The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BROOKWOOD BAPTIST MEDICAL CENTER 2010 BROOKWOOD MEDICAL CENTER DRIVE BIRMINGHAM, AL 35209 July 20, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, review of policies and procedures, medical records, hospital event reports, investigation tools, work orders and interviews, it was determined the hospital failed to:

1. Follow their policy for Patient Complaint, Grievance and Resolution process.

2. Assure all patients were kept safe and remained free from injury while hospitalized which included during the use of seclusion and restraints.

3. Assure all patient showers had a shower curtain in place and water on bathroom floors was dried promptly.

4. Complete accurate documentation of all care settings, ongoing assessments and care provided while a patient was in restraints and seclusion.

5. Assure the plan of care was updated for all patients in seclusion.

6. Obtain a physicians' order for seclusion.


This did affect Patient Identifier (PI) # 1, # 3, # 5, # 6 and had the potential to affect all patients treated at the hospital.

Findings include:

Refer to A 123, A 144, A 165, A 166 and A 168.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of policy and procedure, review of event reports and interview it was determined the facility failed to follow their policy for Patient Complaint, Grievance and Resolution process. This affected 3 of 3 records reviewed related to grievances on the psychiatric unit. This did affect Patient Identifier (PI) # 1, # 3, # 5 and has the potential to affect all patients treated at this facility.


Findings include:

Policy and Procedure Directive
Subject: Patient Complaint, Grievance, Resolution Process
Revised 02/16

" II. Purpose:
Brookwood Medical Center places a high value on delivering excellent service that is responsive to individual needs. This policy provides a mechanism for initiation, review and when possible, resolution of patient complaints concerning the quality of care or service received...

III. Definitions:
B. Patient Grievance- is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made to the hospital by a patient or the patient's representative, regarding the patient's care, abuse or neglect...A written complaint is always considered a grievance...

IV. Policy: The patient at Brookwood Medical Center should have the reasonable expectation of care and service and those expectations should be addressed in a timely, reasonable and consistent manner. Patients have the right to register complaints without fear of retribution, have their complaints investigated and resolved and be provided timely follow-up."

PI # 1, PI # 3 and PI # 5 had events occur while hospitalized between January 2017 and July 2017 which were brought to the attention of hospital staff.

The surveyor requested a list of Psychiatric complaints and grievances on arrival at the hospital 7/18/17 for the time period between January 2017 and July 2017.

Employee Identifier (EI) # 1, Vice President of Quality, provided to the surveyor complaints/ grievances totaling 23 for the time frame requested.

The events and complaints made by PI # 1, PI # 3 and PI # 5 were not included on the list provided. The patients and their representative had written complaints and or conversations with management regarding the events they were involved in. The facility failed to follow its policy for Patient Complaint, Grievance, Resolution Process.

In an interview with EI # 1, 7/20/17 at 10:15 AM the above was confirmed.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedure, hospital event reports and investigation tools, work orders, observations and interviews it was determined in 1 of 2 patients placed in restraint and seclusion and 2 of 2 patients with a diagnosis of Autism the facility staff failed to:

a) Assure all patients were kept safe and remained free from injury while hospitalized which included during the use of seclusion and restraints.

b) Assure all patient showers had a shower curtain in place and water on bathroom floors was dried promptly.

This affected Patient Identifier (PI) # 5 and # 3 and has the potential to affect all patients in this facility.

Findings include:

Hospital Policy:
Subject: Restraint & Seclusion
II. Purpose:
" The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety and preserves his or her dignity, rights and well-being.

III. Definitions:
A." Restraint" means any method, physical or chemical 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. If the effect of using an object fits the definition of restraint for a specific patient at a specific time, then for that patient at that time, the device is a restraint...

B. "Seclusion" is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving...Seclusion may only be used for the management of violent or self-destructive behaviors.

IV. Policy: It is the policy of this organization to limit the use of restraint and seclusion to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and reevaluation.

V. Procedure:
A. Methodology:
2. Document the physician's order for restraint on the Physician's Order Sheet for Restraint or Seclusion...
C. Documentation
1. Each episode of restraint use shall be documented in the patient's medical record and shall include but not be limited to:
a) Assessment and reassessment, including:
1. Significant changes in the patient's condition that warranted restraint use.
2. Patient's response to restraint.
b) Relevant orders for use of restraints, including lease restrictive intervention, time, limit, clinical justification, type of restraint to be used and criteria for release...
2. Patient needs will be met during restraint use.
a) Restraints may not act as a barrier to the provision of safe and appropriate care, treatments and other interventions to meet the needs of the patient.
b) The plan of care will not be compromised by the use of restraints and shall include:
Provision of hygiene needs...
3. Monitoring and Reassessment:
a) The restrained patient is assessed, monitored and reassessed...
c) Monitoring is accomplished by observation, direct face-to-face interaction with the patient or related direct examination of the patient by the trained and competent staff..."

1. PI # 5 was admitted to the facility on [DATE] at 6:33 PM with diagnoses including Mood Disorder, Unspecified, and Mental Retardation, Severity Unknown. PI # 5 was a [AGE] year old male.

Medical record review revealed PI # 5's Psychiatric Services Social History assessment included increasing agitation, combative with parent, previous history was low intellectual functioning, Autistic, history of exposing self and some sexually inappropriate behaviors.

Record review revealed physician's progress and treatment record documentation dated 1/3/17 at 11:00 AM, completed by Employee Identifier (EI) # 5, Licensed Counselor, Program Manager. EI # 5 met with the patient, PI # 5 after an allegation that involved sexually inappropriate situation with another patient (PI # 6). EI # 5 documented PI # 5 was very concrete in the presentation of the facts, childlike and easily distracted. PI # 5 described the inappropriate sexual contact (touching) and alleged sexual act.

Medical record review revealed EI # 5 met with PI # 5 on 1/3/17 at 4:30 PM following evaluation by the SANE RN (sexual assault nurse examiner, Registered Nurse).

Review of hospital document titled, Safety Event Entry- Legal Copy dated 1/2/17 revealed an actual event as described, (Registered Nurse), Clinical Coordinator was notified by staff that a patient (PI # 6) was being sexually inappropriate with his/her roommate (PI # 5). The patients were separated, notified (name) Director, Nursing #1 (name), Hospital Attorney, and local police. Staff attempted to notify PI # 5's mother. The event category was documented as an alleged sexual assault. Immediate actions taken, PI # 5 was transferred to another unit.

Medical record review revealed PI # 6, a [AGE] year old male was admitted on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Mixed Exaceberation with Psychotic Features, Alcohol Intoxication and Dependence and Opiate Intoxication and Opiate Dependence. Review of the Nursing Admission Summary Psychiatric Services documentation dated 12/26/16 revealed a history of alcohol, marijuana use, irritability, possible hallucinations and legal involvement.

