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Based on staff interviews, medical record review, review of facility policies and procedures, and review of security video surveillance, it was determined that the facility failed to ensure patients are free from abuse (physical and verbal).

Findings include:

1. The facility failed to protect patients from abuse by promptly removing a contracted employee from patient care, when an allegation of physical abuse against a psychiatric patient in 4-point restraints was identified and reported to administrative staff. Refer to Tag A-0145.

2. The facility failed to ensure staff use safe and appropriate restraint techniques as determined by the facility's policy titled "Restraint and Seclusion, Violent and Destructive Behavior." Refer to Tag A-0145.

Vineland

Based on staff interview, review of one (1) out of four (4) medical records (#1), and review of facility policies and procedures, it was determined that the facility failed to implement and adhere to safety measures during 1:1 monitoring, with continuous visual observation, to ensure patient safety and wellbeing.

Findings include:

Reference: Facility policy titled "One to One (1:1) Criteria" states, "...II. Definition One to One (1:1) - A specifically designated staff member will maintain constant observation of the patient at all times and maintain arm's length distance. ...IV. Procedure K. There should be no hazardous items in the patient room. Patient belongings will be placed in locked area, on unit, outside of room and visitor should not bring any items into the patient room."

1. On 5/26/2021, during review of Medical Record #1, the Nursing Progress Note dated 4/28/21 at 14:48 (2:48 PM) stated, " ...Provided pt [patient] with gray gown. Pt asked for phone but reiterated that 1:1 pt could not have personal belongings. Addendum ...April 28, 2021 at 19:55 [7:55 PM] ...Approximately 6pm: Pt asked for towels to shower again. When nurse entered to give pt towels, pt was gait was [sic] severely unsteady, unlike prior interactions with pt. Pt's speech is also slightly slurred. Pt has bookbag and other belongings in room. ... Pt did take a shower unsupervised with bathroom door closed. ..."

2. On 5/26/2021, during review of Medical Record #1, the Nursing Progress Note dated 4/28/21 at 22:13 (10:13 PM) stated, "according to 1 to 1, pt at 2030 [8:30 PM] ambulated to bathroom and left door open a crack. A minute after pt then put a towel over the crack, and the 1 to 1 started to smell smoke/nicotine. The 1 to 1, who was standing by the door, tried to open the door put [sic] the pt was holding/locked the door. The 1 to 1 alerted the RN. Upon arrival pt was sitting on bed and the room smelled of smoke/nicotine. Pt stated he was vaping not smoking and he flushed it down the toilet. Alerted security who came and performed a room search no cigarettes or lighter was found."

3. On 5/26/2021 at 12:39 PM, during an interview, Staff #41V stated that patients on 1:1 observation are not allowed to have their belongings in the room. Staff #41V also stated that patients on 1:1 observation need to remain within arms length at all times.

4. The facility failed to ensure that the 1:1 sitter was within arm's length of the patient at all times in accordance with facility policy.

5. The facility failed to ensure that the patient belongings were locked in an area outside of the patient room in accordance with facility policy.

6. The above findings were confirmed by Staff #4V at the time of the finding.

Bridgeton

A. Based on staff interviews, review of one (1) out of one (1) medical record (#1), review of facility documents, and security video surveillance, it was determined that the facility failed to protect patients from abuse by promptly removing a contracted employee from patient care, when an allegation of physical and verbal abuse of a psychiatric patient in 4-point locked violent restraints, was identified and reported to administrative staff.

Findings include:

Reference #1: Facility policy titled "Abuse / Neglect (ADM)" states, " ...III. Criteria: ... F. Institutional Abuse ...4. If (name of facility) receives a report of alleged abuse perpetrated by an (name of facility) employee, (name of facility) will notify the appropriate governmental agency. (Name of facility) HR [Human Resources] representative is to be notified immediately and consideration is to be given to removing the alleged offender from their schedule until such time that an investigation determines patients and others are not at risk. ..."

Reference #2: Facility policy titled "Rights, Patient's Bill Of" states, "...Freedom from Abuse & Restraints: To freedom from physical and mental abuse."

