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.

SAFE HAVEN HOSPITAL OF POCATELLO 1200 HOSPITAL WAY POCATELLO, ID April 11, 2013
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure the right to refuse treatment was afforded to 1 of 6 psychiatric patients (#1) whose medical records were reviewed. This prevented patients from making informed decisions about their care. Findings include:

The policy "Refusal of Medications & Treatments,' dated 1/31/04, stated if a patient refused medications or treatments, the interdisciplinary team would review and address the noncompliance in the care planning process.

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note," written by the RN and dated 3/25/13 at 9:00 PM, stated Patient #1 was angry and refused her medications. A "Nightly Nursing Note," dated 3/25/13 at 11:00 PM, stated Patient #1 "...was resting on her bed but tossing and turning. This nurse offered her HS meds medications [sic] to her one more time and she told me to [expletive deleted]. She had been offered what was explained to her before that she had Scheduled Risperdal and PRN Ativan and Risperdal. She refused and verbally threatened me. This nurse prepared IM Ativan and IM injection was given right buttock. After injection patient waited 2-3 minutes then came charging into hall and grabbed this nurse by the hair." The note then described how staff responded and released the nurse's hair from Patient #1's grasp. The next "Nightly Nursing Note," on "3/25/13 @2300 to 0100," stated "[Patient] states that she was sleeping when shot was given which is a confabulation."

Patient #1's medical record contained a "Master Treatment Plan," dated 3/25/13, for "Non-Compliance with medications." It stated Patient #1 would discuss medications with staff and the psychiatrist. The plan did not state Patient #1 would be medicated against her will.

A male LPN who assisted the RN with the injection on 3/25/13 was interviewed on 4/09/13 beginning at 3:00 PM. He stated Patient #1 appeared to be asleep when he and other staff grabbed her and held her down while the RN gave her the shot. He stated staff did not tell Patient #1 what was happening prior to restraining her.

The Charge RN who administered the injection to Patient #1 on 3/25/13 was interviewed on 4/09/13 beginning at 6:10 PM. She stated Patient #1 was quiet and laying on her abdomen. She stated Patient #1 had threatened staff 4 minutes earlier and she did not think the patient was asleep. She confirmed staff did not speak to Patient #1 prior to giving the injection.

A second RN who was being oriented by the Charge Nurse on the night of 3/25/13 was interviewed on 4/09/13 beginning at 5:40 PM. She stated Patient #1 was lying face down on her bed before receiving the injection. She stated she did not know if Patient #1 was awake or asleep. She stated several staff physically restrained Patient #1 in order to give her the injection. She stated she asked the Charge Nurse why the shot was being given if the patient was asleep and could not refuse the medication. She stated the Charge Nurse said the doctor ordered it and the patient needed it.

Patient #1 was interviewed on 4/10/13 beginning at 8:45 AM. She stated on 3/25/13 she was lying on her bed and was almost asleep when suddenly 7 male staff were holding her to give her a shot. She stated she had refused the shot earlier because the medication did not work for her.

The hospital did not afford Patient #1 the right to refuse treatment.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, and staff interview, it was determined the hospital failed to ensure treatment plans reflected the use of restraints and seclusion for 1 of 1 patient (#1) whose record was reviewed who was restrained and secluded. This resulted in a lack of direction to staff regarding ways to decrease restraint usage and ways to keep the patient safe. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/24/13 at 6:35 PM, stated Patient #1 was threatening self harm and was physically restrained by staff. The note also stated Patient #1 was given an injection for the behavior. A "Nightly Nursing Note" by the RN, dated 3/25/13 at 11:00 PM, stated Patient #1 was given an injection earlier that evening. The note stated Patient #1 then became violent and was physically restrained by staff. A "Nightly Nursing Note" by the RN, dated 3/26/13 at 6:30 PM, stated Patient #1 became self-injurious and violent. The note stated Patient #1 was given injections of medication at 7:20 PM and 8:15 PM. The note stated Patient #1 was placed in seclusion at 7:30 PM. An untitled nursing progress note, dated 3/27/13 at 3:40 PM, stated the seclusion was ended at that time.

