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.

CARRIS HEALTH LLC 301 BECKER AVE SW WILLMAR, MN 56201 Sept. 22, 2017
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on interview and document review the hospital emergency room failed to implement a discharge planning process for 1 of 8 patients reviewed, P3, who was discharged from the emergency room without any follow up care after being assessed to require inpatient mental health treatment.

Findings include:

The hospital's emergency room failure resulted in the hospital's inability to ensure adequate discharge planning coordination and implementation.

Therefore the hospital was unable to meet the Condition of Participation of Discharge Planning at 42 CFR482.43. This deficient practice had the potential to impact all patients requiring mental health treatment discharged from the emergency room without follow up care implemented.

Refer to A-0821 and A-0837. Based on interview and document review, the hospital failed to ensure appropriate post hospital care was arranged after discharge from the emergency room for 1 of 8 patients, P3, who was placed on a 72 hour hold in the emergency room after recommendation from the psychiatrist the patient required inpatient mental health treatment. P3 was discharged from the emergency room and was not provided inpatient mental health treatment or follow up care.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure discharge plans were reassessed to ensure appropriate post hospital care was arranged after discharge from the emergency room for 1 of 8 patients reviewed, P3, who was placed on a 72 hour hold in the emergency room after recommendation from the psychiatrist the patient required inpatient mental health treatment. P3 was discharged from the emergency room and was not provided inpatient mental health treatment. There was no reassessment completed of the patients post-discharge needs prior to discharge.

Findings include:

P3 arrived in the emergency room on [DATE], at 2:30 p.m. for a mental health evaluation. P3's emergency room medical record indicated the patient was brought in by the detox facility because she was delusional, had broken a toilet, and had homicidal ideas. The detox facility felt the patient required a higher level of care than could be provided in the detox facility.

On 7/5/17, at 4:20 p.m. P3 completed a mental health assessment (called a DEC assessment) using tele psych (a psychiatrist evaluation using a television with an off-site psychiatrist). The assessment indicated P3 lacked insight, appropriate judgement, and active listening. The recommendation was for the patient to be admitted to an inpatient mental health unit upon bed availability. The assessment further indicated P3's situation may warrant further investigation and follow through related to commitment and possible long term state hospitalization . The DEC assessment indicated the emergency room physicians stated P3 was known to be very manipulative. P3's emergency contact was contacted and did not respond.

P3's Inpatient Bed Call Log dated 7/5/17, indicated the DEC assessor(s) contacted 34 inpatient mental health facilities and was unable to find an inpatient mental health facility with an open bed or who could take P3 related to the high acuity of care required.

P3's emergency room nursing note dated 7/6/17, at 4:06 p.m. indicated an inpatient mental health could potentially admit the patient, and requested the emergency room physician sign a new 72 hour hold order as the prior 72-hour hold would expire on 7/7/17.

On 7/6/17, at 4:15 p.m. the emergency room physician implemented a 72- hour hold for P3 which indicated the patient is in danger of causing injury to self or others if not immediately detained. The reason for the hold was Methamphetamine abuse, Schizophrenia; out of control, delusional, and poor judgement.

P3's Assessment of Need for Inpatient Behavioral Health Admission signed by the emergency room physician on 7/6/17, at 4:15 p.m. indicated P3 was medically stable and had no health conditions that required treatment, and the patient did not require alcohol or drug detoxification. The criteria for the behavioral health treatment was extreme compromise of ability to be adequately aware of the environment due to P3's mental health condition.

P3's nursing note dated 7/6/17, at 4:56 p.m. indicated the inpatient mental health was unable to admit the patient due to the current acuity (level of care) of the patients currently on the unit.

P3's nursing note dated 7/6/17, at 6:28 p.m. indicated the hospitals mental health unit was contacted for recommendations on placement for P3. The hospital mental health unit recommended the physician go back into reassess the patient again and appropriateness for possible discharge from the emergency room .

P3's physician note filed on 7/6/17, at 6:51 p.m. indicated the patient was in the emergency room for a mental health evaluation and for a higher level of care. P3's drug and alcohol screen came back negative. P3 expressed impulsivity and inappropriate judgement. The patient was aggressive initially but calmed and was cooperative. P3 received Zyprexa (antipsychotic) 5 mg intramuscular (IM) on 7/5/17, at 8:38 p.m., Zyprexa 10 mg IM on 7/5/17, 10:24 p.m., Benadryl (antihistamine) 50 mg IM on 7/5/17, at 10:24 p.m., and Seroquel (antipsychotic) 100 mg orally on 7/5/17, at 11:14 p.m. The physician note indicated P3 was medically stable for discharge. P3 denies being suicidal or homicidal and the patient felt like she was under control. There was no documentation regarding a follow up plan for P3, where the patient was discharged to, and who the patient left the emergency room with. Although the physician had implemented a 72 hour hold for P3 approximately 3 hours earlier indicating the patient was in danger of causing injury to herself or others if not immediately detained, there was no reassessment to determine if P3 was safe to be discharged .

