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.

SILVER HILL HOSPITAL INC 208 VALLEY ROAD NEW CANAAN, CT June 29, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Condition of Patient Rights has not been met.

The hospital failed to ensure that patients were able to be treated/restrained on their units and in their familiar milieu, failed to ensure that the least restrictive device was used when a restraint transport bag was used in order to place patients in 4-point restraints, and failed to maintain patient dignity when patient's in transport bags were transported on the floor of a hospital transport bus to another building for 6 of 11 patients (Patients #1, #12, #17, #18, #19, and #21).

The hospital failed to ensure a safe environment when staff failed to conduct a comprehensive search of a patient and/or belongings for potentially harmful objects, and/or failed to ensure that patients who required every fifteen minute observations and/or video surveillance were monitored in accordance with the physician's order for 5 of 8 (Patients #1, #6, #7, #8 and #9).

The hospital failed to ensure a safe environment for patients who were restrained in a transport bag and placed on the floor of a bus during transportation between buildings for 6 of 11 patients (Patients #1, #12, #17, #18, #19, and #21).

The hospital failed to inform patients and/or responsible parties and/or obtain consent for changes to the patient's medication regime and/or for the use of video surveillance in patient bedrooms for 6 of 10 Patients (Patients #1, #8, #9, #12, #33, and #34).


Please see A131, A144, A154 and A165
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on clinical record reviews, staff interviews and a review of hospital policy and procedures for 6 of 10 Patients (Patients #1, #8, #9, #12, #33, and #34), the hospital failed to inform the patients and/or responsible parties and/or obtain consent for changes to the patient's medication regime and/or for the use of video surveillance in patient bedrooms. The findings included:


a. Review of the clinical record identified Patient #1 was admitted on [DATE] with suicidal ideations. Patient #1 had diagnoses that included Major Depressive Disorder and Obsessive Compulsive Disorder. Interview and review of the clinical record with the Director of Risk Management on 5/11/17 at 1:45 PM identified on 7/29/16, 8/4/16, 8/8/16, 8/15/16, 8/18/16, 8/22/16 and on 8/24/16 (seven occasions), medication changes were made absent a discussion regarding the plan of care and permission from the patient's responsible party prior to the administration of the medications. Interview with the Chief of Psychiatry on 5/11/17 at 10:00 AM identified the responsible party should have been informed of medication changes by the prescribe, as the patient was a minor, and obtained consent prior to the order change and the administration of the medications.


b. Review of the clinical record identified Patient #9 was admitted on [DATE] with depression and suicidal ideation. Patient #9's diagnosis included depression and attention deficit hyperactivity disorder. Patient #9 was on fifteen minute observational checks for safety. Review of the physician's progress notes identified MD #16 was notified on 5/7/16 at 9:59 PM that Patient #9 had been dysregulated throughout the day, upset that he/she was still hospitalized and had suicidal ideations. MD #16 ordered Benadryl 50 milligrams orally and direct observation with a camera while the patient was in his/her bedroom. In this timeframe, Patient #9 was in a 2 bed room which was shared with Patient #8.

i. Review of the clinical record identified Patient #8 was admitted on [DATE] with worsening depression and suicidal ideation. Patient #8's diagnosis included unspecified depressive disorder. Patient #8 was on fifteen minute observational checks for safety.

ii. Interview and review of the clinical record of Patient #8 and #9 with the Director of Nursing and the Director of Risk Management failed to identify that informed consent was obtained from the patients and/or their responsible parties for the use of video surveillance in the shared bedroom. The Director of Risk Management indicated consent should have been obtained and documented from the responsible party of each patient as they were minors.

iii. The policy for camera observation (part of the policy for Patient Observation Levels) identified that camera observation is not to be used for suicidal or patients at high risk for self-harm but may be appropriate for patients on CPAP, who may not be compliant with NPO, behaviorally impulsive patients, patients at risk for purging, and patients at moderate risk for falls. A hospital policy for informed consent identified that the patient or legally responsible person must be given the opportunity to give an "informed consent" prior to the following: videotaping.

iv. An email communication from the Director of Performance Improvement and Risk Management dated 5/16/17 identified that the hospital does not have a general policy or consent for the camera "surveillance".




b. Patient #12 was admitted to the adolescent unit (Main House 3) on 7/25/16 with diagnoses that included Oppositional Defiant Disorder (ODD) and Posttraumatic Stress Disorder (PTSD). Review of a MD Treatment Plan identified problems of aggression/agitation, explosiveness/violence, depressed, impaired social/occupational functioning, inability to control impulses, initiates physical fights, irritability/anger, and self-harm.
A Nursing progress note dated 7/27/16 at 2:08 AM by RN #6 identified that Patient #12 exhibited out-of-control behaviors resulting in the patient being restrained and transported to the ACU building. A Physician Progress Note dated 7/28/16 at 6:29 PM by MD #18 directed to continue on ACU with Special Observation (SO) and video monitoring. A corresponding physician order dated 7/28/16 at 4:58 PM directed observation (SO) and camera now. Review of the clinical record failed to substantiate that Patient #12 and/or a responsible party were informed of and/or consented to the use of the camera in his/her bedroom.



c. Patient #33 was admitted on [DATE] with diagnoses of major depressive disorder, recurrent, severe, generalized anxiety disorder, and obstructive sleep apnea. A plan included to continue CPAP and current medications. A physician order dated 6/5/17 at 7:50 PM directed the use of a camera at night due to the use of the CPAP device. Review of the clinical record failed to substantiate that Patient #33 was informed of and/or consented to the video surveillance in his/her bedroom. Interview with the DNS on 6/28/17 at 2:00 PM identified that staff was assigned to observe all patients who utilize CPAP at night to ensure that the patients do not engage in self-harm behaviors and that no other patients wander into their rooms to utilize the CPAP equipment for self-harm purposes. According to the DNS, the staff is supposed to notify the patients that they are being monitored continuously via camera.