Patient #1's medical record contained a "Master Treatment Plan," dated 3/25/13. The plan addressed 4 items. These included suicidal ideation, depression, non-compliance with medications, and discharge planning. The plan did not mention Patient #1's combativeness or restraint or seclusion.

The Clinical Manager was interviewed on 4/09/13 beginning at 9:10 AM. She reviewed Patient #1's medical record and confirmed a POC addressing seclusion and restraint had not been developed.

The hospital did not modify Patient #1's POC to address the use of restraint and seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, and staff interview, it was determined the hospital failed to ensure orders for seclusion were renewed every 4 hours for 1 of 1 adult patient (#1) whose record was reviewed and who was secluded. This resulted in the use of seclusion without continued authorization. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/26/13 at 6:30 PM, stated Patient #1 became self-injurious and violent. The note stated Patient #1 was placed in seclusion at 7:30 PM. An untitled nursing progress note, dated 3/27/13 at 3:40 PM, stated the seclusion was ended at that time, 20 hours and 10 minutes later. No break in the seclusion was documented between those times. An order dated 3/26/13 at 7:20 PM, authorized the use of seclusion. No orders for continued seclusion were documented after the initial order on 3/26/13 at 7:20 PM.

The CAO and the Clinical Manager were interviewed together on 3/09/13 beginning at 9:10 AM. They reviewed Patient #1's medical record and confirmed the lack of orders every 4 hours to continue the seclusion.

Orders were not renewed every 4 hours to continue seclusion for Patient #1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, and staff interview, it was determined the hospital failed to ensure orders for seclusion were discontinued at the earliest possible time for 1 of 1 patient (#1) whose record was reviewed and who was secluded. This resulted in the continued use of seclusion that was not necessary to keep the patient and others safe. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/26/13 at 6:30 PM, stated Patient #1 became self-injurious and violent. The note stated Patient #1 was placed in seclusion at 7:30 PM. An untitled nursing progress note, dated 3/27/13 at 3:40 PM, stated the seclusion was ended at that time, 20 hours and 10 minutes later. No break in the seclusion was documented between those times.

The "Nightly Nursing Note" by the RN, dated 3/26/13 at 6:30 PM, stated Patient #1 "...eventually fatigued and became drowsy." The note stated she fell asleep by 8:45 PM on 3/26/13. The note then stated it was ordered by the NP and the physician to continue seclusion. Subsequent "Nightly Nursing Notes" stated Patient #1 slept through the night until 5:15 AM on 3/27/13.

An untitled nursing note, dated 3/27/13 at 6:00 AM, stated Patient #1 remained in room sleeping. The note stated she was awakened at that time and refused to take Haldol, an antipsychotic medication, that had been ordered. A nursing note at 6:40 AM stated Patient #1 was given an injection at that time. Otherwise, subsequent nursing notes stated Patient #1 slept until noon on 3/27/13. At that time, she was described as awake and alert. The noon note stated she was sitting without agitation or irritability. The note stated Patient #1 agreed to comply with the medication.

On 3/27/13 at 12:45 PM, nursing notes described Patient #1 as calm and cooperative. On 3/27/13 at 1:30 PM, nursing notes described Patient #1 as resting. On 3/27/13 at 2:00 PM, nursing notes stated Patient #1 took her medication by mouth. On 3/27/13 at 2:25 PM, nursing notes stated Patient #1 was pounding on the door aggressively asking to be let out. On 3/27/13 at 3:00 PM, nursing notes stated Patient #1 was resting quietly and agreed to comply. On 3/27/13 at 3:40 PM, nursing notes stated Patient #1 was released from seclusion.

During the time Patient #1 remained in seclusion, an evaluation of the need for continued seclusion was not documented by nursing staff.

The "Psychiatric Progress Note" by the NP, dated 3/27/13 but not timed, stated "I observed [Patient #1] this morning as she continued to be in the seclusion room sleeping soundly. I called her name and she continued with sonorous respirations. As she was resting comfortably without any signs of physical distress, I chose to not awaken her this morning. She was noted to fall asleep around 21:00 last night and she remained asleep until approximately 0500. She was resistive to medications again this morning but eventually took her scheduled Ativan. She refused the Haldol and received it as an injection. She continues to be directly observed from the isolation room door at all times." The NP's plan stated "Isolation [seclusion] per protocol until she is able to maintain her composure."

