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.

ROGERS MEMORIAL HOSPITAL 34700 VALLEY RD OCONOMOWOC, WI Feb. 21, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, staff and patient interview and records review, the hospital failed to ensure 8 of 8 (#1, 3, 4, 6, 7, 8, 9, 10) patients were safely restrained when the hospital made it a standard of care to restrain all patients in a prone position, and trained all staff to use prone position. Based on non-hospital specific requirements, all patients were restrained prone when using a body wrap, a device per manufacturers recommendations that was designed for transporting a patient.

The hospital failed to comprehensively document for 10 of 10 (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) patients who received restraint or seclusion the required information to paint a clear picture of the event. Documentation failed to include an assessment to determine the appropriate restraint, patient specific interventions in an attempt to de-escalate, and how a patient was transported from the incident to the "comfort room."

The hospital failed to meet restraint training and education requirements for in-patient use of restraints for 2 of 2 staff.

Based on observation, staff interview, patient record and hospital policy and other document review, the hospital failed to ensure 6 of 10 patients (1, 3, 4, 7, 8, 10) were safely restrained when the hospital made it a standard of practice to restrain all patients in a prone position in a body wrap and placing the patient face down on a gurney. Further, the hospital failed to appropriately document the use of the restraints and assessments involving their usage. Per manufacturer's recommended usage, the body wrap is meant to be used as a means of transport. The hospital also did not provide appropriate assessments during restraint and/or seclusion for 4 of 10 additional patients (2, 5, 6, 9).

Findings include:

The facility failed to follow safe restraint techniques. See Tag 0167.

The facility failed to review restraint use when informing patients/families of patient rights. See tag A-117.

The facility's failure to promote and protect all patients safety resulted in potential harm. See tag A-142.

The facility failed to follow safe restraint techniques. See A-167

The facility restrained a 7 year old patient for more than 1 hour. See A-171

The facility failed to follow State law and nursing licensure requirements when writing orders for physical and chemical restraints. See A-176

The hospital failed to have policies and procedures or job description for QMP trained staff to ensure staff complaince with their newly defined duties. A-178

The hospital failed to ensure 1 hour face to face assessment and failed to ensure evalutions were complete and accurate. A-179

The facility continued to utilize restraint techniques on children and adolescents after they received a State memo in 2009 prohibiting specified techniques that cover the body. See A-180

The facility follows unsafe restraint procedures. See A-194

The facility failed to choose restraints based on the patients individualized assessments. See A-201

The facility failed to ensure staff were trained in the safe application of restraints. See A-202

The facility failed to ensure that staff monitor patient's vital signs, skin integrity, psychological, circulatory, and respiratory status while in restraints or seclusion. See A-205

The facility failed to provide qualified staff for educating and training in the areas of restraints and seclusion for hospitals. See A-207


The result of this systemic failure resulted in potential patient harm to all inpatients.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review, and staff and patient interviews, the hospital failed to ensure all patients and patient representatives were informed of all their patient rights. Admitting staff verbally reviewed with patients (and representatives), 10 of 11 Treatment & Related Rights, however, failed to verbally review restraint and/or seclusion rights before asking patients and parents to sign the document that confirmed they understood and received all their patient rights. This was confirmed with three patients that were admitted . This affects all admissions.

Findings include:

On 02/21/12 at 12:40 p.m. Surveyor # observed a hospital admission of a minor who was a first time admission to the hospital. Admission/Intake Staff I conducted the admission.

Admission/Intake Staff I verbally reviewed all admission documents then asked both minor patient and parent to "look it over and sign". During the review of the patients rights document (also used to verify patients have received their patient rights), Admission/Intake Staff I reviewed 10 of the 11 Treatment and Related Rights however, failed to verbally review 1 of 11 rights regarding restraint or seclusion.

Note: The above observation did not include a patient or family interview because the patient was suicidal, and the focus was to get the patient admitted and safe.

On 02/21/12 at 8:15 a.m. Surveyor # interviewed Patient #11 who was [AGE] years old and was admitted on [DATE]. Patient #11 confirmed to Surveyor # the hospital staff had not explained the use of the body wrap (for restraint) or the quiet room (seclusion).

On 02/21/12 at 8:25 a.m. Surveyor # interviewed, Patient #12 who told Surveyor # #12 was [AGE] years old and was legally an adult. Patient #12 signed into the hospital and provided the visitor list during admission defining who #12 would or would not allow to visit. Patient #12 stated " I feel safe here " , however, confirmed the hospital staff had not informed her about restraint or the body wrap (restraint). Patient #12 told Surveyor # that Pt#12 was placed in the quiet room (seclusion) so that is how Patient #12 knew what that was.

On 02/21/12 at 1:30 p.m. Surveyor # during an interview and review of the hospitals Treatment & Related Rights document information with Admission Manager K and Admission/Intake I, Surveyor # asked; why would the hospital admissions verbally cover 10 of the 11 patient treatment rights and responsibilities, yet not verbally cover rights related to restraint or seclusion? Admission Manager K confirmed the admission protocol is not to verbally cover patient's rights for restraint. After 10 of the 11 rights are reviewed the patient and family are asked to "look it over and sign". Admission/Intake I noted it is their responsibility to read the information. Admission/Intake I told Surveyor # , Admissions never addresses restraints.

Admission Manager K confirmed to Surveyor # , in the past a parent left without admitting a minor when admission verbally covered restraint and seclusion information. Admission Manager K told Surveyor we don't want to "freak the patients" out. Admission Manager K and Admission Intake I confirmed parents and patients are often in crisis or under duress when coming to the hospital, and may not fully comprehend or read written instructions.

On 02/20/12 at 9:55 a.m. RN F confirmed to Surveyor # , informing patients or their families about restraint or seclusion is not a part of the admission process for the child and adolescent

RN F told Surveyor # , all patients rights are reviewed in admissions before they come to the unit.

RN F confirmed parents/guardians are called after the application of restraint or seclusion.

On 02/20/12 at 10:30 a.m. during an interview, PCT G confirmed to Surveyor # , that G ' s primary duty is for the child section (ages 4-9/10 years of age). PCT G confirmed he is a part of the admission process and that PCT ' s do not cover restraint use as a part of the admission process to the unit.

On 02/21/12 at 8:45 a.m. during tour/observation and interview on the child and adolescent unit MCAU-D confirmed restraint is covered as a part of patient rights in admissions, and they are posted.

MCAU -D confirmed that the child and adolescent unit has taken in patients as young as 4 years old.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of restraint policy, current standards of practice, manufacturers recommendations and warnings, review of training materials, State published memo, observation and staff and patient interviews, the facility failed to ensure the safety of 6 of 10 (#1, 3, 4, 7, 8, and 10) child and adolescent patients, when the hospital made it a standard of care to place all restrained patients in a prone (face down) position for restraints, physical holds and body wrap, a device to be used for transporting a patient per manufacturer's recommended use. In addition the hospital failed to appropriately assess 4 of 10 patients (2, 5, 6, 9) during episodes of restraint and seclusion.

Contrary to the hospital policy, hospital staff made it a standard of care when a body wrap is applied and the patient needs to be transported from the place restrained to the restraint/seclusion room they are placed prone (face down)while prone in the body wrap, onto the gurney and 2 additional straps (across the chest and legs) are applied, and the patient remains on the gurney for the remainder of the restraint event putting the patients at risk for asphyxiation. The hospital did not obtain an additional assessment, documentation and order. All restraints are used in tandem, and fail to have assessments, cares or interventions in-between.

Findings include:

On 2/20/12 at 8:00 a.m. through 02/21/12 at 3:00 p.m., Surveyor # and # , reviewed the hospital's current Restraint/Seclusion/Therapeutic Hold for Behavioral Management policy #04-087-0911, Manufacturers Recommendations for the body wrap, the American Psychiatric Nurse Association's (APNA) Restraint and Seclusion Standard of Practice revised 2007, and the March 12, 2009 State published 3-page memo, prohibiting practices specific to children and adolescents with Dir PI/RM-A as follows:
____________
The following documents/policies were reviewed:

I. The Body Wrap Manufacturers Recommendation and Intended Use states that this special wrap is designed to transport a person in a horizontal position by using the handles on the side of the wrap. The wrap should go around the limbs and body to prevent flailing of the limbs for patient and staff safety. NOTE: Do not use for prolonged periods of time. Improper adjustment may prohibit proper circulation. Manufacturers Warning states that this product may be dangerous if improperly used or applied.

II. Restraint/Seclusion/Therapeutic Hold for Behavioral Management policy #04-087-0911, Page 3, #8 states:
f: A new order must be obtained if:
i) The time limit has expired,
ii) A new cause for the intervention has been identified,
iii) The type of intervention has changed.
and
14.b.
iv) Vital Signs as appropriate; while in the body wrap, temperature should be taken preferably with a forehead thermometer every 15 minutes.

Page 7 states:
Concurrent use of the Body Wrap and Gurney; General Information: In cases where the body wrap is used and the patient is unable to contain effectively or safely, the use of the gurney may be implemented. If the gurney is used concurrently with the body wrap as a restraint (not just for transport) a physician order must be obtained for the use of the body wrap and the gurney.

III. Seclusion & Restraint Flowsheet that documents the event is a 1 page/1 sided form #HIM-)042-0707 and has a key at the bottom of the document as follows:
Time Limits:
4 hours - Adult
2 hours - (9-17)
1 hours below 9

IV. APNA 2000 Restraint and Seclusion Standards of Practice revised 2007 (13-page document), Page 9 states:
All potential physical and psychological risk factors are considered. When an individual is physically restrained, immediate action is required to mitigate positional risks.

Documentation is required for all aspects of the seclusion and restraint episode as follows:
Specifics of the episode; when it was initiated; specific physical holds; and, evaluation of the person's response to physical interventions including any potential for complication or injury. Monitoring and assessment of the person while in seclusion or restraint. Interventions provided to promote comfort and safety as well as expedite the release and the person's response.