P3's nursing note dated 7/6/17, at 7:25 p.m. indicated all of the patient's belongings returned to her and she is getting dressed at this time.

P3's Patient care Timeline indicated on 7/6/17, at 7:38 p.m. P3 was discharged . There was no further information regarding where the patient was discharged to or any follow up plan of care.

During interview on 9/19/17, at 9:00 a.m. Registered Nurse (RN)-B stated if a patient is assessed as requiring inpatient mental health treatment the DEC assessors assist with finding placement. If the DEC assessors are unable to find an inpatient mental health facility after 16 hours, the emergency room staff is responsible to continuing to find an inpatient mental health unit. RN-B stated the hospitals inpatient mental health unit would generally take patient's from the emergency room if other mental health inpatient facilities were not available. However, P3 had been a former patient in the hospitals inpatient mental health unit and was violent so they were no longer able to admit the patient. RN-B stated P3's medical record did not identify any information regarding P3's discharge, and there was no reassessment completed of P3 which indicated she was safe to be discharged .

The facility policy titled, Emergency Services Patient Outcome Guideline, dated 8/17, directed staff to ensure a safe discharge from the department.

The facility policy titled, Discharge Planning, dated 5/17, indicated the physician is responsible to oversee comprehensive multidisciplinary discharge plan from admission through discharge. The RN is responsible for planning and providing continuity of care in collaboration with the multidisciplinary team.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure appropriate post hospital care was arranged after discharge from the emergency room for 1 of 8 patients reviewed, P3, who was placed on a 72 hour hold in the emergency room after recommendation from the psychiatrist the patient required inpatient mental health treatment. P3 was discharged from the emergency room 3 hours after the 72 hour hold was implemented and was not provided inpatient mental health treatment.

Findings include:

P3 arrived in the emergency room on [DATE], at 2:30 p.m. for a mental health evaluation. P3's emergency room medical record indicated the patient was brought in by the detox facility because she was delusional, had broken a toilet, and had homicidal ideas. The detox facility felt the patient required a higher level of care than could be provided in the detox facility.

On 7/5/17, at 4:20 p.m. P3 completed a mental health assessment (called a DEC assessment) using tele psych (a psychiatrist evaluation using a television with an off-site psychiatrist). The assessment indicated P3 lacked insight, appropriate judgement, and active listening. The recommendation was for the patient to be admitted to an inpatient mental health unit upon bed availability. The assessment further indicated P3's situation may warrant further investigation and follow through related to commitment and possible long term state hospitalization . The assessment indicated the emergency room physicians stated P3 was known to be very manipulative. P3's emergency contact was contacted and did not respond.

P3's Inpatient Bed Call Log dated 7/5/17, indicated the DEC assessor(s) contacted 34 inpatient mental health facilities and were unable to find an inpatient mental health facility with an open bed or who could take P3 related to the high acuity of care required.

P3's emergency room nursing note dated 7/6/17, at 4:06 p.m. indicated an inpatient mental health could potentially admit the patient, and requested the emergency room physician sign a new 72 hour hold order as the prior 72-hour hold would expire on 7/7/17.

On 7/6/17, at 4:15 p.m. the emergency room physician implemented a 72- hour hold for P3 which indicated the patient is in danger of causing injury to self or others if not immediately detained. The reason for the hold was Methamphetamine abuse, Schizophrenia; out of control, delusional, and poor judgement.

P3's Assessment of Need for Inpatient Behavioral Health Admission signed by the emergency room physician on 7/6/17, at 4:15 p.m. indicated P3 was medically stable and had no health conditions that required treatment, and the patient did not require alcohol or drug detoxification. The criteria for the behavioral health treatment was extreme compromise of ability to be adequately aware of the environment due to P3's mental health condition.

P3's nursing note dated 7/6/17, at 4:56 p.m. indicated the inpatient mental health was unable to admit the patient due to the acuity (level of care) of the patients currently on the unit.

P3's nursing note dated 7/6/17, at 6:28 p.m. indicated the hospitals mental health unit was contacted for recommendations on placement for P3. The hospital mental health unit recommended the physician reassess P3 again and appropriateness for possible discharge from the emergency room .

P3's physician note filed on 7/6/17, at 6:51 p.m. indicated the patient was in the emergency room for a mental health evaluation and for a higher level of care. P3's drug and alcohol screen came back negative. P3 expressed impulsivity and inappropriate judgement. The patient was aggressive initially but calmed and was cooperative. P3 received Zyprexa (antipsychotic) 5 mg intramuscularly (IM) on 7/5/17, at 8:38 p.m., Zyprexa 10 mg IM on 7/5/17, 10:24 p.m., Benadryl (antihistamine) 50 mg IM on 7/5/17, at 10:24 p.m., and Seroquel (antipsychotic) 100 mg orally on 7/5/17, at 11:14 p.m. The physician note indicated P3 was medically stable for discharge. P3 denies being suicidal or homicidal and the patient felt like she was under control. There was no documentation regarding a follow up plan for P3, where the patient was discharged to, and who the patient left the emergency room with.

