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.

EASTERN IDAHO REGIONAL MEDICAL CENTER 3100 CHANNING WAY IDAHO FALLS, ID 83404 Oct. 3, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review, and staff interview, it was determined the hospital failed to ensure patients were informed of the process to file a grievance. This directly affected 2 of 4 adult patients (#1 and #2) who were admitted involuntarily and whose records were reviewed. The lack of information had the potential to prevent patients from filing grievances regarding their care. Findings include:

The facility's policy, "BHC - PATIENT GRIEVANCE," implemented 6/14/11, stated "All patients will be notified of the Patient Grievance Procedure during the orientation process within 24 hours after admission to the BHC. In situations when the patient is not at the mental or emotional status to be oriented, it shall be done at the earliest appropriate time thereafter. Delays in informing the patient shall be charted in the medical record."

1. Patient #1 was a [AGE] year old female admitted involuntarily to the BHC on 7/29/17, with a diagnosis of psychosis. She was discharged on [DATE].

Patient #1's record included a form titled "Conditions of Admission." The form stated, "I have received the pamphlet entitled 'Your Patient Rights & Responsibilities' and understand the BHC grievance process as it has been explained to me." The form was not signed by Patient #1. The form included a note signed by an RN, stating Patient #1 was admitted involuntarily. Patient #1's record did not include documentation stating she was informed of the process to file a grievance, within 24 hours of admission. Her record did not include documentation of a delay in informing her of the process to file a grievance.

During an interview on 9/29/17 beginning at 9:20 AM, the BHC Administrator stated the BHC did not obtain patient signatures on the form titled "Conditions of Admission" from patients who were admitted on an involuntary status. He confirmed there was no documentation stating the patients were informed of the process to file a grievance.

Patient #1 was not informed of the process to file a grievance.

2. Patient #2 was a [AGE] year old male admitted involuntarily to the BHC on 7/01/17, with a diagnosis of psychosis. He was discharged on [DATE].

Patient #2 was admitted involuntarily. His printed record, provided by the facility on 9/27/17, did not include a form titled "Conditions of Admission." The form was requested on 10/02/17, but was not provided. Patient #1's record did not include documentation stating he was informed of the process to file a grievance, within 24 hours of admission. His record did not include documentation of a delay in informing him of the process to file a grievance.

During an interview on 9/29/17 beginning at 9:20 AM, the BHC Administrator stated the BHC did not obtain patient signatures on the form titled "Conditions of Admission" from patients who were admitted on an involuntary status. He confirmed there was no documentation stating the patients were informed of the process to file a grievance.

Patient #2 was not informed of the process to file a grievance.

3. Patient #3 was a [AGE] year old female admitted involuntarily to the BHC on 9/22/17, with a diagnosis of psychosis. She was currently a patient as of 9/28/17.

Patient #3's record included a form titled "Conditions of Admission." The form stated, "I have received the pamphlet entitled 'Your Patient Rights & Responsibilities' and understand the BHC grievance process as it has been explained to me." The form was not signed by Patient #3. The form included a note signed by an RN, stating Patient #3 was admitted involuntarily. Patient #3's record did not include documentation stating she was informed of the process to file a grievance, within 24 hours of admission. Her record did not include documentation of a delay in informing her of the process to file a grievance.

During an interview on 9/29/17 beginning at 10:00 AM, the BHC DON confirmed there was no documentation that Patient #3 was informed of her right to file grievances.

Patient #1 was not informed of the process to file a grievance.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**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 the patients' POCs were modified to reflect the use of restraint or seclusion for 1 of 4 patients (Patient #2) for whom restraints and/or seclusion were used. This resulted in a lack of direction to staff regarding ways to decrease restraint/seclusion usage and ways to keep the patient safe. Findings include:

The facility's policy "Patient Restraint/Seclusion" effective 11/23/15, stated "The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications."

