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.

PACIFIC GROVE HOSPITAL 5900 BROCKTON AVE RIVERSIDE, CA 92506 July 8, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on interview and record review, the facility failed to ensure staff training and demonstrated competency, in regards to restraints and seclusion, was successfully completed and documented in the personnel files for five of five employees (Registered Nurse (RN) 2, RN 3, RN 4, Mental Health Associate (MHA) 2, and MHA 3). This resulted in the employee files not indicating the staff had successfully completed training and demonstrated competency for restraint and seclusion use.

Findings:

1. On July 7, 2016, the employee file for RN 2 was reviewed. RN 2 was hired on June 27, 2016, and had completed Management of Assaultive Behavior in June of 2016.

RN 2 completed a test titled "Seclusions and Restraints Competency" on June 14, 2016.

There was no documented evidence RN 2 had demonstrated competency in the application of restraints or was trained on the facility's policy and procedure for seclusion and/or restraints.

2. On July 7, 2016, the employee file of RN 3 was reviewed. RN 3 was hired on December 29, 2015. RN 3 completed Management of Assaultive Behavior on December 29, 2015.

There was no documented evidence RN 3 demonstrated competency in the application and use of restraints.

3. On July 7, 2016, the employee file of RN 4 was reviewed. RN 4 was hired on January 15, 2016. RN 4 completed Management of Assaultive Behavior on April 21, 2016.

There was no documented evidence RN 4 demonstrated competency in the application and use of restraints.

4. On July 7, 2016, the employee file for Mental Health Associate (MHA) 2 was reviewed. MHA 2 was hired on May 20, 2016, and had completed Management of Assaultive Behavior in May of 2016.

MHA 2 completed a test title "Seclusions and Restraints Competency " on May 19, 2016.

There was no documented evidence MHA 2 was trained on the facility's policy and procedure for seclusion and/or restraints, or how to release the restraint in the case of an emergency.

5. On July 7, 2016, the employee file of MHA 3 was reviewed. MHW 3 was hired on January 15, 2016. MHA 3 completed Management of Assaultive Behavior on January 15, 2016.

There was no documented evidence MHA 3 was trained on the facility's policy and procedure for seclusion and/or restraints, or how to release the restraint in the case of an emergency.

On July 7, 2016, at 11:05 a.m. the Director of Nursing (DON) was interviewed. The DON stated the facility Management of Assaultive Behavior Trainer (MABT) does restraint training for new employees during orientation. The DON stated the MHAs were trained on assisting in holding patients and the RNs were trained on the application of restraints. The DON stated the employees attended class and were given written materials to review. The DON stated there was no competency verification with return demonstration on the training for application and removal of restraints

On July 8, 2016, at 10:35 a.m., the MABT was interviewed. The MABT stated "I only do the physical restraint training...I do not do any manual restraint or seclusion training, that's beyond my scope." The MABT further stated "The DON should be doing that."

Review of the facility policy and procedure "Seclusion and restraint of Patient" reviewed July 2015, indicated "STAFF COMPETENCY AND EDUCATION ... Employees must demonstrate competency in [MAB, CPI, etc] procedures. The focus of training is ... 6. Safe application and removal of restraints. 7. Seclusion/restraint policy and procedures. 8. Appropriate monitoring of a patient in seclusion/restraints. ..."

The facility policy and procedure did not indicate how frequently the staff should demonstrate competency on the safe application and removal of restraints, and have training on the facility's policy and procedure for seclusion and/or restraints.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, and record review, the facility failed to ensure:

1. The document titled, "An Important Message From Medicare About Your Rights," was provided on admission to inform one sampled patient (Patient 2) about her right to appeal her discharge (A 116);

2. Acknowledgement of a grievance was completed for one of two sampled patients who filed a grievance (Patient 33) (A 122);

3. Written responses to grievances were provided for two of two sampled patients who filed grievances (Patients 13 and 33) (A 123);

4. A plan of care was developed, implemented, and updated as needed when seclusion and/or restraint was initiated on six of six sampled patients in restraints (Patients 6, 7, 8, 11, 14, and 15) (A 166);

5. Seclusion and/or restraints were applied in accordance with a physician's order for four of six sampled patients in restraints (Patients 6, 7, 8, and 15) (A 168);

6. Orders for restraints and/or seclusion were complete, and included the type and duration, according to the facility policy, for one of six sampled patients in restraints (Patient 6) (A 168);

7. Two of six sampled patients in restraints and/or seclusion were monitored according to the facility policy (Patients 7 and 14) (A 175);

8. Five of six sampled patients placed in restraints and/or seclusion (Patients 7, 8, 11, 14, and 15) were seen face-to-face by a physician or a trained Registered Nurse (RN) within one hour after the initiation of restraint or seclusion (A 178);

9. The face-to-face assessment included the patient's response to the intervention, or the need to continue or terminate the restraints or seclusion for one of one patients who had a face-to-face assessment completed (A 179) (A 184);

10. Continuous monitoring was performed when simultaneous restraint and seclusion was implemented for four of six sampled patients (Patients 6, 7, 11, and 14) (A 183);

11. Application and use of seclusion and/or restraints was appropriately documented for six of six patients (Patients 6, 7, 8, 11, 14, and 15) (A 179) (A 184); and,

12. Five of five staff (RN 2, RN 3, RN 4, MHA 2, and MHA 3) were trained in the safe use of seclusion and restraint, and demonstrated competency in the application of restraints, prior to performing duties related to application and use of seclusion and restraint (A 196)(A 207)(A 208).

The cumulative effect of these systemic problems resulted in failure to ensure the rights of patients at the facility were promoted and protected.

On July 7, 2016, at 1:45 p.m., the Chief Executive Officer (CEO), the Chief Financial Officer (CFO), the Director of Nursing (DON), and the Director of Performance Improvement and Risk Management (PI/RM) were notified of the determination of an Immediate Jeopardy (IJ) situation to the health and safety of patients related to unsafe use of restraints and seclusion.

The facility developed a plan of correction, and the CEO and Director of PI/RM were notified the plan of correction was accepted on July 7, 2016, at 6:30 p.m.

On July 8, 2016, at 11 a.m., implementation of the plan of correction was verified, and the Director of PI/RM was notified the immediate jeopardy was removed.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure "An Important Message From Medicare About Your Rights" was provided on admission to one sampled patient (Patient 2). This had the potential to result in Patient 2 not being aware of her rights to appeal her discharge.

Findings:

On July 6, 2016, the record for Patient 2 was reviewed. Patient 2 was admitted to the facility on on [DATE], with diagnoses of psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and neurocognitive disorder (dementia).

Patient 2 was over 65 years of age and had Medicare as her primary insurance.

Patient 2 signed/acknowledged the "Conditions of Treatment," "Financial Responsibility Acknowledgement," "Consent for Appointment of Representative to File an Appeal or Grievance," "Participant Phone Agreement," and other authorizations on June 29, 2016.

There was no indication Patient 2 received and acknowledged the receipt of "An Important Message From Medicare About Your Rights."

During an interview with the Director of Nursing (DON), on July 6, 2016, at 10:30 a.m., he reviewed the record and was unable to find documentation of Patient 2 receiving and acknowledging receipt of "An Important Message From Medicare About Your Rights." The DON stated "An Important Message From Medicare About Your Rights" was part of the admission packet and should have been provided to and signed by Patient 2 at the time of admission to the facility.

The facility policy and procedure titled "Important Message From Medicare and Tri-Care" dated March 2016, revealed "... Upon admission the Admissions staff explains the "Important Message from Medicare or Tricare" to the patient. The patient signs the form confirming acknowledgment of receipt. The form is placed in the discharge section of the chart. ..."
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, the facility failed to ensure:

1. Performance improvement activities focused on high risk and problem prone areas with the potential to affect health outcomes and patient safety (A283); and,

2. The number and scope of performance improvement (PI) projects was proportional to the scope of services they provided (A297).

The cumulative effect of these systemic problems resulted in failure to ensure quality care and treatment was being provided in a safe and effective manner.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on interview and record review, the facility failed to ensure acknowledgement of a grievance was completed for one of two sampled patients who filed a grievance (Patient 33). This had the potential to result in delays in the investigation of the grievances and missed opportunities for improvement.

Findings:

On July 7, 2016, at 3 p.m., the grievance file for Patient 33 was reviewed.

The file indicated on February 26, 2016, Patient 33's family member/conservator emailed a grievance to the facility's corporate office in regards to Patient 33's inappropriate discharge from the facility on February 25, 2016. The facility received the grievance on February 27, 2016, via email and facsimile.

There was no indication an acknowledgment of the grievance was provided to Patient 33's family member/conservator.

There was no indication the DQRM informed Patient 33's family member/conservator that the facility was still working to resolve the grievance, seven days after receipt of the grievance, and a written response would be made within 30 days.