P3's nursing note dated 7/6/17, at 7:25 p.m. indicated all of the patient's belongings returned to her and she is getting dressed at this time.

P3's Patient Care Timeline indicated on 7/6/17, at 7:38 p.m. indicated, "Patient discharged ." There was no further documentation regarding where the patient was discharged to and any follow up plan of care.

During interview on 9/19/17, at 9:00 a.m. Registered Nurse (RN)-B stated if a patient is assessed as requiring inpatient mental health treatment the DEC assessors assist with finding placement. If the DEC assessors are unable to find an inpatient mental health facility after 16 hours, the emergency room staff is responsible for continuing to find an inpatient mental health unit. RN-B stated the hospitals inpatient mental health unit would generally take patients from the emergency room if other mental health inpatient facilities were not available. However, P3 had been a former patient in the hospital's inpatient mental health unit and was violent so they were no longer able to admit the patient. RN-B stated P3's medical record did not identify any information regarding P3's discharge.

The facility policy titled, Emergency Services Patient Outcome Guideline, dated 8/17, directed staff to ensure a safe discharge from the department.

The facility policy titled, Discharge Planning, dated 5/17, indicated the physician is responsible to oversee comprehensive multidisciplinary discharge plan from admission through discharge. The RN is responsible for planning and providing continuity of care in collaboration with the multidisciplinary team.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review, the hospital failed to ensure patient rights were implemented in the emergency room for 9 of 11 patients reviewed, P1, P3, P4, P5, P6, P7, P8, P9, and P10, who were placed in restraints while in the emergency room during a mental health crisis. The hospital failed to monitor the patients while in restraints according to the facility policy, failed to obtain a timely physician order, and failed to complete the one hour face to face assessment by the physician or licensed independent practitioner (LIP). This resulted in an Immediate Jeopardy situation for all future patients who seek treatment in the emergency room and require restraints for violent behavior.

Findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13. This deficient practice had the potential to impact all patients with behavioral symptoms in the emergency room who required emergency restraints to be applied.

See A178. Based on interview and document review, the hospital failed to ensure a one hour face to face assessment after emergency restraints were applied was completed by a physician or licensed independent practitioner (LIP) for 9 of 11 patients reviewed, P1, P3, P4, P5, P6, P7, P8, P9, and P10, who had an emergency restraint for violent behavior applied in the emergency room .

See A179. Based on interview and document review, the hospital failed to ensure a one hour face to face assessment was completed by a physician or licensed independent practitioner (LIP) which evaluated the patients immediate situation, the patients reaction to the intervention, the patients' medical and behavioral condition, and the need to continue or terminate the restraints for 9 of 11 patients reviewed, P1, P3, P4, P5, P6, P7, P8, P9, and P10, who had an emergency restraint for violent behavior applied in the emergency room .
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure a physician order for violent restraints was obtained for 2 of 11 patients reviewed, P10 and P5, in the emergency room who required emergency restraints due to a mental health crisis.

Findings include:

P10 arrived in the emergency room on [DATE], at 11:51 p.m. for a mental health evaluation. P10's emergency room medical record indicated the patient was brought in by police related to suicidal ideation. P10's violent restraint flowsheet indicated the patient was placed in a five point restraint chair upon arrival to the emergency room on [DATE], at 11:51 p.m. P10 remained in the restraint chair until 7/28/17, at 12:30 a.m. A nursing order was placed into P10's medical record on 7/28/17, at 12:30 a.m. for a restraint chair related to elopement and suicidal ideation. The restraint order was not signed by a physician, and there was no physician order in P10's medical record for the restraint use on 7/27/17, and 7/28/17.

P5 arrived in the emergency room on [DATE], at 6:21 a.m. for a mental health evaluation. P5's emergency room medical record indicated the patient was brought to the emergency room by a friend for alcohol intoxication. P5's violent restraint flowsheet indicated on 8/6/17, at 6:30 a.m. P5 was placed in a five point restraint chair. P5 remained in the restraint chair until 8/6/17, at 7:52 a.m. P5's medical record contained no physician order for the restraint chair on 8/6/17.

During interview on 9/19/17, at 9:00 a.m. Registered Nurse (RN)-B stated P5's medical record contained no physician order for the restraint chair used on 8/6/17, and P10's medical record contained no physician order for the restraint chair used on 7/27/17, and 7/28/17. RN-B stated if an emergency restraint is required to be used for a patient in a mental health crisis, staff should contact the physician immediately to obtain a physician order.