The CAO and the Clinical Manager were interviewed together on 3/09/13 beginning at 9:10 AM. They reviewed Patient #1's medical record and confirmed seclusion was not discontinued at the earliest time.

The hospital did not release Patient #1 from seclusion when she no longer posed a danger to herself or to others.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, patient and staff interview, and review of medical records, and hospital policies, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in the lack of a consistent process that prompted staff to utilize restraint and seclusion in a safe and effective manner and only to protect patients and others from harm. It also resulted in a determination of immediate jeopardy for the failure of the hospital to protect patients from dangerous situations. Findings include:

1. Refer to A 131 as it relates to the hospital's failure to ensure patients were afforded the right to refuse treatment.

2. Refer to A 144 as it relates to the hospital's failure to ensure care was provided in a safe setting.

3. Refer to A 154 as it relates to the hospital's failure to ensure restraint was only imposed to ensure the immediate physical safety of the patient or others.

4. Refer to A 166 as it relates to the hospital's failure to ensure treatment plans reflected the use of restraints and seclusion.

5. Refer to A 167 as it relates to the hospital's failure to ensure safe restraining techniques were utilized.

6. Refer to A 168 as it relates to the hospital's failure to ensure restraint was used in accordance with the order of a physician or an authorized licensed independent practitioner.

7. Refer to A 169 as it relates to the hospital's failure to ensure chemical restraints were not ordered on an as needed basis.

8. Refer to A 171 as it relates to the hospital's failure to ensure orders for seclusion were renewed every 4 hours.

9. Refer to A 174 as it relates to the hospital's failure to ensure orders for seclusion were discontinued at the earliest possible time.

10. Refer to A 178 as it relates to the hospital's failure to ensure an authorized person conducted a face to face assessment within 1 hour of restraining a patient.

11. Refer to A 185 as it relates to the hospital's failure to ensure staff documented a description of interventions used to address patients' behavior.

12. Refer to A 196 as it relates to the hospital's failure to ensure diredct care staff were sufficiently trained in the application of restraints, and were able to provide care for a patient in restraint and/or seclusion.

The cumulative effect of these negative systemic practices impeded the hospital's ability to provide safe and effective interventions to control patients' violent behavior.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, observation, and staff interview, it was determined the hospital failed to ensure care was provided in a safe setting to 1 of 1 patient (#1) who was placed in seclusion and whose medical record was reviewed. The hospital failed to provide a safe environment and adequate supervision and care to protect psychiatric patients from harm. The lack of supervision and care resulted in immediate jeopardy and the potential for serious harm, impairment, or death for for all patients who could be placed in seclusion. Findings include:

1. The facility failed to ensure adequate supervision as follows:

a. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/26/13 at 6:30 PM, stated Patient #1 became angry over the lack of computer and video game privileges. The note stated Patient #1 "...proceeded to tear off the wall outlets, break them into pieces and attempt cutting her arms with the pieces and licking the scratch marks...During this time, patient is kicking, hitting and spitting on staff. [name] NP was present and had attempted during this time to talk with patient." The note stated Patient #1 was medicated with an antipsychotic and an anti-anxiety drug. The note continued: "Then, after about 15 minutes, patient broke more plastic off the wall in the room and attempted to swallow it. Staff assisted patient with removing plastic from her mouth. She continues to attempt to hit, kick, and spit on staff. [name] NP ordered at this time to place patient in safe room and she was assisted by team members to isolation room at 1930. She immediately put mattress against door window and pulled the heater vent off the wall and hit it against the wall and attempted to and possibly succeeded at swallowing two screws which held the plate onto the wall. Then patient vomited. There was no screw in the vomit. Police were called at 1937 per [name of] NP." The note stated the police left but it did not state a time. The note stated Patient #1 was given another injection at 8:15 PM. Then it stated "Afterwards patient at 2020 [sic] and started to dismantle the sprinkler system covers and broke them into pieces and attempted to cut with them. Scratches are superficial on forearms mostly left forearm. Patient continued to pull at sprinkler pipes attempting to pull them down...Pt eventually fatigued and became drowsy. She sat on mattress, then lay down putting her glasses underneath her and fell asleep by 2045."