V. March 13, 2009, State published 3-page memo, prohibiting practices specific to child and adolescents. The memo noted prohibiting techniques or materials that cover the face or body, and any maneuvers that places pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen, causing chest compression.
___________


During an interview on 02/21/12 at 8:00 a.m. with MCAU-D and RN Informatics-C, MCAU-D told Surveyor # , any time a patient is placed in the body wrap, it is the hospital's protocol to use a gurney for transportation. Surveyor # reiterated this statement and confirmed it, while touring, and observing the gurney and comfort room (Seclusion). MCAU confirmed the body wrap is used as a restraint (the only restraint used by the hospital) and the gurney is used for transportation and additional restraint.

MCAU-D further confirmed that all patients are placed in a prone position when restrained, and there was no need for an assessment because prone was the only way child and adolescent patients are restrained at the hospital.

Additional staff interview conducted 02/20/12 at 9:30 a.m. with RN-QMP-F and at 10:30 a.m. with PCT-G, confirmed the body wrap and gurney are used in tandem as a standard of care when a patient is in a body wrap and needs to go from point A to point B in the hospital, and is left on this gurney for the remainder of the restraint event with the potential for additional straps to be used if a child/adolescent is thrashing around so they do not fall off the gurney.

MCAU-D confirmed for Surveyor # , if the gurney is needed for transporting a patient, the patient will be left on the gurney for the restraint event. The patient may or may not be strapped down with two additional gurney straps (one across the chest the other across the legs), and left on the gurney in the wrap until they are released from the restraint. Depending on if the patient is agitated and moving, MCAU-D stated the staff would use the straps to ensure the patients safety and prevent them from rolling off.

Also while touring and observing on 02/21/12 with MCAU-D and RN Informatics-C, surveyor noted different sized body wraps. Surveyor requested information on how the hospital determines which body wrap to use. RN Informatics-C stated they "eyeball it."
________________

Patient #10 is 7 years old. Below is 1 of 6 restraint events for this patient. All events have similar findings that have been reviewed and confirmed during this survey.

On 02/21/12 from 1:30 p.m. - 2:00 p.m., Surveyor # and RN Informatics reviewed the record for Patient #10.

On 12/18/11, time in restraint is 11:15 a.m., and time out of restraint is 12:20 p.m. This fails to meet federal limits of 1 hour maximum for a child under the age of 9, fails to comply with hospital policy #04-087-0911, and fails to comply with the manufacturers recommendations and warnings of not being used for prolonged periods of time. Improper adjustment may prohibit proper circulation. This is contrary to the manufacturers warning that this product may be dangerous if improperly used or applied.

Vital signs that would include a temperature for Patient #10 who was in a body wrap placed prone for 1 hour and 5 minutes were not documented during the restraint event. This fails to meet the hospital policy #04-087-0911 and APNA 2007 standards of practice requiring clear documentation and ongoing assessment.

The restraint documentation failed to include additional device(s) used during this restraint event such as physical hold to escort patient, or the use of the gurney for Patient #10. This fails to meet hospital policy #04-087-0911 and APNA 2007 Standards of Practice.

Patient #10 was placed prone (face down) in the body wrap, and would have required transportation on the gurney placed prone for transport from the place of the incident (group), to the comfort room (seclusion.) This fails to meet current Standard of Practice of the APNA that required an assessment for appropriate use of prone restraints, as well as an assessment to determine safety in the prevention of asphyxia. The body wrap covered the patient's body and the technique places pressure on the back and abdomen which fails to meet the State issued memo from 2009, and fails to comply with the manufacturers recommendation for intended use (transportation), and not to be used for prolonged periods of time, and fails to adhere to the manufacturer's warning.

The 12/18/11 nursing documentation for Patient #10 failed to clearly identify all force and restraints used. Nursing documentation failed to identify every staff involved in this restraint event and all subsequent restraint/seclusion events for Patient #10 who is 7 years old. This is noncompliant with hospital policy #04-087-0911 and the APNA 2007 standards of practice.
__________________


During an interview on 02/20/12 at 9:30 a.m., Surveyor # interviewed CES B, who confirmed the hospital uses one type of restraint, the "body wrap." The body wrap was described as a wrap that encircles a patient's body from shoulders to ankles and then is Velcro closed to prohibit and limit movement. Special precautions related to a patient's temperature are required because of the weight and constriction of the body wrap. CES B confirmed everyone is restrained in a prone position, without an assessment since there is only one restraint type and method.

On 02/20/12 at 9:30 a.m. RN F confirmed to Surveyor # that if a restraint is needed, prone restraints would be used on anyone needing restraint on the child and adolescent unit. If the body wrap is used, it is also used as a restraint and patients would be wrapped in a prone position. RN F confirmed that this was how staff are trained, and that an assessment was not necessary since there is only one type of restraint used.

On 02/20/12 at 10:37 a.m., Surveyor # reviewed training materials provided to inpatient staff for restraint application and requirements. Training video and materials show only use of the 5-point prone position for restraint hold, and the use of the prone position "take down" followed by restraint application of a body wrap with patient maintained in the prone position during the restraint event.

Training materials failed to include assessments or contraindications for using the prone position related to asphyxia.

Training materials failed to include current standards of practice, that might include the APNA May 2000 Standards of Practice that state "When an individual is physically restrained, immediate action is required to mitigate positional risks: prone restraint requires monitoring for risk of positional asphyxiation."

The hospital is accredited by the Joint Commission. On November 18, 1998, the Joint Commission put out a Sentinel Event Alert related to Preventing Restraint Deaths (issue 8) noting "40% of restraint deaths are related to asphyxia." Under "Root Causes Identified" the 4th bullet point "restraining a patient in a prone position patient may predispose the patient to suffocation." This is not a part of the training materials or policy and procedures.

On 02/21/12 after completing the restraint record review for Patient #10 with RN Informatics-C, Surveyor # requested to have Dir PI/RM-A to confirm the material review of all documentation for Patient #10 (policies, and records) on what surveyors found.

RN Informatics-C and Dir PI/RM-A confirmed to surveyor the documentation for Patient #10 fails to clearly indicate all the restrains/holds/escorts used on Patient #10 and the restraint events. Additional restraint and seclusion records were reviewed between 02/20/12 and 02/21/12 by Surveyors # and # and found documentation that supported the above findings included patients #1, 2, 3, 4, 5, 6, 7, 8, and 9. RN Informatics-C and Dir PI/RM by 02/21/12 at 3:00 p.m. had reviewed and confirmed all findings. (See information for Patients 1-9 below.)

_____________

Review of the hospital's restraint log indicated that from 06/2011 until 2/8/2012, 24 patients (some were recurring), had 82 incidents of restraint/seclusion with 52 body wrap incidents.

Between 02/20/12 starting at 10:45 a.m. through 02/21/12 at 3:00 p.m., patient records were reviewed by Surveyors # and , that confirmed assessments for the use of a prone restraint, or the potential for asphyxiation were not documented in Patients #1, 3, 4, 7, 8. Further, patient record review revealed that Patients #2 5, 6, 9 were not appropriately assessed while in while in seclusion and/or other forms of restraint (basket hold.)
_____________
Review of Patients 1-9

Patient #1 was an [AGE] year old child.

3 Restraint events for Patient #1 as follows:
On 6/23/11 Patient #1 was placed prone in a body wrap from 1625 - 1705 (4:25 p.m. - 5:05 p.m.) No psychological assessment during or after the restraint event was documented. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. The debriefing form is signed and dated 6/24/11 but not dated or timed at the top. Therefore there is no way to know if the debriefing occurred within the 24 hours of the event. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points were not checked.

On 6/24/11 from 0945-1008 (9:45 a.m.- 10:08 a.m.) Patient #1 was restrained prone in a body wrap. No psychological assessment during the restraint event was documented. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. The debriefing documentation required after each restraint event was not available. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points were not checked.

On 6/24/11 from 1650 - 1705 (4:05 p.m.- 5:05 p.m.) Patient #1 was restrained prone in a body wrap. On 6/24/11 from 1715 - 1730 (5:15 p.m. - 5:30 p.m.) the documentation shows pt. #1 "sitting quietly in corner." The documentation fails to conclude one restraint before initiating another restraint, and fails to include location of pt. #1. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. The debriefing documentation required after each restraint event was not available. No assessment was completed between the two types of restraint or interventions between each restraint type. No psychological summary was documented that required including history of sexual assault, and emotional comfort. Personal cares were not documented that included the 15 minute checks to include vital signs, elimination, and pressure points were not checked.

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.
_____________
Patient #2 was an 8 year old child.

2 Locked Seclusion events for Patient #2 as follows:
On 6/16/11 Patient #2 was in Locked Seclusion from 1507 - 1529 (3:07 p.m. - 3:29 p.m.). No psychological assessment during or after the locked seclusion event was documented. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. The 1 hour face to face documentation is noted to occur at 1525 (3:25 p.m.). This is prior to pt. #2's release from locked seclusion. "No" is circled for the question, "Currently in restraint/seclusion." This does not match the flow sheet documentation.

On 6/17/11 from 1730-1800 (5:30 p.m.- 6:00 p.m.) Patient #2 was in Locked Seclusion.
No psychological assessment during the seclusion event was documented. The debriefing documentation required after each restraint is not dated or timed at the top of the document to indicate when the debriefing occurred and if it was within 24 hours of the event. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points.
_______________
Patient #3 was an [AGE] year old child.