PI # 6's medical record included Nursing Note documentation dated 1/3/17 at 1:07 PM which revealed: "...Late Note: Reported by MHA (mental health assistant) Patient (PI # 6) said he/she had been having sex with his/her roommate every night. Reported to cc (clinical coordinator)".

During an interview on 7/20/17 at 12:45 PM, EI # 12, Risk Management reviewed the hospital document titled, Risk Management and Patient Safety Rapid Investigation and Debriefing Tool with the surveyor. During the interview, EI # 12 reported the document findings were obtained from staff interviews and medical record review completed by clinical staff.

The Risk Management and Patient Safety Rapid Investigation and Debriefing Tool revealed the debriefing is a meeting to discuss the occurrence includes manager of the area where the occurrence happened, staff members involved and a facilitator from Patient Safety, Risk Management, Performance or Infection Control.

Review of the Risk Management and Patient Safety Rapid Investigation and Debriefing Tool documentation revealed a debriefing session was completed with 6 hospital employees participating that included Team Leader, Risk Management, Registered Nurse (RN), Clinical Coordinator, a staff RN and 3 Mental Health Assistants (MHA).

Further review of the Risk Management and Patient Safety Rapid Investigation tool included demographic documentation, date of the event, 12/31/16, the patient (PI # 5) [AGE], admitting diagnosis, Autism, increase agitation, frustration. The event type was an alleged assault. The event description revealed a another patient on the unit overheard PI # 6 claim that he/she had anal and oral sex with PI # 5 who was Autistic and Mentally Retarded. The police was called per abuse protocol and interviews and an investigation commenced.

Review of the medical record, hospital written interviews accounts, investigation documentation and staff interview documentation revealed the following staff were not present during the 1/2/17 debriefing session: the MHA and the RN on duty on 12/31/16 and 1/1/17 who documented safety round monitoring on PI # 5, the Licensed Counselor, EI # 5 who met with PI # 5 after the alleged assault and following the sexual assault examination and EI # 3, RN, Director, Nursing # 1 who interviewed the alleged assaulting patient, PI # 6.

The 4 staff members listed above had not been documented as present and included during the 1/2/17 debriefing session.

Review of the hospital 1/2/17 Risk Management and Patient Safety Rapid Investigation and Debriefing Tool, Time-line Matrix documentation revealed on 12/30/16 at 2:00 AM, hospital action, the alleged assaulting patient (PI # 6) moved to Seclusion room due to agitation. Roommate (PI # 5) stayed in room.

Review of PI # 6's (the alleged assaulting patient's) medical record documentation included a Psychiatric Precaution Round Sheet dated 12/30/16 in which PI # 6 was in the patient room (RM) at 12:00 AM-until 6:00 AM. Not in the Seclusion room at 2:00 AM as documented on the Risk Management and Patient Safety Rapid Investigation and Debriefing Tool.

Review of PI # 5 's (the patient allegedly assaulted) medical record included a Psychiatric Precaution Round Sheet dated 12/30/16 reported PI # 5 was in the patient room (RM) at 12:00 AM-until 7:30 AM.

Further review of the 1/2/17 Risk Management and Patient Safety Rapid Investigation and Debriefing Tool, Time-line Matrix documentation revealed on 12/31/16 at 10:00 PM the alleged assaulting patient (PI # 6) was moved to the seclusion room for the night after yelling at roommate.

Review of PI # 6's 12/31/16 Psychiatric Precaution Round Sheet documentation revealed the alleged assaulting patient was in seclusion on 12/31/16 from 10:15 PM to 11:45 PM. On 1/1/17, the Psychiatric Precaution Round Sheet documentation revealed at 12:00 AM until 6:00 AM, PI # 6's location was "RM", patient room.

PI # 6 was not in seclusion for the night as documented on the Risk Management and Patient Safety Rapid Investigation Tool.

Review of PI # 5's Psychiatric Precaution Round Sheet documentation dated 12/31/16 revealed PI # 5 was in the patient room at 9:45 PM to 11:45 PM and on 1/1/17 from 12:00 AM to 7:15 AM in the patient room.

The medical record documentation failed to revealed PI # 6 was in the seclusion room "for the night". According to staff documentation on the Psychiatric Precaution Round Sheet dated 1/1/17 from 12:00 AM to 6:15 AM, PI # 6's location was the patient room. This was inconsistent with the hospital investigation documentation that PI # 6 was in the seclusion room for the night.

The Risk Management and Patient Safety Rapid Investigation and Debriefing Tools' Time-line Matrix documentation revealed on 1/1/17 at 10:15 PM, PI #5 was moved to the seclusion room for the night after the alleged assaulting patient (PI# 6) was seen placing a blanket on roommate (PI # 5).

Review of PI # 5's Psychiatric Precaution Round Sheet documentation dated 1/1/17, 10:15 PM to 11:45 PM, PI # 5 was in seclusion. On 1/2/17 from 12:00 AM to 6:45 AM, PI # 5's location as documented by staff was the patient room with PI # 6. The Risk Management and Patient Safety documentation and PI # 5's medical record documentation did not reflect the same patient location on 1/1/17.

The medical records documentation and the hospital investigation findings were not consistent.

On 7/20/17 at 1:40 PM, review of the hospital investigation documentation included SANE (sexual assault nurse examiner) documentation. The documentation revealed the 1/3/17 patient examination finding included redness, the size of a quarter around the anus.

An interview was conducted on 7/20/17 at 12:45 PM with EI # 12, Risk Management. EI # 12 confirmed after a review of the facts, the event "probably took place". EI # 12 verified the hospital Risk Management and Patient Safety Rapid Investigation Tool documentation, according to staff interviews, was not consistent with the medical record documentation. EI # 12 verified all staff interviewed were not documented as participants in the hospital debriefing session.

During the interview on 7/20/17 at 1:40 PM, the surveyor asked when and how staff first learned of PI # 6's prison history? EI # 6, Vice President of Psychiatry presented the surveyor documentation, an Adult Transition Evaluation, dated 12/26/17 in which the CM (case manager) wrote, "...reviewed the chart, spoke with the patient... He/she related he/she was in prison for 28 years..."

EI # 12 reported two different patient types created an at risk situation especially for vulnerable patients. PI # 6's behaviors exhibited while on the unit and prison history and PI # 5's Mentally Retardation diagnosis and Autism, the two patients should not have been placed in the same patient room.






2. PI # 3 was admitted to the facility 4/20/17 with diagnoses of Autism Acute Psychosis.

PI # 3 was mute and had difficulty expressing his/her needs.

