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.

CEDAR HILLS HOSPITAL 10300 SW EASTRIDGE STREET PORTLAND, OR 97225 June 20, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation reviewed in the medical record of a patient (Patient 1) who was restrained and placed in seclusion by hospital staff, and review of medical staff rules and regulations and other documentation, it was determined the hospital failed to ensure the restraints and seclusion were in accordance with a written modification to the patient's plan of care.

Findings include:

1. The medical record of Patient 1 was reviewed. The record reflected the patient was admitted on [DATE] at 1527 with a diagnosis of schizophrenia and was discharged on [DATE] at 1956.

2. Refer to the findings at Tag A175, CFR 482.13(e)(10), Patient Rights: Restraint or Seclusion. That deficiency reflects the following:
* Patient 1 was restrained by hospital staff on 03/15/2016 and there was no modification to the plan of care that addressed the restraint.
* Patient 1 was restrained and placed in seclusion by hospital staff for an unknown period of time beginning on 03/16/2016, and there was no modification to the plan of care that addressed the restraint and seclusion.

3. The hospital's undated Medical Staff Rules and Regulations were reviewed. Section 4 "Care and Treatment of Patients" required the following: "...the treatment plan shall be modified, as necessary, to address restraint and seclusion of the patient."

4. An email from the Administrator dated 06/13/2016 at 1514 was reviewed. In relation to whether the patient's plan of care was modified and addressed the use of restraint and seclusion, the email reflected "There is not a treatment plan update present in the chart."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation reviewed in the medical record of a patient (Patient 1) who was restrained and placed in seclusion by hospital staff, and review of medical staff rules and regulations, policies and procedures and other documentation, it was determined the hospital failed to ensure physician orders for the restraint and seclusion were appropriately written, authenticated, and were time limited in accordance with hospital policies and procedures.

Findings include:

1. The medical record of Patient 1 was reviewed. The record reflected the patient was admitted on [DATE] at 1527 with a diagnosis of schizophrenia and was discharged on [DATE] at 1956.

2. Refer to the findings at Tag A175, CFR 482.13(e)(10), Patient Rights: Restraint or Seclusion. That deficiency reflects the following:
* Patient 1 was restrained by hospital staff on 03/15/2016 and there was no physician order for the restraint.
* Patient 1 was restrained and placed in seclusion for an unknown period of time beginning on 03/16/2016. The 03/16/2016 nurse telephone orders for restraint and seclusion were not time limited; and were not dated, timed or authenticated by a physician.

3. The hospital's undated Medical Staff Rules and Regulations were reviewed. Section 7 "Seclusion and/or Restraint" required the following: "...Orders for seclusion and/or restraint shall...be time limited...be signed by the physician within 24 hours of initiation...Orders for seclusion and/or restraint should be given by a Physician...If a Physician is not immediately available, however, a Registered Nurse may...initiate seclusion and/or restraint, and shall contact a Physician within 1 hour to obtain an order...The order must be reviewed and signed within 24 hours."

4. The hospital's policy and procedure titled "Seclusion, IP" dated revised "05/2015" reflected "...The following are necessary elements for seclusion orders...Each and every seclusion episode requires a physician's order. Orders for seclusion shall be authorized by physician within 14 hours...In an emergency situation, a Registered Nurse may initiate the use of seclusion. An RN must immediately contact the Attending Psychiatrist or his/her designees to obtain a verbal order for restraint if there is not a physician present. The order must be obtained within an hour...Seclusion orders are time-limited as follows...Adults [AGE] and over: 2 hours...A physician shall approve the use of seclusion within one hour of the administration of the procedure...The order must be reviewed and signed within 24 hours...If seclusion is required beyond the time-limited order, a new order is obtained."

5. In an email from the Administrator dated 06/13/2016 at 1514, the Administrator acknowledged that the 03/16/2016 nurse telephone orders for the restraint and seclusion of Patient 1 were not signed by a physician.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation reviewed in the medical record of a patient (Patient 1) who was restrained and placed in seclusion by hospital staff, and review of medical staff rules and regulations, and policies and procedures, it was determined the hospital failed to ensure the patient was monitored and assessed during episodes of restraint and seclusion in the following areas:
* One hour face-to-face medical and behavioral evaluations of the patient were not conducted and/or were not conducted timely;
* Nurse assessments of the patient were not conducted in accordance with hospital policies and procedures; and
* Assessments of the patient's physical and psychological conditions were not conducted in accordance with hospital policies and procedures.