2 Restraint events for Patient #3 as follows:
On 6/26/11 Patient #3 was placed prone in a body wrap from 1010 - 1100 (10:10 a.m. - 11:00 a.m.) The restraint flow sheet shows pt. #3 was in a body wrap restraint but fails to show what time the restraint was applied or removed. It is documented that at 10:30 a.m. the pt. refused personal care. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. No psychological assessment during or after the restraint event was documented. The debriefing form is signed and dated 6/26/11 but not dated at the top and timed 10:45 a.m. Therefore was completed while pt. #3 was restrained in the body wrap.
The 1 hour face to face document was also completed at 10:45 a.m. while pt. #3 was restrained in the body wrap. "No" is circled as an answer to the question, "Currently in restraint/seclusion." Under question #1, "Known medical conditions or physical disabilities increasing risk of injury" "Yes" is checked and "seizures" is listed. Under "Known history of physical or sexual abuse increasing risk of stress/trauma: "yes" is checked and states, "physical abuse at Mendota."

On 6/26/11 patient #3 was restrained prone in a body wrap from 1120 - 1150 (11:20 a.m. - 11:50 a.m.). The restraint flow sheet shows pt. #3 was in a body wrap but fails to show what time pt. #3 was put in the body wrap and what time the body wrap was removed. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. No psychological assessment during or after the restraint event was documented. The 1 hour face to face document was completed at 12:00 p.m. Under question #1, "Known medical conditions or physical disabilities increasing risk of injury," "Yes" is checked and "seizures" is listed. Under "Known history of physical or sexual abuse increasing risk of stress/trauma," "Yes" is checked and states, "physical abuse at Mendota."

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.
_______________
Patient #4 was an [AGE] year old child.

8 Restraint/seclusion events for Patient #4 were as follows:
On 11/19/11 Patient #4 was placed prone in a body wrap from 1620 - 1715 (4:20 p.m. - 5:15 p.m.) No psychological assessment during or after the restraint event was documented. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points.

On 11/19/11 from 1920-2010 (7:20 p.m.- 8:10 p.m.) Patient #4 was restrained prone in a body wrap. Documentation on the restraint flow sheet is not clear as to when the body wrap was applied and removed. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. No psychological assessment during the restraint event was documented. The 1 hour face to face documentation shows pt. #4 refused vital signs. The space for documentation is blank next to the question, "Is the patient able to be released from restraints/seclusion yet?"

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.

On 11/20/11 from 1150-1220 (11:50 a.m. - 12:20 p.m.), patient #4 was restrained prone in a body wrap. Documentation on the restraint flow sheet shows the body wrap was applied at 1205 (12:05 p.m.) and removed at 1208 (12:08 p.m.) and "changed to locked seclusion until 1220 (12:20 p.m.)." There is no physician order for locked seclusion.
The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. No psychological assessment during the restraint event was documented.

On 11/25/11 from 1443-1448 (2:43 p.m.- 2:48 p.m.) Patient #4 was restrained in a prone body wrap. Documentation on the restraint flow sheet shows at 1444 (2:44 p.m.) pt. #4 was " wheeled into comfort room. " The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and what the patient was wheeled on. No psychological assessment during the restraint event was documented. The debriefing form is dated 11/25/11 at 1505 (3:05 p.m.). This is the third episode of restraint or seclusion for this pt. The debriefing form states, "after the 3rd episode of restraint or locked seclusion during this level of care schedule a multidisciplinary team meeting immediately." Meeting date: the space after meeting date is blank. The record does not show a special multidisciplinary team meeting until 11/29/11. The 1 hour face to face document is dated 11/25/11 and timed 1515 (3:15 p.m.) at the top. Documentation shows pt. #4 was complaining of 4/10 pain related to a bump on forehead and lists, "swelling + bruising on forehead." However the restraint flow sheet does not indicate a head injury of any kind.

On 11/25/11 from 1448 - 1456 (2:48 p.m. - 2:56 p.m.) patient #4 was in locked seclusion. Comments section states, "patient tied shirt around neck." The restraint flow sheet does not have documentation to show how the patient was taken to the locked seclusion, which staff were involved. The 1 hour face to face document is dated 11/25/11 and timed 1515 (3:15 p.m.) at the top. Documentation shows pt. #4 was complaining of 4/10 pain related to a bump on forehead. However the restraint flow sheet does not indicate a head injury of any kind. Any injury from the patient's shirt around the neck is not addressed. The debriefing form is identical to the form for the incident immediately pre-ceding this locked seclusion.

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.

On 11/26/11 from 1835-1905 (6:35 p.m.- 7:05 p.m.) Patient #4 was restrained prone in a body wrap. Documentation on the restraint flow sheet shows at 1842 (7:42 p.m.) pt. #4 was "re-wrapped." There is no physician order for the second time pt. #4 was put in a body wrap. Release criteria met section is not answered. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. Documentation does not show what time the body wrap was first applied. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. No psychological assessment during the restraint event was documented.
Patient debriefing form to be completed within 24 hours of the event is dated 11/28/11 at 1700 (5:00 p.m.).

On 11/28/11 from 1130 - 1200 (11:30 a.m. - 12:00p.m.) patient #4 was restrained prone in a body wrap. Restraint flow sheet documentation shows at 1140 (11:40 a.m.) pt. #4 was "rewrapped" and released at 1200 (12:00 p.m.). Physician orders show one order for a body wrap restraint. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, and hydration. The section for "continues to need restraint" is not filled in. The patient debriefing form is not dated or timed at the top, therefore there is no way to determine when the debriefing was completed. The 1 hour face to face document is dated 11/28/11 and timed 1215 (12:15 p.m.), the physical assessment area states, "multiple very superficial scratches, she states are from yesterday." Documentation does not state where the scratches are. Record does not have documentation to show how patient #4 sustained scratches.

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period
______________
Patient 8
On 1/8/12 from 2110 - 2150 (9:10 p.m. - 9:50 p.m.) patient #8 was restrained prone in a body wrap. Restraint flow sheet shows in comment section, "control hold transition" and in the precipitating events section states, "inability to calm after attempt at release from physical hold." The record shows no order for a therapeutic hold. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. Flow sheet states at 2150 (9:50 p.m.) vitals checked but results are not documented. The 1 hour face to face document shows under Physical Summary: 1. Known medical conditions or physical disabilities increasing risk of injury: box No is checked and a hand written note is made, "Non noted on medical or nursing eval though Mother states history of heart problem." The nursing admission assessment dated [DATE] states, "had ECCO 9/11- result pulmonary hypertension, since Concerta was increased, pt. complained of chest pressure, tingling in chest."

On 1/9/12 from 2035 - 2105 (8:35 p.m. - 9:05 p.m.) patient #8 was restrained prone in a body wrap. Personal cares were not documented that included the 15 minute checks for vital signs, elimination, hydration, and pressure points. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained. No psychological assessment during the restraint event was documented. The 1 hour face to face documentation dated 1/9/12 at 2130 (9:30 p.m.) states, "no" for any known medical condition, increasing risk of injury. The nursing admission assessment dated [DATE] states, "had ECCO 9/11- result pulmonary hypertension, since Concerta was increased, pt. complained of chest pressure, tingling in chest." Physical assessment shows pt. #8 refused a blood pressure check.

Surveyor # reviewed and confirmed Patient's # 1, 2, 3, 4 and 8's findings with RN Informatics-C between 12:17 p.m. and 12:45 p.m. on 2-21-12.
___________
Patient #9 was a [AGE] year old adolescent. History noted Patient #9 had a low potassium level. A potassium imbalance has the potential to cause cardiac dysfunction because the heart muscle needs potassium to beat properly and regulate blood pressure (emedicinehealth.com).

2 Restraint events for Patient #9 are as follows:
On 09-20-11 from 1540 - 1650 (3:40 p.m. - 4:50 p.m.) Patient #9 was in a restraint for 1 hour and 10 minutes The type of restraint was not identified. Restraint flow sheet failed to include personal cares that included the 15 minute check for range of motion, vital signs, elimination, and nutrition-hydration for the 50 minutes Patient #9 was restrained.
The 1 hour face to face evaluation did not include the psychological summary of past history of sexual abuse required on the evaluation form # HIM-048-0110.

On 09-20-11 from 1925 - 2010 (7:25 p.m. - 8:10 p.m.) Patient #9 was in a restraint for 45 minutes. The type of restraint was not identified. Restraint flow sheet failed to include personal cares that included the 15 minute checks for range of motion, vital signs, elimination, and nutrition-hydration for the 45 minutes Patient #9 was restrained. The 1 hour face to face evaluation did not include a review of the Medication Administration Record (MAR), vital signs were not obtained during the restraint event or after, "unable to" noted without further explanation that is required on the evaluation form #HIM-048-0110. No new wounds documented on the #HIM-048-0110 1 hour face to face evaluation form, but the body map was blank indicating patient had no abnormal findings, however, the earlier restraint event noted a cut to the right wrist.

Per policy # 04-087-0911 no team case review was found after 2 episodes that occurred within a 12 hour period.
___________
Patient #5 is an 8 year old who has a history of enuresis (inability to control urination) and constipation (infrequent bowel movement or bowel movements hard to pass)

One (1) episode of locked seclusion as follows:
Patient became agitated after going to bed. Patient has a history of enuresis; however interventions prior to restraints did not include potential toileting needs.

1 hour face to face evaluation required after the use of restraint or seclusion was incomplete, for the question "currently in restraints yes/no." "No" was circled, and did not include circumstances required for an answer of "No." Vital signs were not documented, and there was no documentation of the "chest/abdomen" that would include respiratory status

Surveyor # reviewed and confirmed Patient #5's restraint record findings on 02/20/12 at 11:00 a.m. with CES -B and SSM- H.
_____________
Patient #6 was a 4 year old. Patient history noted Patient #6 had a single kidney.

9 restraint/seclusion events for Patient #6 are as follows:
During Patient #6's stay there were 8 episodes of locked seclusion. Documentation noted Patient #6 was "escorted" to the quiet room (locked seclusion). Restraint documentation including the 1 hour face to face evaluations was incomplete. The term "escorted" did not include how the patient was escorted (stand by walking along with or physically holding the 4 year old patient) or by whom (which staff escorted Patient #6).