A Safety Event Entry dated 4/29/17 at 2:00 PM included the following documentation, " During the visit in the dayroom, his/her mother pointed out that there were discolorations on the back of both of the patient's upper arms. The discolorations varied in color...His/her parents strongly questioned what had happened to him/her and how he/she came to receive said bruises... The CC (clinical coordinator) and the physician were called, documentation was checked and staff were questioned and nobody on this unit and this shift knew of any incidents involving the patient."

The skilled nurse documented 5/1/17 at 6:37 PM," Patient was transferred from IM 1 to IM 2...Body audit done on patient. Noted green/yellow bruise to patient right and left arm. 7 on right arm and 6 on left arm. Left hand bruise. Right shoulder bruise. Large bruise to back of left arm green/yellow with red in the middle. Both elbow are red and scab area on left elbow. Call placed to mother made aware that patient had moved...Writer went to dining room and got some straws for patient..."

The skilled nurse documented 5/5/17 at 2:15 PM, " He/she likes to play with straws and spoons to keep him/her occupied... No groups attended."

The skilled nurse documented 5/7/17 at 3:35 PM, " Plays with his/her paper products and continues to pace the hallway..."

The patient received PRN (as needed) medications (Haldol and Benadryl) 22 times for agitation during his/her hospitalization .

PI # 3 was hospitalized from [DATE] through 5/19/17 a total of 30 days. PI # 3 was discharged [DATE] Against Medical Advice by his/her parents after the parents visited and saw bruises on the patient's arms.

The discharge summary prepared by the Psychiatrist documented 5/19/17, " There is no evidence that the patient was ever touched by anybody else. He/she probably has a bruise him/herself, but the patient's parents insist that they want to take him/her home..."

In written questions submitted to staff 7/19/17 at 3:30 PM regarding PI # 3 and the treatment received, the surveyor asked about interventions with PI # 3 versus the number of PRN medications when he/she was entertained with paper products and straws.

No documentation was provided that staff attempted to re-direct PI # 3 or that interventions attempted failed prior to administering PRN medications to address PI # 3's behavior.






****
A tour of the psychiatric hospital unit on 7/18/17 at 8:15 AM was conducted with Employee Identifier (EI) # 1, Vice President Quality. During the tour the below observations were made by the surveyor:

Room 116 - tub drain cover had excessive hair over the drain cover. More than one days accumulation of hair was noted.

Room 123 - two used wet wash cloths were on the bathroom floor. The floor next to the bathtub was wet.

Room 129 - no shower curtain was up in the bathroom.

Room 130 - no shower curtain was up in the bathroom.

At 8:50 AM the tour continued and the following observations were made by the surveyor:

Room 17 - no shower curtain was up in the bathroom.

Room 21 - there was an exposed pipe next to the patient's storage cabinet. Staff stated the pipe cover was removed when the last patient was placed in the room and the cover was not put back. The current patient placed in this room was admitted on [DATE].

Room 23 - no shower curtain was up in the bathroom. The entire floor in the bathroom was wet, even around the handwashing sink and toilet. Staff stated a patient pulled the curtain down and that towels were to be placed on the floor to catch water when patients were showering. There were no towels on the floor in the bathroom and no floor drain in the area for excess water to drain.

Room 27 - in the bathroom a hard plastic soap dispenser was mounted to the bathroom wall in the tub. The soap dispenser was broken with jagged edges.

Room 28 - no shower curtain was up in the bathroom. There is no floor drain in the area for excess water to drain.

Room 30 - no shower curtain was up in the bathroom. There is no floor drain in the area for excess water to drain.

In one of the two seclusion rooms in this unit a ceiling mounted corner wall reflector, used to view patients when the seclusion room door is closed, was off the wall. Staff stated the reflector had been down for "...about a week" and this seclusion room was not to be used until the reflector was replaced.

A review of the psychiatric unit event reports from January 1, 2017 to July 17, 2017 was completed by the surveyor. During this time frame there were 113 falls in the psychiatric unit.

A sample of the 113 falls was reviewed and the following findings were identified.

1. On 1/11/17 an unsampled patient reported a fall in the bathroom of room 1008. The post fall assessment form documented the patient fell when transferring from the toilet. Under the environment section of the fall assessment it was noted the floor was wet.

2. On 1/19/17 an unsampled patient reported a fall in the bathroom of room 1001. The nursing note dated 1/19/17 documented staff was called to the room and the patient was on the floor in the bathroom after falling while ambulating.

3. On 1/23/17 an unsampled patient reported a fall in the seclusion bathroom. The post fall assessment form documented the patient fell when transferring from the toilet. There was no documentation listed under the environment section of the fall assessment.

4. On 2/04/17 an unsampled patient reported a fall in the shower of room 7. There was no post fall assessment form provided for this fall. A nursing note dated 2/05/17 documented at approximately 10:00 PM while the patient was in his bathroom taking a shower he fell . The patient told the nurse, "...he tripped or slipped on the towel on the bathroom floor."

5. On 3/02/17 an unsampled patient reported a fall in the seclusion bathroom. The post fall assessment form documented to prevent the patient from falling again the patient was encouraged to use a shower chair. The only documentation listed for the environment section of the fall assessment was, "N/A" (not applicable).

6. On 3/19/17 an unsampled patient reported a fall in the shower of room 6. The post fall assessment form documented the floor was wet while the patient showered. There was no documentation that towels were placed on the floor to absorb excess water.

7. On 3/20/17 an unsampled patient reported a fall in the shower of room 107. The post fall assessment form documented the floor was wet while the patient showered and that towels were placed on the floor.

A review of the work orders that were submitted for the psychiatric unit from January 1, 2017 to July 17, 2017 was completed by the surveyor. During this time frame there were 13 work orders submitted by staff related to water leaks or clogged plumbing in the psychiatric unit.

Work order number 6 was dated 1/18/17. Under the remarks section psychiatric unit staff reported to maintenance the tub in room 107 was not draining. Unit staff documented this was the second request and the tub was still clogged. The work order was marked completed on 1/19/17 at 3:26 PM.

Work order number 9 was dated 3/23/17. Under the remarks section psychiatric unit staff reported to maintenance the large shower in unit IM 4 was leaking water into the hallway from the wall. The work order was marked completed on 3/24/17 at 10:11 AM. Under the comments section it was documented, "Problems fixed."

Work order number 3 was dated 3/27/17. Under the remarks section psychiatric unit staff reported to maintenance the intake unit shower was not working. The work order was marked completed on 6/13/17 at 1:48 PM (three months later). Under the comments section it was documented, "replace valve."

Work order number 9 was dated 4/12/17. Under the remarks section psychiatric unit staff reported to maintenance the bathtub in room 107 was not draining. The work order was marked completed on 4/12/17 at 1:42 PM.

