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.

ROCK PRAIRIE BEHAVIORAL HEALTH 3550 NORMAND DRIVE COLLEGE STATION, TX 77845 Oct. 9, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
Based upon observation, record review and interview, the governing body failed to:

A.) ensure the patients on the child and adolecent unit were properly assessed for medical issues. Nursing staff failed to assess the patients before and after restraints, document orders for chemical restraints, seclusion, and physical hold restraints, and document nursing interventions to prevent posible restraints. Nursing leadership failed to ensure the facility was staffed appropriately to prevent injury to patients or staff. Nursing staff failed to ensure patients were being monitored by licensed staff at all times.

Refer to Tag A0144, Tag A0160



C.) have RN supervision, failed to have adequate staffing of licensed personnel, failed to have a working schedule, and failed to maintain safety for patients and staff due to inadequate staffing. This deficient practice had the likelihood to cause harm to all presenting and in-patients in the hospital.
Refer to Tag A0392



D.) ensure the patients on the child and adolecent unit were assessed on an ongoing basis and report findings to the attending physician. Nursing staff failed to assess the patients before and after restraints, ensure there were current orders for chemical restraints, seclusion, and physical hold restraints, and document nursing interventions to prevent possible restraints.
Refer to Tag A0395
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon observation, record review and interview, the facility failed to:

ensure the patients on the child and adolecent unit were properly assessed for medical issues. Nursing failed to assess the patients before and after restraints, document orders for chemical, seclusion, and physical hold restraints, and document nursing interventions to prevent possible restraints. Nursing failed to ensure the facility was staffed appropriately to prevent injury to patients or staff. Nursing failed to ensure patients were being monitored by licensed staff at all times.
Refer to Tag A0144, A0160


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, interviews, and observation, Nursing staff failed to ensure the patients on the child and adolecent unit were properly assessed for medical issues. Nursing staff failed to assess the patients before and after restraints, document orders for chemical restraints, seclusion, and physical hold restraints, and document nursing interventions to prevent posible restraints. Nursing leadership failed to ensure the facility was staffed appropriately to prevent injury to patients or staff. Nursing failed to ensure patients were being monitored by licensed staff at all times. Citing 4 of 4 (#7, #8, #12, #2) patients reviewed.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

1.) Review of patient #7's "Psychiatric Evaluation" dated 9/25/15 stated, "HISTORY OF PRESENT ILLNESS: The patient is a [AGE]-year-old female, with a past psychiatric history of bipolar disorder with multiple past psychiatric hospitalization s, who presented secondary to the patient becoming increasingly aggressive and assaultive. As per chart, client was angry at school and was escalating for the past 3 days, had thoughts of wanting to harm the teacher. The patient escalated to the point where the police were called and the patient reportedly assaulted a police officer. The patient was taken to the emergency room , where she told staff she wanted to kill herself by stabbing herself.

Review of patient #7's "Psychiatric Evaluation" dated 9/25/15, at 12:48PM, stated, "During initial assessment, the patient was angry and started throwing furniture around and making aggressive threatening gesture towards staff and a Code Purple (immediate danger) had to be called. The patient was medicated with Zyprexa 10 mg IM.

During the Mental Status Exam dated 9/25/15, at 12:48PM, revealed the psychiatrist documented, "The patient appears sedated and is superficially cooperative with the assessment."

Review of patient #7's chart revealed no physician order or documentation of the drug Zyprexa given IM on 9/24/2015.

Review of patient #7's verbal physician orders dated 9/26/2015, at 7:30PM, stated, "Give Haldol 5mg, Ativan 1mg, and Benadryl 25mg IM now for severe agitation."

Review of patient #7's chart revealed a "Restrictive Intervention Reporting Form" (RI) dated 9/26, at 7:30PM. There was no year documented on the document. The form revealed patient #7 was placed in a hold from 7:30PM -7:40PM, a total of 10 minutes. Patient #7 was administered Haldol 5mg, Ativan 1 mg, and Benadryl 25mg IM on "9/26 at 7:40PM. " Review of patient #7's MAR revealed the injections were given at 7:45 on 9/26/15, by the initials S.S." Review of the MAR revealed there was no signature on the page that matched the initial S.S." There was no documentation of the site of the injection and if the patient tolerated the medication. There was no clear documentation if the medication was given during or after the hold. There was no physician's order to hold the patient in a restraint position for 10 minutes. Staff #25 initiated the restraint and also did the face to face. There were no nursing interventions documented before the restraint was initiated.

Review of the policy and procedure "seclusion and restraint" revealed the following: "Physical Holding for Forced Medications - The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint. The patient has a right to refuse medications, unless a court has ordered medication treatment. A court order for medication treatment only removes the patient's right to refuse the medication. Additionally, in accordance with State law, some patient's may be medicated against their will in certain emergency circumstances. However, in both of these circumstances, health care staff is expected to use the least restrictive method of administering the medication to avoid or reduce the use of force, when possible. The use of force in order to medicate a patient, as with other restraint, must have a physician's order prior to the application of the restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply."

Review of patient #7's nurses notes for 9/26 (no documented year) at 10:40PM, staff #25 documented, "Pt walks into day room after phone call to mom that did not end well when patient asked mom to come take her home. MHT tried to speak with pt, pt threw water cooler *** (Illegible). RN and MHT attempted to de-escalate pt, pt slammed doors, shoved RN. Pt restrained for approximately 10 minutes. Psychiatrist notified- pt refused to speak throughout except to tell staff to move when preventing her from slamming door. Pt was able to calm down in restraint, reported that she was upset from the phone call and did not remember what happened afterwards. Pts family notified of incident. No injuries to pt/staff. To remain on unit for breakfast in AM."

Review of the RI form revealed no documentation of where patient #7 was in a hold from 7:30PM-7:40PM. There was no documentation found on what happened to the patient after the hold or if the chemical restraint was effective. There was no documentation of what interventions were used with the de-escalation.

There was no further nursing documentation found until 6/26/15, at 11:59AM. The note stated, "8 hours of sleep, sound, Unable to complete physical/mental assessment due to patient asleep throughout the shift. Under the "Medication Compliant last 24 hours" section, the nurse circled "N", "missed 3:00PM Thorazine." There was no nursing documentation why the patient missed the Thorazine dose at 3:00PM.

Review of patient #7's verbal physician orders dated 9/26/2015, at 6:55PM, stated, "hold 3:00PM dose of Thorazine 50mg po, give 9:00PM dose."

Review of the Medical Administration record (MAR) for 9/26/15, revealed the Thorazine 50mg po was held at 3:00PM and was blank for the 9:00PM dose. There was no documentation of the medication given at 9:00PM. There was no nursing or physician documentation found on why the scheduled dose was held and why the 9:00PM dose was not documented as administered. The medication was ordered by the physician to be held. However, the nurse documented as patient non-compliant.

Review of patient #7's nurse's note for 9/28/15, at 8:10PM, revealed, patient #7 was upset after another phone call and was asked by the nurse to go to the quiet/seclusion room. Patient #7 refused and a code purple (Immediate danger) was called on the radio for help. Patient #7 charged the nurse and knocked her to floor. Patient #7 continued to assault the RN several times. Patient #7 was "held down 3 points then walked voluntarily to the quiet room. 8:20PM Zyprexa 10mg po given started hitting med room door. Got an order of Zyprexa 10mg IM but he calmed down. 9:00PM Patient calling and requested to go to his room apologized for what she did. 9:15PM MHT accompanied her to room and slept." (SIC) (The patient was transgender and nurse changes from male to female pronouns in the nurse's note.) There was no order found for the patient hold. There was no face to face performed or any further documentation of patients' behavior or effectiveness of medication.

Review of the video footage for 9/28/15, at 8:10PM, revealed patient #7 was pacing the hallway in front of her room. The MHT was walking in and out of rooms taking linen and supplies to other patients. The MHT stops to talk to the patient several times. Patient #7 walks into her room and closes the door. The MHT attempts to open the door and has to unlock it. Patient #7 comes out of the room and stands in the doorway. The RN comes down the hallway and speaks to the patient. The patient is restless and fidgety. Patient #7 pushes the nurse backwards into the room across the hall. The video does not show inside the room. The nurse comes out of the room from a crawling position and attempts to run to the locked door. Patient #7 goes after the nurse dragging the MHT behind her. The patient kicks open the locked door into the foyer and continues after the nurse. Three other employees from other units attempt to stop the patient. One female MHT came up and used force to bring the patient to the ground.

Review of the video footage for 9/28/15, at 8:10PM, revealed patient #7 calming down and escorted to the quiet/seclusion room. The patient was placed in the room and the door was closed. A nurse came into view and opened a medication packet to put in the patients hand. The pill was dropped to the floor and the patient bent down to pick it up and took the medication from the dirty floor. The staff left out of view of the cameras and patient #7 came out of the seclusion room and began to bang the bathroom door open and closed multiple times. Patient #7 was unable to leave the common space area.

The quiet/seclusion room opened up to a small common area that was visible from the nurse's station from a window. This common space had access to the bathroom. However, all exit doors from this common area were locked. Once the patient was placed in the quiet / seclusion room the patient was able to come out of the room but could not leave the immediate area. Patient #7 was not able to go to her room or walk about the unit on her own.

An interview with staff #16 revealed the patient was put in "Quiet Room" and door was not locked. However, patient #7 was locked behind closed doors and the RN had to unlock the door to allow the patient to go to her room. Staff #16 reported the unit had 13 adolescent children and several of the patients were adult size. Staff #16 reported she felt unsafe being the only RN with that many adolescent patients.

Review of a Incident Report dated 9/28/15, revealed patient #7 was in an altercation with staff #16 (RN). Staff #16 stated, "I was pushed to the adjacent room hit bed down on the floor and 6x beaten on top of my head by patient #7." Staff #6 reported the injury happened at 8:15PM and she was not relieved to go to the Emergency Department until her shift was over at 12:00PM. Staff #16 was diagnosed with a head injury and cervical muscle strain."

Review of patient #7's physician order dated 9/29 (no year) at 8:42PM revealed a verbal order was given for Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM x1 now. There was no reason in the order for the emergency medication.

Review of the RI dated 9/29 (no year) at 8:35PM that patient #7 was put in a hold until 8:50PM a total of 15 minutes and then escorted at 8:50PM. Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM was documented as given on 9/26 (no year) and no time found. Under "clinical summary of intervention: patient attacked staff after visit with police officer had to be restrained by RN, MHT, and LPC received prn medication." There was no order found for the hold.

Review of the nurses notes dated 9/29 (no year) at 10:30, two hours later, revealed patient #7 had been in with the police due to the previous staff assault. Patient #7 was upset and started to slam doors. The RN attempted to talk to the patient and patient walked past the RN and attempted to get out of the locked doors. The Licensed Professional Counselor (LPC) slammed the door shut, locking it. Patient #7 slapped the LPC and a code purple was called. The patient was administered medication and escorted to the quiet room when she " **** (illegible) willingness to go to quiet room. Doc and family notified." There was no further reassessment of the patient found.

Review of the nurses note dated 9/30/15, at 10:45AM, stated, "Pt received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM d/t pt being aggressive." There was no further documentation found of a face to face, reason for the intervention, assessment of the patient after the medication administration or if the medication was effective. There was no nursing documentation if there was a hold or where the medication was administered.

Review of the nursing notes dated 9/30 (no year) at 11:00PM stated, "set expectations for leaving quiet room and patient punches walls." Patient #7 was now in seclusion but there was no order for seclusion or assessment documented. There was no documentation on when the patient was allowed to leave the seclusion room.

Review of patient #7's physician order dated 10/1/15, at 9:00AM stated, "1:1 for safety." (1:1- one staff member to one patient to stay within arms length.)

Review of patient #7's nurse's note dated 10/1/15, at 7:30AM, " patient alert and oriented x4. pt was placed on 1-1 with staff . Pt integrated well with other peers. After lunch pt complained of a rapid heartbeat nurse took vitals BP- 120/88, R- 28, O2 sat- 97, and P- 139. MD ordered EKG stat and held her 3:00PM meds Thorazine 100mg po and valium 15mg po. Vital signs were reassessed in 30 minutes her pulse went down to 109. EKG results were prolonged QRST. MD ordered repeat EKG in the morning and decreased Thorazine to 75mg. Pt is walking around and interacting with peers on hall 600." There was no further documentation on why patient #7 was ordered to be on a 1:1 or when the 1:1 was removed.


2.) Review of patient #8's chart revealed, the patient was a [AGE] year old female, brought to the facility by her parents, with a diagnosis of Severe Depression without psychosis. Pt was ordered to be on suicide precautions and every 15 minute observations.

Review of patient #8's physician orders, a verbal order was found, dated on 8/10 (no year) at 7:25PM. The order stated,

"1.) Benadryl 50mg IM now self -harming behavior.
2.) Thorazine 50mg IM now
3.) Restrain pt."

There was no order clarification on what type of restraint or for how long.

Review of patient #8's nurse's notes for 8/10/15, revealed staff #2 did not document the patient was on suicide precautions.