There was no indication written notice of the resolution of the grievance was provided to Patient 33's family member/conservator to include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

On July 7, 2016, the facility's Grievance Log was reviewed.

There was no indication on the facility's Grievance Log that Patient 33's family member/conservator had submitted a grievance.

During an interview with the Director Quality and Risk Management (DQRM), on July 7, 2016, at 11:30 a.m., when asked about the grievance submitted by Patient 33's family member/conservator, she stated she had gotten so caught up in the investigation that she had forgotten to place this grievance on the Grievance Log.

During an interview with the DQRM, on July 7, 2016, at 3:45 p.m., she stated she did not send Patient 33's family member/conservator an acknowledgement letter or a written notice of the resolution to the grievance (129 days after the grievance was submitted to the facility). The DQRM stated she should have sent a resolution letter to Patient 33's family member/conservator within seven days or a letter indicating the facility was still investigating and would send a resolution letter within 30 days.

On July 7, 2016, the following facility policies and procedures were reviewed.

The facility policy and procedure titled "Grievance Procedure - Patient" reviewed December 2015, revealed "... All concerns (verbal, written, email, and fax) brought to the attention of the Patient Advocate are considered grievances ... The Risk Manager will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. Due to the nature and complexity of the grievance, if a written response cannot be made within seven (7) calendar days, the Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance. ..."

The facility policy and procedure titled "Patient Advocate Function Description" dated August 2014, revealed "... Responds to patient/family grievances in a timely manner. ... Insures appropriate written feedback is provided to the individual presenting the grievance. ... Maintains a log or file of grievances for tracking and trending. ..."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview and record review, the facility failed to ensure a written notice of its decision to the patient's grievance was provided for two of two sampled patients who filed grievances (Patients 13 and 33). This resulted in Patients 13 and 33, and/or their family members, not receiving resolutions to the grievances submitted, and the potential for unidentified opportunities to make improvemetst in facility practices.

Findings:

On July 7, 2016, the facility's Grievance Log was reviewed.

1. On July 7, 2016, at 3 p.m., the grievance file for Patient 13 was reviewed with the Director of Quality and Risk Management (DQRM). The DQRM stated she was also the Patient Advocate.

On June 25, 2016, Patient 13's family member called the facility DQRM to file a grievance in regards to her status as Patient 13's conservator, the patient's medical needs, visiting hours and visiting rights for the patient's spiritual leader.

The Grievance Log indicated the grievance was resolved on June 25, 2016.

There was no indication written notice of the resolution of the grievance was provided to Patient 13's family member to include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

During an interview with the DQRM, on July 7, 2016, at 3 p.m., she stated resolution of Patient 13's family members grievance required obtaining physician's orders, informing the direct care staff of the patient's medical issues, arranging alternative visiting hours and ensuring the patient's spiritual leader could visit the patient. The DQRM stated Patient 13/Patient 13's family member was not provided written notice of the resolution to their grievances.

2. On July 7, 2016, at 3 p.m., the grievance file for Patient 33 was reviewed.

On February 26, 2016, Patient 33's family member/conservator emailed a grievance to the facility's corporate office in regards to Patient 33's inappropriate discharge from the facility on February 25, 2016. The facility received the grievance, on February 27, 2016, via email and facsimile.

There was no indication an acknowledgment of the grievance was provided to Patient 33's family member/conservator.

There was no indication written notice of the resolution of the grievance was provided to Patient 33's family member/conservator to include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

There was no indication on the facility's Grievance Log that Patient 33's family member/conservator had submitted a grievance.

During an interview with the Director Quality and Risk Management (DQRM), on July 7, 2016, at 11:30 a.m., when asked about the grievance submitted by Patient 33's family member/conservator she stated she had gotten so caught up in the investigation that she had forgotten to place this grievance in the Grievance Log.

During an interview with the DQRM, on July 7, 2016, at 3:45 p.m., she stated she did not send Patient 33's family member/conservator an acknowledgement letter or a written notice of the resolution to the grievance submitted (129 days after the grievance was submitted to the facility). The DQRM stated she should have sent a resolution letter to Patient 33's family member/conservator.

The facility policy and procedure titled "Grievance Procedure - Patient" reviewed December 2015, revealed "... All concerns (verbal, written, email, and fax) brought to the attention of the Patient Advocate are considered grievances ... The Risk Manager will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. Due to the nature and complexity of the grievance, if a written response cannot be made within seven (7) calendar days, the Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance. ..."

The facility policy and procedure titled "Patient Advocate Function Description" dated August 2014, revealed "... Responds to patient/family grievances in a timely manner. ... Insures appropriate written feedback is provided to the individual presenting the grievance. ... Maintains a log or file of grievances for tracking and trending. ..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure a plan of care was developed, implemented, and updated as needed when seclusion and/or restraints were initiated for violent or self-destructive behavior, for six of six sampled (Patients 6, 7, 8, 11, 14, and 15). This failure had the potential to result in violent or self-destructive behavior to continue without measures developed and implemented to prevent recurrence.

Findings:

1. On July 6, 2016, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on on July 6, 2016, with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

The "Physician's Order Sheet" dated July 7, 2016, at 3:15 a.m., indicated the patient was to be placed in restraints for safety.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 7, 2016, at 3:30 a.m., revealed the restraints were indicated because Patient 6 was "severely aggressive" and "violent against self and others."

The record indicated Patient 6 was in restraints and seclusion on July 7, 2016, from 3:30 a.m., to 4:30 a.m.

There was no indication a plan of care was developed, implemented, and updated as needed when seclusion and restraints were initiated for Patient 6's behaviors.

During an interview with Registered Nurse (RN) 1, on July 7, 2016, at 8:45 a.m., she reviewed the record for Patient 6 and was unable to find documentation of a plan of care when restraints and seclusion were initiated for Patient 6. RN 1 stated a plan of care should have been initiated when Patient 6 was placed in seclusion and restraints were applied.

2. On July 6, 2016, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on on July 1, 2016, with diagnosis of major depressive order (mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities).

The "Documentation of Patient Progress" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 became agitated, demanded to leave, ran towards the exit door and hit staff. The physician was called and "ordered to place pt (patient) in seclusion."

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 was "severely aggressive" and "violent against self and others," and the patient was in seclusion.

The "Physician's Order Sheet" dated July 1, 2016, at 6:50 p.m., indicated the patient was to be placed in four point soft restraints for one hour and then discontinued with checks every 15 minutes.

The "Documentation of Patient Progress" dated July 1, 2016, at 7:30 p.m., indicated Patient 7 was in the "seclusion room" in restraints.

Patient 7 was in seclusion on July 1, 2016, from 5: 40 p.m., to 7 p.m. (1 hour and 20 minutes) before restraints were applied.

Patient 7 was in restraints and seclusion on July 1, 2016, from 7 p.m. to 8 p.m.

There was no indication a plan of care was developed, implemented, and updated as needed when seclusion and restraints were initiated for Patient 7's behaviors.

3. On July 6, 2016, the record for Patient 8 was reviewed. Patient 8 was admitted to the facility on on [DATE], with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

The "Seclusion or Restraint Physician's Order Sheet" indicated a telephone order for seclusion was obtained from the physician on May 2, 2016, at 4 p.m., for the patient's violent behavior, danger to self and others.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated May 2, 2016, at 4 p.m., indicated Patient 8 was "severely aggressive" and "violent against self and others," and the patient was in seclusion.

Patient 8 was removed from seclusion on May 2, 2016, at 5 p.m. (in seclusion for one hour).

The "Seclusion or Restraint Physician's Order Sheet" indicated a telephone order for seclusion was obtained from the physician on May 3, 2016, at 8:10 a.m., for the patient's violent behavior, and for being a danger to others.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated May 3, 2016, indicated Patient 8 was in seclusion from 8:10 a.m. until 8:45 a.m. ( 35 minutes).

The "Documentation of Patient Progress" dated May 4, 2016, at 9:15 a.m., indicated Patient 8 was in the "isolation room (seclusion room)" after attacking staff members and attempting to cause harm to other patients.

Patient 8 was released from the "observation room (seclusion room)" on May 4, 2016, at 10:30 a.m., (seclusion for one hour and 15 minutes).

There was no indication a plan of care was developed, implemented, and updated as needed when seclusion and/or restraints were initiated for Patient 8's behaviors.

4. On July 6, 2016, the record for Patient 11 was reviewed. Patient 11 was admitted to the facility on on July 1, 2016, with diagnoses that included psychosis (lost of contact with reality due to mental illness).

The "Physician's Order Sheet" dated July 3, 2016, at 2:30 a.m., indicated the patient was to be placed in seclusion and restraints for safety.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 3, 2016, at 2:30 a.m., indicated seclusion and restraints were initiated because Patient 11 was "violent against self and others."

Patient 11 was in seclusion and restraints on July 3, 2016, from 2:30 a.m. to 5:40 a.m.