On 11/11/11 the restraint documentation noted Patient #6 to be in a basket hold. A basket hold was described as a hold where one or more staff utilizes the body and arms to restrain a patient. Restraint documentation failed to identify specifically how the hold was implemented and which staff were involved.

Per policy # 04-087-0911 no team case review was found after 2 episodes that occurred within a 12 hour period

Surveyor # reviewed and confirmed Patient's # 6, 7, 9 and 10's findings with RN Informatics-C and PI/RM-A on 06/21/12 between 9:05 a.m. and 3:00 p.m.
___________
Patient #7 was a [AGE] year old adolescent.

3 Restraint events for Patient #7 are as follows:
Restraint flowsheet noted a restraint on 11/09/11 from 1517 - 1602 (3:17 p.m. - 4:02 p.m.) Patient #7 was restrained for 45 minutes. However, restraint documentation failed to identify the type of restraint or seclusion that was used on Patient #7, and that the restraint application occurred on 11/10/11 not 11/09 as documented. Personal cares that requires 15 minute check per policy and procedure failed to include the 15 minute check for range of motion, vital signs, elimination, and pressure points for the 45 minutes patient was restrained. 1 hour face to face evaluation was incomplete and failed to include the circumstances required if the answer is "no" the patient is not out of restraints at the time of the evaluation. The MAR review was not completed. The medications Patient #7 received during the restraint event were not documented on the record. Debriefing record was not completed. Hospital staff documented "refused," however no additional information was documented. The Debrie
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on Physician order and restraint documentation review and staff interviews the hospital failed to ensure that orders were obtained in accordance with state and federal requirements when ordering restraints for 4 of 10 patients (#10, #6, #4 and #8 ).

Findings include:

Patient #10 is a 7 year old child
Physician order for Patient #10 records shows on 11/10/11 at 1645 (4:45 p.m.) a Telephone Order (TO) was obtained for 50 milligrams (mg) of Seroquel p.o.(by mouth) now, if patient refuses give 0.1 mg lorazepam IM (intramuscular).

The wrong dose was documented (small note indicating the order should be "1 mg" . However, the note failed to identify if this was a confirmed order clarification or unintentional mistake written by the original TO writer, because it was undecipherable as to who was adding changes to a physician order, and the note was not authenticated.

Another side note to this order confirms the medication (lorazepam IM) was given at 3:15 p.m. on 11/10/11, 1 hour and 30 minutes before the order was obtained.

This order fails to meet State Administrative Code DHS 124 requirement for accepting and documenting:
____________________
Physicians orders (DHS 124.12 (5)(b)11.): all order will be documented and authenticated.
Pharmacy Services (DHS 124.15(2) Pharmacy Service meets current acceptable standards of practice.
Medical records documentation (DHS 124.14 (5)(b)) and DHS 124.14 (5)(a)1.): Authentication of all entries, all entries shall be legible, and include the name and title of the writer.

Wisconsin Administrative Code Rules of the Board of Nursing (N6)
(2) PERFORMANCE OF DELEGATED MEDICAL ACTS. In the performance of delegated medical acts an R.N. shall:
(a) Accept only those delegated medical acts for which there are protocols or written or verbal orders;
(b) Accept only those delegated medical acts for which the R.N. is competent to perform based on his or her nursing education, training or experience;
<http://docs.legis.wisconsin.gov/code/admin_code/dhs/124.pdf>

A basic RNs license does not allow, in the State of Wisconsin, the administration of medication without a physicians order.
N 6.05 Violations of standards. A violation of the standards of practice constitutes unprofessional conduct or misconduct and may result in the board limiting, suspending, revoking or denying renewal of the license or in the board reprimanding an R.N. or L.P.N.
<http://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf>

N 7.03 Negligence, abuse of alcohol or other drugs or mental incompetency. (1) As used in s. 441.07 (1) (c), Stats., " negligence " means a substantial departure from the standard of care ordinarily exercised by a competent licensee. " Negligence " includes but is not limited to the following conduct:
(a) Violating any of the standards of practice set forth in ch. N 6;
(b) An act or omission demonstrating a failure to maintain competency in practice and methods of nursing care;
<http://docs.legis.wisconsin.gov/code/admin_code/n/7.pdf>
______________
Additional orders that failed to meet State and/or Federal requirements:

Patient #10
On 11/11/11 at 7:00 p.m. a Telephone Order was obtained for two different types of restraints at the same time. The first order states Therapeutic Hold, the second order taken at the same time states: transition into Body Wrap.
These are two separate types of restraints, and need two separate orders.

A late entry was documented and indicates on 12/17/11 at 9:13 p.m. a Telephone Order was obtained for two different types of restraints at the same time and order was written as one order Therapeutic Hold, transition into Body Wrap. These are two separate types of restraints, and need two separate orders.

Back to back restraint orders and Restraint/Seclusion Forms HIM 042-0707 Seclusion & restraint Flowsheet, HIM 048-0110 Restraint/Seclusion Evaluation and HIM 048-0110 Patient Debriefing are completed as if these two restraints are one event.

No other documentation was discovered to include an evaluation of the Patient status after discontinuing one restraint and applying another, or a 1 hour face to face evaluation between restraint types, and what interventions were attempted between the two types of restraints.

A second late entry for the same occurrence was identified 2 pages after the first late restraint order entry and 6 orders in-between.
The second late entry for the 12/17/12 was written after Patient #10s " discharge home today " order was written on 12/20/11/ at 10:30 a.m.
The hand writing was different than that of the first order.

Neither the first or second late entry documented the actual date the order was written as a late entry.

On 02/21/12 at 2:45 p.m. Surveyor # interviewed RN Q. RN-Q confirmed he was on duty the night of 12/17/11 and wrote the first late entry. RN Q confirmed he failed to document the time and date the entry was actually written as a late entry. RN-Q told Surveyor # , Q did not write the second late entry for duplicate restraint order. RN-Q told Surveyor it is not the practice of the hospital for anyone other than the RN receiving the verbal or telephone order to write the order.

RN Q confirmed even though it was not Qs hand writing on the second late order entry, Q did authenticate the second late entry order, and that does not follow standards of nursing practice. Nurses do not authenticate other nurse orders or documentation as your own.

The second order failed to have an authentication by its writer.

RN Q authenticated the second late entry as 12/17/11 at 2113 (9:13 p.m.) which was inaccurate, and confirmed the order had to have been written on, or after the order prior to it. The date on the prior order was 12/20/11 at 10:30 a.m. RN-Q confirmed it is falsification of documentation.

At 02/21/12 at 2:55 p.m. RN Informatics -C also reviewed the second duplicate late entry restraint order for Patient #10s in the physician orders. RN Informatics -C could not identify the second late entry writer, and the writer failed to authenticate their documentation.

The facility failed to have a staff key for medical records to identify, to ensure the safety and content of its medical records. This was confirmed to Surveyors # and # at 3:00 p.m. by Dir PI/RM-A and RN Informatics-C

Additional restraint orders for Patient #10 as follows:
On 12/15/11 at 4:20 a.m. a telephone order was obtained for the use of a Body Wrap.

No other restraint order was found in this time frame on this date. However, Patient #10 was placed in a Therapeutic hold for 10 minutes on 12/15/11 from 4:05 p.m. until 4:15 p.m. and was immediately "transitioned" into a Body Wrap starting 4:15 until 4:45 p.m.

Restraint records and nursing documentation "Restraint/Seclusion Forms HIM 042-0707 Seclusion & restraint Flowsheet, HIM 048-0110 Restraint/Seclusion Evaluation and HIM 048-0110 Patient Debriefing" confirmed Patient #10 had two types of restraints used back to back on #10 12/15/11, and staff completed these documents as if these two restraints are one event.

No other documentation was discovered to include the an evaluation of the Patient status after discontinuing one restraint and applying another, or a 1 hour face to face evaluation between restraint types, and what interventions were attempted between the two types of restraints.
____________
Patient #6 was a 4 year old child.
On 11/11/11 Restraint orders were written as transition order written back to back for Therapeutic Hold transition to Locked seclusion.
Restraint document confirmed on 11/11/11 from at 3:25 p.m. to 3:35 p.m. 4 year old Patient #6 was put in a therapeutic hold and transitioned into locked seclusion from 3:35 p.m. 4:05 p.m.

Orders and Restraint/Seclusion Forms HIM 042-0707 Seclusion & restraint Flowsheet, HIM 048-0110 Restraint/Seclusion Evaluation and HIM 048-0110 Patient Debriefing are completed as if these two restraints are one event. No other documentation was discovered to include an evaluation of the Patient status after discontinuing one restraint and applying another, or a 1 hour face to face evaluation between restraint types, and what interventions were attempted between the two types of restraints.
____________
Patient #4 was a [AGE] year old adolescent.
On 11/20/11 a restraint order was written for a body wrap. The body wrap was initiated at 12:05 p.m. and ended at 12:08 p.m. However, restraint documentation Flowsheet confirmed Patient #4 was then placed in locked seclusion from 12:08 p.m. to 12:20 p.m.

Restraint/Seclusion Forms HIM 042-0707 Seclusion & restraint Flowsheet, HIM 048-0110 Restraint/Seclusion Evaluation and HIM 048-0110 Patient Debriefing are completed as if these two restraints are one event. No other documentation was discovered to include the evaluation of the Patient status after discontinuing one restraint and applying another, or a 1 hour face to face evaluation between restraint types, and what interventions were attempted between the two types of restraints. No physician order was found for the Locked seclusion on 11/20/11 from 12:08 p.m. to 12:20 p.m.

On 11/25/11 Restraint orders were written as transition orders and written back to back for Body Wrap transition to Locked Seclusion. Restraint document confirmed on 11/25/11 from at 2:43 p.m. to 2:48 p.m. [AGE] year old Patient #4 was put in a Body Wrap and transitioned into locked seclusion from 2:48 p.m. 2:56 p.m.

