient walked over to a peer on the telephone and began punching him in the face with both fists repeatedly...staff quickly intervene and he was restrained and secluded. Consultation with nursing staff to develop safety plan and he will remain in the staging area over the weekend. He is to have no contact with peers..."

There was no further documentation or rationale for the continued use of seclusion in the medical record. Documentation in the notes from 4/9/21 to 4/21/21 indicated patient #2 remained in seclusion by himself, was cooperative, and slept during the night.

Review of the facility Restraint (Physical Holding) and Seclusion Policy in the Philosophy section showed:

- Restraint (physical holding) or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff members or others and must be discontinued at the earliest possible time....

- In the section titled Policy, Staffing and Training, showed ... staff will be trained and able to demonstrate competency in the application of restraints (physical holding), implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint (physical holding) or seclusion before performing any of these procedures and as part of their initial hospital orientation and subsequently on an annual basis.....

Based on interview, and record review, the facility failed to provide adequate staffing for supervision in order to prevent 1 (#3) patient from elopement. Findings include:

Record review of patient #3's nursing note dated 5/26/21 at 6:24 p.m., showed ... While outside patient was observed to be whispering with peer [peer initials] and [peer initials]. Staff walked over to peers and the conversations ended. Immediately after patient began to climb the courtyard fence and was successful in getting over the fence and eloped from the facility. Nurses notified house supervisor and police. Patient was followed by nurse into the neighboring field and was able to stop and walk back with nurse and staff...

The facility did not provide an Elopement Risk Assessment that was completed prior to patient #3's elopement.

The video of the courtyard during the time of the incident was reviewed. In viewing the video, there are three MHTs in the courtyard with what looks to be ten to twelve patients. There are three to four patients in one corner of the courtyard and no MHTs are visible except one sitting at a table on the opposite end of the courtyard. A few minutes later, a few patients turn towards the fence, a nurse walks out to the courtyard, and you can then see patient #3 running. The video then shows the patients leaving the courtyard with the staff.

During an interview on 7/8/21 at 9:00 a.m., NF1 stated she has been on the phone with patient #3 just prior to her climbing over the fence. She stated patient #3 was in a really good mood as they (the patients) were all getting ready to go outside. NF1 did not feel that patient #3 presented as a risk to elope at that time, however stated patient #3 knew if she became unstable and a risk that she would get sent out of the building. NF1 stated patient #3 had told her she did not feel safe at the facility anymore since the suicide not long ago. NF1 stated patient #3 said "I knew I could do it so there" in talking about getting over the fence. NF1 stated she was called immediately and told by staff that patient #3 ran towards the assisted living facility and then calmly stopped, and when staff approached her she walked back to the facility with them. NF1 stated she had wondered if patient #3 worked out a plan with two or three other girls to distract staff so she could go over the fence. NF1 said she thought patient #3 was very intentional on what she did in order to get transferred out of the facility so then she would be able to come home as she was a risk. She stated it was not a suicide attempt but a smug attempt to prove she could get over the fence and leave. NF1 stated patient #3 had been telling everyone she wanted to go home and she just out smarted the staff.

During an interview on 7/8/21 at 9:30 a.m., staff member N stated she was just leaving the building the day patient #3 got over the fence. Staff member N stated by the time she got to the other side of the building the staff were following procedure. She stated patient #3 and two other girls were congregated in the corner and became upset when staff went over to them. When the staff member turned his back patient #3 took her shoes off and climbed over the fence. The other two girls threw patient #3's shoes over the fence to her.

During an interview on 7/8/21 at 10: 40 a.m., staff member P stated she assisted to get patient #3 back to the facility on 5/26/21. She stated she walked after patient #3 watching her walk past the ambulance entry and over towards the assisted living building. Staff member P stated when she approached patient #3 she asked her if she was ready to go back to the facility and patient #3 said "yes, I just wanted to see if I could do it". Staff member P stated patient #3 was on the phone just prior to the incident and was happy. She stated there were three MHTs (mental health technician) outside at the time, and she did not think there were more than twelve patients outside.

During an observation and interview on 7/8/21 at 1:10 p.m., with staff member C, three staff members were outside in the courtyard with the patients. Staff member C stated the staff were to use active supervision with the patients. She stated it did not appear the staff were using active supervision. Staff member C stated the facility provided education on active supervision and elopements to the staff in April or May of 2021.