1. On 4/24/2021 at 17:38 [5:38 PM], Patient #1 presented to the Emergency Department (ED) and was transferred to the Crisis unit on 4/25/21 at 00:30 [12:30 AM]. At approximately 11:03 AM, a Code Gray (a mechanism for summoning assistance to manage an aggressive patient) was called and the patient was placed in 4-point Locked Violent Restraints.

a. On 5/19/2021 at 12:25 PM, in the presence of Staff #3BR and Staff #26BR, the security video surveillance of an incident that occurred on 4/25/21 at 11:03 AM, with Patient #1, located in Crisis POD A, was reviewed and revealed the following: (The individuals in the video were identified by Staff #3BR and Staff #26BR)

(i) At 11:08:50 AM, Patient #1, while in 4-point locked restraints, sits up in the bed and appears to spit in the face of Staff #8BR.

(ii) At 11:08:51 AM, Staff #8BR, while standing at the foot of the patient's bed, swings with his/her right closed fist at Patient #1's face. Patient #1 is seen leaning backwards and avoids contact.

(iii) At 11:08:54 AM, Patient #1 appears to spit on Staff #8BR again. Staff #8BR leans toward the patient and swings with his/her right closed fist at Patient #1. Staff #9BR holds Staff #8's BR right arm. It appears that no contact was made with the patient.

(iv) At 11:09:03 AM, Staff #8BR is seen standing at the right side of the head of the patient's bed with his/her closed fist up to Patient #1's face in a threatening manner.

(v) At 11:09:23 AM, Staff #8BR leaves the patient's room and re-enters the room at 11:09:37 AM and stands at the foot of the patient's bed. At 11:09:40 AM, Patient #1 appears to spit at Staff #8BR again. Staff #8BR swings his/her right closed fist towards Patient #1's face. Patient #1's head turns to the right. It is unclear in the video if Staff #8'sBR fist came in contact with Patient #1's chin.

(vi) At 11:09:44 AM, Staff #9BR guards Staff #8's BR right hand. Patient #1 and Staff #8BR appear to be talking/yelling at each other. At 11:09:45 AM, Staff #8BR moves his/her right hand away from Staff #9's BR hold and motions with a closed fist towards Patient #1. Staff #9BR puts his/her hand in front of Staff #8'sBR raised fist.

(vii) At 11:12:08 AM, Staff #8BR lays folded linen across Patient #1's chest and under the patient's right arm. Another staff member places the folded linen under the patient's left arm, thus restricting Patient #1 from being able to sit up.

(viii) At 11:13:00 AM, Staff #8BR attempts to secure the linen to the bed, unsuccessfully, and then holds it to the side of the bed instead, restricting Patient #1 from sitting up. At 11:27:24 AM, Staff #8BR attempts to tie the folded linen to the right side of the bed.

(ix) At 11:28:06 AM, the folded linen across Patient #1's chest is loosened and all staff but Staff #30BR leave the room.

b. On 5/20/2021 at 11:50 AM, during a telephone interview, Staff #10BR indicated that while he/she was in the Medication Room, he/she heard a collective "ohoooo." Staff #10BR stated that the monitor technician stated, "I think (name) [Staff #8BR] hit the patient." When Staff #10BR went to the patient's room, he/she heard the patient state, "you just hit me in my jaw."

c. On 5/19/2021 at 11:20 AM, Staff #3BR stated that on 4/25/2021, he/she received a call from Staff #18BR explaining the situation and expressed concern for the patient's safety, as the physician was still working and caring for the patient. Staff #3BR provided the following notifications to administrative staff on 4/25/2021:

(i) At 12:54 PM, Staff #3BR called Staff #25BR, the Chief Operating Officer for Ambulatory Service Lines and Wellness, and made him/her aware of the altercation.

(ii) At 12:58 PM, Staff #3BR notified Staff #12BR, the Chief Medical Officer, by telephone, of the altercation.

(iii) Staff #3BR indicated that he/she called (physician name) [Staff #12BR], the Chief Medical Officer, at 12:58 PM, and (physician name) [Staff #11BR], the Vice Chair of Emergency Medicine, at 1:05 PM and made them aware of the situation and expressed the staff's concern that the physician [Staff #8BR] was still treating the patient after attempting to punch him/her.

