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.

WEST VALLEY MEDICAL CENTER 1717 ARLINGTON STREET CALDWELL, ID 83605 March 7, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, review of patient rights information, grievance information, restraint documentation, policy review, review of video, and staff interview, it was determined the facility failed to ensure patients' rights were protected and promoted, patients received care in a safe setting, and restraints were used safely, appropriately and only in accordance with a physician's order. Findings include:

1. Refer to A-0117 as it relates to the facility's failure to ensure patients were informed of their rights.

2. Refer to A-0123 as it relates to the facility's failure to ensure the written notice provided to patients or their legal representatives included the steps taken to investigate the grievance, results of the grievance process and the date of completion.

3. Refer to A-0132 as it relates to the facility's failure to ensure patients, or their representatives, were given an opportunity to formulate advance directives.

4. Refer to A-0143 as it relates to the facility's failure to ensure patients' privacy was safeguarded while under video and/or audio surveillance.

5. Refer to A-0144 as it relates to the facility's failure to ensure care was provided in a safe manner and setting. This resulted in the identification of immediate jeopardy on 3/06/17 at 4:30 PM. Lack of education and training of staff, lack of appropriate policies and implementation of policies, and lack of initial and ongoing assessment resulted in patients being placed at risk for serious harm, injury, or death.

6. Refer to A-0145 as it relates to the facility's failure to ensure psychiatric treatment and interventions for violence and aggression were appropriately provided by staff.

7. Refer to A-0154 as it relates to the facility's failure to ensure restraints and/or seclusion were only imposed to ensure the immediate physical safety of the patient or others and were discontinued at the earliest possible time.

8. Refer to A-0160 as it relates to the facility's failure to ensure a policy was developed which clearly identified the use of a drug or medication used as a chemical restraint, criteria for the use of a chemical restraint, and how patients who received a chemical restraint(s) should have been monitored.

9. Refer to A-0165 as it relates to the facility's failure to ensure the type of restraint used was the least restrictive intervention.

10. Refer to A-0168 as it relates to the facility's failure to ensure the use of restraints was in accordance with the order of a physician and facility policy.

11. Refer to A-0171 as it relates to the facility's failure to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours.

12. Refer to A-0172 as it relates to the facility's failure to ensure patients restrained and/or secluded for more than 24 hours consecutively were seen and assessed by a physician or LIP prior to renewal of orders for continued restraint.

13. Refer to A-0174 as it relates to the facility's failure to ensure restraints were discontinued at the earliest possible time.

14. Refer to A-0175 as it relates to the facility's failure to ensure patients in restraints were monitored based on the individual needs of the patient and in accordance with facility policy.

15. Refer to A-0178 as it relates to the facility's failure to ensure a face-to-face meeting by an appropriate staff member was conducted within 1 hour of the application of behavioral restraints.

16. Refer to A-0179 as it relates to the facility's failure to ensure face-to-face assessments were comprehensive and included all necessary information.

17. Refer to A-0182 as it relates to the facility's failure to ensure a psychiatrist, or LIP, was consulted after the face-to-face assessments were completed.

18. Refer to A-0183 as it relates to the facility's failure to ensure patients were continuously monitored when there was simultaneous use of restraint and seclusion.

19. Refer to A-0188 as it relates to the facility's failure to ensure documentation of patient's responses to physical restraint and the rationale for the continued use of restraint.

20. Refer to A-0194 as it relates to the facility's failure to ensure staff caring for patients restrained for violent behavior had education, training, and demonstrated competency to manage patients exhibiting out-of-control and/or aggressive behavior.

21. Refer to A-0196 as it relates to the facility's failure to ensure all staff required competencies for the application of restraints, implementation of seclusion, and in providing care for a patient in restraint or seclusion were up to date.

22. Refer to A-0199 as it relates to the facility's failure to ensure RNs, who worked with potentially violent patients, received required training in factors that could trigger the need for restraints.

23. Refer to A-0201 as it relates to the facility's failure to ensure all staff caring for patients in violent restraints received training in choosing the least restrictive interventions based on individualized assessment of the patient's condition.

24. Refer to A-0204 as it relates to the facility's failure to ensure all staff caring for restrained patients were trained in recognizing when restraints were no longer necessary.

25. Refer to A-0205 as it relates to the facility's failure to ensure BHU staff were trained in assessing a patients physical and emotional response to restraint and seclusion.

The cumulative effects of these negative systemic practices seriously impeded the ability of the facility to protect patient rights and provide services in a safe setting. This resulted in the identification of immediate jeopardy on 3/06/17 at 4:30 PM. Lack of education and training of staff, lack of appropriate policies and implementation of policies, and lack of initial and ongoing assessment, resulted in patients being placed at risk for serious harm, injury, or death.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, facility policy review, and medical record review, it was determined the facility failed to ensure patients or their representative were informed of their rights for 1 of 2 ER patients (Patient #9) whose records were reviewed. This had the potential to prevent patients from exercising their rights while receiving services from the hospital. Findings include:

A facility policy "Patient's Rights and Responsibilities (QUAL)," approved 3/02/15, was reviewed. The policy included:

"[Name of facility] provides each patient with a written statement of patient rights at the time of registration, and again at the time any patient or patient's representative has questions regarding their rights."

The facility failed to follow their policy and notify Patient #9 of his rights.

Patient #9 was a [AGE] year old male admitted on [DATE], at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE], at 1:30 AM to home and his own care.

Patient #9's record included an Emergency Provider Report. The report documented Patient #9 was seen initially in the ER on 1/15/17, at 6:39 PM. The report stated "Pt is a 58 y/o male who presents to ER via EMS status post being found by neighbor approximately hour ago. Pt's neighbor heard a dog barking for 30 minutes before he went outside where he found the pt laying on the ground. As per EMS, pt has been seen here for psych eval [evaluation] and alcoholism, self medicates with alcohol, and has chronic back pain. He frequently visits the firestation while intoxicated. Tonight pt answers some questions appropriately and others not so ..."

Patient #9's record included a copy of "Conditions of Admission and Consent for Outpatient Care." The form included a section related to acknowledgement of notice of patient rights and responsibilities. The form instructed Patient #9 to enter his initials, date, and time, which would indicate he was furnished with a copy of patient rights and responsibilities. Hand written on the form in Patient #9's record was "Pt medically unable to sign." Two unidentified individuals signed the form as witnesses, and entered the date and time, 1/15/17 at 7:41 PM.

The facility did not document attempts to contact a family member, friend, or guardian, who could speak on behalf of Patient #9. Patient #9's competency was later reassessed during his ER visit, and he was prepared for discharge.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She reviewed Patient #9's record and confirmed staff should have attempted to contact a family member, friend, or guardian. Additionally she confirmed staff should have discussed Patient #9's rights and responsibilities with him once he became coherent and before he was discharged from the ER.

The facility failed to follow their policy and provide Patient #9 a copy of his patient rights and responsibilities.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of medical records, facility policies, grievances, staff education transcripts, QAPI documents, Governing Board meeting minutes, and staff interview, it was determined the facility's Governing Board failed to ensure patients' rights were protected and promoted, patients received care in a safe setting, and restraints were used safely and appropriately. Additionally, the Governing Board failed to monitor and oversee the facility's QAPI program related to restraint/seclusion use in the facility. This resulted in deficient practices that placed the health and safety of Patient #6 in immediate jeopardy of serious harm, impairment, or death, and had the potential to impact all patients receiving services at the facility. Findings include:

1. Refer to A-0115 as it related to facility's failure to ensure patients' rights were protected and promoted, and patients received care in a safe setting.

2. Refer to A-0263 as it related to an ineffective Quality Assessment and Performance Improvement Program that ensured monitoring and evaluation of the use of restraints and seclusion.

The cumulative effects of these negative systemic practices seriously impeded the ability of the Governing Board to ensure the facility to protected patient rights and provided services in a safe setting.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, review of a patient video recording, and review of facility policies, and BHU documents, it was determined the facility failed to ensure the personal privacy of 1 of 2 BHU patients (Patient #6) who was video recorded and whose records were reviewed. This resulted in the violation of Patient #6's personal privacy and had the potential for interfering with the personal privacy of all facility patients being monitored and/or recorded by video and/or audio surveillance. Findings include:

The following facility policies, consent form and BHU documents, were reviewed during the survey and found to have been unclear and inconsistent, negatively impacting the facility's practices and preventing the facility from protecting the privacy rights of patients as follows:

1. A facility policy, "Patient's Rights and Responsibilities (QUAL)," approved 3/02/15, included an attached document, "Statement of Patient Rights and Responsibilities." It stated:

- "Considerate and Respectful Care...To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment.

- ...and the right not to remain undressed any longer than is required for accomplishing the medical purpose..."

2. A BHU document, " ...PATIENT AND FAMILY HANDBOOK," documented "Every [name of faciliy] patient has the right: ...To security, personal privacy and confidentiality of information ..."

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Surveyors reviewed a video recording of Patient #6 on 3/06/17, beginning at 9:50 AM. The video recording included the time when Patient #6 was in restraints and/or seclusion. Others in attendance included the facility's COO, the DQRM, and the Director of BHU.

Patient #6 was in restraints and without clothing for 5 hours before he was assisted with donning scrubs. The DQRM and the Director of BHU confirmed Patient #6 was not provided personal privacy during the time he was without clothing and in restraints.

Additionally they confirmed Patient #6 was not offered privacy during times of personal care and toileting.

The camera was never turned off during the 39 hours Patient #6 was in restraints and/or seclusion to allow for privacy.

The facility did not protect the privacy of Patient #6.

3. A facility policy, "Photographing, Video Recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM)," approved 7/29/16, was reviewed. It stated:

- "...Photographing Patients by Workforce Members,...for Security of Health Care Operations Purposes: The Conditions of Admission or Consent for Outpatient Care form (or the equivalent form in non-hospital settings) should advise patients that photographs and/or video monitoring may be taken for security or health care operations purposes (e.g., quality assurance)...

- Storage: Facilities must refer to the facility model Designated Record Set Policy to determine which photographs and/or audio recordings must be stored in the medical record. Facilities must designate a secure area(s) to store photographs and recordings that contain protected health information and will not be housed in the patient's record. Photographs and recordings must be clearly identified, securely stored and transmitted, and readily accessible for retrieval..."

The DQRM was interviewed on 4/03/17 at 10:45 AM. He confirmed the "Patient Rights and Responsibilities" policy and the policy related to "Photographing, Video recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM)," did not reflect the current facility practice. When asked the reason for video monitoring and/or video recording of patients, he stated patient monitoring occurred to ensure patient safety. However, he said video recordings of patients were reviewed and used to improve quality of patient care.

The Director of HIM was interviewed on 4/03/17, beginning at 1:45 PM. When asked if video recordings of patients were retained as a part of the permanent patient record, she confirmed video recordings were not retained and were not considered a part of the permanent record.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:05 AM. He stated video recordings of patients on BHU are made as a part of patients' plans of care.

The "Patient Rights and Responsibilities" policy and the policy related to "Photographing, Video recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM)" were inconsistent and unclear to staff. The policies did not reflect the facility's current practices.

4. A facility form, "Conditions of Admission and Consent for Outpatient Care," included "...Consent to Photographs, Videotapes and Audio recordings. I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the hospital's quality improvement and/or risk management activities. I understand that the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law ..."

The Director of Facility Operations was interviewed on 4/03/17, beginning at 3:30 PM. He stated the IT department now maintains the video monitoring system in the facility. He stated the system is now digital in nature, and information is stored on a corporate server for a maximum of 30 days, when a system override occurs. He stated if a copy of a video is required, his department is responsible for flagging the video, making copies, and if the recording is related to a patient, he discusses with the DQRM for direction. He stated "most of the time, recordings are used for investigation and quality of care." The Director of Facility Operations stated if copies are created on CDs, he keeps them in his locked desk drawer. He stated some CDs are several years old, and he does not really know what to do with them other than keep them locked in his desk. He was uncertain whether patient related video recordings were considered a part of the permanent patient record.

The Systems Administrator was interviewed on 4/04/17, beginning at 1:00 PM. He stated the video surveillance system that is currently in place is approximately 1.5 years old. He stated the staff on the units are unable to change camera views and cannot turn the cameras off/on. He stated if staff needs to disable a camera, they must contact the Systems Department, which has the ability to turn the cameras off and on. He stated the only cameras in the patient care areas that have the capacity to record are on BHU, rooms 306 and 312. He said all other cameras in the patient care areas have only monitoring capabilities. The Systems Administrator confirmed the video surveillance system retained information for 30 days, when the system begins to override, then 30 day old information is no longer available.

If BHU patients were assigned to room 306 or room 312, and the subject of video recording, the facility was unable to provide copies of the recordings if they were 30 days or older.

BHU patients assigned to room 306 or 312 were not afforded personal privacy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure the use of restraint was in accordance with the order of a physician and facility policy for 2 of 4 patients (#8 and #10) who were restrained and whose medical records were reviewed. This had the potential for restraint use without a physician order. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "...Order for Restraint or Seclusion ... If a telephone order is required, the RN must write down the order while the physician is on the phone and read-back the order to verify accuracy." It also stated "Physically holding a patient during a forced psychotropic medication procedure is considered a restraint ...The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint ...The use of force in order to medicate a patient, as with other restraint, must have a physician's order prior to the application of restraint (use of force)...A drug or medication when it is used as a resriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint."

The policy was not adhered to as follows:

1. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.
The following documentation was included in Patient #8's record:

- The Psychiatric Evaluation, dated 12/09/16, dictated by a physician at 11:06 AM, stated Patient #8 began to harm herself when she arrived on the unit. The evaluation included the patient was "...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation." The report included "...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room."

- On 12/09/16 at 9:15 AM, an RN documented she, the RN, was making rounds when she found Patient #8 "...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ... No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ..."

- A Clinical Documentation Record included an initial order for restraints, entered at 12/09/16 at 11:20 AM. The restraint device was described, "locking synthetic leather all."

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM, and released from restraints at 1:15 PM the same day.

The Director of BHU and the DQRM were interviewed together on 3/07/17, beginning at 2:00 PM. They reviewed Patient #8's record. When asked about the 11:20 AM restraint order for Patient #8, the Director of Quality stated the initial verbal order was received on 12/09/16 at 9:25 AM, but the order was not entered into the EMR until 11:20 AM on the same day. He confirmed the restraint orders were unclear and said it was a problem with the EMR for which the facility is currently seeking resolution.

Patient #8's record documented he was restrained from 9:25 AM to 11:20 AM without an order from a physician or LIP.





2. Patient #10 was a [AGE] year old female admitted on [DATE] at 12:54 PM for care related to a suicide attempt and depression. She was medicated and kept for 2 nights in the ER until her discharge home with her mother on 12/21/16.