Work order number 8 was dated 7/17/17. Under the remarks section psychiatric unit staff reported to maintenance the floor was wet from "...constant leak of water from upstairs." The work order was marked completed on 7/18/17 at 8:33 AM. Under the comments section it was documented the drain was stopped up.

A work order submission was provided to the surveyor in response to written questions after reviewing the incident report from 3/20/17, where an unsampled patient fell in the shower of room 107. A work order number of 0 was listed. The remarks documented on this work order was, "water leaking from shower or water fountain in IMCU 4." This work order was not listed on the summary of work orders that was provided to the survey staff and there was no documentation this work order request had been completed.

In an interview on 7/20/17 at 7:20 AM, EI # 13 MHT, was asked if patients had been told to put blankets on the floor to keep water from accumulating since there were no shower curtains. EI # 13 stated the patients are to ask staff for a blanket to catch water and after the patient showers the MHT is suppose to go to the bathroom to make sure the floor is dry.

In an interview on 7/20/17 at 9:03 AM, EI # 8, MHT was asked if patients had been told to put blankets on the floor to keep water from accumulating since there were no shower curtains. EI # 8 stated no one told him to put blankets on the floor, but that he had seen towels on the floor.

Hospital staff provided the surveyor with a 6/12/17 tabulation of bids for psychiatric unit renovations. Part of the psychiatric unit renovations included in the bid was to remove existing tubs and replace them with cultured marble shower base and surround. At the time of the survey these purposed renovations had not been started.

The hospital failed to limit risk factors for falls in the psychiatric unit. There were no shower curtains in place in all patient used showers to limit water accumulation on the floor and staff failed to promptly clean up wet floors after patients had showered.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, medical record and interview, it was determined the facility failed to include accurate documentation of all care settings, ongoing assessments and care provided while Patient Identifier (PI) # 6 was in restraints. This affected 1 of 2 patients in restraints and 1 of 2 patients in seclusion, PI # 1 and had the potential to affect all patients treated at the hospital.

Findings include:

Hospital Policy:
Subject: Restraint & Seclusion
II. Purpose:
" The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety and preserves his or her dignity, rights and well-being.

III. Definitions:
A." Restraint" means any method, physical or chemical 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. If the effect of using an object fits the definition of restraint for a specific patient at a specific time, then for that patient at that time, the device is a restraint...

C. Documentation
1. Each episode of restraint use shall be documented in the patient's medical record and shall include but not be limited to:
a) Assessment and reassessment, including:
1. Significant changes in the patient's condition that warranted restraint use.
2. Patient's response to restraint.
b) Relevant orders for use of restraints, including lease restrictive intervention, time, limit, clinical justification, type of restraint to be used and criteria for release...
2. Patient needs will be met during restraint use.
a) Restraints may not act as a barrier to the provision of safe and appropriate care, treatments and other interventions to meet the needs of the patient.
b) The plan of care will not be compromised by the use of restraints and shall include:
Provision of hygiene needs...
3. Monitoring and Reassessment:
a) The restrained patient is assessed, monitored and reassessed...
c) Monitoring is accomplished by observation, direct face-to-face interaction with the patient or related direct examination of the patient by the trained and competent staff..."

1. PI # 6 was admitted on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Mixed Exaceberation with Psychotic Features, Alcohol Intoxication and Dependence and Opiate Intoxication and Opiate Dependence.

Record review revealed a restraint order, completed on 1/7/17 at 1:00 PM. PI # 6's behavior was attacking and spitting at staff. The restraint order did not include the criteria for release from 4 point restraint. The one hour Seclusion/ Behavior Restraint was signed by a nurse, dated/time recorded on 1/7/17 at 1:25 PM. This was not 1 hour after PI # 6 was placed in restraint. There was no documented recommendations to help PI # 6 regain control and be released.


The Restraint Flowsheet for (Violent) (Behavioral) requires continuous monitoring. Assessment and documentation every 15 minutes. (Enter actual times every 15 minutes).

Review of the 1/7/17 restraint flowsheet documentation revealed no pulse, respiration rate or blood pressure (BP) documentation at 1:15 PM, no BP at 1:45 PM and no Pulse, respiration rate or BP at 4:15 PM.

Record review included a restraint order, completed on 1/7/17 at 4:28 PM. PI # 6's behavior was spitting and attacking staff. The Restraint Order did not include the criteria for release from 4 point restraint. The one hour Seclusion/ Behavior Restraint was signed by a nurse, dated/time recorded on 1/7/17 at 5:00 PM. This was not 1 hour after PI # 6 was placed in restraint. There was no documented recommendations to help PI # 6 regain control and be released.

Review of the 1/7/17 Restraint Flowsheet documentation revealed no pulse or blood pressure documentation at 4:45 PM.

Record review included a Restraint Order, completed on 1/7/17 at 8:15 PM for PI # 6's behavior spitting and threatening staff. The Restraint Order did not include the criteria for release from 4 point restraint. The one hour Seclusion/ Behavior Restraint was signed by staff on 1/7/17 at 8:15 PM which was not 1 hour after the third restraint order was received.

According the 1/7/17 Restraint Flowsheet, PI # 6 remained in 4 point restraints from 8:15 PM through 11:45 PM on 1/7/17 and behavior documented was agitated.

Further record review revealed a Psychiatric Precaution Round Sheet dated 1/7/17 from 12:28 PM until 11:45 PM had PI # 6's location as "RM, which is the patient's room. Behaviors documented were agitated, sleeping, eating and calm.

The staff failed to accurately document PI # 6's location on 1/7/17, perform and document all required Restraint Order and Restraint Flowsheet assessment actions.

Written questions were submitted to staff on 7/19/17 at 3:30 PM. Review of documentation and written responses during an interview on 7/20/17 at 11:30 AM with Employee Identifier # 4, Director, Nursing # 2 confirmed the findings above.




2. PI # 1 was admitted to the facility 6/11/17 with diagnoses of Suicidal Ideation, Major Depression, Polysubstance Abuse and Bipolar Disorder.

A review of a Safety Event Entry- Working Copy dated 6/28/17 included the description from PI # 1 concerning alleged physical assault. PI # 1 informed the RN (Registered Nurse) who released her/him from the seclusion room, " Some members of the night shift staff choked her/him and poured water on her/his head and neck."

A review of the Restraint Order Sheet dated 6/28/17 at 6:30 AM failed to include the indication for restraint, other was marked with seclusion written. The indication area included injury to self (describe), injury to others (describe), alternative measure failed. The nurse failed to document any indicators or alternative measures attempted. The form failed to include criteria for release.

Additional orders printed on the form included offer food, fluids, toileting and position changes every two hours.

The order was signed by the physician 6/29/17. The hospital staff was unable to read the time documented by the physician.