The facility policy titled, Restraint, dated 1/2017, indicated a provider order is needed for each episode of restraint use. When restraints are used for violent or self destructive behavior a Registered Nurse may initiate the restraint based on their judgement that the situation is imminently dangerous. A physicians order must be obtained immediately after the initiation of the restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure ongoing monitoring of patients in emergency restraints was documented and assessed by a licensed nurse according to the facility policy for 6 of 11 patients reviewed, P1, P3, P4, P5, P7, and P9, who had an emergency restraint for violent behavior applied in the emergency room .

Findings include:

P1 arrived in the emergency room on [DATE], at 3:41 p.m. for a mental health evaluation. P1's emergency room medical record indicated the patient was yelling and being disruptive at school earlier that day and refused to leave school with his caregiver.

P1's physician order dated 9/11/17, at 6:18 p.m. indicated a double Velcro five-point restraint to all limbs and chest. The reason for the restraint was listed as "other," and "all the above reasons." P1's medical record did not identify P1's behavior to justify use of the restraint.

P1's violent restraint flowsheet indicated on 9/11/17, at 5:35 p.m. P1 was placed in a restraint chair. P1's medical record contained no documentation indicating the patient was monitored by a licensed nurse every 15 minutes for observation of safety in restraints, CMS (circulation, mobility, and sensation) of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria for discontinuation of the restraint.

P1's nursing note on 9/11/17, at 6:30 p.m. indicated the patient was removed from the restraint chair upon agreement to be safe, calm, and cooperative.

P3 arrived in the emergency room on [DATE], at 2:30 p.m. for a mental health evaluation. P3's emergency room medical record indicated the patient was brought in by the detox facility because she was delusional, had broken a toilet, and had homicidal ideas.

P3's physician order dated 7/5/17, at 10:35 p.m. directed a restraint chair for all four extremities and chest for extreme agitation and disruptive behavior.

P3's violent restraint flowsheet indicated on 7/5/17, at 10:10 p.m. P3 was placed in a restraint chair and remained in the restraint chair until 7/6/17, at 12:13 a.m. P3's medical record contained no 15-minute assessment by a licensed nurse which included observation of safety in restraints, CMS of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria for discontinuation of the restraint from 11:00 p.m. to 11:40 p.m., and from 11:40 p.m. to 12:13 a.m.

P4 arrived in the emergency room on [DATE], at 12:03 p.m. for a mental health evaluation. P4's emergency room medical record indicated the patient was brought in by the police related to drug use and delusional behavior.

P4's physician order dated 7/9/17, at 12:47 p.m. indicated a restraint chair including all four extremities and chest for extreme agitation and disruptive behavior. P4's violent restraint flowsheet indicated on 7/9/17, at 1:05 p.m. P4 was placed in a five point restraint chair. P4's medical record contained no 15-minute assessment completed by a licensed nurse which included observation of safety in restraints, CMS of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria.

P4's nursing progress notes indicated on 7/9/17, at 5:14 p.m. the patient was resting on a cot and supper tray was ordered. There was no other documentation regarding when P4 was removed from the restraint chair.

P5 arrived in the emergency room on [DATE], at 6:21 a.m. for a mental health evaluation. P5's emergency room medical record indicated the patient was brought in by a friend for alcohol intoxication.

P5's violent restraint flowsheet indicated on 8/6/17, at 6:30 a.m. P5 was placed in a five point restraint chair, until 8/6/17, at 7:52 a.m. P5's medical record contained no 15-minute assessment completed by a licensed nurse on 8/6/17, from 7:00 a.m. to 7:52 a.m. which included observation of safety in restraints, CMS of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria.

P7 arrived in the emergency room on [DATE], at 12:41 p.m. for a mental health evaluation. P7's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication and agitation.

P7's physician orders on 7/12/17, at 12:52 p.m. directed a restraint chair, all four extremities and chest for threatening the safety of others, and a verbal order entered by the nurse on 7/13/17, at 12:46 p.m., and signed by the physician on 7/13/17, at 5:52 p.m.

P7's violent restraint flowsheet indicated the patient was placed in the restraint chair upon arrival to the emergency room on [DATE], at 12:41 p.m. and remained restrained until 7/12/17, at 5:00 p.m. P7's medical record contained no 15-minute assessment completed by a licensed nurse on 7/12/17, from 1:45 p.m. to 5:00 p.m. which included observation of safety in restraints, CMS of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria.

P9 arrived in the emergency room on [DATE], at 6:37 p.m. for a mental health evaluation. P9's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication.

P9's physician order dated 7/23/17, at 8:03 p.m. directed full body restraint chair for agitation, disorientation, and interfering with treatment.

P9's violent restraint flowsheet indicated on 7/23/17, at 8:03 p.m. P9 was placed in the restraint chair until 7/23/17, at 10:32 p.m. P9's medical record contained no 15-minute assessment completed by a licensed nurse on 7/23/17, from 8:03 p.m. to 10:10 p.m. which included observation of safety in restraints, CMS of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria.