Review of patient #8's nurses notes for 8/10 (no year) at 10:00PM stated, "Pt was upset at 5:15PM in cafeteria, crying, and requested to go out. Pt went back to the unit with the MHT. Then per MHT attempt to harm self, gear 3 was called (acting out) psychiatrist was notified and pt was restrained in hall laying face up. Receives emergency IM medications at 5:30PM. Thorazine 50mg and Benadryl 50mg IM. Pt continued with self-harming thoughts and cont. to beg to be let go so she could self-harm. "I need to cut." Pt was very apologetic but continued to beg and appears to fixate on a particular MHT. Released from hold was attempted x2 and pt has to be re-restrained immediately both times before being escorted to the quiet/seclusion room and restrained in the quiet room. At 6:35PM, pt asked to go to restroom, did not use restroom and did not cont. self-harming behavior and restraint was ended."

There was no documentation found of nursing interventions attempted before restraint. There was no information on what type of thoughts the patient was having or how she was attempting to cut herself in a safe environment. Review of the RI revealed patient #8 was held sitting from 5:25PM- 6:35PM. There was no documentation where the patient was being held, who was holding her, and what interventions were attempted to release the hold.

During a review of the staffing schedule for 10/8/15, with Staff #3 present, the census was not on the schedule for the child and adolescent units. Staff #3 attempted to call the unit to ask for the patient census but there was no answer. Staff #3 reported he would have to go to the unit. Surveyor followed staff #3 to the child and adolescent units. There was no visual staff or patients on the unit. Staff #3 and the surveyor walked to the cafeteria and found Staff #5 (RN) and a female MHT with the children in the cafeteria.

During an interview with Staff #5 on 10/8/15, revealed she was the only RN on the unit for 10 children. Staff #5 confirmed there was one MHT for each hall. Staff #5 confirmed that she has to leave the unit to come to the cafeteria due to licensed personnel have to be with the children as they eat. Staff #5 reported the child and adolescent unit can become very hostile at times and she does not feel safe with this many children and no other licensed personnel. The surveyor counted the children in the cafeteria and there were only eight children. Staff #5 reported there were two children on the unit with a MHT due to their bad behaviors and would have to eat on the unit.


Surveyor and Staff #3 immediately went to the child and adolescent unit and saw two female patients on the unit. The two girls were in a dayroom, with no cameras, with a male MHT. There was no other female staff with the children. The children were hungry and were asking when they could eat. The MHT reported their trays would be brought down later. The surveyor waited until the DON could come and cover the unit.

An interview with staff #6 was conducted on 10/9/15. Staff #6 confirmed that there has been multiple times when no RN is available to work the child and adolescent unit. Staff #6 reported she was instructed by DON to leave the locked doors between the units open so she can monitor all four units. Staff #6 stated, "It has happened multiple times and I felt uncomfortable trying to manage all those patients. It's hard to chart and do assessments on one unit much less two." Staff #6 confirmed she sometimes does not get a break because there is no one to relieve her. Staff #6 confirmed she has left the unit to go get a patient from admissions, leaving the unit without licensed staff.

On 10/9/2015, at approximately 1:00 am, the surveyors observed the night RN from the child and adolescent unit leave the unit and walk approximately 80-100 yards through two double locked doors to escort a patient from admissions to the unit. There was no RN on the floor, for an extended period of time, for a census of 10 patients.

3.) Review of patient #12's chart revealed on 10/7/2015, patient #12 was admitted involuntarily to the facility with a diagnosis of schizoaffective disorder. Patient #12 was admitted with an Emergency Detention Warrant for suicidal and homicidal ideations. Patient #12 had reported she was hearing voices and wanted to cut her neck.

Review of the Nurses notes dated 10/8/15, at 3:15AM, revealed an assessment was not completed. The nurse checked a box statement that stated, "Unable to complete physical/ mental assessment due to patient asleep throughout the shift." Under the heading Medication Compliant: "Pt will begin scheduled meds 10/8/15, at 9:00AM."

Review of the Physician orders revealed the patient had three medications ordered on [DATE], to be given at nighttime. Seraquel 800mg, Lithium 600mg, and Latuda 80mg. Patient #12 had reported that she had taken her medication before she came in to be admitted .

Review of patient #12's therapy notes revealed patient #12 was in group from 10:15-11:15AM on 10-8 2015. The note stated, "Patient #12 came in and out of group despite asking her to please stay because it disrupts the group when people are in and out. She did not appear to be responding to internal stimuli but appears depressed AEB stating she does not really like herself and she has no self-esteem."

Review of the physician orders dated 10-8-15 at 1:00PM revealed patient #12 was ordered medications to be given now as follows:
1.) Depakote ER( mood stabilizer) 250mg by mouth twice a day
2.) Klonopin (anti-seizure and anti-anxiety) 0.9mg by mouth twice a day.
3.) Ativan (anti-anxiety) 2mg by mouth every 4 hours as needed for anxiety.
4.) Risperdal (Atypical antipsychotic) 0.5mg by mouth twice a day.
5.) Lithium level in am.

Review of the chart revealed there was no medication administration record found. There was no evidence medication was administered. Patient #12 has a history of seizures.

Review of the MHT notes for 10/8/2015, revealed patient #12 stated, "Pt. was crying saying she was tired and wants to lay down and sleep. Pt began to hear voices on 10/8/15, at 1:00PM."

Review of the patient observation sheet for 10/8/2015, for patient #12 revealed the following;
1:00PM patient #12 was crying.
1:15PM patient #12 was in the dayroom lying/sitting.
1:30PM patient 312 was in the Consultation room with Doctor/NP/Nurse.
1:45PM patient was in Quiet Room agitated and restless.

Review of the Therapy Notes for group on 10/8/2015, at 1:15PM,revealed, "Patient was present for the first five minutes of group. Patient walked in circles in the middle of the group room and would not respond when therapist spoke to her. Patient left the group and did not return. Patient appeared distressed." There was no further documentation that the therapist spoke to the nurse and reported the patient behavior or contact with the psychiatrist. There were no further interventions documented.

There was no nursing documentation of the patient's behavior in group or emotional outburst with the MHT documented. There was no documentation of why the patient was in the quiet/seclusion room. There was no documentation that the patient requested to go to the quiet room or was taken by staff due to previous outburst of anger and aggression documented by the MHT. There was no physician order to place the patient in seclusion.

Review of the nurse's notes for 10/8/2015, at 2:00PM, stated, "Pt alert and oriented x4. Pt asks to go to bathroom. Staff over heard pt talking loudly to herself. Nurse was notified. Nurse saw pt. on her knees over the toilet talking to the voices. Pt was having audio and visual hallucinations. Pt. was pacing back and forth in the quiet room and would not respond to staff when asking her questions. Pt received Ativan 2mg po, Risperdol 0.5mg po, Depakote ER 250mg po, Klonopin 0.5mg po. Pt. still not calm, after 30 minutes pt. verbalized to the nurse what the voices are telling her. Nurse got patients mattress and put it in the seclusion room. Pt will not lay down for long. Psychiatrist reports patient needs to have a very quiet environment. Pt has been in the quiet room and seclusion almost 2 hours. Pt vital signs are stable B/P 132/84, P 112, R- 18, O2 sat 99%. Nurse will continue to observe."

There were no orders for seclusion. There was no documentation of a face to face or any nursing interventions other than a quiet room and ordered medications administered. There was no nursing documentation found on the patient until 10/8/15 at 4:00PM (two hours later).

Review of the nurses note for 10/8/15, at 4:00PM, stated, "pt. alert and oriented x4. Pt is having audio and visual hallucinations pt is in the quiet room and attempted to leave out behind the MHT pt got middle left finger caught in door causing a deep laceration. Pt was transferred to the hospital for medical attention. Pt transported by ambulance at 4:40PM. Pt v/s stable HR-100. Pt calm and cooperative during transportation. 5:00PM Pt made it safely to the hospital."

There was no found documentation of complete vital signs after the injury. There was no documentation describing the patients wound, who went with the patient to the hospital, if the hospital was given report and was aware of her medical/ mental/legal condition. There was no nursing documentation of when the patient returned from the hospital, if she had any food/ fluids, or an assessment of the patient. There was no documentation of the patient mental status after she returned to the facility or any physician notification for further orders.

Review of the MHT observation record on 10/8/15, at 7:15PM, revealed that patient #12 was back in the quiet/seclusion room sleeping until 11:15PM then returned to her room. There was no found documentation of why the patient was in the quiet/seclusion room.

An interview was conducted with staff #6 (RN) on 10/8/15, at 11:45PM. Staff #6 reported that she had just come on duty and was not present during patient #12's accident but she had received in report that patient #12 had gotten her finger caught in the door of the quiet room and required six stitches in her left finger. Staff# 6 reported that she understood patient #12 was getting loud and disruptive in the hallway. The nurse put her in the seclusion room to get her away from the others. When staff #6 was asked where the orders were for the seclusion room she responded, "We don't have to get an order if the door is not locked to the seclusion room. If they can come out on their own it's not considered seclusion. We were told we have to physically hold the door handle down to consider that seclusion."

An interview was conducted with patient #12 on 10/9/2015. Patient #12 reported that she was hearing voices last night and tried to explain it to the nurse. Patient #12 reported that she knew she was getting out of control but no one would ask her what was wrong. "They just made me go into that room. They said I had to go in there to keep me calm and wouldn't let me go to my room. When the tech came in I was trying to leave and she pushed me back in and slammed the door on my finger. It hurt really bad. It really made me mad when she tried to blame me. I would have been alright with it if she just would apologize." Staff #12 reported that she agreed to go back into the quiet/seclusion room when she got back because that is where her mattress was and she was really sleepy.

Review of the facility's policy and procedure "Seclusion and Physical Restraint Hold " stated,
"Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. Seclusion is not just confining a patient to an area, but involuntarily confining the patient alone in a room or area where the patient is physically prevented from leaving, if a patient is restricted to a room alone and staff are physically intervening to prevent the patient form leaving the room or giving the perception that threatens the patient with physical intervention of the patient attempts to leave the room, the room is considered locked, whether the door is actually locked or not. In this situation, the patient is being secluded. A patient physically restrained alone in an unlocked room does not constitute seclusion. Confinement on a locked unit or ward where the patient is with others does not constitute seclusion."








4.) On 8/9/2015, in the afternoon the medical record (MR) for patient (Pt/pt) #2 was reviewed in the conference room. The MR review revealed pt #2 was a ten (10) year old female with prior admissions. Pt #2 routinely received four (4) antipsychotic medications. Olanzapine for mood, was discontinued by the admitting Psychiatrist. The psychiatrist continued Clonazepam 0.5 milligram (mg) twice daily (BID) given for Anxiety and Lexapro 20 mg every morning was given for depression. Pt #2 was taking Latuda which was noted by the Psychiatrist to be effective in treating pt #2's psychosis, but caused pt #2 to suffer abnormal weight gain. As a ten (10) year old she had gained 40-50 pounds while taking Latuda. The psychiatrist noted she would try to place pt #2 on Zyprexa, a drug also used to treat psychosis and when pt #2 was stable begin to reduce the Latuda in an attempt to bring her weight gain under control. Pt #2 was admitted with the Psychiatrist continuing her Latuda and adding Zyprexa 10 mg by mouth (PO) BID. Pt #2 was taking two (2) drugs intended to stabilize and treat her Psychosis.


A review of the physician's orders after admission were as follows:


7/19/2015 at 10:30 a.m. "Zyprexa 10 mg (milligram) by mouth (po) twice daily (BID)".

7/19/2015 at 1:19 p.m. "Decrease Zyprexa 15 mg po qhs (At bedtime) for psychosis".

7/19/2015 at 2:15 p.m., "Discontinue above order Zyprexa 15 mg po qhs. Start Zyprexa 5 mg po BID for psychosis"

7/20/2015 at 10:50 a.m. "Zyprexa Zydis (Zydis is the same drug as Zyprexa) 10 mg IM x 1 now (Intra Muscular 1 time now)".

7/20/2015 at 1:15 p.m., "decrease Zyprexa Zydis 2.5 mg po BID".

7/21/2015 at 12:09 p.m. "Increase Zyprexa/Zydis 5 mg PO BID".

7/21/2015 at 8:30 p.m., "Zydis 5 mg po 1 x only emergency med"

7/24/2015 7:25 p.m., "Ativan 3 mg with Haldol 5 mg with Benadryl 50 mg IM now for emergency medications due to violent psychosis". May place in seclusion/restraints".

7/26/2015 at 3:40 p.m., "Zydis 5 mg po 1 x dose now for severe agitation"

7/26/2015 at 4:00 p.m., "May repeat Zydis 5 mg po x 1 dose for severe agitation/aggressive behavior.

7/27/2015 at 8:45 a.m., "Give Zyprexa 10 mg IM now"

7/27/2015 at 2:20 p.m. "Increase Zyprexa 7.5 mg po BID".

7/27/2015 at 4:22 p.m., "Zyprexa 10 mg IM now emergency medication violent psychosis. May seclude".

7/28/2015 at 4:50 p.m., " Zyprexa Zydis 5 mg po now for violent aggression".

7/28/2015 at 12:20 p.m., "May place in seclusion".

7/29/2015 at 9:35 a.m., "Zyprexa 10 mg IM now x 1 dose for severe aggression".