Review of the facility policy titled Elopement Prevention showed:
... - Procedure: Elopement Risk Assessment
a. Charge RN will complete an Elopement Assessment Tool on all patients on admission, when Elopement Risk Precaution is initiated, when Elopement Risk Precaution is discontinued, once daily when a patient is on Elopement Risk Precaution, and any other time as indicated by patient behavior.

Education
a. All clinical staff will receive Crisis Prevention Intervention (CPI) training on hire and yearly. b. Competencies will be conducted on hire and yearly.

Elopement Drills
a. Elopement drills will be conducted quarterly.

Risk Assessment
a. In the event of a patient elopement, a risk assessment will be conducted with an interdisciplinary team including the Medical Director and Director of Clinical Services by the next business day.

Based on interview, and record review, the facility failed to ensure the nursing staff followed policy and procedure regarding the safe administration of medications for 2 (#s 1 and 17) of 4 sampled patients for medication review. Findings include:

1. Review of patient #1's nursing note, dated and timed 5/23/21 at 11:16 p.m., showed patient #1 reported to the nurse "he cheeked his meds" and gave a cup of medication to the nurse. The nurse documented patient #1 had told her he had "done this before but lost them all outside." The nurse documented patient #1 said "we should probably crush my meds so I don't get myself into trouble."

Review of patient #1's nursing note, dated and timed 5/25/21 at 4:47 p.m., showed patient #1 was medication compliant.

Review of patient #1's nursing note, dated and timed 5/25/21 at 10:44 p.m., showed patient #1 had been given a snack by staff and shortly after that, patient #1 had called out for staff. Staff could not understand the patient, got the nurse's attention, and vital signs were taken. Blood pressure 110/70, heart rate 145, respirations 14, temperature 98.1, and oxygen saturations was 97%. Patient #1 was lethargic, drooling, slurred speech, sluggish but responsive to verbal stimuli, and complaining of dizziness. Patient #1 denied ingesting anything he should not have. Patient #1 was asked by nurse about cheeking medications and overdose. Patient #1 nodded yes and said maybe a week that he had been cheeking his medications. Patient #1 said he had saved the medications in a cup, and later said he had only taken medications from that day and the day before. Patient #1 nodded "yes" when asked if he took the medications after dinner. Patient #1 was transported to the emergency room via ambulance.

Review of patient #1's nursing note, dated and timed 5/26/21 at 5:45 a.m., showed patient #1 returned from the emergency room at 3:30 a.m. and was stable and cooperative.

Review of patient #1's emergency room visit notes, dated and timed 5/25/21 at 9:24 p.m., showed staff were with patient #1 and patient #1 denied taking extra medications that day but admitted he took extra medications sometime the week before, and was uncooperative with questioning. Consultation with poison control who recommended six hour observation given the questionable ingestion of medications. During that time patient #1 rested and remained cooperative, heart rate normalized with hydration and required no further intervention. Vitals signs normalized and was discharged back to facility.

During an interview on 7/7/21 at 3:45 p.m., staff member H stated patient #1 had refused medications prior to the incident when the patient went to the hospital.

During an interview on 7/8/21 at 8:25 a.m., staff member M stated she was on shift the evening that patient #1 was sent to the emergency room. Staff member M stated patient #1 did not look good upon entering the patient's room, and looked like he "might have had a stroke." Staff member M stated she heard patient #1 had been "storing" his pills. Staff member M stated she called for the nurse, and ambulance came and took the patient to the emergency room. Staff member M stated patient #1 was back at the facility about two and a half hours later and was fine the next day.

During an interview on 7/8/21 at 9:30 a.m., staff member N stated she reviewed the camera footage for the incident with patient #1. She stated there was nothing on the camera footage and that when staff went to check on the patient they noticed something wrong, notified the nurse, and the patient was sent to the emergency room. Staff member N stated patient #1 had told her the next day that he had cheeked his disaccord medication for two or 3 days prior. Staff member N stated the policy changed after the incident and now the nurses are to have the patients swish and swallow after they have taken medications, and then the nurse is to check their mouth to ensure the patient has swallowed their medication.