During interview on 9/19/17, at 9:00 a.m. Registered Nurse (RN)-B stated she reviewed the medical records of P1, P3, P4, P5, P7, and P9, and verified the patients did not have documentation of the required 15 minute nurse assessment completed while they were in the restraint chair. RN-B stated although the emergency room RN's document patients are checked on every 15 minutes, there was no indication the nurses were completing the required assessment for the patient in restraints.

The facility policy titled, Restraint, dated 1/2017, indicated a Registered Nurse assessment of a patient in restraints must include patient activities are monitored and documented at the initiation of restraints and every 15 minutes thereafter including observation to determine the patient is safe, comfortable, and without any injury associated with the application of the restraint, CMS of the restrained limbs, patient hydration needs, patients behavior, observation for discontinuation of restraint or seclusion, and if the patient is not ready for discontinuation of the restraint reinforcement of behavior criteria for discontinuing the restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure a one hour face to face assessment after emergency restraints were applied was completed by a physician or licensed independent practitioner (LIP) for 9 of 11 patients reviewed, P1, P3, P4, P5, P6, P7, P8, P9, and P10, who had an emergency restraint for violent behavior applied in the emergency room . This had the potential to effect all future patients who came to the emergency room and required an emergency restraint.

Findings include:

P1 arrived in the emergency room on [DATE], at 3:41 p.m. for a mental health evaluation. P1's emergency room medical record indicated the patient was yelling and being disruptive at school earlier that day and refused to leave school with his caregiver.

P1's violent restraint flowsheet indicated on 9/11/17, at 5:35 p.m. P1 was placed in a restraint chair. P1's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P3 arrived in the emergency room on [DATE], at 2:30 p.m. for a mental health evaluation. P3's emergency room medical record indicated the patient was brought in by the detox facility because she was delusional, had broken a toilet, and had homicidal ideas.

P3's violent restraint flowsheet indicated on 7/5/17, at 10:10 p.m. P3 was placed in a restraint chair. P3's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P4 arrived in the emergency room on [DATE], at 12:03 p.m. for a mental health evaluation. P4's emergency room medical record indicated the patient was brought in by the police related to drug use and delusional behavior.

P4's violent restraint flowsheet indicated on 7/9/17 at 1:05 p.m. P4 was placed in a restraint chair. P4's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P5 arrived in the emergency room on [DATE], at 6:21 a.m. for a mental health evaluation. P5's emergency room medical record indicated the patient was brought in by a friend for alcohol intoxication.

P5's violent restraint flowsheet indicated on 8/6/17, at 6:30 a.m. P5 was placed in a restraint chair. P5's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P6 arrived in the emergency room on [DATE], at 8:18 a.m. for a mental health evaluation.

P6's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication and delusional behavior. P6's violent restraint flowsheet indicated the patient was placed in the restraint chair upon arrival to the emergency room on [DATE], at 8:18 a.m. P6's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P7 arrived in the emergency room on [DATE], at 12:41 p.m. for a mental health evaluation. P7's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication and agitation.

P7's violent restraint flowsheet indicated the patient was placed in the restraint chair upon arrival to the emergency room on [DATE], at 12:41 p.m. P7's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P8 arrived in the emergency room on [DATE], at 4:03 p.m. for a mental health evaluation. P8's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication and suicidal ideation.

P8's violent restraint flowsheet indicated the patient was placed in the restraint chair on 9/16/17, at 4:55 p.m. P8's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P9 arrived in the emergency room on [DATE], at 6:37 p.m. for a mental health evaluation. P9's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication.

P9's violent restraint flowsheet indicated on 7/23/17, at 8:03 p.m. P9 was placed in the restraint chair. P9's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

P10 arrived in the emergency room on [DATE], at 11:51 p.m. for a mental health evaluation. P10's emergency room medical record indicated the patient was brought in by the police related to suicidal ideation.

P10's violent restraint flowsheet indicated the patient was placed in a restraint chair upon arrival to the emergency room on [DATE], at 11:51 p.m. P10's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP.

During interview on 9/18/17, at 2:50 p.m. Registered Nurse (RN)-E stated when a patient is placed in emergency restraints in the emergency room staff attempt to notify the physician immediately. RN-E stated the physician does not document in the patient's chart regarding a one hour face to face assessment when the patient is seen.

During interview on 9/19/17, at 9:00 a.m. RN-B stated the emergency room physicians do not document a one hour face to face assessment in the patients medical record. RN-B stated the physician notes for P1, P3, P4, P5, P6, P7, P8, P9, and P10 did not contain any information regarding a one to one assessment completed after the patient's were placed in restraints. RN-B also stated it could not be determined when the physician saw the patient because the electronic medical record automatically populated the time of the note to correlate with the patients admitted and time to the emergency room , and also added the time the physician note was filed; which could be a day or two after the patient was discharged from the emergency room which would not necessarily coorelate with the time the physican saw the patient.