The orders and record indicated Patient #10 was placed locked synthetic restraints at 6:32 PM. However, prior to this, Patient #10 received Haldol 5 mg and Ativan 2 mg given at 6:12 PM via IM injection.

Patient #10's assigned RN was interviewed on 3/06/17 at 12:04 PM. She stated prior to Patient #10 being placed in the synthetic locking restraints, she was asked to "grab medications and staff held Patient #10 down to medicate her." She stated security was called to assist in giving another medication. There was no order written prior to or just after the medications were given forcefully during a physical hold.

The Director of ER was interviewed on 4/03/17 at 11:25 AM. Patient #10's chart was reviewed electronically. She confirmed there was not a restraint order for a physical hold or chemical restraint for Patient #10.

The facility failed to ensure a restraint order was written for Patient #10's physical hold and forced medications.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on staff interview, facility policy review, and review of QAPI documents, it was determined the facility failed to ensure the QAPI program used restraint and seclusion data to identify opportunities for improvement. Additionally, the facility failed to identify high-risk, high-volume, or problem prone areas in order to focus its QAPI program. This prevented the facility from analyzing its processes in order to improve them. Findings include:

1. A facility policy, "Patient Safety Quality Assessment Performance Improvement Plan 2016," next review date 4/19/17, documented some of the QAPI goals for 2016 as follows:

- Behavioral Health - Fall Risk Reduction
- Cardiac/Cardiopulmonary Services - EKG Process
- Case Management - Transitions of Care
- Cath Lab/EP Lab - Radiation Dose/Notification Process
- Education - Meditech Education
- Employee Health - Lift Related Injury Reduction
- Emergency Department - Medication Labeling/Outdate Management
- Medical Staff - Committee/Board Reporting
- Quality - Board/Medical Staff Reporting Process

The DQRM, and the Director of BHU were interviewed together on 3/03/17, beginning at 8:00 AM. When asked how incidents of restraint and/or seclusion were tracked in the facility, the DQRM stated each incident of restraint and/or seclusion was recorded in a log book that was maintained by the facility's nursing supervisors. The DQRM stated he was uncertain how the restraint/seclusion data was tracked through the QAPI program and analyzed to improve patient care in the facility. The DQRM stated he was uncertain whether the data was included in the facility's quality program and presented to the Governing Board.

There was no QAPI documentation about how restraint and seclusion data was tracked, gathered and used to decrease the use of restraint and/or seclusion in the facility. The facility failed to use data to assess care of patients for whom restraint and/or seclusion was used. The lack of data prevented the facility from identifying opportunities for improvement.

The facility did not identify high-risk, high-volume, or problem-prone areas for evaluation.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on medical record review, review of serious reportable events, facility policy review, and staff interview, it was determined the facility failed to ensure adverse patient events were reported, analyzed, and actions were taken to prevent further incidents for patients on whom restraints were used. This affected the care of 2 of 4 patients (#6 and #9) who were in restraints and/or seclusion during their stay in the facility and whose records were reviewed. Additionally, this negative practice affected the safety of employees. The failure to report, analyze, and take actions to prevent future incidents interfered with the facility's ability to keep patients and employees safe. Findings include:

A facility policy, "Patient Safety Quality Assessment Performance Improvement Plan 2016," next review date, 4/19/17, was reviewed. It stated:

- "Patient and Employee Safety is focused on reducing harm, mitigating risk, and seeking to assure a safe environment...Our plan relates specifically to a systemic hospital-wide program to minimize physical injury, accidents and undue psychological stress of our employees and patients during hospitalization ...

- Leadership assumes a role in establishing a culture of safety that minimizes hazards for employee harm and patient harm by focusing on processes. The leaders of the organization are responsible for...emphasizing employee and patient safety as a priority, providing education to medical and hospital staff regarding the commitment to reduction of unsafe practices...

- The Objectives of Employees and Patient Safety are to...Collect and analyze data, evaluate care processes for opportunities to reduce risk and initiate actions

- The severity categories of medical errors/health care errors include: ...Mild to Moderate Adverse Outcome - any set of circumstances that do not achieve the desired outcomes and result in an mild to moderate physical or psychological adverse patient outcome...Hazardous Condition - any set of circumstances, exclusive of disease or condition for which the patient is being treated, which significantly increases the likelihood of a serious adverse outcome

- Components of the organization are integrated through a collaborative effort of multiple disciplines. This is accomplished by: ...Reporting patient safety and operational safety measurements/activity to the performance improvement oversight group, Quality Leadership Council...Reporting of employee safety and operational safety measurements/activity to the performance improvement oversight group; Environment of Care (EOC).

- The procedures for immediate response to employee and patient medical/heath care error are as follows: Staff should immediately report the event to the supervisor (either the Clinical Director or the House Supervisor, if the event occurs during off-hours)...Staff must complete an incident report in the software program for all patient related issues. Incident/Occurrence Report or other documents are needed to preserve information.

- Sources of Data...Incident reports...Employee injuries"

The policy was not adhered to as follows:

1. Facility adverse event reports from 12/03/16 to 4/04/17 were requested from the DQRM and reviewed. Some examples of adverse events were as follows:

- "12/6/2016 Extended stay in PACU d/t [due to] sedation level after 8 hour surgery.

- 12/9/2016 Pt called to complain that wounds from her MVC [motor vehicle collision] were not cleaned

- 12/14/2016 Pt required additional time in PACU [post anesthesia care unit] for anesthesia recovery after extensive cervical surgery. No cause for concern

- 1/5/2017 Blood cultures were not drawn at time of order.

- 1/6/2017 No hx of CT(computerized tomography/commonly known as "cat scan"). Pt very severe reaction to IV [intravenous] contrast. Taken back to ED where he was treated for anaphylaxis

- 2/21/2017 Child climbed on stool in ED with parents nearby and fell off of stool

- 2/28/2017 Pt discharged earlier than wanted by admitting orthopedist

- 3/1/2017 Hypotensive during recovery period

- 3/23/2017 Broken gurney in ED not taken our of commission before pt use.

- 3/28/2017 Pt eloped from ED with Sitter. Returned to ED in handcuffs"

Events related to restraint and/or seclusion, and employee injuries, were not included.

The DQRM and Director of BHU were interviewed on 3/03/17, beginning at 8:00 AM. The DQRM stated the facility did not track incidents of restraint and/or seclusion, or employee injuries, through the Serious Event Analysis (SEA) system. He agreed the events surrounding the seclusion and/or restraint of Patient #6, including the related employee injury and extended time Patient #6 was in restraints and/or seclusion, should have been considered a a reportable serious event appropriate for investigation.

2. Refer to A-0144 as it relates to the facility's failure to ensure care was provided in a safe manner and setting for 2 of 4 patients (#6 and #9) who were secluded and/or restrained, resulting in Patient #6 having been at risk for harm or death and the identification of an immediate jeopardy on 3/06/17 at 4:30 PM.

The facility failed to ensure adverse events were tracked, analyzed and actions were taken to prevent further incidents.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of facility policies and medical records, it was determined the facility failed to ensure patients in restraints were monitored based on the individual needs of the patient and in accordance with facility policy for 1 of 4 patients (Patient #9) who were restrained and whose records were reviewed. This failed practice negatively impacted the safety of Patient #9, and had the potential to compromise patient safety and interfere with quality of patient care for all patients requiring restraints in the facility. Findings include:

A facility policy, Patient Restraint/Seclusion, effective 6/03/14, included "...Monitoring the Patient in Restraints or Seclusion ... Monitoring is based on the individual needs of the patient. Variables of the patient's condition, cognitive status, risks associated with the chosen intervention may require more frequent evaluations."

The facility failed to adhere to the policy as follows:

Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE] at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's emergency room record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physical aggression and combative. The restraint device was described, "locking synthetic leather all." There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release. There was no documentation of uninterrupted 1:1 monitoring.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She reviewed Patient #9's record and confirmed he was not assigned a sitter or 1:1. She stated sitters are routinely requested when a patient is in restraints, but often no one is available. If a sitter is unavailable, she stated patients are moved to 1 of 2 rooms closest to the nurses' station, where staff can more easily observe them.

The facility failed to ensure a restrained patient in the ER was monitored based on his individual needs and in accordance with facility policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure a face-to-face meeting by a competent staff member was conducted within 1 hour of the application of behavioral restraints for 1 of 4 patients (Patient #6) who were restrained to manage violent or self-destructive behavior and whose records were reviewed. This failure prevented the facility from evaluating the causes and appropriateness of the need for restraint. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior..." This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6 was placed in 4 point restraints, all extremities, twice from 2/27/17 until his discharge on 2/28/17. The face-to-face assessment was not completed within 1 hour of placing Patient #6 into restraints and seclusion for both occurrences.

Patient #6's record included a "Restraints Monitor" note, on 2/27/17 at 1:02 AM, which documented restraints were applied at 12:30 AM for physical aggression and he was a danger to himself and others. The note documented the type of restraints used were seclusion and locking synthetic leather restraints.

A nurse's note, dated 2/28/17 at 3:31 AM, signed by RN F documented the face-to-face assessment was completed 3 hours after he was placed into restraints and seclusion.

During an interview at 9:35 AM on 4/04/17, RN A confirmed there was no documentation of a face-to-face assessment within 1 hour of the application of restraints and seclusion.

Patient #6 did not have a face-to-face assessment completed within 1 hour of the application of restraints and seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff education transcript review, policy review, and staff interview, it was determined the facility failed to ensure all staff caring for patients restrained for violent behavior had education, training, and demonstrated competency to manage patients exhibiting out-of-control, aggressive behavior or in restraints. This failure placed all patients experiencing behavioral and psychiatric challenges at risk of physical and/or mental harm. Findings include:

The American Psychiatric Nurses Association website was accessed on 3/08/17. Under their "Seclusion and Restraint Standards of Care," revised April 2014, stated the following regarding staff education:

- "Any staff providing care to persons at risk for harming themselves or others and who participate in seclusion and restraint shall have received training and demonstrate current competency in all aspects of dealing with behavioral emergencies.

- Be approved by the organization assuring that program components include adequate attention to the clinical contributors to behavioral emergencies, the actual management of those emergencies, and the assessments and interventions necessary to maintain physical well-being.

- Be provided during a staff member's orientation period and at least annually thereafter."

The facility policy "Patient Restraint/Seclusion," dated 6/03/14, contained "Appendix A: Training Requirements." Appendix A stated direct care staff, security personnel and non-healthcare staff, as defined and listed by the facility, "will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion...Training will occur:

1. Before performing restraint application, implementation of seclusion, monitoring and assessment and providing care for a patient in restraint and seclusion,

2. As part of orientation, and

3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients."

Additionally, it stated the training for RNs who conducted one-hour face-to-face evaluations should include "Monitoring, assessment and providing care for a patient in restraint or seclusion, including:

The patient's immediate situation

The patient's reaction to the situation

The patients' medical and behavioral condition

The need to continue or terminate the restraint or seclusion."

1. Employee education records documenting restraint training were requested and received 3/07/17. Twenty-eight of the facility's behavioral health employee "Student and Group Transcript Reports" were reviewed. Several BHU training files contained no documentation of restraint training in the last 12 months. Additionally, there was no evidence of competency assessments in managing behavioral emergencies and restraint use in the last 12 months. There was no documentation of evidence of RN training for the one-hour face-to-face evaluation of the restrained or secluded patient.

The Director of BHU was interviewed at starting at 2:00 PM, on 3/07/17. She stated the Non-Violent Crisis Intervention class and the restraint module in Healthstream (the facility's online training program) were to be completed annually by staff involved in restraint and seclusion.

The Director of BHU was interviewed again on 4/03/17, starting at 2:15 PM. She stated the Healthstream modules were an adjunct to the staff restraint training, which they had in a skills fair format prior to 2016. She stated starting in 2016, some of the staff were assigned a module on restraint documentation by the Clinical Educator, rather than the standard restraint module. Additionally, she stated in 2016, the facility had incorporated restraint training into the NVIT. She stated the NVIT course allowed for facilities to put in training according to their own restraint policies. She stated during this part of the course, staff was required to do a return demonstration of restraint use. The Director of BHU stated it was a BHU requirement for the staff to complete the course by the end of June, or they would be suspended. She stated she attested to the fact that all of her employees took the class in 2016.

The BHU failed to provide evidence of training for all staff performing restraint and seclusion.

2. The American Psychiatric Nurses Association "Seclusion and Restraint Standards of Care" stated "Differentiate chemical restraint from medication that may support and assist the person to successfully manage circumstances..."

The facility's policy "Patient Restraint/Seclusion" defined a chemical restraint as "A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint."

Patient #10 was a [AGE] year old female admitted on [DATE] at 12:54 PM for care related to a suicide attempt and depression. She was medicated in the ER, kept for 2 nights in the ER until her discharge home on 12/21/16.

The Director of the ER was interviewed at 2:25 PM, on 3/7/17. She was asked if the staff was trained in chemical restraint use. She stated "Employees are taught that we do not use chemical restraints." However, she confirmed they were using chemical restraints in the emergency room .

The facility failed to ensure staff were trained regarding chemical restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on review of facility policies, staff education transcript review, and staff interview, it was determined the facility failed to ensure all staff were kept up to date in required competencies for the application of restraints, implementation of seclusion, and in providing care for a patient in restraint or seclusion. This resulted in an unsafe environment for all patients. Findings include:

The facility policy "Patient Restraint/Seclusion," approved 4/22/16, included an "APPENDIX A: TRAINING REQUIREMENTS." It stated training will occur:

1. " Before performing restraint application, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion,

2. As part of orientation, and

3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients.

4. The results of skills and knowledge assessment, new equipment, or QAPI data may indicate a need for targeted training or more frequent or revised training."

The Director of BHU was interviewed on 4/03/17, starting at 2:15 PM. She stated restraint education was required annually. In 2016, some of the staff were assigned a module on restraint documentation by the Clinical Educator, rather than the standard restraint module. Additionally, she stated in 2016 the facility had incorporated restraint training into the NVIC. She stated the NVIC course allowed for facilities to put in training according to their own restraint policies. She stated during this part of the course, staff was required to do a return demonstration of restraint use. The Director of BHU stated it was a requirement of the unit for the staff completed the course by the end of June, or they would be suspended. She stated she attested to the fact that all of her employees took the class in 2016.

Documentation of BHU staff demonstrated competencies for 2016 was requested on 4/03/17 during the interview. The Director of BHU was unable to produce documentation for all employees. She stated the education department received the paperwork and placed them in the staff education transcripts, and was unsure what had happened to some of them. She was unable to produce documentation of demonstrated competency for the following staff for the 2016: RN B, RN E, RN G, RN I, RN K, RN L, RN M, RN N, RN Q, BHT A, BHT B, BHT K, BHT L, BHT M, BHT N, BHT O, MSW B, and MSW C.