The one hour assess seclusion/restraint form was completed by the nurse who placed the patient in seclusion at 6:30 AM, Employee Identifier (EI) # 7, RN, the nurse timed the form 6:30 AM, an hour had not passed since the seclusion was started.

The Restraint Flowsheet dated 6/28/17 at 6:30 AM included every 15 minutes assessment and documentation as follows:
6:30 AM completed by the RN included documentation the patient was alert and awake, agitated and restless, refused to have vital signs assessed. Patient needs: continuously observed, fluid/food offered every two hours, hygiene and elimination offered.
6:45 AM completed by the RN included documentation the patient was alert and awake, agitated and restless. Patient needs: continuously observed, fluid/food offered every two hours, hygiene and elimination offered.
7:00 AM completed by the Mental Health Technician (MHT), EI # 8, included documentation the patient was alert and awake, agitated and restless, refused to have vital signs assessed. Patient needs: continuously observed, fluid/food offered every two hours, hygiene and elimination offered.
7:15 AM completed by the MHT, EI # 8 included documentation the patient was sleeping, calm, vital signs were not assessed due to patient sleeping. Patient needs: continuously observed, fluid/food offered every two hours, hygiene and elimination offered.

The one hour assess seclusion/restraint form was completed by the nurse coming on duty, RN, EI # 11, upon face to face at 7:30 AM. The patient was calm and apologetic. The patient was removed from seclusion and understood that her/his previous behavior was unacceptable and warranted her/his placement in seclusion.

The form also included documentation of the evaluation of patient's immediate situation:
"Patient was aggressive toward staff and non-compliant with unit rules per (EI # 7), RN. The patient poured water on the staff member and was unable to redirect."

Patient's reaction to the intervention: " The patient remained agitated and defecated on the floor per EI # 7, RN."

A review of the Psychiatric Precaution Rounding Sheet included the time, location and behavior from 6:00 AM until 7:30 AM on 6/28/17.
6:00 AM in room agitated
6:15 AM in hallway drowsy, disoriented
6:30 AM room, hostile
6:45 AM room, hostile
7:00 AM SEC (seclusion not included in the location codes), restless
7:15 AM SEC, restless
7:30 AM Dining room, calm.

PI # 1 was assessed by the psychiatrist around 5:30 AM and became upset that she could not transfer to a different unit, an injection of Thorazine 100 milligrams was ordered at 5:32 AM.

EI # 7, RN documented the injection was administered at 6:58 AM. The time the patient was in seclusion covered from 6:30 AM until 7:30 AM.

In an interview with EI # 7 on 7/20/17 at 7:35 AM, she confirmed that she administered the injection but did not know what time, she/he got the shot. The shot of Thorazine was administered before PI # 1 before threw water on the RN, EI # 7.

The medical record for PI # 1, failed to have any documentation by the RN, EI # 7, for 6/27/17 through 6/28/17 shift (7:00 PM- 7:00 AM). EI # 7 in an interview on 7/20/17 at 7:35 AM, stated that she would have caught her mistake if she had returned to work the evening of 6/28/17 to work." I'd come back that night to work, I would've documented this."

PI # 1 was placed in seclusion 6/28/17, a review of the record failed to include documentation of the events related to the need for a PRN medication and seclusion. EI # 11 confirmed PI # 1's hair and bed linens were wet, concluding the patient had some altercation with the RN and MHT.

In an interview on 7/19/17 at 12:30 PM with EI # 11, RN, the nurse from day shift who assumed care of PI # 1 confirmed that PI # 11's hair and bed linens were wet.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, hospital policy and interview, the hospital failed to assure the plan of care was updated for 1 of 2 records reviewed for patients in seclusion. This affected Patient Identifier (PI) # 5 and had the potential to affect all patients.

Findings include:

Hospital Policy:
Subject: Restraint & Seclusion
II. Purpose:
" The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety and preserves his or her dignity, rights and well-being.
III. Definitions:

B. "Seclusion" is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving...Seclusion may only be used for the management of violent or self-destructive behaviors.

IV. Policy: It is the policy of this organization to limit the use of restraint and seclusion to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and reevaluation.

V. Procedure:
A. Methodology:
7. When a restraint is implemented, the patient's plan of care must be modified to reflect this change.
C. Documentation:
1.d) Use of restraints must be addressed in the patient's modified plan of care."

1. PI # 5 was admitted on [DATE] at 6:33 PM with diagnoses including Mood Disorder, Unspecified and Mental Retardation, Severity Unknown.

Medical record review revealed Nursing Note documentation dated 12/30/16 that PI # 5 was verbally aggressive, physically hostile to roommate and staff, "unredirectable", and required prn (as needed) injectable medications, Haldol and Benadryl.

Further review revealed Psychiatric Precaution Round Sheet documentation dated 12/30/16 from 9:45 AM to 12:00 PM, 1:45 PM to 3:00 PM, and 3:30 PM to 6:00 PM that PI # 5 was in seclusion (SEC).

Record review revealed Nursing Note documentation dated 1/3/17 that PI # 5 was examined by a Sexual Assault Nurse Examiner.

Review of the Behavioral Health Interdisciplinary Care Plan revealed no documentation of an update for the multiple documented times in seclusion on 12/30/16 and no documentation of an alleged sexual assault. There was no documentation of any updates or reviews of the plan of care from the initial problem(s) dated 12/29/16 and 12/30/16, Safety issues, Chronic/New Acute Medical Conditions, Psychiatric Symptoms, Psychosocial Needs and Occupational therapy assessment until discharge on 1/6/17.

On 7/20/17 at 11:10 AM, Employee Identifier # 5, Licensed Counselor, Program Manager was asked where staff would document changes or updates to the patient's plan of care and she stated on the care plan.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record and interview, it was determine the facility failed to obtain a physicians' order for seclusion in 1 of 2 record reviews. This did affect Patient Identifier (PI) # 5 and had the potential to affect all patients treated at the facility.

Findings include:

Hospital Policy:
Subject: Restraint & Seclusion
II. Purpose:
" The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety and preserves his or her dignity, rights and well-being.

III. Definitions:

B. "Seclusion" is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving...Seclusion may only be used for the management of violent or self-destructive behaviors.

IV. Policy: It is the policy of this organization to limit the use of restraint and seclusion to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and reevaluation.