d. Patient #34 was admitted on [DATE] with diagnoses of bipolar type two disorder and sleep apnea with a history of depression that had recently worsened with the onset of suicidal ideation. The treatment plan included admit to ACU, conduct every 15 minute checks, and CPAP at night (may use own settings). A physician order dated 6/07/17 at 10:13 PM directed to monitor the patient while using the CPAP machine. Review of the clinical record failed to substantiate that Patient #33 was informed of and/or consented to the video surveillance in his/her bedroom.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record reviews, review of hospital documentation, policies and procedures, and interviews for 5 of 8 (Patients #1, #6, #7, #8 and #9), the hospital failed ensure a safe environment when staff failed to conduct a comprehensive search of a patient and/or belongings for potentially harmful objects, and/or failed to ensure that patients who required every fifteen minute observation checks and/or video surveillance were monitored in accordance with the physician's order and/or failed to ensure a safe environment for patients who were restrained in a transport bag and placed on the floor of a shuttle bus during transportation between buildings for 6 of 11 patients (Patients #1, #12, #17, #18, #19, and #21).


a. Review of the clinical record identified Patient #1 was admitted on [DATE] with suicidal ideation's. Patient #1 had diagnoses that included Major Depressive Disorder and Obsessive Compulsive Disorder. Interview and review of the nurses notes with the Director of Nursing on 5/12/17 at 10:00 AM identified on 7/31/16 at 7:30 PM Patient #1 used a piece of glass from a makeup compact to harm his/her self. Patient #1 sustained fifteen superficial cuts approximately three to four inches in length on his/her right outer thigh. Further interview with the Director of Nursing indicated the makeup compact that contained the mirror was missed on admission during the belonging search and was allowed on the unit in error. The hospital policy entitled Valuables Search directed in part that a designated staff member would ensure that any items that are considered to be potentially harmful would be removed and either sent home with the patient's family or stored in the designated locked area in the admissions basement. Additionally a body search would be conducted and all items of clothing would be searched carefully including underwear socks and shoes.


b. Patient #6 was admitted to the adolescent unit (Main House 3) room 131 bed 2 on 12/11/2014. Primary diagnoses included major depressive disorder, recurrent, severe without psychotic features. The patient had a history of anxiety, depression, and social difficulty with feelings of hopelessness and social isolation. Admission orders dated 12/11/14 directed to monitor the patient every via 15 minute checks. Review of the Discharge Summary dated 12/24/2014 by MD #14 identified that Patient #6 participated in all aspects of treatment on the unit. Medications were adjusted and were well tolerated. The patient's mood improved and his/her affect was brighter with a full range. The patient was discharged home on 12/18/14.

Patient #7 was admitted to the adolescent unit (MH3) on 12/10/2014 to room 131 bed 1 (Patient #6's roommate) with diagnoses that included major depressive disorder, anxiety disorder, ADHD, and rule out psychotic disorder versus depression with psychotic features versus substance induced psychotic disorder. He/she had a history of anxiety with worsening mood, panic, and self-injury. Patient #7 had no documented history of sexual inappropriateness. Physician orders dated 12/10/14 directed to monitor the patient via every 15 minute checks. According to MD #14's physician notes, Patient #7 adjusted well to the in-patient setting and tolerated medication adjustments. On 12/17/14, Patient #7 exhibited elevated blood pressure, abdominal pain, vomited blood, and was emergently transferred to an acute care hospital for evaluation and treatment.

Review of hospital documentation and investigation identified that one week after Patient #6's discharge, they were notified that Patient #6 alleged that Patient #7 engaged in inappropriate sexual contact with Patient #6 on the night of 12/16/14. Patient #6 identified that after the sexual contact he/she went into the bathroom. According to the hospital's investigation the alleged sexual contact took place between routine every fifteen minute checks. Patient #6 reported that when he/she was in the bathroom, a staff member knocked on the bathroom door, spoke to Patient #6 through the door, but did not open the door. The staff member was identified as Psychiatric Technician (PT) #4. Patient #6 identified that he/she did not tell staff about the incident during the hospitalization because he/she was afraid of Patient #7 and because Patient #7 left the next morning he/she no longer presented a threat.

The hospital investigation included a review of hallway video surveillance footage for the time period in question, interviewed staff, conducted record reviews and consulted with each patients' therapist. The hospital was unable to substantiate that inappropriate sexual contact had occurred between Patient #6 and Patient #7. However, it was identified that PT #4 failed to visualize the patient during the 15 minute check in accordance with hospital policy.

Interview with PT #4 on 5/11/17 at 2:42 PM identified that he/she had been assigned to conduct safety checks from 1:00 AM to 2:00 AM on 12/17/14. He/she had been employed at the hospital for two weeks and identified that, at the time, he/she thought that the proper way to conduct safety checks on a patient in the bathroom with the door closed was to knock on the door, ask the patient if he/she was OK, and if the response was appropriate the PT would assume that the patient was safe. Subsequent to the occurrence, PT #4 and other staff were re-educated on safety checks that included to visualize the patient in order to verify his/her location and safety. A community meeting module about unit safety was developed and implemented. Following the incident.
A hospital policy for Patient Observation Levels and Observation Checklist identified that all in-patients will be observed according to the standard level of observation unless otherwise ordered by the MD. Observation at all levels is to be conducted with no barriers between the patient and staff member (i.e.) through glass, over a counter, or nursing station, on the other side of the door in a bathroom, etc.)


c. Review of the clinical record identified Patient #9 was admitted on [DATE] with depression and suicidal ideation. Patient #9's diagnosis included depression and attention deficit hyperactivity disorder. Patient #9 was on fifteen minute observational checks for safety. Review of the physician's progress notes identified MD #16 was notified on 5/7/16 at 9:59 PM that Patient #9 had been dysregulated throughout the day, upset that he/she was still hospitalized and had suicidal ideations. MD #16 ordered Benadryl 50 milligrams orally and direct observation with a camera while the patient was in his/her bedroom.