7/29/2015 at 12:00 p.m., "Increase Zyprexa Zydis 10 mg po Bid".

7/30/2015 at 10:15 a.m., "Zyprexa Zydis 2.5 mg po x 1 now for psychosis due to pt's mother consenting to increased dose after a.m. dose had been give".

8/1/2015 at 8:00 p.m., "Ativan 2 mg IM Now x 1 for severe agitation".

8/1/2015 at 8:40 p.m., "Thorazine 25 mg IM x 1 now for continued agitation".

8/1/2015 at 9:20 p.m., "Thorazine 25 mg IM x 1 now for continued agitation".

8/3/2015 at 3:22 p.m., "Discharge to ASH today"

8/4/2015 at 9:15 Zyprexa 10 mg IM x 1 dose now for severe agitation".


On the moring of 10/9/2015 in the conference room an interview with staff #2 confirmed pt #2 recieved multiple emergency IM injections for her behavior.


A comparative review of the medication administration record (MAR) with the physician's orders revealed the following: Omissions of nursing staff initials indicated a dose was not given on the following dates:

7/20/2015 at 9:00 a.m., Zyprexa 5 mg po

7/20/2015 at 9:00 p.m., Zyprexa 2.5 mg po

7/21/2015 at 9:00 a.m., Zyprexa 5 mg po

7/21/2015 at 7:00 a.m., Zyprexa 5 mg Sublingual (SL) 1 x now

7/21/2015 at 8:30 p.m., Zyprexa 5 mg SL 1 x now (no physician's order found for this dose.

7/27/2015 at 9:00 p.m., Zyprexa 7.5 mg

7/28/2015 at 4:50 p.m., Zyprexa 5 mg po now x 1 for violent aggression. PT placed in seclusion.

7/30/2015 at 9:00 a.m., Zyprexa 7.5 mg po initialed as given after the physician changed the order to Zyprexa 10 mg BID on 7/29/2015.

7/30/2015 at 9:00 a.m., Zyprexa 10 mg po not given.

7/30/2015 at 10:15 a.m., Zyprexa 2.5 po now dose.

8/1/2015 at 9:00 p.m. Zyprexa 10 mg po.


Nursing staff failed to administered medications as ordered by the physician eleven (11)times during pt #2's hospitalization .
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy and procedures, and interviews, the facility failed to refrain from using psychoactive medications "as needed" for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, obtain orders for the restraints, perform assessments after the use of a chemical restraint for effectiveness and safety, and prevent use of psychoactive medication for staff convenience in 3 (# 2, 7, and 8) of 3 patients reviewed.


Review of the standard admission physician orders revealed medications used to restrain or cause a restriction in patient movement were ordered as PRN (as needed) for children and adults.


A.) Review of the "Admission Orders for Child/Adolescent" order set stated, "Benadryl (antihistamine) 8-[AGE] years old 25 mg PO: 1 tab qhs PRN for insomnia."


Review of the "Admission Orders" for adult patients revealed the following;


A.) Trazadone (antidepressant) 50 mg po q hs PRN sleep may repeat once if ineffective (NTE - Not To Exceed 600 mg in 24 hours.) (NOTE: If the nurse administered this drug as ordered and administered a second dose it would add up to 100 mg not 600 in a 24 hour period.)


B.) Hydroxyzine (Vistaril- sedative) 50 mg PO q 4 hrs PRN anxiety (NTE 600 mg in 24 hours). (NOTE: If the nurse administered this dosage of Vistaril every 4 hours for 24 hours, the dosage would only be 300 mg for a 24 hour period not 600 mg.)


C.) Olanzapine ODT ( Zyprexa Zydis-Antipsychotic) 5 mg SL q 6 hrs PRN psychotic agitation (NTE 30 mg/24 hr). (NOTE: If the nurse administered this drug as ordered the dosage would only add up to 20mgs in a 24 hour period not 30mgs.


An interview was conducted with nurses Staff #16, #22, and #23 on 10/17/15. The nurses confirmed that the orders were unclear concerning the NTE limits. Overdose of the above medications may cause serious injury or possible death.


1.) Review of patient #7's "Psychiatric Evaluation" dated 9/25/15, stated, "HISTORY OF PRESENT ILLNESS: The patient is a [AGE]-year-old female with a past psychiatric history of bipolar disorder with multiple past psychiatric hospitalization s, who presents secondary to the patient becoming increasingly aggressive and assaultive. As per chart, client was angry at school and was escalating for the past 3 days, had thoughts of wanting to harm the teacher. The patient escalated to the point where the police were called and the patient reportedly assaulted a police officer. The patient was taken to the emergency room , where she told staff she wanted to kill herself by stabbing herself.

Review of patient #7's "Psychiatric Evaluation" dated 9/25/15, at 12:48PM, stated, "During initial assessment, the patient was angry and started throwing furniture around and making aggressive threatening gesture towards staff and a Code Purple (immediate danger) had to be called. The patient was medicated with Zyprexa 10 mg IM.

During the Mental Status Exam dated 9/25/15, at 12:48PM, revealed the psychiatrist documented, "The patient appears sedated and is superficially cooperative with the assessment."

Review of patient #7's chart revealed no physician order or documentation of the drug Zyprexa given IM on 9/24/2015.

Review of patient #7's verbal physician orders dated 9/26/2015, at 7:30PM, stated, "Give Haldol 5mg, Ativan 1mg, and Benadryl 25mg IM now for severe agitation. "

Review of patient #7's chart revealed a "Restrictive Intervention Reporting Form" (RI) dated 9/26 at 7:30PM. There was no year documented on the document. The form revealed patient #7 was placed in a hold from 7:30PM - 7:40PM, a total of 10 minutes. Patient #7 was given Haldol 5mg, Ativan 1 mg, and Benadryl 25mg IM on "9/26 at 7:40PM." Review of patient #7's MAR revealed the injections were given at 7:45 on 9/26/15, by staff with the initials S.S." Review of the MAR revealed there was no signature on the page that matched the initial S.S." There was no documentation of the site of the injection and if the patient tolerated the medication. There was no clear documentation if the medication was given during or after the hold. There was no physician's order to hold the patient in a restraint position for 10 minutes. Staff #25 initiated the restraint and also did the face to face. There were no nursing interventions documented before the restraint was initiated.

Review of the policy and procedure "seclusion and restraint" revealed the following: "Physical Holding for Forced Medications - The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint. The patient has a right to refuse medications, unless a court has ordered medication treatment. A court order for medication treatment only removes the patient's right to refuse the medication. Additionally, in accordance with State law, some patient's may be medicated against their will in certain emergency circumstances. However, in both of these circumstances, health care staff is expected to use the least restrictive method of administering the medication to avoid or reduce the use of force, when possible. The use of force in order to medicate a patient, as with other restraint, must have a physician's order prior to the application of the restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply."

Review of patient #7's nurses notes for 9/26 (no documented year) at 10:40PM, staff #25 documented, "Pt walks into day room after phone call to mom that did not end well when patient asked mom to come take her home. MHT tried to speak with pt, pt threw water cooler *** (Illegible). RN and MHT attempted to de-escalate pt, pt slammed doors, shoved RN. Pt restrained for approximately 10 minutes. Psychiatrist notified - pt refused to speak throughout except to tell staff to move when preventing her from slamming door. Pt was able to calm down in restraint, reported that she was upset from the phone call and did not remember what happened afterwards. Pts family notified of incident. No injuries to pt/staff. To remain on unit for breakfast in AM."

Review of the RI form revealed no documentation of where patient #7 was in a hold from 7:30PM-7:40PM. There was no documentation found on what happened to the patient after the hold or if the chemical restraint was effective. There was no documentation of what interventions were used with the de-escalation.

There was no further nursing documentation found until 6/26/15, at 11:59AM. The note stated, "8 hours of sleep, sound, Unable to complete physical/mental assessment due to patient asleep throughout the shift. Under the "Medication Compliant last 24 hours" section, the nurse circled "N", "missed 3:00PM Thorazine." There was no nursing documentation why the patient missed the Thorazine dose at 3:00PM.

Review of patient #7's verbal physician orders dated 9/26/2015, at 6:55PM stated, "hold 3:00PM dose of Thorazine 50mg po, give 9:00PM dose."

Review of the Medical Administration record (MAR) for 9/26/15, revealed the Thorazine 50mg po was held at 3:00PM and was blank for the 9:00PM dose. There was no documentation of the medication given at 9:00PM. There was no nursing or physician documentation found on why the scheduled dose was held and why the 9:00PM dose was not documented as administered. The medication was ordered by the physician to be held. However, the nurse documented as patient non-compliant.

Review of patient #7's nurse's note for 9/28/15, at 8:10PM, revealed patient #7 was upset after another phone call and was asked by the nurse to go to the quiet/seclusion room. Patient #7 refused and a code purple (Immediate danger) was called on the radio for help. Patient #7 charged the nurse and knocked her to floor. Patient #7 continued to assault the RN several times. Patient #7 was "held down 3 points then walked voluntarily to the quiet room. 8:20PM, Zyprexa 10mg po given started hitting med room door. Got an order of Zyprexa 10mg IM but he calmed down. 9:00PM, Patient calling and requested to go to his room apologized for what she did. 9:15PM, MHT accompanied her to room and slept." (SIC) (The patient is transgender and nurse changes from male to female pronouns in the nurse's note.) There was no order found for the patient hold. There was no face to face performed or any further documentation of patients' behavior or effectiveness of medication.

Review of the video footage for 9/28/15, at 8:10PM, revealed patient #7 was pacing the hallway in front of her room. The MHT was walking in and out of rooms taking linens and supplies to other patients. The MHT stops to talk to the patient several times. Patient #7 walks into her room and closes the door. The MHT attempts to open the door and has to unlock it. Patient #7 comes out of the room and stands in the doorway. The RN comes down the hallway and speaks to the patient. The patient is restless and fidgety. Patient #7 pushes the nurse backwards into the room across the hall. The video does not show inside the room. The nurse comes out of the room from a crawling position and attempts to run to the locked door. Patient #7 goes after the nurse dragging the MHT behind her. The patient kicks open the locked door into the foyer and continues after the nurse. Three other employees from other units attempt to stop the patient. One female MHT came up and used force to bring the patient to the ground.

Review of the video footage for 9/28/15, at 8:10PM, revealed patient #7 calming down and escorted to the quiet/seclusion room. The patient was placed in the room and the door was closed. A nurse came into view and opened a medication packet to put in the patients hand. The pill was dropped to the floor and the patient bent down to pick it up and took the medication from the dirty floor. The staff left out of view of the cameras and patient #7 came out of the seclusion room and began to bang the bathroom door open and closed multiple times. Patient #7 was unable to leave the common space area.

The quiet/seclusion room opened up to a small common area that was visible from the nurse's station from a window. This common space had access to the bathroom. However, all exit doors from this common area were locked. Once the patient was placed in the quiet / seclusion room the patient was able to come out of the room but could not leave the immediate area. Patient #7 was not able to go to her room or walk about the unit on her own.

An interview with staff #16 revealed the patient was put in "Quiet Room" and door was not locked. However, patient #7 was locked behind closed doors and the RN had to unlock the door to allow the patient to go to her room. Staff #16 reported the unit had 13 adolescent children and several of the patients were adult size. Staff #16 reported she felt unsafe being the only RN with that many adolescent patients.

Review of a Incident Report dated 9/28/15, revealed patient #7 was in an altercation with staff #16 (RN). Staff #16 stated, "I was pushed to the adjacent room hit bed down on the floor and 6x beaten on top of my head by patient #7." Staff #6 reported the injury happened at 8:15PM and she was not relieved to go to the Emergency Department until her shift was over at 12:00PM. Staff #16 was diagnosed with a head injury and cervical muscle strain."

Review of patient #7's physician order dated 9/29 (no year) at 8:42PM, revealed a verbal order was given for Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM x1 now. There was no reason in the order for the emergency medication.

Review of the RI dated 9/29 (no year) at 8:35PM that patient #7 was put in a hold until 8:50PM, a total of 15 minutes and then escorted at 8:50PM. Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM was documented as given on 9/26 (no year) and no time found. Under "clinical summary of intervention: patient attacked staff after visit with police officer had to be restrained by RN, MHT, and LPC received prn medication." There was no order found for the hold.

Review of the nurses notes dated 9/29 (no year) at 10:30, two hours later, revealed patient #7 had been in with the police due to the previous staff assault. Patient #7 was upset and started to slam doors. The RN attempted to talk to the patient and patient walked past the RN and attempted to get out of the locked doors. The Licensed Professional Counselor (LPC) slammed the door shut, locking it. Patient #7 slapped the LPC and a code purple was called. The patient was administered medication and escorted to the quiet room when she " **** (illegible) willingness to go to quiet room. Doc and family notified." There was no further reassessment of the patient found.

Review of the nurses note dated 9/30/15, at 10:45AM, stated, "Pt received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM d/t pt being aggressive." There was no further documentation found of a face to face, reason for the intervention, assessment of the patient after the medication administration or if the medication was effective. There was no nursing documentation if there was a hold or where the medication was administered.