Orders and Restraint/Seclusion Forms HIM 042-0707 Seclusion & restraint Flowsheet, HIM 048-0110 Restraint/Seclusion Evaluation and HIM 048-0110 Patient Debriefing are completed as if these two restraints are one event.

No other documentation was discovered to include the an evaluation of the Patient status after discontinuing one restraint and applying another, or a 1 hour face to face evaluation between restraint types, and what interventions were attempted between the two types of restraints.
______________
Patient #8
On 1/8/12 from 2110 - 2150 (9:10 p.m. - 9:50 p.m.) Patient #8 was restrained in a body wrap.

Restraint flow sheet shows in comment section, notes "control hold transition" and in the precipitating events section states, "inability to calm after attempt at release from physical hold."

Patient #8 physician orders contained an order dated 01/08/12 for a body wrap however, failed to have an order for a therapeutic hold restraint documented in the record.

Orders and Restraint/Seclusion Forms HIM 042-0707 Seclusion & restraint Flowsheet, HIM 048-0110 Restraint/Seclusion Evaluation and HIM 048-0110 Patient Debriefing are completed as if these two restraints are one event.

No other documentation was discovered to include an evaluation of the Patient status after discontinuing one restraint and applying another, or a 1 hour face to face evaluation between restraint types, and what interventions were attempted between the two types of restraints.

Surveyors # and # reviewed all the above findings throughout the survey from 02/20/12- 02/21/12. By 3:00 p.m. on 02/21/12 during a final interview and review of findings Dir PI/RM-A and RN Informatics-C confirmed they could provide no documentation, policies and procedures that would refute these findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on patient's restraint records and policy reviews, observation and staff interviews the staff failed to comply with federal law when 1 of 4 children (#10, a 7 year old child ) was restrained for 1 hour and five minutes. Total universe from the child and adolescent unit was 10.

Findings include:

On 02/20/12 Surveyor # reviewed the hospitals current Restraint/Seclusion/Therapeutic Hold for Behavioral Management, an 11 page policy # 04-087-0911 provided by Dir PI/RM-A at 8:15 a.m.
Page #3
Section 8 f: A new order must be obtained if
i) The time limit has expired
ii) A new cause for the intervention has been identified
iii) The type of intervention has changed

14. b.iv) Vital Signs as appropriate; while in the body wrap, temperature should be taken preferably with a forehead thermometer every 15 minutes.

Seclusion & Restraint Flow sheet that documents the event is a 1 page/1 sided form #HIM -042-0707 and has a key at the bottom of the landscape document as follows:
Time Limits:
4 hours-Adult
2 hours- (9-17)
1 hours below 9

On 02/21/12 from 1:30 p.m. - 200 p.m. Surveyor # 8 and RN Informatics reviewed the record for Patient #10 a 7 year old child.

The following pertinent information was extracted from the telephone physicians order:
12/18/11 1111 (11:11 a.m.) Type of Restraint: wrap
Time limit for Restraint: 1 hour
Release criteria: Calm/non aggressive

Review of the completed restraint documentation: Restraint/Seclusion Forms HIM 042-0707 Seclusion & Restraint Flowsheet, HIM 048-0110 Restraint/Seclusion Evaluation and HIM 048-0110 Patient Debriefing as follows:

Time in restraint 11:15 a.m. time out of restraint 12:20 p.m. (1 hour and 5 minutes). Patient #10 was placed prone (face down) in the body wrap for 1 hour and 5 minutes without fluids or vital sign assessment. RN Informatics-C confirmed to Surveyor # , that vital signs, especially a temperature, is critical while a patient is in a body wrap because of the potential to over heat, and is a part of policy #04-087-0911.

On 02/21/12 after completing the restraint record review for Patient #10 with RN Informatics-C. Dir PI/RM -A confirmed to Surveyor # the hospital was aware of the 3 page March 13 2009 State published memo, prohibiting practices specific to child and adolescents. The memo addressed, prohibiting techniques or materials that cover the face or body, and any maneuvers that places pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen, causing chest compression.

RN Informatics-C and Dir PI/RM -A confirmed to Surveyor # , that using two restraints and keeping a 7 year old child restrained for one (1) hour and five (5) minutes failed to comply with their hospital policy, and federal laws for restraining a child.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on restraint documentation review and interviews the hospital failed to clearly define in a policy or procedure or job descriptions, the requirements for the 32 of 32 Registered Nurses performing tasks as a Qualified Medical Personnel, (QMP) allowed to conduct the 1 hour face to face assessment and evaluations of patients who have been restrained. This affects all patients who have the possibliity of being restrained.

Findings include:

On 02/20/12 at 10:45 a.m. while conducting a record review for Patient #5 Surveyor # with CES-B and SSM-H noted the 1 hour face to face evaluation form #HIM 048-4411 dated 02/17/12 was incomplete.

Missing from the 1 hour face to face physical and evaluation form as follows:

"Currently in restraint/Seclusion Yes/No" (no was encircled). " If No, describe circumstances." No narrative describing the circumstances was documented.

"Patients reaction to the Restraint/Seclusion:" had nothing documented.

"Medication List and Medication Administration Record (MAR) Reviewed," check box was checked to indicate this task was completed.
The additional Medication narrative "Comments" section was left blank. Patient #5 had received Benadryl 25 milligram (mg) while in seclusion. However RN-QPM-P left the narrative comments blank, and did not indicate if the Benadryl was an effective or ineffective intervention for Patient #5.

Vital signs (pulse, respirations, blood pressure and temperature) were left blank without an explanation.

Patient #5 Chest/Abdomen assessment that included check boxes for any that applied: respiratory distress, pain/tenderness, n/a (means not applicable) and a narrative to describe any abnormal breathing/lung sounds was never completed.

The RN-QMP-used initials, not a full signature, and did not include a title. The initials were not legible. CES-B and SSM-H confirmed these findings to Surveyor # at 11:00 a.m. on 02/20/12.

On 02/20/12 at 2:40 p.m. Surveyor # and CES-B reviewed the list of QMP RN staff (32 staff for this hospital location), and the hospital based training an RN must complete before being allowed to assess and document the 1 hour face to face physical and evaluation, and being designated as a QMP.

CES-B told Surveyor # , the RN-QMP that conducted the 1 hour face to face evaluation on Patient #5 on 02/17/12 was P. RN-P was identified as on the list of QMPs for the hospital.

CES-B confirmed to Surveyor # , there was no job description specific to the RN QMP duties. On 02/20/12 at 2 45 p.m. RN Informatics- C confirmed to Surveyor # , the hospital does not have a job description or policy or procedure for the RN QMP to ensure they have hospital structured guidance when completing a 1 hour face to face evaluation to ensure compliance.

On 02/20/12 at 3:40 p.m. Surveyor # , asked RN-QMP- P, how P knows what must be completed for a 1 hour face to face evaluation? RN-QMP- P responded, from the training she received. Surveyor # asked RN-QMP-P if the hospital has a policy and procedure for QMP qualified RNs to review if they are uncertain or question what is required to be completed on a 1 hour face to face evaluation? RN-QMP-P responded, we are told to tell surveyors if we are asked something we don't know, that we need to look it up in the policy and procedure. RN-QMP spent 5 minutes searching for a policy and confirmed the hospital did not have a policy or procedure or job description for RN-QMPs.

RN-QMP-P was 1 of 32 RNs (P) who attended and completed the hospital based 1 hour face to face training. However, the hospital failed to include a job aid, such as (but not limited to) a job description, or policy and procedure, to ensure once the training was complete the RNs could reference the job aid to ensure compliance with their new and additional duties.

02/20/12 between 2:40 p.m. and 3:00 p.m. CES-B and RN Informatics-C, confirmed to Surveyor # , not all RNs are QMP trained, and an RN must be nominated by a manager and be reviewed by the Medical Staff.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on staff interviews and review of the 1 hour face to face evaluation forms #HIM 048-4411, the hospital failed to ensure RNs designated as QMP completed the 1 hour face to face evaluations for 10 of 10 patients (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) to include the evaluations of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion.

Findings include:

On 02/20/12 at 10:45 a.m. while conducting a record review for Patient #5 Surveyor # with CES-B and SSM-H noted the 1 hour face to face evaluation form #HIM 048-4411 dated 02/17/12 was incomplete. Missing from the 1 hour face to face physical and evaluation form as follows:

"Currently in restraint/Seclusion Yes/No" (no was encircled). "If No, describe circumstances." No narrative describing the circumstances was documented.

"Patients reaction to the Restraint/Seclusion:" had nothing documented.

"Medication List and Medication Administration Record (MAR) Reviewed" , check box was checked to indicate this task was completed.

The additional Medication narrative "Comments" section was left blank. Patient #5 had received Benadryl 25 milligram (mg) while in seclusion. However RN-QPM-P left the narrative comments blank, and did not indicate if the Benadryl was an effective or ineffective intervention for Patient #5.

Vital signs (pulse, respirations, blood pressure and temperature) were left blank without an explanation.

#5 Chest/Abdomen assessment that included check boxes for any that applied: respiratory distress, pain/tenderness, n/a (means not applicable) and a narrative to describe any abnormal breathing/lung sounds was never completed.

CES-B and SSM-H confirmed to Surveyor # , that the 1 hour face to face evaluation was incomplete, and not completed as the RN was trained to do. CES-B and SSM-H confirmed to Surveyor # , that Patients #5 ' s 1 hour face to face evaluation was done by RN-QMP-P

Nine (9) additional 1 hour face to face evaluation and physical forms were reviewed between 02/20/12 10:45 a.m. and 02/21/12 3:00 p.m. (#1, 2, 3, 4, 6, 7, 8, 9 and 10)

Surveyor # along with RN Informatics-C reviewed and confirmed that Patients #6, 7, 9, and 10 had incomplete 1 hour face to face evaluations completed by RN-QMPs.