Review of the clinical record identified Patient #8 was admitted on [DATE] with worsening depression and suicidal ideation. Patient #8's diagnosis included unspecified depressive disorder. Patient #8 was on fifteen minute observational checks for safety. Interview and review of the video surveillance on 5/12/17 with the Director of Risk Management identified on 5/8/16 from 12:01 AM through 12:08 AM Patients #8 and #9 (who were roommates) engaged in sexual behavior. Interview with Psychiatric Technician #3 on 5/12/17 at 11:30 AM identified s/he was assigned to the observational checks and had completed them at 12:00 AM. Psychiatric Technician #3 indicated when s/he returned to the nurse's station after his/her rounds at 12:08 AM s/he observed sexual activity between Patient #8 and #9 on the video camera. Psychiatric Technician #3 immediately entered the room of Patient #8 and #9 to find both patient's in their respective beds. RN #3 and the physician on call were both notified and Patient #9 was transferred to an alternate unit. Both patients were placed on one to one observation subsequent to the incident. Interview with RN #5 on 5/12/17 at 1:30 PM identified although camera surveillance was ordered a dedicated staff member was not assigned to the task of observing the camera at all times as there was only two staff members, one completing the observational checks and the registered nurse who was responsible for conducting assessments, medication administration and other nursing tasks. Further interview with Psychiatric Technician #3 and RN #5 indicated they never received education or training regarding the implementation or procedures for camera observation. Interview with the Director of Risk Management indicated the staff should have been trained prior to the inception of camera surveillance and were not. Interview with the Director of Risk Management on 5/12/17 identified the hospital failed to have a policy that directed a procedure for camera surveillance and should have. Subsequent to the incident the hospital policy entitled Patient Observation Levels and Observational Checklist directed in part that camera observation served as a higher observation level than fifteen minute checks. Camera observation would be performed by a staff member assigned only to that task and that assignment would not last more than two hours at a time as designated on the assignment sheet. The policy further directed that the assigned observer would not be responsible for other duties. When and if the assigned staff member had to leave the monitor another staff member would take over the responsibility. Interview and review of the clinical record of Patient #8 and #9 with the Director of Nursing and the Director of Risk Management failed to identify that informed consent was obtained from the patient and/or the patient's responsible party for the use of video surveillance. The Director of Risk Management indicated consent should have been obtained and documented from the responsible party of each patient as they were minors.


d. Tour of the in-patient behavioral health units and interviews with the Director of Nurses (DNS) and Nurse Manager (NM) #1 on 05/10/17 identified that the hospital utilized physical holds, seclusion, transport bag restraints and 4-point restraints when deemed necessary. The hospital's only restraint/seclusion room was located in the adult Acute Care Unit (ACU). There were eight other houses on the campus that included both acute psychiatric beds and transitional beds for adults and adolescents. A patient who required restraint or seclusion required transport to the ACU building either voluntarily via shuttle bus accompanied by staff or, involuntarily via transport restraint bag that was placed on the floorin the shuttle bus. Observation of the transport restraint bag identified that it was made of heavy duty canvas and Velcro-type material. According to the hospital policy for use of the transport bag, the bag should be placed on a hard, flat surface, wide open with enough personnel available to hold each patient limb. The patient is placed supine on the wide open transport bag and the staff should try to keep the patient's arms next to the body and the legs together at all stages of application. The Velcro closures (on the outside of the bag) must be fastened quickly to contain the patient within the bag. The RN must check for adequate respiration and observe continuously. The patient is immediately removed from the transport bag restraint once in the safety of a quiet room or if there were any signs of patient distress. The transport bag was a full body restraint that encased the whole patient from the upper chest to the ankles and prevented free movement of the arms, torso, and/or legs.


e. Review of the clinical record identified Patient #1 was admitted on [DATE] with suicidal ideations. Patient #1 had diagnoses that included Major Depressive Disorder and Obsessive Compulsive Disorder. Interview and review of the clinical record with the Director of Nursing on 5/11/17 identified on 8/22/16 Patient #1 was agitated, throwing objects and was unable to be redirected. A decision was made to transport the patient from the adolescent unit to the Acute Care Unit (ACU), which is located in another building. A physicians order dated 8/22/16 at 9:35 PM directed a transport restraint. Patient #1 was placed in a transport bag and placed in a shuttle bus accompanied by staff to the ACU. Further interview with the Director of Nursing identified that the transport bag is utilized to protect the patient from injury to self and others as well as to reduce the potential effects of a hands on intervention involving multiple staff on a patient with a personal history of sexual and/or violent trauma. In addition the Director of Nursing indicated the adolescent unit was not designed to accommodate the use of physical restraints and, therefore, patients requiring four point restraints must be restrained in a transport bag to the ACU thus resulting in the need for an additional restraint prior to being placed in the four point restraint.



f. Patient #12 was admitted to the adolescent unit (Main House 3) on 7/25/16 with diagnoses that included Oppositional Defiant Disorder (ODD) and Posttraumatic Stress Disorder (PTSD). Review of a MD Treatment Plan identified problems of aggression/agitation, explosiveness/violence, depressed, impaired social/occupational functioning, inability to control impulses, initiates physical fights, irritability/anger, and self-harm. A Nursing progress note dated 7/27/16 at 2:08 AM by RN #6 identified that Patient #12 began throwing objects and physically assaulted multiple staff, punching, kicking, and scratching. He/she was restrained on a "patient transport stretcher", given medications IM per order, and transported to the ACU building. Interview and review of the clinical record with the Director of Performance Improvement on 5/17/17 at 3:50 PM identified that the hospital does not utilize a patient transport stretcher and RN #6 must have been referring to the transport bag restraint. In a multidisciplinary restraint record dated 7/26/16 at 11:55 PM, MD #8 identified that less restrictive alternatives had failed and Patient #12 required protection from harming him/her self. MD #8 directed manual hold, transport restraint from Main House 3 (MH3) to the ACU, and restraint for a time limit of 2 hours. Patient #12 was transferred to the ACU where four point restraints were applied. Interview with the supervisor, RN #7 on 5/17/17 at 3:00 PM identified that after approximately 40 minutes of attempts to verbally de-escalate the patient, medication was administered IM. The patient physically resisted and MD #8, ordered four point restraints. The patient was placed in a transport bag restraint per hospital policy and placed on the floor of a hospital shuttle bus accompanied by at least five hospital staff members to the ACU building and placed in four point restraints. Restraint documentation including progress notes and the multidisciplinary restraint record failed to identify the use of the transport bag restraint to transport Patient #12 from MH3 to the ACU for application of four point mechanical restraints. In addition, documentation failed to include an assessment of the patient's needs and/or monitoring during the use of the transport bag restraint. Interview and review of the clinical record with the Physician-In-Chief on 6/29/17 at 1:00 PM identified that restraints could only be applied in the adult ACU building as it would be unsafe to apply the restraints in any other patient unit on the campus.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


