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STRATEGIC BEHAVIORAL CENTER-CHARLOTTE 1715 SHARON ROAD WEST CHARLOTTE, NC 28210 July 14, 2016
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
Based on review of the North Carolina General Statutes (N.C.G.S.), medical record and acute inpatient "REQUEST FOR HEARING" document review, staff and Clerk of Court interviews, facility staff failed to notify the clerk of court within 24 hours of a minor's admission to an acute inpatient mental health facility pursuant to N.C.G.S. for 1 of 6 patients (#4).

Findings include:

Review of N.C.G.S. "Chapter 122C - Article 5 . . . 122C-224. Judicial review of voluntary admission." revealed, ". . . (c) Within 24 hours after admission, the facility shall notify the clerk of court in the county where the facility is located that the minor has been admitted and that a hearing for concurrence in the admission must be scheduled. At the time notice is given to schedule a hearing, the facility shall notify the clerk of the names and addresses of the legally responsible person and the responsible professional. . . ."

Open medical record review on 07/14/2016 revealed an 8 year old male patient (patient #4) voluntarily admitted to the acute section of the named facility on 6/30/2016 at 1246 per MD #1's ". . . PSYCHIATRIC EVALUATION" dated 06/30/2016. Review of patient #4's "REQUEST FOR HEARING" prepared by the named facility "TO: Clerk of Superior Court of Mecklenburg County This serves as official notice that an initial hearing . . . needs to be scheduled for . . ." the inpatient minor revealed a "FILED" stamp dated "2016 JUL - 5 AM 11:44 MECKLENBURG COUNTY, C.S.C. (Clerk of Superior Court)" (46 hours and 58 minutes after the minor's admission; excluding an observed holiday and weekend). Review revealed the clerk of court was not notified within 24 hours after the minor's admission pursuant to N.C.G.S.

Interview on 07/13/2016 at 1600 with the named facility's Director of Risk Management and Compliance (Staff #2) revealed problems were identified regarding timely submission of court documents during an internal audit. Staff #2 reported a "Plan of Action" was developed that included the implementation of a full-time facility "Court Records Custodian" who would be responsible for maintaining compliance with timeliness of court document submission. Staff #2 reported she would be attending a meeting in Raleigh in September to discuss the difficulties in meeting court filing requirements as the State Statutes are currently written. In the interim, per Staff #2, the Court Records Custodian calls the Clerk of Courts with all admissions and discharges every morning at approximately 9:00 AM. Additionally, "We were notifying attorneys via email of children who are admitted and giving them 72 hour notice." Staff #2 stated the new process is a lot more organized and seems to be working; "Flow is a lot better for us."

Telephone interview on 07/15/2016 at 1639 with the Supervisor of the Judicial hospitalization Unit (SJHU) and the Deputy Clerk of Superior Court (CSC) revealed their office has been upholding the filing timelines as defined in the N.C.G.S. and has been receiving pushback from facilities. The CSC reported when a facility calls her with an admission they also bring the request for hearing documentation the same day to be filed. Interview revealed the CSC receives official notification of an admission and request for hearing when the request for hearing paperwork and supporting documentation is received by the court. The date and time of the receipt of notification for a request for hearing is indicated by the CSC's "Filed" stamp on the request for hearing document. The SJHU stated, "If we do not get physician's evaluations and requests for hearing timely, we cannot generate 72 hour notices to responsible parties (parents and attorneys) and we will not schedule the hearing and they will have to start over." The SJHU reported, "It is like a house of cards", if facilities do not submit their request for hearings timely it effects the entire process. Interview revealed, the later a facility submits paperwork to the court, the less time the CSC has to appoint the minor counsel and notify the responsible parties of the date the hearing will be held.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review and staff interview, facility staff failed to obtain a physician's order for a restrictive intervention within 30 minutes from the time the restrictive intervention was initiated per policy for 1 of 3 patients (#7).

Findings include:

Review of the facility's policy and procedure titled "Restrictive Interventions", effective date 05/25/2015, revealed ". . . The Registered Nurse will notify the Medical Director and the physician of the restrictive intervention and will obtain an order from the physician. The order (written or verbal) must be obtained 30 minutes from the time the restrictive intervention was initiated . . . The physician's verbal order must be followed with the physician signature within 24 hours verifying the verbal order. . . ."