V. Procedure:
A. Methodology:
2. Document the physician's order for restraint on the Physician's Order Sheet for Restraint or Seclusion...
C. Documentation
1. Each episode of restraint use shall be documented in the patient's medical record and shall include but not be limited to:
a) Assessment and reassessment, including:
1. Significant changes in the patient's condition that warranted restraint use.
2. Patient's response to restraint.
b) Relevant orders for use of restraints, including lease restrictive intervention, time, limit, clinical justification, type of restraint to be used and criteria for release...
2. Patient needs will be met during restraint use.
a) Restraints may not act as a barrier to the provision of safe and appropriate care, treatments and other interventions to meet the needs of the patient.
b) The plan of care will not be compromised by the use of restraints and shall include:
Provision of hygiene needs...
3. Monitoring and Reassessment:
a) The restrained patient is assesses, monitored and reassessed...
c) Monitoring is accomplished by observation, direct face-to-face interaction with the patient or related direct examination of the patient by the trained and competent staff..."

1. PI # 5 was admitted to the facility on [DATE] at 6:33 PM with diagnoses including Mood Disorder, Unspecified and Mental Retardation, Severity Unknown.

Record review revealed a Psychiatric Precaution Round Sheet documentation dated 12/30/16 from 9:45 AM to 12:00 PM with PI # 5's location, SEC (seclusion) and behaviors were lying and sleeping.

Record review included Nursing Note documentation dated 12/30/16 at 10:00 AM, PI # 5 was yelling, screaming, hitting the walls, hit roommate and female MHA (Mental Health Aide), running down the hallway chasing a female MHA, hitting the MHA in the back of the head. The patient was given prn (as needed) meds (medications), transferred/escorted by staff to "PI on IM one" (psychiatric unit transfer within the facility).

On 12/30/16 at 15:20 (3:20 PM), Nursing Note documentation revealed PI # 5 was verbally aggressive, balling fists up at staff, demanding, threw water on bed and was "unredirectable". Licensed practical med (medication) nurse gave prn Haldol/Benadryl and instructed (PI # 5) to stay in seclusion while medication works.

Further review of the 12/30/16 Psychiatric Precaution Round Sheet revealed that from 1:45 PM to 3:00 PM and 3:30 PM to 6:00 PM, PI # 5's location was SEC (seclusion) with behaviors documented, lying and sleeping as documented by MHA's and nursing staff.

There was no documentation the physician was notified PI # 5 was placed in seclusion on 12/30/16 and no documentation a physician's order was obtained.

Written questions were submitted to the facility on [DATE] at 3:30 PM and written responses received and reviewed on 7/20/17 at 10:00 AM did not include physician's orders for seclusion on 12/30/16.

On 7/20/17 at 11:10 AM, a review of the above documentation with Employee Identifier # 4, Director of Nursing # 2 confirmed staff should have obtained physicians' orders while PI # 5 was in seclusion.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on the review of medical records and interview it was determined the patients failed to attend groups as planned in the Interdisciplinary Care Plans established for 6 of 10 patient records reviewed and failed to complete updates to the plan of care per hospital policy. The facility staff failed to provide individual therapy and update the care plan with alternatives to group therapy.

This affected Patient Indentifer # 4, # 1, # 3, # 2, # 5, # 8 and had the potential to affect all patients served on the Psychiatric units.

Findings include:

1. PI # 4 was admitted to the unit 6/13/17 with diagnoses of Suicidal Ideations and Opiate Withdrawal.

The Behavioral Health Interdisciplinary Care Plan was established 6/13/17 and a Treatment Team Review/Update was completed 6/14/17. The patient's new goals included: " Pt (patient) will attend and actively participate in 100% of groups daily to increase coping skills and decrease depression and anxiety."

The patient did not attend group as part of his/her careplan on the following days- 6/14/17 at 10:00 AM, 6/15/17 at 9:30 AM, 6/16/17 at 2:00 PM, 6/16/17 at 2:30 PM and 6/17/17 at 9:00 AM.

In response to questions submitted by the surveyor 7/19/17 at 3:30 PM the following response was received from Employee Identifier (EI) # 5, Program Manager on 7/20/17 at 11:25 AM. " The patient attended 10 out of 14 groups offered from 6/14/17 through 6/19/17. This would mean he/she attended 70 % of the groups offered."

The surveyor questioned when individual therapy was offered if patients did not attend groups. On 7/20/17 at 11:25 AM, EI # 5 confirmed, " If a patient doesn't attend a majority of groups that week, it triggers the therapist to initiate an individual therapy session." EI # 5 was asked what was considered a majority of groups and no information was provided to the surveyor.

2. PI # 1 was admitted to the facility 6/11/17 with diagnoses of Suicidal Ideation, Major Depression, Polysubstance Abuse and Bipolar Disorder.

The Behavioral Health Interdisciplinary Care Plan was established 6/13/17 and a Treatment Team Review/Update was completed 6/14/17. The patient's new goals included: " Attend 75% of groups."

The patient did not attend group:
6/13/17 at 8:30 AM, 11:00 AM, 1:00 PM
6/14/17 at 11:00 AM, 1:00 PM, 2:00 PM
6/15/17 at 1:00 PM
6/16/17 at 1:00 PM
6/19/17 at 1:00 PM
6/21/17 at 1:00 PM
6/24/17 at 1:00 PM, 2:30 PM
6/26/17 at 9:00 AM
6/27/17 at 9:30 AM, 1:00 PM
6/28/17 at 9:00 AM
6/29/17 at 9:00 AM, 1:00 PM
6/30/17 at 9:00 AM, 1:00 PM
7/1/17 at 11:30 AM
7/2/17 at 1:00 PM
7/3/17 at 1:00 PM
7/4/17 at 9:00 AM
7/5/17 at 10:00 AM, 1:00 PM.

In response to questions submitted by the surveyor 7/19/17 at 3:30 PM the following response was received from EI # 5, Program Manager on 7/20/17 at 11:25 AM. " Patient didn't attend a majority of groups the first week here and was seen 6/20/17 for individual therapy, she/he attended a majority of groups the 2nd week and didn't the 3rd week and did not receive individual therapy. "

3. PI # 3 was admitted to the facility 4/20/17 with diagnoses of Autism Acute Psychosis.

PI # 3 was mute and had difficulty expressing his/her needs.

The Behavioral Health Interdisciplinary Care Plan was established 4/21/17 and a Treatment Team Review/Update was completed 4/27/17. The patient's new goals included: " To attend 3 groups daily."

PI # 3 did not attend groups:
4/22/17 at 9:00 AM, 2:30 PM
4/23/17 at 2:30 PM
4/24/17 at 8:30 AM, 9:00 AM, 2:00 PM, 1:00 PM
4/25/17 at 10:00 AM, unable to read time on second entry
4/26/17 at 10:00 restless, confused impulsive, 1:00 PM patient not appropriate, 2:00 PM
4/27/17 at 8:30 AM, 9:00 AM, 1:00 PM and 2:00 PM patient not appropriate.

