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.

PERIMETER BEHAVIORAL CENTER OF JACKSON 49 OLD HICKORY BLVD JACKSON, TN 38305 Sept. 29, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Intakes: TN 748

Based on facility policy review, record review, and interview, the hospital failed to ensure the patient's right to be free from restraints was exercised and restraints were in accordance with facility policies and physician orders for 2 of 2 sampled patients reviewed for restraints.

The findings included:

1. The hospital failed to ensure staff followed written protocols for time limits on physical restraints.
Refer to A 167

2. The hospital failed to ensure restraints were discontinued at the earliest possible time.
Refer to A 174

3. The hospital failed to ensure staff were adequately trained and deemed competent to safely apply restraints.
Refer to A 194
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and interview, the facility failed to ensure staff followed the written protocols for time limits on physical restraints for 2 of 2 (Patient #1 and 3) sampled patients reviewed for restraints.
The findings included:
1. Review of the facility policy "RESTRAINT OR SECLUSION USE " revealed, "...restraint orders ...Restraint must be in accordance with the order of a physician or other licensed independent practitioner ...the licensed nurse obtains an order for each separate emergency safety intervention ...Written and verbal orders for restraint are limited to the following: No more than one (1) hour ..."

2. Medical record review for Patient #1 revealed an admission date of [DATE] with a primary diagnosis of Schizoaffective Disorder. Patient #1 was [AGE] years old and admitted from a long term care nursing facility. Review of a Restraint Justification Progress note dated 9/26/16 revealed Nurse #3 documented Patient #1 was placed in a physical restraint at 12:30 PM and was released from the restraint at 5:00 PM. The nurse did not obtain additional physician orders to maintain the physical restraint for longer than one hour per the facility policy. Patient #1 was restrained for 4 hours and 30 minutes.

Medical record review for Patient #3 revealed an admission date of [DATE] with a primary diagnosis of Psychosis. Patient #3 was [AGE] years old. A physician's order dated 8/19/16 at 4:30 PM documented, "...soft wrist restraints and ankle restraints ..." Review of a Restraint Justification Progress note dated 8/19/16 revealed Nurse #1 documented Patient #3 was placed in a physical restraint at 4:40 PM and was released from the restraint at 6:00 PM. The nurse did not obtain additional physician orders to maintain the physical restraint for longer than one hour per the facility policy. Patient #3 was restrained for 1 hours and 20 minutes.

3. During a telephone interview on 9/28/16 at 11:15 AM, Nurse #3 verified Patient #1 was in a four point soft physical restraint on 9/26/16 for 4 hours and 30 minutes.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and interview, the facility failed to ensure restraints were discontinued at the earliest possible time for 1 of 2 (Patient #1) reviewed for restraints.
The findings included:

1. Review of the facility policy "RESTRAINT OR SECLUSION USE" revealed, "...The LIP [Licensed Independent Practitioner] (RN [Registered Nurse]) discontinues the restraint at the earliest possible time ..."

2. Medical record review for Patient #1 revealed an admission date of [DATE] with a primary diagnosis of Schizoaffective Disorder. Patient #1 was [AGE] years old and admitted from a long term care nursing facility. Review of a Restraint Justification Progress note dated 9/26/16 revealed Nurse #3 documented that Patient #1 was placed in a physical restraint at 12:30 PM and was released from the restraint at 5:00 PM. Review of page 3 of the Restraint Justification Progress note, revealed Nurse #3 documented the following:
1:45 PM- the patient was coded as "sitting/lying, sad/crying"
200 PM- the patient was coded as "sitting/lying, sad/crying"
2:15 PM- the patient was coded as "sitting/lying, calm/quiet/willing to talk"

There were no additional 15 minutes checks documented. Patient #1 was not released from the physical restraint until 5:00 PM, well after the resident was documented as calm quiet and willing to talk.

3. During a telephone interview on 9/28/16 at 11:15 AM, Nurse #3 verified Patient #1 was in a four point soft physical restraint on 9/26/16 for 4 hours and 30 minutes. When asked about the 15 minute monitoring documentation that ended at 2:15 PM, Nurse #3 stated, "We did monitor her...I would release the restraint on her hands to check her circulation and while feeding her..." She verified the release was not documented. She further stated, "I should have documented that ..." She stated she was provided no training on how to complete the Restraint Justification Progress note.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, personnel file review and interview, the facility failed to ensure staff were adequately trained and deemed competent to safely apply restraints for 2 of 3 (Nurse #1 and 3) files reviewed.
The findings included:

1. Medical record review for Patient #1 revealed an admission date of [DATE] with a primary diagnosis of Schizoaffective Disorder. Patient #1 was [AGE] years old and admitted from a long term care nursing facility. Review of a Restraint Justification Progress note dated 9/26/16 revealed Nurse #3 documented Patient #1 was placed in a physical restraint at 12:30 PM and was released from the restraint at 5:00 PM. Nurse #3 placed the patient into the restraint.

Medical record review for Patient #3 revealed an admission date of [DATE] with a primary diagnosis of Psychosis. Patient #3 was [AGE] years old. A physician s order dated 8/19/16 at 4:30 PM documented, "...soft wrist restraints and ankle restraints ..." Review of a Restraint Justification Progress note dated 8/19/16 revealed Nurse #1 documented Patient #3 was placed in a physical restraint at 4:40 PM and was released from the restraint at 6:00 PM. Nurse #1 placed the patient into the restraint.

2. Review of Nurse #1 ' s personnel file revealed she was hired on 1/12/16. Further review revealed she had participated in training with a Licensed Independent Practitioner (LIP) from a residential setting, owned by the same company on 2/3/16 and 6/8/16.

Review of Nurse #3 ' s personnel file revealed she was hired on 9/22/15. Further review revealed she had participated in training with a LIP from a residential setting, owned by the same company on 1/5/16.

3. During an interview in the conference room on 9/28/16 at 11:30 AM, the Executive Director (ED) stated the training had been conducted by a licensed independent practitioner (LIP) from the residential program upstairs in the same building. The surveyor requested to speak with the LIP who conducted the training.

During an interview in the conference room on 9/28/16 at 11:50 AM, the LIP stated the training was 16 hour training with 4 modules. She further stated she only covered the first two modules with staff from this facility because of the elderly population physical holds would not be appropriate. She further stated the focus of the training was on de-escalation techniques, how to approach a patient, and posture. When asked if she demonstrated how to apply a soft wrist restraint, she stated " No... because we don't use them upstairs [residential program] ... " She again verified she did not train or determine competency on physical restraint application.

During an interview in the conference room on 9/28/16 at 12:10 PM, when asked how training and competencies were documented, the ED stated, "I don't think they get that [training]...they only cover...read the [restraint] policy. The ED was asked for the facility policy on restraint training. The ED stated there was no facility policy on restraint training requirements for staff.