During interview on 9/19/17, at 11:00 a.m. medical doctor (MD)-J stated when a patient is placed in emergency restraints in the emergency room the physician will attempt immediately to do a "brief" visit with the patient. MD-J stated the one hour face to face assessment is not documented by the physician and the information regarding the physician seeing the patient after the emergency restraints were applied would be documented in the nursing notes.

During interview on 9/19/17, at 11:15 a.m. RN-H stated after emergency restraint application in the emergency room the physician tries to see the patient as soon as possible. RN-H stated the physician does not document when they see the patient after the restraint is applied, and was not aware of any assessment completed by a physician regarding restraints.

The facility policy titled, Restraints, dated 1/2017, indicated a face to face assessment by the provider must be completed within one hour of the initiation of the violent or self destructive restraint. If the restraint is discontinued prior to the one hour face to face evaluation completed, the patient must still be evaluated by the provider.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure a one hour face to face assessment was completed by a physician or licensed independent practitioner (LIP) which evaluated 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 restraints for 9 of 11 patients reviewed, P1, P3, P4, P5, P6, P7, P8, P9, and P10, who had an emergency restraint for violent behavior applied in the emergency room . This had the potential to effect all future patients who came to the emergency room and required an emergency restraint.

Findings include:

P1 arrived in the emergency room on [DATE], at 3:41 p.m. for a mental health evaluation. P1's emergency room medical record indicated the patient was yelling and being disruptive at school earlier that day and refused to leave school with his caregiver.

P1's violent restraint flowsheet indicated on 9/11/17, at 5:35 p.m. P1 was placed in a restraint chair. P1's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP which evaluated 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 restraints.

P3 arrived in the emergency room on [DATE], at 2:30 p.m. for a mental health evaluation. P3's emergency room medical record indicated the patient was brought in by the detox facility because she was delusional, had broken a toilet, and had homicidal ideas.

P3's violent restraint flowsheet indicated on 7/5/17, at 10:10 p.m. P3 was placed in a restraint chair. P3's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP which evaluated 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 restraints.

P4 arrived in the emergency room on [DATE], at 12:03 p.m. for a mental health evaluation. P4's emergency room medical record indicated the patient was brought in by the police related to drug use and delusional behavior.

P4's violent restraint flowsheet indicated on 7/9/17 at 1:05 p.m. P4 was placed in a restraint chair. P4's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP which evaluated 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 restraints.

P5 arrived in the emergency room on [DATE], at 6:21 a.m. for a mental health evaluation. P5's emergency room medical record indicated the patient was brought in by a friend for alcohol intoxication.

P5's violent restraint flowsheet indicated on 8/6/17, at 6:30 a.m. P5 was placed in a restraint chair. P5's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP that evaluated 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 restraints.

P6 arrived in the emergency room on [DATE], at 8:18 a.m. for a mental health evaluation. P6's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication and delusional behavior.

P6's violent restraint flowsheet indicated the patient was placed in the restraint chair upon arrival to the emergency room on [DATE], at 8:18 a.m. P6's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP that evaluated 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 restraints.

P7 arrived in the emergency room on [DATE], at 12:41 p.m. for a mental health evaluation. P7's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication and agitation.

P7's violent restraint flowsheet indicated the patient was placed in the restraint chair upon arrival to the emergency room on [DATE], at 12:41 p.m. P7's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP that evaluated 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 restraints.

P8 arrived in the emergency room on [DATE], at 4:03 p.m. for a mental health evaluation. P8's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication and suicidal ideation.

P8's violent restraint flowsheet indicated the patient was placed in the restraint chair on 9/16/17, at 4:55 p.m. P8's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP that evaluated 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 restraints.

P9 arrived in the emergency room on [DATE], at 6:37 p.m. for a mental health evaluation. P9's emergency room medical record indicated the patient was brought in by the police related to alcohol intoxication.

P9's violent restraint flowsheet indicated on 7/23/17, at 8:03 p.m. P9 was placed in the restraint chair. P9's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP that evaluated 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 restraints.

P10 arrived in the emergency room on [DATE], at 11:51 p.m. for a mental health evaluation. P10's emergency room medical record indicated the patient was brought in by the police related to suicidal ideation.

P10's violent restraint flowsheet indicated the patient was placed in a restraint chair upon arrival to the emergency room on [DATE], at 11:51 p.m. P10's medical record contained no documentation of the one hour face to face assessment completed by a physician or LIP that evaluated 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 restraints.

During interview on 9/18/17, at 2:50 p.m. Registered Nurse (RN)-E stated when a patient is placed in emergency restraints in the emergency room staff attempt to notify the physician immediately. RN-E stated the physician does not document in the patient's chart regarding a one hour face to face assessment which would identify 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 restraints.