Review of the nursing notes dated 9/30 (no year) at 11:00PM, stated, "set expectations for leaving quiet room and patient punches walls." Patient #7 was now in seclusion but there was no order for seclusion or assessment documented. There was no documentation on when the patient was allowed to leave the seclusion room.

Review of patient #7's physician order dated 10/1/15 at 9:00AM, stated, "1:1 for safety." (1:1- one staff member to one patient to stay within arms length.)

Review of patient #7's nurse's note dated 10/1/15, at 7:30AM, revealed "patient alert and oriented x4. pt was placed on 1-1 with staff . Pt integrated well with other peers. After lunch pt complained of a rapid heartbeat nurse took vitals BP- 120/88, R- 28, O2 sat- 97, and P- 139. MD ordered EKG stat and held her 3:00PM meds Thorazine 100mg po and valium 15mg po. Vital signs were reassessed in 30 minutes her pulse went down to 109. EKG results were prolonged QRST. MD ordered repeat EKG in the morning and decreased Thorazine to 75mg. Pt is walking around and interacting with peers on hall 600." There was no further documentation on why patient #7 was ordered to be on a 1:1 or when the 1:1 was removed.



2.) Review of patient #8's chart revealed the patient was a 15 year old, female, brought to the facility by her parents with a diagnosis of Severe Depression without psychosis. Pt was ordered to be on suicide precautions and every 15 minute observations.

Review of patient #8's physician orders, a verbal order was found, dated on 8/10 (no year) at 7:25PM. The order stated,

"1.) Benadryl 50mg IM now self -harming behavior.
2.) Thorazine 50mg IM now
3.) Restrain pt."

There was no order clarification on what type of restraint or for how long.

Review of patient #8's nurse's notes for 8/10/15, revealed staff #2 did not document the patient was on suicide precautions.

Review of patient #8's nurses notes for 8/10 (no year) at 10:00PM, stated, "Pt was upset at 5:15PM in cafeteria, crying, and requested to go out. Pt went back to the unit with the MHT. Then per MHT attempt to harm self, gear 3 was called (acting out) psychiatrist was notified and pt was restrained in hall laying face up. Receives emergency IM medications at 5:30PM. Thorazine 50mg and Benadryl 50mg IM. Pt continued with self-harming thoughts and cont. to beg to be let go so she could self-harm. "I need to cut." Pt was very apologetic but continued to beg and appears to fixate on a particular MHT. Released from hold was attempted x2 and pt has to be re-restrained immediately both times before being escorted to the quiet/seclusion room and restrained in the quiet room. At 6:35PM, pt asked to go to restroom, did not use restroom and did not cont. self-harming behavior and restraint was ended."

There was no documentation found of nursing interventions attempted before restraint. There was no information on what type of thoughts the patient was having or how she was attempting to cut herself in a safe environment. Review of the RI revealed patient #8 was held sitting from 5:25PM - 6:35PM. There was no documentation where the patient was being held, who was holding her, and what interventions were attempted to release the hold.







3.) On 10/9/2015, in the afternoon in the conference room the medical record (MR) for patient (Pt/pt) number (#) 2 was reviewed and revealed the following physician's order:


7/20/2015, at 10:50 a.m., "Zyprex/ Zydis (same drug) 10 mg (milligrams) IM (Intra Muscular) x 1 now". The physician's order failed to include the rational for the IM Zyprexa.


Review of the restraint record indicated the rationale for continuing the restraint intervention was "thrashing around/using physical aggression to get out of restraint".


The documentation found on the "Restrictive Intervention Report Form," indicated the behavior that resulted in emergency IM drug use and seclusion included all of the following: Verbal threats, threats to harm self, yelling, arguing, threatening to harm others, hit staff with both hands. Interventions were not specifically documented, however "Verbal de-escalation attempted". Review of the "Restrictive Intervention Observation Flow Sheet" reflected documentation that pt #2 was physically held for 10 minutes then released, during which time pt #2 was given the emergency IM dose of Zyprexa. The Seclusion restraint log indicated pt #2 was physically held, given Zyprexa IM as an emergency drug while in seclusion. Pt #2 was released as soon as the IM was given, with no further documentation of physical outburst, monitoring or interventions.


7/24/2015, at 7:25 p.m., a physician's order was identified to 1) may place in seclusion/restraint. 2) Ativan 2 mg IM with Haldol 5 mg with Benadryl 50 mg IM now emergency medication due to violent psychosis." The physician failed to include required behaviors to obtain release from seclusion. Review of the "Seclusion/Restraint face to face evaluation" revealed the behavior describes leading up to the seclusion or restraint as: assaulted peer, threw property at staff and ran through nurses station". "The Clinical Summary of Events: Pt placed in seclusion after having to be restrained after running through nurses station and hitting peer". Again there was no description of how or where pt #2 hit her peer. The nurses failed to document any assessment of pt #2 prior to the "Violent Psychosis," failed to document interventions attempted prior to the use of a placement of pt #2 in seclusion, or being held to administer the emergency injection. There was no further documentation of monitoring or assessment after pt #2 was given the IM Zyprexa.


7/26/2015, at 4:20 p.m., pt #2 was restrained. The psychiatrist signed a "Physician order for restrictive interventions for behavior" on 2/27/2015, at 2:00 p.m. Documentation identified from this form indicated pt #2 was restrained by physical force from 4:20 until 4:35 then she was seclude from 4:40 until 5:07 where "DC' d" (discontinued) appears of the form. The only information documented on this form was the date, time and method of restraint. The form was signed only by a Mental Health Tech (MHT). Documentation found on the seclusion/restraint form indicated the following: "Describe behaviors and or events leading up to the seclusion or restraint: Pt agitated c/o (complained of) hearing voices, aggressive towards staff". "Describe the patient's response to interventions including toleration, positive/negative behaviors, and and adverse psychological or physical reactions: Resisted PRT (Pt Restraint Time), agitated in seclusion then calm (Sic) down". Documentation did indicate pt #2 had been :"given rescue inhaler during PRT". No nursing documentation before or after reflecting intervention, observation s or monitoring or patient was found.


7/27/2015, at 8:45, pt #2 was restrained. The psychiatrist signed the "Physician Order for Restrictive Interventions for Behaviors" on 2/27/2015 at 2:00 p.m. Documentation found on the "Restrictive Intervention Observation/Assessment Flow Sheet" revealed pt #2 was placed in seclusion and held from 8:45-8:55 and given an IM emergency medication. Documentation found on the seclusion/restraint form under "Describe behaviors and or events leading up to seclusion or restraint: spitting, biting, kicking, cussing, yelling". Describe the patients's response to intervention including tolerance, positive/negative and any adverse psychological or physical reactions: Belligerent initially then calmed down". No nursing documentation of pt #2's behavior, interventions, assessment or monitoring prior to the outburst were found. No documentation of assessment after pt #2 left the seclusion room was found.


7/27/2015, at 4:22 p.m., a physician's order was identified to 1) Zyprexa 10 mg IM now emergency medications violent psychosis and 2) May seclude pt". Again the physician failed to include behaviors required to obtain release from seclusion. The "Assessment of the Immediate situation" included the following documentation: "spitting, biting, kicking, cussing and yelling". Nursing documentation failed to indicate who was being assaulted and if staff or peer was bitten by the patient. Review of the "Restrictive Intervention Observation/ Assessment Flow Sheet" revealed pt #2 was physically held for 10 minutes while the Emergency IM drug was administered and then she was released. The nurses failed to document any observations of monitoring, intervention or assessment prior to pt #2's outburst. The nursing documentation was limited to single descriptive words but gave no indication if the patient was alone in her room or with peers. There was no documentation of observation and monitoring after the injection was administered.


On 7/28/2015, at 4:50 p.m., a physician's order was identified as follows: "Zyprexa/Zydis 5 mg po now for violent aggression". Review the documentation for "Discontinuing the intervention" revealed a "Manual restraint used and released and a successive restrictive intervention not needed". Review of the "behaviors leading up to the seclusion or restraint" revealed the following: "Pt attacked peer after meeting with FNP (Family Nurse Practitioner) and being upset. She was on *****(illegible) related to *** (illegible) evening meal due to not following directions from prior staff."


On 7/29/2015, at 7:15 a.m., the psychiatrist signed a "Physician Order for Restrictive Interventions for Behaviors" for "Manual hold sitting or standing up to 1 hour manual restraint or seclusion. There was insufficient documentation from the nursing staff to determine what behaviors pt #2 exhibited that required restraint.


8/2/2015, 1:40 p.m., the psychiatrist signed a "Physician Order for Restrictive Interventions for Behaviors" the transport method was not identified but the restrictive intervention was identified as "sitting or Standing" "up to 1 hour for manual restraint or seclusion". The "Restrictive Intervention Observation/Assessment Flow Sheet" indicated pt #2 was secluded from "1:40 p.m. until 2:05 p.m.". Documentation found on the "Seclusion/Restraint evaluation form indicated the following: Describe behaviors and or events leading up to seclusion or restraint: Eloped from unit, ran to other unit, closed self in room, raised fist at Registered Nurse (RN)". "Describe the patient's response to intervention including toleration, positive/negative behaviors, and any adverse psychological or physical reactions: escorted cooperatively, yelled a short time then followed direction". The nursing staff placed pt #2 on 1:1 observation with a female staff. .


8/1/2015, at 8:00 p.m., a telephone order found on the "Physician's Orders" for Ativan 2 mg IM now x 1 for severe agitation".


8/1/2015, at 8:40 p.m., a telephone order found on the "Physician;s Orders" for Thorazine 25 mg IM now x 1 for continued agitation".


8/1/2015, at 9:20 p.m., a telephone order found on the "Physician's Orders" for Thorazine 25 mg IM now x 1 for continued agitation". These three injections were ordered sequentially over 1 hour and twenty minutes for a [AGE] year old child.


The only documentation found on the "seclusion/Restraint form as follows: Describe behaviors and or events leading up to seclusion or restraint: "Stole staff keys and badge, attempted to hit staff". Staff failed to secure their keys and badges and punished pt #2 when she took them. No violence was documented yet the nursing staff felt unable to manage pt #2's behavior. The staff;s inability to manage pt #2's behavior resulted in the pt #2 receiving three separate injection over a 1 hour and 20 minute time frame. Pt #2 received 50 mg of IM Thorazine and 2 mg of IM Ativan, as well as all her routine psychotropic mediations. There was no nursing documentation of assessment of pt #2 after she was medicated and placed in seclusion.


8/4/2015, at 9:45 a.m., the morning of discharge, only the nurses note reflected the following: "Pt placed into quiet room due to (d/t) severe agitation. Pt able to walk self into quiet room. Pt given Zyprexa 10 mg IM d/t severe agitation. Pt stayed in quiet room and rested in quiet room after IM injection." That is the final nursing entry for pt #2. There is no assessment or explanation as to how pt #2 left the facility or when she was discharged .



On 10/9/2015, in the late afternoon in the conference room the policies and procedures were reviewed and policy subject "Seclusion and Physical Restraint" revealed the following:


Page 1 of 20

1. Each patient has the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience or retaliation. Restraint of seclusion shall be an a way that is humane and caring and used in a way in which the patient;s rights, dignity, well being and safety are assured.

4. The uses of restraint or seclusion shall always be implemented, utilizing the least restrictive measures to prevent a patient from injuring self or others in an emergency safety situation. Any use of Restraint and/or Seclusion require clinical justification by a qualified registered nurse and must have a physician's order.


Page 5 of 20

Physical holding for forced medication: The application of force to physically hold a patient in order to administer a medication against the patient's wishes, is considered a restraint. The patient has a right to refuse medications, unless a court has ordered medication treatment. A court order for medication treatment only removes the patient;s right to refuse the medication. Additionally, in accordance with the State law, some patients may be medicated against their will in certain emergency circumstances, However, in both of these circumstances, health care staff is expected to use the least restrictive method administering the medication to avoid or reduce the risk of force. when possible. The use of force in order to medicate a patient , as with other restraint ,must have a physician's order prior to the application of the restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1- hour face-to-face evaluation requirement would also apply.


Page 8 of 20

d. If physical restraint is indicated, 2 staff must participate in the physical hold application. If the physical restraint/hold is on a small statured patient, one staff may implement the hold (e.g. Children's Control Position) while a second staff serves as a witness to monitor patient and staff safety for the duration of the hold.


Page 10 of 20

4. All least restrictive intervention or seclusion utilized to prevent the use of restraint or seclusion will be documented such as:

a. Emphasis of self-control
b. Appropriate venting of anger with a staff member
c. Discussion of the problem ina one-to-one meting with staff.
d. Separation form person contributing/feeding into the aggression or escalating behavior.
e. Emphasis on responsisbility for one's own choice behaviaor.


Page 13 of 20

d. Nursing staff/direct care staff monitors the physical and psychological status of the patient for a minimum of 30 minutes following release from seclusion of restraint.


Page 14 of 20

Notification of Registered Nurse to Clinical Director and Medical Director
1. b. A patient experiences two (2) or more separate episodes of restraint or seclusion of any duration within a twelve (12) hour period.

Documentation for Emergency Safety Interventions:
1. All restraint or seclusion will be documented by a qualified registered nurse in the patient's medical record and will reflect justification, implementation, and outcome of procedure (to include behavior at time of release) and shall address the failure of less restraint or seclusion.


