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.

BATON ROUGE GENERAL MEDICAL CENTER 3600 FLORIDA BLVD BATON ROUGE, LA 70806 March 20, 2013
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure patients' rights to dignity and comfort were provided as required by Louisiana Revised Statute 28:171(G) as evidenced by observation of patients wearing paper scrubs or a hospital gown while in the day room of the behavioral health unit on 03/18/13 (#1, #2, #4, #5, #9, #10) and 03/19/13 (#1, #4, #6, #7, #9, #10) for 8 of 8 patients observed who had orders for suicide precautions (hospital policy required patients to wear paper scrubs) from a total of 10 sampled patients (#1-#10). Patient #5 was taken to court on 03/12/13 while wearing paper scrubs, socks, no shoes, and no jacket. Findings:

Review of Louisiana Revised Statute 28:171(G) revealed every patient shall have the right to wear his own clothes; to keep and use his personal possessions, including toilet articles, unless determined by a physician, medical psychologist, or psychiatric mental health nurse practitioner that these are medically inappropriate and the reasons are documented in his/her medical record. Further review revealed the patient shall also be allowed to spend a reasonable sum of his own money for canteen expenses and small purchases, and to have access to individual storage spaces for his private use. If the patient is financially unable to provide these articles for himself/herself, the treatment facility shall provide a reasonable supply of clothing and toiletries.

Review of the hospital policy titled "Patient Rights-Mental Health Code", number BHS RTS 06, effective 05/84, revised 06/06, and presented by S3Regulatory Coordinator as the current policy for patient rights related to mental health, revealed the purpose of the policy was to ensure all patients admitted to the BHU were aware of their rights as determined by the Mental Health Code (Louisiana Revised Statute 28:171). Further review revealed the hospital's policy was to ensure that all patients were treated with respect and dignity. Further review revealed a patient's rights may be restricted only by a physician's order and with clinical justification. Any restriction must be communicated to the patient, family, as authorized, and the Mental Health Advocate or patient's attorney. Further review revealed the treatment plan should reflect the restriction as it applies to the patient's plan of care, and the restriction must be reviewed by the physician for therapeutic effectiveness and necessity at least every 24 hours.

Review of the hospital's document titled "Rights Of persons Suffering From Mental Illness And Substance Abuse Summarized In Layman's Terms", presented by S4Behavioral Health Unit (BHU) Manager when asked if she had the Mental Health Advocacy Bill of Rights, revealed under the section titled "Right To Keep Your Possessions" the following: "You have the right to wear your own clothes and keep and use your personal possessions. You have the right to individual storage space for your private use".

Review of the hospital policy titled "Assessment of the Patient at Risk for Suicide/Violence", number BHS CC 14, effective 03/11, revised 02/12, and presented by S3Regulatory Coordinator as the current policy for suicidal precautions, revealed a physician's order must be given to initiate and discontinue suicide precautions. Further review revealed the patient's room and environmental surroundings would be assessed for suicidal risks, the patient would be placed in a paper gown for safety purposes.

Patient #1
Patient #1 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions.

An observation on 03/18/13 at 10:30 a.m. revealed Patient # 1 was sitting in the patient's activity room with 9 other patients and Patient #1 was wearing paper scrubs.

An observation on 03/19/13 at 9:50 a.m. revealed Patient #1 was sitting in the patient's activity room with 10 other patients and Patient #1 was wearing paper scrubs.

An interview on 03/19/13 at 3:55 p.m. was conducted with Patient #1 in his room. The patient was sitting in a chair and was wearing paper scrubs. The patient was asked about the paper scrubs he was wearing. Patient #1 indicated he was given paper scrubs to wear upon admit. The patient further indicated that the paper scrubs were thin and he gets cold at times and would ask staff for a blanket. Patient #1 indicated he had been admitted to the hospital with clothes, but was not sure what happened to his clothes. There was only a white T-shirt and a pair of boxer shorts observed in the patient's closet.

The review of Patient #1's Admission Inventory Sheet in his medical record revealed a blank sheet.

Patient #2
Observation of patients seated in the day room of the behavioral health unit on 03/18/13 at 10:20 a.m. revealed Patient #2 was seated in a geri-chair in the day room wearing a hospital gown.

Observation of patients seated in the day room of the behavioral health unit on 03/19/13 at 9:50 a.m. revealed Patient #2 was in paper scrubs

Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Further review revealed a CEC was signed on 03/10/13 at 3:52 p.m. due to Patient #2 being gravely disabled.

Review of Patient #2's admit physician orders received on 03/08/13 at 5:45 p.m. revealed an order for suicide precautions, agitation precautions, and paper scrubs.

Review of Patient #2's "Admission Inventory Sheet" dated 03/08/13 at 8:15 p.m. revealed the following items: 1 pajama top, 1 gown, 1 pair of sweat pants, and 1 robe.

There was no documented evidence in Patient #2's medical record that explained why she was allowed to wear a hospital gown rather than paper scrubs as ordered. Further reviewed revealed no documented evidence of clinical justification for not allowing her to wear her own clothing and not adhering to Patient #2's Mental Health Rights according to the law.

In a face-to-face interview on 03/20/13 at 10:10 a.m., PsychiatristS12 indicated he admitted most patients on suicide precautions until the psychiatrist evaluated the patient. He further indicated he usually decreased the precautions, such as leaving the patient on suicide precautions but saying the patient can wear their own clothes. When asked what he expected when he ordered agitation precautions, PsychiatristS12 indicated it means that patient has medication orders to be given as needed for agitation. He further indicated ordering the precautions is a trigger for staff to watch a patient closely who the staff may not know has a history of violence. When asked if agitation was synonymous with violence, PsychiatristS12 answered "yes". He further indicated any patient on Track II (area of unit where Patients #1, #2, #4, #5, #6, #7, #9, #10 were located) who had a diagnosis of [DIAGNOSES REDACTED]#2 probably didn't need to be on suicide precautions since 03/14/13 or 03/15/13. He confirmed Patient #2 was in a hospital gown but soul be able to wear her own clothes.

Patient # 4
Patient # 4 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/17/13 revealed Patient #4 was placed on Suicide, Agitation and Fall Precautions.

An observation on 03/18/13 at 10:30 a.m. revealed Patient # 4 was sitting in the patient's activity room with 9 other patients and Patient #4 was wearing paper scrubs.

An observation on 03/19/13 at 9:50 a.m. revealed Patient #4 was sitting in the patient's activity room with 10 other patients and Patient #4 was wearing paper scrubs and was wrapped in a blanket.

An interview on 03/19/13 at 3:35 p.m. was conducted with Patient #4 in the patient's activity room. The patient was observed wearing paper scrubs and was wrapped in a blanket. The patient was asked about the paper scrubs he was wearing. Patient #4 indicated he was given paper scrubs to wear upon admit. The patient further indicated that everyone (patients) wears paper scrubs. The patient further indicated the paper scrubs are not very warm and that he asked staff for a blanket today. Patient #4 indicated he had been admitted to the hospital with clothes and they were locked up somewhere.

A review of Patient #4's Admission Inventory Sheet in his medical record revealed the following articles of clothes: 1 brown belt, 1 brown pair of shorts, 1 blue shirt, 1 white shirt and 1 pair of black shoes.

Patient #5
Observation of patients seated in the day room of the behavioral health unit on 03/18/13 at 10:20 a.m. revealed Patient #5 was seated in a chair against the wall dressed in paper scrubs.

Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. that revealed he had a history of Chronic Paranoid Schizophrenia with bizarre behavior, flight of ideas, was unable to take care of himself, was a danger to himself, and was gravely disabled. Patient #5 had a CEC (coroner's emergency certificate) signed on 02/13/13 at 10:35 a.m. that revealed he had bizarre behavior with flight of ideas, was not caring for himself, and was gravely disabled.

Review of Patient #5's physician orders revealed S8Psychiatrist ordered Patient #5 to be on suicide precautions, detox precautions, fall precautions, and "agitation precautions/paper scrubs" at admit on 02/12/13 at 9:30 a.m. Further review revealed he remained on agitation precautions until S8Psychiatrist wrote an order to discontinue it on 03/18/13 at 9:20 a.m. and included that Patient #5 could wear hs own clothes.

Review of Patient #5's nursing flowsheets revealed S21RN (registered nurse) documented that Patient #5 went to court on 03/12/13 at 8:45 a.m. accompanied by a sheriff's deputy and S10Mental Health Tech (MHT).

There was no documented evidence in Patient #5's medical record of clinical justification for not allowing him to wear his own clothing and not adhering to Patient #5's Mental Health Rights according to the law.

Review of Patient #5's "Admission Inventory Sheet" documented on 03/18/13 at 4:25 p.m. by S6MHT revealed the following clothing was inventoried: 1 jacket, 4 shirts, 2 pair of pants, 5 pair of socks, 2 T-shirts, 2 underwear, and 2 pair of shoes.

In a face-to-face interview on 03/19/13 at 4:45 p.m., S21RN indicated she worked as the day RN on 03/12/13 when Patient #5 went to court. She further indicated she was in another patient's room when she got a call telling her that the sheriff's deputy was here to pick up Patient #5. S21RN indicated Patient #5 was already gone when she came out the other patient's room. She further indicated she was present when Patient #5 returned from court on 03/12/13, and he was dressed in paper scrubs. S21RN indicated she wasn't aware Patient #5 was going to court, and it was not reported to her during the shift report that morning. She further indicated patients were not supposed to go to court in paper scrubs, but she didn't know if that was written in a policy. She further indicated it was told to her by someone but couldn't remember who told her that patients weren't supposed to go to court in paper scrubs.

In a face-to-face interview on 03/20/13 at 8:00 a.m., S8Psychiatrist, when informed that Patient #5's treatment plan updates documented during the treatment team meetings revealed no mention of Patient #5 being on suicide precautions, S8Psychiatrist indicated Patient #5 remained at risk for hurting himself through self-neglect or impulsivity. He confirmed the language in the suicide precaution policy should be integrated to include violence and not aggression. When asked what Patient #5 wore to court on 03/12/13, he indicated he believed he was in paper scrubs. He further indicated he never wrote an order for clothing when patients go to court. S8Psychiatrist indicated he'd never seen a patient in court in anything other than his/her own clothes. He further indicated he thought what a patient wears to court gets back to dignity, and he knew that the Mental Health Advocacy had a problem with Patient #5 going to court in paper scrubs. S8Psychiatrist indicated he wasn't pleased to see Patient #5 in court in paper scrubs.

In a face-to-face interview on 03/20/13 at 9:40 a.m., S8Psychiatrist, after having reviewed his progress notes for Patient #5, indicated there was more documentation related to violence rather than suicide.

In a face-to-face interview on 03/20/13 at 10:45 a.m., S10MHT indicated she accompanied Patient #5 to court on 03/12/13 with the sheriff's deputy. She further indicated she was told by another MHT 15 minutes before leaving that that she had to go to court with Patient #5. She further indicated she got to Patient #5 when the other MHT was rolling him out the door. S10MHT indicated Patient #5 was wearing paper scrubs, socks, no shoes, and no jacket. She further indicated it was cold enough outside for a jacket, and she wore a light jacket that day. She confirmed Patient #5 did not have a jacket on that day while he was being transported to court.

In a face-to-face interview on 03/20/13 at 1:15 p.m., S5RN Charge Nurse indicated she told the unit clerk on 03/12/13 to get Patient #5's security inventory sheet and take it to security to get his clothing. She further indicated the unit clerk called to tell her security couldn't find Patient #5's clothes. She further indicated since the unit did not have any "lost and found" items left by other patients, she had to send Patient #5 to court in paper scrubs. S5RN Charge Nurse indicated after Patient #5 had left, security came to the unit with Patient #5's clothes which were sent back to security. She indicated patient clothing was only stored in bins in the storage closet if the patient was allowed to wear their own clothing. She further indicated when a patient was ordered off suicidal precautions, the nursing staff would send for the patient's clothing from security.

Patient #6
Observation of patients seated in the day room of the behavioral health unit on 03/19/13 at 9:50 a.m. revealed Patient #6 was seated in a geri-chair dressed in paper scrubs.

Review of Patient #6's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #6's "Admission Inventory Sheet" dated 03/05/13 at 1:45 p.m. revealed she had 1 gown, 1 shirt, a pair of pants, a pair of shoes, and a pair of socks. Review of her "Admission Inventory Sheet" dated 03/05/13 at 6:00 p.m. revealed she had 1 gown, 1 mini-blanket, 2 pair of socks, 2 diapers and added on 03/08/13, with no documented evidence of the time or the author of the addition, was 1 shirt and 1 pair of pants.

There was no documented evidence in Patient #6's medical record of clinical justification for not allowing her to wear her own clothing and not adhering to Patient #6's Mental Health Rights according to the law.

Patient #7
Patient #7 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/19/13 revealed Patient #7 was placed on Suicide and Fall Precautions.

