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OPTIONS BEHAVIORAL HEALTH SYSTEM 5602 CAITO DRIVE INDIANAPOLIS, IN 46226 Aug. 11, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on document review and interview, the facility failed to ensure that an order for restraint was not written on an as needed (PRN) basis for 1 of 1 patient who had restraints documented (Pt. #1).

Findings:
1. Review of the policy "Restraint/Seclusion for Inpatient Acute Programs', policy number PC 8.04, last reviewed 1/15/15, indicated:
a. On page 5 under section "II. Restraint Procedure", it reads: "...When a patient is placed in a restraint, a clinical order must be obtained...".
b. On page 7 under section "Restraint Process", it reads: "...(1) Any restraint requires a clinical order from a licensed independent practitioner...(3)...If restraint is required beyond the expiration of the original order, a registered nurse or other licensed staff...must immediately contact the licensed practitioner to receive further instructions...".

2. Review of the medical record for patient #1 indicated:
a. A physician order was noted on 7/9/15 at 3:30 AM to "Place patient in a physical restraint for up to 1 hour as patient is a danger to self and others Patient will be released from hold when no longer a danger to self and others", due to "increased aggression towards staff and peers".
b. Nursing documented that patient #1 was verbally and physically aggressive to staff and patients and was placed in hold at about 3:25 AM on 7/9/15. Documentation continued as: "Pt was repeatedly told that once he/she calmed down and agreed to no hitting [they would] be released. Pt began cursing, stomping on this nurse and CNA's feet. Attempts to talk pt down continued until pt agreed to no hitting. Pt was released after approximately 7 minutes...".
c. Nurse N1 then wrote: "Pt was verbally aggressive and began threatening staff again. [Pt] was yelling at other patients...Pt. was placed in hold again after attempting to harm staff and verbally threatening other pts...nurse from unit 4 (N2) came to assist...pt calmed down within 5 mins and rested in a nearby chair...".

3. At 2:15 PM on 8/10/15, interview with staff member #50, the CEO (chief executive officer), indicated:
a. It was thought that a trial release could be utilized after a restraint, without the need for another restraint order.
b. Per documentation, it appears that the patient was released after a 7 minute restraint, but then began to become physically aggressive to staff and patients requiring restraint a second time for a 5 minute time frame, so that it could be considered a PRN order since a second restraint order was not obtained.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on document review and interview, the facility failed to ensure the implementation of its policy regarding staff training, for restraint/seclusion, for 1 (RN N2) of 3 RNs (registered nurses).

Findings:
1. Review of the policy "Restraint/Seclusion for Inpatient Acute Programs", policy number PC 8.04, last reviewed 1/15/15, indicated:
a. On page 3, under "Staff Training", it reads: "...all staff members who provide direct care to the patients, as well as any other staff members involved in the use of restraint will undergo Crisis Prevention Intervention (CPI) training prior to working with patients. Staff will be required to demonstrate competency in the use of CPI on a semiannual basis...".

2. Review of documentation related to a restraint episode for patient #1 at 3:30 AM on 7/9/15, indicated that RN N2 participated, or was involved, in the event.

3. Review of personnel files indicated that RN N2 last had documentation of CPI training on 6/4/14, and lacked semiannual, or annual, documentation of competency.

4. At 8:00 AM on 8/11/15, staff member #50, the CEO (chief executive officer), acknowledged that staff RN N2 lacked documentation of CPI instruction/competency since 6/4/14.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on document review and interview, the facility failed to ensure that the policy related to CPR (cardio pulmonary resuscitation) competency was implemented for 2 of 3 RNs (registered nurses). (RNs N2 and N3)

Findings:
1. Review of the policy "Restraint/Seclusion for Inpatient Acute Programs", policy number PC 8.04, last reviewed 1/15/15, indicated:
a. On page 3 under "Staff Training", it reads: "...In addition, staff will be required to demonstrate their competency in the use of cardiopulmonary resuscitation (CPR)...and First Aid training on an annual basis...".

2. Review of employee files indicated that RN N2 last had CPR competency documented for 6/6/14, and RN N3 had CPR competency last noted on 9/20/13.

3. At 3:50 PM on 8/10/15 and 8:00 AM on 8/11/15, interview with staff member #50, the CEO (chief executive officer), indicated agreement that RNs N2 and N3 were delinquent in annual CPR competency, as required per the restraint policy.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on document review and interview, the facility failed to ensure that the practitioner authenticated a restraint order within 48 hours, as per facility policy, for 1 of 1 patient who had a restraint event. (Pt. #1)

Findings:
1. Review of the policy "Restraint/Seclusion for Inpatient Acute Programs", policy number PC 8.04, last reviewed 1/15/15, indicated:
a. On page 7 under "Restraint Process", it reads: "...(2)...The licensed practitioner must sign the order in the patient's record as soon as possible, but no later than 48 hours after the order is issued...".

2. Review of the medical record for patient #1 indicated:
a. A physician telephone order was written on 7/9/15 at 3:30 AM to "Place patient in a physical restraint for up to 1 hour as patient is a danger to self and others Patient will be released from hold when no longer a danger to self and others", due to "increased aggression towards staff and peers".
b. The telephone order lacked authentication by the practitioner who gave it.

3. At 3:50 PM on 8/10/15, interview with staff member #50, the CEO (chief executive officer), indicated there was agreement that the telephone order written on 7/9/15 for a restraint/hold was not authenticated as of 8/10/15, even though policy requires an authentication within 48 hours of the issuance of the order.