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.

ADVENTIST HEALTHCARE BEHAVIORAL HEALTH & WELLNESS 14901 BROSCHART ROAD ROCKVILLE, MD Nov. 1, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the review of records and other pertinent documentation , it was determined that the hospital failed to protect patient rights as required by the Condition of Participation Patient Rights as evidence by the deficiencies cited at:

1. A 131 due to the failure to obtain consent for IM medications;
2. A154 due to the inappropriate manner that restraint and seclusion was used;
3. A 162 due to the inappropriate use of seclusion;
4. A 167 due to the use of inappropriate physical holds ;
5 A168 due to the failure to have appropriately executed orders for restraint and seclusion; and
6. A 175 due to the failure monitoring patients in seclusion and restraint consistently.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of 4 open and 6 closed adolescent patient records, and facility policy, it is revealed that orders for by-mouth medications for agitation include physician permission to administer the medication IM if the patient refuses by-mouth, and patient #1 was given IM medications for which there was no consent.

Patient #1 is a [AGE]-year-old female admitted voluntarily on 9/22/2012 at 1:15 pm to an acute adolescent unit after becoming aggressive at home with family, destroying property, and verbalizing suicidal ideation. Patient #1's diagnoses included Bipolar disorder. Patient #1 has a history of sexual abuse, and Post Traumatic Stress Disorder (PTSD).

On 9/24 at 2030, a telephone medication order with a rationale of "agitation" appears in the record for "Zyprexa 10 mg po x 1, Benadryl 50 mg po x 1, Ativan 2 mg po x 1, If pt refuses po may give IM (intramuscular)." An indication of "agitation" was documented. Agitation ,of itself, does not warrant the risk to benefit of giving intramuscular medication, and does not meet the standard of care with associated risks of infection and air embolus.

Review of patient #1's record for 9/24 reveals an untimed nursing note for 3 pm to 11:30 pm shift which states "She was loud and angry when staff redirected her for allowing a peer to braid her hair. Later settled. Interacted well with peers, took her meds and responded finally to unit rules." No behaviors are noted that would rise to the level of requiring emergency IM medication, and patient #1 did not received IM medication at that time.

New orders for by-mouth medications with a rationale of "agitation" could be appropriate. However, it is not appropriate in the absence of a clear emergency to give IM medication to a patient who has refused by-mouth medications.

The facility failed to obtain consent for medications in the absence of an emergency, and failed to honor patient #1's right to refuse medication in the absence of an emergency.

Review of policy MM-210 "Informed Consent for Use of Medications" reveals in part, " ...No medication is to be given without informed consent by the parent/guardian." The policy also states "The only exception to this would be an emergency situation where a delay in the initiation of treatment or a medication would place the patient at risk for immediate and life threatening consequences."

On 9/25/12, patient #1 was restrained for 15 minutes. Following the restraint, she went to a bathroom with her therapist where she removed her piercings as requested by staff. Patient #1 demonstrated she was in control of her behavior and was not at risk for immediate and life threatening consequences. However, RN #1 insisted on administering IM medication of Zyprexa, 5 mg, Benadryl 50 mg, and Ativan 1 mg IM at 1615. Review of patient #1's record reveals two "Consent for use of Medication with Minors" forms. No consent for Zyprexa or Ativan was found.

The hospital failed to obtain consent for medications administered in the absence of immediate and life-threatening conditions.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on an onsite investigation consisting of review 4 open and 6 closed adolescent patient records, policies, quality data, patient rights information, and interviews, it is determined that for 3 of 10 reviewed patients #1, #3 and #4, staff variously used physical and chemical restraint, and seclusion in a manner that was coercive, of convenience, and disciplinary.

Patient #1 is a [AGE]-year-old female admitted voluntarily on 9/22/2012 at 1:15 pm to an acute adolescent unit after becoming aggressive at home with family, destroying property, and verbalizing suicidal ideation. Patient #1's diagnoses included Bipolar disorder. Patient #1 has a history of sexual abuse, and Post Traumatic Stress Disorder (PTSD).

The hospital policy, "Contraband Definitions and Security (PCC-109)" lists one contraband item on acute units as "jewelry." The hospital has an "Acute Adolescent Services Family & Patient Handbook" that delineates the items that patients may have on the unit. Listed under "Not Allowed" are " ...piercings/gauges, jewelry."

The hospital "Comprehensive Assessment Tool Nursing Assessment" under "Jewelry/Essentials Kept by Patient" reveals entries of, "eye ring, right lip ring, 1 nose ring. Patient is wearing it doesn't want to take it out. Hole will close she stated. "

A nursing note of 9/22 at 10:45 pm states in part, " Pt was angry for trying to remove her jewelry on lip and ear because she saw another peer wearing hers. Pt. has her lip jewelry and ear because she was crying that the hole will close."
Interviews with staff reveal that at the time patient #1 was admitted , there were other peers on the unit who staff had been allowed to retain jewelry piercings, namely patient #6. However, three days following patient #1's admission, staff on the unit decided to enforce the contraband policy, requesting that all patients with jewelry piercings turn them in. Additionally, staff state that patient #1 was roomed with another peer who had a tendency to harm herself with such things as sharps, of which jewelry could be used.

Staff interview with RN #1 revealed that patient #1's peers did turn in piercings, but that patient #1 retained her piercings, which created a problem with peers who had complied. RN #1 states that multiple attempts during patient #1's admission were made to obtain the piercings. However, no other documentation other than on admission and just prior to patient #1's subsequent restraint indicated other staff attempts to obtain patient #1's piercings. Additionally, no documentation of efforts to consult team members is found. Interview with the Nursing Supervisor revealed he was not consulted prior to the restraint event. Interview with the therapist revealed that she advised RN #1 against the RN's intended use of restraint of patient #1.

On 9/25, documentation reveals that while at school, patient #1, " ...was actively engaged in all group activities. Pt. (patient worked well with peers), and related to groups, Pt active in discussion about overcoming challenges and keeping hope and faith. Pt stated she went through something between 4-6 years old and is told she has PTSD as result. Pt stated she doesn't let that bother her and has matured to the point she is looking to make changes in life."

A psychiatry note of 1350 stated "Pt remains irritable, oppositional to staff members, refuses to follow up with directions given by staff members. Exhibits mood swings, occasional episodes of aggression ... "

A "24-Hour Safety Check of Patient and Environment" (SCPE) form which every 15-minutes, documents patient locations and behaviors, reveals that on 9/25 from 8 am through 3:45 pm, patient #1 was "1=calm."

On 9/25/12 at 3 pm, no physician was on the unit, but were available by phone. Interview with RN #1 who on 9/25 was the Charge RN, revealed that at approximately 3-3:30 pm, he and the male senior care assistant went to patient #1's bedroom to request patient #1 give up her piercings. Patient #1 refused. RN #1 then asked patient #1's therapist to ask her for the piercings which the therapist did. Patient #1 refused again.

Interview with RN #1 revealed that the requests to patient #1 were made at change of shift; a time when multiple staff are available. When patient #1 refused for the second time, the RN #1 stated that with the second refusal, staff "Would have to call a code and get the piercings out." As described by an administrator, a code is the method by which the facility "accesses support staff." However, review of the "CODE GREEN KEY ROLES" protocol, revealed 12 pages of detailed instruction on how to perform an "escort restraint" or perform holds when a patient is taken to the ground in restraint, and perform IM medication administration to a restrained patient. A code green was called and 14 support staff consisting of at least 8 male staff, 4 female staff and two security personnel responded to the unit. According to interview, the 8 males confronted patient #1 in the dayroom where RN #1 states "She (patient #1) was sitting in a chair."