An observation on 03/19/13 at 9:50 a.m. revealed Patient #7 was sitting in the patient's activity room with 10 other patients and Patient #7 was wearing paper scrubs.

An interview on 03/19/13 at 3:15 p.m. was conducted with Patient #7. Patient #7 was in her room lying in bed watching television and was wearing paper scrubs. The patient was asked about the paper scrubs she was wearing. Patient #7 indicated the hospital staff took all her clothes and gave her paper scrubs to wear when she was admitted . She indicated the hospital told her she would get her clothes back when she was discharged from the hospital. There were no clothes observed in the patient's closet.

A review of Patient #7's Admission Inventory Sheet in her medical record revealed the following articles of clothes: 1 new pink gown, 1 new blue gown, 1 pair of new pink slippers and 4 pair of white underwear.

Patient #9
Patient #9 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED][DIAGNOSES REDACTED].

A review of the Admission Orders dated 03/07/13 revealed Patient #9 was placed on Agitation and Fall Precautions.

An observation on 03/18/13 at 10:30 a.m. revealed Patient # 9 was sitting in the patient's activity room with 9 other patients and Patient #9 was wearing a hospital gown.

A review of the Doctor's Order Sheet dated 03/19/13 at 9:30 a.m. revealed Patient #9 was discharged from Agitation Precautions and could wear her own clothes.

An observation on 03/19/13 at 9:50 a.m. revealed Patient #9 was sitting in the patient's activity room with 10 other patients and Patient #9 was wearing a hospital gown.

An observation on 03/20/13 at 11:40 a.m. was made of Patient # 9 sitting in the patient's activity room wearing a hospital gown.

An interview was conducted on 03/20/13 at 11:40 a.m. with Patient #9. The patient was asked about the hospital gown she was wearing. Patient #9 indicated the hospital staff took her clothes and gave her a hospital gown to wear when she was admitted . The patient further stated that she would prefer to be wearing her own clothes. The visitor sitting next to Patient #9 who identified herself as the patient's niece indicated that she would bring Patient #9 clothes back from the patient's home as soon as she was allowed to have her own clothes. Patient #9 and the niece indicated that staff had not informed them that Patient #9 could wear her own clothes.

The review of Patient #9's Admission Inventory Sheet in her medical record revealed a blank sheet.

Patient #10
Patient #10 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/15/13 revealed Patient #10 was placed on Agitation and Fall Precautions.

An observation on 03/18/13 at 10:30 a.m. revealed Patient #10 was sitting in the patient's activity room with 9 other patients and Patient #10 was wearing a hospital gown and was wrapped in a blanket.

An observation on 03/19/13 at 9:50 a.m. revealed Patient #10 was sitting in the patient's activity room with 10 other patients and Patient #10 was wearing a hospital gown and was wrapped in a blanket.

An interview on 03/20/13 at 11:50 a.m. was conducted with Patient #10. Patient #10 was asked about the hospital gown she was wearing. The patient indicated she had clothes when she was admitted to the hospital and the clothes were given to a relative to bring home. The patient indicated she was given a hospital gown to wear. Patient #10 further indicated that it gets cold in the activity room and she had to ask staff for a blanket.

The review of Patient #10's Admission Inventory Sheet in her medical record revealed the following article of clothing: a pair of socks.

In a face-to-face interview on 03/18/13 at 11:45 a.m., S3Regulatory Coordinator indicated the hospital did not have a policy and procedure for agitation precautions.

In a face-to-face interview on 03/20/13 at 8:00 a.m., S8Psychiatrist was asked what he expected to be done by the staff when he ordered agitation precautions. He presented a policy he was currently assisting in modifying that was derived from the hospital's policy on suicide risk assessment. S8Psychiatrist was asked again what he expected to be done by the staff when he ordered agitation precautions. He indicated agitation precautions referred to a policy they're currently working on. He further indicated at the time they worked on suicide precaution policies, the hospital had expanded the behavioral health unit to include a lower age group who had the potential to be more violent. He further indicated that by ordering suicide precautions, the staff would be cued to observing for suicide risk. When asked for a third time what he expected to be done by the staff when he ordered agitation precautions, S8Psychiatrist again referred to the suicide precaution policy and talked about safety-proofing the patient's environment and placing patients in paper scrubs. S8Psychiatrist, when asked how placing patients in paper scrubs provide more safety for patients than their own clothing, S8Psychiatrist indicated the paper scrubs don't have pockets. He further indicated that some patients cheek medications then place the medication in their pockets to be used for overdosing. He further indicated patients also can hide items found in their environment in their pockets that could be used to hurt themselves or other patients or staff. S8Psychiatrist indicated regular scrubs have strings attached to them which could be used as a means of hanging or strangulation. When asked about patient's right to dignity, S8Psychiatrist indicated patient "safety comes before dignity". He indicated that most patients would prefer to be in their own clothes.

Observation of the paper scrubs used for patients on the mental health unit provided by S2Director of Quality and Patient Safety revealed the pants did not have strings attached, and there was a pocket on the right buttock area. Further observation revealed the shirt had a pocket on the left chest and at the right lower hem.

In a face-to-face interview on 03/20/13 at 9:40 a.m., S8Psychiatrist, when shown the paper scrubs with 3 pockets that were used on the behavioral health unit, he indicated he didn't realize they had pockets, and he indicated there were no strings or loops on the pants. When S8Psychiatrist tore the scrub and saw that he could not tear the long strip apart, he indicated the torn length could be used by a patient to harm him/her self.

In a face-to-face interview on 03/20/13 at 4:00 p.m. with S4Behavioral Health Unit Manager and S1Chief Nursing Officer (CNO) present, S4BHU Manager indicated the physician usually wrote specifically what he wanted done when he wrote the order for agitation precautions. S4BHU Manager and S1CNO indicated agitation to them didn't mean violence or aggression. Both S4Behavioral Health Unit Manager and S1CNO indicated they were aware of the document presented ("Rights Of Persons Suffering From Mental Illness And Substance Abuse Summarized In Layman's Terms") but was not aware of the actual law related to patients' mental health rights.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on policy and procedure review, clinical record review, and staff interview, the hospital failed to ensure the patient's plan of care (Master Treatment Plan) was modified and updated with the use of restraints for 2 (#1, #3) of 3 (#1, #2, #3) sampled patients reviewed with restraints out of a total sample of 10. Findings:

Review of the hospital policy titled "Treatment Planning", policy number BHS TX GEN 02, effective 08/97, revised 01/13, and presented as the current care plan policy by S3Regulatory Coordinator, revealed the Multidisciplinary Treatment Plan included a summary of information obtained through interdisciplinary assessments that encompasses diagnoses, strengths and deficits, identified problems (psychiatric and medical) and an individualized plan of care based on individual needs and resources. Each patient would have a nursing care plan initiated by a RN within 24 hours of admission that would identify and prioritize psychiatric and medical problems based on the Nursing Admission Assessment, the Intake Assessment, and other available clinical data. The Multidisciplinary Treatment Plan would be developed within 72 hours of Admission. Further review revealed the Master Treatment Plan would be developed by the multidisciplinary treatment team and include problems to be addressed and related short-term goals, interventions to be implemented, and long-term goals (discharge criteria). The Multidisciplinary treatment team would meet weekly to review and update the Master Treatment Plan of each patient. Further review revealed on the Geriatric Psychiatric Unit, medical plans of care were to be utilized in the Master Treatment Plan and reviewed daily by a RN and revised as needed.


Patient #1
Patient #1 was admitted on [DATE] with diagnoses to include: atypical psychosis with delirium secondary to a recent CVA (cardiovascular accident) and chronic alcohol abuse, confusion, HTN (hypertension) and aggressive behavior.

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions.

A review of Patient #1's nursing flowsheet dated 03/17/13 at 10:45 p.m. revealed documentation that the patient was confused and argumentative with staff and became upset with staff and patient was unaware of his limitations. Patient was unable to be re directed and became more upset and 4 point restraint was initiated. Patient #1's doctor was notified.

Review of Patient #1's restraint nursing flowsheet revealed S9RN documented Patient #1 was in 4 point restraints on 03/17/13 from 11:10 p.m. until 5:45 a.m.

A review of the Master Treatment Plan for Patient #1 updated on 03/18/13 revealed: Problem #1: altered cognition as evidenced by confusion and agitation, Problem #2: risk for injury as evidenced by weakness and agitation, Problem #3: altered tissue perfusion as evidenced by hypertension, Problem #4: altered communication. There was no documented evidence that the patient's Master Treatment Plan included a plan of care for the use of restraints.

A face to face interview on 03/20/13 at 9:05 a.m. was conducted with S9RN. S9RN indicated the patient's nurse was responsible for updating the patient's care plan on the Master Treatment Plan. S9RN indicated that a restraint plan of care was documented on the restraint nursing flowsheet only for the use of restraints that were initiated on 03/17/13 for Patient #1 and was not included on Patient #1's Master Treatment Plan.



Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13. The patient's admitting diagnoses included Schizoaffective Disorder, Bipolar Disorder, Dehydration, and Severe Depression with Catatonia (lack of movement, stupor). The record also revealed the patient was transferred from an LTAC (Long Term Acute Care) hospital for Electro Convulsive Therapy (ECT). Review of the record revealed the patient had received Procal IV (continuous intravenous infusion nutritional supplement) due to his catatonia and dehydration.

Further review of the record revealed Patient #3 was transferred to the telemetry unit on 03/01/13 for the treatment of hospital acquired pneumonia. On 03/04/13 the patient was transferred back to the BHU.

Review of the patient's record revealed the patient was in restraints daily (4 point, 3 point, 2 point) from 03/04/13 to 03/18/13 for "interfering with treatment, pulling tubes."

Review of the Master Treatment Plan dated 03/04/13 revealed a problem of "Restraints", as evidence by unaware of limitation, self-care deficit, pulling heparin lock, IV tubing. Interventions identified in the Treatment Plan included reevaluation and justification for the restraint will be completed at least every 4 hours; assess, evaluate, and document behavior every 2 hours; discontinue restraint at earliest time possible....
Review of the Treatment Team update dated 03/12/13 revealed only the following:
Problem #7: Restraint PoC (Plan of Care)
Update: Unaware of limitation, pulling IV heparin lock, IV tubing.
There was no documented evidence of any new approaches or interventions to address the continued use of restraints (8 days in restraints at the time of team update). There was no documented evidence of an evaluation of the effectiveness of the restraints.

In a face-to-face interview on 03/19/13 at 10:05 a.m. S23RN verified the update to the treatment plan on 03/12/13 only re-stated the patient's problem of unaware of limitation, pulling IV heparin lock, IV tubing. S23RN stated the Restraint Flow Sheets also had documentation of the restraint plan of care. Review of the Restraint Flow Sheets from 03/04/13 to 03/18/13 revealed the evaluation of progress was documented as "plan continue", the goals/outcome was documented as "injury free", and priority/timeline was documented as "hospitalization ". There was no documented evidence of any new interventions or approaches for the continued use of restraints.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4RN BHU Manager indicated the patient's treatment plan update should include any changes or improvements experienced by the patient, as well as documentation when a patient's problem is resolved. She further indicated restraints usually were not care planned, because patients usually were not admitted with restraints. She further indicated the restraint should be added during the treatment plan update.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, policy and procedure review, clinical record review and staff interview, the hospital failed to ensure physician's orders for the use of restraints were obtained in accordance with hospital policy and procedure for 1 (#3) of 3 (#1, #2, #3) sampled patients reviewed for restraint use out of a total sample of 10. Findings:

Review of the hospital policy titled, Restraint and Seclusion, policy number TX-510, revised date of 12/12, provided as current by S3 Regulatory Coordinator, revealed in part the following: 2. Non-violent E. Orders: .... b. If the LIP (Licensed Independent Practitioner) is not present, the RN will consult with the physician as soon as possible (either during restraint application, or immediately thereafter) concerning the patient's physical and emotional status and to obtain an order for the use of restraint.... e. Must be re-ordered once each calendar day with a face-to-face re-evaluation by the LIP to clinically justify for continued use of restraint for non-violent behavior.... h. If the restraint is discontinued then a new order is needed to reapply the restraint. A trial release is not permitted....

Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13 from the emergency room under a PEC (Physician Emergency Certificate) dated 01/02/13 for Gravely Disabled and Unwilling/Unable to seek voluntary admission. The patient's admitting diagnoses included Schizoaffective Disorder, Bipolar Disorder, Dehydration, and Severe Depression with Catatonia (lack of movement, stupor). The record also revealed the patient was transferred from an LTAC (Long Term Acute Care) hospital for Electro Convulsive Therapy (ECT). Review of the record revealed the patient had been receiving Procal IV (continuous intravenous infusion nutritional supplement) due to his catatonia and dehydration.