During interview on 9/19/17, at 9:00 a.m. RN-B stated the emergency room physicians do not document a one hour face to face assessment in the patients medical record. RN-B stated the physician notes for P1, P3, P4, P5, P6, P7, P8, P9, and P10 did not contain any information regarding a one to one assessment completed by the physician 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 restraints. RN-B also stated it could not be determined when the physician saw the patient because the electronic medical record automatically populated the time of the note to correlate with the patients admitted and time to the emergency room , and also added the time the physician note was filed; which could be a day or two after the patient was discharged from the emergency room .

During interview on 9/19/17, at 11:00 a.m. Medical Doctor (MD)-J stated when a patient is placed in emergency restraints in the emergency room the physician will attempt immediately to do a "brief" visit with the patient. MD-J stated the one hour face to face assessment is not documented by the physician and the information regarding the physician seeing the patient after the emergency restraints were applied would be documented in the nursing notes. MD-J stated the assessment information including 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 restraints was located in the nursing notes and not documented in the physician notes.

During interview on 9/19/17, at 11:15 a.m. RN-H stated after emergency restraint application in the emergency room , the physician tries to see the patient as soon as possible. RN-H stated the physician does not document when they see the patient after the restraint is applied, and was not aware of any assessment completed by a physician regarding restraints.

The facility policy titled, Restraints, dated 1/2017, indicated a face to face assessment by the provider must be completed within one hour of the initiation of the violent or self destructive restraint. If the restraint is discontinued prior to the one hour face to face evaluation being completed, the patient must still be evaluated by the provider. The face to face assessment must include an evaluation of the patients immediate situation including an assessment of the incident or situation that led to the restraint, the patients reaction to the restraint, the patient physiologic and psychological condition, and the need to continue or terminate the restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure an assessment of behaviors was documented for emergency restraint application for 1 of 11 patients reviewed (P1), who had an emergency restraint applied in the emergency room after being admitted for a mental health evaluation.

Findings include:

P1 arrived in the emergency room on [DATE], at 3:41 p.m. for a mental health evaluation. P1's emergency room medical record indicated the patient was yelling and being disruptive at school earlier that day and refused to leave school with his caregiver.

P1's physician order dated 9/11/17, at 6:18 p.m. indicated a double Velcro five-point restraint to all limbs and chest. The reason for the restraint was listed as "other," and "all the above reasons."

P1's violent restraint flowsheet indicated on 9/11/17, at 5:35 p.m. P1 was placed in a restraint chair. P1's medical record contained no documentation from the physician or nursing regarding the behavior which led up to the use of the restraint chair. P1's nursing note on 9/11/17, at 6:30 p.m. indicated the patient was removed from the restraint chair upon agreement to be safe, calm, and cooperative.

During interview on 9/18/17, at 2:50 p.m. Registered Nurse (RN)-E stated she was working on 9/11/17, when P1 was placed in the restraint chair. RN-E stated P1 refused to have labwork completed which was necessary to provide care to the patient so the patient was placed in the restraint chair for blood to be drawn. RN-E verified there was no assessment documented of P1's behavior which led up to the use of the restraint chair on 9/11/17.

The facility policy titled, Restraint, dated 1/2017, indicated the physician order must contain the specific behaviors requiring restraint intervention. The Registered Nurse assessment of a patient in restraints must include patient activities are monitored and documented at the initiation of restraints and every 15 minutes thereafter including patients behavior.
VIOLATION: QAPI Tag No: A0263
Based on interview and document review, the hospital failed to ensure a process for Quality Assessment and Performance Improvement (QAPI) activities that reflected the need for patient safety and enhanced health outcomes when providing treatment for patients with behavioral symptoms who required restraint use in the emergency room . This had the potential to affect all patients who received services from the hospital emergency room and require restraint use.

Findings include:

The failure to ensure the QAPI committee had a process to identify quantitative and qualitative measures in accordance with the hospital's complexity to provide a safe environment when treating individuals in the emergency room with behavioral symptoms who required restraint use resulted in the hospital's inability to determine qualitative assessment measures and implement improvement activities. Therefore, the hospital was unable to meet the Condition of Participation: Quality Assessment and Performance Improvement Program at 42 CFR 482.21. The cumulative effect of this system failure resulted in the hospital's inability to ensure an effective QAPI program.

The deficient practice had the potential to impact all patients receiving behavioral services at the hospital emergency room and requiring restraint use for violent or self harm behavior.

Based on interview and document review, the hospital failed to ensure a Quality Assessment and Performance Improvement program that measured, analyzed, and tracked accurate information of performance that assess processes of care, emergency services, and restraint use and therefore, failed to use that data to monitor the effectiveness and safety of services and quality of care for all patients with behavioral symptoms who required restraint use in the emergency room including 2 of 11 patients reviewed who required emergency restraint application without a physician order, 6 of 11 patients who required restraint use for violent behavior and were not monitored and assessed by a registered nurse every 15 minutes, and 9 of 11 patients who required emergency restraint application and had no one hour face to face assessment completed by the physician.