The facility failed provide evidence all staff was trained in restraint use at adequate intervals.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0199
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on video review, record review, staff interview, it was determined the facility failed to ensure RNs, who worked with potentially violent patients, received required training in factors that could trigger the need for restraints. This directly effected 1 of 3 patients (Patient #6) who were restrained for violent behavior and had the potential to result in injury to other patients and staff dealing with application of restraints. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

It was documented in Patient #6's record he attacked an employee on 7/27/10 at 12:00 AM, and was placed in seclusion and restraints after the attack. He was removed from restraints at 1:30 PM, but remained in seclusion. On the staffing assignments sheet it was documented RN K was the nurse caring for Patient #6 during the shift starting at 7:00 PM, on 7/27/16.

On 3/06/17 segments of the video of Patient #6 taped on 2/27/2 17 and 2/28/17 were viewed by surveyors with the Director of BHU, The DQRM, and the Facility COO. Patient #6 was seen going to the door and talking to someone through the window at 10:18 PM. It was documented in his record Patient #6 had requested a bedpan at that time. He waited, until 10:28 PM, and went to the door again.

Patient #6 then became increasingly agitated, and proceeded to defecate in his scrub pants. The feces fell out of his scrub pants on to the floor. He appeared to be agitated and shook his arms in frustration. Patient #6 removed his scrub pants and proceeded to smear feces around the room with his feet using the scrub pants at 10:41 PM. At 10:45 PM he is at the door talking to staff, gesturing to the feces with his right palm up. He then sat on the bed, and feces was left on the uncovered mattress.

At the 10:48 PM marking on the recording, RN K was identified at the door by the Director of BHU. She stated RN M was at the monitor during that time. She stated they were watching Patient #6 as he smeared his feces against the wall with his buttocks.

At 10:51 it appeared Patient #6 was told to sit in the corner, which he did. Staff placed a bedpan, saniwipes, a white towel, clean scrubs, a medicine cup, and a styrofoam cup full of water on the feces contaminated bed. Patient #6 proceeded to attempt to clean himself, using wipes soiled with feces to wipe his arms, chest and legs. He took some time to place what was in the medicine cup in his mouth. At 10:56, Patient #6 continued to attempt to clean the floor with feces covered wipes.

During Patient #6's attempts at cleaning, RN K was watching through the window. Patient #6 continued to clean himself and the room, spending time on his hands and knees to wipe the floor. He had new scrub pants on by 11:10 PM. At 11:15 PM, he wiped his head with a contaminated saniwipe.

At 11:24, staff comes in and sprays air freshener. At 11:28 PM, staff places some popcorn contained in a coffee filter and some granola bars on the contaminated bed. Patient #6 ate some food despite not being properly cleaned or washing his hands.

At 2:19 AM Patient #6 is seen talking at the door, and then starts kicking hard at the door at 2:20 AM. The door appeared to loosen, and the DQRM stated the door lock was broken from Patient #6's kicking.

It was unclear how the staff during this shift were identifying and reducing behaviors that could trigger agitation and aggression in Patient #6. He was placed back in 4 point hard restraints facedown on the contaminated bed at 2:38 AM.

The security guard that was the sitter for Patient #6 was interviewed on 3/02/17 at 2:40 PM. He stated Patient #6 requested to go to the bathroom, and he let "the nurse" know right away. He stated it was a "long time before the nurse came."

RN K was interviewed at 12:40 PM, on 3/06/17. He stated he had previously offered Patient #6 the bedpan and he had declined. RN K stated he was assessing another patient when Patient #6 requested the bedpan and finished with the other patient first, before returning to Patient #6. RN K's orientation was discussed. He stated he had not yet received restraint training or attended the Non-Violent Intervention Class.

The Director of BHU was interviewed on 3/06/17, at 3:05 PM. She stated RN K had worked 5 nights of orientation and was being precepted by the charge nurse, RN M, when RN K cared for Patient #6 in seclusion. She confirmed RN K had not received NVIT or restraint training.

The facility failed to ensure staff caring for patients were educated in techniques for identifying situations that could trigger circumstances requiring restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0201
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff education transcripts, record review, staff interview, and review of facility policy, the facility failed to ensure all BHU staff caring for patients in violent restraints received training in choosing the least restrictive interventions based on individualized assessment of the patient's condition. This resulted in the lack of assessments for choosing the least restrictive restraint for 2 of 2 patients (#6 and #8) and the potential to result in the lack of assessment for other patients upon which to base restraint decisions. Findings include:

The facility's policy "Patient restraint/Seclusion" stated "Staff will be trained on choosing the least restrictive intervention based on the individualized assessment of the patient's medical or behavioral status or condition. Safe patient care requires looking at the patient as an individual and assessing the patients's condition, needs, strengths, weaknesses, and preferences, and tailoring interventions to individual patient's needs after weighing factors such as the patient's condition, behaviors, history and environmental factors."

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a "Restraint/Seclusion Observation Form." The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document "Y" or "N," for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and from 2:35 AM on 2/28/17 to 4:15 PM on 2/28/17.
Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a MAR. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine 100 mg IM, another medication used for psychosis and sedation.

The observation form documented the following:

- 1:45 AM, sleeping

- 2:00 AM, sleeping

- 2:15 AM, sleeping

- 2:30 AM, resting with eyes closed

- 2:45 AM, awake

Between 3:00 AM and 7:00 AM, Patient #6 was documented as "calling out" 2 times and "pulling" and "messing" with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he was threatening or inappropriate.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what the conversation entailed.

Patient #6 remained in 4 point restraints and seclusion until 2/27/17 at 1:30 PM, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was then medicated with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg.

A nurse's note, on 2/28/17 at 11:00 AM , signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the BHU Director. Patient #6 requested to use the bathroom and RN A documented "I was told per the above named supervisors [CNO and BHU Director] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by."

The observation form documented from 3:00 AM to 1:00 PM, Patient #6 was sleeping and cooperative. There was no documentation he was aggressive, threatening, or a risk for harming himself or others.

2. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- On 12/08/16 at 1:57 PM, an RN assessment was documented in Patient #8's record. It included the question "What are some things that make you angry ..." Patient #8's response was documented "Being isolated, Being restrained ..." The question "Have you ever been restrained ..." was also asked, to which Patient #8 responded "No."

- The Psychiatric Evaluation dated 12/09/16, completed by a physician, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included Patient #8 was " ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation." The report included "...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room." The evaluation did not document Patient #8 was violent or aggressive.

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she, the RN, was making rounds when she found Patient #8 " ...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ...No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self-harm or release tension. After assessment the patient said that she wanted another "shot". I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ..." Patient #8's behavior was not described as aggressive or violent toward others.

- The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described, "locking synthetic leather all." The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM. At 11:45 AM, the observation form included "Pt stated she's calm and wants out." At 12:00 PM, documentation included "Pt laying quietly." At 12:15 PM, it was documented "Pt stating she want restraints off." At 1:15 PM, it was documented Patient #8 was released from restraints on 12/09/16. Patient #8 remained in 4-point, locking restraints. Although Patient #8 was held in 4 point, locking restraints, an RN documented the least restrictive restraint application was used.

Patient #8's behavior did not justify the use of 4 point, locking restraints.

The Director of BHU was interviewed on 3/07/17, at 4:20 PM. She stated she was unable to find documentation in Patient #8's record supporting the use of 4 point restraints, as opposed to bilateral wrist restraints only.

Documentation of restraint training content was requested during the interview. She stated there was no other training agenda besides the "Restraint Application Competency " form to show evidence of class content. Twenty "Restraint Application Competency" forms were presented. The form had 4 columns. The title of the second column was "Points of Measure," which named the skill being demonstrated for competency. The column did not contain any skill related to using the least restrictive restraint.

The facility failed to ensure staff were trained in assessing patients for the least restrictive restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0204
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, staff interview and policy review, the facility failed to ensure all staff caring for restrained patients were trained in recognizing when restraints were no longer necessary. This impacted 3 of 4 patients (#6, #8, and #9) that were restrained and whose records were reviewed, and had the potential to result in the continuation of patient restraints without justification on other restrained patients in the facility. Findings include:

The facility policy "Restraint and Seclusion," approved 4/22/16, stated "The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period..." additionally, it stated:

"Staff will be trained and able to demonstrate competency in identification of specific behavioral changes that may indicate that restraint or seclusion is no longer necessary and can safely be discontinued."

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

The observation form documented Patient #6 was cooperative for significant periods of time. On 2/27/17 from 5:15 AM to 7:00 AM, the form documented he was cooperative. During that time the only restraint released was on Patient #6's left leg. The observation form included documentation Patient #6 was cooperative from 2/27/17 at 4:00 PM to 2/28/17 at 2:15 AM. There was no documentation staff attempted to discontinue seclusion during that time.

According to the record, Patient # 6 was cared for by RN K on 3/27 night shift. RN K was interviewed at 12:40 PM, on 3/06/17. His orientation was discussed. He stated he had not yet received restraint training or attended the Non-Violent Intervention Class.

RN A, who acted as a charge nurse on the BHU, was interviewed on 4/04/17 at 9:15 AM. He stated it appeared from the documentation the patient was not given the opportunity to be kept in the least restrictive restraint.

2. Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharge on 1/16/17 at 1:30 AM to home and his own care.

An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, was reviewed. The provider report included "...2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints." The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

3. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

A "Restraint/Seclusion Observation Form" documented Patient #8 was placed in restraints on 12/09/17, beginning at 9:30 AM, and released from restraints at 1:15 PM the same day. At 11:45 AM, the observation form included "Pt stated she's calm and wants out." At 12:00 PM, documentation included "Pt laying quietly." At 12:15 PM, it was documented "Pt stating she want restraints off."

Patient #8 was not released from restraints at the earliest possible time.

The Director of BHU was interviewed on 3/07/17, at 4:20 PM. Documentation of BHU staff demonstrated competencies for 2016 was requested on 4/03/17 during the interview. Twenty "Restraint Application Competency" forms were presented. The form had 4 columns. The title of the second column was "Points of Measure," which named the skill being demonstrated for competency. The column did not contain any skill related to recognizing behaviors indicating a patient might be safe to release from seclusion or restraint.

The facility failed to ensure employees were trained in recognizing behaviors indicating when a patient could be safely removed from restraint or seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
Based on review of facility policy review, and staff interview, it was determined the facility failed to develop a policy that clearly identified the use of a drug or medication used as a chemical restraint, criteria for the use of a chemical restraint, and how patients who received a chemical restraint(s) should have been monitored. The lack of a fully developed policy, that included clear guidance, prevented staff from recognizing the use of chemical restraints and impeded adequate patient monitoring of those patients who received medication(s) as a chemical restraint. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated:

- "APPENDIX D: DEFINITIONS ...Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint. When medications are used as restraints, it is important to note that the decision as to whether they constitute restraint is not specific to the treatment setting, but to the situation the restraint is being used to address. A medication that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint.

- ...standard use of a psychotherapeutic medication to treat the patient's condition enables the patient to more effectively or appropriately function in the world around him/her than would be possible without the use of the medication. Psychotherapeutic medications are to enable, not disable."

The policy did not include criteria to identify and determine the need for a chemical restraint, or staff guidance related to monitoring patients who received a chemical restraint. A separate policy that specifically addressed chemical restraints was requested, but was not provided.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. The practice of using chemical restraints in the facility was discussed. She stated "We talk about that we do not use chemical restraints. The order has to reflect the reason for the medication." She however agreed chemical restraints were being used in the facility.

The policy did not include criteria to identify and determine the need for chemical restraint or staff guidance related to monitoring patients who received a chemical restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0205
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, it was determined the facility failed to ensure BHU staff was trained in assessing a patients' physical and emotional response to restraint and seclusion. This directly impacted the care of 1 of 2 patients (Patient #6) who were placed in restraints in the BHU and whose records were reviewed, and had the potential to impact other BHU patients placed in restraints. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

Patient #6's record included a Restraint/Seclusion Observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM Patient #6 was sleeping. There was no documentation of Patient #6's response to the restraints, seclusion, and medications. According to the 2/27/17 the staff assignment sheet, RN K was caring for Patient #6.

The Director of the BHU was interviewed on 3/06/17, at 3:05 PM. RN K had worked 5 nights of orientation and was being precepted by the charge nurse, RN M, when RN K cared for Patient #6 in seclusion. She confirmed RN K had not received his NVIC or restraint training.

The facility failed to ensure RN K was appropriately trained to monitor Patient #6 while in seclusion/restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0183
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, facility policy review, review of video recording, and staff interview, it was determined the facility failed to ensure patients were continuously monitored when there was simultaneous use of restraint and seclusion for 1 of 1 patients (Patient #6) who was simultaneously restrained and secluded and whose record was reviewed. This had the potential for patients to experience serious harm and/or injury. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "A patient in restraint and seclusion simultaneously requires a higher level of monitoring." The policy further stated "Continuous, uninterrupted monitoring, face-to-face by a specifically assigned staff member with demonstrated competence in close proximity to the patient for at least the first hour." After the first hour, the policy stated continuous uninterrupted monitoring by a specifically assigned staff member must be done in close proximity to the patient to allow emergency intervention if a problem arises. This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a Restraint/Seclusion Observation form which documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form.

The observation form included documentation by staff in 15 minute increments. The observation form did not include documentation he was continuously monitored while in simultaneous seclusion and restraints. Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and 4 point restraints.

During the time Patient #6 was in restraints and seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and Quality staff.

While observing the video recording it was noted there was no audio recorded. Staff was observed intermittently watching Patient #6 through the window of the seclusion room door.

During an interview at 4:00 PM on 3/07/17, the Director of the BHU confirmed the record did not include documentation Patient #6 was continuously monitored. She also confirmed that during observation of the video recording staff was visible at times behind the seclusion room door, however they were not continuously watching Patient #6.

Patient #6 was not continuously monitored while simultaneously in restraints and seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and staff interview, it was determined the facility failed to ensure 1 of 4 restrained patients' medical records (Patient #6) included documentation of his response to physical restraint and the rationale for the continued use of restraint. This resulted in the inability of the facility to evaluate the efficacy of restraint use. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included an observation form, dated 2/27/17. The observation form documented between 1:45 AM and 2:45 AM Patient #6 was sleeping or resting after the initiation of the restraints and seclusion. There was no documentation of Patient #6's response to the restraints and seclusion.

On 2/27/17, between 3:00 AM and 7:00 AM, Patient #6 was documented as "calling out" 2 times and "pulling" and "messing" with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he reacted adversely with them.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what criteria Patient #6 met to keep him in restraints and seclusion.