Findings include:

1. The hospital's undated Medical Staff Rules and Regulations were reviewed. Section 7 "Seclusion and/or Restraint" required the following: "...The Physician/LIP or QRN must see and evaluate the patient face-to-face, within 1 hour of the restraint or seclusion...The person shall be examined by a nurse every two hours until such time as a physician examines the person...the condition of the patient who is in restraint or in seclusion must be continually assessed, monitored and reevaluated...Each patient placed in restraint or seclusion shall have his physical condition and psychiatric condition assessed by competent trained professional staff at the initiation of restraint or seclusion and reassessed every 15 minutes thereafter. The assessment shall include signs of injury, nutrition/hydration, circulation and range of motion in the extremities, vital signs, hygiene and elimination, physical and psychological status and comfort, and readiness for discontinuation of restraint or seclusion."

2. The hospital's policy and procedure titled "Seclusion, IP" dated revised "05/2015" reflected "...The physician, LIP or QRN must see and evaluate the patient face-to-face, immediately (no later than 1 hour) after the application/authorization of the seclusion...the person shall be examined by a nurse every two hours until such time as a physician examines the person...The condition of a patient in seclusion must be continually assessed, monitored and reevaluated. Monitor the patient continuously through 1:1 observation in person. Document observations every fifteen (15) minutes...Assessment includes as appropriate: signs of injury, nutrition/hydration, vital signs, hygiene, elimination, readiness for release, etc..."

3. The medical record of Patient 1 was reviewed. The record reflected the patient was admitted on [DATE] at 1527 with a diagnosis of schizoaffective disorder.

Nurse progress notes dated 03/15/2016 at 0900 reflected "Pt tried to attack roommate. Pt required hands on to restrain [him/her]..."

Physician progress notes signed by the physician and dated 03/16/2016 were reviewed. The notes were not timed when they were signed and reflected the following: "Patient has been quite labile per staff and has tried to attack other patients. [He/she] needed to be on hands-on restraint yesterday..."

The record contained no documentation reflecting how long the patient was restrained on 03/15/2016, no initial or ongoing assessment of the patient's physical and psychiatric condition, no physician order, and no one hour face-to-face medical and behavioral evaluation addressing the restraint episode.

A five page "Seclusion/Restraint Record" form dated 03/16/2016 was reviewed. Page one on the form reflected the following:
* At 1720 "Pt. violent..."
* At 1721 "Pt. physically restrained by CHH staff..."
* At 1722 "Pt. locked in seclusion room..."
* At 1800 "Pt...in seclusion."
The form reflected the patient was in seclusion on 03/16/2016 at the following times: 1722, 1726, 1730, 1745, 1800, 1815, 1823, 1830, 1845, 1900, 1915, 1931, 1945, 2000, 2015, 2030, and 2045. Areas on the form for those same times were blank for:
* "Circulation;"
* "ROM (Q 2 hr):"
* "Toilet Offered (Q 1 hr);"
* "Fluids Offered (Q 1 hr);"
* "Meal Offered (Q Shift);" and
* "1 Hour Assessment;"
* The "Vitals Taken (upon initiation and Q 1hr)" area on the form had only one set of vital signs recorded at 1823.
Although the "Comments" section at 2045 reflected "...Door opened, cooperative," there was no documentation reflecting the seclusion was discontinued at that time.

Page two on the "Seclusion/Restraint Record" form had a telephone order for "Seclusion" and "Physical Hold" that was signed by an RN and dated 03/16/2016 at 1725. The following areas on the order were blank:
* "The Maximum Time;"
* "Vital Signs Orders" and
* "MD Signature" and Date/Time.
The order was not time limited; and was not signed, dated or timed by the physician in accordance with hospital policy.

Page three of the "Seclusion/Restraint Record" form was signed by an RN and dated 03/16/2016 at 1730. It reflected that the patient was placed in a physical hold (restraint) at 1721, and was removed from the physical hold at 1722. It also reflected the patient was placed in seclusion at 1722. However, the seclusion "Time Out" area was blank.