Page 16 of 20

Restraint or seclusion Guidelines:
1. When a patient is placed in seclusion, the patient is searched to assure there are no objects on his/her person other than necessary clothing. All shoes, jackets and other potential harmful objects will be removed. More than one staff member must be present during the search.

The nursing staff failed to follow the facility policy for least restrictive restraint. The facility failed to document observations and interventions other than "talking" with patient prior to use of both physical and chemical restraint or seclusion. There was no documentation to support the excessive use of IM medication. There was no documentation explaining why it was necessary to physically hold pt #2, give her an injection and then place pt #2 in seclusion.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on chart reviews, interviews, policy and procedures the facility failed to:


A.) have RN supervision, failed to have adequate staffing of licensed personnel, failed to have a working schedule, and failed to maintain safety for patients and staff due to inadequate staffing. This deficient practice had the likelihood to cause harm to all presenting and in-patients in the hospital.

Refer to Tag A0392


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.





B.) Nursing failed to ensure the patients on the child and adolecent unit were assessed when appropriate on an ongoing basis and report findings to the attending physician. Nursing failed to assess the patients before and after restraints, ensure there were current orders for chemical, seclusion, and physical hold restraints, and document nursing interventions to prevent possible restraints.
Refer to Tag A0395

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.






C.) Based on record review and interview the facility failed to develop and keep current a care plan that identified the nursing care needs of 2 (#2 and #7) of 3 (#2, #7, and #8,) patients reviewed.

Refer to Tag A0396
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on chart reviews, interviews, and policy and procedures review, the facility failed to have RN supervision, failed to have adequate staffing of licensed personnel, failed to have a working schedule, and failed to maintain safety for patients and staff due to inadequate staffing. This deficient practice had the likelihood to cause harm to all presenting and in-patients in the hospital.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Review of the staffing schedule for 9/29/15-10/8/2015, revealed the facility was having difficulties in staffing the assigned schedules. Review of the staffing grid revealed the following staff to patient matrix. The staffing grid is the minimal staffing requirement, as seen by the facility, to meet their patient needs.

Adolescent Unit: Patient capacity is 20 for halls 500 and 600 combined. MHT are staffed per hall and nursing is staffed per unit.
1.) 1 RN for a census of 1-12 patients on day shift 7:00AM-3:00PM and evening 3:00PM- 11:00PM, 1 RN for a census of 1-14 patients on nights 11:00PM-7:00AM.
2.) 1 RN and 1 LVN for a census of 12-20 for days and evenings, 1 RN and 1 LVN for a census of 15-20 for nights.
3.) 1 MHT for a census of 1-8 patients and 2 MHT are assigned for 9-10 patients.

Geriatric Unit: Patient capacity is 16 for hall 200.
1.) 1 RN for a census of 1-12 patients for days and evenings and 1-14 patients on nights.
2.) 1 RN and 1 LVN for a census of 13-16 days and evenings and 15-16 on nights.
3. 1 MHT for a census of 1-8 patients and 2 MHT for 9-16 patients on all shifts.

Adult Unit: Patient capacity is 32 for halls 300 and 400 combined. MHT are staffed per hall and nurses are staffed per unit.
1.) 1 RN for a census of 1-10 days and evenings, 1-17 patients for nights.
2.) 1 RN and 1 LVN for a census of 11-24 patients days and evenings, 18-32 nights.
3.) 1 RN and 2 LVN are for a census of 25-32 for days and evenings.
4.) 1 MHT for 1-8 patients on all shifts and 2 MHT are for 9-18 patients all shifts, per hall.

Review of the staffing schedule dated 9/28/15- 10/8/2015 revealed out of 63 shifts from 9/28-10/4/2015 the facility was short 8 licensed personnel (6 RN positions) and 25 MHT positions. Reviews of the schedule from 10/5- 10/8/2015 revealed out of 36 shifts the facility was short 1 RN position and 15 MHT's. The following is a breakdown of the shifts and missing personnel according to the facility's schedule and matrix;

Geriatric Unit 200:
1.) On 9/30/15 - 1 MHT short on all three shifts, census was 9.
2.) On 10/2/15 - 1 MHT short on all three shifts, census was 10.
3.) On 10/3/15- 1 MHT was short on days and nights, census was 10.
4.) On 10/4/15- 1 MHT short on all three shifts, census was 11.
5.) On 10/5/2015- 1 MHT was short on evenings and nights, census was 12.
6.) On 10/6/2015- 1 MHT short on all three shifts, census was 10.
7.) On 10/7/2015- 1 MHT short on all three shifts, census was 11.
8.) On 10/8/2015-1 MHT was short on evenings and nights, census was 12.

Child and Adolescent Unit halls 500 and 600:
1.) On 9/28/2015- No RN assigned to the night shift, census 13.
2.) On 9/29/15- No RN assigned to the night shift. 1 MHT short for evening shift, census 13.
3.) On 9/30/15- No RN assigned to the night shift and short 1 LVN for days. Patient census was 14.
4.) On 10/1/15- No RN assigned to the night shift and short 1 LVN for days. Patient census was 12.
5.) On 10/3/15- No RN assigned to the night shift, census was 10.
6.) On 10/4/15- No RN assigned to the night shift, census was 10.
7.) On 10/5/15- No RN assigned to the night shift, census was 8.

Adult Unit halls 300 and 400:
1.) On 9/28/15- 1 MHT short on all three shifts, census was 32.
2.) On 9/29/15- 1 MHT short on days and evenings, census was 25.
3.) On 9/30/15- 1 MHT short on nights, census was 25.
4.) On 10/1/15- 1 MHT short on days and nights, census was 24.
5.) On 10/3/15- 1 MHT short on evenings and nights, census was 26.
6.) On 10/4/15- 1 MHT short on all three shifts, census was 26.
7.) On 10/5/15- 1 MHT short on days and nights, census was 28.
8.) On 10/6/15-1 MHT short on days, census was 28.
9.) On 10/7/15-1 MHT short on days and nights, census was 28.

" POLICY: The Director of Nursing (DON) will be responsible for assessing and evaluating the nursing staffing needs of all units. Staffing needs will be based on patient-nurse ration, acuity, safety concerns, staff mix and availability. During off shift, the Charge Nurse will be responsible, and will provide notice to the Administrator-On-Call. The designated staffing person will be responsible for calling in and off staff. Overtime, agency use, sick calls, call off's, education, training, PTO/EIL and other staffing issues will be tracked.
5.6 The master schedule, scheduling book and daily staffing sheets are to be updated to ensure consistency and correct information.
5.7 The DON will keep staffing schedules and daily staffing sheets in his/her office. "

An interview with staff #2 on 10/9/15 confirmed there was no working schedule for the facility. The working schedule shows the daily changes made to a schedule to ensure adequate staffing such as call in's, increase or decrease of census, when a 1:1 (one staff member to one patient within arm's length at all times) was required, or when additional staff were called in to work for behavioral issues on the unit.

Staff #2 reported the "Charge Nurse" is responsible for checking on the other units and assist with staffing. Staff #2 stated, "We use the charge nurse to monitor staffing needs on nights and weekends."

An interview with staff #2 on 10/9/2015 reported that she is on call 24/7 but she depends on the "Management Milieu" (employees who are trained to work as MHT's, not licensed personnel) to fill in when needed and monitor the schedule.

Staff #2 confirmed that she did not have the schedule and had to retrieve the information from staff #19's (Management Milieu employee) office. Staff #19 reported that she keeps up with the staffing and assists in making the schedules. Staff #19 and #2 could not provide a working schedule or staffing sheets that are updated on an ongoing basis to ensure consistency and correct information.

Review of the schedule revealed there was no RN scheduled for the night shift on the child and adolescent unit. Staff #2 was questioned why the shift was not covered on 9/28/2015- 10/1/15 and on 10/3/15. Staff #2 reported that they open the locked double doors from the other units and the RN can be available. Staff #2 was asked if the child and adolescent unit was opened to potential adult patients that were predators and psychotic. Staff #2 reported the unit hallways were locked and that could not happen.

Review of patient #2's chart revealed she had managed to have in her possession the employee keys, to the unit doors, from staff members on 2 occasions. Patient #2 was able to use the keys to leave the unit.

Staff #2 was questioned concerning RN coverage for breaks and face to face events. Staff #2 reported during the day the DON is available to cover for breaks. Staff #2 was questioned on who covers on the evening, nights, weekend, and holidays staff #2 stated, "We are different here we have provisions from our corporate office that states we don't have to have RN coverage. They are on radios and can come when they need to. "Staff #2 confirmed she was not aware of the federal guidelines for staffing. There was no written materials offered for "corporate provisions."

During a review of the staffing schedule for 10/8/15, with Staff #3 present, the census was not on the schedule for the child and adolescent units. Staff #3 attempted to call the unit to ask for the patient census but there was no answer. Staff #3 reported he would have to go to the unit. Surveyor followed staff #3 to the child and adolescent units. There was no visual staff or patients on the unit. Staff #3 and the surveyor walked to the cafeteria and found Staff #5 (RN) and a female MHT with the children in the cafeteria.

During an interview with Staff #5 on 10/8/15 revealed she was the only RN on the unit for 10 children. Staff #5 confirmed there was one MHT for each hall. Staff #5 confirmed that she has to leave the unit to come to the cafeteria due to licensed personnel have to be with the children as they eat. Staff #5 reported the child and adolescent unit can become very hostile at times and she does not feel safe with this many children and no other licensed personnel. The surveyor counted the children in the cafeteria and there were only eight children. Staff #5 reported there were two children on the unit with a MHT due to their bad behaviors and would have to eat on the unit.

Surveyor and Staff #3 immediately went to the child and adolescent unit and saw two female patients on the unit. The two girls were in a dayroom, with no camera's, with a male MHT. There was no other female staff with the children. The children were hungry and were asking when they could eat. The MHT reported their trays would be brought down later. The surveyor waited until the DON could come and cover the unit.

During a tour of the Geriatric Unit -200 on 10/9/2015 11:30PM, staff# 4 (RN) reported she was not a charge nurse. Staff #4 confirmed she was the only RN on that closed unit. Staff #4 reported that staff #6 was the charge nurse. Staff #4 was asked what RN relieves her for a break. Staff #4 stated, "no one." Staff #4 confirmed she has left the unit to go to the break room with no nurse on the unit.

An interview with staff #6 on 10/9/15 revealed this RN was the charge nurse. Staff #6 reported she started at the facility in January of 2015. Staff #6 was questioned about the schedule and staffing. Staff #6 reported she only calls about her unit if there is an issue with staffing.

Staff #6 was questioned by surveyor on the RN's responsibility as the charge nurse. Staff #6 reported she was told she was the charge nurse but was not sure what that entailed. Staff #6 stated, "I was just told to do it. I just do extra stuff the DON tells me to do." Staff #6 reported she was not given a pay increase or a job description of these specific duties related to the charge nurse position.

Staff #6 confirmed that there has been multiple times when no RN is available to work the child and adolescent unit. Staff #6 reported she was instructed by DON to leave the locked doors between the units open so she can monitor all four units. Staff #6 stated, "It has happened multiple times and I felt uncomfortable trying to manage all those patients. It's hard to chart and do assessments on one unit much less two. "Staff #6 confirmed she sometimes does not get a break because there is no one to relieve her. Staff #6 confirmed she has left the unit to go get a patient from admissions.

On 10/9/2015 at approximately 1:00 am, the surveyors observed the night RN from the child and adolescent unit leave the unit and walk approximately 80-100 yards through two double locked doors to escort a patient from admissions to the unit. There was no RN on the floor, for an extended period of time, for a census of 10 patients.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, interviews, and observation Nursing failed to ensure the patients on the child and adolecent unit were assssed when appropriate on an ongoing basis and report findings to the attending physician. Nursing failed to assess the patients before and after restraints, ensure there were current orders for chemical, seclusion, and physical hold restraints, and document nursing interventions to prevent possible restraints. Citing 2 (#7, #12) of 4 (#2, #7, #8, #12) patients reviewed.
These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.
2.) Review of patient #7's Psychiatric Evaluation dated 9/25/15 stated, "HISTORY OF PRESENT ILLNESS: The patient is a [AGE]-year-old female with a past psychiatric history of bipolar disorder with multiple past psychiatric hospitalization s, who presents secondary to the patient becoming increasingly aggressive and assaultive. As per chart, client was angry at school and was escalating for the past 3 days, had thoughts of wanting to harm the teacher. The patient escalated to the point where the police were called and the patient reportedly assaulted a police officer. The patient was taken to the emergency room , where she told staff she wanted to kill herself by stabbing herself.

Review of patient #7's Psychiatric Evaluation dated 9/25/15 at 12:48PM stated, "During initial assessment, the patient was angry and started throwing furniture around and making aggressive threatening gesture towards staff and a Code Purple had to be called. The patient was medicated with Zyprexa 10 mg IM.

During the Mental Status Exam dated 9/25/15 at 12:48PM revealed the psychiatrist documented, "The patient appears sedated and is superficially cooperative with the assessment. "

Review of patient #7's chart revealed no physician order or documentation of the drug Zyprexa given IM on 9/24/2015.