There was no indication a plan of care was developed, implemented, and updated as needed when seclusion and restraints were initiated for Patient 11's behaviors.

5. On July 6, 2016, the record for Patient 14 was reviewed. Patient 14 was admitted to the facility on on [DATE], with diagnoses that included brief reactive psychosis (lost of contact with reality due to mental illness).

The "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET" indicated the following:
a. February 5, 2016, at 6:00 p.m., Patient 14 was to be placed in seclusion due to danger to self and agitation.
b. February 5, 2016, at 9:20 p.m., Patient 14 was to be placed in seclusion and restraints due to danger to self /others and agitation.
c. February 6, 2016, at 9:35 p.m., Patient 14 was to be placed in seclusion and restraint for agitation.
d. February 9, 2016, at 11:50 p.m., Patient 14 was to be placed in seclusion for safety.

Patient 14's record indicated a total of two episodes of seclusion, and two episodes of simultaneous seclusion with restraint during the hospital admission.

There was no indication a plan of care was developed, implemented, and updated as needed when seclusion and/or restraints were initiated for Patient 14's behaviors.

6. On July 7, 2016, the record for Patient 15 was reviewed. Patient 15 was admitted to the facility on on [DATE], with diagnoses that included bipolar disorder (mental disorder characterized by periods of elevated mood and periods of depression).

The "Physician's Order Sheet" indicated the following:
a. May 16, 2016, at 9:45 a.m., Patient 15 was to be placed in seclusion due to danger to others, violent behavior.
b. May 16, 2016, at 11 a.m., Patient 15 was to be placed in seclusion due to danger to others.
c. May 16, 2016, at 4 p.m., Patient 15 was to be placed in seclusion due to danger to others.
d. May 19, 2016, at 7:45 p.m., Patient 15 was to be placed in seclusion due to severe agitation and danger to others.

Patient 15's record indicated a total of four episodes of seclusion during the hospital admission.

There was no indication a plan of care was developed, implemented, and updated as needed when seclusion was initiated for Patient 15's behaviors.

On July 7, 2016, at 3:30 p.m., the Director of Nursing (DON) was interviewed. The DON confirmed there were no plans of care initiated for the use of seclusion and restraint for the patients.

The facility policy and procedure titled "Seclusion and Restraint of Patient" reviewed July 2015 indicated "...The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if patient is restrained on more than one occasion...The treatment plan shall be reviewed and revised following the first episode of seclusion to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if patient is secluded on more than one occasion..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure seclusion and/or restraints were applied in accordance with a physician's order for four of six sampled patients who were placed in seclusion and/or restraint (Patients 6, 7, 8, and 15) when:

- Two patients (Patients 6 and 7) had orders for restraints but were also placed in seclusion;

- One patient (Patient 8) was placed in seclusion without a physician's order;

- Telephone or verbal orders for seclusion were not signed by the physician for two patients (Patients 8 and 15); and

- An order for restraints did not include the type of restraint or for how long (duration), per facility policy and procedure, for one patient (Patient 6).

This failed practice resulted in the potential for unnecessary use of seclusion and/or restraint.

Findings:

1. On July 6, 2016, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on on July 6, 2016, with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

The "Documentation of Patient Progress" dated July 7, 2016, at 3:20 a.m., indicated Patient 6 was getting increasingly agitated, there was blood on both of his knuckles and the bathroom mirror, and he was observed punching a wall in the room. Patient 6 was walked to the "Seclusion Room" where he punched and attacked one of the Mental Health Workers. Staff restrained the patient on the floor and "he was given an IM (medication administered through a needle into a muscle)." Patient 6 remained aggressive with staff and an order was obtained for restraints.

The "Physician's Order Sheet" dated July 7, 2016, at 3:15 a.m., indicated the patient was to be placed in restraints for safety.

There was no indication as to the type of restraint to be used or for how long (the duration).

There was no indication of a physician's order to place Patient 6 in seclusion.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 7, 2016, at 3:30 a.m., revealed the restraints were indicated because Patient 6 was "severely aggressive" and "violent against self and others."

Patient 6 was in restraints and seclusion on July 7, 2016, from 3:30 a.m., to 4:30 a.m.

2. On July 6, 2016, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on on July 1, 2016, with diagnosis of major depressive order (mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities).

The "Documentation of Patient Progress" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 became agitated, demanded to leave, ran towards the exit door and hit staff. The physician was called and "ordered to place pt (patient) in seclusion."

There was no indication of a physician's order being written, and signed by the physician, to place Patient 7 in seclusion.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 was "severely aggressive" and "violent against self and others," and indicated the patient was in seclusion.

The "Physician's Order Sheet" dated July 1, 2016, at 6:50 p.m., indicated the patient was to be placed in four point soft restraints for one hour and then discontinued with checks every 15 minutes.

The "Documentation of Patient Progress" dated July 1, 2016, at 7:30 p.m., indicated Patient 7 was in the "seclusion room" in restraints.

Patient 7 was in restraints and seclusion on July 1, 2016, from 7 p.m., to 8 p.m.

On July 7, 2016, at 10:45 a.m., a tour of the "Secure Unit" was conducted with Registered Nurse (RN) 1 and Mental Health Associate (MHA) 1.

The "Seclusion Room (the sign outside the room labeled "Observation Room" and number 23)" was located next to the Nurses' Station and across from room number 24. The "Seclusion Room" was locked and a key was required to get into the room and to leave the room (seclusion - involuntary confinement, alone in a room from which the patient is physically prevented from leaving, i.e. locked door).

On July 7, 2016, at 12:20 p.m., the Director of Nursing (DON) was interviewed. The DON stated all patients with restraint orders were placed in the seclusion room, further stating "There's no way we can put restraint (s) but in the seclusion room."

3. On July 6, 2016, the record for Patient 8 was reviewed. Patient 8 was admitted to the facility on on [DATE], with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

The "Seclusion or Restraint Physician's Order Sheet" indicated a telephone order for seclusion was obtained from the physician on May 2, 2016, at 4 p.m.

There was no indication the seclusion order was signed by the physician until 63 days after the telephone order was obtained by the nurse from the physician.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated May 2, 2016, at 4 p.m., indicated Patient 8 was "severely aggressive" and "violent against self and others," and indicated the patient was in seclusion.

Patient 8 was removed from seclusion on May 2, 2016, at 5 p.m.

The "Documentation of Patient Progress" dated May 4, 2016, at 9:15 a.m., indicated Patient 8 was in the "isolation room (seclusion room)" after attacking staff members and attempting to cause harm to other patients.

There was no indication of a physician's order being written to place Patient 8 in seclusion on May 4, 2016, at 9:15 a.m.

Patient 8 was released from the "observation room (seclusion room)" on May 4, 2016, at 10:30 a.m.

During an interview with the Director of Nursing (DON), on July 7, 2016, at 12:15 p.m., he reviewed the records for Patients 6, 7, and 8, and was unable to find complete and signed orders for the patients when seclusion and/or restraints were initiated. The DON stated an order for seclusion was required if the patient was placed in seclusion, the order for restraints should include type and duration, and the orders for seclusion and/or restraints should be signed by the physician.

4. On July 7, 2016, the record for Patient 15 was reviewed. Patient 15 was admitted to the facility on on [DATE], with diagnoses that included bipolar disorder (mental disorder characterized by periods of elevated mood and periods of depression).

The "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET" indicated the following:
a. May 16, 2016, at 9:45 a.m., Patient 15 was to be placed in seclusion due to danger to others, violent behavior.
b. May 16, 2016, at 11 a.m., Patient 15 was to be placed in seclusion due to danger to others.
c. May 16, 2016, at 4 p.m., Patient 15 was to be placed in seclusion due to danger to others.

There was no indication the seclusion orders were signed by the physician until 53 days after the telephone order was written and initiated.

Patient 15's record indicated the patient was placed in seclusion on May 16, 2016 from 9:45 a.m. to 10 a.m., 11 a.m. to 11:45 a.m., and 4 p.m. to 4:20 p.m.

On July 7, 2016, at 3:30 p.m., Patient 15's record was reviewed with the Director of Nursing (DON). The DON stated the seclusion orders for May 16, 2016, were not signed by the physician. The DON stated there was no other documentation in the record that showed the physician ordered and signed for Patient 15 to be placed in seclusion on May 16, 2016.

The facility policy and procedure titled "Seclusion and Restraint of Patient" reviewed July 2015 indicated "...Restraint may only be ordered by a practitioner (Physician)...The order shall indicate the indication and maximum duration of restraint...Seclusion may only be ordered by a Practitioner (Physician or Nurse Practitioner)...The order shall indicate the reason and maximum duration of seclusion..."

On July 7, 2016, at 1:45 p.m., the Chief Executive Officer (CEO), the Chief Financial Officer (CFO), the Director of Nursing (DON), and the Director of Performance Improvement and Risk Management (PI/RM) were notified of the determination of an Immediate Jeopardy (IJ)situation to the health and safety of patients related to unsafe use of restraints and seclusion.

