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Based on record review and interview the facility failed to meet the Condition of Participation to protect the patients right by not ensuring the least restrictive intervention was used in restraints for 1 (P [patient] 11) of 10 (P11-P20) patients reviewed for restraint use. This deficient practice could lead to patient abuse and neglect by a violation of rights.

The findings are:

A. The facility failed to keep patients safe by not ensuring staff were properly monitoring patients' activity. Refer to tag A-0144.

B. The facility failed to ensure the appropriate doses of Benadryl (allergy medication used in psychiatry cases for sedating effect) were utilized. Refer to tag A-0160.

C. The facility failed to utilize the least restrictive intervention. Refer to tag A-0165.

Based on observation, record review and interview the facility failed to keep patients safe by not ensuring staff were properly monitoring patients' activities, (sleeping, sitting in day room, patients in their room) for all patients admitted on the behavioral health unit. This failed practice can lead to patient neglect and harm.

The findings are:

A. Record review of facility policy titled "Levels of Observation" effective 08/2023 showed, "Policy: Definitions: Levels of Observation, *15-minute Checks: Required for all patients, at a minimum. Staff makes visual contact with the patient and confirms that the patient is safe and in no physical distress at frequent and random intervals not to exceed 15 minutes apart. Whenever possible, verbally interact with patient to assess safety and well-being. MHT (Mental Health Tech) A. Q15 checks: Patient is visually observed once in every 15 minute block of time. Staff will make direct visual contact and be vigilant for potential risk factors identified for each patient (precautions). Ongoing and oncoming staff walk/monitor the unit jointly, correlating the patient location/behaviors with the Patient Observation Rounds forms to ensure continuity of care. Both staff initials the Patient Observation Rounds form at the change of shift to indicate the completion of the handoff procedure. Sleeping patients will be observed to confirm no physical distress and observe rise and fall of the chest for 3 intervals. Position of patient will also be documented on the level of observation sheets during sleep H. Patient Observation Sheet. Each patient's location and behaviors must be documented once every quarter hour on the Patient Observation Sheet. 5. Staff initial and print name at the bottom of the sheet identify the staff monitoring the patient. 6. When checking on patient: document in the appropriate time slot, assign the appropriate code(s) and initial each entry. 9. If a patient is sleeping, shine a flashlight on his/her chest if needed, to avoid awakening the patient while making sure that the he/she is in no distress and observe rise and fall of the chest for 3 intervals. Position of patient will also be documented on the level of observation sheets during sleep."

B. Record review of video camera N.22 (unit 3 North hallway) on 08/28/2023 between the times of 1449:00 (2:49:00 pm) to 1659:59 (4:59:59 pm) showed the following:
1. Observed S20, Mental Health Tech (MHT), sitting in chair in hallway across from dayroom entry way for 28 minutes.
2. Observed S20, MHT, sitting in chair in hallway across from dayroom entry way coloring for 16 minutes.
3. Observed S20, MHT, leaving unit for total of 35 minutes with patients in rooms and dayroom with no supervision
4. Observed 15-minute patient observation checks (Q15's) being completed by MHT/RN outside 15 minute window 3 times in 2 hour 10 minute time frame.
5. Observed S21, Registered Nurse (RN) conducting Q15's. RN was standing in middle of hallway filling out observation form for patients. RN never entered any patient rooms and video showed one patient in room laying in bed with covers on.
6. Observed S20, MHT, sitting in chair across from dayroom entry way making patient observations without making visual contact with patients.

C. During tour of Unit 3 North on 08/28/2023 at 4:28 PM observed S20, MHT sitting in chair across from entry way of dayroom coloring with markers on a preprinted image of paper.

D. Record review of P11's Patient Observation Round, dated 08/13/2023 showed at 9:15 PM patient was in room asleep on back.

E. Record review of P11's Seclusion/Restraint Order, dated 08/13/2023 at 9:15 PM showed Type of intervention - Physical Restraint. (Means of purposely limiting or obstructing the freedom of a person's bodily movement).

F. Record review of P11's Seclusion/Restraint Observation, dated 08/13/2023 at 9:15 PM showed patient combative, (ready or eager to fight) placed in hold/restraint.

G. During interview with S3, Chief Nursing Officer (CNO), on 08/29/2023 at 12:23 pm when asked what the expectation of the mental health techs is when monitoring patients, S3 answered, "The expectation is they have their eyes on them at all times, they round on them every 15 minutes."

H. During interview with S3, CNO on 08/31/2023 at 12:45 PM the Seclusion/Restraint Order and Patient Observation Rounds dated 08/13/2023 for P11 were reviewed and it was asked what could be concluded from the charting inconsistencies. It was confirmed that the charting did not make sense and it was stated, "If this was brought to my attention I would investigate it further."

I. During interview with S3, CNO, on 09/07/2023 at 11:15 am when asked "Would it be appropriate for a tech to be coloring while on the clock?" S3 answered, "No there are other things for them to do in between Q15 checks."