Further review of the record revealed Patient #3 was transferred to the telemetry unit on 03/01/13 for the treatment of hospital acquired pneumonia. On 03/04/13 the patient was transferred back to the BHU.

On 03/18/13 at 10:30 a.m., Patient #3 was observed in bed in his room. S6MHT (Mental Health Technician) was observed seated in a chair next to the patient's bed and S7MHT was observed standing in the doorway to the patient's room. The patient was observed to have 4 point restraints in place to all extremities. The patient was observed to have an IV (Intravenous) infusion in progress to the left arm. The Upper and Mid siderails were raised on both sides of the bed. There was no siderail noted at the foot of the bed for either side. The patient was observed to be pulling against all 4 restraints, and was non-verbal. S6MHT stated the patient was on 1 to 1 observation and she was assigned to observe the patient. S6MHT stated the reason for the patient's restraints was for his safety and to keep the patient from pulling out his IV. S6MHT stated the patient was combative at times and was very strong.

Review of the physician's orders dated/timed 03/04/13 at 5:00 p.m. revealed an Initial Restraint Order for 4 point limb restraints for attempting to remove essential medical equipment-IV lines. Further review of the physician's orders revealed on 03/06/13 at 9:00 a.m., the daily restraint order was changed to limb restraints to the upper extremities only.
Review of the daily restraint orders dated/timed 03/08/13 at 7:40 a.m., 03/09/13 at 10:20 a.m., and 03/10/13 at 10:20 a.m., revealed 4 point restraints were ordered.
Review of the daily restraint order dated/timed 03/11/13 (no time) revealed an order for 4 point restraints.

Review of the nursing documentation revealed Patient #3 was placed in 4 point restraints on 03/04/13 at 5:00 p.m. and remained in the restraints until 03/05/13 at 8:00 a.m. when the ankle restraints were removed. On 03/06/13 at 7:30 p.m. 4 point restraints were re-applied.
There was no documented evidence of a physician's order for the 4 point restraints applied at 7:30 p.m. on 03/06/13.
Review of the nursing documentation revealed the patient remained in 4 point restraints until 03/10/13 at 4:00 p.m., when the right wrist restraint was removed.
The 4 point restraints were again applied on 03/10/13 at 5:22 p.m. There was no documented evidence of a physician's order to re-apply the right wrist restraint after it was removed for 1 hour and 22 minutes. On 03/10/13 at 6:00 p.m. the right ankle restraint was removed for 2 hours, and the patient was again placed in 4 point restraints at 8:00 p.m. There was no documented evidence of a physician's order to re-apply the right ankle restraint after it was removed for 2 hours.

Further review of the nursing documentation revealed the patient was in 3 point restraints on 03/16/13 at 5:30 a.m. to 03/18/13 at 3:30 a.m., when the patient was placed in 4 point restraints. There was no documented evidence of a physician's order to increase the restraints at 3:30 a.m. on 03/18/13. The daily restraint order was dated/timed 03/18/13 at 8:00 a.m. for 4 point restraints, 31/2 hours after the restraints were applied.

In a face-to-face interview on 03/19/13 at 10:05 a.m., S23RN reviewed the electronic and paper record for Patient #3 and verified the above findings. S23RN stated the restraint orders were good for 24 hours. S23RN verified the above restraints were decreased, and there was no physician's order to increase the restraints until the physician did his daily face-to-face evaluations.

Further review of the clinical record for Patient #3 revealed on 02/16/13 at 8:10 a.m. an Initial Restraint Order for bilateral upper extremity restraints was obtained as a verbal order and the nursing documentation revealed the patient was in bilateral cloth wrist restraints. The nursing documentation revealed on 02/16/13 at 10:00 p.m. the began twisting wrist restraints and putting feet on floor in order to stand without assistance and bilateral ankle restraints were applied. There was no documented evidence of a physician's order for the ankle restraints.

Review of the physician's orders titled Initial Restraint Order and Communication Record (Non-violent Behavior) dated 02/22/13 at 10:00 p.m. revealed 4 point limb restraints were ordered for "Disruption of acute medical/post procedure care by: (Left blank), Demonstrating activity that poses high risk for re-injury, impaired balance/gait, unaware of own limitations, and confusion." The verbal order was documented by S11RN.

Review of the nurse's documentation dated 02/22/13 at 10:00 p.m. revealed, "Patient was agitated and disruptive. Patient attacked staff, grabbing. Patient was given Ativan 1 mg. IM (intramuscular injection) in leg, also bilateral wrist restraints initiated. Still 1 :1 (1 to 1 observation status) will continue to monitor." Review of the restraint flow sheet dated 02/22/13 at 10:00 p.m. revealed the reason for the restraints was interfering with treatment and pulling tubes. The patient's status was documented as "in room."

Review of the nurse's documentation dated 02/24/13 revealed the patient's restraints were decreased to the left wrist restraint only on 02/24/13 at 10:00 a.m. At 2:00 p.m. the right restraint was applied (4 hours later). At 6:00 p.m. the right wrist restraint was removed. At 7:30 p.m. the right wrist restraint was applied, 1 and a half hours later. There was no documented evidence of a physician's order to re-apply the right wrist restraint after it had been discontinued on 02/24/13 at 10:00 a.m. The only restraint order on 02/24/13 was at 9:30 a.m. for bilateral wrist restraints.

In a face-to-face interview on 03/19/13 at 2:25 p.m., S23RN reviewed the electronic and paper record for Patient #3. S23RN verified the above findings and verified there was no physician's order to increase the restraints on 02/16/13 and 02/24/13. S23RN verified the documentation revealed the patient had attacked the staff on 02/22/13, but the RN had used the non-violent order sheet for the verbal order for the restraints. S23RN agreed the patient's behavior of attacking the staff should have been considered violent behavior and the violent restraint order form should have been used. S23RN was unable to explain why the non-violent order form was used.

In a face-to-face interview on 03/20/13 at 9:50 a.m., S11RN stated he was usually the charge nurse on the weekends and stated he never had to get restraint orders for Patient #3. S11RN stated he did sign the LPN assessments. S11RN stated he had witnessed Patient #3 being very labile, catatonic, then 5 minutes later he might flailing legs and trying to get out of bed. S11RN stated the patient was never violent but his aggressive behavior can be misconstrued as violent. S11RN verified yelling, screaming, trying to pull IVs can be aggressive. S11RN stated he had witnessed Patient #3 grab or pull on staff. S11RN stated he interpreted the patient's behavior as non-violent but as the potential for injury to self or others. S11RN stated there had been discussion about violent versus non-violent restraints among the nurses and physicians and he agreed this was a gray area that needed work. S11RN stated they could focus more on stronger assessments and on de-escalation techniques.

In a face-to-face interview on 03/20/13 at 10:10 a.m., S12 Physician was interviewed and verified he was the Psychiatrist for Patient #3. S12 Physician stated the patient has been in some kind of restraints for about 1 month and on 1 to 1 observation before that. S12 Physician stated once the patient had an IV, he had to have soft restraints. S12 Physician stated the patient has been in and out of 4 point restraints. When informed there was no order to re-apply 4 point restraints (when the restraints had been discontinued previously), he stated he did not know the process but knew a new order was required.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4 BHU Manager confirmed a new physician's order was needed when restraints were changed to and from least restrictive.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure an evaluation of the patient in restraints for violent behavior was conducted within 1 hour after initiation of restraint and included an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint for 1 (#3) of 3 (#1, #2, #3) current sampled patients reviewed for the use of restraints out of a total sample of 10. Findings:

Review of the hospital policy titled, Restraint and Seclusion, policy number TX-510, revised date of 12/12, provided as current by S3 Regulatory Coordinator, revealed in part the following: 3. Violent...E. Orders: f. The patient placed in restraints for violent behavior must be seen face-to-face within one hour by an LIP (Licensed Independent Practitioner). A telephone call or telemedicine methodology is not permitted....h. The face-to-face evaluation will include but is not limited to the: Patient's immediate condition. Patient's reaction to alternatives attempted and the subsequent intervention. Patient's medical and behavioral condition. Need to continue or terminate the use of restraint and/or seclusion. Systems assessment to determine if factors such as medications, electrolyte imbalances, hypoxia, etc. are contributing to the violent or self-destructive behavior.

Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13 from the emergency room under a PEC (Physician Emergency Certificate) dated 01/02/13 for Gravely Disabled and Unwilling/Unable to seek voluntary admission. The patient's admitting diagnoses included Schizoaffective Disorder, Bipolar Disorder, and Severe Depression with Catatonia (lack of movement, stupor). The record also revealed the patient was transferred from an LTAC (Long Term Acute Care) hospital for Electro Convulsive Therapy (ECT).

Further review of the record revealed Patient #3 was transferred to the telemetry unit on 03/01/13 for the treatment of hospital acquired pneumonia. On 03/04/13 the patient was transferred back to the BHU.

Review of the physician's orders dated/timed 02/04/13 at 8:00 a.m. revealed a Restraint Initial Order for Violent Behavior/Seclusion. The order revealed the patient was at imminent risk for injury to others by spitting, hitting, and kicking staff, and the patient broke a piece off of a rolling chair. The order revealed 4 point limb restraints were ordered for up to 4 hours. The order was a verbal order from S12 Psychiatrist. Further review of the restraint order revealed a section titled "One Hour Face-To-Face Evaluation." The space for the face-to-face evaluation and the signature and date/time of the evaluation were left blank. At the bottom of this section the signature of S12 Psychiatrist was documented with a date of 02/04/13 and a time of 8:45 a.m.

Review of the physician's progress notes revealed the only progress note documented by a physician on 02/04/13 was documented by S12 Psychiatrist at 12:40 p.m. There was no documented evidence of a face-to-face evaluation of the patient within one hour of being placed in 4 point restraints for violent behavior that included the patient's reaction to alternatives attempted and the subsequent intervention, the patient's medical and behavioral condition, the need to continue or terminate the use of restraint and/or seclusion. There was no documented evidence of a systems assessment.

In a face-to-face interview on 03/19/13 at 2:25 p.m. S23RN reviewed the electronic record for Patient #3. S4 BHU Manager was also present for the interview. After reviewing the physician's orders and physician's progress notes, S23RN verified there was no documented evidence of the one hour face-to-face evaluation that was required within one hour of placing the patient in restraints for violent behavior. S23RN verified the patient's psychiatrist had signed the one hour face-to-face evaluation on the physician orders, but there was no documentation of the results of the evaluation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and staff interview, the hospital failed to ensure the patient's medical record included a description of the patient's behavior that warranted placing the patient in restraints for 2 (#1,#3) of 3 (#1, #2, #3) sampled patients reviewed for the use of restraints out of a total sample of 10 (#1-#10). Findings:

Review of the hospital policy titled, Restraint and Seclusion, policy number TX-510, revised date of 12/12, provided as current by S3 Regulatory Coordinator, revealed in part the following: 2. Non-violent A. Assessment: ....b. Evaluation reveals a continuous detrimental disruption of the patient's medical healing or well-being where the risk associated with the use of restraints outweighs the risk of not using restraints. c. Identifies the clinical justification for initiation of restraint for non-violent behavior....J. Documentation a. The following must be documented in the medical record: A description of the patient's behavior, condition or symptoms that justified restraint use....I. Re-Evaluation and Discontinuation: the non-violent restraint must be discontinued at the earliest possible time regardless of the length of time identified in the order. Re-evaluation and justification for the restraint will be completed at least every 4 hours by the RN....

Patient #1
Patient #1 was admitted on [DATE] with diagnoses to include: atypical psychosis with delirium secondary to a recent CVA (cardiovascular accident) and chronic alcohol abuse, confusion, HTN (hypertension) and aggressive behavior.

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions.

A review of Patient #1's nursing flowsheet dated 03/17/13 at 10:45 p.m. revealed S9RN documented the patient was confused and augmentative with staff and became upset with staff and patient was unaware of his limitations. Patient was unable to be re-directed and became more upset and 4 point restraint was initiated. Patient #1's doctor was notified. Further review of the nursing flowsheet for Patient #1 revealed no documented evidence of a clear description of the patient's behavior that warranted the use restraints or of any interventions used by staff prior to the use of restraints.

A review of the doctor's orders on 03/17/13 at 11:10 p.m. revealed an order for siderails x 4 and 4 point restraint. Further review of the order revealed Patient #1's medical condition or symptoms indicating the need for restraints included: impaired balance/gait, unaware of own limitations and agitation.

In a face-to-face interview on 03/20/13 at 9:05 a.m. S9RN confirmed she did not document a detailed description of the patient's behavior or the interventions used prior to the use of the restraints.


Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13 from the emergency room under a PEC (Physician Emergency Certificate) dated 01/02/13 for Gravely Disabled and Unwilling/Unable to seek voluntary admission. The patient's admitting diagnoses included Schizoaffective Disorder, Bipolar Disorder, Dehydration, and Severe Depression with Catatonia (lack of movement, stupor). The record also revealed the patient was transferred from an LTAC (Long Term Acute Care) hospital for Electro Convulsive Therapy (ECT). Review of the record revealed the patient had been receiving Procal IV (continuous intravenous infusion nutritional supplement) due to his catatonia and dehydration.