The facility developed a plan of correction, and the CEO and Director of PI/RM were notified the plan of correction was accepted on July 7, 2016, at 6:30 p.m.

The plan of correction included education of all staff who participated in the seclusion and restraint process, prior to the beginning of their next shift, regarding:

a. The need for a physician's order for every application and use of seclusion and/or restraint;

b. Reimplementation of the, "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET," with areas for the physician to complete the reason, type (seclusion, wrist restraints, walking restraints, or four point [all four limbs] restraints), and duration of restraint and/or seclusion; and,

c. When the door to the seclusion room should be locked vs. unlocked.

In addition, the plan included changing the lock on the door to the seclusion room so it could be left unlocked and allow patients who were placed in restraints to be in a quiet room without being secluded.

On July 8, 2016, at 11 a.m., implementation of the plan of correction was verified, and the Director of PI/RM was notified the immediate jeopardy was removed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure restraint and/or seclusion monitoring occurred every 15 minutes per facility policy and procedure, for two of six sampled patients placed in seclusion and/or restraints (Patients 7 and 14). This had the potential to result in unwitnessed decline in the patient's condition, harm, or death while the patient was in restraints and/or seclusion.

Findings:

1. On July 6, 2016, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on on July 1, 2016, with diagnosis of major depressive order (mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities).

The "Documentation of Patient Progress" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 became agitated, demanded to leave, ran towards the exit door and hit staff. The physician was called and "ordered to place pt (patient) in seclusion."

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 was "severely aggressive" and "violent against self and others," and the patient was in seclusion.

There was no indication every 15 minute monitoring occurred between 5:40 p.m., and 6:27 p.m. (47 minutes).

The "Physician's Order Sheet" dated July 1, 2016, at 6:50 p.m., indicated the patient was to be placed in four point soft restraints for one hour and then discontinued, with checks every 15 minutes.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, indicated Patient 7 was placed in restraints at 7 p.m.

The "Documentation of Patient Progress" dated July 1, 2016, at 7:30 p.m., indicated Patient 7 was in the "seclusion room" in restraints.

There was no indication every 15 minute monitoring occurred on July 1, 2016, between 7 p.m. and 8 p.m., to include vital signs, injury assessment, range of motion, and nutrition/hydration assessment.

During an interview with the Director of Nursing (DON), on July 7, 2016, at 12:15 p.m., he reviewed the record for Patient 7 and was unable to find documentation of Patient 7 being assessed every 15 minutes while in restraints and/or seclusion. The DON stated Patient 7 should have been assessed every 15 minutes per facility policy and procedure to include vital signs, injury, hydration, elimination, and comfort.

2. On July 6, 2016, the record for Patient 14 was reviewed. Patient 14 was admitted to the facility on on [DATE], with diagnoses that included brief reactive psychosis (lost of contact with reality due to mental illness).

The "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET" indicated the following:
a. February 5, 2016, at 6 p.m., patient was to be placed in seclusion due to danger to self and agitation.
b. February 9, 2016, at 11:50 p.m., patient was to be placed in seclusion for safety.

The "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET" dated [DATE], 8:55 p.m., indicated "...Pt (patient) was in seclusion from the former shift...".

The "Documentation of Patient Progress" dated February 9, 2016, at 11:50 p.m., indicated "...Pt was then placed to seclusion room for safety...Pt banging on door at this time..."

There was no documented evidence in Patient 14's record of the length of time Patient 14 was in seclusion for the above seclusion orders.

There was no documented evidence in Patient 14's record of monitoring or an assessment of needs while in seclusion for the above seclusion orders was completed.

On July 7, 2016, at 3:30 p.m., Patient 14's record was reviewed with the Director of Nursing (DON). The DON confirmed there was no documentation of duration and monitoring for Patient 14's seclusion on February 5, 2016, at 6 p.m. and February 9, 2016, at 11:50 p.m. The DON stated Patient 14 should have been monitored and assessed for needs every 15 minutes while in seclusion.

Review of the facility's policy and procedure "Seclusion and Restraint of Patient" reviewed July 2015, indicated "...All patients in restraint or seclusion are assessed and their needs addressed by a Registered Nurse at the initiation of restraint or seclusion and every 15 minutes thereafter. This assessment includes 1. Vital Signs ... 2. Injury Assessment ... 3. Nutrition/Hydration Assessment ... 4. Circulation and Range of Motion ... 5. Hygiene and Elimination ... 8. Need for Continued Containment..."

On July 7, 2016, at 1:45 p.m., the Chief Executive Officer (CEO), the Chief Financial Officer (CFO), the Director of Nursing (DON), and the Director of Performance Improvement and Risk Management (PI/RM) were notified of the determination of an Immediate Jeopardy (IJ) situation to the health and safety of patients related to unsafe use of restraints and seclusion.

The facility developed a plan of correction, and the CEO and Director of PI/RM were notified the plan of correction was accepted on July 7, 2016, at 6:30 p.m.

The plan of correction included education of all staff who participated in the seclusion and restraint process, prior to the beginning of their next shift, regarding:

a. The need to monitor the patient and document an assessment every 15 minutes;

b. Use of the, "Nurses Documentation of Behavioral Health Seclusion and/or Restraint," document, and the, "Restraint Observation Record," where the staff could document an assessment of the patient every 15 minutes, as well as interventions and care provided; and,

c. When the door to the seclusion room should be locked vs. unlocked, and the appropriate level of monitoring in each situation (door locked or unlocked).

On July 8, 2016, at 11 a.m., implementation of the plan of correction was verified, and the Director of PI/RM was notified the immediate jeopardy was removed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure five of six sampled patients placed in seclusion and/or restraint (Patients 7, 8, 11, 14, and 15) were seen face-to-face by a physician or a trained Registered Nurse (RN) within one hour after the initiation of seclusion or restraint. This failed practice resulted in the patients not being evaluated in order to determine if a serious medical or psychological condition existed, and/or to determine if the continued use of seclusion and/or restraints was necessary.

Findings:

1. On July 6, 2016, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on on July 1, 2016, with diagnosis of major depressive order (mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities).

The "Documentation of Patient Progress" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 became agitated, demanded to leave, ran towards the exit door and hit staff. The physician was called and "ordered to place pt (patient) in seclusion."

There was no indication of a physician's order being written and signed by the physician to place Patient 7 in seclusion.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 was "severely aggressive" and "violent against self and others," and indicated the patient was in seclusion.

The "Physician's Order Sheet" dated July 1, 2016, at 6:50 p.m., indicated the patient was to be placed in four point soft restraints for one hour and then discontinued with checks every 15 minutes.

The "Documentation of Patient Progress" dated July 1, 2016, at 7:30 p.m., indicated Patient 7 was in the "seclusion room" in restraints.

Patient 7 was in seclusion on July 1, 2016, from 5: 40 p.m., to 7 p.m. (1 hour and 20 minutes) before restraints were applied.

Patient 7 was in restraints and seclusion on July 1, 2016, from 7 p.m., to 8 p.m.

There was no indication Patient 7 was seen face-to-face by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

2. On July 6, 2016, the record for Patient 8 was reviewed. Patient 8 was admitted to the facility on on [DATE], with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

a. The "Seclusion or Restraint Physician's Order Sheet" indicated a telephone order for seclusion was obtained from the physician on May 2, 2016, at 4 p.m., for the patient's violent behavior, and for being a danger to self and others.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated May 2, 2016, at 4 p.m., indicated Patient 8 was "severely aggressive" and "violent against self and others," and indicated the patient was in seclusion.

Patient 8 was removed from seclusion on May 2, 2016, at 5 p.m. (in seclusion for one hour).

There was no indication Patient 8 was seen face-to-face by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

b. The "Seclusion or Restraint Physician's Order Sheet" indicated a telephone order for seclusion was obtained from the physician on May 3, 2016, at 8:10 a.m., for the patient's violent behavior, danger to others.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated May 3, 2016, indicated Patient 8 was in seclusion from 8:10 a.m., until 8:45 a.m. (in seclusion for 35 minutes).

There was no indication Patient 8 was seen face-to-face by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

c. The "Documentation of Patient Progress" dated May 4, 2016, at 9:15 a.m., indicated Patient 8 was in the "isolation room (seclusion room)" after attacking staff members and attempting to cause harm to other patients.

There was no indication of a physician's order being written to place Patient 8 in seclusion on May 4, 2016, at 9:15 a.m.

Patient 8 was released from the "observation room (seclusion room)" on May 4, 2016, at 10:30 a.m. (in seclusion for one hour and 15 minutes).

There was no indication Patient 8 was seen face-to-face by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

3. On July 6, 2016, the record for Patient 11 was reviewed. Patient 11 was admitted to the facility on on July 1, 2016, with diagnoses that included psychosis (lost of contact with reality due to mental illness).