RN #1 revealed that patient #1 was asked several times again to give up the piercings, and when she refused, the male staff advanced on patient #1. He described himself as taking one arm, another staff taking the other arm, then two staff each taking a leg and moving patient #1 from the chair to the floor where she was held in a supine position with the intention of a female staff removing the piercings. However, patient #1 was described as "screaming" and "struggling" so much that removal of the piercings was not possible. Patient #1 was held to the floor for 15 minutes until she stopped struggling and agreed to remove the piercings.

Interview with patient #1's therapist, who was present and remained at patient #1's head attempting to calm her, describes her observations of patient #1 being "Backed into a corner" and during restraint as "flailing" and screaming "I've been raped" and "You are hurting me." The therapist remembers no self or other-harming threats made by patient #1, and felt the intervention "was unnecessary" and "traumatizing" to patient #1.

The "Assessment Within One Hour" done by RN #1, and also known as a "Face to face" revealed that RN #1 documented the indication for physical restraint as "Homicidal Behavior or threats with Plan " with the documented detail of "Pt refused to hand staff piercings, refused to remove them, became combative with staff, threatening, restrained." No documentation supports that patient #1 was "homicidal" or had any plan to harm others. No evidence of imminent danger to self or other was demonstrated by patient #1 prior to this restraint event.

RN #1 writes in one area of the Seclusion and Restraint Record (SRR), "Pt was told that she needed to have piercings removed. Pt refused, became combative, restrained in dayroom, pt screaming, threatening." Further SRR documentation revealed "Pt restrained in dayroom due to combative behavior." RN #1's documentation is not descriptive of actual events where staff unnecessarily restrained patient #1 to obtain her piercings, and who though oppositional, was not a danger to herself or others.

Patient #1 was restrained by male staff from 1610 to 1625. RN #1's note addressing the restraint of 9/25, which was not written until 2000 reveals in part, "Pt refused to follow staff directions when asked to remove piercings. Pt disrespectful, and argumentative, defiant. Restraint initiated in day room due to combative behavior. Pt screaming, sobbing, combative. Pt came to NS (nursing station), used bathroom to remove piercings and gave them to staff, cleaned area with alcohol wipe provided by staff." Again, RN #1's documentation fails to accurately describe the events of the restraint.

The facility "Seclusion and Restraint Summary" which gives patients/families information on restraint and seclusion, states in part under "Clinical Justification of Intervention: A comprehensive assessment of the patient by a physician or registered nurse must determine that the risks associated with the use of the restraint or seclusion is outweighed by the risk of not using it." Patient #1 was known to be high risk of being re-traumatized due to a diagnosed PTSD secondary to a history of sexual abuse, yet other interventions were not considered. For example, if after three days of allowing patient #1 to wear her piercings, she was considered a safety risk on the unit, 1:1 staff could have been assigned, she could have had more frequent monitoring, or a loss of privilege due to noncompliance. According to the record, no other interventions were considered or tried.

Interview with the therapist revealed her belief that patient #1 was re-traumatized by the restraint. She states that she accompanied patient #1 to the bathroom, where patient #1 was compliant with taking out and giving her piercings to the therapist. The therapist continued, that while patient #1 was upset following the restraint, she was in control of her behavior.

The RN #1 note of 9/25 at 2000 continues "Pt asked to walk to open quiet room for safety purposes." Pt explained that she (patient) had medication ordered for agitation by physician. Pt refused to follow directions arguing with staff, cursed at staff when pt was told that a restraint would be initiated if she did not follow directions ... " In violation of patient #1's rights, RN #1 mandated patient #1 to go to the quiet room (a voluntary process), and then violated patient #1's rights again when he used the threat of another restraint event to coerce patient #1 into the quiet room. RN #1 clearly had no understanding to the trauma that already had been caused to patient #1, and no understanding of how these multiple events violated patient #1's rights.

RN #1's note continues " ...pt walked to open QR (quiet room) where staff attempted to calm patient, explain reasoning for medication. Patient crying but able to allow staff to give IM medication. Pt had refused po medication when asked, multiple times. Patient given Zyprexa, 5 mg, Benadryl 50 mg, Ativan 1 mg IM at 1615 .... "

Review of the record revealed no by-mouth now order, but only a new order for IM medication written at 1615 of "Zyprexa 5 mg IM x 1, Benadryl 50 mg IM x 1, and Ativan 1 mg IM x 1" with a rationale of "agitation" The RN #1 note continues ... " Pt denies pain, discomfort, no signs of distress. Staff processed situation with pt, then allowed her to rejoin peers in milieu. Will continue to monitor."

Documentation revealed that the IMs could not have been given at 1615 as patient #1 was in restraint from 1610 to 1625, and 15-minute monitoring of the SCPE reveals patient #1 was in the quiet room by 6:30 pm. The 15-minute difference is significant in that patient #1, was in control of her behavior, and had demonstrated control sufficient to accompany the therapist to the bathroom and remove her piercings. She had also refused by-mouth medication as was her right to do when not an imminent danger to herself or other.

Interview with patient #1's therapist who was with patient #1 throughout the restraint and afterwards, revealed that while in the quiet room, the therapist asked RN #1 to wait and see if patient #1 would take meds by mouth. The therapist relates that RN #1 stated patient #1 had already refused by-mouth medication, and would receive IM medication. Therefore, RN #1 again violated patient #1's rights, by ignoring patient #1's refusal, and administering IM emergency medication where no emergency condition existed.

Per the Seclusion and Restraint Record, criteria for release from seclusion and/or restraint reveals pre-printed check-box choices as follows:

"a. Verbalizes willingness to maintain safetyb. Demonstrates ability to maintain safety, e.g. willingness to stay in open seclusion room for 15 minutes, or other (explain):
c. Positive response to medications resulting in patient ' s ability to participate in treatment and unit activities
- Anticipated release Time:_______ or
-Reassessment at ______________: RN assessment with call to M.D."
(time)
Both " a, and c. " were used as criteria for patient #1.
Regarding "a" while it is desirable that a patient verbalize willingness to maintain safety, the ability to verbalize this is not a criterion for release from restraint or seclusion.
Regarding "b" while patient willingness to further demonstrate safe behaviors is the goal, and a patient may be asked to remain in the quiet room for an agreed time, it is not a criterion for release from restraint/seclusion that a patient remain in the "open seclusion room" for 15 minutes.
Regarding "c" while a patient might require emergency medications, the response from those medications cannot be predicted to result in the patient ability to participate in treatment and unit activities, and is not a criterion for release from seclusion and restraint.

All of these criterions are in violation of a patient's right to be free of restraint and seclusion, where the only criterion for release is the cessation of the dangerous behaviors which prompted the seclusion/restraint.

Nowhere does the record reveal that patient #1 received any "criteria" from staff other than giving up her piercings, and the mandate that she go to the quiet room.

In summary, the facility failed to meet patient #1's rights to be free of restraint by:
1) Allowed patient #1, who has a known diagnosis of PTSD, to retain piercings at admission. Then 8 male staff restrained patient #1 who was not presenting an immediate danger to herself or other three days later by when she refused to give up those same piercings.

2) Coerced patient #1 to go to the quiet room by threats of an additional restraint, solely for the purpose of administering emergency IM medication where no emergency existed, and after patient #1's expressed refusal to take medication, as was her right to do so.


Patient #3 is a [AGE]-year-old Trinidad-American female who was recently discharged from the facility, but then ran away from home. She was found approximately one week later and readmitted on a voluntary basis on 8/30/2012. Patient #3 is aggressive at times, and has a history of suicidal ideation with attempt. Patient #3 was given a diagnosis of Mood disorder, not otherwise specified.