Further review of the record revealed Patient #3 was transferred to the telemetry unit on 03/01/13 for the treatment of hospital acquired pneumonia. On 03/04/13 the patient was transferred back to the BHU.

On 03/18/13 at 10:30 a.m., Patient #3 was observed in bed in his room. S6MHT (Mental Health Technician) was observed seated in a chair next to the patient's bed and S7MHT was observed standing in the doorway to the patient's room. The patient was observed to have 4 point restraints in place to all extremities. The patient was observed to have an IV (Intravenous) infusion in progress to the left arm. The Upper and Mid siderails were raised on both sides of the bed. There was no siderail noted at the foot of the bed for either side. The patient was observed to be pulling against all 4 restraints, and was non-verbal. S6MHT stated the patient was on 1 to 1 observation and she was assigned to observe the patient. S6MHT stated the reason for the patient's restraints was for his safety and to keep the patient from pulling out his IV. S6MHT stated the patient was combative at times and was very strong. S6MHT stated the patient was incontinent and 3-4 staff members were needed to change the patient. During this observation, S5RN Charge Nurse entered the patient's room and began talking to the patient. The patient grabbed S5RN Charge Nurse's hand and held on to her hand. Another nurse entered the room and was directed by S5RN Charge Nurse to apply tape to the patient's IV site. As the second nurse walked to the left side of the bed, the patient was observed to attempt to grab the nurse. Patient #3 continued to hold S5RN Charge Nurse's hand as she attempted to release his grip on her hand. Once the nurse was able to free her hand from the patient's grip, the patient was observed to become agitated. S5RN Charge Nurse stated the 4-point restraints were for the patient's safety because the patient will kick his legs and try to get out of bed. S5RN Charge Nurse stated the patient had been aggressive towards the staff and had pulled out his PICC (Peripherally Inserted Central Catheter).

Review of the physician's orders dated/timed 03/15/13 at 10:20 p.m. revealed an "Initial Restraint Order Form (Expires in one calendar day) for non-violent behavior" documented as a verbal order for 4 point limb restraints. The order revealed the justification for the restraint was disruption of acute medical/post procedure care by attempting to remove essential medical equipment - IV fluids. The order revealed the medical condition indicating the need for protective intervention was impaired balance/gait and unaware of own limitations.

Further review of the physician's orders revealed the "Daily Restraint Order Form (Non-violent behavior) was documented as follows:
03/16/13 at 8:20 a.m. "Restraint Day 1" with justification for the restraint as disruption of acute medical/post procedure care by attempting to remove essential medical equipment - IV fluids. 4 point limb restraints were continued.
03/17/13 at 11:00 a.m. "Restraint Day 2" with justification for the restraint as disruption of acute medical/post procedure care by attempting to remove essential medical equipment - IV fluids. 4 point limb restraints were continued.
03/18/13 at 8:00 a.m. "Restraint Day 3" with justification for the restraint documented as disruption of acute medical/post procedure care by attempting to remove essential medical equipment - IV therapy. 4 point limb restraints were continued.

Review of the nursing documentation for 03/15/13 revealed the following:
10:20 p.m. - bilateral wrist and ankle cloth restraints applied. The potential cause was documented as lines/tubes and unaware of limit. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, agitated and restless." There was no documentation of the behavior that warranted use of the ankle restraints.

Review of the nursing documentation for 03/16/13 revealed the following:
1:30 a.m. - left wrist cloth restraint and bilateral ankle cloth restraints. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless." There was no documentation of a reason/justification for the ankle restraints, and there was no documented reason one of the wrist restraints was removed.
5:30 a.m. - left wrist cloth restraint and bilateral ankle restraints documented. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless."
8:00 a.m. - bilateral cloth wrist restraints and left ankle cloth restraint documented. There was no documented evidence of the patient's status and there was no documented evidence of why the patient needed restraints.
9:30 a.m., 1:30 p.m., 5:30 p.m., 7:30 p.m., 11:30 p.m., - bilateral cloth wrist restraints and left ankle cloth restraint documented. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, quiet."

Review of the nursing documentation for 03/17/13 revealed the patient remained in 3 point restraints for "interfering with treatment, pulling tubes", and the patient's status was "in room, quiet."

Review of the nursing documentation for 03/18/13 revealed the patient was placed in 4 point restraints to all limbs at 2:01 a.m. and remained in the restraints until 03/19/13 at 9:13 a.m. when the ankle restraints were removed. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless." There was no documentation of the behavior that warranted the use of the ankle restraints.

Review of the Observation Flow Sheets for 03/15/13 to 03/17/13 revealed the patient's behavior was documented every 15 minutes. The Observation Flow Sheet revealed High Risk Behaviors were pacing, crying, yelling/cursing, talking incoherent, combative, attempting self-harm, elopement attempt, talking loud, and making threats. Review of the flow sheet dated 03/15/13 revealed at 9:15 p.m. to 9:30 p.m. the patient was yelling/cursing. At 9:45 p.m. the patient was documented as "elopement attempt." From 10:00 p.m. to 11:45 p.m. the patient was documented as talking loud. At 12:00 a.m. the documentation revealed the patient was talking incoherently. There was no documented evidence of any other high risk behaviors on the Observation Flow Sheets for 03/15/13 to 03/17/13.

Further review of the nursing documentation revealed Patient #3 was placed in 4 point restraints on 03/04/13 at 5:00 p.m. and remained in the restraints until 03/05/13 at 8:00 a.m. when the ankle restraints were removed. On 03/06/13 at 7:30 p.m. 4 point restraints were re-applied and the patient remained in 4 point restraints until 03/10/13 at 4:00 p.m., (4 days) when the right wrist restraint was removed. The 4 point restraints were again applied on 03/10/13 at 5:22 p.m. At 6:00 p.m. the right ankle restraint was removed, and the patient was again placed in 4 point restraints at 8:00 p.m. The documentation revealed the patient remained in 4 point restraints from 03/10/13 at 8:00 p.m. until 03/15/13 at 12:00 a.m. (5 days) when only the left wrist was restrained. The only documented evidence of the patient's behavior was "interfering with treatment, pulling tubes, and restless. There was no documented evidence of the behavior that warranted use of the ankle restraints.

Further review of the Observation Flow Sheets for 03/06/13 to 03/15/13 revealed the patient's behavior was documented every 15 minutes. Review of the flow sheets from 03/06/13 to 03/11/13 revealed no documented evidence of any behaviors. Review of the 03/12/13 Observation Flow Sheet revealed at 11:45 a.m. and 1:45 p.m., the patient was combative. Review of the 03/13/13 flow sheet revealed from 10:15 a.m. to 11:15 a.m. the patient was talking. Review of the flow sheet dated 03/14/13 revealed the patient was talking incoherently at 4:00 a.m. and 5:15 a.m., and was combative at 9:00 a.m. There was no documentation of any other high risk patient behaviors on the Observation Flow Sheets.

In a face-to-face interview on 03/19/13 at 10:05 a.m., S23RN reviewed the electronic and paper record for Patient #3 and verified the above findings. S23RN verified there was no documented evidence of the patient's behavior that warranted the use of ankle restraints. S23RN stated, "He gets his legs out of bed, that is why the ankles are restrained." S23RN verified the documented reason for the use of restraints was interfering with treatment and pulling tubes. S23RN stated the patient would not eat and was receiving Procal IV. S23RN stated the patient attempted to pull the IV line out and that was the reason for the restraints. After reviewing the patient's record, S23RN verified there was no documented evidence that the patient had pulled out an IV line. S23RN stated the patient would have the restraints until the IV was discontinued.

In a face-to-face interview on 03/19/13 at 4:50 p.m. S21RN verified she had been assigned to Patient #3. S21RN stated they (staff) have trouble keeping an IV line in. S21RN stated she noticed the PICC line slightly out and it had to be discontinued. S21RN stated, "That's why he is in restraints, he pulls the IV tubing." S21RN stated the restraints were more for neurological changes and "messing with IVs." S21RN stated the ankle restraints were for violent behavior. She stated the patient was hard to hold for injections. "He was so agitated and restless, that was the way we could administer injections." S21RN stated the patient pulled his legs over the rails and he was very strong. S21RN stated when she would go around the bed to flush the IV, he gets agitated and tried to kick, grab, pull whatever he can. S21RN stated he kicks and tries to obstruct care. "I he can't use his hands, he uses his feet."

In a telephone interview on 03/19/13 at 5:45 p.m., S20RN verified she had been assigned to Patient #3 and was familiar with his care. S20RN stated she recalled the incident when the patient had to be restrained when he was readmitted to BHU from the medical unit on 03/04/13. S20RN stated the patient's behavior was very unstable and the restraints were for his safety. She stated they did not want him to get up and fall or pull out the IV line. S20RN stated the patient also had violent behavior, "He scratched me and tried to punch us." S20RN stated she did not recall the patient's behavior on 03/04/13 when she placed the patient in 4 point restraints. "If I put in 4 point restraints, he must have had some violent behavior." When asked why the non-violent restraint orders were chosen, S20RN stated in her nursing judgement, he was not going to hurt self or staff.

In a face-to-face interview on 03/20/13 at 10:10 a.m., S12 Physician was interviewed and verified he was the Psychiatrist for Patient #3. S12 Physician stated the patient has been in some kind of restraints for about 1 month and on 1 to 1 observation before that. S12 Physician stated the patient became psychotic-yelling, talking in tongues, throwing himself on the floor and restraints were started. S12 Physician stated once the patient had an IV, he had to have soft restraints. S12 Physician stated the patient has been in and out of 4 point restraints when he tried to get out of bed.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4 BHU Manager stated the nurses were documenting according to available boxes in the computer and not consistently using the narrative for restraint use. S4 BHU Manager stated they had realized this was a problem about 3 weeks ago. She stated they had discussed this in their morning report meetings, but they had not done formal inservice's yet.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure there was documentation in the patient's medical record of other alternatives or less restrictive interventions attempted and the effects of these alternatives or interventions prior to initiating the use of restraints for 1 (#1) of 3 (#1, #2, #3) patients' medical records reviewed for the use of restraints from a total of 10 sampled patients. Findings:

Review of the hospital policy titled, Restraint and Seclusion, policy number TX-510, revised date of 12/12, provided as current by S3 Regulatory Coordinator, revealed in part the following: 2. Non-violent A. Assessment: ....b. Evaluation reveals a continuous detrimental disruption of the patient's medical healing or well-being where the risk associated with the use of restraints outweighs the risk of not using restraints. c. Identifies the clinical justification for initiation of restraint for non-violent behavior. d. Determine the least restrictive measures pose a greater risk than the risk of using a restraint...J. Documentation a. The following must be documented in the medical record: A description of the patient's behavior, condition or symptoms that justified restraint use, alternatives, interventions used, least restrictive interventions, patient's response to the intervention....

Patient #1
Patient #1 was admitted on [DATE] with diagnoses to include: atypical psychosis with delirium secondary to a recent CVA (cardiovascular accident) and chronic alcohol abuse, confusion, HTN (hypertension) and aggressive behavior.

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions.

A review of Patient #1's nursing flowsheet dated 03/17/13 at 10:45 p.m. revealed documentation that the patient was confused and argumentative with staff and became upset with staff and patient was unaware of his limitations. Patient was unable to be re-directed and became more upset and 4 point restraint was initiated. Patient #1's doctor was notified.

A review of the doctor's orders on 03/17/13 at 11:10 p.m. revealed an order for siderails x 4 and 4 point restraint. Further review of the order revealed Patient #1's medical condition or symptoms indicating the need for restraints included: impaired balance/gait, unaware of own limitations and agitation.

Review of Patient #1's restraint nursing flowsheet dated 03/17/13 revealed S9RN documented Patient #1 was in 4 point restraints from 11:10 p.m. until 5:45 a.m. Further review of the nursing flowsheet for Patient #1 revealed no documentation of other alternatives used or less restrictive interventions attempted and the effects of these alternatives or interventions prior to initiating the use of restraints.

In a face-to-face interview on 03/20/13 at 9:05 a.m. S9RN, S9RN confirmed she did not document the use of other alternatives used or less restrictive interventions attempted and the effects of these alternatives or interventions prior to initiating the use of restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure there was documentation in the patient's medical record of the patient's response to the restraints applied, including the rationale for the continued use of restraints for 3 (#1 #2, #3) of 3 patients' medical records reviewed for the use of restraints from a total of 10 sampled patients. Findings:

Review of the hospital policy titled, Restraint and Seclusion, policy number TX-510, revised date of 12/12, provided as current by S3 Regulatory Coordinator, revealed in part the following: 2. Non-Violent A. Assessment:....c. Identifies the clinical justification for initiation of restraint for non-violent behavior...J. Documentation: The following must be documented in the medical record: A description of the patient's behavior, condition or symptoms that justified restraint use,....and patient's response to the intervention....