1. Patient #2 was a [AGE] year old male admitted on [DATE], with a diagnosis of psychosis. He was discharged on [DATE].

Patient #2's record included documentation of 1 minute physical holds for administration of IM medications at the following times:
- 7/07/17 at 8:25 PM
- 7/08/17 at 3:50 AM
- 7/08/17 at 10:22 AM
- 7/08/17 at 4:25 PM
- 7/08/17 at 10:25 PM
- 7/09/17 at 7:02 PM

Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM.

Patient #2's record included a treatment plan signed by 4 members of the treatment team on 7/03/17. The plan did not include the use of restraints or physical holds. His treatment plan was not updated on 7/07/17 or 7/08/17, when physical holds were implemented.

Patient #2's record included an updated treatment plan signed by 6 members of the treatment team on 7/10/17. The plan included an active problem titled "Restraint/Seclusion," with 2 goals listed as follows:

"PT'S THREATENING, VIOLENT BEHAVIOR WILL DECREASE WHILE AT BHC."
"PT'S NEED FOR PHYSICAL HOLDS WILL DECREASE BY DC."

The interventions listed for both goals were medication administration, and 1 to 1 observation. The treatment plan did not include an assessment of the situation that led to Patient #2's need for physical holds, or of his response to the physical holds. It did not include an evaluation of the restraint use. His POC did not include direction to staff regarding use of restraints, or of interventions to prevent the use of restraints.

Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM. A form titled "Documentation of Restraint/Seclusion for Violent/Self-Destructive Behavior" signed by the RN on 7/10/17 at 11:00 AM, stated "Pt becoming assaultive [with] staff/police during med override resulting in physical hold/police intervention."

A clinical note signed by the RN on 7/10/17 at 11:00 AM, stated "Pt needed physical hold with police involvement and transport to safe area."

The RN who completed Patient #2's restraint documentation was interviewed on 9/28/17 at 12:15 PM. He was asked about the police involvement in Patient #2's physical hold on 7/10/17. He stated he believed 3 police officers were involved during the physical hold, and was unable to state whether they had hands on Patient #2. He stated the BHC staff could call the police directly, but it was more typical for the staff to call the hospital security officers, who would call in the city police for reinforcement as needed.

During an interview on 9/28/17 at 2:45 PM, the DON stated security officers and/or on duty police officers were involved with several physical holds to administer medication to Patient #2. The DON reviewed Patient #2's record and confirmed his treatment plan was not updated to reflect his need for physical holds initiated on 7/07/17. He confirmed the update to the treatment plan on 7/10/17 did not include specific interventions or direction to staff to achieve the goal of decreased physical holds. He stated the treatment plan did not include the use of security officers or on duty police officers to restrain Patient #2.

Patient #2's treatment plan was not updated to include assessment and evaluation related to use of restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility to ensure policies were followed for specifying the type of restraint in their orders for 1 of 4 patients (Patient #6) who had restraints ordered and whose records were reviewed. This resulted in orders which were unclear as to the type of restraints used and had the potential for the inappropriate use of behavioral restraints. Findings include:

The policy "Patient Restraint/Seclusion," dated 11/23/15, stated "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." This order was not followed.

Patient #6 was a [AGE] year old female admitted to BHC on 7/17/17, for psychosis. Patient #6 was brought in to the ED by police from a crisis center for abnormal behavior.

Patient #6's nursing progress notes stated she was restrained by "physical holding" and "seclusion/restraint" on 7/17/17 at 7:02 PM. At 7:49 PM, the progress notes stated Patient #6 was still restrained by "physical holding" and "seclusion/restraint." A nursing progress note at 9:52 PM on 7/17/17 stated Patient #6 was restrained in "4 point restraints."

Patient #6's record included an order for "physical holding" and "seclusion/restraint," dated 7/17/17 at 7:02 PM. The "seclusion/restraint" order did not specify what type of restraint should be utilized. Additionally, the order did not specify whether to restrain 2 or 4 extremities.

During an interview at 10:25 AM on 9/29/17, the RN Clinical Supervisor reviewed Patient #6's record and confirmed the order was for physical hold and seclusion/restraint. She also confirmed the order did not specify the type of restraint.