Patient #6 remained in 4 point restraints and seclusion until 1:30 PM on 2/27/17. There was no further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

Patient #6's record included a Restraint/Seclusion Observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM and 8:45 AM to 10:00 AM Patient #6 was sleeping. There was no documentation of Patient #6's response to the restraints, seclusion, and medications.

A nurse's note, at 11:00 AM on 2/28/17, signed by RN A documented the plan was for Patient #6 to remain in restraints until he was discharged per the CNO and the Director of BHU.

Physician B, who discharged Patient #6, was interviewed by phone on 4/04/17 at 12:40 PM. When asked if he was aware of the decision to keep Patient #6 in restraints until he was discharged to jail, he stated he remembered having a conversation with the Medical Director of BHU and Physician C. He stated to keep the other patients and staff safe, the decision was made to keep Patient #6 in the isolation room until he was discharged to jail. He stated he was not aware of the "restraint part."

RN A, who was a Charge Nurse on BHU, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17 during the day shift. RN A stated he was approached by the Director of BHU on 2/28/17, when Patient #6 was in 4 point restraints for the second time. RN A stated the Director of BHU informed him a decision had been made to keep Patient #6 in restraints until he was discharged .

The facility failed to document an assessment of Patient #6's reaction to the use of restraints, seclusion, and medications. Additionally, the facility failed to document a rationale for the continued use of restraints and seclusion.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, video review, and staff interview, it was determined the facility failed to ensure the RN evaluated and appropriately provided the nursing care for 1 of 4 patients (Patient #6) who was in restraints and/or seclusion and whose records were reviewed. This resulted in directly impacting the nursing care received by Patient #6 and compromised his dignity, safety, and treatment. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

A facility policy "Patient Restraint/Seclusion," dated 4/22/16, stated monitoring of patients in restraints or seclusion included assessment by an RN immediately after they are initiated. The policy further stated an RN will assess the patient at least every 2 hours and the assessment will include the following when appropriate:

- Signs of injury associated with restraint, including circulation of extremities

- Respiratory and cardiac status

- Psychological status

- Needs for range of motion

- Hydration/nutritional needs are being met

- Hygiene, toileting/elimination needs are being met

- The patient's rights, dignity, and safety are maintained

The policy also stated patients in simultaneous restraints and seclusion must be continuously monitored by competent staff. This policy was not followed.

During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and Quality staff.

While observing the video recording it was noted Patient #6 was restrained in a prone position for 12 hours. Additionally, his scrubs were removed at the initiation of the restraints and were not replaced for almost 5 hours. Patient #6 was only covered with a blanket.

On 2/27/17, beginning at 10:38 PM, Patient #6 was no longer restrained but remained in seclusion. He was observed shaking feces from the left leg of his scrubs, while talking with a staff member through the locked door. Patient #6 was observed removing his scrub pants, dragging them on the floor, then picking the pants up with his hands and dropping them in a corner of the seclusion room.

Patient #6 became increasingly agitated, pacing around the restraint bed, while dragging his soiled scrub pants on the floor. He appeared to have feces on his buttocks, hands, legs and feet. Patient #6 was observed shaking his fists while speaking with a staff member through the seclusion room door. He then dragged his buttocks along one of the seclusion room walls, smearing feces. Staff entered the seclusion room and provided Patient #6 with a bed pan, disposable wipes, a towel, a small white medicine cup and a cup of water. The staff member then left the room.

Patient #6 began to clean between his buttocks with one of the wipes, and attempted to clean other parts of his body with the same, soiled wipe. He was observed repeating this process with another 1-2 wipes, cleaning himself with the wipes that were clearly soiled with feces. Patient #6 was also observed putting the small white medication cup to his mouth, followed by a drink of water. Next he began to clean the bed, floor, and walls with the towel that was provided, and used the same, contaminated towel on his body.

Throughout the time of these events, staff was observed intermittently watching Patient #6 through the window in the seclusion room door. Staff was not observed offering hand sanitizer or assisting Patient #6 with cleaning himself. Staff was not observed cleaning the floors, walls, or bed during this time. At approximately 11:27 PM, staff brought some popcorn, 2 granola bars and a cup of water to Patient #6. He began to eat the food with his hands that were still contaminated with feces.

Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and 4 point restraints. Additionally, the restraint monitoring which was documented was inconsistent and incomplete. Documentation did not clearly include consistent assessment of respiratory and cardiac status during the time Patient #6 was in restraints and in a prone position. Examples include:

1. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6 was not monitored or assessed by the RN, as required according to the facility policy, while he was in seclusion and/or restraints. Additionally, the RN did not ensure all of Patient #6's needs were being met while in restraints and/or seclusion.

- A "Restraints Monitor" note, dated 2/27/17 at 12:47 AM, did not include documentation of his respiratory or cardiac status, hygiene or toileting needs, or range of motion needs. Additionally, there was no documentation Patient #6's dignity and safety was maintained during initial application of the restraints and seclusion.

- A "Restraints Monitor" note, dated 2/27/17 at 1:06 AM, did not include documentation of Patient #6's respiratory or cardiac status, hygiene or toileting needs, or if he was offered food or water.

- A "Restraints Monitor" note, dated 2/27/17 at 2:55 AM, did not include documentation of Patient #6's respiratory or cardiac status, hygiene or toileting needs, or range of motion needs. Additionally, there was no documentation his dignity and safety was maintained.

- A "Restraints Monitor" note, dated 2/27/17 at 4:17 AM, did not include documentation of Patient#6's respiratory or cardiac status, hygiene or toileting needs, or range of motion needs. The note stated his "Safety/Rights/Dignity maintained verified: Done now," however, the note did not state how that was accomplished.

During an interview at 4:20 PM on 3/02/17, RN A stated every 2 hours the RN responsible for the direct care of the patient was required to perform an assessment. He confirmed the documentation of assessments was not comprehensive.

The RN failed to comprehensively assess Patient #6 and his needs while in restraints/seclusion.

2. Patient #6 was in restraints/seclusion for 39 hours until he was discharged from the facility. During that time his vital signs were documented twice in his record.

Patient #6's vital signs were documented at 4:40 AM on 2/27/17. His oxygen saturation was documented at 86%. At 4:44 AM, the RN documented his oxygen saturation was rechecked with a hand monitor and it was 98%. The RN documented Patient #6's "CMS (Circulation, Movement, and Sensation) remain good." There was no documentation of the RN performed a cardiopulmonary or respiratory assessment.

Vital signs were next documented in Patient #6's record at 6:33 AM on 2/28/17.

During an interview at 4:20 PM on 3/02/17, RN A confirmed Patient #6's vital signs were only documented twice in his record after application of restraints.

During an interview at 12:40 PM on 3/06/17, RN K stated he checked Patient #6's vital signs once during his 12 hour night shift.

Patient #6's vital signs were not checked frequently according to his status and needs.

3. Patient #6's record included a "Restraint/Seclusion Observation Form." The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document "Y" or "N," for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

The observation form included documentation by staff in 15 minute increments. The observation form did not include documentation Patient #6 was continuously monitored while in simultaneous seclusion and restraints.

During an interview at 4:20 PM on 3/02/17, RN A stated every 2 hours the RN responsible for the direct care of the patient was required to perform an assessment. He confirmed the documentation of assessments was not comprehensive. RN A confirmed Patient #6's vital signs were only documented once in his record after application of restraints.

The RN failed to comprehensively assess Patient #6 and his needs while in restraints/seclusion.

During an interview on 3/06/17 at 3:00 PM, the Director of BHU stated monitoring of Patient #6 was documented every 15 minutes. She confirmed the documentation did not include continuous monitoring of Patient #6 while he was in seclusion and restrained. She confirmed the video showed staff intermittently looking through the window in the door of the seclusion room. The Director of BHU confirmed Patient #6's restraints were not routinely released to allow for range of motion.

The facility failed to ensure Patient #6 was appropriately monitored, assessed, and his needs were met while in restraint/seclusion.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility policy, and staff interview, it was determined the facility failed to ensure patients, or their representatives, were given an opportunity to formulate advance directives for 1 of 2 ER patients (Patient #9) whose records were reviewed. This had the potential to result in patients' wishes not being addressed. Findings include:

A facility policy "Advance Directives," approved 2/27/15, included "PURPOSE: To protect and assure the patient's right to complete and/or execute advance directives and make known their desires regarding healthcare choices ...POLICY: [Name of facility] will offer the adult patient (inpatient and outpatient [AGE] years or older)/legal guardian /family/primary caregiver information concerning advance directives. Upon admission to the facility, the existence, change, or revocation of the patient's advance directives is determined, documented and communicated to all appropriate staff." This policy was not adhered to as follows:

Patient #9 was a [AGE] year old male admitted on [DATE], at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE], at 1:30 AM to home and his own care.

Patient #9's record included an "Emergency Provider Report." The report documented Patient #9 was seen initially in the ER on 1/15/17, at 6:39 PM. The report stated "Pt is a 58 y/o male who presents to ER via EMS status post being found by neighbor approximately hour ago. Pt's neighbor heard a dog barking for 30 minutes before he went outside where he found the pt laying on the ground. As per EMS, pt has been seen here for psych eval and alcoholism, self medicates with alcohol, and has chronic back pain. He frequently visits the firestation while intoxicated. Tonight pt answers some questions appropriately and others not so ..."

Patient #9's record included a "Conditions of Admission and Consent for Outpatient Care." The form included a section related to advance directives. Contained within this section were instructions to initial the box beside the description that best described the patient's advance directive status. The choices allowed patients to use an existing advance directive and provide the facility with a copy of the information, to receive information and execute an advance directive while a patient in the facility, and to refuse information and refuse to execute an advance directive. The boxes beside all options were blank.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed staff should have followed up with Patient #9 once he was coherent, and prior to discharge, to allow him the opportunity to formulate advance directives.

Patient #9 was not informed about advance directives or allowed to request/refuse information.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient video, record review, policy review, and staff interview, it was determined the facility failed to ensure restraints and/or seclusion were only imposed to ensure the immediate physical safety of the patient or others and were discontinued at the earliest possible time for 3 of 4 patients (#6, #8, and #9) who were restrained and/or secluded, and whose records were reviewed. This resulted in unnecessary use of restraint and/or seclusion. Findings include:

A facility policy, "Patient Restraint/Seclusion," effective 6/03/14, included:

- "PURPOSE: To protect the dignity and safety of inpatients, outpatients, staff and visitors through safe restraint process...

- " ...Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restraint will be used...

- "...Duration of order for restraint must not exceed twenty-four (24) hours for the initial order...Twenty-four (24) hours is the maximum duration...

- "...Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met...

- " ...The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time."

- "APPENDIX D: DEFINITIONS ...Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient ' s behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient ' s condition is considered a restraint. When medications are used as restraints, it is important to note that the decision as to whether they constitute restraint is not specific to the treatment setting, but to the situation the restraint is being used to address. A medication that is not being used as a standard treatment or in a dosage for the patient ' s medical or psychiatric condition and that results in controlling the patient ' s behavior and/or in restricting his or her freedom would be a drug used as a restraint.

- ...standard use of a psychotherapeutic medication to treat the patient's condition enables the patient to more effectively or appropriately function in the world around him/her than would be possible without the use of the medication. Psychotherapeutic medications are to enable, not disable."

The policy was not adhered to as follows:

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

a. Patient #6's record included documentation he was initially placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a "Restraint/Seclusion Observation Form." The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document "Y" or "N," for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

A nurses note, dated 2/28/17 at 11:00 AM, documented "Restraint Face to Face...Per Nursing Director [Directorof BHU's Name] and CNO [CNO's Name] patient is to remain in restraints until transferred to jail."

Physician B, who discharged Patient #6, was interviewed by phone on 4/04/17 at 12:40 PM. When asked if he was aware of the decision to keep Patient #6 in restraints until he was discharged to jail, he stated he remembered having a conversation with the Medical Director of BHU and Physician C. He stated to keep the other patients and staff safe, the decision was made to keep Patient #6 in the isolation room until he was discharged to jail. He stated he was not aware of the "restraint part."

RN A, who was a Charge Nurse on BHU, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17 during the day shift. RN A stated he was approached by the Director of BHU on 2/28/17, when Patient #6 was in 4 point restraints for the second time. RN A stated the Director of BHU informed him a decision had been made to keep Patient #6 in restraints until he was discharged .

Patient #6 was in locking synthetic leather restraints and/or seclusion for 39 hours.

b. During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and Quality staff.

While observing the video recording it was noted Patient #6 was restrained in a prone position for 12 hours. Additionally, his scrubs were removed at the initiation of the restraints and were not replaced for almost 5 hours. Patient #6 was covered only with a blanket.

On 2/27/17, beginning at 10:38 PM, Patient #6 was no longer restrained but remained in seclusion. He was observed shaking feces from the left leg of his scrubs, while talking with a staff member through the locked door. Patient #6 was observed removing his scrub pants, dragging them on the floor, then picking the pants up with his hands and dropping them in a corner of the seclusion room.

Patient #6 became increasingly agitated, pacing around the restraint bed, while dragging his soiled scrub pants on the floor. He appeared to have feces on his buttocks, hands, legs and feet. Patient #6 was observed shaking his fists while speaking with a staff member through the seclusion room door. He then dragged his buttocks along one of the seclusion room walls, smearing feces. Staff entered the seclusion room and provided Patient #6 with a bed pan, disposable wipes, a towel, a small white medicine cup and a cup of water. The staff member then left the room.

Patient #6 began to clean between his buttocks with one of the wipes, and attempted to clean other parts of his body with the same, soiled wipe. He was observed repeating this process with another 1-2 wipes, cleaning himself with the wipes that were clearly soiled with feces. Patient #6 was also observed putting the small white medication cup to his mouth, followed by a drink of water. Next he began to clean the bed, floor, and walls with the towel that was provided, and used the same, contaminated towel on his body.

Throughout the time of these events, staff was observed intermittently watching Patient #6 through the window in the seclusion room door. Staff was not observed offering hand sanitizer or assisting Patient #6 with cleaning himself. Staff was not observed cleaning the floors, walls, or bed during this time. At approximately 11:27 PM, staff brought some popcorn, 2 granola bars and cup of water to Patient #6. He began to eat the food with his hands that were still contaminated with feces.

Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and 4 point restraints. Additionally, the restraint monitoring which was documented was inconsistent and incomplete. Documentation did not clearly include consistent assessment of respiratory and cardiac status during the time Patient #6 was in restraints and in a prone position.