g. Patient #17 was admitted to the in-patient substance abuse treatment program (The Lodge) on 10/16/16 and identified as intoxicated. Diagnoses included major depressive disorder and bulimia with an extensive history of alcohol misuse. An MD Treatment Plan (MDTP) identified problems of black outs, excessive time spent obtaining/using substance and impaired social/occupational functioning. Review of a physician progress note dated 10/16/16 at 8:18 PM identified that Patient #17 became severely agitated, unable to follow directions and started screaming, crying, banging doors, and wanting to leave or go to smoke. The patient required four point restraint and was transferred in a transfer bag restraint from the Lodge to the ACU building to ensure patient safety and the safety of others. According to MD #9's documentation, Haldol 5 mg was utilized for a chemical restraint which "put the patient to sleep". Review of a multidisciplinary restraint record dated 10/16/16 at 6:30 PM identified that Patient #17 was a danger to self and others and least restrictive alternatives were unsuccessful. The MD order included a manual hold, and restraint for a time limit of four hours. The (restraint) intervention was initiated on 10/16/16 at 6:28 PM and terminated at 6:55 PM. Review of the patient care plan for restraints identified interventions that included manual hold, transport restraint (transport bag), and emergency medications (Haldol 5 mg) given as the patient was combative and agitated. RN #8 documented on 10/16/16 at 6:55 PM that Patient #17 had become verbally and physically threatening to the staff and required a manual hold for administration of IM Haldol. The Patient initially calmed with the medications, but then became agitated again and required a manual hold and placement in a transfer bag restraint and transferred via shuttle bus from the Lodge to the ACU (across the street and on the other side of the campus) . The patient was able to relax in the transfer bag in the restraint room in the ACU, four point restraints were not implemented, the transport bag restraint was discontinued at 6:55 PM and the patient was transferred to another room on the ACU. Review of the clinical record documentation failed to include an assessment of the patient's needs and/or monitoring during the use of the transport bag restraint.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


h. Patient #18 was admitted to the Transitional Living Program for eating disorders (TLPED) on 10/10/2016 with diagnoses of bipolar disorder with psychotic features and social phobia. An MD Treatment Plan note dated 12/2/16 identified problems that included a blunted affect, decreased sleep, decreased social/occupational functioning, suicidal ideation, agitation, extreme emotional reactivity, and labile, self-harm, and anxious affect. A physician progress note by MD #10 dated 12/02/16 identified that Patient #18 was planning to re-engage with a family member but was informed that the family member would not be able to visit due to illness. Patient #18's reaction to this news was severe: verbalizing feelings of anger, rejection, being wronged and being punished. The patient began to engage in self- injurious behaviors including biting, and trying to strangle his/herself with staff present. The patient was placed on Constant Observation (CO) for safety leading to further agitation and suicidal ideation. The patient refused voluntary transfer to the ACU and was subsequently transferred to a crisis bed on the ACU via transport bag restraint and admitted on a PEC. Four point restraints were later required. A multidisciplinary restraint record dated 12/1/16 at 8:15 PM on the TLPEDO by MD #11 and RN #9 identified an initial problem of danger to self (locked self in the bathroom). Alternative measures were unsuccessful. An MD order directed to utilize a transport bag restraint secondary to the patient's danger to self. The transport bag restraint was applied at 8:15 PM (and the patient was transported to the ACU building). According to the DNS the TLP/EDO was not designed to accommodate the needs of a patient that required crisis intervention and/or four point restraints and transfer to a higher level of care required transport via transport bag carried by a minimum of five staff and the patient was placed on the floor of a shuttle bus for transport from building to building. The patient was transferred back to the EDO TLP on 12/12/16.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


i. Patient #19 was admitted to the in-patient adult substance abuse treatment program on 3/23/17. MD #13 documented diagnoses that included primary alcohol use disorder; secondary alcohol intoxication disorder, alcohol induced depressive disorder, rule out primary mood disorder, and bipolar disorder versus mood disorder by history. An MD treatment plan identified problems of being depressed and active suicidal ideation. A Physician Progress noted dated 3/26/17 by MD #12 identified that Patient #19 insisted on being released immediately, refused to sign a request for discharge, would not follow re-direction, continued to escalate, refused oral medications and became combative. Per MD #12, the patient was restrained (type of restraint not identified). Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg was administered IM and the patient was transferred to the ACU. Review of the Multidisciplinary Restraint/Seclusion Record dated 3/26/17 at 10:15 PM identified that Patient #19 presented as a danger to self and others with assaultive behavior and verbal threats to hurt others. Alternative measures were ineffective. MD #12 ordered a manual hold, followed by a transport bag restraint, followed by a four point restraint. RN #2 documented that Patient #19 was transferred from Main 1 via security transport (via shuttle bus) in the restraint bag. Four point restraints were initiated by RN #2 and MD #12 at 10:15 PM and discontinued at 10:50 PM. The time of the initiation of the manual hold and transport restraint was not documented. Interview and review of the clinical record with MD #13 on 6/29/17 at 11:15 AM identified that Patient #19 was initially admitted to Main 1 for detox from alcohol. However, Main 1 was not able to manage the level of agitation that Patient #19 presented and was unable to implement restraints. Therefore, the patient was transferred to the ACU due to the increased staffing.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