Patient #1
Patient #1 was admitted on [DATE] with diagnoses to include: atypical psychosis with delirium secondary to a recent CVA (cardiovascular accident) and chronic alcohol abuse, confusion, HTN (hypertension) and aggressive behavior.

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions.

A review of Patient #1's nursing flowsheet dated 03/17/13 at 10:45 p.m. revealed documentation that the patient was confused and augmentative with staff and became upset with staff and patient was unaware of his limitations. Patient was unable to be re-directed and became more upset and 4 point restraint was initiated. Patient #1's doctor was notified.

A review of the doctor's orders on 03/17/13 at 11:10 p.m. revealed an order for siderails x 4 and 4 point restraint. Further review of the order revealed Patient #1's medical condition or symptoms indicating the need for restraints included: impaired balance/gait, unaware of own limitations and agitation.

Review of Patient #1's restraint flowsheet revealed S9RN documented Patient #1 was in 4 point restraints from 11:10 p.m. until 5:45 a.m. Further review of the nursing flowsheet for Patient #1 revealed no documented evidence of the behaviors exhibited by Patient #1 at these times that warranted him to remain in restraints.

In a face-to-face interview on 03/20/13 at 9:05 a.m., S9RN confirmed she did not document the behaviors exhibited by Patient #1 during those times that warranted him to remain in restraints on 03/17/13 from 11:10 p.m. until 5:45 a.m.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of Psychosis. Further review revealed an order on 03/15/13 at 11:00 p.m. revealed an order, with no documented evidence whether the order was received by verbal or telephone order and which physician had given the order for restraints, for side rails times 4 and a vest restraint for non-violent behavior. Further review of the order revealed Patient #2's medical condition or symptoms indicating the need for restraints included an impaired balance/gait, unaware of own limitations, and she was hanging over the side rails.

Review of Patient #2's restraint flowsheets revealed S19RN (registered nurse) documented Patient #2 was in her room and restless on 03/16/13 at 1:30 a.m. and 5:30 a.m. while she remained in restraints. Further review revealed no documented evidence of the behaviors exhibited by Patient #2 at these times that warranted her to remain in restraints.

In a face-to-face interview on 03/19/13 at 12:30 p.m., S24Manager of Clinical Informatics confirmed Patient #2's medical record did not have documentation of the patient's behaviors that were exhibited that warranted her restraints to be continued at 1:30 a.m. and 5:30 a.m. on 03/16/13.






Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13 from the emergency room under a PEC (Physician Emergency Certificate) dated 01/02/13 for Gravely Disabled and Unwilling/Unable to seek voluntary admission. The patient's admitting diagnoses included Schizoaffective Disorder, Bipolar Disorder, Dehydration, and Severe Depression with Catatonia (lack of movement, stupor). The record also revealed the patient was transferred from an LTAC (Long Term Acute Care) hospital for Electro Convulsive Therapy (ECT). Review of the record revealed the patient had been receiving Procal IV (continuous intravenous infusion nutritional supplement) due to his catatonia and dehydration.

Further review of the record revealed Patient #3 was transferred to the telemetry unit on 03/01/13 for the treatment of hospital acquired pneumonia. On 03/04/13 the patient was transferred back to the BHU.

On 03/18/13 at 10:30 a.m., Patient #3 was observed in bed in his room. S6MHT (Mental Health Technician) was observed seated in a chair next to the patient's bed and S7MHT was observed standing in the doorway to the patient's room. The patient was observed to have 4 point restraints in place to all extremities. The patient was observed to have an IV (Intravenous) infusion in progress to the left arm. The Upper and Mid siderails were raised on both sides of the bed. There was no siderail noted at the foot of the bed for either side. The patient was observed to be pulling against all 4 restraints, and was non-verbal. S6MHT stated the patient was on 1 to 1 observation and she was assigned to observe the patient. S6MHT stated the reason for the patient's restraints was for his safety and to keep the patient from pulling out his IV. S6MHT stated the patient was combative at times and was very strong. S6MHT stated the patient was incontinent and 3-4 staff members were needed to change the patient. During this observation, S5RN Charge Nurse entered the patient's room and began talking to the patient. The patient grabbed S5RN Charge Nurse's hand and held on to her hand. Another nurse entered the room and was directed by S5RN Charge Nurse to apply tape to the patient's IV site. As the second nurse walked to the left side of the bed, the patient was observed to attempt to grab the nurse. Patient #3 continued to hold S5RN Charge Nurse's hand as she attempted to release his grip on her hand. Once the nurse was able to free her hand from the patient's grip, the patient was observed to become agitated. S5RN Charge Nurse stated the 4-point restraints were for the patient's safety because the patient will kick his legs and try to get out of bed. S5RN Charge Nurse stated the patient had been aggressive towards the staff and had pulled out his PICC (Peripherally Inserted Central Catheter).

Review of the nursing documentation revealed Patient #3 was placed in 4 point restraints on 03/04/13 at 5:00 p.m. and remained in the restraints until 03/05/13 at 8:00 a.m. when the ankle restraints were removed. Review of the restraint flow sheet dated 03/04/13 to 03/05/13 revealed no documented evidence of the patient's response to the restraints. Further review of the flow sheet revealed the patient's status was documented as "in room sleeping" from 03/04/13 at 7:00 p.m. to 8:00 a.m. on 03/05/13. Review of the flow sheets revealed the reason for the 4 point restraints was "interfering with treatment, pulling tubes". There was no documented evidence of a rationale for the use of the ankle restraints.

On 03/06/13 at 7:30 p.m. 4 point restraints were re-applied and the patient remained in 4 point restraints until 03/10/13 at 4:00 p.m., (4 days) when the right wrist restraint was removed. There was no documented evidence of the patient's response to the restraints, and there was no documented evidence of the rationale for the use of the ankle restraints.

The 4 point restraints were again applied on 03/10/13 at 5:22 p.m. At 6:00 p.m. the right ankle restraint was removed, and the patient was again placed in 4 point restraints at 8:00 p.m. The documentation revealed the patient remained in 4 point restraints from 03/10/13 at 8:00 p.m. until 03/15/13 at 12:00 a.m. (5 days) when only the left wrist was restrained. The only documented evidence of the patient's behavior was "interfering with treatment, pulling tubes, and restless. There was no documented evidence of the rationale for the continued use of the ankle restraints. There was no documented evidence of the patient's response to the restraints.

Review of the nursing documentation for 03/15/13 revealed the following:
10:20 p.m. - bilateral wrist and ankle cloth restraints applied. The potential cause was documented as lines/tubes and unaware of limitations. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, agitated and restless."

Review of the nursing documentation for 03/16/13 revealed the following:
1:30 a.m. - left wrist cloth restraint and bilateral ankle cloth restraints. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless." There was no documentation of the rationale for the ankle restraints, and there was no documented reason one of the wrist restraints was removed.
5:30 a.m. - left wrist cloth restraint and bilateral ankle restraints documented. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless."
8:00 a.m. - bilateral cloth wrist restraints and left ankle cloth restraint documented. There was no documented evidence of the patient's status and there was no documented evidence of why the patient needed restraints.
9:30 a.m., 1:30 p.m., 5:30 p.m., 7:30 p.m., 11:30 p.m., - bilateral cloth wrist restraints and left ankle cloth restraint documented. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, quiet."

Review of the nursing documentation for 03/17/13 revealed the patient remained in 3 point restraints for "interfering with treatment, pulling tubes", and the patient's status was "in room, quiet."

Review of the nursing documentation for 03/18/13 revealed the patient was placed in 4 point restraints to all limbs at 2:01 a.m. and remained in the restraints until 03/19/13 at 9:13 a.m. when the ankle restraints were removed. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless."

There was no documentation of the rationale for the use of the ankle restraints, and there was no documentation of the patient's response to the restraints for 03/15/13 to 03/18/13.

In a face-to-face interview on 03/19/13 at 10:05 a.m., S23RN reviewed the electronic and paper record for Patient #3 and verified the above findings. S23RN verified there was no documented evidence of the patient's behavior that warranted the use of ankle restraints. S23RN stated, "He gets his legs out of bed, that is why the ankles are restrained." S23RN verified the documented reason for the use of restraints was interfering with treatment and pulling tubes. S23RN stated the patient would not eat and was receiving Procal IV. S23RN stated the patient attempted to pull the IV line out and that was the reason for the restraints. After reviewing the patient's record, S23RN verified there was no documented evidence that the patient had pulled out an IV line. S23RN stated the patient would have the restraints until the IV was discontinued. S23RN verified there was no documentation of the patient's response to the restraints or the rationale for the use of the ankle restraints.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4 BHU Manager stated the nurses were documenting according to available boxes in the computer and not consistently using the narrative for restraint use. S4 BHU Manager stated they had realized this was a problem about 3 weeks ago. She stated they had discussed this in their daily morning meetings, but they had not done any formal inservice's yet.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record reviews and interviews, the hospital failed to ensure action plans implemented to address identified opportunities for improvement related to restraint use and appropriate documentation were revised when audits performed revealed staff were not documenting appropriately. Findings:

Review of the hospital's "2013 Quality Management Plan", presented by S4RN (registered nurse), Behavioral Health Unit (BHU) Manager, revealed key indicators that represent the overall quality provided to the hospital's patients were tracked routinely by the Quality Management department and reported through the QAPI (quality assessment performance improvement) flow of information. Further review revealed in addition to overall organizational quality indicators, all clinical and operational services within the hospital develop departmental dashboards. For each indicator, the service will describe the measurement method, the frequency of measurement, the threshold value or values that trigger a more detailed review, and the rationale for the indicator (regulatory, high risk, high volume, problem-prone).

Review of data collected by the BHU revealed it included number of restraint episodes per number of patients admitted , crash cart logs, medication temperature logs, washing machine logs, nutrition refrigerator logs. Further review revealed no documented evidence of quality indicators specific to the use of restraints and documentation requirements.

Review of the components of the BHU skills day for 2012 revealed S23RN presented education on restraints and treatment plans that included appropriate documentation of restraints, correct application of restraints, different types of restraints, and a treatment plan case study.

Review of a medical record review of 5 opportunities related to non-violent restraint use dated March 2013 revealed the following:
Restraint use is clinically justified - 100% (per cent);
Initial restraint order present - 100%;
Initial restraint order selections 100% complete - 60%;
Restraint plan of care present - 100%;
Patient/Family education present - 100%;
Restraint re-order present for every current calendar day - 80%;
Restraint re-order sections 100% complete - 100%;
24-hour restraint documentation 100% complete - 60%
Restraint was discontinued at earliest possible time and documented in restraint section of electronic record - 80%.
There was no documented evidence of a medical record review of opportunities related to violent restraint use.

Review of 3 sampled patients records (#1, #2, #3) from a total sample of 10 patient records revealed the following:
1) Patients #1 and #3 failed to have their plan of care modified and updated with the use of restraints;
2) Patient #3 failed to have physician orders obtained according to the hospital's policy and procedure;
3) Patient #3 failed to have a face-to-face evaluation conducted within 1 hour after initiation of restraints for violent behavior that included the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint;
4) Patients #1 and #3 failed to have documentation in their medical record of the description of the behaviors exhibited that warranted placing the patients in restraint;
5) Patient #1 failed to have documentation of other alternatives or less restrictive interventions attempted and the effects of these alternatives or interventions prior to initiating restraints;
6) Patients #1, #2, and #3 failed to have documentation of the patient's response to the restraints applied that included the rationale for the continued use of restraints.

Review of the information presented throughout the survey revealed no documented evidence that the results of the education provided related to restraint use had been evaluated until March 2013 to determine the effectiveness of the training and if re-education was required.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4RN BHU Manager indicated she realized about 3 weeks ago that the nursing staff was documenting restraint use in the electronic medical record by using the available check boxes and not consistently using the narrative box for restraint and prn (as needed) medication use. She further indicated the educator discussed these findings in a morning report meeting, but no formal in-service had been conducted as of the time of this interview. She indicated the BHU skills day was held in November 2012. When informed of the survey findings related to restraint use and documentation compared to the chart audit performed in March 2013 that showed many areas at 100% compliance, S4RN BHU Manager indicated S23RN accepted subjective data as justification when she reviewed the records rather than looking for specific behaviors exhibited by the patient in the nursing staff's documentation.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to assess patients in restraints and document the patients' behaviors that justify the use of restraints, the behaviors that justify the need to continue the restraint usage, and assess the patient at the time of discontinuation of the restraints for 3 of 3 (#1, #2, #3) patients' medical records reviewed for the use of restraints from a total of 10 sampled patients;

2) Failing to have the RN assess and document the patients' behavior prior to administering prn (as needed) medications for 2 (#5, #6) of 3 (#1, #2, #3) patients' medical records reviewed for the use of restraints from a total of 10 sampled patients; and

3) Failing to clarify a physician's order for agitation precautions when the hospital did not have a policy and procedure for agitation precautions for 6 (#1, #2, #4, #5, #9, #10) of 7 (#1, #2, #3, #4, #5, #9, #10) patients' medical records reviewed for the use of agitation precautions from a total of 10 sampled patients.