The facility failed to ensure Patient #6's safety and dignity were maintained and protected while he was admitted to the BHU and in restraints and/or seclusion.

c. The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:47 AM to 2/27/17 at 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

i. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a MAR. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol a medication to reduce pshychosis and anxiety)10 mg IM, Benadryl (a medication to reduce allergies and side effects, it can cause drowiness), 50 mg IM, and Ativan (a medication to reduce anxiety, it can cause drowsiness), 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine ( amedication for schizophrenia and reduces anxiety, it can cuase drowsiness) 100 mg IM, another medication used for psychosis and sedation.

The observation form documented the following:

- 1:45 AM, sleeping

- 2:00 AM, sleeping

- 2:15 AM, sleeping

- 2:30 AM, resting with eyes closed

- 2:45 AM, awake

Between 3:00 AM and 7:00 AM, Patient #6 was documented as "calling out" 2 times and "pulling" and "messing" with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he was threatening or inappropriate.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what criteria Patient #6 met to keep him in restraints.

Patient #6 remained in 4 point restraints and seclusion until 2/27/17 at 1:30 PM, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and confirmed Patient #6 was not released from restraints and seclusion at the earliest possible time.

Staff failed to remove or discontinue restraints and seclusion as early as possible.

ii. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was then medicated with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

A nurse's note, on 2/28/17 at 11:00 AM , signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the Director of BHU. Patient #6 requested to use the bathroom and RN A documented "I was told per the above named supervisors [CNO and Director of BHU] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by."

The observation form documented from 3:00 AM to 1:00 PM, Patient #6 was sleeping and cooperative. There was no documentation he was aggressive, threatening, or at risk for harming himself or others.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17, and he assigned the care of Patient #6 to himself during that shift. RN A stated he was in the ante-room (a room immediately outside the locked door of the restraint and seclusion room,) preparing to enter the seclusion room, and based on behavior, remove Patient #6 from his restraints, assess him, and assist him with toileting needs. RN A stated he planned to observe Patient #6 during this time out of restraints, and if appropriate behavior was observed, leave the restraints off. However, RN A stated he was approached by the Director of BHU, who informed him a decision was made to keep Patient #6 in restraints until he was discharged . RN A stated, without removing Patient #6's restraints, he assessed him and assisted him with personal care and toileting needs, but felt he had a good rapport with Patient #6 and would have preferred to remove his restraints.

Though Patient #6's behavior was documented cooperative, the facility failed to begin removing his restraints to ensure the least restrictive intervention was used for Patient #6 during the time he was in restraints and/or seclusion.

d. Medications were ordered by Psychiatrist A, Psychiatrist B, and Psychiatrist C, for Patient #6 on a PRN basis to help with anxiety, agitation, and psychosis. The medication orders were written as follows:

- 2/06/17 at 9:00 AM: Haldol 10 mg PO every 6 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Ativan 2 mg PO every 6 hours PRN, PRN Reason: Agitation, Special Instructions: Give with Haldol and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Benadryl 50 mg PO every 6 hours PRN, PRN Reason: Agitation/Extrapyramidal Symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Haldol 10 mg PO every 4 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Ativan 2 mg PO every 4 hours PRN, PRN Reason: Agitation, Special Instructions: Give Haldol and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Benadryl 50 mg PO every 4 hours PRN, PRN Reason: Agitation/Extrapyramidal symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/24/17 at 4:15 PM: Ativan 2 mg PO every 3 hours PRN, PRN Reason: Agitation, Special Instructions: If possible, try to give first before antipsychotic. However, may give with Haldol and Benadryl if needed or give IM if patient unable to take oral or violent.

Medications were not given as ordered. Examples include:

- On 2/09/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 7:55 AM and 12:44 PM. However, the order was for the medications to be given as needed every 6 hours. The orders for these medications to be given every 4 hours had not been received until after the second dose. Additionally, at 7:55 AM RN L documented the combination of medications were given per Patient #6's request due to anxiety, not for agitation/psychosis.

- On 2/10/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 10:09 AM per Patient #6's request. On 2/12/17, 2/13/17, 2/19/17, and 2/21/17 Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO twice per Patient #6's request. However, the order for the combination of medications was for agitation/psychosis.

During his admission, Patient #6 received the combination of medications 19 out of 28 days. On 2/09/17 to 2/13/17, 2/19/17, 2/21/17, 2/22/17, 2/24/17, and 2/26/17, Patient #6 received the combination of medications 2 times a day. On 2/20/17, he received the combination of medications 3 times. On 2/27/17, he received the combination 4 times.

It was unclear whether the use of the combination of medications was being used to restrict or control Patient #6's behavior.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and confirmed medication orders were not consistently followed, and chemical restraints were administered to Patient #6 to control his behavior.

Staff failed to follow orders for administration of medication to Patient #6 and did not recognize the use of chemical restraints.

e. A facility policy "Use of Force Policy (Safety)," approved 10/24/12, stated "Law enforcement agencies will be called when needed."

The policy did not provide staff guidance regarding criteria for use of law enforcement in the facility. Additionally, the policy did not clearly define the role of law enforcement versus the role of facility staff, when law enforcement was called to the facility.

Patient #6's record included documentation of police involvement 4 times during his admission and commitment.

The following entry in Patient #6's record described an example of potentially unnecessary police involvement.

A nurse's note, dated 2/27/17 at 2:15 AM, signed by RN N documented Patient #6 had physically attacked a staff member. Staff called a Code Grey and also called the local police. Patient #6 had barricaded himself in the bathroom of his room, and police talked him out. They then attempted to escort him to the seclusion room and Patient #6 walked past the room toward the exit. Police then handcuffed Patient #6 and lifted him off his feet and into the seclusion room to be restrained by staff.

The Director of BHU was interviewed on 3/03/17, beginning at 8:00 AM. She stated law enforcement was called to assist staff with restraining Patient #6 on 2 occasions. When asked why staff was unable to restrain Patient #6 and required the assistance of law enforcement, she said because facility staff was unable to deal with Patient #6.

The Director of BHU was again interviewed on 3/03/17 at approximately 11:03 AM. She stated "When police are called and come to assist, they run the show. They do not listen to directions. They do their own thing."

The DQRM was interviewed on 3/02/17 at approximately 3:10 PM. He stated the second time assistance was requested from law enforcement was when staff was preparing to remove Patient #6 from restraints. He stated "there were 2 law enforcement officers in the ER, and we asked if they would help us release Patient #6 because we were worried about staff safety."

The facility failed to provide adequate guidance to staff regarding the use of law enforcement in the facility.




2. Patient #8 was a [AGE] year old female who was admitted on [DATE], at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- The Psychiatric Evaluation, dated 12/09/16, dictated by a physician at 11:06 AM, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included the patient was " ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation." The report included " ...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room."

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she was making rounds when she found Patient #8 "...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ...No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ..."

- On 12/09/16 at 9:25 AM, an order for restraints was received by an RN, but not entered until 12/09/16 at 11:20 AM. The record did not include an explanation of the late entry. The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described as "locking synthetic leather all." The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert. Additionally, the RN verified the least restrictive restraint application was used.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM. At 11:45 AM, the observation form included "Pt stated she's calm and wants out." At 12:00 PM, documentation included "Pt laying quietly." At 12:15 PM, it was documented "Pt stating she want restraints off." At 1:15 PM, it was documented Patient #8 was released from restraints on 12/09/16. Patient #8 was not released from restraints at the earliest possible time.

The Director of BHU was interviewed on 3/07/17 at approximately 4:20 PM. She confirmed Patient #8's record did not include documentation that clearly supported she was released from restraints at the earliest possible time.

The facility failed to ensure Patient #8 was released from restraints at the earliest possible time.

3. Patient #9 was a [AGE] year old male admitted on [DATE],7 at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE], at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's ER record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physically aggression and combative. The restraint device was described as "locking synthetic leather all."

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release.

- An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, was reviewed. The provider report included "...2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints." The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

Patient #9's record did not clearly document he was released from restraints at the earliest possible time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records, facility policy, and staff interview, it was determined the facility failed to ensure restraints were discontinued at the earliest possible time for 3 of 4 patients who were restrained (#6, #8, and #9) and whose records were reviewed. This resulted in patients being restrained longer than was necessary to ensure safety. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "...The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time."

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

An observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and from 2:35 AM on 2/28/17 to 4:15 PM on 2/28/17.
Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

An initial restraint order for locking synthetic leather restraints and seclusion, dated 2/27/17 at 1:09 AM, stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/27/17. The observation form documented between 1:45 AM and 2:45 AM Patient #6 was sleeping or resting after the initiation of the restraints and seclusion. There was no documentation of the above described criteria.

On 2/27/17, between 3:00 AM and 7:00 AM, Patient #6 was documented as "calling out" 2 times and "pulling" and "messing" with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation of the above described criteria.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what criteria Patient #6 met to keep him in restraints.

Patient #6 remained in 4 point restraints and seclusion until 1:30 PM on 2/27/17, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed there was no documentation in the record for the continuation of restraints and/or seclusion.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

An initial restraint order, for locking synthetic leather restraints, was documented on 2/28/17 at 2:40 AM. The order stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM and 8:45 AM to 10:00 AM Patient #6 was sleeping. There was no documentation of the above described criteria.

A nurse's note, at 11:00 AM on 2/28/17, signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the Director of BHU. Patient #6 requested to use the bathroom and RN A documented "I was told per the above named supervisors [CNO and Director of BHU] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by."

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed there was no documentation in the record for the continuation of restraints and/or seclusion. She confirmed a decision was made by herself and the CNO for Patient #6 to remain in seclusion unless police were on stand by, in order to keep staff safe.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. RN A stated he planned to remove the restraints and observe Patient #6 during his time out of restraints, and if appropriate behavior was observed, leave the restraints off. However, RN A stated he was approached by the Director of BHU, who informed him a decision was made to keep Patient #6 in restraints until he was discharged . RN A stated, without removing Patient #6's restraints, he assessed him and assisted him with personal care and toileting needs, but felt he had a good rapport with Patient #6 and would have preferred to remove his restraints.

Patient #6 was not released from restraints or seclusion at the earliest possible time.





2. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- The Psychiatric Evaluation, dated 12/09/16, dictated by a physician on 11:06 AM, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included the patient was " ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation." The report included " ...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room."

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she was making rounds when she found Patient #8 "...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ... No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ..."

- Patient #8's record documented a restraint order on 12/09/16 at 11:20 AM. The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described, "locking synthetic leather all." The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM, and released from restraints at 1:15 PM the same day. At 11:45 AM, the observation form included "Pt stated she's calm and wants out." At 12:00 PM, documentation included "Pt laying quietly." At 12:15 PM, it was documented "Pt stating she want restraints off."

The Director of BHU was interviewed on 3/07/17 at approximately 4:20 PM. She confirmed Patient #8's record did not include documentation that clearly supported she was released from restraints at the earliest possible time.

Patient #8 was not released from restraints at the earliest possible time.

3. Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharge on 1/16/17 at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's ER record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physical aggression and combative. The restraint device was described, "locking synthetic leather all."

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release.

- An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, was reviewed. The provider report included "... 2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints." The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

Patient #9's record did not clearly document he was released from restraints at the earliest possible time.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on staff interview, review of facility policies, restraint/seclusion documentation, and QAPI documents, it was determined the facility failed to ensure quality indicators were developed to assess processes of care, facility services, and operations related to the use of restraint/seclusion in the facility. Additionally, the facility failed to use restraint/seclusion data to monitor effectiveness and safety of patient care provided in the facility. This resulted in the inability of the facility to evaluate programs and systems, and prevented the facility from identifying measurable improvement methods. Findings include:

A facility policy "Patient Safety Quality Assessment Performance Improvement Plan 2016," next review date 4/19/17, documented:

- "The purpose of the Patient and Employee Safety/Quality Assessment/Performance Improvement Plan for [Name of the facility] is to ensure that the Board of Trustees, medical staff, and professional staff consistently endeavor to deliver safe, effective, optimal patient care and services in a safe environment for our patients and employees. The Board of Trustees is ultimately accountable for the quality of care provided by the facility. This plan allows for a systematic, coordinated, continuous data-driven approach to improving performance, focusing upon the processes and mechanisms that address our values. In carrying out the plan, our ultimate focus is a desire for an excellent patient experience and safe work conditions.

- The plan identified an interdisciplinary, Quality Leadership Council (QLC.) The plan stated the Council established the 2016 Patient Safety Quality Assessment Performance Improvement Plan, with support and approval from the facility's Governing Body (GB.) The plan documented the council " ...has the responsibility for monitoring all aspects of patient care and services (including contracted services), from the time of patient's initial participation with any of the services provided, including diagnosis, treatment recovery, and discharge activities. These activities are monitored in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate the best patient outcomes."

Also included in the policy was the following:

- " ...Provide a systematic mechanism for the organization's appropriate individuals, departments and professions to function collaboratively in their efforts toward performance improvement, providing feedback and learning throughout the organization;

- ...Incorporate available information from internal sources and other organizations about the occurrence of medical errors and sentinel events to reduce the risk of similar events;

- ...Assures that the improvement process is organization-wide, monitoring, assessing and evaluating the quality and appropriateness of patient care, patient safety practices and clinical performance, to resolve identified problems and improve performance.

- ...Appropriately report information to the Governing Board, providing leaders with the information needed to ensure quality patient care and safety.

- ...Track identified problems and action plans to ensure improvement or problem resolution.

- ...Use information from departments/services and the findings of discrete performance improvement activities and adverse patient events to detect trends, patterns of performance or potential problems that affect multiple departments/services ...

- Membership on the Quality Leadership Council is composed of leaders of the organization ...Directors from the following departments: Quality and Risk Management, Case Management, Medical Staff Services, Human Resources, Education & Training, ...Emergency Department/Cardiopulmonary, ICU, Telemetry, etc."

The facility did not adhere to this policy as follows:

1. Refer to A-0144 as it relates to the facility's failure to ensure care was provided in a safe manner and setting for 2 of 4 patients (#6 and #9) who were secluded and/or restrained, resulting in Patient #6 having been at risk for harm or death and the identification of an immediate jeopardy on 3/06/17 at 4:30 PM.

2. An untitled electronic report, listing each incident of restraint and/or seclusion, and physical hold, included incidents from 12/03/16 to 3/01/17 and was provided during the survey. The report involved 13 different patients and included 13 separate incidents of restraint, 1 incident of seclusion, 2 incidents of physical hold.

According to an interview with the DQRM, on 3/06/17 at 9:15 AM, the report was used for auditing restraint and/or seclusion documentation in patient records.

A copy of a page from the Restraint/Seclusion Log, listing each incident of restraint and/or seclusion from, 12/03/16 to 3/01/17, was provided during the survey. The document included 7 separate incidents of restraint involving 6 different patients. The document did not include incidents of seclusion or "hands-on" physical holds.