The staff continued to document not appropriate for groups until 5/16/17, the Treatment Team Review/Update was completed. Patient's new goals included, " Clinical Therapist will provide individual interventions, consulting with Occupational Therapist on specific tasks. Treatment team will continue to assess if patient is appropriate for group therapy."

In response to questions submitted by the surveyor 7/19/17 at 3:30 PM the following response was received from EI # 5, Program Manager on 7/20/17 at 11:15 AM. " The therapy staff provided some individual therapy...He/she was provided crayons, coloring sheets, soft balls for physical stimulation, paper to draw or write."

The surveyor asked for documentation concerning the individual therapy and alternatives provided 7/19/17 at 3:30 PM. No documentation was provided to the surveyor.

4. PI # 2 was admitted to the facility 4/3/17 with diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder.

The Behavioral Health Interdisciplinary Care Plan was established 4/3/17 and a Treatment Team Review/Update was completed 4/5/17. The patient's new goals included: " To attend 3:3 (3 out of 3 groups) groups daily to decrease depression, decrease isolating behaviors, medication management."

PI # 2 did not attend groups:
4/4/17 at 9:30 AM 10:00 AM, 11:00 AM
4/5/17 at 9:30 AM 10:00 AM, 11:00 AM

In response to questions submitted by the surveyor 7/19/17 at 3:30 PM the following response was received from EI # 5, Program Manager on 7/20/17 at 11:00 AM, " Patient didn't attend groups per therapist notes, due to not getting out of bed and seeking meds (medications) from nursing staff."





5. PI # 5 was admitted on [DATE] at 6:33 PM with diagnoses including Mood Disorder, Unspecified, and Mental Retardation, Severity Unknown.

The Behavioral Health Interdisciplinary Care Plan, initiated on 12/30/16 by Occupational Therapy included documentation of expected outcomes for group attendance with 2-3 weekly. On 1/2/17 Recreational Therapy established plan included expected outcomes of group attendance 2-3 week and on 1/3/17 the Art Therapy Care Plan included expected outcome 2-3 times a week group attendance.

In response to questions submitted by the surveyor on 7/19/17 at 3:30 PM, the following response was received from EI # 5, Program Manager on 7/20/17 at 11:10 AM, "The patient participated in clinical group and individual group".

Review of facility submitted documentation revealed one individual therapy session on 1/2/17 at 3:05 PM, and 2 clinical therapy sessions on 1/3/17 at 11:00 AM and at 4:30 PM. Both 1/3/17 individual sessions were in relation to the alleged sexual assault.

The patient did not attend group on 12/31/17, 1/1/17 and 1/4/17 and there was no documentation individual group therapy was attempted on the above dates.

6. PI # 8 was admitted on [DATE] with diagnoses including Altered Mental Status and Dementia With Behavioral Disturbance and Agitation.

The Behavioral Health Interdisciplinary Care Plan was initiated on 3/7/17 with Occupational Therapy expected outcomes to attend 4-5 sessions a week and Recreation Therapy 2-3 weekly therapy group attendance.

On 5/12/17 the Treatment Team Review/Update to the Plan of Care revealed the problem list review which included agitation and delusional (behaviors) and PI # 8 had minimal participation in groups. Assessment of the PI # 8's previous goals revealed medication noncompliance. The Patient's New Goals were "...pt (patient) prefers to not attend group and spend time alone..." There was no documentation how the facility planned to address PI # 8's medication noncompliance, agitation and delusions.

Review of the medical record revealed Individual Therapy was completed on 6/6/17. There was no documentation therapy was completed from 6/6/17 until 7/1/17.

During record review on 7/19/17 at 12:05 PM, an interview was conducted with EI # 5, Licensed Counselor, Program Manager. EI # 5 confirmed 1 individual therapy session was completed the week of 6/5/17. There was no therapy provided the weeks of 6/12/17, 6/19/17 and 6/26/17.

The last Treatment Team Review/Update to the Plan of Care was 5/12/17. There was no documentation reassessment of the patient's care needs, response to interventions and no revisions to the plan had been completed during June 2017. As of 7/19/17, there was no documentation a July Treatment team update was completed.

On 7/19/17 at 12:05 PM, record review and an interview with EI # 5 revealed that after 1 month, Updates to the Plan of Care are completed at a minimum of every 30 days by the Treatment Team. According to EI # 5, the June Treatment Team update was "missing" and no July update had been completed as of 7/19/17.

In response to written questions submitted by the surveyor on 7/19/17 at 3:30 PM, the surveyor reviewed written responses with EI # 5 on 7/20/17 at 11:10 AM. EI # 5 confirmed the facility failed to provide individual therapy as ordered. There was no documentation of a Treatment Team updates for June and July 2017.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

ased on review of medical records, policy and procedures and interview it was determined the facility staff failed:

1. To complete the Psychiatric Precaution Rounding Sheets as selected.
2. To document patient response to prn (as needed) medications.
3. To document legibly and accurately.
4. To document nursing assessment each shift.

This affected 6 of 10 records reviewed and did affect Patient Identifier (PI) # 5, # 7, # 1, # 3, # 9 and # 10. This had the potential to affect all patients served by this facility.

Findings include:

Policy and Procedure Directive
Subject: Medical Surgical Nursing Documentation- Routine Shift Assessment
Revised: 02/16

" II. Purpose: To provide guidelines for the documentation of nursing care provided patient response, and patient status in the medical surgical areas.
III. Policy:
B. Nursing Documentation:
Assessment:
1. An assessment at the beginning of the shift, at transfer to another unit by the transferring unit and receiving unit is required and throughout shift when changes are identified...
2. If the patient's condition changes, the nurse should reassess the patient and note the changes in... under shift assessment. The end of the shift assessment is to be documented in the nursing note..."

Policy and Procedure
Policy Name: Nursing Rounds
Revised: 03/25/15

Purpose: To ensure a safe and therapeutic environment.

Policy:
A. The Charge Nurse is responsible for assigning nursing staff to make patient rounds in order to account for all patients' whereabouts and ensure a safe environment.
B. Rounds are made a minimum of every fifteen (15) minutes...

Procedure:
A. The Charge Nurse designates the staff member(s) responsible for each set of rounds...
H. RN's (Registered Nurses) will round every two hours on their assigned patients.

1. PI # 5 was admitted on [DATE] at 6:33 PM with diagnoses including Mood Disorder, Unspecified, and Mental Retardation, Severity Unknown.

Review of the Psychiatric Precaution Round Sheet dated 12/30/16 revealed the RN/LPN (Licensed Practical Nurse) Must Initial Q (every) hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM.

Review of the Psychiatric Precaution Round Sheet dated 1/1/17 revealed the RN/LPN Must Initial Q hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 7:00 PM, 9:00 PM and 11:00 PM.