On 8/31/12 at 6 pm, patient #3 was noted to be in a physical altercation with a peer in the dayroom. Staff responded and called a psychiatric code. Witnesses stated that patient #3 had attacked her peer, unprovoked. RN documentation on the Care and Observation Code sheet reveals that from 6 pm through 6:15 pm, patient #3 was in a manual restraint. No order is found for the restraint.


RN documentation states in part, "and the patient was escorted inside the QR (quiet room). Patient was nonverbal, agitated. She was given Benadryl IM 50 mg. She did not resisted (sic). MD put her on 1:1 for safety. At 1930 she went out of the QR and started pacing, combative towards her 1:1. She was then placed in lock seclusion at 1945-2015. " No other documentation reflects combativeness with her 1:1, and all seclusion documentation reflects only the physical altercation with her peer which occurred one hour earlier.


Following her seclusion release of was a series of staff-documented quiet rooms, seclusion, and zoning, all which in practice, were seclusion events.


Every 15-Minute documentation at 8:30, and 8:45 pm reveal patient #3 as "1=calm." Again, at 9:30 pm and 9:45 pm, patient #3 is "1=calm." However, no RN attempted to move patient #3 to her bedroom. Additionally, while 15-minute location documentation is QR (quiet room) following release from seclusion at 8:15 pm, documentation revealed a staff entry of "S=seclusion" at 8:45 pm, a time when patient #3 was stated to be in quiet room, and was awake and calm.


Criterion for release from "locked seclusion" is documented as "Demonstrates ability to maintain safety, e.g. willingness to stay in open seclusion room for 15-minutes, or other (explain):" Following this criteria, the RN wrote "Pt sleeping in quiet room." Actual Federal and State regulatory criterion requires only that the patient cease the dangerous behaviors which prompted the seclusion/restraint intervention. Patient #3 had ceased her dangerous behaviors.


Patient care documentation at 11:50 pm revealed "Pt. very upset and was zoned to the quiet room." No definition of the term "zoned" is found or described in quiet room/time out policy.


While patient #3 had every 15-minute checks a 1:1, and per nursing documentation came out of seclusion at 8:15 pm she remained in the quiet room area through 9/1 at 9 am without appropriate documentation. Per COMAR Use of Quiet Room 10.21.12.11 F. and G. sections respectively, patient #3 should have had 2-hour nursing assessments. Additionally, no physician note appears in the record following 6-hours of continuous quiet room per the regulation.


On 9/1, patient #3 left the quiet room area to use the bathroom at 9:15 am. The 24 hour safety check form reveals that patient #3 was 1=calm at that time and calm until 9:45 am when she is documented as "4=crying," and then calm again for entries following. Per RN documentation on the Care and Observation form, patient #3 is noted as "Combative at 9:45 am" and "medication given." Patient #3 was again placed in seclusion.


Seclusion documentation beginning at on 9/1 at 9:40 am states in part, "Pt in QR to receive IM Benadryl 50 mg continued to be combative. Door closed and pt continued to beat on door and push against it. Was pacing and angry until she laid down on her mat @ 10:10." Based on documentation, patient #3 was in the quiet room to receive medication, and did receive IM Benadryl, though no emergency behaviors are documented prior to staff approach with the IM warranting a seclusion intervention.


A nursing progress note of 9/1, not written until 1400 states in part, "Pt. was sleepy in a.m., awake @ approx 0930 and pt. became defiant, attempting to push through staff to join group. Pt. did not appear stable @ the time, face eyes blank .... " Dr. __ called and pt received 50 mg Benadryl IM @ 9:40 a (sic_) while sitting in the QR. Pt. became combative __, kicking and flailing @ 1:1. Door was closed and locked and Dr. ___ was called for the order. Pt. remained angry, hitting @ door and yelling. Pt became drowsy and returned to bed and locked seclusion was ended @ 10:10 am." According to staff documentation, patient #3 attempted to leave the QR but could not do so because staff blocked her progress. Staff documented no dangerous behaviors which justified blocking patient #3 from exiting the quiet room.


A social worker note of 9/1 at 10 am documents a meeting with the parents of patient #3 and the RN taking care of patient #3. The note states in part, " (RN) joined meeting + reported on status of meds w/pt. (RN) reported that Pt had not taken prescribed meds due to refusal and was given 50 mg Benadryl IM at 9:45. (RN) reported Pt was pacing, not speaking & moving to restricted part of unit and staff had to intervene this morning. "

The Hospital Policy and Procedure for patient rights states in part, " Each patient and resident will: 1) have the right to refuse medication, except when medication is provided on the order of a physician in an emergency where the individual presents a danger to the life or safety of themselves or others .... " Facility documentation reveals no danger to the life or safety of patient #3 or others just prior to the administration of IM Benadryl; only that she had refused her medications, and attempted to leave the quiet room. Staff ' s assumption that patient #3 was " unstable " is nonspecific and does not describe a dangerous behavior. Likewise, " face eyes blank " does not describe a dangerous behavior. Further, while one account states patient #3 attempted to join the group, the other states she was moving to a restricted part of the unit. It is unclear how either represented a danger to patient #3 or other.


The rights of patients protect that a patient may pace; may choose to not speak, and may refuse medication in the absence of an emergency. Patient #3 demonstrated no dangerous behavior was warranting IM medication following her refusal of medication. Further, patient #3's combativeness as documented appears to have been precipitated by staff ' s approach with IM medication, precipitating defensive " kicking, flailing " for which she was subsequently secluded.


The Seclusion and Restraint Record section in which the RN is to " Describe specific behaviors that led to the seclusion or restraint and how the behavior posed a serious or imminent danger to physical safety of self or others " is left completely blank.


While documentation states that patient #3 " Did have a short period this aft. when she was quietly standing outside of QR and 1:1 staff was helping her adjust her hair, " ...and " went to Dayroom to eat ... " . However, an untimed nursing note between " 1500 and 2300 " reveals, " She tried to push past nurse to go to day room. Staff explained __ plan again and directed her to open QR where she went voluntarily and ___ & returned to sleep. "


Staff again blocked patient #3 from exiting the quiet room, yet also state patient #3 voluntarily went back to the quiet room after discussion of " her __ plan. " The plan as documented by the RN in a progress note was to have patient #3's father come to give medication since patient #3 was amenable to taking meds from him. Additionally, since patient #3 was not eating, her mother would bring in foods from home. Staff was attempting to acclimate patient #3 to the milieu. However, the plan to acclimate patient #3 to the milieu did not accommodate that it was against patient #3 ' s rights to be kept in the quiet room. Patient #3 was not allowed to move about the milieu with the 1:1, or even go to her own room. Excepting a short period when she received medication from her father, and ate a meal in the family therapy room, patient #3 was isolated to the quiet room, which was tantamount to seclusion.


Documentation on the 24-Hour Safety Check of Patient and Environment sheet reveals that following the termination of seclusion on 9/1 at 10:10 am, patient #3 largely remained in the quiet room with a 1:1 through 8 am of 9/2. Throughout that time she was described as " calm," and at times, "sleeping." If the intervention was a quiet room, it was prolonged without regulatory documentation of the voluntary nature of the quiet room, a discussion of the length of time to stay in quiet room, or the behaviors expected on return to the milieu. Additionally, no two-hour RN quiet room assessments are found. If it was "open seclusion," no justification is found, no orders appear every two hours commensurate with patient #3's age, and no care documentation is found. Consequently, and in practice, staff secluded patient #3 with no regard as to regulatory compliance.


Patient #3 spent an approximate total of 38 hours in seclusion. Of that period, consisting of sleep, with the balance of time, approximately 16 hours, of waking, calm behavior. Staff had approximately 16 hours to mobilize other interventions than the isolation that staff called quiet room, but was in reality, seclusion.