The facility failed to follow their policy when ordering restraints and to identify the type of restraints used for Patient #6.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**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 restraints were discontinued at the earliest possible time for 2 of 4 patients (#2 and #7), who were restrained and whose records were reviewed. This resulted in patients being restrained longer than was necessary to ensure their safety. Findings include:

A facility policy "Patient Restraint/Seclusion," dated 11/23/15, 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." This policy was not followed.

1. Patient #7 was a [AGE] year old male admitted to BHC on 5/08/17, for major depressive disorder. He was discharged from a residential treatment center due to no participation in programming or therapy, and acting out in the unit by throwing chairs and jumping on top of the nurse's station.

Patient #7's record included a "Patient Observation Record," dated 5/09/17, which documented he was on the unit and quiet from 2:00 PM to 2:30 PM. The observation record also documented Patient #7 attended group therapy from 1:15 PM to 1:45 PM. At 2:45 PM, the record documented Patient #7 was in a "safe room." There was no further documentation why he was placed in the safe room.

A restraint/seclusion form documented Patient #7 was in seclusion on 5/09/17 from 2:45 PM to 4:00 PM. The form documented he was initially in a physical hold from 2:30 PM to 2:45 PM, for agitation and yelling. At 2:45 PM, Patient #7 was placed in seclusion and he was beginning to calm down and was crying. From 3:00 PM to 4:00 PM, Patient #7 was described on the form as quiet. The observation form documented Patient #7 was not removed from seclusion until 4:00 PM, 1 hour after he was first documented as beginning to calm and quiet.

During an interview at 1:35 PM on 10/02/17, the interim DON reviewed Patient #7's record and confirmed the restraint/seclusion form documented he was quiet for 45 minutes prior to him being released from seclusion. He stated Patient #7 should have been removed from seclusion earlier.

Patient #7 remained in seclusion longer than necessary per his documented behavior.





2. Patient #2 was a [AGE] year old male admitted on [DATE], with a diagnosis of psychosis. He was discharged on [DATE].

Patient #2's record included documentation of 1 minute physical holds for administration of IM medications at the following times:
- 7/07/17 at 8:25 PM, behavior documented as agitated and yelling
- 7/08/17 at 3:50 AM, behavior documented as agitated and yelling, hitting staff, spitting at staff
- 7/08/17 at 10:22 AM, behavior documented as agitated and yelling
- 7/08/17 at 4:25 PM, behavior documented as agitated
- 7/08/17 at 10:25 PM, behavior documented as agitated and yelling
- 7/09/17 at 7:02 PM, behavior documented as agitated and yelling, threats
On each of these occasions, the injection was administered and Patient #2 was released from the hold within 1 minute.

Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM. His behavior was documented as agitated and yelling at 10:15 AM. Patient #2's medication record documented he was given an IM injection at 10:24 AM, 9 minutes after the hold was initiated. At 10:30 AM, he remained in a physical hold and he continued to be agitated and yelling. There was no documentation of threatening or violent behavior. His restraint record documented release from the physical hold at 10:45 AM, 21 minutes after his injection was administered. There was no documentation stating why he was not released after the injection, as he was on the previous holds.

During an interview on 9/28/17 at 2:45 PM, the DON reviewed Patient #2's record and confirmed the IM injection was documented at 10:24 AM. He stated the RN administered the injection, then left the room to dispose of the syringe and needle, while Patient #2 remained in a physical hold. He confirmed the RN documented the injection at 10:24 AM, after it was administered. The DON confirmed the documentation of the physical hold on 7/10/17, did not state why Patient #2 continued to be held for 21 minutes after his injection was administered.

The facility failed to ensure Patient #2's physical hold was discontinued at the earliest possible time.
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 qualified 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:

The policy "Patient Restraint/Seclusion," effective 11/23/15, 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 female admitted to BHC on 7/17/17, for psychosis. Patient #6 was brought in to the ED by police from a crisis center for abnormal behavior.

Patient #6's record included a 1 hour face-to-face evaluation form, dated 7/17/17, which documented the face-to-face was completed at 7:50 PM. The face-to-face documented Patient #6 was placed in physical restraints of all 4 extremities and in seclusion. However, this was not consistent with the restraint/seclusion observation form in Patient #6's record.