PT C was interviewed on 4/09/13 beginning at 3:30 PM. She stated Patient #1 was violent on the evening of 3/26/13 and was taken to the seclusion room. She stated there were 3 mattresses in the seclusion room. She stated the RN locked the door and kept the key. She stated the RN stayed in the area. The door to the seclusion room had a window so patients could be observed by staff. PT C stated Patient #1 immediately took 1 of the mattresses and used it to cover the window so staff could not observe the patient. PT C stated she heard the patient tearing up the seclusion room for approximately 5 minutes. PT C stated during this time the patient moved the mattress away from the window and showed her she had 2 screws from the heater cover. PT C stated the patient tried to swallow pieces of plastic and then vomited. PT C stated she kept thinking "We need to get in there" but the nurse did not unlock the door. PT C stated, when the nurse unlocked the door to give the patient new clothes and remove the extra mattresses, staff could not find the screws the patient had exhibited and did not know where they were. PT C stated, when the door was closed and locked again, the patient pulled down the plastic cover over the sprinkler pipes and tried to cut herself with it for approximately 10 minutes without staff intervening to protect the patient. PT C stated a few days after the incident, administrative staff interviewed her about the events that occured on 3/26/13. She stated as far as she knew, procedures at the facility had not been changed relating to the supervision of patients in seclusion.

The NP was interviewed on 4/09/13 beginning at 10:25 AM. He stated he had been present when Patient #1 was placed in seclusion and supervised her care. He confirmed Patient #1 was locked in the seclusion room and allowed to remove plastic covers and hardware and allowed to try to attempt to cut herself without staff intervention. He stated through the window he observed Patient #1 try to cut herself. He stated if she had injured herself staff would have removed the potential weapons sooner.

The CAO was interviewed on 4/09/13 beginning at 9:10 AM. She stated she became aware of problems and staff dissatisfaction regarding the incident of seclusion and restraints on 3/26/13. She stated an investigation had begun into the events but it had not been completed. She stated formal changes regarding staff supervision in relation to seclusion and restraints had not been implemented.

The seclusion room was observed with the CAO on 4/08/13 beginning at 4:45 PM. The south wall contained a hole approximately 1 foot by 1 foot where a heater cover had been removed. Inside were sharp fan blades and exposed wires. The surveyor pulled at the control knob on the heater and it came off. The CAO stated the power to the heater had been turned off. Sprinkler pipes were exposed on 2 walls. Screws were missing from the brackets that held the pipes secure and the pipes wobbled when touched. The CAO stated the room had not been used for seclusion since the above incident but it had not been officially taken out of service. She stated the room had been used as a storage room, and the night of the occurance with Patient #1, staff had quickly emptied the room of all but 3 mattresses.

Surveyors requested patients not be housed in the room until it was made safe. The CAO stated the room would be made off limits to patients. The CAO stated signs would be placed and staff would be notified. This was confirmed by interview and observation the following morning.

NOTE: On Tuesday 4/09/13 at approximately 7:00 PM, the CAO was notified of the immediate jeopardy related to the facility's failure to ensure staff intervened when patients were in danger of harming themselves or others. As a result of this failed practice, the safety of all subsequent patients admitted to the facility was found to be at risk.

A plan of correction was received, reviewed, and accepted on 4/10/13 at approximately 11:00 AM. [The plan included a prohibition on the use of seclusion until 1) an appropriate seclusion room has been constructed and 2) staff had been trained to care for patients in seclusion. The plan also included revisions to the patient assessment process, development and implementation of a contraband policy, revisions to restraint policies.] The plan included education to begin on the afternoon of 4/10/13. The education was to be provided for all staff who cared directly for patients prior to them working with patients. Education included the importance of immediate intervention for patients in potentially dangerous situations, a review of acceptable restraint techniques, a high risk notification alert process and initial treatment planning, a new contraband policy, a new safety check protocol, and changes to restraint policies.