In summary, patient #3:

1) On at least two occasions, was prevented from exiting the "quiet room," which effectively made quiet room a seclusion. Following the first appropriate seclusion, patient #3 was essentially kept seclusion without benefit or documentation of justification, physician orders, continuing RN 2-hour assessments, and monitoring for needs.


2) Patient #3 refused medication as was her right, yet received IM medication without a clear behavioral reason to do so. Further, where interventions such as seclusion are based on patient behaviors, no demonstrated calm behavior on the part of patient #3 terminated seclusion because seclusion was used at staff discretion, and therefore at staff convenience.


The facility failed to honor the rights of patient #3 to remain free of seclusion.


Patient #4 is a [AGE]-year-old male, transferred to the psychiatric facility on 9/7/2012 from an acute hospital following homicidal threats towards others. Patient #4 has a diagnosis of Mood Disorder.

On 9/11 at 11:15 am, patient #4 is documented on the "24 Hour Safety Check of Patient and Environment" as being in the hallway with behaviors of " restless/pacing, irritable, and physically aggressive. Patient #4 was apparently deescalated and continued through the day without needing intervention of restraint or seclusion. However, he had incurred a unit penalty of an Early Bed Time (EBT). By 11:30 am, patient #4 was listed as "Calm" and largely remained so through 7:30 pm.

Patient #4, who had been documented on the SCPE as being in the dayhall and "calm" since 5 pm, and who had "participated well in school" that day, was determined by the 15-minute patient safety checks to be "irritable" at 7:45 pm and for the following 45 minutes through 8:15 pm. During that time, staff and RN #1 approached patient #4 and attempted to enforce the EBT.

Patient #4 was physically restrained from 8 pm until 8:15pm. Justification by RN #1 states "Pt unable to follow staff directions, cursing disrespectful. Had EBT from previous behavior which he refused to follow. States, " I know how it works here. I do what I want. Combative, attempting to lunge at staff. " An order of 9/11 at 2000 is found in the record for "Benadryl 50 mg po x 1, and Zyprexa 10 mg po x 1, agitation (May give IM if pt refuses)." Patient #4 received zyprexa 10 mg IM at and Benadryl 50 mg IM at 8:05 pm. No documentation revealed that the by-mouth medication was offered and refused.

An untimed staff note for shift 3-11:30 pm revealed "(Patient #4) was observed cursing and testing limits with staff. Patient was reminded that he had an early bedtime due to his behavior on days. __ observed on q 15 minute checks; __ Patient had a code called on him at 8 pm ... " It is noted that neither the latter documentation nor the 15-minute safety checks which observed patient #4 as " 5=irritable, " found him to be combative, or having any other behaviors which might require restraints prior to the approach of staff to enforce the EBT. The Seclusion and Restraint Record reveals RN #1's justification for restraint as "Homicidal Behavior or Threats with Plan." No documentation gives supporting descriptors of this justification. While patient #4 is stated to have made threats, no actual threats and no actual plans are described. However, patient #4 is described as telling staff to "Get the __away from me" and "Get out of my face."

Criteria for patient #4 to be free of restraint is documented as "Demonstrates ability to maintain safety, e.g. willingness to stay in open seclusion room for 15 minutes, or other (explain), " and "Positive response to medications resulting in patient's ability to participate in treatment and unit activities." Neither criterion meets regulatory directives. Patient #4 had only to cease the behaviors which required restraint. Additionally, the second criterion assumes that a patient must have medication to gain control of behavior, and assumes an outcome which is not within the staff or patient ' s ability to control.

Under "Events or Circumstance leading to seclusion and/or restraint," RN #1 wrote, "Pt unwilling to follow directions, combative, cursing." RN #1 documentation follows, "Pt became combative in dayroom, restrained for safety. Pt screaming, cursing at staff. Walked to QR with assistance, continued to struggle." Based on this documentation, patient #4 did not go to the quiet room voluntarily, but was taken there by staff against his will. No order for what was actually a seclusion, is found. The 24-hour Safety Check of Patient and Environment reveals that patient #4 was in "S= Seclusion Room " and " 10 = sleeping."

A progress note written by RN #1 at 2130 states "Pt told at start of shift that he had an EBT for negative behaviors on day shift. Pt overheard saying "I'm not a f---ing child." During evening, pt. prompted multiple times for being disrespectful, cursing. At bedtime, staff approached pt and encouraged him to make a good decision. Code called and pt became combative, attempting to hit, kick, cursing and making threats. Pt given Zyprexa 10 mg IM with Benadryl 50 mg IM at 2005. Once calm, pt escorted to open QR (quiet room) where he continued to curse, threaten. Pt searched for contraband and comb, pencil removed from pocket. Pt. currently resting in open quiet room without complaints, denied pain. Family informed. Will continue to monitor for safety."

Clearly, RN #1 appears to have made attempts to gain patient #4's compliance with the EBT. However, when patient #4 refused to comply, RN #1 called a code which brought support staff, and which ultimately resulted in restraint. RN #1's insistence that an oppositional patient follow an EBT penalty resulting in a code and restraint event is clearly an unsafe, coercive, and disciplinary action for what is otherwise a compliance issue, and not dangerous behavior. Staff failed to demonstrate knowledge of less-restrictive interventions and/or consequences for oppositional behaviors (for example, a lower privilege level), failed to demonstrate techniques to avoid restraint/seclusion, and failed to demonstrate techniques of de-escalation. Further, patient #4 had a right to refuse the EBT penalty and have his oppositional behavior addressed by his team.

In this case, patient #4 was calm just prior to the approach of staff on evenings and had been documented on as "Calm" for hours prior to the staff approach, and code. In summary:

1) Staff, who are charged with using techniques and interventions to avoid restraint and seclusion, precipitated a restraint event as a disciplinary measure when they confronted patient #4 for failing to comply with an EBT.

2) Staff took patient #4 to the quiet room against his will, which is tantamount to seclusion, without order, ongoing monitoring or documentation appropriate to a seclusion intervention.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of 4 open and 6 closed adolescent patient records, and facility policies it is revealed that patients #3, #4, #5, and #6 were kept in the seclusion for hours after documented seclusion/restraint ended for what staff alternately called quiet room (without informing patients of their rights), open quiet room, zoning, and open door seclusion, but was in practice, seclusion. This was done without safe seclusion practices of justification, physician orders, on-going RN assessments, and care monitoring as required by Federal and State regulation.

The facility has a Time Out policy issued August 2011, which states in part:

" ...Intimidation, force or threat in using time out is strictly prohibited," and which gives the JCAHO definition as "A procedure that is used to help a patient (or resident) served regain emotional control and that involves removing him or her from the immediate environment and restricting him or her to a quiet area or unlocked quiet room."

The time out policy states that the intervention is limited to no longer than 30 minutes.

This is in contrast to CMS guidelines under A-162 which state in part, "Timeout is not considered seclusion. Timeout is an intervention in which the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving. Therefore, the patient can leave the designated area when the patient chooses."
Patient #3 is a [AGE]-year-old Trinidad-American female who was recently discharged from the facility, but then ran away from home. She was found approximately one week later and readmitted on a voluntary basis on 8/30/2012. Patient #3 is aggressive at times, and has a history of suicidal ideation with attempt. Patient #3 was given a diagnosis of Mood disorder, not otherwise specified.


On 8/31/12 at 6 pm, patient #3 was noted to be in a physical altercation with a peer in the dayroom. Staff responded and called a psychiatric code. Witnesses stated that patient #3 had attacked a peer, unprovoked. RN documentation on the Care and Observation Code sheet reveals that from 6 pm through 6:15 pm, patient #3 was in a manual restraint. No order is found for the restraint.