Findings:

1) Failing to assess patients in restraints and document the patients' behaviors that justify the use of restraints as well as justifying the need to continue the restraint usage:
Review of the hospital policy titled, Restraint and Seclusion, policy number TX-510, revised date of 12/12, provided as current by S3 Regulatory Coordinator, revealed in part the following: 2. Non-Violent A. Assessment:....c. Identifies the clinical justification for initiation of restraint for non-violent behavior...J. Documentation: The following must be documented in the medical record: A description of the patient's behavior, condition or symptoms that justified restraint use,....and patient's response to the intervention....

Patient #1
Patient #1 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions.

A review of Patient #1's nursing flowsheet dated 03/17/13 at 10:45 p.m. revealed documentation that the patient was confused and argumentative with staff and became upset with staff and patient was unaware of his limitations. Patient was unable to be re-directed and became more upset and 4 point restraint was initiated. Patient #1's doctor was notified.

A review of the doctor's orders on 03/17/13 at 11:10 p.m. revealed an order for siderails x 4 and 4 point restraint. Further review of the order revealed Patient #1's medical condition or symptoms indicating the need for restraints included: impaired balance/gait, unaware of own limitations and agitation.

Review of Patient #1's restraint nursing flowsheet revealed S9RN documented Patient #1 was in 4 point restraints from 11:10 p.m. until 5:45 a.m. Further review of the nursing flowsheet for Patient #1 revealed no documented evidence of the behaviors exhibited by Patient #1 at these times that warranted him to remain in restraints.

In a face-to-face interview on 03/20/13 at 9:05 a.m. S9RN, S9RN confirmed she did not document the behaviors exhibited by Patient #1 during those times that warranted him to remain in restraints on 03/17/13 from 11:10 p.m. until 5:45 a.m.


Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Further review of the order revealed Patient #2's medical condition or symptoms indicating the need for restraints included an impaired balance/gait, unaware of her own limitations, and she was hanging over the side rails.

Review of Patient #2's restraint flowsheets revealed S19RN documented Patient #2 was in her room and restless on 03/16/13 at 1:30 a.m. and 5:30 a.m. while she remained in restraints. Further review revealed no documented evidence of the behaviors exhibited by Patient #2 at these times that warranted her to remain in restraints. Further review revealed Patient #2's restraints were discontinued on 03/16/13 at 9:05 a.m. by S27LPN. There was no documented evidence of an assessment of Patient #2 by a RN prior to his restraints being discontinued.

In a face-to-face interview on 03/19/13 at 12:30 p.m., S24Manager of Clinical Informatics confirmed Patient #2's medical record did not have documentation of the patient's behaviors that were exhibited that warranted her restraints to be continued at 1:30 a.m. and 5:30 a.m. on 03/16/13.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S3RN BHU (behavioral health unit) Manager indicated a RN is supposed to assess a patient prior to restraints being discontinued.

Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13. The patient's admitting diagnoses included [DIAGNOSES REDACTED]. On 03/04/13 the patient was transferred back to the BHU.

On 03/18/13 at 10:30 a.m., Patient #3 was observed in bed in his room. S6MHT (Mental Health Technician) was observed seated in a chair next to the patient's bed and S7MHT was observed standing in the doorway to the patient's room. The patient was observed to have 4 point restraints in place to all extremities. The patient was observed to have an IV (Intravenous) infusion in progress to the left arm. The Upper and Mid siderails were raised on both sides of the bed. There was no siderail noted at the foot of the bed for either side. The patient was observed to be pulling against all 4 restraints, and was non-verbal. S6MHT stated the patient was on 1 to 1 observation and she was assigned to observe the patient. S6MHT stated the reason for the patient's restraints was for his safety and to keep the patient from pulling out his IV. S6MHT stated the patient was combative at times and was very strong. S6MHT stated the patient was incontinent and 3-4 staff members were needed to change the patient. During this observation, S5RN Charge Nurse entered the patient's room and began talking to the patient. The patient grabbed S5RN Charge Nurse's hand and held on to her hand. Another nurse entered the room and was directed by S5RN Charge Nurse to apply tape to the patient's IV site. As the second nurse walked to the left side of the bed, the patient was observed to attempt to grab the nurse. Patient #3 continued to hold S5RN Charge Nurse's hand as she attempted to release his grip on her hand. Once the nurse was able to free her hand from the patient's grip, the patient was observed to become agitated. S5RN Charge Nurse stated the 4-point restraints were for the patient's safety because the patient will kick his legs and try to get out of bed. S5RN Charge Nurse stated the patient had been aggressive towards the staff and had pulled out his PICC (Peripherally Inserted Central Catheter).

Review of the physician's orders dated/timed 03/15/13 at 10:20 p.m. revealed an "Initial Restraint Order Form (Expires in one calendar day) for non-violent behavior" documented as a verbal order for 4 point limb restraints. The order revealed the justification for the restraint was disruption of acute medical/post procedure care by attempting to remove essential medical equipment - IV fluids. The order revealed the medical condition indicating the need for protective intervention was impaired balance/gait and unaware of own limitations. Further review of the physician's orders from 03/04/13 to present revealed the justification for the use of restraints was disruption of acute medical/post procedure care by attempting to remove essential medical equipment - IV fluids. The orders revealed the medical condition indicating the need for protective intervention was impaired balance/gait and unaware of own limitations.

Review of the nursing documentation for 03/15/13 revealed the following:
10:20 p.m. - bilateral wrist and ankle cloth restraints applied. The potential cause was documented as lines/tubes and unaware of limit. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, agitated and restless." There was no documentation of an assessment of the patient's behavior that warranted use of the ankle restraints.

Review of the nursing documentation for 03/16/13 revealed the following:
1:30 a.m. - left wrist cloth restraint and bilateral ankle cloth restraints. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless." There was no documentation of an assessment of the patient's behavior that warranted the use of the ankle restraints, and there was no documented assessment of the patient when one of the wrist restraints was removed.
5:30 a.m. - left wrist cloth restraint and bilateral ankle restraints documented. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless."
8:00 a.m. - bilateral cloth wrist restraints and left ankle cloth restraint documented. There was no documented evidence of an assessment of the patient's status and there was no documented assessment of why the patient needed restraints.
9:30 a.m., 1:30 p.m., 5:30 p.m., 7:30 p.m., 11:30 p.m., - bilateral cloth wrist restraints and left ankle cloth restraint documented. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, quiet." There was no documented assessment to indicate why the patient continued to require 3 point restraints.

Review of the nursing documentation for 03/17/13 revealed the patient remained in 3 point restraints for "interfering with treatment, pulling tubes", and the patient's status was "in room, quiet." There was no documented assessment to indicate why the patient continued to require 3 point restraints.

Review of the nursing documentation for 03/18/13 revealed the patient was placed in 4 point restraints to all limbs at 2:01 a.m. and remained in the restraints until 03/19/13 at 9:13 a.m. when the ankle restraints were removed. "Why restrained" was documented as interfering with treatment, pulling tubes. The patient's status was documented as "in room, restless." There was no documentation of an assessment of the behavior that warranted the use of the ankle restraints.

Further review of the nursing documentation revealed Patient #3 was placed in 4 point restraints on 03/04/13 at 5:00 p.m. and remained in the restraints until 03/05/13 at 8:00 a.m. when the ankle restraints were removed. On 03/06/13 at 7:30 p.m. 4 point restraints were re-applied and the patient remained in 4 point restraints until 03/10/13 at 4:00 p.m., (4 days) when the right wrist restraint was removed. The 4 point restraints were again applied on 03/10/13 at 5:22 p.m. At 6:00 p.m. the right ankle restraint was removed, and the patient was again placed in 4 point restraints at 8:00 p.m. The documentation revealed the patient remained in 4 point restraints from 03/10/13 at 8:00 p.m. until 03/15/13 at 12:00 a.m. (5 days) when only the left wrist was restrained. The only documented evidence of the patient's behavior was "interfering with treatment, pulling tubes, and restless. There was no documented evidence of an assessment of the patient's behavior that warranted use of the ankle restraints. There was no documented evidence of an assessment of the patient when the ankle restraints were removed.

In a face-to-face interview on 03/19/13 at 10:05 a.m., S23RN reviewed the electronic and paper record for Patient #3 and verified the above findings. S23RN verified there was no documented evidence of an assessment of the patient's behavior that warranted the use of ankle restraints. S23RN stated, "He gets his legs out of bed, that is why the ankles are restrained." S23RN verified the only documented reason for the use of restraints was interfering with treatment and pulling tubes.

In a face-to-face interview on 03/19/13 at 4:50 p.m. S21RN verified she had been assigned to Patient #3. S21RN stated they (staff) have trouble keeping an IV line in. S21RN stated she noticed the PICC line slightly out and it had to be discontinued. S21RN stated, "That's why he is in restraints, he pulls the IV tubing." S21RN stated the restraints were more for neurological changes and "messing with IVs." S21RN stated the ankle restraints were for violent behavior. She stated the patient was hard to hold for injections. "He was so agitated and restless, that was the way we could administer injections." S21RN stated the patient pulled his legs over the rails and he was very strong. S21RN stated when she would go around the bed to flush the IV, he got agitated and tried to kick, grab, pull whatever he could. S21RN stated he kicks and tries to obstruct care. "If he can't use his hands, he uses his feet."

In a telephone interview on 03/19/13 at 5:45 p.m., S20RN verified she had been assigned to Patient #3 and was familiar with his care. S20RN stated she recalled the incident when the patient had to be restrained when he was readmitted to BHU from the medical unit on 03/04/13. S20RN stated the patient's behavior was very unstable and the restraints were for his safety. She stated they did not want him to get up and fall or pull out the IV line. S20RN stated the patient also had violent behavior, "He scratched me and tried to punch us." S20RN stated she did not recall the patient's behavior on 03/04/13 when she placed the patient in 4 point restraints. "If I put in 4 point restraints, he must have had some violent behavior." When asked why the non-violent restraint orders were chosen, S20RN stated in her nursing judgement, he was not going to hurt self or staff.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4 BHU Manager stated the nurses were documenting according to available boxes in the computer and not consistently using the narrative for restraint use. S4 BHU Manager stated they had realized this was a problem about 3 weeks ago. She stated they had discussed this in their morning report meetings, but they had not done formal inservice's yet.

2) Failing to assess and document the patients' behavior prior to administering prn medications:
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."

Patient #5
Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. that revealed he had a history of Chronic Paranoid Schizophrenia with bizarre behavior, flight of ideas, was unable to take care of himself, was a danger to himself, and was gravely disabled. Patient #5 had a CEC (coroner's emergency certificate) signed on 02/13/13 at 10:35 a.m. that revealed he had bizarre behavior with flight of ideas, was not caring for himself, and was gravely disabled.

Review of Patient #5's admit physician orders signed by S8Psychiatrist on 02/12/13 at 9:40 a.m. revealed an order for Lorazepam 1 mg (milligram) orally every 6 hours as needed for acute anxiety, agitation, or insomnia, and if the patient refused and have severe symptoms may give 1 mg IM (intramuscular) every 6 hours as needed.

Review of Patient #5's MAR (medication administration record) and nurses' notes revealed he received Ativan 1 mg orally on 02/16/13 at 10:25 a.m. Further review revealed no documented evidence of the behaviors exhibited by Patient #5 that warranted the administration of Ativan prn.

In a face-to-face interview on 03/19/13 at 8:30 a.m., S25RN Informatics Analyst, after reviewing Patient #5's computer medical record, confirmed there was no documentation of behaviors when Patient #5 was administered Ativan at 10:25 .M. ON 02/16/13.

Patient #6
Review of Patient #6's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #6's physician orders revealed an order on 03/11/13 at 5:45 p.m. from S12Psychiatrist that was received by S26LPN (licensed practical nurse) to administer Ativan 1 mg IM now.

Review of Patient #6's MAR revealed S26LPN administered Ativan 1 mg IM on 03/11/13 at 6:24 p.m.

Review of Patient #6's computer medical record revealed S26LPN documented on 03/11/13 at 5:54 p.m. (after the physician order had been received at 5:45 p.m.) that Patient #6 was lying in bed, "unable to arouse, but you can see pt (patient) eyes dancing under the eye lids S12Psychiatrist aware this am and pm about why pt didn't take meds, called him back this afternoon and rec'd (received) an order for ativan 1 mg IM now will monitor for effects". Further review revealed no documented evidence of an assessment of Patient #6 by a RN when S26LPN found her unable to be aroused with her "eyes dancing under the eye lids".