Implementation of the above plan was verified by fax and telephone on 4/11/13 at approximately 11:30 AM.





b. The facility failed to ensure psychiatric patients were in a safe environment.

A tour of the facility with the Administrator was conducted on 4/08/13 from 4:40 PM to 5:10 PM. The following patient safety hazards were noted:

Rooms 1-6 each had a bathroom door, with external hinges that could enable a patient to hang themself. The bathrooms had a fire sprinkler system that was mounted on the walls near the ceiling. The plastic sprinkler pipes were enclosed within a plastic cover which could be removed by patients. The lighting fixture over the bathroom sink was covered with a rigid plastic light diffuser, which also could be easily removed by patients. The plastic light diffuser, if broken, would produce sharp pieces that could be used as contraband for self-injury or injury to another patient or staff. When the light diffuser was lifted, there was easy access to 2 fluorescent bulbs.

Rooms 1-6 had window curtains that were connected to a metal track with metal "s" type hooks. The "s" hooks were easily slipped out from the curtain and then twisted out from the track and could be used as contraband for self-injury or injury to others. The metal track was fastened to a wooden board that was secured with screws to the wall above the windows. The board was mounted in such a fashion that it could be easily pulled from the wall.

Rooms 1-6 had storage cabinets for clothing and other patient belongings. The cabinet doors had brass colored metal tag frames in which a patient name card was placed to identify which cabinet was assigned to the patient in the room. The tag frames were approximately 1 inch by 3 inches with sharp edges. They were secured to the cabinet with short stubby nails, and a tag frame was easily removed from the cabinet door during the tour.

Room 5 had bedside table storage with a top drawer and a door. The door had a metal base plate but the pull handle was missing. The baseplate was approximately 1 inch by 4 inches, and was secured with short tacks. The plate was loose and easily pulled off the door by the surveyor.

Room 2 had a bedside table with a broken drawer pull that was hanging lopsided with one remaining loose screw. The screw was easily removed with fingers, thus removing the drawer pull from the bedside table.

The Seclusion Room had an in-wall heater on one wall close to the floor that was missing the cover plate. The heater internal components were exposed, with electric cords, fan parts, and metal pieces that could be easily broken.

The fire sprinkler system in the Seclusion Room was mounted on the top of the walls towards the ceiling. The brackets that supported the plastic pipes of the sprinkler system were secured with short screws. The pipes on one wall were fastened with a single bracket that had one remaining screw that had been pulled partially out from the wall.

The Administrator was present during the tour of the facility. She confirmed the hardware that was noted above could be easily removed and used as contraband, or could present as a potential for patient injury. In the Seclusion Room, the Administrator confirmed the heater face plate had been removed by a patient. She stated the power to the heater unit had been disconnected. The Administrator stated it was not a practice for staff to perform contraband checks.

A tour of the facility was conducted the following morning, on 4/09/13 at 9:00 AM. The Administrator and a maintenance worker were present. The Administrator stated the rooms had been secured by removing the cabinet name holders in each room and removing loose hardware from furniture. The Administrator stated room contraband checks would be initiated that day, and be performed twice daily.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, and staff interview, it was determined the hospital failed to ensure restraint was only imposed to ensure the immediate physical safety of the patient or others for 1 of 1 patient (#1) whose record was reviewed and who was physically restrained. This resulted in the unnecessary use of restraint. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/25/13 at 11:00 PM, stated Patient #1 "...moved from the TV area and went to her room. She was resting on her bed but tossing and turning. the nurse offered her HS meds medications [sic] to her one more time and she told me to '[expletive] off' and 'get the [expletive] away.' She had been offered what was explained to her before that she had Scheduled Risperdal and PRN Ativan and Risperdal. She refused and verbally threatened me. This nurse prepared IM Ativan and IM injection was given right buttock. After injection patient waited 2-3 minutes then came charging into hall and grabbed this nurse by the hair. A code was called and with staff assistance patient released my hair and then sat in hallway shouting obscenities and threats at this nurse."