Page four of the "Seclusion/Restraint Record" form was reviewed. The top section of the page reflected it was a "One Hour Assessment (Within 1 hour of initiating intervention)" and was dated 03/16/2016 at 1830 (more than one hour after the patient was restrained and placed in seclusion at 1722). The "MD/NP/QRN" signature, date and time on the one hour assessment were blank.
The bottom of page four was a "Termination/Post-Intervention" section and the following areas were blank:
* "Time of Termination;"
* "Total Time of Intervention;"
* "Behavior/Psychological status at Termination;"
* "Physical Status at Termination;"
* "ABC's fully intact;"
* "Circulation;"
* "Musculoskeletal system intact;"
* "Complaints of Injuries or Pain Associated With Intervention;" and
* "MD/NP/QRN" signature and date/time.
The record contained no page five of the "Seclusion/Restraint Record" form.

Nurse progress notes dated 03/16/2016 at 1800 reflected "At 1720...patient was escorted to seclusion..." The next RN note was 03/16/2016 at 2130 and that was primarily a checklist related to suicide risk, homicide risk, assistance needed for ADLs, meal consumption and mood.

The first physician note after the patient was placed in seclusion was dated 03/17/2016. The note was not signed, dated or timed by the physician. The note reflected "Patient seen...has been responding to internal stimuli...[He/she] is currently in seclusion."

Nurse progress notes dated 03/19/2016 at 1700 reflected "[Patient] was agitated and pacing the pod...[Patient] began to throw [his/her] body against seclusion room door." The note was unclear related to whether the patient was in seclusion or in another area of the hospital.

The record lacked documentation of the following:
* Clear information related to when the patient was in seclusion versus when the patient was in other areas of the hospital;
* A timely one hour face-to-face medical and behavioral evaluation after initiation of seclusion;
* An examination by a nurse every two hours after initiation of seclusion until the patient was examined by a physician in accordance with policies and procedures; and
* An assessment of the patient's physical and psychiatric condition including his/her nutrition/hydration, circulation and range of motion, vital signs, hygiene, elimination, physical and psychological status, comfort, and readiness for discontinuation of seclusion initially and every 15 minutes in accordance with hospital policies and procedures.

The "Master Treatment Plan, Part I;" Master Treatment Plan, Part 2;" and the "Alteration of Mood Individual Treatment Plan" were reviewed. There was no documentation on the treatment plans or any other evidence reflecting the patient's plan of care was modified and addressed the use of restraint and seclusion.

The record reflected the patient was discharged from the hospital on [DATE] at 1956.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation reviewed in the medical record of a patient (Patient 1) who was restrained and placed in seclusion by hospital staff, and review of medical staff rules and regulations, and policies and procedures, it was determined the hospital failed to ensure a one hour face-to-face medical and behavioral evaluation of the patient was completed and/or was completed timely after each episode of restraint and seclusion.

Findings include:

1. The medical record of Patient 1 was reviewed. The record reflected the patient was admitted on [DATE] at 1527 with a diagnosis of schizophrenia, and was discharged on [DATE] at 1956.

2. Refer to the findings at Tag A175, CFR 482.13(e)(10), Patient Rights: Restraint or Seclusion. That deficiency reflects the following:
* Patient 1 was restrained by hospital staff on 03/15/2016 and there was no one hour face-to-face medical and behavioral evaluation of the patient.
* Patient 1 was restrained and placed in seclusion by hospital staff beginning on 03/16/2016, and the one hour face-to-face evaluation of the patient for the restraint and seclusion was not authenticated, and was not conducted within one hour as required by hospital policy.

3. The undated Medical Staff Rules and Regulations were reviewed. Section 7 "Seclusion and/or Restraint" required the following: "...The Physician/LIP or QRN must see and evaluate the patient face-to-face, within 1 hour of the restraint or seclusion..."