The restraint/seclusion observation form, dated 7/17/17, documented Patient #6 was in seclusion from 7:00 PM to 8:45 PM. At 8:50 PM, the form documented Patient #6 was placed in restraints for agitation, yelling, and biting. The form documented Patient #6 was in restraints until 10:45 PM. There was no documentation she was in seclusion after 8:50 PM.

When Patient #6 was taken out of seclusion and placed into physical restraints, to 4 extremities, there was no documentation in her record of a 1 hour face-to-face for the restraints.

During an interview at 1:05 PM on 10/02/17, the interim DON reviewed Patient #6's record and confirmed there was 1 face-to-face form documented by the RN, for seclusion and restraint. He confirmed at the time the face-to-face was documented as completed by the RN, 7:50 PM, Patient #6 was not in restraints. The interim DON also confirmed when Patient #6 was taken out of seclusion and placed in restraints there should have been a second 1 hour face-to-face completed.

Patient #6 did not have a 1 hour face-to-face completed after she was placed in physical restraints. Additionally, the 1 hour face-to-face in the record was inconsistent with the seclusion/restraint documentation on the observation form.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and medical record review, it was determined the hospital failed to ensure a description of the behavior and intervention used was not documented for 1 of 4 restrained patients (Patient #2) whose records were reviewed. The lack of documentation prevented the hospital from evaluating the efficacy of the restraint. Findings include:

Patient #2 was a [AGE] year old male admitted on [DATE], with a diagnosis of psychosis. He was discharged on [DATE].

Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM. The documentation did not describe the interventions used during the physical hold. Examples include:

a. A form titled "Documentation of Restraint/Seclusion for Violent/Self-Destructive Behavior" signed by the RN on 7/10/17 at 11:00 AM, stated "Pt becoming assaultive [with] staff/police during med override resulting in physical hold/police intervention."

A clinical note signed by the RN on 7/10/17 at 11:00 AM, stated "Pt needed physical hold with police involvement and transport to safe area."

The 2 documents did not state how many police officers were present or how the police were involved in the physical hold.

b. The form titled "Documentation of Restraint/Seclusion for Violent/Self-Destructive Behavior" signed by the RN on 7/10/17 at 11:00 AM, documented Patient #2 was placed in a physical hold on 7/10/17 at 10:15 AM, and remained in the hold until 10:45 AM. The document included the first names of 6 people who participated in the physical hold. It did not include titles of the people involved and it did not include names of police officers.

The document did not state how many people had hands on Patient #2 during the physical hold. It did not state what type of hold was used, or what position he was in during the hold.

The RN who completed Patient #2's restraint documentation was interviewed on 9/28/17 at 12:15 PM. He was asked about the police involvement in Patient #2's physical hold on 7/10/17. He stated he believed 3 police officers were involved during the physical hold, and was unable to state whether they had hands on Patient #2. He stated the BHC staff could call the police directly, but it was more typical for the staff to call the hospital security officers, who would call in the city police for reinforcement as needed. He stated the facility's security department was staffed by off-duty city police officers and was unable to state whether the officers present were on-duty hospital security officers or city police officers. He confirmed the restraint documentation did not include the names of the officers or the number of officers present during the physical hold. The RN was asked if an incident report was completed due to the involvement of the police. He stated an incident report was not completed.

The Security Supervisor was interviewed on 9/28/17 at 12:50 PM. He stated the hospital had 2 security officers on duty between 11:00 AM and 3:00 AM, with 1 officer on duty from 3:00 AM to 11:00 AM. He stated 1 officer was on duty during the time of Patient #2's physical hold from 10:15 AM to 10:45 AM, and the other 2 officers present were city police. He stated the facility staff have the option of calling 911 for police assistance, or calling hospital security, and hospital security may call city police for back up if necessary. He stated hospital security officers and city police officers may or may not be directly involved in a physical hold. He confirmed the officers did not document their involvement in Patient #2's physical hold on 7/10/17.

Patient #2's record did not include documentation of the interventions used during a physical hold.