The Charge RN who wrote the above nursing notes was interviewed on 4/09/13 beginning at 6:10 PM. She stated the physician had ordered Patient #1's medications by mouth or by injection. She stated Patient #1 refused her medications by mouth so the nurse had to give them by injection. She stated when she went to give Patient #1 the injection the patient was awake lying on her bed. She stated staff did not speak to Patient #1 prior to holding her down and administering the injection. She stated following the injection, Patient #1 attacked her.

A second RN who was being oriented by the Charge Nurse on the night of 3/25/13 was interviewed on 4/09/13 beginning at 5:40 PM. She stated Patient #1 was lying face down on her bed before receiving the injection. She stated she did not know if Patient #1 was awake or asleep. She stated several staff physically restrained Patient #1 in order to give her the injection. She stated she asked the Charge Nurse why the shot was being given if the patient was asleep and could not refuse the medication. She stated the Charge Nurse said the doctor ordered it and the patient needed it.

A male LPN who assisted the RN with the injection on 3/25/13 was interviewed on 4/09/13 beginning at 3:00 PM. He stated Patient #1 appeared to be asleep when he and other staff grabbed her and held her down while the RN gave her the shot. He stated staff did not tell Patient #1 what was happening prior to restraining her.

The hospital did not restrain Patient #1 to protect her or others from harm. The patient did not present a threat when staff restrained her. Instead, the restraint increased the risk of harm to Patient #1 and others because it provoked her to attack the Charge RN.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient and staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure safe restraining techniques were utilized for 1 of 1 psychiatric patient (Patient #1) who was physically restrained and whose medical record was reviewed. The use of unsafe restraining techniques increased the chance of injury to patients that required restraint. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note," written by the RN and dated 3/25/13 at 9:00 PM, stated Patient #1 was angry and refused her medications. A "Nightly Nursing Note," dated 3/25/13 at 11:00 PM, stated Patient #1 "...was resting on her bed but tossing and turning. This nurse offered her HS meds medications [sic] to her one more time and she told me to [expletive deleted]. She had been offered what was explained to her before that she had Scheduled Risperdal and PRN Ativan and Risperdal. She refused and verbally threatened me. This nurse prepared IM Ativan and IM injection was given right buttock. After injection patient waited 2-3 minutes then came charging into hall and grabbed this nurse by the hair. A code was called and with staff assistance patient released my hair and then sat in hallway shouting obscenities and threats at this nurse."

A male LPN who assisted with restraining Patient #1 on 3/25/13 was interviewed on 4/09/13 beginning at 3:00 PM. He stated he responded to a call for help on the evening of 3/25/13 and assisted staff to free an RN from an attack by Patient #1. He stated one of the staff who responded used a "gooseneck hold" to restrain the patient. A gooseneck hold is utilized by police and some martial arts participants. It involves grabbing a person's hand and twisting or bending it in a non-natural position to immobilize the person.

Patient #1 was interviewed on 4/10/13 beginning at 8:45 AM. She stated on 3/25/13 staff restrained her using a hold like a cop behind her back. She stated it did not really hurt but she said it prevented her from moving.

The hospital utilized a behavior management system called the Mandt System. The Mandt module used to train staff was titled "Restraining Skills-Standing." The module did not describe a gooseneck or similar hold to restrain patients.

The Director of Human Resources was also the Mandt Trainer for the hospital. He was interviewed on 4/09/13 beginning at 8:30 AM. He stated the hospital did not utilize gooseneck or similar holds and staff were not taught such holds.

Hospital personnel utilized an unsafe restraint on Patient #1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, and staff interview, it was determined the hospital failed to ensure restraint was used in accordance with the order of a physician or an authorized licensed independent practitioner for 1 of 1 patient (#1) whose record was reviewed and who was restrained. This resulted in the use of restraints without orders. Findings include:

1. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/24/13 at 6:35 PM, stated Patient #1 was threatening self harm and was physically restrained by staff. The note also stated Patient #1 was given an injection for the behavior. Another "Nightly Nursing Note" by the RN, dated 3/25/13 at 11:00 PM, stated Patient #1 was given an injection earlier that evening. The note stated Patient #1 then became violent and was physically restrained by staff. No orders were present for these episodes of restraint.

The NP who cared for Patient #1 was interviewed on 4/09/13 beginning at 10:25 AM. He reviewed the record and confirmed orders were not present for the restraint incidents noted above.