When compared to the electronic audit report for the same time period, 12/03/16 to 3/01/17, the Restraint/Seclusion Log was missing the names and correlating events of 4 patients.

The DQRM, and the Director of BHU were interviewed together on 3/03/17, beginning at 8:00 AM. When asked how incidents of restraint/seclusion were tracked in the facility, the DQRM stated each incident of restraint and/or seclusion was recorded in a log book that was maintained by the facility's nursing supervisors. The DQRM stated he was uncertain how the restraint/seclusion data was tracked and analyzed to improve patient care in the facility. The DQRM said he was uncertain whether the data was included in the facility's quality program and presented to the Governing Board.

The DQRM was interviewed on 4/03/17, beginning at 10:45 AM. He confirmed the information contained on the Restraint/Seclusion log and the audit tool were different. When asked which was accurate, he stated the audit tool was probably more accurate than the Restraint/Seclusion log. He stated it was the responsibility of the nursing supervisors to complete the Restraint/Seclusion log. The DQRM stated they become busy at times and may forget to make an entry.

The facility failed to accurately collect data related to the use of restraint and/or seclusion in the facility. Additionally, data was not used to adequately monitor the effectiveness and safety of patient care provided in the facility regarding those patients on whom restraints and/or seclusion were used.

3. A facility policy "Patient Safety Quality Assessment Performance Improvement Plan 2016," next review date 4/19/17, identified an interdisciplinary Quality Leadership Council (QLC.) The plan stated the Council established the 2016 Patient Safety Quality Assessment Performance Improvement Plan, with support and approval from the facility's Governing Board. The plan documented the council " ...has the responsibility for monitoring all aspects of patient care and services (including contracted services), from the time of patient's initial participation with any of the services provided, including diagnosis, treatment recovery, and discharge activities. These activities are monitored in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate the best patient outcomes."

The policy documented "...Membership on the Quality Leadership Council was composed of leaders of the organization ... Directors from the following departments: Quality and Risk Management, Case Management, Medical Staff Services, Human Resources, Education & Training, ... Emergency Department/Cardiopulmonary, ICU, Telemetry ..." Twenty six departments in the facility were represented on the QLC. However, the Director of BHU was not included on the QLC.

An untitled electronic report, listing each incident of restraint and/or seclusion, and physical hold, included incidents from 12/03/16 to 3/01/17 and was provided during the survey. The report documented 8 of 13 restraint incidents and 1 incident of seclusion occurred on the Behavioral Health Unit of the facility.

A copy of a page from the Restraint/Seclusion Log, listing each incident of restraint and/or seclusion from, 12/03/16 to 3/01/17, was provided during the survey. The log documented 4 of the 7 recorded restraint incidents occurred on the Behavioral Health Unit of the facility.

The Director of BHU was not included on the QLC, preventing involvement in the committees' responsibility for monitoring all aspects of patient care and services provided by the facility.

The facility did not develop a specific QAPI program that was sufficient to show measurable improvement in indicators that would improve health outcomes.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of facility policies, and staff interview, it was determined the facility failed to ensure the type of restraint used was the least restrictive intervention for 2 of 4 patients (#6 and #8) who were restrained and whose records were reviewed. This resulted in unnecessary use of restraint. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "POLICY: Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints or seclusion." This policy was not followed.

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a "Restraint/Seclusion Observation Form." The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document "Y" or "N," for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and from 2:35 AM on 2/28/17 to 4:15 PM on 2/28/17. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a MAR. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine 100 mg IM, another medication used for psychosis and sedation.

The observation form documented the following:

- 1:45 AM, sleeping

- 2:00 AM, sleeping

- 2:15 AM, sleeping

- 2:30 AM, resting with eyes closed

- 2:45 AM, awake

Between 3:00 AM and 7:00 AM, Patient #6 was documented as "calling out" 2 times and "pulling" and "messing" with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he was threatening or inappropriate.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what the conversation entailed.

Patient #6 remained in 4 point restraints and seclusion until 2/27/17 at 1:30 PM, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was then medicated with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg.

A nurse's note, on 2/28/17 at 11:00 AM , signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the BHU Director. Patient #6 requested to use the bathroom and RN A documented "I was told per the above named supervisors [CNO and BHU Director] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by."

The observation form documented from 3:00 AM to 1:00 PM, Patient #6 was sleeping and cooperative. There was no documentation he was aggressive, threatening, or a risk for harming himself or others.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. RN A stated he planned to remove the restraints and observe Patient #6 during his time out of restraints, and if appropriate behavior was observed, leave the restraints off. However, RN A stated he was approached by the Director of BHU, who informed him a decision was made to keep Patient #6 in restraints until he was discharged . RN A stated, without removing Patient #6's restraints, he assessed him and assisted him with personal care and toileting needs, but felt he had a good rapport with Patient #6 and would have preferred to remove his restraints.

The facility failed to ensure the least restrictive intervention was used for Patient #6.

2. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- On 12/08/16 at 1:57 PM, an RN assessment was documented in Patient #8's record. It included the question "What are some things that make you angry ..." Patient #8's response was documented "Being isolated, Being restrained ..." The question "Have you ever been restrained ..." was also asked, to which Patient #8 responded "No."

- The Psychiatric Evaluation dated 12/09/16, completed by a physician, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included the patient was "...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation." The report included "...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room." The evaluation did not document Patient #8 was violent or aggressive.

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she, the RN, was making rounds when she found Patient #8 "...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ... No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ..." Patient #8's behavior was not described as aggressive or violent toward others.

- On 12/09/16 at 9:25 AM, an order for restraints was received by an RN, but not entered until 12/09/17 at 11:20 AM. The record did not include an explanation of late order entry. The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described, "locking synthetic leather all." The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert. Although Patient #8 was held in 4 point, locking restraints, an RN documented the least restrictive restraint application was used.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM. At 11:45 AM, the observation form included "Pt stated she's calm and wants out." At 12:00 PM, documentation included "Pt laying quietly." At 12:15 PM, it was documented "Pt stating she want restraints off." At 1:15 PM, it was documented Patient #8 was released from restraints on 12/09/16. Patient #8 remained in 4-point, locking restraints.

Patient #8's behavior did not justify the use of 4 point, locking restraints.

The Director of BHU was interviewed on 3/07/17, beginning at 2:00 PM. She stated she was unable to find documentation in Patient #8's record supporting the use of 4 point restraints, as opposed to bilateral wrist restraints only.

The facility failed to ensure the least restrictive restraint application was used on Patient #8.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, review of video recording, and staff interview, it was determined the facility failed to ensure care was provided in a safe manner and setting for 2 of 4 patients (#6 and #9) who were secluded and/or restrained and whose records were reviewed. Lack of education and training of staff, lack of appropriate policies and implementation of policies, and lack of initial and ongoing assessment resulted in patients being placed at risk for serious harm, injury, or death. This resulted in Patient #6 being at risk for immediate harm or death and the identification of an immediate jeopardy on 3/06/17 at 4:30 PM. Additionally, this had the potential for all patients being treated for Behavioral Health at risk for serious harm, injury, or death. Findings include:

The facility policy "Patient Restraint/Seclusion" policy, effective 6/03/14, included:

"PURPOSE: ...To protect the dignity and safety of inpatients, outpatients, staff and visitors through safe restraint process ...To provide guidelines for use of least restrictive interventions to avoid restraint or seclusion use. To define the procedure to be followed when all alternatives have been exhausted and proven ineffective, and restraints are necessary to maintain patient safety ...To define staff training requirements related to safe restraint or seclusion processes ...

POLICY: ...Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints or seclusion.

- An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.

- If a telephone order is required, the RN must write down the order while the physician is on the phone and read-back the order to verify accuracy. The order must specify clinical justification for restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

- When a LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.

- Duration of order for restraint must not exceed twenty-four (24) hours for the initial order ...
Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met.

- To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of the restraint is necessary.
If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/physician.

- Orders for restraint or seclusion must not exceed: ...4 hours for adults, aged 18 years and older. Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint or seclusion when criteria for release are met.

- Orders may be renewed according to time limits ...for a maximum of 24 consecutive hours.

- Restraints are applied by staff with demonstrated competence in restraint application.
Patients are assessed by an RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion.

- An RN will assess the patient at least every 2 hours. The assessment will include ...circulation of affected extremities, respiratory and cardiac status, psychological status including level of distress or agitation, mental status and cognitive functioning ..., Hygiene, toileting /elimination needs are being met, The patient's rights, dignity, and safety are maintained, consideration of less restrictive alternatives to restraint.

- A trained staff member monitors each patient in restraint or seclusion at least 3 times an hour for safety, and to confirm that the patient's rights and dignity are maintained.

- A patient in restraint and seclusion simultaneously requires a higher level of monitoring: Continuous, uninterrupted monitoring, face-to-face by a specifically assigned staff member with demonstrated competence in close proximity to the patient for at least the first hour.

- A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation ...
The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time.

- The medical record contains documentation of: Determination of effectiveness/ineffectiveness of restraint or seclusion ..., Order for restraint or seclusion and any renewal orders ..., Assessment of the patient in restraint or seclusion ..., Monitoring of patient in restraint or seclusion, Medical and behavioral evaluation for restraint or seclusion management of violent or self destructive behavior.

DEFINITIONS Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement ... Psychotherapeutic medications are to enable, not disable."

A separate policy was requested related to the identification and use of chemical restraints, criteria for use of chemical restraints, and appropriate monitoring of patients who receive chemical restraints. It was reported the facility did not have a chemical restraint policy.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. The practice of using chemical restraints in the facility was discussed. She stated "We talk about that we do not use chemical restraints. The order has to reflect the reason for the medication." However, she agreed chemical restraints are being used in the emergency room .

The facility failed to adhere to the "Patient Restraint/Seclusion" policy as follows:

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a "Psychiatric Evaluation," dated 2/01/17, and signed by Psychiatrist B. Psychiatrist B documented Patient #6 was admitted to the BHU on a mental health hold and had a long history of psychiatric illness and multiple inpatient psychiatric admissions. The evaluation documented Patient #6 appeared anxious and had a blunt affect, with obvious facial tics. Patient #6 denied suicidal or homicidal thought, but stated he had auditory hallucinations and heard God's voice. Psychiatrist B documented Patient #6's thought processes were "...illogical, with grandiose and religious delusions ..." The evaluation further documented Patient #6 had poor impulse control and judgment.

An RN clinical note, dated 2/27/17 at 2:15 AM, documented Patient #6 physically assaulted a BHU staff member. The note stated "Patient lay in wait for staff member to do 15 minute rounds. When staff member entered room she was immediately set upon by patient who used pens to stab staff member repeatedly with both hands and with extreme force. And attempted to force staff member into corner [sic]. Patient tripped on his bed in the process and staff member was able to move past patient. fell ow staff members were able to come and close the door to patients [sic] room as he fought against them. Staff from hospital responded to Code Gray (A facility wide call for assistance). And Caldwell police called [sic]. Police arrived and patient resisted and barricaded in shower. Turned water on and soaked himself. He was talked to hallway and and [sic] moved past the obs (observation) room that was the destination. And was moving toward end of hallway and emergency exit where staff were standing in a line [sic]. Police determined it best to handcuff him in the interest of protecting staff and patients. As patients were in rooms nearby [sic]. Patient handcuffed and medication provided IM. Patient lifted to feet. And patient guided by police to room [sic]. Patient placed in restraints. Patient was yelling in confused fashion and fighting against police. Placed in restraints. Restraints checked for adequacy and patient safety. Patient scrubs were removed due to being soaked with water. Sheft [sic] placed on patients [sic] body. Patient tolerating well. Was provided additional medication by physician order. Currently resting with 2 arms and 1 leg in restraint. Staff debriefed."

a. Patient #6's orders restraints and/or seclusion exceeded the policy time frames.

i. An initial restraint order was documented in Patient #6's medical record on 2/27/17 at 1:09 AM. The order was documented as a telephone order from Psychiatrist C. The order was for seclusion/restraint and locking synthetic leather restraints to all extremities. The order documented the restraint order expired on [DATE] at 5:09 AM. The order was signed by Psychiatrist C on 2/27/17 at 2:04 PM.

Subsequent restraint renewal orders for Patient #6 did not meet regulatory time frames for behavioral/ violent restraint and seclusion orders as follows:

- Renewal order for seclusion/restraint ordered on [DATE] at 8:40 AM. This was documented as a telephone order from Psychiatrist C. The order did not include locking synthetic leather restraints to all extremities. The order expired on [DATE] at 12:40 PM. The order was signed by Psychiatrist C on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 7 hours and 31 minutes later.

- Renewal order for seclusion/restraint and locking synthetic leather restraints to all extremities on 2/27/17 at 9:27 AM. This was documented as a telephone order from the Psychiatrist B. The order expired on [DATE] at 1:27 PM. Psychiatrist B signed the order on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 8 hours and 18 minutes later.

ii. A nursing note, dated 2/28/17 at 3:16 AM, signed by RN B documented Patient #6 began kicking at the door of his room around 2:30 AM. Local law enforcement were called by staff and assisted staff with placing Patient #6 back into restraints to all of his extremities.

An initial order for locking synthetic leather restraints to all extremities was entered on 2/28/17 at 2:50 AM. The order expired on [DATE] at 6:50 AM. The renewal order was entered on 2/28/17 at 7:18 AM, for locking synthetic leather restraints to all extremities. The order was greater than 4 hours after the initial order. It was entered 28 minutes later.

During an interview at 4:20 PM on 3/02/17, RN A reviewed the record and confirmed the orders were not written every 4 hours for restraint and/or seclusion.

During an interview at 11:50 AM on 4/04/17, Psychiatrist C stated patients in restraint and/or seclusion should be seen by a physician or LIP every 4 hours and again at 24 hours. He confirmed he signed the orders but stated Psychiatrist B should have seen Patient #6 after 24 hours because he had returned at that point.

During an interview at 12:40 PM on 4/04/17, Psychiatrist B stated all the physicians discussed Patient #6 and his safety, and the decision was to keep him isolated but was not aware of the continued use of restraints.

Patient #6 was restrained and secluded without orders and he was in locking synthetic leather restraints and/or seclusion for 39 hours.

b. Patient #6's record included a "Restraint/Seclusion Observation Form." The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document "Y" or "N," for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraint on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM on 2/28/17 to 4:15 PM. The observation form documented Patient #6 was in seclusion the entire time. There was no documentation of continuous uninterrupted 1:1 monitoring for Patient #6.