Review of the Physician History and Physical dated 9/24/15 at 4:29PM revealed the Nurse Practitioner (NP) that patient #7 "reports no BM in 3 days, usually has one every day. "There was no nursing intervention documented to address the constipation. There was no assessment of bowel sounds or discomfort found.

Review of the Physician History and Physical dated 9/24/15 at 4:29PM revealed patient #7's pulse was documented at 108.

Review of the policy and procedure "Vital Signs" stated,
"PROCEDURE
A. The staff member responsible for taking vital signs will record the vital signs in the appropriate column(s) as soon as practical after taking them.
B. The staff member responsible for taking vital signs will be responsible for making the licensed nurse aware of any vital signs that fall in the categories listed below in paragraph "D", they will also be responsible for the transfer of the vital signs into the EMR, if they are unable to accomplish this during their shift they must pass it on to the next shift.
C. If the vital signs are needed to administer medications, the nurse dispensing the medication will verify vital signs before administering medications.
D. Any of the following vital signs readings will be reported to the staff or unit nurse immediately.
1. Pulse - Greater than 100 beats per minute; or less than 50 beats per minute for more than one hour.
2. Blood Pressure - Greater than 150/90 or less than 100/60, OR: a reading of 20 mm Hg above the patient's normal systolic pressure, OR: a reading of 20 mm Hg below the patient ' s normal diastolic pressure.
3. Any elevation of temperature greater than 100 degrees. There was no further documentation found of vital signs until 9/25/15.
4. Respiration below 12 per minute or above 26 per minute."
There were no vital sign parameters for children addressed in the policy and procedures.

Review of patient #7's the vital sign sheet stated "date-9/25, time- night, Temperature (T) 98.1, Pulse (P) 120, Respirations (R) 16, Oxygen Saturation Percentage (O2 sat) 98, and Blood Pressure (B/P) 93/60." Patient #7's pulse has increased out of range. Review of the vital sign sheet stated, "date-9/25, time- day, (T) 98.0, (P) 108, (R) 18, (O2 sat) 98, and (B/P) 120/70." There was no time documented when the vital signs were taken.

There is no nursing documentation of increased pulse, nursing assessment, or intervention of the elevated pulse. There is no documentation that the licensed staff was aware or that the vital signs were evaluated before the nurse administered medications. There is no documentation that the licensed staff took a second set of vital signs to verify the MHT's findings or physician notification.

Review of patient #7's verbal physician orders dated 9/26/2015 at 6:55PM stated, "Staff #24 said hold 3:00PM dose of Thorazine 50mg po give 9:00PM dose. "Review of the Medical Administration record (MAR) for 9/26/15 revealed the Thorazine 50mg po was held at 3:00PM. There was no documentation that the medication was given at 9:00PM. There was no nursing or physician documentation found on why the scheduled dose was held and why the 9:00PM dose was not documented as administered.

Review of patient #7's verbal physician orders dated 9/26/2015 at 7:30PM stated, "Give Haldol 5mg, Ativan 1mg, and Benadryl 25mg IM now for sever agitation."

Review of patient #7's chart revealed a "Restrictive Intervention Reporting Form" (RI) dated 9/26 at 7:30PM. There was no year documented on the document. The form revealed patient #7 was placed in a hold from 7:30PM -7:40PM a total of 10 minutes. Patient #7 was administered Haldol 5mg, Ativan 1 mg, and Benadryl 25mg IM on "9/26 at 7:40PM." Review of patient #7's MAR revealed the injections were given at 7:45PM on 9/26/15 by the initials S.S. "Review of the MAR revealed there was no signature on the page that matched the initial S.S. "There was no documentation of the site of the injection and if the patient tolerated the medication. There was no clear documentation if the medication was given during or after the hold. There was no physician's order to hold the patient in a restraint position for 10 minutes. Staff #25 initiated the restraint and also did the face to face. There was no documentation of vital signs.

Review of the nurse's notes for 9/26/15 revealed 4 different "Daily Assessment Sheets." The following cardiac and administration of Emergent Psychotropic Medications assessments were as follows;

A.) 11:00PM-7:00AM- signed by nurse at 1:00AM- The form was blank under Cardiovascular, Pulses, Neuro, Precautions and Risk assessment. A box was checked by the statement, "Unable to complete physical/mental assessment due to patient asleep throughout the shift."

B.) 7:00AM-3:00PM - signed by nurse at 9:00AM- Under cardiovascular "N" was checked. Under pulses, "strong" was circled. There were no vital signs documented. There was no documented assessment of heart sounds or if the patient was symptomatic.

C.) 3:00PM-11:00PM- signed by nurse at 9:00PM. Under cardiovascular "N" was checked. Under pulses, "strong" was circled. Patient #7 had also been restrained and medicated with psychotropic emergency medication this shift. There were no vital signs documented. There was no documented assessment of heart sounds or if the patient was symptomatic. There was no patient name or patient identification on this note to determine if this belonged to patient #7.

D.) 11:00PM- 7:00AM- signed by nurse at 11:59PM. The form was blank under Cardiovascular, Pulses, Neuro, Precautions and Risk Assessment. A box was checked by the statement, "Unable to complete physical/mental assessment due to patient asleep throughout the shift."

Review of patient #7's physician progress notes revealed there was no documentation of patient's elevated pulse. There was no physician progress note found for 9/27/15.

Review of the vital sign sheet for 9/28/15, on the 11:00PM-7:00AM shift, revealed patient #7 had a pulse of 112 and no B/P reading. Written the B/P space stated, "No reading." The RN initials were in the RN initial box but there were no nursing interventions, assessments, or physician notification documented concerning the elevated pulse and absent B/P.

Review of patient #7's nurse's note for 9/28/15 at 8:10PM revealed patient #7 was upset after another phone call and was asked by the nurse to go to the quiet/seclusion room. Patient #7 refused and a code purple (Immediate danger) was called on the radio for help. Patient #7 charged the nurse and knocked her to floor. Patient #7 continued to assault the RN several times. Patient #7 was "held down 3 points then walked voluntarily to the quiet room. 8:20PM Zyprexa 10mg po given started hitting med room door. Got an order of Zyprexa 10mg IM but he calmed down. 9:00PM Patient calling and requested to go to his room apologized for what she did. 9:15PM MHT accompanied her to room and slept." (SIC)

The patient was transgender and nurse changes from male to female pronouns in the nurse's note. There was no order found for the patient hold. There was no face to face performed or any further documentation of patient ' s behavior or effectiveness of medication.

Review of the video footage for 9/28/15 at 8:10PM revealed patient #7 was pacing the hallway in front of her room. The MHT was walking in and out of rooms taking linen and supplies to other patients. The MHT stops to talk to the patient several times. Patient #7 walks into her room and closes the door. The MHT attempts to open the door and has to unlock it. Patient #7 comes out of the room and stands in the doorway. The RN comes down the hallway and speaks to the patient. The patient is restless and fidgety. Patient #7 pushes the nurse backwards into the room across the hall. The video does not show inside the room. The nurse comes out of the room from a crawling position and attempts to run to the locked door. Patient #7 goes after the nurse dragging the MHT behind her. The patient kicks open the locked door into the foyer and continues after the nurse. Three other employees from other units attempt to stop the patient. One female MHT came up and used force to bring the patient to the ground.

Review of the video footage for 9/28/15 at 8:10PM revealed patient #7 calming down and escorted to the quiet/seclusion room. The patient was placed in the room and the door was closed. A nurse came into view and opened a medication packet to put in the patients hand. The pill was dropped to the floor and the patient bent down to pick it up and took the medication from the dirty floor. The staff left out of view of the camera's and patient #7 came out of the seclusion room and began to bang the bathroom door open and closed multiple times. Patient #7 was unable to leave the common space area.

The quiet/seclusion room opened up to a small common area, that was visible from the nurses station from a window. This common space held access to the bathroom. However, all exit doors from this common area were locked. Once the patient was placed in the quiet / seclusion room the patient was able to come out of the room but could not leave the immediate area. Patient #7 was not able to go to her room or walk about the unit on her own.

An interview with staff #16 revealed the patient was put in "Quiet Room" and door was not locked. However, patient #7 was locked behind closed doors and the RN had to unlock the door to allow the patient to go to her room. Staff #16 reported the unit had 13 adolescent children and several of the patients were adult size. Staff #16 reported she felt unsafe being the only RN with that many adolescent patients.

Review of patient #7's physician order dated 9/29 (no year) at 8:42PM revealed a verbal order was given for Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM x1 now. There was no reason on the order for the emergency medication.

Review of the RI dated 9/29 (no year) at 8:35PM that patient #7 was put in a hold until 8:50PM a total of 15 minutes and then escorted at 8:50PM. Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM was documented as given on 9/29 (no year) and no time found. Under " clinical summary of intervention: patient attacked staff after visit with police officer had to be restrained by RN, MHT, and LPC received prn medication." There was no order found for the hold.

Review of the nurses notes dated 9/29 (no year) at 10:30 , two hours later, revealed patient #7 had been in with the police due to the previous staff assault. Patient #7 was upset and started to slam doors. The RN attempted to talk to the patient and walked past the RN and attempted to get out of the locked doors. The Licensed Professional Counselor (LPC) slammed the door shut, locking it. Patient #7 slapped the LPC and a code purple was called. The patient was administered medication and escorted to the quiet room when she " **** (illegible) willingness to go to quiet room. Doc and family notified." There was no further re-assessment of the patient found for this shift.

Review of the vital sign sheet revealed patient #7's vitals were only recorded once on the day shift. No specific time documented. Patient 's pulse was 81.

Review of the nurses note dated 9/30/15 at 10:45AM stated, "Pt received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM d/t pt. being aggressive." There was no further documentation found of a face to face, reason for the intervention, assessment of the patient after the medication administration, or if the medication was effective. There was no nursing documentation if there was a hold or where the medication was administered.

Review of the nursing notes dated 9/30 (no year) at 11:00PM stated, "set expectations for leaving quiet room and patient punches walls." Patient #7 was now in seclusion but there was no order for seclusion or assessment documented. There is no documentation on when the patient was allowed to leave the seclusion room.

Review of patient #7's physician order dated 10/1/15 at 9:00AM stated, " 1:1 for safety." (1:1- one staff member to one patient to stay within arm's length.) There was no further documentation on why patient #7 was ordered to be on a 1:1.

Review of patient #7's nurse's note dated 10/1/15 at 7:30AM, " patient alert and oriented x4. pt. was placed on 1-1 with staff . Pt integrated well with other peers. After lunch pt. complained of a rapid heartbeat nurse took vitals BP- 120/88, R- 28, O2 sat- 97, and P- 139. MD ordered EKG stat and held her 3:00PM meds Thorazine 100mg po and valium 15mg po. EKG results were prolonged QRST physician ordered repeat EKG in the morning and decreased Thorazine to 75mg. Pt is walking around and interacting with peers on hall 600." Vital signs were reassessed in 30 minutes her pulse went down to 109.

Review of the physician note dated 10/1/15 at 12:40PM stated, "Pt c/o chest pain that is sharp, worsens when she moves 9/10. Pt. is Tachycardic (139). Pt allowed to leave quiet room to calm down. B/P- 125/88, O2 sat 97%, RR- 20. MD documented the patient was "sedated" and "slapped staff 1 day ago." Under assessment MD documented, "Bipolar, v/s repeated at 1:20PM B/P 91/51, P- 109, RR- 20, pain 6/10. Hold Thorazine and Valium due to sedation stop Lamictal. Will decrease Thorazine to 75 mg TID and repeat EKG in AM. "

Review of patient #7's vital sign sheet dated 10/1/15 revealed in the "evening time" patient #7 had a pulse rate of 127 and 102 on the night shift. There was no nursing documentation of nurse assessment for elevated pulse, if MD was notified, documentation found on nursing assessment under Cardiovascular stated, "N" and Pulses: "strong." There was no further nursing assessments concerning the patients' vital signs or if the patient was still symptomatic.

Review of the chart revealed the second EKG was performed on 10/2/15 at 10:00AM. The EKG showed "Abnormal EKG, Long QT interval." Review of the nurse's notes at 10:00AM stated, "Patient alert and oriented x4. Patient got a repeat EKG. Physician notified of results received new orders. Documentation found on nursing assessment under Cardiovascular stated, "N" and Pulses: "strong." There were no vital signs documented for 10/2/2015 or further assessment of the patients' cardiovascular status.

Review of the physician orders dated 10/2/2015 reveled Patient #7's Thorazine was to be decreased to 50mg three times a day and patient #7 was to be discharged . There was no physician progress note found for 10/2/15. There was no evidence found that patient #3 was seen by the physician before discharge on 10/2/15.

Review of patient #7's Discharge Instructions and Plan revealed there was no documentation for patient #7 to follow up with her MD or cardiologist concerning her elevated pulse rate and abnormal EKG. There was no assessment of the patients' cardiovascular status at discharge or vital signs.

Review of patient #7's treatment plan revealed no documentation of the patient #7's elevated pulse, abnormal EKG, or over sedation, or cardiovascular status.