RN documentation states in part, "and the patient was escorted inside the QR (quiet room). Patient was nonverbal, agitated. She was given Benadryl IM 50 mg. She did not resisted (sic). MD put her on 1:1 for safety. At 1930 she went out of the QR and started pacing, combative towards her 1:1. She was then placed in lock seclusion at 1945-2015. No other documentation reflects combativeness with her 1:1, and all seclusion documentation reflects only the physical altercation with her peer which occurred one hour earlier.



Following her seclusion release was a series of staff-documented quiet rooms, seclusion, and zoning, all which in practice, were seclusion events.



Patient #3 spent an approximate total of 38 hours in seclusion. Of that period, consisting of sleep, with the balance of time, approximately 16 hours, of waking, calm behavior. Staff had approximately 16 hours to mobilize other interventions than the isolation that staff called quiet room.


Staff failed to utilize seclusion, only for the management of violent or self-destructive behaviors.



Patient #4 is a [AGE]-year-old male, transferred to the psychiatric facility on 9/7/2012 from an acute hospital following homicidal threats towards others. Patient #4 has a diagnosis of Mood Disorder.

On 9/11 patient #4 was physically restrained from 8 pm until 8:15pm. Justification by RN #1 states "Pt unable to follow staff directions, cursing disrespectful. Had EBT from previous behavior which he refused to follow. States, " I know how it works here. I do what I want. Combative, attempting to lunge at staff."

The RN #1 progress note states "Pt given Zyprexa 10 mg IM with Benadryl 50 mg IM at 2005. Once calm, pt escorted to open QR (quiet room) where he continued to curse, threaten. Pt searched for contraband and comb, pencil removed from pocket. Pt. currently resting in open quiet room without complaints, denied pain. Family informed. Will continue to monitor for safety."

Under " Events or Circumstance leading to seclusion and/or restraint, " RN #1 wrote, " Pt unwilling to follow directions, combative, cursing. " RN #1 documentation follows, " Pt became combative in dayroom, restrained for safety. Pt screaming, cursing at staff. Walked to QR with assistance, continued to struggle. "

Based on this documentation, patient #4 did not go to the quiet room voluntarily, but was taken there by staff against his will. No order for seclusion is found. The 24-hour Safety Check of Patient and Environment reveals that patient #4 was in " S= Seclusion Room " and " 10 = sleeping. " It is unclear why patient #4 was taken to the seclusion room as opposed to allowing him to go to his own room. Patient #4 slept in the seclusion room until 1 am and then returned to his room without further documented interaction with staff.

The facility failed to protect patient #4 ' s right to be free of seclusion, and failed to obtain a physician order or perform appropriate monitoring and care.


Patient #5 is a [AGE]-year-old female admitted involuntarily from an acute care hospital on [DATE] after she became physically aggressive, assaulting staff and a police officer at her group home.


The facility gives journals and short pencils to patients for discreet time periods each day. The journals and pencils are expected to be turned-in to staff at the end of that time, and are prohibited from being used to give personal information to peers.


According to RN #1 Seclusion and Restraint documentation for patient #5 on 8/24 at 3:20 pm, " Pt attempting to give personal information to discharging peer, refused to give staff journal, pencil, and made threats to staff, then became violent, cursing and threatening to " kill " staff, kicking, hitting at staff. " Patient #5 was restrained from 3:20 pm to 3:45 pm. During that time, she received IM medication of zyprexa 5 mg, and Benadryl 50 mg.


Further Seclusion and Restraint RN #1 documentation reveals, " Pt. restrained in hallway due to fighting with staff, held 4-pt restraint, threatening, refused to walk to QR (quiet room), when pt stood up, attempted to fight. Pt carried due to combative kicking, punching. "


The RN #1 progress note of 7 pm states, " Pt was attempting to give personal information to peer that was being discharged . Pt refused to give pencil to staff and was argumentative about giving up journal which she had used inappropriately. Staff had to forcibly take pencil, pt refused to go to room, defiant. Staff explained consequences to pt, she threw crackers on the floor, cursed at staff and became combative. Staff restrained pt in hall, pt fought, kicking punching at staff etc ... The nurse gave pt Zyprexa 5 mg IM and Benadryl 50 mg IM at 1530. Pt yelled " If you give me that F ' ing shot, I will F ' ing kill you bitch. "


Criteria for release from restraint/seclusion is documented as " Positive response to medications resulting in patient ' s ability to participate in treatment and unit activities. " This criterion does not meet regulatory directives of ceasing the imminently dangerous behavior which required the intervention.


Care and Observation notes reveal that at 4:45 pm, patient #5 was " Out of seclusion. " However, the 24-hour Safety Check of Patient and Environment form reveals that patient #1 remained in the quiet room and calm through 8 pm. No discussion of the voluntary nature of quiet room; discussion of the amount of time she would remain in quiet room, or the expected behaviors on exit are found. Additionally, no 2-hour RN assessments are found. Patient #5 was essentially secluded during the balance of time in quiet room area, for a period of 3 hours and 15 minutes.


The hospital failed to protect patient #5 ' s right to be free of seclusion.


Patient #6 is a [AGE]-year-old female admitted on [DATE] on a voluntarily, following a suicide attempt. While in the emergency department, patient #6 was in 4-point restraint for combative behaviors. She has a diagnosis of Dysthymic Disorder.


On admission, patient #6 became combative while in the admission process. She was appropriately restrained at that time. Seclusion and Restraint documentation by RN #1 states in part, " Pt restrained in family meeting room when she refused to leave room, cooperate, pt became combative, escorted to open quiet room and restrained. " It is unclear what is meant by " open quiet room. " Documentation reveals that patient #6 was in restraint from 4:55 pm until 5:30 pm.


The criterion for release from restraint is documented as, " Verbalizes willingness to maintain safety, " and " Positive response to medications resulting in patient ' s ability to participate in treatment and unit activities. " Regulatory directives require only that the patient cease the dangerous behaviors requiring restraint or seclusion.


RN #1 ' s progress note, written at 10 pm states in part, " Pt. making passive suicidal statements, states, I hate my life. I want to die. Currently in open quiet room for safety ... " Patient #6 remained in the quiet room through the night through 7 am on 9/13/12. Though 15-minute checks were done, no seclusion order, no ongoing monitoring, no care documentation and no 2-hour RN assessments are found in the record. Patient #6 was, in practice, secluded without benefit of an order or other appropriate documentation.


In summary, Pt charts contain various terms for what in practice is seclusion. Further, due to a lack of identification of seclusion episodes, the facility does not follow regulatory guidelines designed to provide safety for those under such restrictions, in this case, adolescents.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

An onsite review of 4 open and 6 closed adolescent patient records, video, interviews and policies, reveals the use of 1) the administration of emergency intramuscular (IM) chemical restraint for non-emergent episodes involving patients #1, and #3, 2) non-evidenced-based holds resulting in bruising to patient #1, and 3) a non-evidenced based restraint management of patient #2, resulting in a right knee dislocation.

Patient #1 is a [AGE]-year-old female admitted voluntarily on 9/22/2012 at 1:15 pm to an acute adolescent unit after becoming aggressive at home with family, destroying property, and verbalizing suicidal ideation. Patient #1 ' s diagnoses included Bipolar disorder. Patient #1 has a history of sexual abuse, and Post Traumatic Stress Disorder (PTSD).

On 9/25, patient #1 was physically restrained. According to Seclusion/Restraint documentation, patient #1 sustained "One small bruise on each shoulder." However, an interview with administrative staff, revealed first-hand knowledge of finger print bruising to patient #1's upper arms and forearms. It is established by all accounts that patient #1 was "struggling."