In a face-to-face interview on 03/20/13 at 1:15 p.m., S5RN Charge Nurse reviewed Patient #6's documentation related to S26LPN assessing Patient #6 and administering Ativan ordered to be given now on 03/11/13 at 5:45 p.m. She indicated she thought S26LPN was describing Patient #6's catatonic state when she wrote about her eyes dancing under the eyelids. When asked to show where a RN had assessed Patient #6 prior to S26LPN administering Ativan on 03/11/13 at 6:24 p.m., she indicated the RN assesses each patient cared for by a LPN at the start of the shift and co-signs the computer medical record at that time, so the RN assessed Patient #6 at the start of the 7:00 a.m. to 7:00 p.m. shift on 03/11/13. When asked if she was aware of the LSBN's (Louisiana State Board of Nursing) requirement that a RN assess a patient with a change in condition, S5RN Charge Nurse indicated that she did know the LSBN's requirements.

3) Failing to clarify a physician's order for agitation precautions when the hospital did not have a policy and procedure for agitation precautions:

Patient #1
Patient #1 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions. There was no documented evidence of a clarification order written by or received by the nurse regarding what the physician specifically wanted done for agitation precautions.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Further review revealed a CEC was signed on 03/10/13 at 3:52 p.m. due to Patient #2 being gravely disabled.

Review of Patient #2's physician's admit orders received on 03/08/13 at 5:45 p.m. revealed an order for agitation precautions and paper scrubs. There was no documented evidence of a clarification order written by or received by the nurse regarding what the physician specifically wanted done for agitation precautions.

Patient #4
Patient #4 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/17/13 revealed Patient #4 was placed on Suicide and Agitation Precautions. There was no documented evidence of a clarification order written by or received by the nurse regarding what the physician specifically wanted done for agitation precautions.

Patient #5
Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. that revealed he had a history of Chronic Paranoid Schizophrenia with bizarre behavior, flight of ideas, was unable to take care of himself, was a danger to himself, and was gravely disabled. Patient #5 had a CEC (coroner's emergency certificate) signed on 02/13/13 at 10:35 a.m. that revealed he had bizarre behavior with flight of ideas, was not caring for himself, and was gravely disabled.

Review of Patient #5's physician orders revealed S8Psychiatrist ordered Patient #5 to be on suicide precautions, detox precautions, fall precautions, and "agitation precautions/paper scrubs" at admit on 02/12/13 at 9:30 a.m. There was no documented evidence of a clarification order written by or received by the nurse regarding what the physician specifically wanted done for agitation precautions.

Patient #9
Patient #9 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/07/13 revealed Patient #9 was placed on Agitation and Fall Precautions. There was no documented evidence of a clarification order written by or received by the nurse regarding what the physician specifically wanted done for agitation precautions. Patient #9 had remained on Agitation Precautions since admit.

Patient #10
Patient #10 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/15/13 revealed Patient #10 was placed on Agitation and Fall Precautions. There was no documented evidence of a clarification order written by or received by the nurse regarding what the physician specifically wanted done for agitation precautions.

In a face-to-face interview on 03/18/13 at 11:45 a.m., S3Regulatory Coordinator indicated the hospital did not have a policy and procedure for agitation precautions.

In a face-to-face interview on 03/20/13 at 8:00 a.m., S8Psychiatrist was asked what he expected to be done by the staff when he ordered agitation precautions. He presented a policy he was currently assisting in modifying that was derived from the hospital's policy on suicide risk assessment. S8Psychiatrist was asked again what he expected to be done by the staff when he ordered agitation precautions. He indicated agitation precautions referred to a policy they're currently working on. He further indicated at the time they worked on suicide precaution policies, the hospital had expanded the behavioral health unit to include a lower age group who had the potential to be more violent. He further indicated that by ordering suicide precautions, the staff would be cued to observing for suicide risk. When asked for a third time what he expected to be done by the staff when he ordered agitation precautions, S8Psychiatrist again referred to the suicide precaution policy and talked about safety-proofing the patient's environment and placing patients in paper scrubs.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient that included the patients' medical problems and interventions for identified problems for 8 of 10 sampled patients's record reviewed for complete and current care plans that included medical problems (#1, #2, #3, #4, #5, #6, #9, #10).

Findings:

Review of the hospital policy titled "Treatment Planning", policy number BHS TX GEN 02, effective 08/97, revised 01/13, and presented as the current care plan policy by S3Regulatory Coordinator, revealed the Multidisciplinary Treatment Plan included a summary of information obtained through interdisciplinary assessments that encompasses diagnoses, strengths and deficits, identified problems (psychiatric and medical) and an individualized plan of care based on individual needs and resources. Each patient would have a nursing care plan initiated by a RN within 24 hours of admission that would identify and prioritize psychiatric and medical problems based on the Nursing Admission Assessment, the Intake Assessment, and other available clinical data. The Multidisciplinary Treatment Plan would be developed within 72 hours of Admission. Further review revealed the Master Treatment Plan would be developed by the multidisciplinary treatment team and include problems to be addressed and related short-term goals, interventions to be implemented, and long-term goals (discharge criteria). The Multidisciplinary treatment team would meet weekly to review and update the Master Treatment Plan of each patient. Further review revealed on the Geriatric Psychiatric Unit, medical plans of care were to be utilized in the Master Treatment Plan and reviewed daily by a RN and revised as needed.

Patient #1
Patient #1 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Admission Orders dated 03/15/13 revealed Patient #1 was placed on Agitation and Fall Precautions.

A review of Patient #1's nursing flowsheet dated 03/17/13 at 10:45 p.m. revealed documentation that the patient was confused and argumentative with staff and became upset with staff and patient was unaware of his limitations. Patient was unable to be re directed and became more upset and 4 point restraint was initiated. Patient #1's doctor was notified.

Review of Patient #1's restraint nursing flowsheet revealed S9RN documented Patient #1 was in 4 point restraints on 03/17/13 from 11:10 p.m. until 5:45 a.m.

A review of the Master Treatment Plan for Patient #1 updated on 03/18/13 revealed: Problem #1: altered cognition as evidenced by confusion and agitation, Problem #2: risk for injury as evidenced by weakness and agitation, Problem #3: altered tissue perfusion as evidenced by hypertension, Problem #4: altered communication. There was no documented evidence that the patient's Master Treatment Plan included a plan of care for the use of restraints.

A face to face interview on 03/20/13 at 9:05 a.m. was conducted with S9RN. S9RN indicated the patient's nurse was responsible for updating the patient's care plan on the Master Treatment Plan. S9RN indicated that a restraint plan of care was documented on the restraint nursing flowsheet only for the use of restraints that were initiated on 03/17/13 for Patient #1. She further indicated she did not revise Patient #1's care plan to include a restraint care plan on his Master Treatment Plan after the initial use of restraints.


Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Further review revealed a CEC (Coroner's Emergency Certificate) was signed on 03/10/13 at 3:52 p.m. due to Patient #2 being gravely disabled.

Review of Patient #2's "Multidisciplinary Treatment Plan - Master" initiated 03/08/13 by S5RN (registered nurse) Charge Nurse revealed her active problems included altered thought process, depressed mood, risk for injury, Bipolar Disorder, and suicide risk, and her inactive problems included Hypertension, [DIAGNOSES REDACTED], and Diabetes Mellitus. Further review revealed no documented evidence of individual care plans for each identified problem with goals and interventions related to the problem.

Review of Patient #2's Nephrology Consult conducted on 03/13/13 revealed her assessment included the following:
Acute Renal Failure on Chronic Kidney Disease - in and out catheterization to quantitate bladder volume and obtain urine for urinalysis and an ultrasound to ensure no reversible cause from an obstructive point of view were ordered;
Chronic Kidney Disease;
Hypertension - avoid hypotension;
Diabetes mellitus;
[DIAGNOSES REDACTED];
Leukopenia - mild; will recheck in the morning;
Mild Anemia - given dementia consider work-up for concomitant B12 and iron deficiencies;
Dementia with Psychosis.

Review of Patient #2's treatment plan update completed on 03/13/13 by S5RN Charge Nurse revealed no documented evidence that Patient #2's care plan was revised to include her new medical problems of Acute Renal Failure, Leukopenia, and Mild Anemia. Review of the treatment plan update completed on 03/18/13 by RNS11 revealed her problems of depressed mood and suicide risk were not included and had no documented evidence whether the problems were resolved. Further review revealed no documented evidence that any of Patient #2's medical problems had been included in the care plan as of 03/18/13.

In a face-to-face interview on 03/20/13 at 11:35 a.m., S5RN Charge Nurse confirmed Patient #2 did not have individual care plans for each identified problem on the master treatment plan. She further indicated the unit was in the process of changing care plan forms, and the old forms used for Patient #2 did not have the individual plans with goals and interventions. She confirmed she initiated Patient #2's care plan. S5RN Charge Nurse indicated the night nurse completes the problem list update on the night before the treatment team meeting. She further indicated the nursing staff did have individual care plans for medical problems, but Patient #2's medical problems were not care planned.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4RN BHU (behavioral health unit) Manager indicated Patient #2's acute renal failure should have been included in her care plan update.

Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13. The patient's admitting diagnoses included [DIAGNOSES REDACTED]. Review of the record revealed the patient had received Procal IV (continuous intravenous infusion nutritional supplement) due to his catatonia and dehydration.

Further review of the record revealed Patient #3 was transferred to the telemetry unit on 03/01/13 for the treatment of hospital acquired pneumonia. On 03/04/13 the patient was transferred back to the BHU.

Review of the patient's record revealed the patient was in restraints daily (4 point, 3 point, 2 point) from 03/04/13 to 03/18/13 for "interfering with treatment, pulling tubes."

Review of the "Multidisciplinary Treatment Plan - Master" dated 03/04/13 revealed a problem of "Restraints", as evidence by unaware of limitation, self-care deficit, pulling heparin lock, IV tubing. Interventions identified in the Treatment Plan included reevaluation and justification for the restraint will be completed at least every 4 hours; assess, evaluate, and document behavior every 2 hours; discontinue restraint at earliest time possible....
Review of the Treatment Team update dated 03/12/13 revealed only the following:
Problem #7: Restraint PoC (Plan of Care)
Update: Unaware of limitation, pulling IV heparin lock, IV tubing.
There was no documented evidence of any new approaches or interventions to address the continued use of restraints (8 days in restraints at the time of team update). There was no documented evidence of an evaluation of the effectiveness of the restraints.

Further review of the record for Patient #3 revealed the patient was court-ordered to receive ECT on 02/15/13. Review of the record revealed the patient was currently receiving ECT three times a week. Review of the "Multidisciplinary Treatment Plan - Master" dated 03/04/13 and the Treatment Team Update dated 03/12/13 revealed no documented evidence the ECT was included in the treatment plan.

In a face-to-face interview on 03/19/13 at 10:05 a.m. S23RN verified the update to the treatment plan on 03/12/13 only re-stated the patient's problem of unaware of limitation, pulling IV heparin lock, IV tubing. S23RN stated the Restraint Flow Sheets also had documentation of the restraint plan of care. Review of the Restraint Flow Sheets from 03/04/13 to 03/18/13 revealed the evaluation of progress was documented as "plan continue", the goals/outcome was documented as "injury free", and priority/timeline was documented as "hospitalization ". There was no documented evidence of any new interventions or approaches for the continued use of restraints. S23RN confirmed Patient #3 was receiving ECT and the ECT was not included in the treatment plan.

Patient #4
Patient #4 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Master Treatment Plan for Patient #4 updated on 03/19/13 revealed: Problem #1: altered cognition as evidenced by mental illness, Problem #2: depression, Problem #3: risk for injury due to falls, Problem #4: self care deficit, Problem #5: altered thought process as evidenced by suicide ideations, Problem #6: alcohol abuse. A further review of Patient #4's Master Treatment Plan revealed no documented evidence that the patient's Master Treatment Plan included an individualized plan of care for hypertension with goals and interventions.

Patient #5
Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Patient #5 had a CEC signed on 02/13/13 at 10:35 a.m. that revealed he had bizarre behavior with flight of ideas, was not caring for himself, and was gravely disabled.

Review of Patient #5's "Multidisciplinary Treatment Plan - Master" signed by S5RN Charge Nurse on 02/12/13 revealed the identified problems were altered cognition, altered thoughts, impaired mobility, and self-care deficit. Further review revealed no documented evidence of an individualized care plan for altered cognition.

Review of Patient #5's physician orders revealed S8Psychiatrist ordered Patient #5 to be on suicide precautions, detox precautions, fall precautions, and "agitation precautions/paper scrubs" at admit on 02/12/13 at 9:30 a.m. Review of his History and Physical documented on 02/13/13 revealed Patient #5 was diagnosed with [DIAGNOSES REDACTED]#5.