Orders were not obtained authorizing the use of restraint on 3/24/13 and 3/25/13.

2. A "Nightly Nursing Note" by the RN, dated 3/26/13 at 6:30 PM, stated Patient #1 became self-injurious and violent. The note stated Patient #1 was given injections of medication at 7:20 PM and 8:15 PM.

The NP who cared for Patient #1 was interviewed on 4/09/13 beginning at 10:25 AM. He reviewed the record. He stated physical restraints were used to administer both injections. He confirmed orders were not present for the use of physical restraint on 3/26/13.

Orders were not obtained authorizing the use of restraint on 3/26/13.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital failed to ensure chemical restraints were not ordered on an as needed basis for 1 of 9 patients (#1) who whose medical records were reviewed. This resulted in the potential for patients to be unnecessarily restrained. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder. A diagnosis of psychosis was not listed.

An order, dated 3/26/13 at 7:05 PM, called for Patient #1 to be given the antipsychotic medication Haldol 10 mg and the anti-anxiety medication Ativan 2 mg by mouth or by injection every 8 hours routinely and 2 times a day as needed "...for Violent/Aggressive behavior." According to Medline Plus, a National Institute of Health website, accessed on 4/11/13, Haldol is used to treat psychotic disorders. No documentation of hallucinations, delusions, or psychotic behavior was present in Patient #1's medical record. The medication was ordered to control behavior which constituted a chemical restraint. The order for as needed Haldol remained in effect until Patient #1 was discharged on [DATE].

The CAO and the Clinical Manager were interviewed on 4/09/13 beginning at 9:10 AM. The reviewed Patient #1's medical record and confirmed the prn restraint order.

An as needed chemical restraint was ordered for Patient #1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure an authorized person conducted a face to face assessment within 1 hour of restraining 1 of 1 patient (#1) whose record was reviewed who was restrained and secluded. This resulted in a lack of evaluation of the restrained patient in order to determine the reasons for the behavior and to prevent further episodes of restraint. Findings include:

1. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/24/13 at 6:35 PM, stated Patient #1 was threatening self harm and was physically restrained by staff. The note also stated Patient #1 was given an injection for the behavior. A "Nightly Nursing Note" by the RN, dated 3/25/13 at 11:00 PM, stated Patient #1 was given an injection earlier that evening. The note stated Patient #1 then became violent and was physically restrained by staff. No documentation was present that a face to face assessment by an authorized person was conducted following either of the incidents of restraint.

The Clinical Manager was interviewed on 4/09/13 beginning at 9:10 AM. She reviewed Patient #1's medical record and confirmed a face to face assessment had not been conducted for the above episodes of restraint usage.

The hospital did not conduct face to face assessments following the use of restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, and staff interview, it was determined the hospital failed to ensure staff documented a description of interventions used to address the behavior of 1 of 1 patient (#1) whose record was reviewed and who was physically restrained. This resulted in a lack of transparency regarding the treatment of patients. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note" by the RN, dated 3/24/13 at 6:35 PM, stated Patient #1 threatened to cut herself with pieces of metal. The note stated Patient #1 refused to give up the metal. The note stated the RN got an order for IM medication and this was given to Patient #1. The note stated Patient #1 then went to her room. The note stated Patient #1 became violent in her room and tried to strike staff and herself with a curtain rod. The note stated the RN tried to intervene and Patient #1 grabbed her, kicked her, and pulled her hair. The note stated staff responded and Patient #1 released her grip on her weapons and the RN.

A "Nightly Nursing Note" by the RN, dated 3/25/13 at 11:00 PM, stated Patient #1 refused her ordered medication and swore at the RN. The note stated "this nurse prepared IM Ativan and IM injection was given right buttock. After injection patient waited 2-3 minutes then came charging into hall and grabbed this nurse by the hair. A code was called and with staff assistance patient released my hair and then sat in hallway shouting obscenities and threats at this nurse."

Neither nursing note mentioned Patient #1 was physically restrained.