j. Patient #21 was admitted to the adolescent unit (Main House 3) on 5/26/17 with a diagnosis of major depressive disorder, recurrent episode, severe, rule out eating disorder and rule out Lyme disease, was anxious and had self-harm and suicidal ideation. A physician's admission assessment dated [DATE] identified that Patient #17 had exhibited self-injurious behaviors for the past two weeks and expressed feelings of hopelessness and worthlessness. A physician progress note dated 6/14/17 at 11:30 PM by MD #17 identified that he/she was called to assess Patient #21 who was in bed screaming, attempting to strike staff, and despite verbal redirection continued to engage in self-injurious behavior (no specific self-harm behavior identified). MD #17 documented that staff lifted Patient #21 off the bed and the patient was placed on the floor in a cloth restraint (transport bag). Within minutes of being placed in the transport bag restraint the patient calmed and accepted oral medications. Review of the multidisciplinary restraint record identified that Patient #21 was a danger to self and MD #17 ordered transport restraint with a time limit of 2 hours. Patient #21 was in the transport bag restraint from 9:35 PM to 9:50 PM, became calm, and was able to walk to the van with minimal assistance and was transferred to the ACU building. Interview with the DNS on 06/28/17 at 2:30 PM identified that the ACU's restraint room was the only safe, appropriate place to restrain or seclude a patient on the campus. Interview and review of the clinical record with MD #10 on 6/29/17 at 1:30 PM identified that Patient #21 required a higher level of care than was available on the adolescent unit due to his/her dysregulated behavior that was disrupting the adolescent community as well as requiring the potential need for mechanical restraints.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of an additional restraint (transport restraint), with the intention to transfer the patient to another building and another therapeutic milieu (ACU) for use/potential use of four point restraints.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record reviews, review of hospital policies and procedures, tours of behavioral health units located in separate and distinct buildings on the hospital grounds, and staff interviews for 6 of 11 patients (Patients #1, #12, #17, #18, #19, and #21) who required physical restraints and were transported via transport bag (full body wrap-type restraint) to a restraint room in another building, the hospital failed to ensure that the patients were able to be treated/restrained on their units and in their familiar milieu, failed to ensure that the least restrictive device was used when a restraint transport bag was used in order to place patients in 4-point restraints, and failed to maintain patient dignity when patient's in transport bags were transported on the floor of a hospital transport bus to another building. The findings include:


Tour of the in-patient behavioral health units and interviews with the Director of Nurses (DNS) and Nurse Manager (NM) #1 on 05/10/17 identified that the hospital utilized physical holds, seclusion, transport bag restraints and 4-point restraints when deemed necessary. The hospital's only restraint/seclusion room was located in the adult Acute Care Unit (ACU). There were eight other houses on the campus that included both acute psychiatric beds and transitional beds for adults and adolescents. A patient who required restraint or seclusion required transport to the ACU building either voluntarily via shuttle bus accompanied by staff or, involuntarily via transport restraint bag that was placed on the floorin the shuttle bus. Observation of the transport restraint bag identified that it was made of heavy duty canvas and Velcro-type material. According to the hospital policy for use of the transport bag, the bag should be placed on a hard, flat surface, wide open with enough personnel available to hold each patient limb. The patient is placed supine on the wide open transport bag and the staff should try to keep the patient's arms next to the body and the legs together at all stages of application. The Velcro closures (on the outside of the bag) must be fastened quickly to contain the patient within the bag. The RN must check for adequate respiration and observe continuously. The patient is immediately removed from the transport bag restraint once in the safety of a quiet room or if there were any signs of patient distress. The transport bag was a full body restraint that encased the whole patient from the upper chest to the ankles and prevented free movement of the arms, torso, and/or legs.


a. Review of the clinical record identified Patient #1 was admitted on [DATE] with suicidal ideations. Patient #1 had diagnoses that included Major Depressive Disorder and Obsessive Compulsive Disorder. Interview and review of the clinical record with the Director of Nursing on 5/11/17 identified on 8/22/16 Patient #1 was agitated, throwing objects and was unable to be redirected. A decision was made to transport the patient from the adolescent unit to the Acute Care Unit (ACU), which is located in another building. A physicians order dated 8/22/16 at 9:35 PM directed a transport restraint. Patient #1 was placed in a transport bag and placed in a shuttle bus accompanied by staff to the ACU. Further interview with the Director of Nursing identified that the transport bag is utilized to protect the patient from injury to self and others as well as to reduce the potential effects of a hands on intervention involving multiple staff on a patient with a personal history of sexual and/or violent trauma. In addition the Director of Nursing indicated the adolescent unit was not designed to accommodate the use of physical restraints and, therefore, patients requiring four point restraints must be restrained in a transport bag to the ACU thus resulting in the need for an additional restraint prior to being placed in the four point restraint.



b. Patient #12 was admitted to the adolescent unit (Main House 3) on 7/25/16 with diagnoses that included Oppositional Defiant Disorder (ODD) and Posttraumatic Stress Disorder (PTSD). Review of a MD Treatment Plan identified problems of aggression/agitation, explosiveness/violence, depressed, impaired social/occupational functioning, inability to control impulses, initiates physical fights, irritability/anger, and self-harm. A Nursing progress note dated 7/27/16 at 2:08 AM by RN #6 identified that Patient #12 began throwing objects and physically assaulted multiple staff, punching, kicking, and scratching. He/she was restrained on a "patient transport stretcher", given medications IM per order, and transported to the ACU building. Interview and review of the clinical record with the Director of Performance Improvement on 5/17/17 at 3:50 PM identified that the hospital does not utilize a patient transport stretcher and RN #6 must have been referring to the transport bag restraint. In a multidisciplinary restraint record dated 7/26/16 at 11:55 PM, MD #8 identified that less restrictive alternatives had failed and Patient #12 required protection from harming him/her self. MD #8 directed manual hold, transport restraint from Main House 3 (MH3) to the ACU, and restraint for a time limit of 2 hours. Patient #12 was transferred to the ACU where four point restraints were applied. Interview with the supervisor, RN #7 on 5/17/17 at 3:00 PM identified that after approximately 40 minutes of attempts to verbally de-escalate the patient, medication was administered IM. The patient physically resisted and MD #8, ordered four point restraints. The patient was placed in a transport bag restraint per hospital policy and placed on the floor of a hospital shuttle bus accompanied by at least five hospital staff members to the ACU building and placed in four point restraints. Restraint documentation including progress notes and the multidisciplinary restraint record failed to identify the use of the transport bag restraint to transport Patient #12 from MH3 to the ACU for application of four point mechanical restraints. In addition, documentation failed to include an assessment of the patient's needs and/or monitoring during the use of the transport bag restraint. Interview and review of the clinical record with the Physician-In-Chief on 6/29/17 at 1:00 PM identified that restraints could only be applied in the adult ACU building as it would be unsafe to apply the restraints in any other patient unit on the campus.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