(iv) Staff #3BR confirmed that (name) [Staff #11BR] indicated that he/she spoke with (name) [Staff #8BR], the situation was de-escalated and he/she was not removing Staff #8BR from his/her shift.

(v) Staff #3BR responded to a text message to Staff #25 stating "(name) [Staff #8BR] is still treating the patient. (Name) [Staff #11BR] said that he felt [Staff #8BR] was de-escalated. (Name) [Staff #8BR] brought video to (name) [Staff #18BR] on phone. I have serious concerns about his/her judgement."

(vi) Staff #25BR responded to the text message to Staff #3BR stating "This should be included as part of the investigation of this incident. (Name) [Staff #11BR] and (name) [Staff #12BR] have made their decision. I have concerns and asked (name) [Staff #11BR] if he/she was going to send (name) [Staff #8BR] home, and (name) [Staff #11BR] said he/she is not sending him/her home after speaking with him/her. [Staff #11BR] felt he was deescalated."

d. On 5/19/2021 at 3:04 PM, during an interview, Staff #11BR confirmed that he/she was made aware of the incident in the early afternoon of 4/25/2021. Staff #11BR stated that he/she called Staff #8BR after he/she was made aware of the altercation and Staff #8BR stated that "he lost his temper and swung at the guy, but there isn't a mark on him [Patient #1BR]." Staff #11BR indicated that Staff #8BR stated "I may have grazed him [Patient #1BR] when I pulled back." Staff #11BR stated that Staff #8BR seemed cool and calm and the situation was de-escalated.

(i) Staff #11BR indicated that he/she had been in contact with Staff #12BR and it was to his/her understanding that an investigation would be conducted by Staff #12BR.

(ii) On 5/19/2021 at 3:10 PM, Staff #11BR confirmed that Staff #8BR continued to work his/her shift on 4/25/2021 and that he/she relieved Staff #8BR at 7:00 PM. Staff #11BR also stated that Staff #8BR worked on 4/27/2021 between 7:00 AM and 11:00 AM, until he/she was called by Staff #12BR and told to relieve Staff #8BR of patient care duties.

e. On 5/19/2021 at 12:17 PM, during an interview, Staff #6, the Director of Risk Management, stated that he/she was made aware of the incident on 4/26/2021 through the incident reporting system. Staff #6BR stated that after reviewing the incident report, he/she reviewed the patient's medical record to see if there was a physical injury to the patient (no injury documented), interviewed all staff present during incident, including the physician (with a representative from HR) and reviewed the security surveillance video. The video was then turned over to the (name) Staff #12BR for a separate investigation by Medical.

f. On 5/19/2021 at 3:20 PM, Staff #7BR provided a timeline that indicated on 4/27/2021 Staff #12BR notified all physician leadership of the incident and the practitioner would not be allowed to work pending investigation. CEO (Chief Executive Officer) was also notified.

2. The following interviews were conducted and revealed that there was a verbal confrontation between Patient #1 and Staff #8BR. Staff #8BR was heard being verbally abusive to Patient #1:

a. On 5/19/2021 at 11:08 AM, Staff #18BR indicated that the patient threatened the physician [Staff #8BR] and his/her family and that Staff #8BR was heard stating, "you can't afford a lawyer with your little d..k [slang male anatomy]."

(i) On 5/20/2021 at 11:00 AM, Staff #21BR stated that the doctor [Staff #8BR] told the patient [Patient #1] he had a little d..k (slang for male anatomy). Staff #21 stated that "The doctor was way out of control" and "I felt so uncomfortable I had to leave the room."

(ii) On 5/20/2021 at 11:23 AM, Staff #22BR stated the patient [Patient #1] said "oh your gonna hit me mother f..ker" and the doctor [Staff #8BR] responded "yeah I'll hit you mother f..ker." Staff #22BR also stated that the doctor [Staff #8BR] told the patient [Patient #1] how small his [the patient's] penis was.

(iii) On 5/20/2021 at 11:50 AM, Staff #10BR stated the physician [Staff #8BR] and the patient [Patient #1] were having an inappropriate conversation. The physician told the patient "mine is bigger than yours."