The PMAB (Prevention and Management of Aggressive Behavior) training received by all staff on orientation and annually with demonstration states in part, "The arm restraint is applied by using as little pressure as necessary at the far end of the arm, near the patient's hand. No pressure is to be applied neither to the elbow nor near the shoulder."

Following the restraint, patient #1 was given zyprexa, 5 mg, Benadryl 50 mg, and ativan 1 mg IM at 1615 non-emergently following a physical restraint event. Documentation as found in CMS citation A-154 reveals that patient #1, who was exhibiting no imminently dangerous behavior or threats, and who had refused by-mouth medication, was made to go to the quiet room to receive the intramuscular medications under the threat of a second restraint if she did not comply with the inappropriate directive. Neither the fact that it was the right of patient #1 to refuse medication when not exhibiting imminently dangerous behaviors, nor the additional risks of infection, and air embolism, related to IM administration was considered by staff.

Patient #2 is a [AGE]-year-old female admitted to the facility on [DATE] after becoming aggressive at a residential treatment center (PRTF).

On 9/26/12, a Patient Care Documentation note not written until of 1730 states, " At 0815 pt was provoking and threatening a peer. Staff redirected pt & she began pushing staff member. A code was called & pt was restrained in D.R. (dining room) and received 5 mg zyprexa, 25 mg Benadryl and 1 mg ativan. Pt when released from restraint pt walked down hall and refused to go to QR (quiet room). Pt received 5 mg zyprexa, 25 mg benadryl and 1 mg ativan at 0900. Respondents from initial code then assisted in carrying pt to QR. Pt was aggressive and combative. When pt in seclusion, visible thru monitor using an item to attempt to harm self. Restraint reinitiated to obtain comb and pt's clothing checked for contraband."

"Per COMAR ( Code of Maryland Regulations) 10.21.12.05 Procedures in the Use of Restraint.
F. Staff shall search the patient for potentially harmful objects"


Other Seclusion and Restraint documentation reveal that patient #2 was searched. However, patient #2 was not searched initially when placed in seclusion per facility policy and safe seclusion/restraint technique.

On 10/15, patient #2 was physically restrained from 1200 to 1215, and in locked seclusion from 1215 to 1245.


According to video, of 10/15, patient #2 was appropriately placed in seclusion for dangerous behaviors which included threats to the physician. While there, patient #2 removed her shirt, wrapped it around her neck, and then stood at the seclusion door window to show staff she was tightening the shirt around her neck. Staff re-entered the seclusion room. Two male staff held patient #2 arms while she was in a standing position. A female staff removed the tightened shirt from her neck. Staff then apparently planned to bring patient #2 down to the mat.

Review of the video revealed that two staff, each holding one of patient #2's arms, moved forward and downwards, attempting to guide patient #2 who was between them, down towards the mat. Video of the area from a ceiling viewpoint reveals that while patient #2's left leg moved out from under and behind her, her right leg remained under her body while she and the two staff continued towards the mat. It appears that the weight of patient #2 close to 300+ lbs, and the staff on each arm attempting to guide her to the floor apparently did not allow for patient #2 ' s leg to move out behind her as the other had. Patient #2's right knee dislocated.

Of note is that facility staff feels that the mat slid-out from under patient #2 causing the dislocation. While this was not observed by the surveyor, patient #2's right leg was not controlled and remained under her during the lowering to the floor by way of a non-evidenced based technique. Therefore, patient #2 was at high risk for injury of some kind. If the mat was able to move, that was also a risk factor that was not considered prior to the intervention.

Patient Care Documentation reveals in part that "The staff member tried to remove her top from the pt. and tried to move her to a safe place." It is unclear what the staff felt was a "safe place" as the only movement observed by video was of patient #2 moving towards the floor.

According to Prevention and Management of Aggressive Behaviors (PMAB) training, a Forward Lowering Technique requires five staff for safe implementation. This consists of one staff at each of the patient arms, one staff at the patient head and one staff at each of the patient legs by which to guide the patient legs safely out and behind the patient. Though one staff was in front of the patient ready to direct her head, and two staff were are her arms, no staff was controlling her right leg resulting in a serious injury to patient #2.

Following the dislocation, staff quickly identified that patient #2 had been injured, and obtained emergency services for transport to a local acute care hospital. While making assessment of patient #2 immediately following being lowered to the mat, video reveals staff's provision of privacy for patient #2 during the intervention by covering her upper torso.

Interview with the facility educator reveals a great regard for patient safety. Documentation reveals that staff has received training on orientation and are annually instructed, including mandatory staff demonstrations at the annual skills fair.

However, in this case, the facility failed to provide safe, evidenced-based hold techniques for patient #2 resulting in severe injury.

Patient #3 is a [AGE]-year-old Trinidad-American female who was recently discharged from the facility, but then ran away from home. She was found approximately one week later and readmitted on a voluntary basis on 8/30/2012. Patient #3 is aggressive at times, and has a history of suicidal ideation with attempt. Patient #3 was given a diagnosis of Mood disorder, not otherwise specified.


RN documentation states in part, "and the patient was escorted inside the QR (quiet room). Patient was nonverbal, agitated. She was given Benadryl IM 50 mg. She did not resisted (sic). MD put her on 1:1 for safety." At 1930 she went out of the QR and started pacing, combative towards her 1:1. She was then placed in lock seclusion at 1945-2015. Patient #3 remained in the room throughout the night.


On 9/1, patient #3 left the quiet room area to use the bathroom at 9:15 am. The 24 hour safety check form reveals that patient #3 was 1=calm at that time and calm until 9:45 am when she is documented as "4=crying," then calm again or sleeping for most every entry following. Per RN documentation on the Care and Observation form, patient #3 is noted as "Combative at 9:45 am" and "medication given." Patient #3 was again placed in seclusion. Seclusion documentation beginning at on 9/1 at 9:40 am states in part, "Pt in QR to receive IM Benadryl 50 mg continued to be combative. Door closed and pt continued to beat on door and push against it. Was pacing and angry until she laid down on her mat @ 10:10." Based on documentation, the intention of staff was to administer an IM though no emergency behaviors are documented prior to staff approach with the IM .


A nursing progress note of 9/1, not written until 1400 states in part, "Pt. was sleepy in a.m., awake @ approx 0930 and pt. became defiant, attempting to push through staff to join group. Pt. did not appear stable @ the time, face eyes blank .... " Dr. __ called and pt received 50 mg Benadryl IM @ 9:40 a (sic_) while sitting in the QR. Pt. became combative __, kicking and flailing @ 1:1. Door was closed and locked and Dr. ___ was called for the order. Pt. remained angry, hitting @ door and yelling. Pt became drowsy and returned to bed and locked seclusion was ended @ 10:10 am." According to staff documentation, patient #3 attempted to leave the QR but could not do so because staff blocked her progress. Staff documented no dangerous behaviors which justified blocking patient #3 from exiting the quiet room or for receiving IM.


A social worker note of 9/1 at 10 am documents a meeting with the parents of patient #3 and the RN taking care of patient #3. The note states in part, "(RN) joined meeting + reported on status of meds w/pt. (RN) reported that Pt had not taken prescribed meds due to refusal and was given 50 mg Benadryl IM at 9:45. (RN) reported Pt was pacing, not speaking & moving to restricted part of unit and staff had to intervene this morning."


Based on documentation, there is no clear reason why patient #3, who had a right to refuse by-mouth medication and did so, received IM Benadryl. According to documentation, patient #3 became combative only following the IM, and perhaps in protest of the IM. RN documentation reveals " combative " behavior, but the patient safety check sheet reveals only that patient #3 was "4=crying " at 9:45 am, and that before and after 9:45 am, patient #3 was 1=calm."

The administration of an IM medication which was not done on the basis of a clear emergency, does not meet the standard of care, and poses increased risk to the patient.