3.) Review of patient #12's chart revealed on 10/7/2015 patient #12 was admitted involuntarily to the facility with a diagnosis of schizoaffective disorder. Patient #12 was admitted with an Emergency Detention Warrant for suicidal and homicidal ideations. Patient #12 had reported she was hearing voices and wanted to cut her neck.
Review of the Nurses notes dated 10/8/15 at 3:15AM revealed an assessment was not completed. The nurse checked a box statement that stated, "Unable to complete physical/ mental assessment due to patient asleep throughout the shift." Under the heading Medication Compliant: "Pt will begin scheduled meds 10/8/15 at 9:00AM."
Review of the Physician orders revealed the patient had three medications ordered on [DATE] to be given at nighttime. Seraquel 800mg, Lithium 600mg, and Latuda 80mg. Patient #12 had reported that she had taken her medication before she came in to be admitted .
Review of patient #12's therapy notes revealed patient #7 was in group from 10:15-11:15AM on 10-8 2015. The note stated, "Patient #12 came in and out of group despite asking her to please stay because it disrupts the group when people are in and out. She did not appear to be responding to internal stimuli but appears depressed AEB stating she does not really like herself and she has no self-esteem."
Review of the physician orders dated 10-8-15 at 1:00PM revealed patient #12 was ordered medications to be given now as follows:
1.) Depakote ER( mood stabilizer) 250mg by mouth twice a day
2.) Klonopin (Benzodiazepine) 0.9mg by mouth twice a day.
3.) Ativan (anti-anxiety) 2mg by mouth every 4 hours as needed for anxiety.
4.) Risperdal (Atypical antipsychotic) 0.5mg by mouth twice a day.
5.) Lithium level in am.
Review of the chart revealed there was no medication administration record found. There was no evidence medication was administered. Patient #12 had a history of seizures.
Review of the MHT notes for 10/8/2015 revealed patient #12 stated, "Pt. was crying saying she was tired and wants to lay down and sleep. Pt began to hear voices on 10/8/15 at 1:00PM."
Review of the patient observation sheet for 10/8/2015 for patient #12 revealed the following;
1:00PM patient #12 was crying.
1:15PM patient #12 was in the dayroom lying/sitting.
1:30PM patient #12 was in the Consultation room with Doctor/NP/Nurse.
1:45PM patient was in Quiet Room agitated and restless.
Review of the Therapy Notes for group on 10/8/2015 at 1:15PM revealed, "Patient was present for the first five minutes of group. Patient walked in circles in the middle of the group room and would not respond when therapist spoke to her. Patient left the group and did not return. Patient appeared distressed." There was no further documentation that the therapist spoke to the nurse and reported the patient behavior or contact with the psychiatrist. There were no further interventions documented.
There was no nursing documentation of the patient's behavior in group or emotional outburst with the MHT documented. There was no documentation of why the patient was in the quiet/seclusion room. There was no documentation that the patient requested to go to the room or was taken by staff due to previous outburst of anger and aggression documented by the MHT. There was no physician order to place the patient in seclusion.
Review of the nurse's notes for 10/8/2015 at 2:00PM stated, "Pt alert and oriented x4. Pt asks to go to bathroom. Staff overheard pt talking loudly to herself. Nurse was notified. Nurse saw pt. on her knees over the toilet talking to the voices. Pt was having audio and visual hallucinations. Pt. was pacing back and forth in the quiet room and would not respond to staff when asking her questions. Pt received Ativan 2mg po, Risperdol 0.5mg po, Depakote ER 250mg po, Klonopin 0.5mg po. Pt. still not calm after 30 minutes pt. verbalized to the nurse what the voices are telling her. Nurse got patients mattress and put it in the seclusion room. Pt will not lay down for long. Psychiatrist reports patient needs to have a very quiet environment. Pt has been in the quiet room and seclusion almost 2 hours. Pt vital signs are stable B/P 132/84, P 112, R- 18, O2 sat 99%. Nurse will continue to observe."
There were no orders for seclusion. There was no documentation of a face to face or any nursing interventions other than a quiet room and ordered medications administered. There was no nursing documentation found on the patient until 10/8/15 at 4:00PM two hours later.
Review of the nurses note for 10/8/15 at 4:00PM stated, "pt. alert and oriented x4. Pt is having audio and visual hallucinations pt is in the quiet room and attempted to leave out behind the MHT pt got middle left finger caught in door causing a deep laceration. Pt was transferred to the hospital for medical attention. Pt transported by ambulance at 4:40PM. Pt v/s stable HR-100. Pt calm and cooperative during transportation. 5:00PM Pt made it safely to the hospital."
There was no found documentation of complete vital signs after the injury. There was no documentation describing the patients wound, who went with the patient to the hospital, if the hospital was given report and was aware of her medical/ mental/legal condition. There was no nursing documentation of when the patient returned from the hospital, if she had any food/ fluids, or an assessment of the patient. There was no documentation of the patient mental status after she returned to the facility or any physician notification for further orders.
Review of the MHT observation record on 10/8/15 at 7:15PM revealed that patient #12 was back in the quiet/seclusion room sleeping until 11:15PM then returned to her room. There was no found documentation of why the patient was in the quiet/seclusion room.
An interview was conducted with staff #6 (RN) on 10/8/15 at 11:45PM. Staff #6 reported that she had just come on duty and was not present during patient #12's accident but she had received in report that patient #12 had gotten her finger caught in the door of the quiet room and required six stitches in her left finger. Staff# 6 reported that she understood patient #12 was getting loud and disruptive in the hallway. The nurse put her in the seclusion room to get her away from the others. When staff #6 was asked where the orders were for the seclusion room she responded, "We don't have to get an order if the door is not locked to the seclusion room." If they can come out on their own it's not considered seclusion. We were told we have to physically hold the door handle down to consider that seclusion." Surveyor viewed the seclusion room on 10/9/15 at 12:05AM and there was no patient in there at that time.
An interview was conducted with patient #12 on 10/9/2015. Patient #12 reported that she was hearing voices last night and tried to explain it to the nurse. Patient #12 reported that she knew she was getting out of control but no one would ask her what was wrong. "They just made me go into that room. They said I had to go in there to keep me calm and wouldn't let me go to my room. When the tech came in I was trying to leave and she pushed me back in and slammed the door on my finger. It hurt really bad. It really made me mad when she tried to blame me. I would have been alright with it if she just would apologize." Staff #12 reported that she agreed to go back into the quiet/seclusion room when she got back because that is where her mattress was and she was really sleepy.
Review of the facility's policy and procedure "Seclusion and Physical Restraint Hold " stated,

"Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. Seclusion is not just confining a patient to an area, but involuntarily confining the patient alone in a room or area where the patient is physically prevented from leaving, if a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention of the patient attempts to leave the room, the room is considered locked, whether the door is actually locked or not. A patient physically restrained alone in an unlocked room does not constitute seclusion. Confinement on a locked unit or ward where the patient is with others does not constitute seclusion."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to develop and keep current a care plan that identified the nursing care needs of 2 (#2 and #7) of 3 (#2, #7, and #8,) patients reviewed.

1.) On 10/9/2015 in the afternoon in the conference room the medical record (MR) for patient (Pt/pt) #2 (number two) was reviewed. Documentation found in the "Psychiatrist Evaluation" indicated "The patient is a [AGE] year-old African American female with multiple past psychiatric hospitalization (sic) including an over one-month hospitalization at a state institution, where she was just discharged 4 days ago, presents secondary to patient having auditory hallucinations and severe anxiety. The patient reports feeling depressed, having anhedonia (unable to feel emotion), decrease energy. The patient is also angry and irritable. She is intermittently hostile and aggressive. The patient reports that the voices are telling her to kill her (sic) and the voices are of her stepfather who sexually abused her for years. The patient was taken away from her parents for neglect. The patient was physically and sexually abused as a child. She went into a foster family for approximately 1 month and was abused there as well sexually and physically and then was staying with her aunt. The patient however, had been in the hospital more than she had been at home. The patient has active suicidal ideation. She stated that she does want to kill herself. Does not express a plan, but denies homicidal ideation. No frank delusions elicited and no history of mania or hypomania".

Review of the initial "Interdisciplinary Treatment Plan" is as follows:

Pt #2 "Assets" were documented as: "supportive family and friends, motivation for treatment/growth, Special hobby/interest-dancing"

Pt #2's "Stressors" were documented as: Loss of contact with parents, legal issues, marital or family conflict, traumatic events.

"Patient stated goal #1: To control my anxiety and anger".
"Patient stated Goal #1: To learn cool stuff".

The following were documented as "Problems" for Pt #2:

"7/19/2015 problem #1 Asthma, evaluate and treat".
"7/20/2015 problem #2 Altered thought process, evaluate and treat".
"7/20/2015 problem #3 Altered mood, depressed, evaluate and treat".
"7/20/2015 problem #4 Seclusion/restraint, evaluate and treat".

The following statement was identified above the signature spaces for attendees:
"This treatment plan has been presented to and reviewed with the patient and/or family member(s).The patient and family member(s) have been given the opportunity to ask questions and make suggestions.

The following statement was documented: "Pt unable to sign-sedated" 7/19/2015 3:48 p.m."

The "Initial Treatment Plan Developed By", include the following disciplines: Nursing, Social Worker, Recreational Therapy, Licensed Practical Counselor Intern, Registered Dietician, and Psychiatrist. Neither the family (pt #2's Aunt) nor pt #2 were present for the initial treatment plan. Pt #2 signed the document with her first name on 7/20/2015.

The "Short term goals and interventions" dated 7/20/2015 contained the following single objective: "Patient will be restraint free for at least 48 hours before discharge". The target date was 7/26/2015 the review dates were listed as 7/24, 7/26, 7/27,and 8/2. Each date indicated "Continuation" of the target. Pt #2 was discharged on [DATE].

The "Interventions" dated 7/20/2015, contained the following single intervention: "Patient will attend daily process psychoeducational groups to discuss triggers and coping skills". There was no target date and no other objectives or goals documented.


Review of pt #2's MR revealed she suffered from drug induced abnormal hunger that resulted in weight gain. The following documentation revealed the facilities efforts to control patient #2's weight gain:

On 7/20/2015 at 3:40 p.m., the Registered Dietician (RD) documented the following: "Titrating off Zyprexa Zydis. D/C (discharged ) from ASH 4 days ago. Pt reports weight gain, *** (illegible) from extreme hunger from medications. Pt agreed to try to eat only one plate at meals. Pt will be limited to one plate to prevent further weight gain. Follow up in 2-3 days".

On 7/20/2015 at 11:42 a.m., "Physician's Orders" revealed: "Gatorade 2, 8 oz. (Ounces) TID (three times a day)".

On 7/20/2015 at 3:50 p.m. "Physician's Orders" revealed: "Pt is only to have one (1) helping at all meals. Pt may have main entree, sides and salad if desired- prevent weight gain".

On 7/22/2015 at 1055 a.m., "Physician's Orders" revealed: "Pt may have second helpings of salad at meals".

On 7/30/2015 at 1:00 p.m., "Physician's Orders" (written by the RD) revealed: "D/C (discontinue) any restrictions on pt's portions at meals. Consult with RD if pt shows signs of binge eating ( greater than 200 percent at meals)".

The psychiatrist documented in her admission note the following: "The patient has had trial of Zyprexa, which worked initially, and was maximized to 30 mg. However, the patient has gained significant weight on that medication".

The treatment plan reflected pt #2 was offered no aid to assist in dealing with her extreme hunger that was caused by the physician ordered drug. Pt #2 was restricted from food and left to deal with her hunger on her own.

Review of the documents titled "Restrictive Interventions-Behavioral Assessment" revealed the following dates and times of physical and verbal outburst that resulted in emergency medications and restraint usage:

7/20/2015 10:45 a.m.
7/24/2015 7:23 p.m.
7/26/2015 4:20 p.m.
7/27/2015 8:45 p.m.
7/28/2015 4:55 p.m.
7/29/2015 7:15 a.m.
8/2/2015 1:40 p.m.
8/2/2015 9:15 p.m.

Review of these times revealed the times were within 2 hours before and after meals and near bedtime.







2.) Review of patient #7's Psychiatric Evaluation dated 9/25/15 stated, "HISTORY OF PRESENT ILLNESS: The patient is a [AGE]-year-old female with a past psychiatric history of bipolar disorder with multiple past psychiatric hospitalization s, who presents secondary to the patient becoming increasingly aggressive and assaultive. As per chart, client was angry at school and was escalating for the past 3 days, had thoughts of wanting to harm the teacher. The patient escalated to the point where the police were called and the patient reportedly assaulted a police officer. The patient was taken to the emergency room , where she told staff she wanted to kill herself by stabbing herself.

Review of patient #7's Psychiatric Evaluation dated 9/25/15 at 12:48PM stated, "During initial assessment, the patient was angry and started throwing furniture around and making aggressive threatening gesture towards staff and a Code Purple had to be called. The patient was medicated with Zyprexa 10 mg IM.

During the Mental Status Exam dated 9/25/15 at 12:48PM revealed the psychiatrist documented, "The patient appears sedated and is superficially cooperative with the assessment. "

Review of patient #7's chart revealed no physician order or documentation of the drug Zyprexa given IM on 9/25/2015.