3. The facility failed to protect patients from abuse by promptly removing a contracted employee from patient care, when an allegation of physical and verbal abuse against a psychiatric patient in 4-point locked violent restraints was identified and reported to administrative staff.

4. The above findings were confirmed by Staff #3BR and Staff #4.

These findings resulted in an Immediate Jeopardy (IJ) on 5/20/2021 at 2:15 PM. Staff #4BR and Staff #7BR were informed of the IJ and the IJ template was provided to Staff #4BR via email at 2:19 PM. An IJ removal plan was requested at that time. An IJ removal plan was provided by the facility on 5/21/2021 at 3:04 PM.

On 5/21/2021, while on-site, it was determined that the facility implemented the following to remove the IJ: notification to the NJ Board of Medical Examiners of Staff #8's unprofessional conduct on 5/20/2021; Staff #8BR resigned on 5/7/2021; a new policy was developed to address allegations of abuse specifically reporting responsibilities; "Just in time" education (de-escalation procedures, appropriate restraint application; proper use of blocking agents; code of conduct and the newly developed policy) was provided to all employees involved in the incident; a healthstream module was developed for all staff; a debriefing form for Code Gray's was developed and distributed to unit managers (which will be reviewed by Risk Management); any future allegations of abuse will be immediately reported to senior leadership. On 5/21/2021, it was determined that the IJ removal plan was implemented and the IJ was removed on 5/21/2021 at 3:35 PM.

B. Based on staff interviews, review of one (1) of one (1) medical record (#1), review of facility policies and procedures, and review of security video surveillance, it was determined that the facility failed to protect patients from abuse by not using safe and appropriate restraint techniques in accordance with facility policy.

Findings include:

Reference #1: Facility policy titled "Restraint and Seclusion, Violent and Destructive Behavior" states, "...policy...B. Types of Restraint: The following types are the only ones approved for violent and destructive restraints: Soft Velcro/locked restraints, Body Net, CPI Team Control Position, CPI Children's Control Position, CPI Transport Position; Interim Control Position and therapeutic physical hold. ..."

Reference #2: Facility policy titled "Rights, Patient's Bill Of" states, "...Freedom from Abuse & Restraints: To freedom from physical and mental abuse."

1. On 4/24/2021 at 17:38 [5:38 PM], Patient #1 presented to the Emergency Department (ED) and was transferred to the Crisis unit on 4/25/2021 at 00:30 [12:30 AM]. At approximately 11:03 AM, a Code Gray (a mechanism for summoning assistance to manage an aggressive patient) was called and the patient was placed in 4-point locked violent restraints.

a. On 5/19/2021 at 12:25 PM, in the presence of Staff #3BR and Staff #26BR, the security video surveillance of an incident that occurred on 4/25/2021 at 11:03 AM, with Patient #1, located in Crisis POD A, was reviewed and revealed the following: (The individuals in the video were identified by Staff #3BR and Staff #26BR)

(i) At 11:06:45 AM, while the patient was in 4-point locked violent restraints, Staff #27BR, standing to Patient #1's left side, is holding the patient's head down and facing towards the right side, by pressing his/her hand onto the patient's left cheek/jaw.

(ii) At 11:07:01 AM, Staff #21BR, standing to Patient #1's right side, by the head of the bed, is observed to place a pillow on top of the patient's face to block the patient's spitting. Staff #21BR kept the pillow in place by placing both hands on top of the pillow.

(iii) At 11:07:04 AM, Staff release the physical hold on Patient #1's right arm, head, and pillow. Patient #1 uses his/her right arm (in secured restraint) to remove the pillow from over his/her face.

(iv) At 11:12:08 AM, Staff #8BR lays folded linen across Patient #1's chest and under the patient's right arm. Another staff member places the folded linen under the patient's left arm, restricting Patient #1 from being able to sit up.

(v) At 11:13:00 AM, Staff #8BR attempts to secure the linen to the bed, unsuccessfully, and then holds it to the side of the bed instead, restricting Patient #1 from sitting up. At 11:27:24 AM, Staff #8BR attempts to tie the folded linen to the right side of the bed.