c. Patient #17 was admitted to the in-patient substance abuse treatment program (The Lodge) on 10/16/16 and identified as intoxicated. Diagnoses included major depressive disorder and bulimia with an extensive history of alcohol misuse. An MD Treatment Plan (MDTP) identified problems of black outs, excessive time spent obtaining/using substance and impaired social/occupational functioning. Review of a physician progress note dated 10/16/16 at 8:18 PM identified that Patient #17 became severely agitated, unable to follow directions and started screaming, crying, banging doors, and wanting to leave or go to smoke. The patient required four point restraint and was transferred in a transfer bag restraint from the Lodge to the ACU building to ensure patient safety and the safety of others. According to MD #9's documentation, Haldol 5 mg was utilized for a chemical restraint which "put the patient to sleep". Review of a multidisciplinary restraint record dated 10/16/16 at 6:30 PM identified that Patient #17 was a danger to self and others and least restrictive alternatives were unsuccessful. The MD order included a manual hold, and restraint for a time limit of four hours. The (restraint) intervention was initiated on 10/16/16 at 6:28 PM and terminated at 6:55 PM. Review of the patient care plan for restraints identified interventions that included manual hold, transport restraint (transport bag), and emergency medications (Haldol 5 mg) given as the patient was combative and agitated. RN #8 documented on 10/16/16 at 6:55 PM that Patient #17 had become verbally and physically threatening to the staff and required a manual hold for administration of IM Haldol. The Patient initially calmed with the medications, but then became agitated again and required a manual hold and placement in a transfer bag restraint and transferred via shuttle bus from the Lodge to the ACU (across the street and on the other side of the campus) . The patient was able to relax in the transfer bag in the restraint room in the ACU, four point restraints were not implemented, the transport bag restraint was discontinued at 6:55 PM and the patient was transferred to another room on the ACU. Review of the clinical record documentation failed to include an assessment of the patient's needs and/or monitoring during the use of the transport bag restraint.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


d. Patient #18 was admitted to the Transitional Living Program for eating disorders (TLPED) on 10/10/2016 with diagnoses of bipolar disorder with psychotic features and social phobia. An MD Treatment Plan note dated 12/2/16 identified problems that included a blunted affect, decreased sleep, decreased social/occupational functioning, suicidal ideation, agitation, extreme emotional reactivity, and labile, self-harm, and anxious affect. A physician progress note by MD #10 dated 12/02/16 identified that Patient #18 was planning to re-engage with a family member but was informed that the family member would not be able to visit due to illness. Patient #18's reaction to this news was severe: verbalizing feelings of anger, rejection, being wronged and being punished. The patient began to engage in self- injurious behaviors including biting, and trying to strangle his/herself with staff present. The patient was placed on Constant Observation (CO) for safety leading to further agitation and suicidal ideation. The patient refused voluntary transfer to the ACU and was subsequently transferred to a crisis bed on the ACU via transport bag restraint and admitted on a PEC. Four point restraints were later required. A multidisciplinary restraint record dated 12/1/16 at 8:15 PM on the TLPEDO by MD #11 and RN #9 identified an initial problem of danger to self (locked self in the bathroom). Alternative measures were unsuccessful. An MD order directed to utilize a transport bag restraint secondary to the patient's danger to self. The transport bag restraint was applied at 8:15 PM (and the patient was transported to the ACU building). According to the DNS the TLP/EDO was not designed to accommodate the needs of a patient that required crisis intervention and/or four point restraints and transfer to a higher level of care required transport via transport bag carried by a minimum of five staff and the patient was placed on the floor of a shuttle bus for transport from building to building. The patient was transferred back to the EDO TLP on 12/12/16.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


e. Patient #19 was admitted to the in-patient adult substance abuse treatment program on 3/23/17. MD #13 documented diagnoses that included primary alcohol use disorder; secondary alcohol intoxication disorder, alcohol induced depressive disorder, rule out primary mood disorder, and bipolar disorder versus mood disorder by history. An MD treatment plan identified problems of being depressed and active suicidal ideation. A Physician Progress noted dated 3/26/17 by MD #12 identified that Patient #19 insisted on being released immediately, refused to sign a request for discharge, would not follow re-direction, continued to escalate, refused oral medications and became combative. Per MD #12, the patient was restrained (type of restraint not identified). Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg was administered IM and the patient was transferred to the ACU. Review of the Multidisciplinary Restraint/Seclusion Record dated 3/26/17 at 10:15 PM identified that Patient #19 presented as a danger to self and others with assaultive behavior and verbal threats to hurt others. Alternative measures were ineffective. MD #12 ordered a manual hold, followed by a transport bag restraint, followed by a four point restraint. RN #2 documented that Patient #19 was transferred from Main 1 via security transport (via shuttle bus) in the restraint bag. Four point restraints were initiated by RN #2 and MD #12 at 10:15 PM and discontinued at 10:50 PM. The time of the initiation of the manual hold and transport restraint was not documented. Interview and review of the clinical record with MD #13 on 6/29/17 at 11:15 AM identified that Patient #19 was initially admitted to Main 1 for detox from alcohol. However, Main 1 was not able to manage the level of agitation that Patient #19 presented and was unable to implement restraints. Therefore, the patient was transferred to the ACU due to the increased staffing.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


f. Patient #21 was admitted to the adolescent unit (Main House 3) on 5/26/17 with a diagnosis of major depressive disorder, recurrent episode, severe, rule out eating disorder and rule out Lyme disease, was anxious and had self-harm and suicidal ideation. A physician's admission assessment dated [DATE] identified that Patient #17 had exhibited self-injurious behaviors for the past two weeks and expressed feelings of hopelessness and worthlessness. A physician progress note dated 6/14/17 at 11:30 PM by MD #17 identified that he/she was called to assess Patient #21 who was in bed screaming, attempting to strike staff, and despite verbal redirection continued to engage in self-injurious behavior (no specific self-harm behavior identified). MD #17 documented that staff lifted Patient #21 off the bed and the patient was placed on the floor in a cloth restraint (transport bag). Within minutes of being placed in the transport bag restraint the patient calmed and accepted oral medications. Review of the multidisciplinary restraint record identified that Patient #21 was a danger to self and MD #17 ordered transport restraint with a time limit of 2 hours. Patient #21 was in the transport bag restraint from 9:35 PM to 9:50 PM, became calm, and was able to walk to the van with minimal assistance and was transferred to the ACU building. Interview with the DNS on 06/28/17 at 2:30 PM identified that the ACU's restraint room was the only safe, appropriate place to restrain or seclude a patient on the campus. Interview and review of the clinical record with MD #10 on 6/29/17 at 1:30 PM identified that Patient #21 required a higher level of care than was available on the adolescent unit due to his/her dysregulated behavior that was disrupting the adolescent community as well as requiring the potential need for mechanical restraints.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of an additional restraint (transport restraint), with the intention to transfer the patient to another building and another therapeutic milieu (ACU) for use/potential use of four point restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record reviews, review of hospital policies and procedures, tours of behavioral health units located in separate and distinct buildings on the hospital grounds, and staff interviews for 6 of 11 patients (Patients #1, #12, #17, #18, #19, and #21) who were transported via transport bag (full body wrap-type restraint) to a restraint room in another building necessitating the use of 2 or 3 restraints (manual hold, transport bag, 4-point), the hospital failed to ensure that the least restrictive device was used. The findings include:


Tour of the in-patient behavioral health units and interviews with the Director of Nurses (DNS) and Nurse Manager (NM) #1 on 05/10/17 identified that the hospital utilized physical holds, seclusion, transport bag restraints and 4-point restraints when deemed necessary. The hospital's only restraint/seclusion room was located in the adult Acute Care Unit (ACU). There were eight other houses on the campus that included both acute psychiatric beds and transitional beds for adults and adolescents. A patient who required restraint or seclusion required transport to the ACU building either voluntarily via shuttle bus accompanied by staff or, involuntarily via transport restraint bag that was placed on the floorin the shuttle bus. Observation of the transport restraint bag identified that it was made of heavy duty canvas and Velcro-type material. According to the hospital policy for use of the transport bag, the bag should be placed on a hard, flat surface, wide open with enough personnel available to hold each patient limb. The patient is placed supine on the wide open transport bag and the staff should try to keep the patient's arms next to the body and the legs together at all stages of application. The Velcro closures (on the outside of the bag) must be fastened quickly to contain the patient within the bag. The RN must check for adequate respiration and observe continuously. The patient is immediately removed from the transport bag restraint once in the safety of a quiet room or if there were any signs of patient distress. The transport bag was a full body restraint that encased the whole patient from the upper chest to the ankles and prevented free movement of the arms, torso, and/or legs.


a. Review of the clinical record identified Patient #1 was admitted on [DATE] with suicidal ideations. Patient #1 had diagnoses that included Major Depressive Disorder and Obsessive Compulsive Disorder. Interview and review of the clinical record with the Director of Nursing on 5/11/17 identified on 8/22/16 Patient #1 was agitated, throwing objects and was unable to be redirected. A decision was made to transport the patient from the adolescent unit to the Acute Care Unit (ACU), which is located in another building. A physicians order dated 8/22/16 at 9:35 PM directed a transport restraint. Patient #1 was placed in a transport bag and placed in a shuttle bus accompanied by staff to the ACU. Further interview with the Director of Nursing identified that the transport bag is utilized to protect the patient from injury to self and others as well as to reduce the potential effects of a hands on intervention involving multiple staff on a patient with a personal history of sexual and/or violent trauma. In addition the Director of Nursing indicated the adolescent unit was not designed to accommodate the use of physical restraints and, therefore, patients requiring four point restraints must be restrained in a transport bag to the ACU thus resulting in the need for an additional restraint prior to being placed in the four point restraint.



b. Patient #12 was admitted to the adolescent unit (Main House 3) on 7/25/16 with diagnoses that included Oppositional Defiant Disorder (ODD) and Posttraumatic Stress Disorder (PTSD). Review of a MD Treatment Plan identified problems of aggression/agitation, explosiveness/violence, depressed, impaired social/occupational functioning, inability to control impulses, initiates physical fights, irritability/anger, and self-harm. A Nursing progress note dated 7/27/16 at 2:08 AM by RN #6 identified that Patient #12 began throwing objects and physically assaulted multiple staff, punching, kicking, and scratching. He/she was restrained on a "patient transport stretcher", given medications IM per order, and transported to the ACU building. Interview and review of the clinical record with the Director of Performance Improvement on 5/17/17 at 3:50 PM identified that the hospital does not utilize a patient transport stretcher and RN #6 must have been referring to the transport bag restraint. In a multidisciplinary restraint record dated 7/26/16 at 11:55 PM, MD #8 identified that less restrictive alternatives had failed and Patient #12 required protection from harming him/her self. MD #8 directed manual hold, transport restraint from Main House 3 (MH3) to the ACU, and restraint for a time limit of 2 hours. Patient #12 was transferred to the ACU where four point restraints were applied. Interview with the supervisor, RN #7 on 5/17/17 at 3:00 PM identified that after approximately 40 minutes of attempts to verbally de-escalate the patient, medication was administered IM. The patient physically resisted and MD #8, ordered four point restraints. The patient was placed in a transport bag restraint per hospital policy and placed on the floor of a hospital shuttle bus accompanied by at least five hospital staff members to the ACU building and placed in four point restraints. Restraint documentation including progress notes and the multidisciplinary restraint record failed to identify the use of the transport bag restraint to transport Patient #12 from MH3 to the ACU for application of four point mechanical restraints. In addition, documentation failed to include an assessment of the patient's needs and/or monitoring during the use of the transport bag restraint. Interview and review of the clinical record with the Physician-In-Chief on 6/29/17 at 1:00 PM identified that restraints could only be applied in the adult ACU building as it would be unsafe to apply the restraints in any other patient unit on the campus.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