J. During interview with S3, CNO, on 09/07/2023 at 11:15 am when asked "Who monitors the patient when they are in R/S (restraint and seclusion)?" S3 answered, "Whoever is with them would normally, we would not pull the tech from the floor." When asked about the restraint and seclusion documentation having it's own observation sheet and if that is the one that is being filled out what should be documented on the standard Q15 sheet, S3 answered "The normal Q15 sheet should indicate where the patient is - whatever code is appropriate for example off the unit or in seclusion, I don't remember what the codes are exactly."


47302

Based on record review and interview the facility failed to ensure that medication dosages were appropriate for the intervention and within standard treatment dosing for 1 (P (patient) 11) of 10 (P11-P20) patients reviewed for restraint use. The facility failed to follow policies in place related to ordering chemical restraints and failed to ensure staff was trained on the policy. This failed practice can lead to poor outcomes for the patient related to medication side effects.

The findings are:

A. Record review of facility policy titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" dated 12/2022 on page 2 under, "Definitions" it states, "Chemical (Medication) Restraint: The administration of a medication for the purpose of controlling an acute episodic behavior, [sudden and short lived outburst of aggression, agitation, etc.] with the intent to restrict the patient's functioning or movement and/or to bring about sedation. Medication/chemical restraint occurs when a patient is given a medication or combination of medications to control the patient's acute episodic behavior or restrict the patient's freedom of movement and/or which is not the standard treatment or dosage prescribed for the patient's condition. Whether an order for a medication is ONE TIME, PRN [as needed], or STAT [immediately] does not determine whether the use of that medication is considered a restraint; if the specific purpose of administering that medication, at that dose, via that route, and at that time is to impact acute episodic behavior, it qualifies as a chemical restraint."

B. Record review of P11's "Seclusion/Restraint Order" dated 08/13/2023 at 9:15 PM revealed that the "Type of Intervention" was "Physical Restraint" under "Less Restrictive Interventions to prevent use" it is written "Benadryl [medication given for allergies but used in psychiatry to help with side effects and/or sedative effects] 50 mg (milligrams), IM [intramuscular, injection into the muscle] 1X [1 time]" and "Haldol [medication given for agitation] 5 mg IM 1X."

C. Record review of P11's "Medication Administration Record" revealed that on 08/13/23 at 11:42 PM the patient received Haldol 5 mg oral "STAT for Agitation" along with Benadryl 100 mg oral "STAT for Agitation".

D. Record review of P11's "Medication Administration Record" revealed that on 08/14/23 at 12:06 AM the patient received Haldol 5 mg injection "Now for Agitation" along with Benadryl 50 mg injection "Now for Agitation".

E. Record review of P11's "Daily Nurse Progress Note" dated 08/14/2023 under "2300-0700 [11:00 PM - 7:00 AM] Sleep/Behaviors Note" stated "Restrained @ [at] 2115 [9:15 PM] for 30 min [minutes] w/ [with] IM 50 [mg] Benadryl/5 [mg] Haldol for pushing tech. . ."

F. Record review of P11's medical record does not reveal that a chemical restraint was ordered or documented on 08/13/2023 at 9:15 PM per policy.

F. During an interview on 09/07/2023 at 10:45 AM with S19, Registered Nurse (RN) it was asked if Benadryl is given to calm a patient down during an acute episode of agitation or aggression is an order for chemical restraint obtained. It was answered, "From my understanding a chemical restraint is if the child falls asleep right away. I would get the order for the restraint if the child falls asleep [after administration of the medication]."

G. During an interview on 09/07/2023 at 10:58 AM with S16, Medical Doctor (MD) confirmed that an order needs to be placed if a chemical restraint is used. It was asked if a medication is given to calm a child who is acting out in an aggressive or disruptive manner is that medication considered a restraint. It was explained that it would only be considered a restraint if the medication sedates the patient.

H. During an interview on 09/07/2023 at 11:15 AM with S3, Chief Nursing Officer it was asked when does medications become considered a chemical restraint. It was answered, "If it is not the usual dose or if we specifically give a medication that prevents a patient from returning to normal programming [term utilized for daily activities like group, therapy, etc. while in treatment at the hospital]."

Based on record review and interview the facility failed to ensure that the least restrictive intervention was used before moving on to the next intervention for 1 (P [patient]11) of 10 (P11-P20) patients reviewed for restraint use. This failed practice can lead to poor outcomes for the patient related to medication side effects.

The findings are:

A. Record review of facility policy titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" dated 12/2022 on page 4 under "Procedure" it states, "Use of Less-Restrictive Measures: The RN [registered nurse] and unit staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to seclusion/restraint, including: 1. Redirecting the patient's focus 2. Employing verbal de-escalation 3. Separating patient from group or community 4. Engaging the patient in 1:1 (one to one) activity to promote safe expression of feelings 5. Offering the use of the quiet room to decrease stimuli [something that can cause an increase in energy or excitement] and regain control 6. Offering food and drinks 7. Administering medication as ordered by the physician to help the patient more effectively function in his/her environment 8. Documents the alternatives attempted or the rationale for not using alternatives as well as the patient's response to those measures."