(vi) At 11:28:06 AM, the folded linen across Patient #1's chest is loosened and all staff but Staff #30BR leave the room.

2. The facility failed to ensure staff use safe and appropriate restraint techniques as determined by the facility's policy titled "Restraint and Seclusion, Violent and Destructive Behavior."

3. The above finding was confirmed by Staff #3BR and Staff #4BR at the time of the finding.

These findings resulted in an Immediate Jeopardy (IJ) on 5/20/2021 at 2:15 PM. Staff #4BR and Staff #7BR were informed of the IJ and the IJ template was provided to Staff #4BR via email at 2:19 PM. An IJ removal plan was requested at that time. An IJ removal plan was provided by the facility on 5/21/2021 at 3:04 PM.

On 5/21/2021, while on-site , it was determined that the facility implemented the following to remove the IJ: notification to the NJ Board of Medical Examiners of Staff #8's unprofessional conduct on 5/20/21; Staff #8BR resigned on 5/7/21; a new policy was developed to address allegations of abuse specifically reporting responsibilities; "Just in time" education (de-escalation procedures; appropriate restraint application; proper use of blocking agents; code of conduct and the newly developed policy) was provided to all employees involved in the incident; a healthstream module was developed for all staff; a debriefing form for Code Gray's was developed and distributed to unit managers (which will be reviewed by Risk Management); any future allegations of abuse will be immediately reported to senior leadership. On 5/21/2021 it was determined that the IJ removal plan was implemented and the IJ was removed on 5/21/2021 at 3:35 PM.

Bridgeton

Based on review of security video surveillance, review of one (1) out of one (1) medical record (#1), staff interview, and review of facility documents, it was determined that the facility failed to develop and implement a policy to ensure that psychotropic medications are not utilized as a chemical restraint.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion, Violent and Destructive Behavior, ***IHN*** states, " ... Policy: ... A. Definitions: ... Violent/destructive Need for Restraint: refers to the use of a physical device, material or equipment that immobilizes or reduces the ability of a patient or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. ... Should a patient demonstrate behavior that places himself and others at risk for injury and extremities are held (physical hold) while attempting to de-escalate the patient, (time pass) - and the patient continues to escalate at which point a decision is made to administer medication used as restraints ... B. Types of Restraint: The following types are the only ones approved for violent and destructive restraints: Soft Velcro/locked restraints, Body Net, CPI Team Control Position, CPI Children's Control Position, CPI Transport Position; Interim Control Position and therapeutic physical hold. ..."

1. On 5/19/2021 at 12:25 PM, a review of a video surveillance, dated 4/25/2021 starting at 11:04 AM, of the application of four (4) point restraints on Patient #1 was completed and revealed the following:

a. At 11:04:48 AM, multiple staff members enter the patient's room and apply four (4) point behavioral restraints onto Patient #1.

b. At 11:14:41 AM, Patient #1 remains agitated. Staff #28BR administers an IM (Intramuscular) injection into Patient #1's right thigh.

(i) A review of Medical Record #1 determined that this was an IM injection of 200 mg (milligrams) of Ketamine.

(ii) During an interview on 5/20/2021 starting at 10:00 AM, Staff #25BR, a pharmacist, stated that Ketamine is a sedating medication.

c. At 11:32 AM, Patient #1 is laying still in the bed with four (4) point behavioral restraints in place. Staff #8BR enters the patient's room with two (2) syringes with needles attached at the end. Staff #8BR injects the contents of the first syringe into Patient #1's IV (Intravenous) infusion. Staff #8 then injects the contents of the second syringe into Patient #1's right thigh. Upon contact of the second syringe's needle with Patient #1's thigh, the patient jerks his/her whole body, and opens his/her eyes before returning to a quiet, calm state.

(i) A review of Medical Record #1's Behavioral Health Nursing Documentation Note, dated and timed for 4/25/2021 at 1:41 PM, states, "... Request for writer to give haldol IM and ativan IV at approximately 11:30 but pt [patient] was calming down but still awake making threats. At 11:32 [Staff #8BR] requested that [he/she] be given the haldol and ativan to administer him/herself. [Staff #8BR] gave haldol 5 mg IM at approx 11:30 and ativan 2 mg IV at the same time."