While Patient #6 was in 4 point restraints there was no documentation on the observation form his upper extremities were released. There was documentation by staff, during the first time period he was restrained, Patient #6's left leg was released for a total period of 2 hours and 15 minutes. His right leg was released for a total period of 1 hour and 30 minutes. During the second time period Patient #6 was restrained, his left leg was released for 3 hours. His right leg was released for 2 hours and 15 minutes.

The observation form documented Patient #6 was cooperative for significant periods of time. On 2/27/17 from 5:15 AM to 7:00 AM, the form documented he was cooperative. During that time the only restraint released was on Patient #6's left leg. The observation form included documentation Patient #6 was cooperative from 2/27/17 at 4:00 PM to 2/28/17 at 2:15 AM. There was no documentation staff attempted to discontinue seclusion during that time.

During an interview on 3/06/17 at 3:00 PM, the Director of BHU stated monitoring of Patient #6 was documented every 15 minutes. She confirmed the documentation did not include continuous monitoring of Patient #6 while he was in seclusion and restrained. She confirmed the video showed staff intermittently looking through the window in the door of the seclusion room. The Director of BHU confirmed Patient #6's restraints were not routinely released to allow for range of motion.

The facility failed to ensure Patient #6 was appropriately monitored while in seclusion/restraint and his restraints were released to allow for range of motion.

c. Medications were ordered, by Psychiatrist A, Psychiatrist B, and Psychiatrist C, for Patient #6 on a PRN basis to help with agitation and psychosis. During his admission, Patient #6 received the combination of medications 19 out of 28 days. On 2/19/17, 2/21/17, 2/22/17, 2/24/17, and 2/26/17, Patient #6 received the combination of medications 2 times a day. On 2/20/17, he received the combination of medications 3 times. On 2/27/17, he received the combination 4 times.

It was unclear whether the use of the combination of medications was being used to restrict or control Patient #6's behavior.

During an interview at 9:35 AM on 4/04/17, RN A confirmed medications were being given to Patient #6 at his request. He also confirmed they were not given as ordered.

During a telephone conversation at 11:30 AM on 3/23/17, the CNO confirmed administering Haldol, Ativan, and Benadryl at the same time was considered a chemical restraint and should have been treated as one for Patient #6.

d. Patient #6's record included documentation of police involvement 4 times during his admission and commitment.

- Local police were called to assist staff with Patient #6 on 2/06/17 at 12:26 PM. RN C documented Patient #6 was at a door and used his shoulder to charge at the door 3 to 4 times. He then walked down the hall and hit another set of doors which divided the unit. The local police were contacted by staff and a Code Gray was called using the facility overhead paging system after he hit the second set of doors. Patient #6 was medicated per order and RN C documented he became cooperative and " ... we did not need to go hands on."

- A nurse's note, dated 2/27/17 at 2:15 AM, signed by RN N documented Patient #6 had physically attacked a staff member. Staff called a Code Grey and also called the local police. Patient #6 had barricaded himself in the bathroom of his room and police talked him out. They then attempted to escort him to the seclusion room and Patient #6 walked past the room toward the exit. Police then handcuff Patient #6 and lifted him off his feet and into the seclusion room to be restrained by staff.

- A Social Service note, dated 2/27/17 at 2:51 PM, documented police came to the BHU so Patient #6 could be taken off restraints. When asked about this on 3/03/17 at 8:00 AM, the Director of BHU stated police were already in the facility in the ED. They were asked to come up to the BHU as a "stand-by" in case Patient #6 became violent.

- A nurse's note, dated 2/28/17 at 3:16 AM, documented at 2:30 AM Patient #6 kicked at the door to his room. Patient #6 continued to kick at the door and the security guard, who was stationed outside the door, had to hold it to keep the lock from breaking. RN B documented local police were called. The note documented 5 police officers went into the room with RN M. RN M placed Patient #6 in 4 point restraints while law enforcement stood by.

The Director of BHU was interviewed on 3/03/17, beginning at 8:00 AM. She stated law enforcement was called to assist staff with restraining Patient #6 on 2 occasions. When asked why staff was unable to restrain Patient #6 and required the assistance of law enforcement, she said because facility staff was unable to deal with Patient #6.

The Director of BHU was again interviewed on 3/03/17 at approximately 11:03 AM. She stated "When police are called and come to assist, they run the show. They do not listen to directions. They do their own thing."

The DQRM was interviewed on 3/02/17 at approximately 3:10 PM. He stated the second time assistance was requested from law enforcement was when staff was preparing to remove Patient #6 from restraints. He stated "there were 2 law enforcement officers in the ER, and we asked if they would help us release Patient #6 because they were worried about staff safety."

The facility failed to identify a process regarding the use of law enforcement in the facility.

e. During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM and quality staff.

A BHU document, "...PATIENT AND FAMILY HANDBOOK," documented "Every [name of faciliy] patient has the right: ... To security, personal privacy and confidentiality of information ..."

While observing the video recording it was noted Patient #6 was restrained in a prone position for 12 hours. Additionally, his scrubs were removed at the initiation of the restraints and were not replaced for almost 5 hours. Patient #6 was only covered with a blanket.

On 2/27/17, beginning at 10:38 PM, Patient #6 was no longer restrained but remained in seclusion. He was observed shaking feces from the left leg of his scrubs, while talking with a staff member through the locked door. Patient #6 was observed removing his scrub pants, dragging them on the floor, then picking the pants up with his hands and dropping them in a corner of the seclusion room.

Patient #6 became increasingly agitated, pacing around the restraint bed, while dragging his soiled scrub pants on the floor. He appeared to have feces on his buttocks, hands, legs and feet. Patient #6 was observed shaking his fists while speaking with a staff member through the seclusion room door. He then dragged his buttocks along one of the seclusion room walls, smearing feces. Staff entered the seclusion room and provided Patient #6 with a bed pan, disposable wipes, a towel, a small white medicine cup and a cup of water. The staff member then left the room.

Patient #6 began to clean between his buttocks with one of the wipes, and attempted to clean other parts of his body with the same, soiled wipe. He was observed repeating this process with another 1-2 wipes, cleaning himself with the wipes that were soiled with feces. Patient #6 was also observed putting the small white medication cup to his mouth, followed by a drink of water. Next he began to clean the bed, floor, and walls with the towel that was provided, and used the same, contaminated towel on his body.

Throughout the time of these events, staff was observed intermittently watching Patient #6 through the window in the seclusion room door. Staff was not observed offering hand sanitizer or assisting Patient #6 with cleaning himself. Staff was not observed cleaning the floors, walls, or bed during this time. At approximately 11:27 PM, staff brought some popcorn, 2 granola bars and cup of water to Patient #6. He began to eat the food with his hands that were still contaminated with feces.

Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and/or 4 point restraints. Additionally, the restraint monitoring which was documented was inconsistent and incomplete. Documentation did not clearly include consistent assessment of respiratory and cardiac status during the time Patient #6 was in restraints and in a prone position.

The DQRM and the Director of BHU confirmed Patient #6 was not provided personal privacy during the time he was without clothing and in restraints. He was in restraints and without clothing for 5 hours before he was assisted with donning scrubs.

The DQRM was interviewed on 4/03/17 at 10:45 AM. He confirmed the "Patient Rights and Responsibilities" policy and the policy related to "Photographing, Video recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM)," did not reflect the current facility practice. When asked the reason for video monitoring and/or video recording of patients, he stated patient monitoring occurred to ensure patient safety. However, he said video recordings of patients were reviewed and used to improve quality of patient care.

The Director of HIM was interviewed on 4/03/17, beginning at 1:45 PM. When asked if video recordings of patients were retained as a part of the permanent patient record, she confirmed video recordings were not retained and were not considered a part of the permanent record.

The Director of Facility Operations was interviewed on 4/03/17, beginning at 3:30 PM. He stated the IT department now maintains the video monitoring system in the facility. He stated the system is now digital in nature, and information is stored on a corporate server for a maximum of 30 days, when a system override occurs. He stated if a copy of a video is required, his department is responsible for flagging the video, making copies, and if the recording is related to a patient, he discusses with the DQRM for direction. He stated "most of the time, recordings are used for investigation and quality of care. The Director of Facility Operations stated if copies are created on CDs, he keeps them in his locked desk drawer. He stated some CDs are years old, and he does not really know what to do with them other than keep them locked in his desk. He was uncertain whether patient related video recordings were considered a part of the permanent patient record.

The facility failed to follow their policies and provide a safe patient care environment.

2. Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE] at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's emergency room record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physical aggression and combative. The restraint device was described, "locking synthetic leather all." There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release. There was no documentation of uninterrupted 1:1 monitoring.

An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, included "...2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints." The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She reviewed Patient #9's record and confirmed he was not assigned a sitter or 1:1. She stated sitters are routinely requested when a patient is in restraints, but often no one is available. If a sitter is unavailable, she stated patients are moved to 1 of 2 rooms closest to the nurses' station, where staff can more easily observe them. The Director of ER also confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

Restraint documentation did not support Patient #9 was under constant observation during the time he was in restraints. Additionally, documentation did not clearly indicate Patient #9 was released from restraints at the earliest possible time.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient video, record review, policy review, and staff interview, it was determined the facility failed to ensure psychiatric treatment and interventions for violence and aggression were appropriately provided for 1 of 4 patients (Patient #6) who was placed in seclusion and/or restraints and whose records were reviewed. This resulted in potentially unnecessary mental anguish and neglect. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period." Additionally, the policy stated monitoring of the patient in restraints and/or seclusion should include "The patient's rights, dignity, and safety are maintained," as well as "Patient's understanding of reasons for restraint and criteria for release from restraint." This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Beginning on 2/27/17 at 12:47 AM, Patient #6 was placed in 4 point restraints and/or seclusion. Patient #6 was in either 4 point restraints and/or seclusion for 39 hours until his discharge. During that time he did not have access to a bathroom, privacy, or was he released from restraint/seclusion at the earliest time.

1. Patient #6's record included documentation he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

a. An initial restraint order for locking synthetic leather restraints and seclusion, dated 2/27/17 at 1:09 AM, stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/27/17. The observation form documented between 1:45 AM and 2:45 AM Patient #6 was sleeping or resting after the initiation of the restraints and seclusion. There was no documentation of the above described criteria.

On 2/27/17, between 3:00 AM and 7:00 AM, Patient #6 was documented as "calling out" 2 times and "pulling" and "messing" with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation of the above described criteria.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what criteria Patient #6 met to keep him in restraints.

Patient #6 remained in 4 point restraints and seclusion until 1:30 PM on 2/27/17, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back in 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine (a medication for schizophrenia, and to reduce anxiety, it can cause drowsiness) 100 mg IM, Benadryl (a medication to reduce allergic reactions and side effects of some medications, it can cuae drowsiness), 50 mg IM, and Ativan (a medication to reduce anxiety, it can cause drowsiness), 2 mg IM.

An initial restraint order, for locking synthetic leather restraints, was documented on 2/28/17 at 2:40 AM. The order stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM and 8:45 AM to 10:00 AM Patient #6 was sleeping. There was no documentation of the above described criteria.

A nurse's note, at 11:00 AM on 2/28/17, signed by RN A, documented Patient #6 was to remain in restraints until he was discharged per the CNO and the Director of BHU. Patient #6 requested to use the bathroom and RN A documented "I was told per the above named supervisors [CNO and BHU Director] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by."

During an interview at 9:35 AM on 4/04/17, RN A stated he felt Patient #6 should have had a period where restraints were removed to assess his reaction and response. He stated he was directed not to remove the restraints, after the second application, by the Director of BHU.

Patient #6 was not released from restraints or seclusion at the earliest possible time, or when the ordered criteria were met.

2. Renewal orders for continued use of seclusion/restraint and locking synthetic leather to all extremities did not include documentation of Patient #6's behaviors or if he continued to pose a threat to staff, himself, or other patients on the unit.

Patient #6's record included a "Restraint/Seclusion Observation Form." The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document "Y" or "N," for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was cooperative for significant periods of time. On 2/27/17 from 5:15 AM to 7:00 AM, the form documented he was cooperative. The observation form also documented Patient #6 was cooperative from 4:00 PM on 2/27/17 to 2:15 AM on 2/28/17. There was no documentation staff attempted to discontinue seclusion during that time.

3. During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and quality staff.

While observing the video recording it was noted Patient #6 had all 4 of his extremities restrained and he was in a prone position for 12 hours. Additionally, his scrubs were removed at the initiation of the restraints and Patient #6 was covered only with a blanket for almost 5 hours.

Throughout the time of these events, staff was observed intermittently offering the use of a bedpan for Patient #6. He was not offered privacy when toileting. Additionally, at one point Patient #6 was not released from his restraints or assisted with changing his position in order to use a bedpan.

Physician B, who discharged Patient #6, was interviewed by phone on 4/04/17 at 12:40 PM. When asked if he was aware of the decision to keep Patient #6 in restraints until he was discharged to jail, he stated he remembered having a conversation with the Medical Director of BHU and Physician C. He stated to keep the other patients and staff safe, the decision was made to keep Patient #6 in the isolation room until he was discharged to jail. He stated he was not aware of the "restraint part."

RN A, who was a Charge Nurse on BHU, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17 during the day shift. RN A stated he was approached by the Director of BHU on 2/28/17, when Patient #6 was in 4 point restraints for the second time. RN A stated the Director of BHU informed him a decision had been made to keep Patient #6 in restraints until he was discharged .

The facility failed to ensure Patient #6 was free from the potential of possible neglect and mental anguish related to his treatment and interventions.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours for 1 of 1 patients (Patient #6) who was restrained for more than 4 hours to manage violent or self-destructive behavior and whose record was reviewed. This resulted in lack of oversight by a physician or qualified LIP and had the potential to interfere with patient safety. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "Physician orders for restraint or seclusion must be time limited, and must specify clinical justification for the restraint or seclusion, the date and time ordered, duration of restraint or seclusion use, the type of restraint, and behavior-based criteria for release." The policy stated orders for restraint or seclusion must not exceed 4 hours for adults, and for a maximum of 24 consecutive hours. "Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion." This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

An initial restraint order was documented in Patient #6's medical record on 2/27/17 at 1:09 AM. The order was documented as a telephone order from Psychiatrist C. The order was for seclusion/restraint and locking synthetic leather restraints to all extremities. The order documented the restraint order expired on [DATE] at 5:09 AM. The order was signed by Psychiatrist C on 2/27/17 at 2:04 PM.

Subsequent restraint renewal orders for Patient #6 did not meet regulatory time frames for behavioral/ violent restraint and seclusion orders as follows:

- Renewal order for seclusion/restraint ordered on [DATE] at 8:40 AM. This was documented as a telephone order from Psychiatrist C. The order did not include locking synthetic leather restraints to all extremities. The order expired on [DATE] at 12:40 PM. The order was signed by Psychiatrist C on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 7 hours and 31 minutes later.