The "Physician's Order Sheet" dated July 3, 2016, at 2:30 a.m., indicated the patient was to be placed in seclusion and restraint for safety.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 3, 2016, at 2:30 a.m., indicated seclusion and restraint were initiated because Patient 11 was "violent against self and others."

Patient 11 was in seclusion and restraint on July 3, 2016, from 2:30 a.m. to 5:40 a.m.

There was no documented evidence in Patient 11's record of a face-to-face by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

4. On July 6, 2016, the record for Patient 14 was reviewed. Patient 14 was admitted to the facility on on [DATE], with diagnoses that included brief reactive psychosis (lost of contact with reality due to mental illness).

The "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET" indicated the following:
a. February 5, 2016, at 6:00 p.m., Patient 14 was to be placed in seclusion due to danger to self and agitation.
b. February 5, 2016, at 9:20 p.m., Patient 14 was to be placed in seclusion and restraints due to danger to self /others and agitation.
c. February 6, 2016, at 9:35 p.m., Patient 14 was to be placed in seclusion and restraint for agitation.
d. February 9, 2016, at 11:50 p.m., Patient 14 was to be placed in seclusion for safety.

Patient 14's record indicated a total of two episodes of seclusion, and two episodes of seclusion and restraint during the hospital admission.

There was no documented evidence in Patient 14's record of a face-to-face by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

5. On July 7, 2016, the record for Patient 15 was reviewed. Patient 15 was admitted to the facility on on [DATE], with diagnoses that included bipolar disorder (mental disorder characterized by periods of elevated mood and periods of depression).

The "Physician's Order Sheet" indicated the following:
a. May 16, 2016, at 9:45 a.m., Patient 15 was to be placed in seclusion due to danger to others, violent behavior.
b. May 16, 2016, at 11 a.m., Patient 15 was to be placed in seclusion due to danger to others.
c. May 16, 2016, at 4 p.m., Patient 15 was to be placed in seclusion due to danger to others.
d. May 19, 2016, at 7:45 p.m., Patient 15 was to be placed in seclusion due to severe agitation and danger to others.

Patient 15's record indicated a total of four episodes of seclusion during the hospital admission.

There was no documented evidence in Patient 15's record of a face-to-face by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

On July 7, 2016, at 3:30 p.m., the Director of Nursing (DON) was interviewed. The DON stated face to face should have been done within one hour after the initiation of restraint and/or seclusion. The DON confirmed there was no documented evidence in the patients' records of a face to face being done when seclusion and/or restraints were initiated.

Review of the facility policy and procedure "Seclusion and Restraint of Patient" reviewed July 2015, indicated "... A Licensed Independent Practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. ... A Licensed Independent Practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention..."

On July 7, 2016, at 1:45 p.m., the Chief Executive Officer (CEO), the Chief Financial Officer (CFO), the Director of Nursing (DON), and the Director of Performance Improvement and Risk Management (PI/RM) were notified of the determination of an Immediate Jeopardy (IJ) situation to the health and safety of patients related to unsafe use of restraints and seclusion.

The facility developed a plan of correction, and the CEO and Director of PI/RM were notified the plan of correction was accepted on July 7, 2016, at 6:30 p.m.

The plan of correction included education of all staff who participated in the seclusion and restraint process, prior to the beginning of their next shift, regarding:

a. The need for a face-to-face assessment by the physician or the Director of Nursing (DON - trained to perform face-to-face assessments following the application of seclusion and/or restraint) within one hour of initiating seclusion and/or restraint;

b. The need to perform a separate face-to-face assessment if seclusion and/or restraint is discontinued and a new episode is necessary; and,

c. Implementation of the, "RESTRAINT FACE TO FACE PROGRESS NOTES," to document the face-to-face assessment.

On July 8, 2016, at 11 a.m., implementation of the plan of correction was verified, and the Director of PI/RM was notified the immediate jeopardy was removed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on interview and record review, the facility failed to ensure the face-to-face assessment for one of one sampled patients (Patient 6), included the patient's reaction to the restraint and/or seclusion, and whether the restraints and/or seclusion needed to continue. This failed practice resulted in the potential for unnecessary and prolonged use of restraint and/or seclusion.

Findings:

On July 6, 2016, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on on July 6, 2016, with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

The "Documentation of Patient Progress" dated July 7, 2016, at 3:20 a.m., indicated Patient 6 was getting increasingly agitated, there was blood on both of his knuckles and the bathroom mirror, and he was observed punching a wall in the room. Patient 6 was walked to the "Seclusion Room" where he punched and attacked one of the Mental Health Workers. Staff restrained the patient on the floor and "he was given an IM (medication administered through a needle into a muscle)." Patient 6 remained aggressive with staff and an order was obtained for restraints.

The "Physician's Order Sheet" dated July 7, 2016, at 3:15 a.m., indicated the patient was to be placed in restraints for safety.

There was no indication as to the type of restraint to be used and for how long.

There was no indication of a physician's order to place Patient 6 in seclusion.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 7, 2016, at 3:30 a.m., revealed the restraints were indicated because Patient 6 was "severely aggressive" and "violent against self and others."

The "Documentation of Patient Progress" dated July 7, 2016, at 4:05 a.m., indicated Patient 6 was seen and evaluated by the Director of Nursing (DON). The evaluation included Patient 6's immediate situation, medical and behavioral condition, and the need to continue the restraints.

There was no indication of Patient 6's reaction to the interventions of restraints and seclusion, or the continuation or termination of seclusion.

Patient 6 was in restraints and seclusion on July 7, 2016, from 3:30 a.m., to 4:30 a.m.

During an interview with the DON, on July 7, 2016, at 12:15 p.m., he reviewed the record and was unable to find documentation of an order for seclusion. The DON stated currently the only room that could be used for restraint application was the "seclusion room" which was a locked room. The DON stated he did the face-to-face with Patient 6, on July 7, 2016, at 4:05 a.m., and he should have included the patient's reaction to interventions.

The facility policy and procedure titled "Seclusion and Restraint of Patient" reviewed July 2015, revealed a Licensed Independent Practitioner or trained Registered Nurse would conduct an in-person evaluation of the patient within one hour of initiation of seclusion or restraint to assess physical and psychological status. The in-person evaluation included the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention of seclusion snd/or restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0183
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure four of six sampled patients in simultaneous seclusion and restraint (Patients 6, 7, 11, and 14) were continually monitored. This failed practice had the potential to result in harm or death to the patients.

Findings:

On July 7, 2016, at 10:45 a.m., a tour of the "Secure Unit" was conducted with Registered Nurse (RN) 1 and Mental Health Associate (MHA) 1.

The "Seclusion Room (the sign outside the room labeled "Observation Room" and number 23)" was located next to the Nurses' Station and across from room number 24. The "Seclusion Room" was locked and a key was required to get into the room and to leave the room (seclusion - involuntary confinement, alone in a room from which the patient is physically prevented from leaving, i.e. locked door). There was a window (approximately six inches by six inches) in the center of the door which was located approximately five feet from the floor. There was a bathroom to the left as you entered the room, but this was not accessible even with a key.

The "Seclusion Room" contained a solid plastic bed frame which was bolted to the floor in the middle of the room. Each side of the bed contained three brackets at floor level, one at the top of the bed (for hands/wrists) and two at the bottom of the bed (for feet/ankles). There was a mattress on the bed.

On the wall in the "Seclusion Room," which was located next to the Nurses' Station, was a window (approximately six inches by six inches). This window, in the Nurses' Station, was covered by a piece of wood, which could be opened to look into the "Seclusion Room," and was located on the wall at a height which was between the desk and built in cabinets. It was located towards a corner of the room next to a computer screen/monitor.

No video or audio equipment was observed in the "Seclusion Room."

During a concurrent interview with RN 1, she stated there was no audio or video equipment available for surveillance when a patient was in the "Seclusion Room." When RN 1 was asked if someone continuously monitored the patient in the "Seclusion Room" when the patient was placed in seclusion and restraints, she stated a staff member did not necessarily stay in the room and continuously monitor the patient but the patient could be looked at through the door in the window or the window that was located in the Nurses's Station. RN 1 stated the patient was evaluated every 15 minutes.

During an interview with MHA 1, on July 7, 2016, at 10:55 a.m., when asked if someone remained with the patient in the "Seclusion Room" when the patient was placed in seclusion and restraints, she stated the patient was not continuously monitored, and in order for the patient to be continuously monitored, the physician would have to order a one to one. MHA 1 stated the patient was left in the room by themselves and the staff could look into the room through the window in the door or the window in the Nurses' Station to see the patient. MHA 1 stated the patient was evaluated every 15 minutes and this was documented by the nurse. In addition, MHA 1 stated the door to the "Seclusion Room" was always locked and required a key to get into the room and out of the room.