(ii) During an interview on 5/20/2021 starting at 11:52 AM, Staff #10BR, Patient #1's Registered Nurse (RN), stated that the patient was awake but was "drifting off to sleep" when Staff #8BR ordered Haldol and Ativan. Staff #10BR was not comfortable to give the medications because the patient was calming down. Staff #10BR stated that Ativan and Haldol medications would have been appropriate if they were administered before Ketamine.

2. During an interview on 5/20/2021 at 10:40 AM, Administrative Staff #3BR stated that the facility policy on restraints does not include chemical restraints because they are not an approved form of restraint. Administrative Staff #3BR stated that a chemical restraint is one that impedes the patient's functioning and does not help provide therapy to the patient.

Bridgeton

Based on review of two (2) out of four (4) medical records (#1 and #11BR), staff interview, and review of facility policy and procedure, it was determined that the facility failed to implement restraint monitoring in accordance with hospital policy by ensuring there is a physicians order for 1:1 observation of patients in 4-point locked violent restraints in accordance with facility policy.

Findings include:

Reference #1: Facility policy, "Restraint and Seclusion, Violent and Destructive Behavior" states, "... E. Reassessment/Monitoring... Upon initiation of physical restraint or seclusion and every 15 minutes while maintained in restraints or seclusion, the patient must be monitored for... Q 2-hour monitoring of below... Nutrition/hydration/hygiene/elimination needs... Circulation and range of motion in the extremities... Physical/psychological status and comfort... Readiness for discontinuing use of restraint or seclusion... Changes in clinical status to report to registered nurse... 2. Four point restraints require every 15 minute monitoring and documentation of same. In the acute care hospital, regardless of location, requires 1:1 observation for 4 point restraint use. ... ."

Reference #2: Facility policy titled "One to One (1:1) Criteria" states, "I. Policy ...C. a physicians order is required ..."

1. Review of Medical Record #11BR on 5/21/2021 revealed the following:

a. The patient arrived to the ED (Emergency Department) on 3/2/2021 at 8:35 PM with complaints of aggressive and assaultive behavior.

b. An ED nursing note, dated 3/3/21 at 9:49 AM states, "Immediately following change of shift, the patient sat up in bed and reached over the rail and flung the keyboard of the computer off of the shelf (no damage), took off his gown, sheet and blanket and threw them to the floor. ... Decision made to medicated [sic] patient for his/our safety. ... Immediately upon the needle entering his arm, the patient reached over with his L hand and grabbed the needle, swung and threw the needle point first across the room. ... Security was called and decision made by [name of physician] to place pt into 4 pt restraints."

(i) A restraint order for violent behavior was ordered on 3/3/2021 at 7:49 AM. The order was discontinued on 3/3/2021 at 11:24 AM.

c. There was no evidence of a physician's order for one to one (1:1) monitoring.


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2. On 5/19/2021, during review of Medical Record #1, there was an ED (Emergency Department) Note Nursing dated 4/24/2021 at 19:11 (7:11 PM) that stated, "...pt [patient] started threatening staff and punched the wall. pt medicated and restrained per MD order."

a. On 4/24/2021 at 19:21 (7:10 PM), there was a physician order for "Restraint Initiate Violent 18 Yrs [Years] and more." The Order details section states, "Locked Velcro, Physical, (L)[left] Lower, (L) Upper, (R)[right] Lower, (R) Upper, ..."

b. On 5/21/2021 at 11:01 AM, Staff #3BR indicated that facility policy requires a patient to be on 1:1 observation when in 4-point restraints and that the 1:1 observation requires a physician order.

(i) The 1:1 observation record was requested and reviewed. The 1:1 observation was initiated on 4/24/2021 at 19:10 (7:10 PM) and was discontinued on 4/24/2021 at 21:00 (9:00 PM), when the restraints were discontinued.

c. The medical record lacked evidence of a physician order for 1:1 observation when Patient #1 was placed in 4-point violent restraints on 4/24/2021 at 19:11 (7:11 PM).