Refer to A-0168. Based on interview and document review, P5 and P10, were placed in emergency restraints for violent behavior in the emergency room without a physician order.

Refer to A-0175. Based on interview and document review, P1, P3, P4, P5, P7, and P9, were placed in emergency restraints for violent behavior in the emergency room and were not monitored every 15 minutes by a registered nurse.

Refer to A-0178 and A-0179. Based on interview and document review, P1, P3, P4, P5, P6, P7, P8, P9, and P10, were placed in emergency restraints for violent behavior in the emergency room and had no one hour face to face assessment by a physician or licensed independent practitioner (LIP).
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and document review, the hospital failed to ensure a Quality Assessment and Performance Improvement (QAPI) program accurately measured, analyzed, and tracked restraint use in the emergency room and therefore, failed to use that data to monitor the effectiveness and safety of emergency restraint application use for 9 of 11 patients reviewed, P1, P3, P4, P5, P6, P7, P8, P9, and P10, who were placed in restraints in the emergency room and facility policy and procedure was not followed to ensure patient safety and rights when using emergency restraints. Although the facility audited emergency restraint use in the emergency room and presented the information to the governing board, the information provided in the audits were not accurate and audits were not completed to ensure the facility policy and protocols were being implemented for emergency violent restraints.

Findings include:

A review of 11 medical records from 6/1/17- 9/18/17 established that 9 of 11 patients were placed in violent, emergency, restraints in the emergency room . There was no evidence of any QAPI activity related to this high-risk practice.

P1, P3, P4, P5, P6, P7, P8, P9, and P10 were admitted to the emergency room for a mental health evaluation. All nine patient's were placed in a five point restraint chair for violent, self destructive behaviors. None of the nine patient's had a one hour face to face assessment completed by a physician or licensed independent practitioner (LIP) which evaluated 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 restraints.

P1, P3, P4, P5, P7, and P9, were admitted to the emergency room for a mental health evaluation. All six patient's were placed in a five point restraint chair for violent, self destructive behaviors. None of the six patient's had ongoing monitoring and assessment while restrained completed by a licensed nurse which included observation of safety in restraints, CMS (circulation, mobility, and sensation) of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria for discontinuation of the restraint.

P5 and P10 were admitted to the emergency room for a mental health evaluation. Both patient's were placed in a five point restraint chair for violent, self destructive behaviors. Both patient's medical records lacked a physician order for the restraints.

P1 was admitted to the emergency room for a mental health evaluation. P1 was placed in a five point restraint chair. The patient's medical record contained no documentation or assessment of the behavior which resulted P1 requiring emergency restraints to be applied.

During interview on 9/22/17, at 10:15 a.m. Registered Nurse (RN)-D stated random audits are done throughout the hospital of restraint use. The most current audit of restraints was completed and reviewed at the Quality Review Meeting on July 25, 2017. The audit indicated patients who required behavioral restraints and patient violence records were audited to ensure the physician was contacted as soon as possible after the restraints were applied, the initial face to face assessment was completed within one hour, the order to continue the restraints was written at the time of the evaluation, a phone order to continue the restraints was written within four hours after the initial physician order was written, and nursing documented in notes and the flow sheet at time intervals and according to the policy. The audit indicated four of the five patient charts reviewed for restraint use were in the emergency room . The audit indicated patient #3 (the facility identifier for the patient) on the audit form, who was a patient in the emergency room , did not have a physician order for restraints but indicated, "Provider documented regarding restraint use but no order." The audits did not identify any other concerns or quality improvement actions required regarding restraint use. RN-D reviewed the four patient charts from the emergency room which were used in the restraint audit and verified none of the four patients had a one hour face to face assessment completed by a physician, and none of the patients had consistent 15-minute assessments completed by a licensed nurse which included observation of safety in restraints, CMS of restrained limbs, hydration needs, patient's behavior, observation for discontinuation of restraint, and reinforcement of behavior criteria for discontinuation of the restraint. RN-D stated during the audit process the patient charts are reviewed to make sure the physician saw the patient sometime after the restraints were applied, and also made sure 15 checks were being completed but did not review what was being documented and assessed during the 15 minute checks. RN-D verified that any patient in the emergency room who is suicidal and/ or in a mental health crisis has 15 minute checks documented in the medical record. RN-D stated there was no current quality assurance projects in place for restraint use.

During interview on 9/22/17, at 11:45 p.m. Chief Quality Officer (CQO) stated restraint use and procedures regarding emergency restraint application and monitoring was not presented as a concern to the Quality Assurance Committee so there were no current improvement projects being worked on or monitored.