4. The hospital's policy and procedure titled "Seclusion, IP" dated revised "05/2015" reflected "...The physician, LIP or QRN must see and evaluate the patient face-to-face, immediately (no later than 1 hour) after the application/authorization of the seclusion...
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of documentation in 3 of 3 medical records (Patients 1, 2, 3), it was determined that the hospital failed to ensure that medical record documentation was accurate, legible, dated, timed, and authenticated. Entries related to patient visual cues, patient observations, restraint and seclusion, medication administration, nurse progress notes, social worker notes, physician notes and physician orders were not clear or complete.

Findings include:

1. The medical record of Patient 1 was reviewed. The record reflected the patient was admitted on [DATE] at 1527 with a diagnosis of schizophrenia, and was discharged on [DATE] at 1956. Examples included but were not limited to the following:
* A "Visual Cue Sheet" form that reflected information about patient precautions and risks was signed by an RN on 03/14/2016 but was not timed.
* Nurse progress notes dated 03/15/2016 at 0900 reflected the patient required physical hold (restraint). The record contained no documentation reflecting how long the patient was restrained, an initial or ongoing assessment of the patient's physical and psychiatric condition, no physician order, and no one hour face-to-face evaluation addressing the restraint episode. In addition, the "0900" time entry on the note had been altered and did not reflect the author of the alterations or when those alterations occurred.
* A nurse progress note (day shift) was signed by a nurse and dated 03/16/2016 but was not timed when it was signed.
* Numerous areas on a five page "Seclusion/Restraint Record" form dated 03/16/2016 were missing, not completed or were altered including but not limited to: There were altered entries in the "Comments" section at 1721, 1722, and 1730 on page one, a verbal order for restraint and seclusion was not authenticated, dated or timed by the physician on page two, the seclusion "Time Out" and "Family Member Notified" sections were blank on page three, the one hour assessment was not signed, dated or timed on page four; and page five on the form was missing.
* A physician progress note signed by the physician and dated 03/16/2016 was not timed when it was signed.
* Entries related to patient behaviors and patient location on a "Q8 Observation Rounds" form dated 03/17/2016 were altered and/or illegible at the following times: 0730, 0745, 1000, 1015, and 1200. Similar findings were reflected for entries on a "Q8 Observation Rounds" form dated 03/19/2016. In addition, the 03/19/2016 "Q8 Observation Rounds" form had missing entries at 0115 and 1515.
* A physician progress note dated 03/17/2016 was not signed, dated or timed by the physician.
* A Diabetic MAR entry on 03/17/2016 had a written over and illegible time in the "Date/Time" column.
* A physician note dated 03/17/2016 reflected the patient was in seclusion. However, an email from the the Administrator dated 05/20/2016 at 1637 reflected the patient was in seclusion for a "limited period of time" on 03/16/2016. The record contained unclear information related to the patient's course of care specific to when the patient was in seclusion versus when the patient was in other areas of the hospital, such as a "Seclusion Pod" area.
* A Diabetic MAR entry on 03/18/2016 at 1800 reflected the patient's CBG was "86" but the "Signature" column and other columns on the MAR were blank.
* The nurse progress note dated 03/19/2016 at 1700 had written over and illegible entries.
* A physician progress note signed by the physician and dated 03/19/2016 was not timed when it was signed.

2. The record of Patient 2 reflected the patient was admitted on [DATE] at 1439 with a diagnosis of bipolar disorder. The patient was discharged on [DATE] at 1313. Examples included but were not limited to the following:
* The "Discharge/Aftercare Plan" was dated 04/13/2016 by a social services staff, but was not timed.
* The MD/NP Discharge Order was signed but had an illegible date and was not timed when it was signed.
* The Discharge Summary was signed by a physician but was not dated or timed when it was signed.

3. The record of Patient 3 reflected the patient (MDS) dated [DATE] at 1607 with a diagnosis of major depressive disorder. The patient was discharged on [DATE] at 1030. Examples included but were not limited to the following:
* The "Inpatient Nursing Admission Assessment" had written over and illegible entries in the MRSA screening and nurse admission note sections.
* The "Risk of Homicide/Violence" form had entries with lines through them for suicide/self-harm and justification for risk level. There was no information related to who or why the entries were lined through.
* The LCSW progress notes dated 05/04/2016 at 1200 and 1230 were signed but were not dated and timed when they were signed.