B. Refer to tag A-0160 finding B. - D.

C. Record review of P11's "Post Intervention Face to Face Evaluation" dated 08/13/2023 at 10:00 PM it is documented under, "Assessment of Immediate Situation" that patient is "sitting in room." The "Patient's Response to the Intervention" is documented as "Calmer".

D. During an interview on 08/31/2023 at 12:45 PM with S(staff) 3, Chief Nursing Officer it was asked how long should staff wait after administering oral medications for agitation to be effective. It was explained at least 30 minutes to an hour.

E. During an interview on 08/31/2023 at 12:05 PM with S16, Medical Doctor it was asked if it would be appropriate to give 5 mg of Haldol and 50 mg of Benadryl injection less than 30 minutes after administering oral doses of the same medications. It was answered "Generally not, but it depends on what is going on, there are situations that fall outside the normal."

Based on record review and observation the facility failed to meet the Condition of Participation to have a prevention and surveillance program to prevent the spread of infection for all patients. This failed practice can lead to contamination of the specimen (a sample for medical testing) inaccurate reading of test results and exposure to infections for all patients during blood draws.

The findings are

A. The facility failed to maintain an ongoing infection control program by ensuring proper hand hygiene is practiced by staff before and after patient contact. Refer to tag A-0749

Based on interview and record review, the facility failed to maintain an ongoing infection control program by ensuring proper hand hygiene is practiced by staff before and after patient contact. This failed practice can lead to contamination of the specimens (a sample for medical testing), inaccurate reading of test results and exposure to infections for all patients during blood draws.

The findings are:

A. Record review of Hand Washing Policy last approved date of 09/2023
Policy Number 1600.17 states "Hand hygiene shall be practiced before and after each patient contact (even if gloves are worn)."

B. Review of video surveillance dated 08/03/2023 revealed:
03:20:51 (03:20 AM) Phlebotomist (a medical professional who is trained to perform blood draws) applied clean gloves from box of gloves located on top of cart without washing hands or using hand sanitizer.
03:21:27 (03:21 AM) Phlebotomist gathered supplies and placed them on top of cart.
03:22:16 (03:22 AM) Unidentified patient 1 sits in chair.
03:25:33 (03:25 AM) Blood is drawn from patient 1 by Phlebotomist.
03:26:23 (03:26 AM) Phlebotomist removed gloves and placed them on top of cart.
03:26:31 (03:26 AM) Phlebotomist observed applying clean gloves from box of gloves located on top of cart without washing hands or using hand sanitizer.
03:26:57 (03:26 AM) Supplies are gathered from cart by Phlebotomist.
03:27:22 (03:27 AM) Phlebotomist leaves unit.

C. During an interview with Staff (S)3, Chief Nursing Officer on 09/18/2023 at 2:30 PM, reviewed the video. S3 confirmed that the Phlebotomist did not wash or sanitize her hands before or after putting gloves on during blood draw.

Based on record review and interview the facility did not ensure that discharge was appropriate based on ongoing care needs for 1 (P [patient]17) of 10 (P11-P20) patients reviewed for appropriate discharge planning. This deficient practice could lead to patients being discharged from the hospital too soon and can lead to frequent re-admissions.

The findings are:

A. Record review of P17's restraint/seclusion order dated 08/18/2023 8:40 AM stated under, "Reason for Intervention. . ." the boxes for "Imminent Danger to Self and Imminent Danger to Others" were checked and it was written, "pt [patient] was physically aggressive towards staff throwing trash can and chairs across the room. He was also hurting himself by punching walls and windows on the unit."

B. Record review of P17's discharge note dated 08/18/2023 at 10:11 AM on page 2 under "Recommendation based on Mental Status Exam" it was written "Stable to discharge." There is no documentation of patient's restraint from the morning of 08/18/2023 in this discharge note.

C. Record review of P17's nurse's notes dated 08/18/2023 the narrative under "Psychiatric" stated, "pt is physically and verbally aggressive towards staff and peers. He is defiant and difficult to redirect. Threatens staff and other patients. Denies thoughts of suicide and hallucinations. Pt was restrained from 0840 [8:40 AM] to 0841 [8:41 AM] for 30 seconds and he was secluded for 5 mins [minutes] in the seclusion room from 0841-0846 [8:41 AM-8:46 AM]. . . Pt was discharge @ [at] 1345 [1:45 PM] to [initials of state agency] worker/guardian."

D. During an interview on 08/31/2023 at 12:05 PM S16, Medical Doctor it was asked if a discharge would be delayed due to a patient requiring restraints on the day of discharge. It was explained,"yes" and often times the restraint happens because patient is at risk of hurting themselves and it would typically lead to a delay in discharge.