Open medical record review on 07/13/2016 of patient #7 revealed a [AGE] year old male admitted to the acute section of the named facility on 06/22/2016 at 1045 with diagnoses of Attention Deficit Hyperactivity Disorder (restlessness or fidgeting; inability to pay attention), Oppositional Defiant Disorder (frequent and persistent patterns of anger, irritability, and arguing), Intermittent Explosive Disorder (outbursts of anger and violence), and Conduct Disorder (a pattern of disruptive and violent behavior; problems with following rules) per the "Initial Psychiatric Evaluation" dated 06/22/2016 at 1730. Review of the "Restrictive Intervention Reporting Form" revealed after verbal de-escalation was unsuccessful, patient #7 was placed in a "Manual Hold: Sitting" on 07/01/2016 at 1715 and released on 07/01/2016 at 1718. Further review revealed a telephone "PHYSICIAN ORDER FOR RESTRICTIVE INTERVENTIONS (RI) FOR BEHAVIORS" for patient #7 with an initial RI date and time of 07/01/2016 at 1715. The RI order listed the "Name of MD (medical doctor) . . . giving-read back telephone order . . ." as MD #1 on 07/02/2016 at 0725 and signed by the Registered Nurse (RN #1) taking the order on 07/02/2016 at 0725. Further review revealed the physician signature line was blank on the RI order form. Review revealed RN #1 did not obtain the physician verbal order within 30 minutes of the time the emergency safety intervention was initiated by staff and the physician's verbal order was not signed by MD #1 within 24 hours verifying the verbal order per facility policy.

RN #1 was not available for interview.

Telephone interview with MD #1 on 07/13/2016 at 1530 revealed the psychiatrist expects to be notified immediately by the nurse if a restrictive intervention is initiated. MD #1 stated, "Even if they put their hand on a patient; any physical contact with a patient, they need to call me." Regarding verification/signing of verbal orders, MD #1 reported, "Most likely I would sign the next day, unless I didn't see it. Should be within 24 hours."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record reviews, and staff interviews, facility staff responsible for authenticating orders failed to sign restrictive intervention orders within twenty-four (24) hours verifying the verbal order per facility policy for 2 of 3 patients (#4 and #5).
Findings include:
Review of the named facility's nursing policy titled "Physical Restrictive Interventions and Seclusion" last revised 3/10/10 revealed, "A written order from the physician is required for the use of a restrictive intervention. . . . If the physician is not in the facility to order the use of a restrictive intervention, the registered nurse provides an emergency assessment, obtains the physician verbal order at the time the emergency safety intervention is initiated by staff . . . The physicians' verbal order must be followed with the physician signature within 24 hours verifying the verbal order. . . . "
1. Review of the open medical record on 7/12/2016 for patient #4 revealed an eight year old male that was admitted as an acute inpatient to the facility on [DATE] at 1246 with diagnoses of Oppositional Defiance Disorder (frequent and persistent patterns of anger, irritability, and arguing), Intermittent Explosive Disorder (outbursts of anger and violence), Attention Deficit Disorder with Hyperactivity (restlessness or fidgeting, inability to pay attention), Impulse Control Disorder (failure to resist a temptation or urge that may harm oneself or others) and Conduct Disorder (a pattern of disruptive and violent behavior, problems following rules). Review of restrictive intervention orders revealed patient #4 had restrictive interventions requiring manual holds on 7/1/2016, 7/3/2016 and 7/5/2016. The record further revealed MD #1 was notified per telephone by the nurse to obtain a verbal order for the restrictive interventions. Review of the "PHYSICIAN ORDER FOR RESTRICTIVE INTERVENTIONS FOR BEHAVIORS" revealed MD #1 did not sign verifying the verbal orders within 24 hours per facility policy.
2. Review of the open medical record on 7/12/2016 for patient #5 revealed a ten year old male that was admitted as an acute inpatient to the facility on [DATE] at 1430 with diagnoses of Impulse-Conduct Disorder, Oppositional Defiance Disorder, Attention Deficit Disorder, Intellectual Disability (limitations in reasoning, learning, problem solving), and Bipolar Disorder (unusual shifts in mood). Review of restrictive intervention orders revealed patient #4 had restrictive interventions requiring manual holds on 6/13/2016, 6/15/2016, 6/16/2016, 6/20/2016, 6/24/2016, 6/28/2016, 7/3/2016, 7/4/2016, 7/5/2016 and 7/12/2016. The record further revealed MD #1 was notified per telephone by the nurse to obtain a verbal order for each restrictive intervention. Review of the "PHYSICIAN ORDER FOR RESTRICTIVE INTERVENTIONS FOR BEHAVIORS" revealed MD #1 did not sign verifying the verbal orders within 24 hours per facility policy.
An interview was conducted on 07/13/2016 at 1200 with Staff #2 who verified the restrictive intervention verbal orders written by nursing staff for patient #4 and patient #5, exceeded the 24 hour period for physician signature. Staff #2 confirmed this did not meet the facility's policy time frame verbal orders for restrictive interventions are to be signed by a physician.
Telephone interview with MD #1 on 07/13/2016 at 1530 revealed the psychiatrist expects to be notified immediately by the nurse if a restrictive intervention is initiated. MD #1 stated, "Even if they put their hand on a patient; any physical contact with a patient, they need to call me." Regarding verification/signing of verbal orders, MD #1 reported, "Most likely I would sign the next day, unless I didn't see it. Should be within 24 hours."
NC 216; NC 311; NC 322; NC 827