Review of Patient #5's physician progress notes revealed he had an x-ray of the cervical spine and a MRI (magnetic resonance Imaging) of the cervical spine and brain that showed a high cord compression at C2, and Patient #5 refused surgery. There was no documented evidence that Patient #5's care plan was revised to include the medical problem of the high cord compression at C2.

Patient #6
Review of Patient #6's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #6's "Multidisciplinary Treatment Plan - Master" signed by S5RN Charge Nurse on 02/12/13 revealed the identified problems were depresses mood and altered thought.

Review of Patient #6's History and Physical performed on 03/05/13 revealed her TSH (thyroid stimulating hormone) report "seems conflicting, so we will repeat another TSH", and she had conjunctivitis and a recurrent bladder infection. Review of the "Multidisciplinary Treatment Plan - Master" and the treatment plan updates completed on 03/12/13 and 03/19/13 revealed no documented evidence that Patient #4's care plan was revised to include her medical problems.

Patient #9
Patient #9 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Master Treatment Plan for Patient #9 updated on 03/20/13 revealed: Problem #1: altered thought process as evidenced by paranoia, confusion and delusions, Problem #2: risk for injury due to falls, Problem #3: impaired gas exchange due COPD. A further review of Patient #9's Master Treatment Plan revealed no documented evidence that the patient's Master Treatment Plan included an individualized plan of care for hypertension, [DIAGNOSES REDACTED] or UTI. with goals and interventions.

Patient #10
Patient #10 was admitted on [DATE] with diagnoses that include [DIAGNOSES REDACTED]

A review of the Master Treatment Plan for Patient #10 updated on 03/19/13 revealed: Problem #1: altered thought process as evidenced by hallucinations, Problem #2: risk for injury due to Parkinson disease, Problem#3: altered tissue perfusion as evidenced by hypertension. A further review of Patient #10's Master Treatment Plan revealed no documented evidence that the patient's Master Treatment Plan included an individualized plan of care for diabetes with goals and interventions.

A face to face interview on 03/20/13 at 11:10 a.m. was conducted with S23RN. She indicated that she was the nurse educator for the BHU (Behavioral Health Unit). S23RN was asked about the patient's medical conditions not being care planned on the patient's Master Treatment Plans. S23RN indicated that only patient medical conditions that are being actively treated by the BHU are care planned. S23RN further indicated that non active medical conditions are considered controlled and are not care planned even if the nurse was administrating medication to the patient for the medical condition and labs were being monitored.

In a face-to-face interview on 03/20/13 at 4:00 p.m., S4RN BHU Manager indicated the patient's treatment plan update should include any changes or improvements experienced by the patient, as well as documentation when a patient's problem is resolved. She further indicated restraints usually were not care planned, because patients usually were not admitted with restraints. She further indicated the restraint should be added during the treatment plan update. S4RN BHU Manager indicated patients' medical problems were only included in their care plan if the medical problem was active, and medical problems were not care planned if The diagnosis was [DIAGNOSES REDACTED]
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) assigned the nursing care of each patient to nursing personnel who had been evaluated for competency for 3 of 5 personnel records reviewed for competency from a total of 77 employed nursing personnel on the Behavioral Health Unit (BHU) (S10, S15, S19).

Findings:

Review of the hospital's "Unit Based Orientation / Initial Competency Inventory" revealed the preceptor's initials were to be entered under the appropriate letter to indicate the type of evaluation method used for each task listed. Further review revealed the column with the respective letters were as follows:
R - review of policy and procedure and/or process;
S - simulated performance of task;
C - clinical performance of task;
D - verified complete and accurate documentation of task.
Further review revealed a variety of evaluation methods should be used to evaluate competency.

S10 MHT(Mental Health Technician)
Review of S10MHT's personnel file revealed she was hired on 09/20/10. Review of her "Initial Competency Inventory" completed on 08/31/11 revealed no documented evidence of the clinical performance of the following tasks with verification of complete and accurate documentation of the task: policy and procedure review; recognizing, reporting, and documenting changes in a patient's condition; performance improvement processes; unit/department routine; core competency statements; fall prevention and safety risks competency; hand washing/hand hygiene; restraints; pain management; telephone etiquette, safety and infection control safety; demonstrating the process for calling and responding to a Code White and understanding the MHT's role; knowledge of the process of locking and unlocking bathrooms to ensure patient safety; ability to conduct belongings and room searches; identifying restricted items/contraband and the appropriate procedure for disposing; orienting the patient and family to the room, bed controls, and visiting policy; electronic documentation; assisting with the prevention of skin breakdown through skin care; processes related to nutrition, elimination, specimen collection, Code Blue response, and post mortem care; unit-specific competencies; unit specific equipment.

S15Patient Observation Technician (POT)
Review of S15POT's personnel file revealed she was hired on 06/25/12 as a prn (as needed) resource pool employee and had no previous healthcare experience. Review of her job description revealed her experience requirements included "previous healthcare experience preferred". Further review revealed her safety requirements included knowledge of and adherence to safety practices including the exposure control plan and incident reporting.

Review of S15POT's computer transcript of completed computer courses revealed her POT education was completed on 12/02/12 and lasted 20 minutes, and her suicide risks and warning signs course was completed on 12/05/12 and lasted 15 minutes.

Review of S15POT's "Initial Competency Inventory" completed on 06/26/12, 1 day after her date of hire, revealed no documented evidence of the clinical performance of the following tasks with verification of complete and accurate documentation of the task: policy and procedure review; performance improvement processes; unit/department routine; hand washing/hand hygiene; telephone etiquette; safety and infection control safety; patient rights and customer service including assessing for signs and symptoms of abuse; core competency statements; unit based safety including knowledge of Code White; unit-specific competency; unit-specific equipment. Further review revealed all competency evaluations were performed the first day after hire.

In a face-to-face interview on 03/19/13 at 6:05 p.m., S23RN stated the POTs used on the BHU were from the nursing service pool. S23RN verified the POTs were used to observe patients on 1 to 1 observation status. S23RN verified S15POT was assigned to monitor Patient #3 1 to 1 on 03/06/13. S23RN stated the POTs document the observation record, but they can only redirect patients and they cannot do any personal care. S23RN stated the POTs only have general hospital orientation and they are not trained in MOAB (Management of Aggressive Behavior).

In a telephone interview on 03/20/13 at 3:00 p.m., S15POT indicated she had observed Patient #3 in the BHU, and some of the time he was in restraints. She further indicated most of the patients she had observed were ambulatory. S15POT indicated her role was to observe and note any changes, but she was not supposed to touch the patient. She further indicated she was due to attend MOAB class, since it was a requirement of her job.

S19RN
Review of S19RN's personnel file revealed she was hired on 11/15/10. Review of her "Initial Competency Inventory" completed on 08/30/12 revealed no documented evidence that she had reviewed the hospital's policies and procedures and the performance improvement processes. Further review revealed no documented evidence of the clinical performance of the following tasks with verification of complete and accurate documentation of the task: core competency statements; incident reporting; the process for Code White; conducting and documenting restraint post-debriefing; notification of the Infection Control Officer of any suspected or confirmed communicable diseases; the exposure control plan; the discharge/transfer process; Code Blue response; process for reporting drug variances and adverse drug reactions; performing venipuncture according to hospital policy; inserting urinary catheters and providing catheter care and bladder irrigation; preparing patients for radiological and surgical procedures.

All above findings were confirmed during the personnel record review by S16Director of Employment and Human Resources.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure drugs and biological's were administered as ordered by the physician for 3 (#3, #5, #8) of 10 sampled patients.

Findings:

Review of the hospital policy and procedure titled, "Medication Use: Medication Variance", number TX-335, revised date of 10/11, and provided as current by S3 Regulatory Coordinator, revealed in part the following: .... Medication Variance: any preventable event that may cause or lead to inappropriate medication use or patient while the medication is in control of the health care professional, patient, or consumer....Medication Variances include, but are not limited to, the following: wrong patient, wrong dose, wrong medication, wrong time, wrong route, allergy, omission of medication, and improper dispensing....When a medication variance occurs, the person who made the error, or if not available, the person who discovered the variance will assess the patient, notify the patient's physician....notify Department Manager/House Supervisor, report all levels of medication variances to the online incident reporting system, the department manager/house supervisor will conduct a follow up investigation....

Patient #5
Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizoaffective Disorder, Bipolar Type. Patient #5 had a PEC (physician emergency certificate) signed on 02/11/13 at 9:10 p.m. that revealed he had a history of Chronic Paranoid Schizophrenia with bizarre behavior, flight of ideas, was unable to take care of himself, was a danger to himself, and was gravely disabled. Patient #5 had a CEC (coroner's emergency certificate) signed on 02/13/13 at 10:35 a.m. that revealed he had bizarre behavior with flight of ideas, was not caring for himself, and was gravely disabled.

Review of Patient #5's admit physician orders signed by S8Psychiatrist on 02/12/13 at 9:40 a.m. revealed an order for Lorazepam 1 mg (milligram) orally every 6 hours as needed for acute anxiety, agitation, or insomnia, and if the patient refused and have severe symptoms may give 1 mg IM (intramuscular) every 6 hours as needed. Review of an order written on 02/15/13 at 10:40 a.m. revealed Zyprexa Zydis was to be increased to 15 mg orally every night at bedtime.

Review of Patient #5's MAR (medication administration record) revealed he received he received Zyprexa Zydis 10 mg orally at 9:35 p.m. on 02/15/13 rather than 15 mg as ordered. Further review revealed Patient #5 received Lorazepam 1 mg orally on 02/17/13 at 8:31 a.m. administered by S20RN (registered nurse). Review of his computer nurses' notes revealed S20RN documented on 02/17/13 at 8:51 a.m. "the client is yelling loudly, will give prn Ativan IM per MD (medical doctor) order per hospital policy". The documentation of both medication errors was confirmed during the record review by S25RN Informatics Analyst.

In a telephone interview on 03/19/13 at 5:25 p.m., S20RN indicated she couldn't remember whether she gave Patient #5 his Ativan orally or IM, but she "probably was rushing".





Patient #3
Review of the clinical for Patient #3 revealed the patient was a [AGE] year old male admitted to the hospital's BHU (Behavioral Health Unit) on 01/02/13 with diagnoses of Schizoaffective Disorder, Bipolar Disorder, Dehydration, and Severe Depression with Catatonia (lack of movement, stupor). Review of the record revealed the patient had been receiving Procal IV (continuous intravenous infusion nutritional supplement) due to his catatonia and dehydration.
Further review of the record revealed Patient #3 was transferred to the telemetry unit on 03/01/13 for the treatment of hospital acquired pneumonia. On 03/04/13 the patient was transferred back to the BHU.

Review of the physician's orders dated/timed 03/15/13 at 1:10 p.m. the following order:
Zyprexa Zydis 10 mg. P.O. BID (by mouth, twice a day). Zyprexa 10 mg. IM BID (Intramuscular injection, twice a day) if refuses P.O. (Zyprexa is an antipsychotic medication used to treat Schizophrenia and Bipolar Disorder).

Review of the MAR for Patient #3 dated 03/15/13 revealed the patient refused the oral dose of Zyprexa Zydis at 8:50 p.m. The MAR dated 03/16/13 revealed the patient refused the oral dose of Zyprexa Zydis at 10:36 a.m. There was no documented evidence that Zyprexa 10 mg. IM was administered as ordered when the patient refused the oral medication.

In a face-to-face interview on 03/19/13 at 10:45 a.m., S23RN reviewed the electronic and paper record for Patient #3 and verified the Zyprexa was not administered as ordered by the physician on 03/15/13 and 03/16/13. S23RN verified the physician had ordered the Zyprexa to be administered IM if the patient refused the oral dose. S23RN verified the MAR revealed the patient refused the first 2 doses, and there was no documented evidence the IM injection of Zyprexa was administered.

Patient #8
Review of the clinical record for Patient #8 revealed the patient was an [AGE] year old female admitted on [DATE] with diagnoses of Major Depression. Review of the record revealed the patient was transferred to the medical unit on 03/06/13 for an evaluation of chest pain. On 03/11/13 the patient was transferred back to the BHU.

Review of the transfer orders dated/timed 03/11/13 at 6:00 p.m. revealed the following medication orders: Clonazepam (drug used for anxiety and seizures) 0.25 mg. PO BID (by mouth, twice a day), and Clonazepam 0.5 mg. PO at bedtime.

Review of the MAR for Patient #8 revealed on 03/14/13 only one dose of Clonazepam 0.25 mg. was administered at 8:50 a.m. There was no documented evidence the second dose of 0.25 mg. was administered on 03/14/13.

In a face-to-face interview on 03/19/13 at 2:25 p.m., S23RN reviewed the electronic and paper record for Patient #8 and verified the Clonazepam 0.25 mg PO BID was not administered as ordered on [DATE]. S23RN verified the p.m. dose was omitted.