1. On July 6, 2016, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on on July 6, 2016, with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

The "Documentation of Patient Progress" dated July 7, 2016, at 3:20 a.m., indicated Patient 6 was getting increasingly agitated, there was blood on both of his knuckles and the bathroom mirror, and he was observed punching a wall in the room. Patient 6 was walked to the "Seclusion Room" where he punched and attacked one of the Mental Health Associates. Staff restrained the patient on the floor and "he was given an IM (medication administered through a needle into a muscle)." Patient 6 remained aggressive with staff and an order was obtained for restraints.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 7, 2016, revealed the restraints were indicated because Patient 6 was "severely aggressive" and "violent against self and others." In addition, Patient 6 did not have one to one observation (continuously observed) while restrained in the "Seclusion Room."

Patient 6 was simultaneously placed in restraints and seclusion on July 7, 2016, from 3:30 a.m., to 4:30 a.m.

2. On July 6, 2016, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on on July 1, 2016, with diagnosis of major depressive order (mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities).

The "Documentation of Patient Progress" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 became agitated, demanded to leave, ran towards the exit door and hit staff. The physician was called and "ordered to place pt (patient) in seclusion."

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, indicated Patient 7 was "severely aggressive" and "violent against self and others," and indicated the patient was in seclusion. In addition, Patient 6 did not have one to one observation (continuously observed) while restrained in the "Seclusion Room."

The "Physician's Order Sheet" dated July 1, 2016, at 6:50 p.m., indicated the patient was to be placed in four point soft restraints for one hour and then discontinued with checks every 15 minutes.

The "Documentation of Patient Progress" dated July 1, 2016, at 7:30 p.m., indicated Patient 7 was in the "seclusion room" in restraints.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, indicated Patient 7 did not have one to one observation (continuously observed) while restrained in the "Seclusion Room."

Patient 7 was simultaneously placed in restraints and seclusion on July 1, 2016, from 7 p.m., to 8 p.m.

3. On July 6, 2016, the record for Patient 11 was reviewed. Patient 11 was admitted to the facility on on July 1, 2016, with diagnoses that included psychosis (lost of contact with reality due to mental illness).

The "Physician's Order Sheet" dated July 3, 2016, at 2:30 a.m., indicated the patient was to be placed in seclusion and restraint for safety.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 3, 2016, at 2:30 a.m., indicated seclusion and restraint were initiated because Patient 11 was "violent against self and others."

Patient 11 was in simultaneous seclusion and restraint on July 3, 2016, from 2:30 a.m. to 5:40 a.m.

4. On July 6, 2016, the record for Patient 14 was reviewed. Patient 14 was admitted to the facility on on [DATE], with diagnoses that included brief reactive psychosis (lost of contact with reality due to mental illness).

The "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET" indicated the following:
a. February 5, 2016, at 9:20 p.m., patient was to be placed in seclusion and restraints due to danger to self /others and agitation.
b. February 6, 2016, at 9:35 p.m., patient was to be placed in seclusion and restraint for agitation.

Patient 14's record indicated a total of two episodes of simultaneous seclusion and restraint during the hospital admission.

On July 7, 2016, at 12:20 p.m., the Director of Nursing (DON) was interviewed. The DON stated patients placed in seclusion and restraint were monitored every 15 minutes. The DON stated there was no audio or video capability in the seclusion room. The DON stated all patients with restraint orders were placed in the seclusion room, further stating "There's no way we can put restraint but in the seclusion room."

The facility policy and procedure titled "Seclusion and Restraint of Patient" reviewed July 2015, revealed "... Mechanical Restraint ... The patient shall be monitored and reassessed through continuous in-person observation. The Nurse in charge will assign trained staff to continuously monitor the patient during the restraint event. Continuous means ongoing without interruption. ... Seclusion ... The patient shall be monitored and reassessed through continuous in-person observation. Continuous means ongoing without interruption. The Nurse in charge will assign trained staff to continuously monitor the patient during the seclusion event. ..."

On July 7, 2016, at 1:45 p.m., the Chief Executive Officer (CEO), the Chief Financial Officer (CFO), the Director of Nursing (DON), and the Director of Performance Improvement and Risk Management (PI/RM) were notified of the determination of an Immediate Jeopardy (IJ) situation to the health and safety of patients related was to unsafe use of restraints and seclusion.

The facility developed a plan of correction, and the CEO and Director of PI/RM were notified the plan of correction was accepted on July 7, 2016, at 6:30 p.m.

The plan of correction included education of all staff who participated in the seclusion and restraint process, prior to the beginning of their next shift, regarding:

a. The need to do, "constant," monitoring on all patients in seclusion through a window in the door leading into the seclusion room;

b. The need to place all patients in restraints on 1:1 monitoring and remain in the room with the patient (thus all patients in simultaneous seclusion and restraint would be continually monitored face-to-face); and,

c. The need to complete the, "Nurses Documentation of Behavioral Health Seclusion and/or Restraint," document.

In addition, the plan included changing the lock on the door to the seclusion room so it could be left unlocked and allow patients who were placed in restraints to be in a quiet room without being secluded.

On July 8, 2016, at 11 a.m., implementation of the plan of correction was verified, and the Director of PI/RM was notified the immediate jeopardy was removed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure there was documentation in the record of the one hour face-to-face medical and behavioral evaluation when restraints and/or seclusion were used to manage violent or self-destructive behavior for five of six sampled patients in seclusion and/or restraint (Patients 7, 8, 11, 14, and 15). This failed practice resulted in the potential for missed opportunities to identify the source of violent behavior and reduce the time spent in restraint and/or seclusion.

Findings:

1. On July 6, 2016, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on on July 1, 2016, with diagnosis of major depressive order (mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities).

The "Documentation of Patient Progress" dated July 1, 2016, at 5:40 p.m., indicated Patient 7 became agitated, demanded to leave, ran towards the exit door and hit staff. The physician was called and "ordered to place pt (patient) in seclusion."

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, indicated Patient 7 was "severely aggressive" and "violent against self and others," and indicated the patient was in seclusion. In addition, Patient 6 did not have one to one observation (continuously observed) while restrained in the "Seclusion Room."

The "Physician's Order Sheet" dated July 1, 2016, at 6:50 p.m., indicated the patient was to be placed in four point soft restraints for one hour and then discontinued with checks every 15 minutes.

The "Documentation of Patient Progress" dated July 1, 2016, at 7:30 p.m., indicated Patient 7 was in the "seclusion room" in restraints.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 1, 2016, indicated Patient 7 did not have one to one observation (continuously observed) while restrained in the "Seclusion Room."

Patient 7 was in restraints and seclusion on July 1, 2016, from 7 p.m., to 8 p.m.

There was no documented evidence in the record of the one hour face-to-face medical and behavior evaluation when restraints and seclusion were used to manage Patient 7's violent behavior.

2. On July 6, 2016, the record for Patient 8 was reviewed. Patient 8 was admitted to the facility on on [DATE], with diagnosis of schizoaffective disorder, bipolar effect (condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, such as mania or depression).

a. The "Seclusion or Restraint Physician's Order Sheet" indicated a telephone order for seclusion was obtained from the physician on May 2, 2016, at 4 p.m., for the patient's violent behavior, danger to self and others.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated May 2, 2016, at 4 p.m., indicated Patient 8 was "severely aggressive" and "violent against self and others," and indicated the patient was in seclusion.

Patient 8 was removed from seclusion on May 2, 2016, at 5 p.m. (in seclusion for one hour).

There was no documented evidence in the record of the one hour face-to-face medical and behavior evaluation when seclusion was used to manage Patient 8's violent behavior on May 2, 2016, from 4 p.m. to 5 p.m.

b. The "Seclusion or Restraint Physician's Order Sheet" indicated a telephone order for seclusion was obtained from the physician on May 3, 2016, at 8:10 a.m., for the patient's violent behavior, danger to others.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated May 3, 2016, indicated Patient 8 was in seclusion from 8:10 a.m., until 8:45 a.m. (in seclusion for 35 minutes).

There was no documented evidence in the record of the one hour face-to-face medical and behavior evaluation when seclusion was used to manage Patient 8's violent behavior on May 3, 2016, from 8:10 a.m. until 8:45 a.m.

c. The "Documentation of Patient Progress" dated May 4, 2016, at 9:15 a.m., indicated Patient 8 was in the "isolation room (seclusion room)" after attacking staff members and attempting to cause harm to other patients.

Patient 8 was released from the "observation room (seclusion room)" on May 4, 2016, at 10:30 a.m. (in seclusion for one hour and 15 minutes).

There was no documented evidence in the record of the one hour face-to-face medical and behavior evaluation when seclusion was used to manage Patient 8's violent behavior on May 4, 2016, from 9:15 a.m. until 10:30 a.m.

3. On July 6, 2016, the record for Patient 11 was reviewed. Patient 11 was admitted to the facility on on July 1, 2016, with diagnoses that included psychosis (lost of contact with reality due to mental illness).