During an interview on 7/8/21 at 10:40 a.m., staff member P stated patient #1 was tired the next day from the emergency room visit. She stated the procedure changed after the incident, to the staff are to do both, have the patient swish and swallow and check their mouth after given medications, and to only have one patient at the medication window at a time.

2. Review of facility MEDICATION VARIANCE REPORT, showed patient #17 received an extra dose of famotidine 20 mg (milligrams) on 4/20/21 due to the computer system down in the medication room.

Patient #17 received famotidine 20 mg on 4/24/21 instead of Sirolimus 5 mg as ordered due to computer system down in the medication room.

There were no ill effects documented or observed with patient #17 after each incident. The facility had a lap top for use for the computer system. The two different nurses had education on the proper check of medications prior to administration.

Review of the facility MEDICATION MANAGEMENT POLICY MANUAL, Medication Administration, showed under the section titled Procedure:
A. Medication Administration...
4. Medication administration process should be as follows"
a. Nursing staff will review each medication order for accuracy in the eMAR against the order.
b. At the time of administration administering nurse will verify patient using two identifiers.
c. Obtain and prepare the medication checking the following: medication name, dose, route, frequency, and expiration.
d. Medication should be kept in the original packaging until time of administration....

During an interview on 7/8/21 at 2:45 p.m., staff member U stated the facility has a back up system in place if the medication administration computer system is down, and that the OMNICELL in the medication room would still be functional and has all the patient information and physician orders in that system.

Based on observation, interview, and policy review, facility staff failed to effectively implement infection control practices to mitigate the spread of infection in the facility by wearing surgical masks during a public health emergency. This deficient practice had the potential to affect all patients living in the facility. Findings include:

During an observation on 7/8/21 at 7:20 a.m., a cart at the front door on 7/8/21 had a sign that showed:

Covid-19 Symptoms Check
ARE YOU EXPERIENCING ANY OF THE FOLLOWING?
- Fever
- Cough
- Shortness of breath
- Difficulty Breathing
- Chills
- Muscle Pain
- Sore Throat
- Loss of Taste or Smell
- HAVE YOU BEEN EXPOSED TO COVID-19
IF YES TO ANY OF THE ABOVE PLEASE LET OUR STAFF KNOW. THANK YOU

Observed on the cart was a bottle of hand sanitizer and one surgical mask. While on site during survey, only one staff member was observed to wear a surgical mask.

One male adult and one male teenager were observed in the lobby area on 7/8/21 at 2:30 p.m., without masks on. The facility was allowing visitors.

The facility was not screening visitors, including when the surveyor entered the facility on 7/7/21 and 7/8/21.

During an interview on 7/7/21 at 7:25 a.m., staff members A and B stated the facility stopped the masks use sometime in May 2021, due to information from the health department and the county. Staff member A stated the facility was having a meeting that morning to discuss new information that had come out from OSHA (Occupation Safety and Health Administration) and the "Feds" June 21, 2021. Staff member A stated there were other facilities in town that the employees were not wearing masks.

During the interview on 7/7/21, the facility was informed that the CDC guidance has remained unchanged for the use of universal source control for healthcare personnel. During obesrvations on 7/8/21, most facility staff were not implementing universal source control measures, to include well-fitting masks or respirators.

During an interview on 7/8/21 at 2:45 p.m., staff member U was wearing a surgical mask and stated all the staff in the pharmacy have continued to wear surgical masks.

Review of the facility policy titled Shodair Infection Control Manual showed ... All employees tested are expected to adhere continually to all other policies and procedures regarding reduction of COVID-19 transmission such as, but not limited to, handwashing, wearing a surgical face mask & other Personal Protective Equipment (PPE) as designated, self-screening and physical distancing when possible. An employee with a negative test result must adhere to all safety policies and procedures....

Review if the facility COVID-19 Pandemic Plan showed ... the medical and professional staff shall follow infection prevention and control measures to prevent and control the spread of COVID-19 and ensure that the current evidence-based practice is followed at all times in the treatment of any patients with known or suspected COVID-19.

Infection prevention and control measures will follow the recommendations by the Center for Disease Control (CDC), World Health Organization (WHO), and the Lewis and Clark Public Health Department.