Surveyor # along with RN Informatics-C reviewed and confirmed that patients #1, 2, 3, 4, and 8 had incomplete 1 hour face to face evaluations completed by RN-QMPs.

During an interview on 02/20/12 at 3:00 p.m. both RN Informatics-C and CES-B confirmed to Surveyor # , that the hospital does not have a job description or policies and procedures specific to the responsibilities of the RN as a QMP to ensure documentation is complete and accurate.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0180
Based on tour, interviews and 2009 State memo, and standards of practice review, the facility failed to follow State published "prohibited practices for children and adolescents for 8 of 8 (#1, 3, 4, 6, 7, 8, 9 and 10) patients that were placed in a prone position. The total universe was 10.

Findings include:

From 02/20/12 10:45 a.m. through 02/21/12 at 3:00 p.m. Surveyors # and # reviewed restraint records for child and adolescent patients #1, 3, 4, 6, 7, 8, 9 and 10. Patients #1, 3, 4, 6, 7, 8, 9 and 10 restraint records included being restrained in a prone (face down) position, while being wrapped in a Velcro closure system body wrap restraint, that wraps a patient from shoulders to ankles to prevent and limit movements.

Restraint records for Patients #1, 3, 4, 6, 7, 8, 9 and 10, were incomplete and failed to clearly identify how a patient was transported from the point of incident requiring restraint to the seclusion/restraint room (labeled: "comfort room").

During a tour on the Child and Adolescent Unit and interview with MCAU -D on 02/21/12 7:45 a.m. (also present was RN Informatics- C), D told Surveyor # , that patients that need transportation from the area of an incident requiring restraints, to the "comfort room" (seclusion/restraint room), the patient would be placed on a gurney strapped on to prevent the patient from falling or rolling off when transported.

MCAU -D (also present was RN Informatics- C), told Surveyor # , that the patient would remain prone (face down) on the gurney, wrapped in the shoulder to ankle Velcro closed body wrap for the remainder of the restraint.

MCAU -D confirmed to Surveyor # (also present was RN Informatics- C), that MCAU-D was aware of the 2009 State published memo, since it was published on March 13, 2009.

MCAU -D confirmed to Surveyor # (also present was RN Informatics- C), that D as Manager of the Child and Adolescent Unit, could not tell Surveyor the Standard of Practice used for the restraint and seclusion of children and adolescents.

MCAU -D confirmed to Surveyor # (also present was RN Informatics- C), that D was not sure if the current restraint and seclusion procedures used on the Child and Adolescent Unit, were up to date with current accepted Standards of Practice.

On 02/21/12 at 2:00 p.m. during an interview with Dir PI/RM -A confirmed the facility was aware of the State released memo in 2009 specific to child and adolescents, prohibiting techniques or materials that that cover the face or body, and any maneuvers that places pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen, causing chest compression.

Dir PI/RM -A confirmed, in 2006, Dir PI/RM took a 2006 article of an incident related to death while being prone in restraints to the Risk Management Committee, and the Committee didn't believe the death article was applicable to their hospital.

Dir PI/RM -A confirmed, in 2009, Dir PI/RM took the 2009 State published memo, specific to child and adolescents, prohibiting techniques or materials that cover the face or body, and any maneuvers that places pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen, causing chest compression, to the Risk Management Committee, and the Committee didn't believe the 2009 State released memo was applicable to their hospital.

Dir PI/RM -A told Surveyors # and # , that their hospital relied on how other mental health hospitals structured their unit procedures; what worked and what didn't, to structure their own hospital's restraint and seclusion policies and procedures. Dir PI/RM -A confirmed to Surveyors # and # , that their hospital failed to incorporate current Standards of Practice, Manufacturers Recommendations or the 2009 State published memo into their current policies and procedure to ensure the hospital was following current State mandates and requirements.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on training material review and staff interview the hospital failed to train staff in safe retraint and self defense practices. This jeopardized the safety of all patients being restrained.


Findings include:
On 2-20-12 at 10:37 AM an interview with ES/SE L was completed with Dir. PI A and RN Informatics C present. ES/SE L explained that the staff that work directly with the patients receive S.A.F.E. training at orientation and on an annual basis. The training is 7-8 hours long. The training includes all restraints, de-escalation techniques, self defense and hands-on techniques. The training materials used are a video created by the hospital, based on the current policy & procedure, and a set of power point information slides.

ES/SE L stated the training is completed by SDT M and SED N. SDT M and SED N complete the hands on demonstration and the return demonstration from staff. The manufacturer of the body wrap used for restraining pt.'s has not assisted with training.

A review of the training video was completed. The video starts with self defense training that includes what to do if a pt. bites a staff member and won't let go. The video instructs staff to "push into the bite." Demonstration of pt. escort shows two staff members, one on each side of pt. holding pt. with hands and squeezing pt. between the two staff to restrict pt. movement.

Next a 4 person takedown was demonstrated and showed staff restraining the pt. at the feet and arms, forcing pt. down to the floor face down (prone).

The next section of training covered restraint use. The body wrap restraint demonstration shows the pt. on the floor in prone position with 1 staff holding feet, 1 staff holding pt.'s arms on the pt.'s back near buttocks and 1 staff at shoulders and head. Another staff member brings the body wrap and the pt. is rolled side to side to place the body wrap under the pt. The wrap is secured with Velcro on the pt.'s back. There is no instruction on how tight or how to select the correct size for the pt. The pt. is then picked up by four staff and placed face down (prone) on a gurney and secured with straps using 2 fingers space.

Five (5) point leather restraint bed was demonstrated with the pt. in the body wrap removed from the gurney and placed prone on the bed and wrist restraints applied. Body wrap removed and ankle restraint applied. Staff are instructed to document on the flow sheet, HIM-042-0707. ES/SE L could not tell me what professional standards are used to develop the policy & procedures, training video and materials used for educating staff to restraints and self defense.

On 2-20-12 at 2:15 PM a review of SED N's personnel file was completed with ES/SE L. The file shows SED N completed the same S.A.F.E training as all other staff and doesn't hold a professional license or certification. ES/SE L stated that SED N was trained by SDT M and ES/SE L to provide restraint/seclusion and self defense training to staff.

On 2-22-12 at 2:28 PM a review of SDT M's personnel file was completed with ES/SE L. The file shows SDT M was approved through the State of WI for training CBRF (community based residential facility) staff first aid/choking, fire safety and standard precautions.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0201
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and clinical records and policy reviews, the hospital staff failed to demonstrate a clear understanding of and implementation of individual patients' assessments when choosing the least restrictive interventions for 10 of 10 patients (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) who were restrained and/or secluded. Education and training of staff lacked information on appropriate assessment of the patients medical or behavioral status and follow up to determine the least restrictive practice.

Findings include:

On 06/20/12 at 10:45 a.m. Surveyor # along with CES-B and SSM -H reviewed Patient #5's restraint/seclusion flow sheet. The " Seclusion and Restraint " flow sheet #`HIM-042-0707, consisted of pre-printed and pre-defined interventions that staff used prior to restraint or seclusion use. No additional space was provided for a patient's individualized self assessment of interventions that is obtained upon admission. These were things Patient #5 noted as working in the past to de-escalate Patient #5.

CES-B and SSM -H confirmed to Surveyor # that, form #`HIM-042-0707 contained a list of the following interventions:
Determine internal/external cause for behavior; Supportive, exploratory attitude; Mediation of dispute; Ventilation of feelings; Decrease in stimuli; and Suggest privacy/voluntary time out.

Review of the admission questionnaire and admission nursing assessment dated [DATE], documentation noted:
Patient #5 had difficulty falling and staying asleep, and sleep was disrupted, patient has enuresis (problem controlling urination), and wets the bed. RN assessment documented this as within normal limits and/or no complaints.
Triggers to elicit behaviors= "not having control and/or input"
Things that help you feel better= self time out in patient room, self time out in quiet room, watching TV or video, working with clay, crafts or hobbies.

CES-B and SSM -H confirmed to Surveyor # that hospital staff did not implement known de-escalation interventions for Patient #5 on 02/17/12 before Patient #5 was placed in locked seclusion for 11 minutes. CES-B and SSM -H confirmed to Surveyor # that self described triggers to de-escalate are not a part of Patient #5s Care/Treatment Plan

CES-B and SSM -H confirmed to Surveyor # that when restraint or seclusion are used, they are not put on any patient's care/treatment plan. Restraint or seclusion were not found in the care/treatment plan for Patient #5 from the event dated 02/17/12 in Patient #5s record.

CES-B, SSM -H and Surveyor # reviewed the current care/treatment plan for Patient #5 and confirmed the seclusion event was not included in the care/treatment plan to improve care/treatment or to identify ways to decrease restraint/seclusion events.

CES-B, SSM -H and Surveyor # reviewed the current care/treatment plan for Patient #5 and confirmed the interventions used during the seclusion event dated 02/17/12 that did not work, were not incorporated into Patient #5s care/treatment plan to make improvements or changes to decrease or eliminate the potential for future episodes of restraint or seclusion.

On 02/20/12 Dir PI/RM-A provided Surveyor # with an 11 page policy and procedure # 04-087-0911 entitled " Restraint/Seclusion for Behavioral Management " .
Page 2 of 11 under the header " Procedure,"

#2. Trauma Informed Care:
The last sentence states: " Collaboration in the treatment experience and empowering patients to proactively set goals and be active in their treatment process includes developing a plan to assist them in times when emotional regulation is needed " .
#3 " Alternative approaches to assist the patient in controlling his/her behavior will be attempted first " Nine (9) interventions were listed using lower case alpha letters.
g. " Calling family, members who have been identified as being helpful in calming the patient " .
h. " Identified individually designed alternatives " .