The "Physician's Order Sheet" dated July 3, 2016, at 2:30 a.m., indicated the patient was to be placed in seclusion and restraint for safety.

The "Nursing Documentation of Behavioral Health Seclusion and/or Restraint" dated July 3, 2016, at 2:30 a.m., indicated seclusion and restraint were initiated because Patient 11 was "violent against self and others."

Patient 11 was in seclusion and restraint on July 3, 2016, from 2:30 a.m. to 5:40 a.m.

There was no documented evidence in Patient 11's record of a face-to-face evaluation by a physician or a trained Registered Nurse (RN) within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

4. On July 6, 2016, the record for Patient 14 was reviewed. Patient 14 was admitted to the facility on on [DATE], with diagnoses that included brief reactive psychosis (lost of contact with reality due to mental illness).

The "SECLUSION OR RESTRAINT PHYSICIAN'S ORDER SHEET" indicated the following:
a. February 5, 2016, at 6:00 p.m., Patient 14 was to be placed in seclusion due to danger to self and agitation.
b. February 5, 2016, at 9:20 p.m., Patient 14 was to be placed in seclusion and restraints due to danger to self /others and agitation.
c. February 6, 2016, at 9:35 p.m., Patient 14 was to be placed in seclusion and restraint for agitation.
d. February 9, 2016, at 11:50 p.m., Patient 14 was to be placed in seclusion for safety.

Patient 14's record indicated a total of two episodes of seclusion and, two episodes of seclusion and restraint during the hospital admission.

There was no documented evidence in Patient 14's record of a face-to-face evaluation by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

5. On July 7, 2016, the record for Patient 15 was reviewed. Patient 15 was admitted to the facility on on [DATE], with diagnoses that included bipolar disorder.

The "Physician's Order Sheet" indicated the following:
a. May 16, 2016, at 9:45 a.m., patient was to be placed in seclusion due to danger to others, violent behavior.
b. May 16, 2016, at 11 a.m., Patient 15 was to be placed in seclusion due to danger to others.
c. May 16, 2016, at 4 p.m., Patient 15 was to be placed in seclusion due to danger to others.
d. May 19, 2016, at 7:45 p.m., Patient 15 was to be placed in seclusion due to severe agitation and danger to others.

Patient 15's record indicated a total of four episodes of seclusion during the hospital admission.

There was no documented evidence in Patient 15's record of a face-to-face evaluation by a physician or a trained RN within one hour after the initiation of the intervention of restraints and/or seclusion for violent and self destructive behavior.

On July 7, 2016, at 3:30 p.m., the Director of Nursing (DON) was interviewed. The DON stated face-to-face should have been done within one hour after the initiation of restraint and/or seclusion. The DON confirmed there was no documented evidence in the patients' records of a face-to-face being done when the restrains and/or seclusions were initiated.

Review of the facility policy and procedure "Seclusion and Restraint of Patient" reviewed July 2015, indicated "... Mechanical Restraint ... A Licensed Independent Practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. ... Seclusion ... A Licensed Independent Practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on interview and record review, the facility failed to ensure staff were trained on facility policy and procedure, and able to demonstrate competency in the use and application of restraints for five of five employees (Registered Nurse [RN] 2, RN 3, RN 4, Mental Health Associate [MHA] 2, and MHA 3). This had the potential to result in the unsafe application and use of restraints and/or seclusion.

Findings:

During an interview with MHA 1, on July 7, 2016, at 10:50 a.m., she stated a staff member was in the room with the patient in seclusion and restraints only if a one to one observation was also ordered by the physician, otherwise the patient was in the "seclusion room" by themselves. MHA 1 stated only the RN could apply and release restraints. In addition, MHA 1 stated the patient who did not have a one to one observation order was in the "seclusion room" by themselves and would be evaluated every 15 minutes.

1. During an interview with RN 2, on July 6, 2016, at 10:10 a.m., she stated she was not familiar with the facility's restraint and seclusion policy.

On July 7, 2016, the employee file for RN 2 was reviewed. RN 2 was hired on June 27, 2016, and had completed Management of Assaultive Behavior in June of 2016.

RN 2 completed a test titled "Seclusions and Restraints Competency" on June 14, 2016.

There was no indication RN 2 had demonstrated competency in the application of restraints or was trained on the facility's policy and procedure for seclusion and/or restraints.

2. On July 7, 2016, the employee file of RN 3 was reviewed. RN 3 was hired on December 29, 2015. RN 3 completed Management of Assaultive Behavior on December 29, 2015.

There was no documentary evidence RN 3 demonstrated competency in the application and use of restraints.

3. On July 7, 2016, the employee file of RN 4 was reviewed. RN 4 was hired on January 15, 2016. RN 4 completed Management of Assaultive Behavior on April 21, 2016.

There was no documentary evidence RN 4 demonstrated competency in the application and use of restraints.

4. On July 7, 2016, the employee file for Mental Health Associate (MHA) 2 was reviewed. MHA 2 was hired on May 20, 2016, and had completed Management of Assaultive Behavior in May of 2016.

MHA 2 completed a test title "Seclusions and Restraints Competency " on May 19, 2016.

There was no indication MHA 2 was trained on the facility's policy and procedure for seclusion and/or restraints, or how to release the restraint in the case of an emergency.

5. On July 7, 2016, the employee file of MHA 3 was reviewed. MHA 3 was hired on January 15, 2016. MHA 3 completed Management of Assaultive Behavior on January 15, 2016.

There was no indication MHA 3 was trained on the facility's policy and procedure for seclusion and/or restraints, or how to release the restraint in the case of an emergency.

On July 7, 2016, at 11:05 a.m. the Director of Nursing (DON) was interviewed. The DON stated the facility Management of Assaultive Behavior Trainer (MABT) does restraint training for new employees during orientation. The DON stated the MHAs were trained on assisting in holding patients and the RNs were trained on the application of restraints. The DON stated the employees attended class and were given written materials to review. The DON stated there was no competency verification with return demonstration on the training for application and removal of restraints.

On July 8, 2016, at 10:35 a.m., the MABT was interviewed. The MABT stated "I only do the physical restraint training...I do not do any manual restraint or seclusion training, that's beyond my scope." The MABT further stated "The DON should be doing that."

Review of the facility policy and procedure "Seclusion and Restraint of Patient" reviewed July 2015, indicated "STAFF COMPETENCY AND EDUCATION ... Employees must demonstrate competency in [MAB, CPI, etc] procedures. The focus of training is ... 6. Safe application and removal of restraints. 7. Seclusion/restraint policy and procedures. 8. Appropriate monitoring of a patient in seclusion/restraints. ..."

On July 7, 2016, at 1:45 p.m., the Chief Executive Officer (CEO), the Chief Financial Officer (CFO), the Director of Nursing (DON), and the Director of Performance Improvement and Risk Management (PI/RM) were notified of the determination of an Immediate Jeopardy (IJ) situation to the health and safety of patients related to unsafe use of restraints and seclusion.

The facility developed a plan of correction, and the CEO and Director of PI/RM were notified the plan of correction was accepted on July 7, 2016, at 6:30 p.m.

The plan of correction included education of all staff who participated in the seclusion and restraint process, prior to the start of their next shift, in application/implementation, ordering, monitoring, assessing, and documenting seclusion and/or restraint.

In addition, prior to the start of their next shift, all staff responsible for placing patients in restraints would perform a return demonstration on the safe application of the restraints used at the facility.

On July 8, 2016, at 11 a.m., implementation of the plan of correction was verified, and the Director of PI/RM was notified the immediate jeopardy was removed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0207
Based on interview and record review the facility failed to ensure a qualified individual was providing staff training for the use and application of restraint and/or seclusion This resulted in the omission of demonstrated competency for restraint application and staff unfamiliarity with the facility policy and procedure.

Findings:

On July 7, 2016, at 11:05 a.m. the Director of Nursing (DON) was interviewed. The DON stated the facility Management of Assaultive Behavior Trainer (MABT) does restraint training for new employees during orientation. The DON stated the MHAs were trained on assisting in holding patients and the RNs were trained on the application of restraints. The DON stated the employees attended class and were given written materials to review. The DON stated there was no competency verification with return demonstration on the training for application and removal of restraints.

On July 7, 2016, the MABT employee file was reviewed. There was no evidence in the employee file of training and competency on the use of restraints and/or seclusion. There was also no evidence in the employee file of training specific to the facility policy and procedure for the use of restraints and/or seclusion.