3. The above finding was confirmed by Staff #3BR at the time of the finding.

Vineland

Based on staff interview, review of one (1) of one (1) medical record (#1) and review of facility policy and procedure, it was determined that the facility failed to implement the policy titled "Restraints and Seclusion, Violent and Destructive Behavior" and ensure the use of violent restraints is in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient.

Findings include:

Reference: Facility policy titled "Restraints and Seclusion, Violent and Destructive Behavior" states, " ...Policy: ...B. Types of Restraints: the following types are the only ones approved for violent and destructive restraints: Soft Velcro/locked restraints, ...C. Orders: Physician/Physician's Assistant (PA)/Advance Practice Nurse (APN) 1. A physician/PA/APN order is required when restraints or seclusion are used and should be obtained prior to initiation of restraint or seclusion. In emergency, the Registered Nurse (RN) may authorize initiation without an order, and obtain a Computer Physician Order Entry (CPOE) order from the attending or on call physician/PA/APN immediately as a verbal order and have the order signed at the time of the face-to-face assessment; ...3. All orders must have time limits as to the length of time and type of restraint used for the patient. All orders MUST be submitted by CPOE but if unable to do so the written order be signed, dated and timed. ...5. Orders for violent restraints or seclusion are limited to the following: 4 hours for adults ages 18 years or older ..."

1. On 5/26/2021 at 10:20 AM, during review of Medical Record #1 in the presence of Staff #31V, the nursing restraint flowsheet indicated that on 4/26/2021, the patient was in 4-point locked velcro violent restraints between 7:00 AM and 20:00 (8:00 PM).

a. The medical record lacked evidence of a physician or other LIP order for the use of violent restraints between 7:00 AM and 20:00 (8:00) PM on 4/26/2021, as per facility policy referenced above.

b. Staff #31V confirmed that there were no orders for the use of violent restraints between 7:00 AM and 20:00 PM on 4/26/2021.

2. The above finding was confirmed by Staff #31V and Staff #4BR/V.

Bridgeton

Based on review of two (2) out of four (4) medical records (#9BR and #11BR), staff interview and review of facility documents, it was determined that the facility failed to ensure that all patients in restraints are monitored every two hours in accordance with facility policy.

Findings include:

Reference: Facility policy and procedure titled, "Restraint and Seclusion, Violent and Destructive Behavior" states, " ... Policy ... E. Reassessment/ Monitoring: ... [bullet] Q [every] 2-hour monitoring of below: [bullet] Nutrition/hydration/hygiene/elimination needs [bullet] Circulation and range of motion in the extremities [bullet] Physical/psychological status and comfort [bullet] Readiness for discontinuing use of restraint or seclusion [bullet] Changes in clinical status to report to registered nurse ..."

1. Review of Medical Record #11BR on 5/21/2021 revealed the following:

a. The patient arrived to the ED (Emergency Department) on 3/2/2021 at 8:35 PM with complaints of aggressive and assaultive behavior.

b. An ED nursing note dated 3/3/2021 at 9:49 AM states, "Immediately following change of shift, the patient sat up in bed and reached over the rail and flung the keyboard of the computer off of the shelf (no damage), took off his gown, sheet and blanket and threw them to the floor. ... Decision made to medicated [sic] patient for his/our safety. ... Immediately upon the needle entering his arm, the patient reached over with his L [left] hand and grabbed the needle, swung and threw the needle point first across the room. ... Security was called and decision made by [name of physician] to place pt into 4 pt restraints."

(i) A restraint order for violent behavior was ordered on 3/3/2021 at 7:49 AM. The order was discontinued on 3/3/2021 at 11:24 AM.

c. There was no evidence that the patient was monitored every two (2) hours for the following: nutrition, hydration, hygiene, or elimination needs, circulation and range of motion in the extremities, physical or psychological status and comfort, or readiness for discontinuing the use of restraints.


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Bridgeton

2. On 5/20/2021 at 2:40 PM, Medical Record #9BR was reviewed for the use of restraints, in the presence of Staff #5BR. Restraints were used on Patient #9BR from 2:34 PM through 10:33 PM on 3/14/2021. The following times lacked documented evidence of reassessment/monitoring every two (2) hours as required by facility policy and procedure:

a. 5:46 PM

b. 7:46 PM