On 2/20/2012 at 10:37 AM surveyor # completed staff interview and training material review. ES/SE L shared the computer based training slides for annual training of staff for the 2010-2011 year. The title of the training is "Keys to therapeutic communication and pre crises intervention." The ten page document is a copy of the power point slides viewed by staff. None of the slides direct staff to refer to and incorporate information (past sexual/physical abuse, medical conditions contraindicating restraint use/prone position, pt. identified interventions helpful for de-escalation) from the pts. nursing admission assessment. A review was also completed of the orientation training for inpatient and residential program staff, in use from October 2011 to date. The 13 page copy of the power point slides included in the computer training do not instruct staff to refer to and incorporate information (past sexual/physical abuse, medical conditions contraindicating restraint use/prone position, pt. identified interventions helpful for de-escalation) from the pts nursing admission assessment.


Medical record reviews were conducted from 02/20/12 10:45 a.m. through 02/21/12 at 3:00 p.m. Nine(9) additional medical records were reviewed by Surveyor # and with Dir PI/RM-A and RN Informatics -C, for patients (#1, 2, 3, 4, 6, 7, 8, 9 and 10), who had been restrained or in seclusion.

The following events were identified:

Patient 1 had 3 events of body wrap.
Patient 2 had 2 events of locked seclusion.
Patient 3 had 2 events of body wrap.
Patient 4 had 8 events of restraint/seclusion.
Patient 6 had 9 events of restraint/seclusion.
Patient 7 had 4 events of restraint/seclusion.
Patient 8 had 2 events of body wrap.
Patient 9 had 2 events of restraint/seclusion.
Patient 10 had 5 events of restraint/seclusion.

For all 9 patients, the facility failed to include restraint events into the patients' care treatment plan, to make improvements or changes to decrease or eliminate the potential for future episodes of restraint or seclusion.

For all 9 patients, the care treatment plan failed to define individualized self-defined interventions to de-escalate. These interventions were obtained at admission.

For all 9 patients, there were no self-defined interventions attempted prior to the use of restraints or seclusion.

In addition, Patient #7's medical record failed to include the additional multi-disciplinary case review required by policy and procedure #04-087-0911.

On 02/21/12 at 3:00 p.m, Surveyor # and met with Dir. PI/RM-A and RN Informatics C, to discuss findings of record review, interviews and review of the restraint and seclusion policy #04-087-0911 and the nine(9) additional medical records for patients (#1, 2, 3, 4, 6, 7, 8, 9 and 10) who had been restrained or in seclusion.

Dir PI/RM-A and RN Informatics -C confirmed to Surveyors # and , patient defined interventions are being documented at the time of admission however, confirmed staff are not incorporating the patient defined de-escalation interventions to manage, prevent decline or improve each patient ' s physical or mental health for the 10 of 10 (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) patient records reviewed.

Dir PI/RM-A and RN Informatics -C confirmed to Surveyors # and ,the hospital staff failed the hospital ' s policy and procedures when prior to applying restraint or seclusion to utilize the patient define de-escalation interventions .

Dir PI/RM-A and RN Informatics -C confirmed to Surveyors # and # , the current restraint and seclusion policy and procedures #04-087-0911 failed to meet current accepted Standards of Practice.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on Interviews and records reviewed the facility failed to provide appropriate training and education for staff responsible for care for patients who are restrained. Hospital staff did not include assessments for 8 of 9 (#1, 3, 4, 5, 6, 7, 8, 9 and 10) patients who were restrained in a prone (face down) position. The total universe was 10.

Findings include:

On 06/20/12 at 10:37 AM Surveyor # reviewed training materials provided to in-patient staff for restraint application and requirements. Training video and materials show only use of the 5 point prone position for restraint holds, and the use of prone restraint with the application of a body wrap.

Training materials failed to include assessments or contraindications for using the prone position related to asphyxia.

Policies and procedures failed to include current standards of practice, that might include the American Psychiatric Nurses Association May 2000 Standards of Practice that state " When an individual is physically restrained, immediate action is required to mitigate positional risks; prone restraint requires monitoring for risk of positional asphyxiation."

The hospital is accredited by the Joint Commission, that in November 18, 1998 put out a Sentinel Event Alert related to Preventing Restraint Deaths (issue 8) noting " 40 % of restraint deaths are related to asphyxia " . Under " Root Causes Identified " the 3rd of 4 bullet points " Restraining a patient in a prone position may predispose the patient to suffocation. "

The State of Wisconsin issued a 3 page memo on March 13, 2009 defining " Prohibited Practices in the Application of Emergency Safety Interventions with Children and Adolescents in a Community Based Program or Facility. Page 2 under " Prohibited Procedures " bullet # 5 (of 6 define prohibited practices); " Any technique that involves pushing on or into an individual ' s mouth, nose, or eyes, or covering the face or body with anything, including soft objects such as pillows or washcloths, blankets or bedding etc ...

During an interview on 02/21/12 at 8:00 a.m, MCAU -D confirmed he was aware of the 2009 memo issued by the State. Also present was SSM H.

On 06/21/12 at 9:00 a.m. PI/RM -A confirmed to Surveyor # , that A was aware of the 2009 memo as well as the death that occurred in 2006 related to a death while a patient was in a prone restraint. PI/RM A told Surveyor # that A took the prone restraint death information to the Risk committee and then the Board in 2006, however nothing was done at that time, or when the 2009 memo came out.

During an interview on 02/20/12 at 9:30 a.m. Surveyor # interviewed CES B, who confirmed the hospital uses one type of restraint the "body wrap." The Body Wrap was described as a wrap that encircles a patient ' s body (from shoulders to ankles and then is Velcro closed to prohibit and limit movement. Special precautions related to a patient ' s temperature are required because of the weight and constriction of the body wrap. CES B confirmed everyone is restrained in a prone position, without an assessment since there is only one restraint type and method.

On 02/20/12 at 9:30 RN F confirmed to Surveyor # that if a restraint is needed prone restraints would be used on anyone needing restraint on the child and adolescent unit. If the body wrap is used it is also used as a restraint and patients would be wrapped in a prone position. RN F confirmed that this was how staff are trained, and that an assessment was not necessary since there was only one type of restraint.

Between 02/20/12 starting at 10:45 through 02/21/12 at 3:00 p.m. patient restraint records were reviewed by Surveyors # and , that confirmed assessments for the use of a prone restraint or the potential for asphyxiation were not documented in Patients #1, 3, 4, ,5 ,6, 7, 8, 9 and 10)

The hospitals failure to incorporate current standards of practice and eliminate prohibited practices was confirmed by PI/RM-A
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0205
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and interview the hospital failed to provide appropriate staff knowledge for the specific needs for 10 of 10 (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) patients reviewed on the child and adolescent unit for the following: monitoring the psychological well-being while in restraint or seclusion, or monitoring vital signs that might include respiratory and circulatory status, skin integrity, vital signs.

Findings include:

During restraint policy and patient record reviews for Patient #5, 6, 7, 9 and 10 Surveyor # identified the following:
Restraint flow sheets are not individualized for a child under the age of 9. HIM 042-0707 entitled Restraint and Seclusion Flowsheet " , has a 2 hour requirement for staff to offer range of motion, nutrition hydration, elimination and vital signs every 2 hours. However, a child under 9 can not be restrained for more than 1 hour.

Policy # 04-087-0911 #14 (page 3 of 11) requires every 15 minutes the patient's basic needs are assessed and addressed as needed. Page #4 of 11 #18 states: "the administrator on call and the attending practitioner will be notified of instances in which a patient experiences extended or multiple episodes of seclusion and/or restraint.

b. Notification occurs if the patient experiences two (2) or more separate episodes of seclusion and/or restraint within a 12 hour period.

c. Notification every 24 hours if either of the above conditions continues. If a patient experiences three(3) seclusion and/or restraint episodes in a level one care, a multi disciplinary case review should be conducted within 24 hours when the majority of team members are available (or as soon as possible) for in-patients."

Patient #10 was a 7 year old child.
History noted heart palpitations with Concerta medication doses higher than 18 milligrams. On 12/16/11 at 1400 (2:00 p.m.) Concerta was increased to 27 mg. The physician order required daily vital signs at noon..

5 Restraint events for Patient #10 are as follows:
On 12/14/11 Patient #10 was in a body wrap from 1550 - 1605 (3:50 p.m. - 4:05 p.m.)
No psychological assessment during or after the restraint event was documented. No debriefing was completed as patient refused to participate immediately preceding the event, and 30 minutes later. However, nurse failed to document objective observational findings. Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points checked.

On 12/15/11 from 0945-1015 (9:45 a.m.- 10:15 a.m.) Patient #10 was restrained in a body wrap. No psychological assessment during the restraint event was documented.
The debriefing documentation required after each restraint event, was dated 12-17-11 and not timed. It was completed 2 days after the event and not within the 24 hours required on the form (HIM-048-0110). Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points checked.

On 12/15/12 from 1605 - 1705 (4:05 p.m.- 5:05 p.m.) Patient #10 was restrained in a therapeutic hold for 10 minutes then transitioned into the body wrap for 50 minutes.
The documentation fails to conclude one restraint before initiating another restraint.
No assessment was completed between the two types of restraint or interventions between each restraint type. The 1 hour face to face evaluation after both restraint events were concluded, was incomplete and documentation was inaccurate. The 1 hour face to face form (HIM 048- 0110) failed to include the circling of a "yes" or "no" to whether the patient was in or out of restraint at the time of the assessment. If a no answer is recorded, additional documentation was required.

No psychological summary was documented that required including history of sexual assault, and emotional comfort. The physical assessment failed to document vital signs as well as patient presentation. At the end of the document a question requires the writer to document the date and time the patient was released from restraints. The writer documented 1615 (4:15 p.m.) as the time released. However, this time does not coincide with the restraint flow sheet that notes patient's time out of restraints was 1705 (5:05 p.m.) Personal cares were not documented that included the 15 minutes to include vital signs, elimination, and pressure points not checked for the 40 minutes Patient #7 was in restraints.

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.