On July 8, 2016, at 10:35 a.m., the MABT was interviewed. The MABT stated "I only do the physical (manual measures to limit or restrict body movement, shall not exceed 30 minutes) restraint training...I do not do any manual (mechanical, bed restraints up to four points) restraint or seclusion training, that's beyond my scope." The MABT further stated "The DON should be doing that."
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interview and record review, the facility failed to ensure performance improvement activities focused on high risk and problem prone areas with the potential to affect health outcomes and patient safety. The facility implemented a new 5150 unit (a locked unit housing psychiatric patients on an involuntary legal hold who require seclusion and restraint at times) in December 2015, without putting indicators in place to track the performance of staff applying, initiating, and using seclusion and restraint.

This failed practice resulted in the identification of immediate jeopardy related to unsafe use of seclusion and restraint, violations of patient's rights (A 115), and the potential for harm or death to patients.

Findings:

The facility, "Quality Improvement Plan 2016," was reviewed on July 7, 2016. The plan indicated, "We provide Inpatient psychiatric and chemical dependency services for adults in the community. The recent opening of our Inpatient psychiatric secure unit has enabled us to treat a broader range of psychiatric patients within the community."

The, "Quality Initiatives," in the plan included, "Identify 2016 Performance Improvement Initiatives and desired outcomes (...restraints, seclusion...)."

During an interview with the Director of Performance Improvement/Risk Management (PI/RM) on July 8, 2016, at 9:20 a.m., the director stated the facility opened a 5150 unit in December 2015 (seven months earlier).

The director stated after the 5150 unit opened, the facility began to experience their first episodes of violence among patients, with attacks on staff and other patients, as well as the need to use seclusion and restraints.

She stated in order to be approved, "By the County," to have a locked (5150) unit, they had to train staff to deal with potentially violent patients and patients that would require seclusion and restraint.

The director stated she was collecting statistical data on use of seclusion and restraint (total numbers of times it was used each month). She stated there were no quality indicators in place, "yet," to track staff performance in application of restraints, or implementation and use of seclusion and restraint. The director stated she was developing a form to monitor seclusion and restraint use, but she had not completed it, "yet."

A review of the PI meeting minutes indicated there was no data being collected, reported, or analyzed for application, initiation, or use of seclusion or restraint.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on interview and record review, the facility failed to ensure the number and scope of performance improvement (PI) projects was proportional to the scope of services they provided by failing to:

1. Develop indicators to track the performance of staff applying, initiating, and using seclusion and restraint after implementation of a new 5150 unit (a locked unit housing psychiatric patients on an involuntary legal hold who require seclusion and restraint at times) in December 2015, resulting in the identification of immediate jeopardy related to unsafe use of seclusion and restraint and violations of patient's rights (A 115), and the potential for harm or death to patients;

2. Implement and maintain a PI project on discharge planning, according to the 2016 Quality Improvement Plan, resulting in the potential for unsafe discharge planning/practices to go unrecognized and uncorrected; and,

3. Require all departments to participate in the PI program, resulting in the potential for missed opportunities to improve the quality of care provided to their patients.

Findings:

1. The facility, "Quality Improvement Plan 2016," was reviewed on July 7, 2016. The plan indicated, "We provide Inpatient psychiatric and chemical dependency services for adults in the community. The recent opening of our Inpatient psychiatric secure unit has enabled us to treat a broader range of psychiatric patients within the community."

The, "Quality Initiatives," in the plan included, "Identify 2016 Performance Improvement Initiatives and desired outcomes (...restraints, seclusion...)."

During an interview with the Director of Performance Improvement/Risk Management (PI/RM) on July 8, 2016, at 9:20 a.m., the director stated the facility opened a 5150 unit in December 2015 (seven months earlier).

The director stated after the 5150 unit opened, the facility began to experience their first episodes of violence among patients, with attacks on staff and other patients, as well as the need to use seclusion and restraints.

She stated in order to be approved, "By the County," to have a locked (5150) unit, they had to train staff to deal with potentially violent patients and patients that would require seclusion and restraint.

The director stated she was collecting statistical data on use of seclusion and restraint (total numbers of times it was used each month). She stated there were no quality indicators in place, "yet," to track staff performance in application of restraints, or implementation and use of seclusion and restraint. The director stated she was developing a form to monitor seclusion and restraint use, but she had not completed it, "yet."

A review of the PI meeting minutes on July 8, 2016, indicated there was no data being collected, reported, or analyzed for application, initiation, or use of seclusion or restraint.

2. The facility, "Quality Improvement Plan 2016," was reviewed on July 7, 2016. According to the plan, quality indicators would include full completion of the discharge plan.

A review of the PI meeting minutes on July 8, 2016, indicated there was no data on discharge planning reported or discussed.

During an interview with the Director of PI on July 8, 2016, at 11:40 a.m., she stated the Director of Social Services (DSS) was supposed to be collecting and submitting the data for discharge planning. She stated the monitoring was supposed to be ongoing, but she did not have any 2016 data submitted by the DSS (no data for six months). She stated the DSS had the data collection tool, and he told her every month that the discharge planning indicators were 100% compliant, but he did not, "have time," to collect and submit the data.

3. The facility, "Quality Improvement Plan 2016," was reviewed on July 7, 2016. The plan indicated the facility would, "make sure that all departments are completing all audits."

A review of the PI meeting minutes on July 8, 2016, indicated there was no data submitted in 2016 for the following departments:

a. Social Services (discharge planning/treatment plan);

b. Housekeeping;

c. Information Technology (IT);

d. Maintenance/Plant Operations;

e. Human Resources (HR);

f. Medical Records (MR);

g. Dietary (not submitted two of six months); and,

h. Contracted Services.

During an interview with the Director of PI on July 8, 2016, at 11:40 a.m., the director stated the departments who were supposed to submit data for PI did not always turn their information in, so the meetings were held without the information, and the minutes did not reflect data from those departments.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure discharge planning started on admission for five of five sampled inpatients (Patients 21, 22, 23, 24, and 25). This failed practice resulted in the potential for delays in discharge or unsafe discharge for high risk psychiatric patients.

Findings:

1. The record for Patient 21 was reviewed on July 6, 2016. Patient 21, a [AGE] year old female, was admitted to the facility (voluntarily) on June 29, 2016 (seven days earlier), with thoughts of wanting to hurt herself due to her home life.

The, "Discharge Care Plan," document in the record was blank. There was no evidence a discharge plan had been considered among the members of the treatment team, or discussed with the patient.

2. The record for Patient 22 was reviewed on July 6, 2016. Patient 22, [AGE] year old male, was admitted to the facility (voluntarily) on July 5, 2016, with increasing psychiatric issues due to problems functioning at his new job.

The, "Discharge Care Plan," document in the record was blank. There was no evidence a discharge plan had been considered among the members of the treatment team, or discussed with the patient.

3. The record for Patient 23 was reviewed on July 6, 2016. Patient 23, a [AGE] year old female with previous suicide attempts, was admitted to the facility (voluntarily) on July 4, 2016, with thoughts of wanting to hurt herself due to problems at home.

The, "Discharge Care Plan," document in the record was blank. There was no evidence a discharge plan had been considered among the members of the treatment team, or discussed with the patient.

4. The record for Patient 24 was reviewed on July 7, 2016. Patient 24, a [AGE] year old male, was admitted to the facility (voluntarily) on July 6, 2016, with, "Severe," Depression.

The, "Discharge Care Plan," document in the record was blank. There was no evidence a discharge plan had been considered among the members of the treatment team, or discussed with the patient.

5. The record for Patient 25 was reviewed on July 7, 2016. Patient 25, [AGE] year old male, was admitted to the facility (voluntarily) on June 29, 2016 (eight days earlier), with, "Severe," Depression.

The, "Discharge Care Plan," document in the record was blank. There was no evidence a discharge plan had been considered among the members of the treatment team, or discussed with the patient.

During an interview with the Director of Social Services (DSS) on July 7, 2016, at 9 a.m., the DSS stated the discharge care plan was, "done," on the day they received the order for discharge. The DSS stated the patients at the facility were, "short term patients," and they did not have time to start discharge planning on the day of admission.

During an interview with Social Worker (SW) 1 on July 7, 2016, the SW stated the discharge plan was up to the patient and what she thought, not up to him and what he thought. He stated he did not make recommendations to patients, they could go wherever they wanted to go. The SW stated they did the discharge care plan when they received a discharge order.

The facility policy titled, "Discharge Planning," was reviewed on July 6, 2016. The policy indicated the following:

a. Discharge planning would start during the admission assessment and continue throughout the patient's stay;

b. The multidisciplinary treatment team would organize, coordinate, and work with the patient and their family to develop a discharge plan;

c. Information used to plan the discharge would include criteria for discharge, the patient's needs after discharge, and plans to meet those needs;

d. The patient would establish treatment goals that could be accomplished in the hospital, and those goals would be used as a measuring tool to determine the appropriateness of discharge; and,

e. The patient would be assisted to explore and resolve issues/concerns related to employment....and living situations prior to discharge.

There was no evidence the inpatients reviewed had discharge planning started on admission, had been given criteria for discharge, or were being assisted with a plan for resolving issues and/or setting goals for discharge.