Record review revealed Medication Administration documentation dated 1/1/17 at 10:55 PM that PI # 5 required prn (as needed) injectable medications, Haldol 5 milligram (mg) IM (intramuscular) and Benadryl 50 mg IM for agitation. There was no record documentation that staff evaluated the effectiveness or therapeutic response to the prn medications.

Review of the Psychiatric Precaution Round Sheet dated 1/3/17 revealed the RN/LPN Must Initial Q hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM.

Review of the Psychiatric Precaution Round Sheet dated 1/5/17 revealed the RN/LPN Must Initial Q hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 3:00 AM, 5:00 AM, 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM and 6:00 PM.

Review of the Psychiatric Precaution Round Sheet dated 1/6/17 revealed the RN/LPN Must Initial Q hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 7:00 AM and 9:00 AM.

Nursing staff failed to complete and document hourly patient safety rounds as identified on the Psychiatric Precaution Round Sheet.

Written questions were submitted to the facility on [DATE] at 3:30 PM. The facility written responses were received and reviewed on 7/20/17 at 10:00 AM that confirmed the findings above.

2. PI # 7 was admitted on [DATE] at 5:16 PM with diagnoses including Schizoaffective Disorder, Bipolar Type and Depression.

Review of the Psychiatric Precaution Round Sheet dated 7/7/17 revealed the RN/LPN Must Initial Q hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 1:00 AM, 3:00 AM, 5:00 AM, 7:00 AM and 9:00 AM.

Review of the Psychiatric Precaution Round Sheet dated 7/8/17 revealed the RN/LPN Must Initial Q hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 6:00 AM, 12:00 PM, 2:00 PM, 5:00 PM, 7:00 PM and and 8:00 PM.

Review of the Psychiatric Precaution Round Sheet dated 7/12/17 revealed the RN/LPN Must Initial Q hour in order to account for all patients' whereabouts and ensure a safe environment. The nurse failed to document at 8:00 AM, 10:00 AM, 1:00 PM, 3:00 PM, 7:00 PM, 9:00 PM and 11:00 PM.

Written questions were submitted to the facility on [DATE] at 3:30 PM. The facility written responses were received and reviewed on 7/20/17 at 10:00 AM with documentation the hospital was to do every 2 hour rounds.

Nursing staff failed to complete and document hourly patient safety rounds as identified on the Psychiatric Precaution Round Sheet which is completed by nursing staff.






3. PI # 1 was admitted to the facility 6/11/17 with diagnoses of Suicidal Ideation, Major Depression, Polysubstance Abuse and Bipolar Disorder.

The Psychiatric Precaution Rounding Sheets (PPRS) dated 6/12/17 documented Type of Monitoring:
1. every 15 minutes
2. RN/LPN must initial Q hour.
The nurse failed to document 6/12/17 at 7:00 PM, 9:00 PM and 11:00 PM.

The PPRS dated 6/13/17 failed to document the two hour rounds at 8:00 AM and 12:00 noon.

The PPRS form dated 6/14/17 included instruction to have the RN/LPN initial Q hour.
The nurse failed to document 6/14/17 at 3:00 AM, 5:00 AM, 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 2:00 PM, 3:00 PM, 5:00 PM, 6:00 PM, 7:00 PM, 9:00 PM, and 11:00 PM.

The PPRS dated 6/19/17 failed to document the two hour rounds at 8:00 AM.

The PPRS form dated 6/21/17 included instruction to have the RN/LPN initial Q hour.
The nurse failed to document 6/21/17 at 1:00 AM, 3:00 AM, 5:00 AM, 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 2:00 PM, 3:00 PM and 5:00 PM.

The PPRS form dated 6/22/17 included instruction to have the RN/LPN initial Q hour.
The nurse failed to document 6/22/17 at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM.

The PPRS form dated 6/23/17 included instruction to have the RN/LPN initial Q hour.
The nurse failed to document 6/23/17 at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM.

The PPRS dated 7/3/17 failed to document the two hour rounds at 6:00 PM.

The PPRS dated 7/5/17 failed to document the two hour rounds at 6:00 AM.

In an interview 7/19/17 at 3:00 PM with Employee Identifier (EI) # 6, Vice President of Psychiatry, she confirmed the missing initials of the nurses. EI # 6 provided a Psychiatric Precaution Rounding Sheet form 7/20/17 that included documentation for the every two hour checks, stating that somehow the wrong forms had been printed and used on the units.

PI # 1 was placed in seclusion 6/28/17 at 6:30 AM. A review of the medical record and the Psychiatric Physician Progress note written 6/28/17. The progress note was illegible, no information was legible to understand the patient's mind set or condition prior to seclusion.

A review of the Restraint Order Sheet dated 6/28/17 at 6:30 AM failed to include the Indication for Restraint, other was marked with Seclusion written. The indication area included injury to self (describe), injury to others (describe), alternative measure failed. The nurse failed to document any indicators or alternative measures attempted. The form failed to include criteria for release.

An 1 hour assess seclusion/restraint form was completed by the nurse who placed the patient in seclusion at 6:30 AM, Employee Identifier (EI) # 7, RN, timed the form 6:30 AM, an hour had not passed since the seclusion was started.

The medical record for PI # 1, failed to have any documentation by the RN, EI # 7, for 6/27/17 through 6/28/17 shift. EI # 7 in an interview on 7/20/17 at 7:35 AM, stated that she would have caught her mistake if she had returned to work the evening of 6/28/17 to work. "I'd come back that night to work, I would've documented this."

The order for seclusion was signed by the physician on 6/29/17. The time the physician signed the order was not legible.

In an interview on 7/19/17 at 10:40 AM with EI # 3, Director of Nursing # 1, confirmed the progress note was not legible and the record information was not complete.

4. PI # 3 was admitted to the facility 4/20/17 with diagnoses of Autism Acute Psychosis.

The discharge for PI # 3 was dated incorrectly by the Psychiatrist. The Psychiatrist documented the date of discharge 4/29/17. The patient was actually discharged [DATE].

In an interview on 7/20/17 at 11:15 AM with EI # 3, the above information was confirmed.





5. PI # 9 was admitted on [DATE] with Schizoaffective Disorder Bipolar Type with Psychosis.

A review of the medical record psychiatric precaution rounding sheets dated 7/13/17 and 7/14/17 failed to include rounding on PI # 9 every two hours by the RN or LPN.

6. PI # 10 was admitted on [DATE] with a diagnosis of brief Psychotic Disorders.

A review of the medical record psychiatric precaution rounding sheets dated 7/10/17, 7/12/17, 7/13/17 and 7/17/17 failed to include rounding on PI # 10 every two hours by the RN or LPN.

In a response to written questions on 7/20/17 at 10:30 AM, EI # 6, Vice President of Psychiatry confirmed the above findings.