The Charge RN who wrote the above nursing notes was interviewed on 4/09/13 beginning at 6:10 PM. She stated Patient #1 required physical restraint for the injections that were noted above and for the subsequent assaults on staff. She confirmed the use of restraints was not documented.

The hospital did not ensure the use of restraint for Patient #1 was documented.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, staff interview and review of personnel training records, it was determined the hospital failed to ensure staff was sufficiently trained in the application of restraints, for 3 of 14 staff (Staff A, B, and C) whose training records were reviewed. This had resulted in patients being subjected to unauthorized restraint techniques. Findings include:

A policy, titled "Mandt training," dated 8/21/09 and reviewed 9/2012, stated "All employees having any direct contact with patients are required to complete Mandt training ...within 60 days of hire. Only practices used by staff within the Mandt guidelines are sanctioned by this facility. Any employee acting outside of Mandt guidelines is acting as an independent agent and thereby assumes all liability for such actions." In addition, the policy stated "Code green responders in the hospital MUST have both Day 1 & Day 2 of Mandt training." The policy concluded with "The DNS shall have in a file a list of all employees and the demonstrable training for Mandt."

However, Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included major depressive disorder and borderline personality disorder.

A "Nightly Nursing Note," written by the RN and dated 3/25/13 at 9:00 PM, stated Patient #1 was angry and refused her medications. A "Nightly Nursing Note," dated 3/25/13 at 11:00 PM, stated Patient #1 "...was resting on her bed but tossing and turning. This nurse offered her HS meds medications [sic] to her one more time and she told me to [expletive deleted]. She had been offered what was explained to her before that she had Scheduled Risperdal and PRN Ativan and Risperdal. She refused and verbally threatened me. This nurse prepared IM Ativan and IM injection was given right buttock. After injection patient waited 2-3 minutes then came charging into hall and grabbed this nurse by the hair. A code was called and with staff assistance patient released my hair and then sat in hallway shouting obscenities and threats at this nurse."

A male LPN who assisted with restraining Patient #1 on 3/25/13 was interviewed on 4/09/13 beginning at 3:00 PM. He stated he responded to a call for help on the evening of 3/25/13 and assisted staff to free an RN from an attack by Patient #1. He stated one of the staff who responded used a "gooseneck hold" to restrain the patient. A gooseneck hold is utilized by police and some martial arts participants. It involves grabbing a person's hand and twisting or bending it in a non-natural position to immobilize the person.

Patient #1 was interviewed on 4/10/13 beginning at 8:45 AM. She stated on 3/25/13 staff restrained her using a hold like a cop behind her back. She stated it did not really hurt but she said it prevented her from moving.

The hospital utilized a behavior management system called the Mandt System. The Mandt module used to train staff was titled "Restraining Skills-Standing." The module did not describe a gooseneck or similar hold to restrain patients.

During an interview on 4/08/13 beginning at 1:00 PM, the Director of Human Resources, was also the Mandt Trainer for the hospital, stated the hospital staff was trained in the "Mandt System" of restrictive physical interaction. He stated the staff was not allowed to assist with restraint of a patient unless they had training. He stated training was offered once monthly, and was renewed annually. During a subsequent interview, on 4/09/13 beginning at 8:30 AM, the Director of Human Resources stated the hospital did not utilize gooseneck or similar holds and staff were not taught such holds.

When asked, during an interview on 4/09/13 beginning at 4:15 PM, the DNS stated she was unable to produce a list of staff that had current Mandt training. She stated she had been in her role as DNS for a short time and another individual who no longer worked there had maintained records of Mandt training.

A sample of hospital direct patient care staff was selected for review of Mandt training. The following staff members were found not to be current with Mandt training:

Staff A was a RN, date of hire 1/19/12. Training 1/26/12, overdue, yet currently scheduled for patient care duties.

Staff B was a RN, date of hire 2/08/13. No evidence of Mandt training.

Staff C was a CNA/Psych Tech II, date of hire 11/16/10. Training 2/29/12, overdue, yet currently scheduled for patient care duties.

During an interview on 4/09/13 at 10:30 AM, the Administrator stated "If the staff has not taken the required Mandt training, then they would be off the schedule until training was completed."

The facility did not maintain current Mandt training for direct patient care staff.