c. Patient #17 was admitted to the in-patient substance abuse treatment program (The Lodge) on 10/16/16 and identified as intoxicated. Diagnoses included major depressive disorder and bulimia with an extensive history of alcohol misuse. An MD Treatment Plan (MDTP) identified problems of black outs, excessive time spent obtaining/using substance and impaired social/occupational functioning. Review of a physician progress note dated 10/16/16 at 8:18 PM identified that Patient #17 became severely agitated, unable to follow directions and started screaming, crying, banging doors, and wanting to leave or go to smoke. The patient required four point restraint and was transferred in a transfer bag restraint from the Lodge to the ACU building to ensure patient safety and the safety of others. According to MD #9's documentation, Haldol 5 mg was utilized for a chemical restraint which "put the patient to sleep". Review of a multidisciplinary restraint record dated 10/16/16 at 6:30 PM identified that Patient #17 was a danger to self and others and least restrictive alternatives were unsuccessful. The MD order included a manual hold, and restraint for a time limit of four hours. The (restraint) intervention was initiated on 10/16/16 at 6:28 PM and terminated at 6:55 PM. Review of the patient care plan for restraints identified interventions that included manual hold, transport restraint (transport bag), and emergency medications (Haldol 5 mg) given as the patient was combative and agitated. RN #8 documented on 10/16/16 at 6:55 PM that Patient #17 had become verbally and physically threatening to the staff and required a manual hold for administration of IM Haldol. The Patient initially calmed with the medications, but then became agitated again and required a manual hold and placement in a transfer bag restraint and transferred via shuttle bus from the Lodge to the ACU (across the street and on the other side of the campus) . The patient was able to relax in the transfer bag in the restraint room in the ACU, four point restraints were not implemented, the transport bag restraint was discontinued at 6:55 PM and the patient was transferred to another room on the ACU. Review of the clinical record documentation failed to include an assessment of the patient's needs and/or monitoring during the use of the transport bag restraint.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


d. Patient #18 was admitted to the Transitional Living Program for eating disorders (TLPED) on 10/10/2016 with diagnoses of bipolar disorder with psychotic features and social phobia. An MD Treatment Plan note dated 12/2/16 identified problems that included a blunted affect, decreased sleep, decreased social/occupational functioning, suicidal ideation, agitation, extreme emotional reactivity, and labile, self-harm, and anxious affect. A physician progress note by MD #10 dated 12/02/16 identified that Patient #18 was planning to re-engage with a family member but was informed that the family member would not be able to visit due to illness. Patient #18's reaction to this news was severe: verbalizing feelings of anger, rejection, being wronged and being punished. The patient began to engage in self- injurious behaviors including biting, and trying to strangle his/herself with staff present. The patient was placed on Constant Observation (CO) for safety leading to further agitation and suicidal ideation. The patient refused voluntary transfer to the ACU and was subsequently transferred to a crisis bed on the ACU via transport bag restraint and admitted on a PEC. Four point restraints were later required. A multidisciplinary restraint record dated 12/1/16 at 8:15 PM on the TLPEDO by MD #11 and RN #9 identified an initial problem of danger to self (locked self in the bathroom). Alternative measures were unsuccessful. An MD order directed to utilize a transport bag restraint secondary to the patient's danger to self. The transport bag restraint was applied at 8:15 PM (and the patient was transported to the ACU building). According to the DNS the TLP/EDO was not designed to accommodate the needs of a patient that required crisis intervention and/or four point restraints and transfer to a higher level of care required transport via transport bag carried by a minimum of five staff and the patient was placed on the floor of a shuttle bus for transport from building to building. The patient was transferred back to the EDO TLP on 12/12/16.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


e. Patient #19 was admitted to the in-patient adult substance abuse treatment program on 3/23/17. MD #13 documented diagnoses that included primary alcohol use disorder; secondary alcohol intoxication disorder, alcohol induced depressive disorder, rule out primary mood disorder, and bipolar disorder versus mood disorder by history. An MD treatment plan identified problems of being depressed and active suicidal ideation. A Physician Progress noted dated 3/26/17 by MD #12 identified that Patient #19 insisted on being released immediately, refused to sign a request for discharge, would not follow re-direction, continued to escalate, refused oral medications and became combative. Per MD #12, the patient was restrained (type of restraint not identified). Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg was administered IM and the patient was transferred to the ACU. Review of the Multidisciplinary Restraint/Seclusion Record dated 3/26/17 at 10:15 PM identified that Patient #19 presented as a danger to self and others with assaultive behavior and verbal threats to hurt others. Alternative measures were ineffective. MD #12 ordered a manual hold, followed by a transport bag restraint, followed by a four point restraint. RN #2 documented that Patient #19 was transferred from Main 1 via security transport (via shuttle bus) in the restraint bag. Four point restraints were initiated by RN #2 and MD #12 at 10:15 PM and discontinued at 10:50 PM. The time of the initiation of the manual hold and transport restraint was not documented. Interview and review of the clinical record with MD #13 on 6/29/17 at 11:15 AM identified that Patient #19 was initially admitted to Main 1 for detox from alcohol. However, Main 1 was not able to manage the level of agitation that Patient #19 presented and was unable to implement restraints. Therefore, the patient was transferred to the ACU due to the increased staffing.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of two additional restraints (manual hold and transport restraint) in order to transfer the patient to another building and another therapeutic milieu (ACU) for use of four point restraints.


f. Patient #21 was admitted to the adolescent unit (Main House 3) on 5/26/17 with a diagnosis of major depressive disorder, recurrent episode, severe, rule out eating disorder and rule out Lyme disease, was anxious and had self-harm and suicidal ideation. A physician's admission assessment dated [DATE] identified that Patient #17 had exhibited self-injurious behaviors for the past two weeks and expressed feelings of hopelessness and worthlessness. A physician progress note dated 6/14/17 at 11:30 PM by MD #17 identified that he/she was called to assess Patient #21 who was in bed screaming, attempting to strike staff, and despite verbal redirection continued to engage in self-injurious behavior (no specific self-harm behavior identified). MD #17 documented that staff lifted Patient #21 off the bed and the patient was placed on the floor in a cloth restraint (transport bag). Within minutes of being placed in the transport bag restraint the patient calmed and accepted oral medications. Review of the multidisciplinary restraint record identified that Patient #21 was a danger to self and MD #17 ordered transport restraint with a time limit of 2 hours. Patient #21 was in the transport bag restraint from 9:35 PM to 9:50 PM, became calm, and was able to walk to the van with minimal assistance and was transferred to the ACU building. Interview with the DNS on 06/28/17 at 2:30 PM identified that the ACU's restraint room was the only safe, appropriate place to restrain or seclude a patient on the campus. Interview and review of the clinical record with MD #10 on 6/29/17 at 1:30 PM identified that Patient #21 required a higher level of care than was available on the adolescent unit due to his/her dysregulated behavior that was disrupting the adolescent community as well as requiring the potential need for mechanical restraints.
The intervention of a mechanical restraint could not be accommodated on the patient's unit necessitating the use of an additional restraint (transport restraint), with the intention to transfer the patient to another building and another therapeutic milieu (ACU) for use/potential use of four point restraints.