- Renewal order for seclusion/restraint and locking synthetic leather restraints to all extremities on 2/27/17 at 9:27 AM. This was documented as a telephone order from the Psychiatrist B. The order expired on [DATE] at 1:27 PM. Psychiatrist B signed the order on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 8 hours and 18 minutes later.

b. A nursing note, dated 2/28/17 at 3:16 AM, signed by RN B documented Patient #6 began kicking at the door of his room around 2:30 AM. Local law enforcement were called by staff and assisted staff with placing Patient #6 back into restraints to all of his extremities.

An initial order for locking synthetic leather restraints to all extremities was entered on 2/28/17 at 2:50 AM. The order expired on [DATE] at 6:50 AM. The renewal order was entered on 2/28/17 at 7:18 AM, for locking synthetic leather restraints to all extremities. The order was greater than 4 hours after the initial order. It was entered 28 minutes later.

During an interview at 4:20 PM on 3/02/17, RN A reviewed the record and confirmed the orders were not written every 4 hours for restraint and/or seclusion.

During an interview at 12:40 PM on 4/04/17, Psychiatrist B stated all the physicians discussed Patient #6 and his safety, and the decision was to keep him isolated but was not aware of the continued use of restraints until after his discharge.

Patient #6 was restrained and secluded without an order.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0172
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure patients restrained and/or secluded for more than 24 hours consecutively were seen and assessed by a physician or LIP for 1 of 1 patients (Patient #6) who were restrained and/or secluded for more than 24 consecutive hours and whose records were reviewed. This had the potential for patients to be harmed physically and mentally, and endanger their safety. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion." This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included orders for locking synthetic leather restraints to all extremities and/or seclusion. Patient #6 was placed in seclusion and 4 point restraints on 2/27/17 at 12:47 AM. The initial order for locking synthetic leather restraints to all extremities and seclusion was documented in his record on 2/27/17 at 1:09 AM.

An Interdisciplinary Education note, dated 2/27/17 at 1:56 PM, documented Patient #6 was released from the locking synthetic leather restraints at 1:40 PM, 12 hours and 53 minutes after they were initiated, but remained in seclusion. The order for Patient #6 to remain in seclusion was renewed by telephone orders 3 additional times on 2/27/17, at 1:51 PM, 6:04 PM, and 9:54 PM.

On 2/28/17 at 12:47 AM, Patient #6 had been in seclusion for 24 hours. Another renewal order was documented on 2/28/17 at 1:48 AM. There was no documentation Patient #6 was seen, assessed, and evaluated by a psychiatrist prior to the order. Additionally, Patient #6 was placed back into 4 point restraints on 2/28/17 around 2:40 AM.

During an interview at 8:00 AM on 3/03/17, the Director of BHU confirmed Patient #6 was not evaluated by a physician after 24 hours of continuous restraint/seclusion orders.

During an interview at 11:50 AM on 4/04/17, Psychiatrist C stated patients in restraint and/or seclusion should be seen by a physician or LIP every 4 hours, and again at 24 hours. He confirmed he signed the orders, but stated Psychiatrist B should have seen and evaluated Patient #6 after 24 hours because he had returned from vacation at that point.

Patient #6 was in 4 point restraints and/or seclusion beyond 24 hours and was not evaluated in person by a physician or psychiatrist prior to renewal of orders for continued seclusion and/or restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure face-to-face assessments were comprehensive and included all necessary information for 1 of 4 patients (Patient #6) for whom face-to-face assessments were conducted and whose records were reviewed. This resulted in a lack of information on which to base additional intervention and treatment decisions and had the potential for an adverse outcome. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior..." The policy also stated at the time of the 1 hour face-to-face the physician/LIP/RN will evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, the need for continued restraint or seclusion, and revise the plan of care as needed. This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

a. Patient #6's record included a "Restraints Monitor" note, on 2/27/17 at 1:02 AM, which documented restraints were applied at 12:30 AM for physical aggression and he was a danger to himself and others. The note documented the type of restraints used were seclusion and locking synthetic leather restraints. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine 100 mg IM, another medication used for psychosis and sedation.

A nurse's note, dated 2/28/17 at 3:31 AM, signed by RN F documented the face-to-face assessment was completed, 3 hours after he was placed into restraints/seclusion. The note stated "Face to face assessment completed. Pt [Patient #6] remains at risk for violent behavior. Pt verbalizing his need to stab staff as he is being told to and he could not "Rat out." Pt was explained [sic] why restraints were on and criteria for release. CMS [circulation, motion, sensation] good in extremities. Currently rt [right] leg released from restraint."

The face-to-face did not include documentation of Patient #6's reaction to the intervention and medical condition. There was no documentation of vital signs, cardiac status or assessment, respiratory status or assessment, bowel or gastrointestinal assessment, or urologic assessment. There was also no documentation of Patient #6's reaction or response to the medications which were administered.

b. Patient #6's record included a nurse's note, on 2/28/17 at 3:02 AM. The note documented while Patient #6 was in seclusion, he kicked at the seclusion room door around 2:30 AM. RN K documented local law enforcement were called and when they arrived Patient #6 was restrained in 4 point restraints, all 4 extremities, in the face down position on his bed. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

A nurse's note, dated 2/28/17 at 4:54 AM, RN K documented "Face to face nurses [sic] note at about 0300 [3:00 AM] this was done. Pt's [Patient #6] reaction to intervention of being in leather restraints is calm and answering questions [sic] Pt has good circulation to all extremities. CRT [capillary refill time] < 2 sec [seconds] all ext [extremities]. Pulses strong. Pt is breathing non labored. He is calm now."

The face-to-face did not include documentation of Patient #6's vital signs, bowel or gastrointestinal assessment, or urological assessment. There was no documentation of his reaction or response to the medications which were administered.

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed the face-to-face 1 hour assessments were not comprehensive for Patient #6 and did not include the required elements stated in the policy.

The 1 hour face-to-face evaluation for Patient #6 was not comprehensive and did not include the information necessary on which to base future interventions and treatment.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0182
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a psychiatrist, or LIP, was consulted after the face-to-face assessments were completed for 1 of 4 patients (Patient #6) for whom face-to-face assessments were completed and whose records were reviewed. This resulted in the potential for patients to not receive additional interventions or treatments. Findings include:

A facility policy "Patient Restraint/Seclusion," effective 6/03/14, stated "The RN or physician assistant with demonstrated competence must consult the attending physician or LIP who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. ("As soon as possible" is to be as soon as the attending physician is able to be reached by phone or in-person.)" This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6 was placed in 4 point restraints, all extremities, 2 times from 2/27/17 until his discharge on 2/28/17. The face-to-face assessment was not completed within 1 hour of placing Patient #6 into restraints and seclusion for both occurrences.

a. Patient #6's record included a "Restraints Monitor" note, on 2/27/17 at 1:02 AM, which documented restraints were applied at 12:30 AM for physical aggression and he was a danger to himself and others. The note documented the type of restraints used were seclusion and locking synthetic leather restraints.

A nurse's note, dated 2/27/17 at 3:31 AM, RN F documented the face-to-face assessment was completed. There was no documentation a psychiatrist was consulted after completion of the face-to-face.

b. Patient #6's record included a nurse's note, on 2/28/17 at 3:02 AM, which documented while he continued to be in seclusion he started kicking at the seclusion room door at around 2:30 AM. RN K documented local law enforcement were called and when they arrived Patient #6 was restrained, all 4 extremities, in the face down position on his bed.

A nurse's note, dated 2/28/17 at 4:54 AM, RN K documented "Face to face nurses [sic] note at about 0300 [3:00 AM] this was done." There was no documentation a psychiatrist was consulted after completion of the face-to-face.

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed there was no documentation in Patient #6's record a psychiatrist was consulted after the face-to-face assessments.

During an interview at 12:40 PM on 4/04/17, Psychiatrist B stated all the physicians discussed Patient #6 and his safety, and the decision was to keep him isolated but was not aware of the continued use of restraints.

Patient #6's psychiatrist was not consulted after the completion of the face-to-face by an RN.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, staff education transcript review, and staff interview, it was determined the facility failed to ensure nursing assignments were based on staff competency and patients' needs for 1 of 4 patients (Patient #6) who were in s restraints and whose records were reviewed. This failure resulted inadequate assessments and resulted in poor quality of care. Findings include:

The facility policy titled "Assignments (PCS)," approved 12/08/16, stated " Patient Care Assignments are based upon specific patient needs and nursing care competency of available personnel. Assignments include the following:

a. Patients rooms and bed numbers
b. Times for meetings, inservices and education programs.
c. Code Team assignment, if applicable.
d. Notation of students assigned to specific patients. ...
e. Special duty area assignments."

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

An observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. The BHU staff assignment sheet for the night of 2/27/17 was reviewed. RN K was listed as caring for 5 patients, including Patient #6. There was no documented charge RN or preceptor on the staff sheet.

RN K was interviewed at 12:40 PM, on 3/06/17. His orientation was discussed. He stated he had not yet received restraint training or attended the Non-Violent Intervention Training.

The Director of BHU was interviewed on 3/06/17, at 3:05 PM. She stated RN K had worked 4 nights of orientation and was being precepted by the charge nurse, RN M, when RN K cared for Patient #6 in seclusion. She confirmed RN K had not received his NVCI or restraint training.

It was unclear why he was assigned a patient in restraints and seclusion.

b. A Labor and Delivery CNA monitored Patient #6 on 2/28/17, from 7:00 AM until 11:28 PM.

The CNA's education transcript was reviewed. She completed a basic Healthstream (the facility's online education program), however, she had not participated in the NVIT or demonstrated restraint competency since 2014.

The CNA was interviewed on 3/02/17 at 3:15 PM. She stated she had worked in the ER where there were restrained patients, however, because she now worked in Labor and Delivery, she no longer took the restraint courses. She stated she was told to sit outside the room and observe the patient every 15 minutes, so she looked through the window of the door to the seclusion room every 15 minutes, and filled out their form.

The Director of the BHU was interviewed on 4/03/17, starting at 2:15 PM. She stated the Healthstream modules were a adjunct to the staff restraint training, which they had previously done in a skills fair format. In 2016, some of the staff were assigned a module on restraint documentation by the Clinical Educator, rather than the standard restraint module. Additionally, she stated in 2016 the facility had incorporated restraint training into the NVIC. She stated the NVIC course allowed for facilities to put in training according to their own restraint policies. She stated during this part of the course, staff was required to do a return demonstration of restraint use.

It was unclear why a CNA without updated restraint training was assigned to a restrained and secluded patient.

The facility failed to assign staff who was adequately trained, educated and competent to care for Patient #6.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to define and educate RNs on chemical restraints and their use which directly impacted 1 of 2 patients (Patient #6) who received chemical restraints and whose records were reviewed. This had the potential to result in serious harm and/or adverse reactions for patients receiving care in the facility related to behavioral problems and diagnosis. Findings include:

A facility policy was requested regarding the use of chemical restraints on 3/01/17, the Clinical Quality Coordinator stated there was not a policy for chemical restraints.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Medications were ordered by Psychiatrist A, Psychiatrist B, and Psychiatrist C, for Patient #6 on a PRN basis to help with anxiety, agitation, and psychosis. The medication orders were written as follows:

- 2/06/17 at 9:00 AM: Haldol 10 mg PO every 6 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Ativan 2 mg PO every 6 hours PRN, PRN Reason: Agitation, Special Instructions: Give with Haldol and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Benadryl 50 mg PO every 6 hours PRN, PRN Reason: Agitation/Extrapyramidal Symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Haldol 10 mg PO every 4 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Ativan 2 mg PO every 4 hours PRN, PRN Reason: Agitation, Special Instructions: Give Haldol and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Benadryl 50 mg PO every 4 hours PRN, PRN Reason: Agitation/Extrapyramidal symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/24/17 at 4:15 PM: Ativan 2 mg PO every 3 hours PRN, PRN Reason: Agitation, Special Instructions: If possible, try to give first before antipsychotic. However, may give with Haldol and Benadryl if needed or give IM if patient unable to take oral or violent.

Medications were not given as ordered. Examples include:

- On 2/09/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 7:55 AM and 12:44 PM. However, the order was for the medications to be given as needed every 6 hours. The orders for these medications to be given every 4 hours had not been received until after the second dose. Additionally, at 7:55 AM RN L documented the combination of medications were given per Patient #6's request due to anxiety, not for agitation/psychosis.

- On 2/10/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 10:09 AM per Patient #6's request. On 2/12/17, 2/13/17, 2/19/17, and 2/21/17 Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO twice per Patient #6's request. However, the order for the combination of medications was for agitation/psychosis.

During his admission, Patient #6 received the combination of medications 19 out of 28 days. On 2/09/17 to 2/13/17, 2/19/17, 2/21/17, 2/22/17, 2/24/17, and 2/26/17, Patient #6 received the combination of medications 2 times a day. On 2/20/17, he received the combination of medications 3 times. On 2/27/17, he received the combination 4 times.

It was unclear whether the use of the combination of medications was being used to restrict or control Patient #6's behavior.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. The practice of using chemical restraints in the facility was discussed. She stated "We talk about that we do not use chemical restraints. The order has to reflect the reason for the medication." However, she agreed chemical restraints are being used in the emergency room .

During a telephone interview at 11:30 AM on 3/23/17, the CNO confirmed administering Haldol, Ativan, and Benadryl at the same time was considered a chemical restraint and should have been treated as one for Patient #6.

During an interview at 9:35 AM on 4/04/17, RN A confirmed medications were being given to Patient #6 at his request. He also confirmed they were not given as ordered.

Patient #6 was did not receive his medications as ordered and the RNs failed to recognize the use of chemical restraints.
VIOLATION: QAPI Tag No: A0263
Based on staff interview, review of policies, incident reports, and review of QAPI documents, it was determined the hospital failed to ensure an effective, ongoing, hospital-wide, data-driven QAPI program was developed and implemented regarding restraints. It was also determined the hospital's Governing Body failed to provide leadership and oversight of the QAPI program. This resulted in the inability of the hospital to monitor the quality of services it provided. Findings include:

Refer to A-0273 as it relates to the facility's failure to collect and analyze data related to the use of restraint and seclusion.

Refer to A-0283 as it relates to the facilities failure to ensure the QAPI program used restraint and seclusion data to identify opportunities for improvement, and the facility's failure to identify high-risk, high-volume, or problem prone areas in order to focus its QAPI program.

Refer to A-0286 as it relates to the facilities failure to ensure adverse patient events were reported, analyzed, and actions were taken to prevent further incidents for patients on whom restraints were used.

These failures seriously impeded the facilities ability to safely care for patients requiring restraints and/or seclusion.