In summary, the facility failed to provide safe implementation of seclusion and restraint processes of patients #1, #2, and #3.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of 4 open and 6 closed adolescent patient records, and facility policy, patients # 1) a physical restraint order for patient #1 reveals no physician signature, 2) an order sheet of 9/26/12 for patient #2 reveals no actual orders were obtained for two physical restraints and locked seclusion; an order sheet on 10/9/12 for patient #2 reveals only one physician order for a physical restraint and a locked seclusion at 2000 and 2020 respectively; an order sheet on 10/9 for patient #2 reveals only one physician order for a locked seclusion and an unlocked seclusion at 2145 and 10/10 at 0200 respectively; an order sheet of 10/15 for patient #2 reveals an unsigned physician telephone order for a physical restraint and an locked seclusion. Additionally, a separate physician's orders sheet of 10/15 (illegible time) for patient #2 reveals a physician-written order for "seclusion for now for safety" which does not meet the regulatory guidelines for seclusion orders; 3) No order is found for a restraint event for patient #3 on 8/31/12; 4) No order is found for a seclusion event for patient #4 on 9/11/12 at 8:15 pm, 5) A seclusion/restraint order sheet for patient #5 reveals only one unsigned physician telephone order for restraint and seclusion events occurring on 8/24/12; and 6) A physician telephone order of 9/12/12 for patient #6 was never signed.


The facility utilizes a Physician Order Sheet on which to document a "physical restraint," a "locked seclusion," or an "unlocked seclusion" event. However, for patients requiring multiple emergency interventions, e.g. restraint leading to seclusion, staff is not obtaining orders for each new intervention. Instead, staff uses whatever the original intervention order is, to cover all subsequent interventions noted on the order sheet, and then simply documents the time frames in which the interventions are done. This does not meet regulatory directives which state that all new emergency interventions for seclusion/restraint must have separate orders.

Patient #1 is a [AGE]-year-old female admitted voluntarily on 9/22/2012 at 1:15 pm to an acute adolescent unit after becoming aggressive at home with family, destroying property, and verbalizing suicidal ideation. Patient #1's diagnoses included Bipolar disorder. Patient #1 has a history of sexual abuse, and Post Traumatic Stress Disorder (PTSD).

On 9/25/12 at 1610, patient #1 was physically restrained. An telephone order for the restraint reveals no signature.

Patient #2 is a [AGE]-year-old female admitted to the facility on [DATE] after becoming aggressive at a residential treatment center.

On 9/26/12 from 0835 to 0855, patient #2 was physically restrained. No order appears in the record. Patient #2 was then taken to seclusion, but produced a comb with which she was attempting to harm herself. Restraint was reinitiated in order to get the comb. No order for the second restraint is noted. The physician order sheet reveals that patient #2 was in seclusion from 0910 to 0930. No order appears in the record. Additionally, an RN note reveals, that patient #2 was actually in seclusion through 11:20 am, though no seclusion order is found.

On 10/9, an order sheet reveals only one physician telephone order for a physical restraint and a locked seclusion at 2000 and 2020 respectively; a second order sheet for 10/9 reveals only one physician order for a locked seclusion and an unlocked seclusion at 2145 through 10/10 at 0200 respectively. Being an adolescent, this patient required orders every two-hours. However, the last seclusion spanned five hours but had only one order.

On 10/15, an order sheet reveals one unsigned physician telephone order for a physical restraint and a locked seclusion. A separate physician ' s orders sheet of 10/15 with an illegible time between 11:15 am and 12:05 pm reveals a physician-written order for " seclusion for now for safety " which does not meet the regulatory guidelines for seclusion orders which must show justification and a time limit.

Patient #3 is a [AGE]-year-old Trinidad-American female who was recently discharged from the facility, but then ran away from home. She was found approximately one week later and readmitted on a voluntary basis on 8/30/2012. Patient #3 is aggressive at times, and has a history of suicidal ideation with attempt. Patient #3 was given a diagnosis of Mood disorder, not otherwise specified.


On 8/31/12 at 6 pm, patient #3 was noted to be in a physical altercation with a peer in the dayroom. Staff responded and called a psychiatric code. Witnesses stated that patient #3 had attacked her peer, unprovoked. RN documentation on the Care and Observation Code (COC) sheet reveals that from 6 pm through 6:15 pm, patient #3 was in a manual restraint. No order is found for the restraint.

Patient #4 is a [AGE]-year-old male, transferred to the psychiatric facility on 9/7/2012 from an acute hospital following homicidal threats towards others. Patient #4 has a diagnosis of Mood Disorder.

On 9/11 at 8 pm, patient #4 was restrained in the dayroom. On the Seclusion and Restraint record, under "Events or Circumstance leading to seclusion and/or restraint," RN #1 wrote "Pt unwilling to follow directions, combative, cursing." RN #1 documentation follows "Pt became combative in dayroom, restrained for safety. Pt screaming,cursing at staff. Walked to QR with assistance, continued to struggle." Based on this documentation, patient #4 did not go to the quiet room voluntarily, but was taken there by staff against his will. No order for what was actually a seclusion, is found.

Patient #5 is a [AGE]-year-old female admitted involuntarily from an acute care hospital on [DATE] after she became physically aggressive, assaulting staff and a police officer at her group home.


A seclusion/restraint order sheet of 8/24/12 reveals only one unsigned physician telephone order for a physical restraint from 1520 to 1545, and a locked seclusion from 1545 to 1640.



Patient #6 is a [AGE]-year-old female admitted on [DATE] on a voluntarily, following a suicide attempt. While in the emergency department, patient #6 was in 4-point restraint for combative behaviors. She has a diagnosis of Dysthymic Disorder.


On 9/12/12, a physician telephone order for physical restrain was never signed.


In summary, the facility variously failed to obtain orders, failed to sign orders and failed to write appropriate orders for seclusion and restraint as required by regulation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Review of records for 4 open and 6 closed adolescent patients, revealed discrepancies in the Face to Face assessment for patient #1, and #3, and omissions in the documentation of restraint/seclusion records for patient #2.

The facility states that RNs are to perform the "Assessment Within One Hour" otherwise known as a Face to Face (F2F). Facility Seclusion and Restraint policy states in part that the F2F is inclusive of the patient ' s immediate situation, reaction to the intervention, the medical and behavioral condition, and the need to continue or to terminate the restraint or seclusion. The staff educator states that the "Assessment Within One Hour" (AWOH) form is used to document the face to face, but is also used to train RNs and Physicians who perform the face-to-face.

The facility AWOH form does not address the patient immediate situation, or the patient reaction to the intervention. Only "circumstances leading to seclusion and/or restraint" are noted. Additionally, the patient reaction to the intervention is not described on the form at all.

Patient #1 is a [AGE]-year-old female admitted voluntarily on 9/22/2012 at 1:15 pm to an acute adolescent unit after becoming aggressive at home with family, destroying property, and verbalizing suicidal ideation. Patient #1's diagnoses included Bipolar disorder. Patient #1 has a history of sexual abuse, and Post Traumatic Stress Disorder (PTSD).

Patient #1 was physically restrained on 9/25/2012 from 1610 to 1625. The "Assessment Within One Hour" done by RN #1, and which is also known as a "Face to face" (F2F) revealed an indication for physical restraint due "Homicidal Behavior or threats with Plan" with the documented detail of "Pt refused to hand staff piercings, refused to remove them, became combative with staff, threatening, restrained."

No documentation supports that patient #1 was "homicidal" or had any plan to harm others. Further, the RN documentation of "combative" and "threatening" includes no descriptors. Interview with RN #1 reveals that patient #1 was "Sitting in a chair" in the dayroom, and that staff placed hands on patient #1 and physically moved her to the floor, in order for staff to remove her piercings at which time she became "combative." No evidence of imminent danger to self or other was demonstrated by patient #1 prior to the restraint event or after.