Review of the Physician History and Physical dated 9/24/15 at 4:29PM revealed the Nurse Practitioner (NP)documented that patient #7 "reports no BM in 3 days, usually has one every day. "There was no nursing intervention documented to address the constipation. There was no assessment of bowel sounds or discomfort found.

Review of the Physician History and Physical dated 9/24/15 at 4:29PM revealed patient #7's pulse was documented at 108.

Review of the policy and procedure "Vital Signs" stated,
"PROCEDURE
A. The staff member responsible for taking vital signs will record the vital signs in the appropriate column(s) as soon as practical after taking them.
B. The staff member responsible for taking vital signs will be responsible for making the licensed nurse aware of any vital signs that fall in the categories listed below in paragraph "D", they will also be responsible for the transfer of the vital signs into the EMR, if they are unable to accomplish this during their shift they must pass it on to the next shift.
C. If the vital signs are needed to administer medications, the nurse dispensing the medication will verify vital signs before administering medications.
D. Any of the following vital signs readings will be reported to the staff or unit nurse immediately.
1. Pulse - Greater than 100 beats per minute; or less than 50 beats per minute for more than one hour.
2. Blood Pressure - Greater than 150/90 or less than 100/60, OR: a reading of 20 mm Hg above the patient's normal systolic pressure, OR: a reading of 20 mm Hg below the patient ' s normal diastolic pressure.
3. Any elevation of temperature greater than 100 degrees.
4. Respiration below 12 per minute or above 26 per minute."
There were no vital sign parameters for children addressed in the policy and procedures.

Review of patient #7's vital sign sheet stated "date-9/25, time- night, Temperature (T) 98.1, Pulse (P) 120, Respirations (R) 16, Oxygen Saturation Percentage (O2 sat) 98, and Blood Pressure (B/P) 93/60." Patient #7's pulse had increased out of range. Review of the vital sign sheet stated, "date-9/25, time- day, (T) 98.0, (P) 108, (R) 18, (O2 sat) 98, and (B/P) 120/70." There was no time documented when the vital signs were taken.

There was no nursing documentation of increased pulse, nursing assessment, or intervention of the elevated pulse. There is no documentation that the licensed staff was aware or that the vital signs were evaluated before the nurse administered medications. There was no documentation that the licensed staff took a second set of vital signs to verify the MHT's findings or physician notification.

Review of patient #7's verbal physician orders dated 9/26/2015 at 6:55PM stated, "Staff #24 said hold 3:00PM dose of Thorazine 50mg po give 9:00PM dose. "Review of the Medical Administration record (MAR) for 9/26/15 revealed the Thorazine 50mg po was held at 3:00PM. There was no documentation that the medication was given at 9:00PM. There was no nursing or physician documentation found on why the scheduled dose was held and why the 9:00PM dose was not documented as administered.

Review of patient #7's verbal physician orders dated 9/26/2015 at 7:30PM stated, "Give Haldol 5mg, Ativan 1mg, and Benadryl 25mg IM now for severe agitation."

Review of patient #7's chart revealed a "Restrictive Intervention Reporting Form" (RI) dated 9/26 at 7:30PM. There was no year documented on the document. The form revealed patient #7 was placed in a hold from 7:30PM -7:40PM, a total of 10 minutes. Patient #7 was administered Haldol 5mg, Ativan 1 mg, and Benadryl 25mg IM on "9/26 at 7:40PM." Review of patient #7's MAR revealed the injections were given at 7:45PM on 9/26/15 by the initials S.S. "Review of the MAR revealed there was no signature on the page that matched the initial S.S. "There was no documentation of the site of the injection and if the patient tolerated the medication. There was no clear documentation if the medication was given during or after the hold. There was no physician's order to hold the patient in a restraint position for 10 minutes. Staff #25 initiated the restraint and also did the face to face. There was no documentation of vital signs.

Review of the nurse's notes for 9/26/15 revealed 4 different "Daily Assessment Sheets." The following cardiac and administration of Emergent Psychotropic Medications assessments were as follows:
11:00PM-7:00AM- signed by nurse at 1:00AM- The form was blank under Cardiovascular, Pulses, Neuro, Precautions and Risk assessment. A box was checked by the statement, "Unable to complete physical/mental assessment due to patient asleep throughout the shift."
7:00AM-3:00PM - signed by nurse at 9:00AM- Under cardiovascular "N" was checked. Under pulses, "strong" was circled. There were no vital signs documented. There was no documented assessment of heart sounds or if the patient was symptomatic.
3:00PM-11:00PM- signed by nurse at 9:00PM. Under cardiovascular "N" was checked. Under pulses, "strong" was circled. Patient #7 had also been restrained and medicated with psychotropic emergency medication this shift. There were no vital signs documented. There was no documented assessment of heart sounds or if the patient was symptomatic. There was no patient name or patient identification on this note to determine if this belonged to patient #7.
11:00PM- 7:00AM- signed by nurse at 11:59PM (one hour into shift). The form was blank under Cardiovascular, Pulses, Neuro, Precautions and Risk Assessment. A box was checked by the statement, "Unable to complete physical/mental assessment due to patient asleep throughout the shift."
Review of patient #7's physician progress notes revealed there was no documentation of patient's elevated pulse. There was no physician progress note found for 9/27/15.

Review of the vital sign sheet for 9/28/15, on the 11:00PM-7:00AM shift, revealed patient #7 had a pulse of 112 and no B/P reading. Written in the B/P space stated, "No reading." The RN initials were in the RN initial box but there were no nursing interventions, assessments, or physician notification documented concerning the elevated pulse and absent B/P.

Review of patient #7's nurse's note for 9/28/15 at 8:10PM revealed patient #7 was upset after another phone call and was asked by the nurse to go to the quiet/seclusion room. Patient #7 refused and a code purple (Immediate danger) was called on the radio for help. Patient #7 charged the nurse and knocked her to floor. Patient #7 continued to assault the RN several times. Patient #7 was "held down 3 points then walked voluntarily to the quiet room. 8:20PM Zyprexa 10mg po given started hitting med room door. Got an order of Zyprexa 10mg IM but he calmed down. 9:00PM Patient calling and requested to go to his room apologized for what she did. 9:15PM MHT accompanied her to room and slept." (SIC) (The patient was transgender and nurse changes from male to female pronouns in the nurse's note.) There was no order found for the patient hold. There was no face to face performed or any further documentation of patient's behavior or effectiveness of medication.

Review of the video footage for 9/28/15 at 8:10PM revealed patient #7 was pacing the hallway in front of her room. The MHT was walking in and out of rooms taking linen and supplies to other patients. The MHT stops to talk to the patient several times. Patient #7 walks into her room and closes the door. The MHT attempts to open the door and has to unlock it. Patient #7 comes out of the room and stands in the doorway. The RN comes down the hallway and speaks to the patient. The patient is restless and fidgety. Patient #7 pushes the nurse backwards into the room across the hall. The video does not show inside the room. The nurse comes out of the room from a crawling position and attempts to run to the locked door. Patient #7 goes after the nurse dragging the MHT behind her. The patient kicks open the locked door into the foyer and continues after the nurse. Three other employees from other units attempt to stop the patient. One female MHT came up and used force to bring the patient to the ground.

Review of the video footage for 9/28/15 at 8:10PM revealed patient #7 calming down and escorted to the quiet/seclusion room. The patient was placed in the room and the door was closed. A nurse came into view and opened a medication packet to put in the patients hand. The pill was dropped to the floor and the patient bent down to pick it up and took the medication from the dirty floor. The staff left out of view of the cameras and patient #7 came out of the seclusion room and began to bang the bathroom door open and closed multiple times. Patient #7 was unable to leave the common space area.

The quiet/seclusion room opened up to a small common area, that was visible from the nurses station from a window. This common space held access to the bathroom. However, all exit doors from this common area were locked. Once the patient was placed in the quiet/seclusion room the patient was able to come out of the room but could not leave the immediate area. Patient #7 was not able to go to her room or walk about the unit on her own.

An interview with staff #16 revealed the patient was put in "Quiet Room" and door was not locked. However, patient #7 was locked behind closed doors in the common area and the RN had to unlock the door to allow the patient to go to her room. Staff #16 reported the unit had 13 adolescent children and several of the patients were adult size. Staff #16 reported she felt unsafe being the only RN with that many adolescent patients.

Review of patient #7's physician order dated 9/29 (no year) at 8:42PM revealed a verbal order was given for Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM x1 now. There was no reason on the order for the emergency medication.

Review of the RI dated 9/29 (no year) at 8:35PM that patient #7 was put in a hold until 8:50PM a total of 15 minutes and then escorted at 8:50PM. Haldol 5mg, Ativan 2 mg, and Benadryl 50mg IM was documented as given on 9/29 (no year) and no time found. Under " clinical summary of intervention: patient attacked staff after visit with police officer had to be restrained by RN, MHT, and LPC received prn medication." There was no order found for the hold.

Review of the nurses notes dated 9/29 (no year) at 10:30 , two hours later, revealed patient #7 had been in with the police due to the previous staff assault. Patient #7 was upset and started to slam doors. The RN attempted to talk to the patient and patient walked past the RN and attempted to get out of the locked doors. The Licensed Professional Counselor (LPC) slammed the door shut, locking it. Patient #7 slapped the LPC and a code purple was called. The patient was administered medication and escorted to the quiet room when she " **** (illegible) willingness to go to quiet room. Doc and family notified." There was no further re-assessment of the patient found for this shift.

Review of the vital sign sheet revealed patient #7's vitals were only recorded once on the day shift. No specific time documented. Patient 's pulse was 81.

Review of the nurses note dated 9/30/15 at 10:45AM stated, "Pt received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM d/t pt. being aggressive." There was no further documentation found of a face to face, reason for the intervention, assessment of the patient after the medication administration, or if the medication was effective. There was no nursing documentation if there was a hold or where the medication was administered.

Review of the nursing notes dated 9/30 (no year) at 11:00PM stated, "set expectations for leaving quiet room and patient punches walls." Patient #7 was now in seclusion but there was no order for seclusion or assessment documented. There is no documentation on when the patient was allowed to leave the seclusion room.

Review of patient #7's physician order dated 10/1/15 at 9:00AM stated, " 1:1 for safety." (1:1- one staff member to one patient to stay within arm's length.) There was no further documentation on why patient #7 was ordered to be on a 1:1.

Review of patient #7's nurse's note dated 10/1/15 at 7:30AM, " patient alert and oriented x4. pt. was placed on 1-1 with staff . Pt integrated well with other peers. After lunch pt. complained of a rapid heartbeat nurse took vitals BP- 120/88, R- 28, O2 sat- 97, and P- 139. MD ordered EKG stat and held her 3:00PM meds Thorazine 100mg po and valium 15mg po. EKG results were prolonged QRST physician ordered repeat EKG in the morning and decreased Thorazine to 75mg. Pt is walking around and interacting with peers on hall 600." Vital signs were reassessed in 30 minutes and her pulse went down to 109.

Review of the physician note dated 10/1/15 at 12:40PM stated, "Pt c/o chest pain that is sharp, worsens when she moves 9/10. Pt. is Tachycardic (139). Pt allowed to leave quiet room to calm down. B/P- 125/88, O2 sat 97%, RR- 20. MD documented the patient was "sedated" and "slapped staff 1 day ago." Under assessment MD documented, "Bipolar, v/s repeated at 1:20PM B/P 91/51, P- 109, RR- 20, pain 6/10. Hold Thorazine and Valium due to sedation stop Lamictal. Will decrease Thorazine to 75 mg TID and repeat EKG in AM. "

Review of patient #7's vital sign sheet dated 10/1/15 revealed in the "evening time" patient #7 had a pulse rate of 127 and 102 on the night shift. There was no nursing documentation of nurse assessment for elevated pulse, if MD was notified, documentation found on nursing assessment under Cardiovascular stated, "N" and Pulses: "strong." There was no further nursing assessments concerning the patients' vital signs or if the patient was still symptomatic.

Review of the chart revealed the second EKG was performed on 10/2/15 at 10:00AM. The EKG showed "Abnormal EKG, Long QT interval." Review of the nurse's notes at 10:00AM stated, "Patient alert and oriented x4. Patient got a repeat EKG. Physician notified of results received new orders. Documentation found on nursing assessment under Cardiovascular stated, "N" and Pulses: "strong." There were no vital signs documented for 10/2/2015 or further assessment of the patients' cardiovascular status.

Review of the physician orders dated 10/2/2015 revealed Patient #7's Thorazine was to be decreased to 50mg three times a day and patient #7 was to be discharged . There was no physician progress note found for 10/2/15. There was no evidence found that patient #3 was seen by the physician before discharge on 10/2/15.

Review of patient #7's Discharge Instructions and Plan revealed there was no documentation for patient #7 to follow up with her MD or cardiologist concerning her elevated pulse rate and abnormal EKG. There was no assessment of the patients' cardiovascular status at discharge or vital signs.
Review of patient #7's treatment plan revealed patient #7's elevated pulse, abnormal EKG, or over sedation, or cardiovascular status was not addressed on the treatment plan at all any time during this hospitalization .