While the facility trains RNs to monitor the condition of patients while in seclusion/restraint, RN#1's assessment of patient's homicidal ideation with plan contradicts his own, and other documentation in the record.

Patient #2 is a [AGE]-year-old female admitted to the facility on [DATE] after becoming aggressive at a residential treatment center.

On 9/26/12 Patient #2 was restrained from 0835 until 0855, and then placed in seclusion from 0910 until 0930. When contraband was noted in the seclusion room, patient #2 was restrained again to obtain the contraband, and then secluded again.

No 15-minute, nursing care, ongoing nursing assessment, F2F, or criteria for release documentation is noted in the record for any of the 3 interventions. Based on a nursing note of 1730, patient #2 is noted to have been released from seclusion at 11:20 am.

On 10/9, patient #2 was restrained and secluded twice. No RN 15-minute Care and Observation notes for ongoing monitoring and no RN ongoing assessments are noted in the record for any of the restraint/seclusions documented to have occurred.

Patient #3 is a [AGE]-year-old Trinidad-American female who was recently discharged from the facility, but then ran away from home. She was found approximately one week later and readmitted on a voluntary basis on 8/30/2012. Patient #3 is aggressive at times, and has a history of suicidal ideation with attempt. Patient #3 was given a diagnosis of Mood disorder, not otherwise specified.


Patient #3 was placed in seclusion on 8/31/12 at 1945. Seclusion and Restraint documentation for the event, as well and the nursing progress note are not written until 2350. Additionally, the Assessment within one hour of event form, also known as the Face to Face, is neither signed nor timed by the RN charged with performing the assessment. Though the form is filled-out, it cannot be determined if the assessment was done within the regulatory hour following initiation of seclusion.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of 4 open and 6 closed adolescent patient records, interviews, and facility policy, it is determined that 1) A seclusion event of 9/1/12 for patient #3 is not found on the seclusion/restraint log; 2) The facility did not identify a high-use and non-emergent pattern of seclusion/restraint events initiated by RN #1.

The hospital Monthly Seclusion & Restraint Log is a quality tool used by the facility to gather data for review of seclusion and restraint events. There are 14 data points, for example, the type, reason, and length of time of intervention. One of the data points is for the initiating RN signature.

Review of months August, September and October 2012, revealed a total of 19 seclusion/restraint events on the acute adolescent unit.

Patient #3 is a [AGE]-year-old Trinidad-American female who was recently discharged from the facility, but then ran away from home. She was found approximately one week later and readmitted on a voluntary basis on 8/30/2012. Patient #3 is aggressive at times, and has a history of suicidal ideation with attempt. Patient #3 was given a diagnosis of Mood disorder, not otherwise specified.


During a review of patient #3's record, it was revealed that a seclusion event of 9/1/12 at 0940 was not added to the Restraint Log. Therefore, the actual known number of restraint and seclusions are 20, and patient #3's seclusion was not reviewed for quality indicators.


Of the 20 events, at least 12 were on the 3-11:30 shift (two of the log had no documented time), and at least 10 (50%) were initiated by RN #1 (two of the log had no documented RN). The significance of RN #1 being the initiating RN for 50 % of the seclusion/restraints events is apparent after close scrutiny of documentation as revealed in CMS tag A-154 revealing patient rights violations, and unnecessarily confrontational techniques which have a high risk of precipitating aggressive behaviors in acutely ill psychiatric adolescents.

While the facility appears to have a strong quality program including seclusion and restraint, the latter issues had not been identified or addressed at the time of survey. Consequently, a high use pattern of seclusion/restraint events initiated by RN #1 was not identified or analyzed by the facility.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of 10 adolescent patient records, it is determined that the records of patients #1, #2, #3, #5 and #6, variously have unsigned telephone orders, untimed and undated documentation, and omissions of orders and assessments.

Patient #1 is a [AGE]-year-old female admitted voluntarily on 9/22/2012 at 1:15 pm to an acute adolescent unit after becoming aggressive at home with family, destroying property, and verbalizing suicidal ideation. Patient #1's diagnoses included Bipolar disorder. Patient #1 has a history of sexual abuse, and Post Traumatic Stress Disorder (PTSD).

Documentation in patient #1's record reveals:

1) An unsigned telephone order of 9/24/12 at 2030 for Zyprexa 10 mg po x 1, Benadryl 50 mg po x 1, Ativan 2 mg po x 1, If patient refuses may give IM

2) An unsigned telephone order for 9/25 at 1615 for Zyprexa 5 mg IM x 1, Benadryl 50 mg IM x 1, Ativan 1 mg IM x 1

3) An unsigned telephone order of 9/25/12 at 1920, "Discharge Today."

Patient #2 is a [AGE]-year-old female admitted to the facility on [DATE] after becoming aggressive at a residential treatment center.

Documentation in patient #2's record reveals:
1) Multiple restraint, seclusion orders and assessments are missing from the record for 9/26, and 10/9,
which are cited under A-168.


2) An unsigned telephone order of 10/16 0150, " continue with pain meds per SGER doctor, Percocet (5 mg-325 mg) tablet pain (one ) tab PO QID PRN "


3) An unsigned telephone order of 10/16 2100, "HP consult"


Patient #3 is a [AGE]-year-old Trinidad-American female who was recently discharged from the facility, but then ran away from home. She was found approximately one week later and readmitted on a voluntary basis on 8/30/2012. Patient #3 is aggressive at times, and has a history of suicidal ideation with attempt. Patient #3 was given a diagnosis of Mood disorder, not otherwise specified.


Documentation in patient #3's record reveals:


1) An untimed patient tech (PT) note of 8/31/12


2) An undated Care and Observation Codes sheet presumably for 8/31/2012


3) An RN progress note written almost 6 hours following a restraint and seclusion


4) No time is documented on the seclusion telephone order of 8/31/12


Patient #5 is a [AGE]-year-old female admitted involuntarily from an acute care hospital on [DATE] after she became physically aggressive, assaulting staff and a police officer at her group home.


Documentation in patient #5's record reveals:


1. No physician signature for an 8/24/12 restraint order of 1520 as cited in A-168

Patient #6 is a [AGE]-year-old female admitted on [DATE] on a voluntarily, following a suicide attempt. While in the emergency department, patient #6 was in 4-point restraint for combative behaviors. She has a diagnosis of Dysthymic Disorder.



Documentation in patient #6's record reveals:

An unsigned TO of 9/12 at 1200, Admit to (unit), medications: lexapro 20 mg po Q am, buspar 15 mg po BID


An unsigned TO order of 9/12 at 1655 for Zyprexa Zydis 5 mg po x 1/agitation, if patient refuses, give Haldol 2 mg IM x 1, Benadryl 50 mg x 1/agitation


An unsigned TO order of 9/12 at 1655 for restraint


An unsigned TO order of 9/12 at 1745 for Seroquel 100 mg po Qhs/mood


An unsigned TO order of 9/13 at 1300 for " Please block pt ' s room for safety reasons "


An unsigned TO of 9/14 at 1810 for AWOL Risk Give medications now


An unsigned TO of 9/14 at 1940 for seroquel 50 mg po x 1/ agitation


An unsigned telephone order (TO) of 9/17 at 11:35 for motrin 400 mg po one time/pain


An unsigned TO of 9/19 at 1730 for motrin 400 mg po Q8 hours prn.pain NTE (not to exceed) 3 x 24 hours


An unsigned TO of 9/19 at 2100 for Benadryl 25 mg po x1/agitation


An Interdisciplinary Master Treatment Plan Safety Risk Assessment which was never done.