On 12/17/11 from 2115-2200 (9:15 p.m. - 10:00 p.m.) Patient #10 was restrained in a body wrap. No psychological assessment during the restraint event was documented. The 1 hour face to face form identified the patient was in restraints at the time of assessment. If a "no" was answered, additional documentation was required, however there is no documentation subsequent to the no answer. Patient ' s reaction related to the restraint event was not documented. Vital signs were not documented. There is no mention of Patient #10 monitoring with increased Concerta dosing. A physicians' signature is required if a Qualified Registered Nurse completes the 1 hour face to face assessment. However, no physician's signature was documented to confirm the physician reviewed the document.

On 12/18/11 from 1115 - 1220 (11:15 a.m. - 12:20 p.m.) Patient #10 was restrained in a body wrap. No psychological assessment during the restraint event was documented. Vital signs were not documented throughout the 1 hour and 5 minute restraint episode in a body wrap to include temperature required because of the potential for overheating in the body wrap. Documentation notes patient was refusing water and had not eliminated during the entire time of the event.

Patient #9 was a [AGE] year old adolescent. History noted Patient #9 had a low potassium level. A potassium imbalance has the potential to cause cardiac dysfunction.

2 Restraint events for Patient #9 are as follows:
On 09-20-11 from 1540 - 1650 (3:40 p.m. - 4:50 p.m.) Patient #9 was in a restraint for 1 hour and 10 minutes The type of restraint was not identified. Restraint flow sheet failed to include personal cares that included the 15 minute check for range of motion, vital signs, elimination, and nutrition-hydration for the 50 minutes Patient #9 was restrained.
The 1 hour face to face evaluation did not include the psychological summary of past history of sexual abuse required on the evaluation form # HIM-048-0110.

On 09-20-11 from 1925 - 2010 (7:25 p.m. - 8:10 p.m.) Patient #9 was in a restraint for 45 minutes. The type of restraint was not identified. Restraint flow sheet failed to include personal cares that included the 15 minute checks for range of motion, vital signs, elimination, and nutrition-hydration for the 45 minutes Patient #9 was restrained.

The 1 hour face to face evaluation did not include a review of the Medication Administration Record (MAR), vital signs were not obtained during the restraint event or after "unable to" noted without further explanation that is required on the evaluation form # HIM-048-0110. No new wounds documented on the # HIM-048-0110 1 hour face to face evaluation form, but the body map was blank indicating patient had no abnormal findings, however, the earlier restraint event noted a cut to the right wrist.

Per policy # 04-087-0911 no team case review was found after 2 episodes that occurred within a 12 hour period.

Patient #7 was a [AGE] year old adolescent.

3 Restraint events for Patient #7 are as follows:
Restraint flowsheet noted a restraint on 11/09/11 from 1517 - 1602 (3:17 p.m. - 4:02 p.m.) Patient #7 was restrained for 45 minutes. However, restraint documentation failed to identify the type of restraint or seclusion that was used on Patient #7, and that the restraint application occurred on 11/10/11 not 11/09 as documented.

Personal cares that requires 15 minute check per policy and procedure failed to include the 15 minute check for range of motion, vital signs, elimination, and pressure points for the 45 minutes patient was restrained. 1 hour face to face evaluation was incomplete and failed to include the circumstances required if the answer is "no" the patient is not out of restraints at the time of the evaluation. The MAR review was not completed. The medications Patient #7 received during the restraint event were not documented on the record. Debriefing record was not completed. Hospital staff documented "refused," however no additional information documented. The Debriefing was not completed in the 24 hour time frame noted 11/11/11 at 1000 a.m. (for restraints applied 11/09/11 at 3:17 p.m.)

On 11/10/11 from 2055 - 2150 (8:55 p.m.- 9:50 p.m.) Patient #7 was restrained in a body wrap for 55 minutes. Vital signs were not obtained during this restraint event that included a body wrap. The 1 hour face to face evaluation failed to include a review of the MAR or any additional comments to include medication given patient while restrained. The 1 hour face to face evaluation failed to identify the circumstances required with a "no" answer indicating patient was not out of restraints at the time of the evaluation.

Five (5) hours between restraint application on 11/10/11 occurred, and per policy # 04-087-0911 no team case review was found after 2 episodes that occurred within a 12 hour period

On 11/11/11 at 1820-1910 (6:10 p.m. - 7:10 p.m.) Patient #7 was restrained 50 minutes first in a therapeutic hold for 20 minutes, and then transitioned into a body wrap.
The hospital failed to stop one order and complete documentation and assessments before implementing another type of restraint.

Personal Cares failed to include 15 minute pressure point checks, range of motion, elimination and vital signs. One documented offer/refused of nutrition-hydration. However the restraint event lasted 50 minutes and policy # 04-087-0911 requires every 15 minute checks. Two (2) questions of the Patient 1 hour face to face evaluation form #HIM048-0110 were not completed to include a yes/no question to indicate if the patient was currently in restraint/seclusion, and a required statement as to "patient reaction to the Restraint/Seclusion."

Patient #6 was a 4 year old. Patient history noted Patient #6 had a single kidney.

9 restraint/seclusion events for Patient #6 are as follows:
During Patient #6's stay there were 8 episodes of locked seclusion. Documentation noted Patient #6 was "escorted" to the quiet room (locked seclusion). Restraint documentation including the 1 hour face to face evaluations was incomplete. The term "escorted" did not include how the patient was escorted (stand by walking along with or physically holding the 4 year old patient) or by whom (which staff escorted Patient #6).

On 11/11/11 the restraint documentation noted Patient #6 to be in a basket hold. A basket hold was described as a hold where one or more staff utilizes the body and arms to restrain a patient. Restraint documentation failed to identify specifically how the hold was implemented and which staff were involved.

Per policy # 04-087-0911 no team case review was found after 2 episodes that occurred within a 12 hour period

Patient #5 is an 8 year old who has a history of enuresis (inability to control urination) and constipation (infrequent bowel movement or bowel movements hard to pass)

One (1) episode of locked seclusion as follows:
Patient became agitated after going to bed. Patient has a history of enuresis; however interventions prior to restraints did not include potential toileting needs.

1 hour face to face evaluation required after the use of restraint or seclusion was incomplete, for the question "currently in restraints yes/no." "No" was circled, and did not include circumstances required for an answer of "No." Vital signs were not documented, and there was no documentation of the "chest/abdomen" that would include respiratory status

Surveyor # reviewed and confirmed Patient # 5s restraint record findings on 02/20/12 at 11:00 a.m. with CES -B and SSM- H.

Surveyor # reviewed and confirmed Patient's # 6, 7, 9 and 10s findings with RN Informatics-C and PI/RM-A on 06/21/12 between 9:05 a.m. and 3:00 p.m.

RN Informatics-C and PI/RM-A confirmed that the incomplete and inaccurate documentation failed to comply with the hospitals policies and procedures for restraint and seclusion or demonstrate a clear understanding and knowledge of training provided annually.

RN Informatics-C and PI/RM-A confirmed to Surveyor # , the hospital did not have a policy and procedure for QMP RNs trained to complete the one hour face to face assessment/evaluation of a patient after a restraint/seclusion event that would define monitoring the physical and psychological well-being of the patient who is restrained or secluded.




Findings by surveyor # :

Patient #1 was an [AGE] year old child.

3 Restraint events for Patient #1 as follows:
On 6/23/11 Patient #1 was in a body wrap from 1625 - 1705 (4:25 p.m. - 5:05 p.m.)
No psychological assessment during or after the restraint event was documented. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.
The debriefing form is signed and dated 6/24/11 but not dated or timed at the top. Therefore there is no way to know if the debriefing occurred within the 24 hours of the event.
Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.

On 6/24/11 from 0945-1008 (9:45 a.m.- 10:08 a.m.) Patient #1 was restrained in a body wrap.
No psychological assessment during the restraint event was documented. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.

The debriefing documentation required after each restraint event was not available.
Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.

On 6/24/11 from 1650 - 1705 (4:05 p.m.- 5:05 p.m.) Patient #1 was restrained in a body wrap. On 6/24/11 from 1715 - 1730 (5:15 p.m. - 5:30 p.m.) the documentation shows pt. #1 " sitting quietly in corner. " The documentation fails to conclude one restraint before initiating another restraint, and fails to include location of pt. #1. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.

The debriefing documentation required after each restraint event was not available.
No assessment was completed between the two types of restraint or interventions between each restraint type.
No psychological summary was documented that required including history of sexual assault, and emotional comfort.
Personal cares were not documented that included the 15 minute to include vital signs, elimination, and pressure points were not checked.

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.

Patient #2 was an 8 year old child.

2 Locked Seclusion events for Patient #2 as follows:
On 6/16/11 Patient #2 was in Locked Seclusion from 1507 - 1529 (3:07 p.m. - 3:29 p.m.)
No psychological assessment during or after the locked seclusion event was documented.

Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.
The 1 hour face to face documentation is noted to occur at 1525 (3:25 p.m.). This is prior to pt. #2 ' s release from locked seclusion. " No " is circled for the question, " Currently in restraint/seclusion " . This does not match the flow sheet documentation.

On 6/17/11 from 1730-1800 (5:30 p.m.- 6:00 p.m.) Patient #2 was in Locked Seclusion.
No psychological assessment during the seclusion event was documented.
The debriefing documentation required after each restraint is not dated or timed at the top of the document to indicate when the debriefing occurred and if it was within 24 hours of the event.
Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.

Patient #3 was an [AGE] year old child.

2 Restraint events for Patient #3 as follows:
On 6/26/11 Patient #3 was in a body wrap from 1010 - 1100 (10:10 a.m. - 11:00 a.m.)
The restraint flow sheet shows pt. #3 was in a body wrap restraint but fails to show what time the restraint was applied or removed. It is documented that at 10:30 a.m. the pt. refused personal care. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.

Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.
No psychological assessment during or after the restraint event was documented.
The debriefing form is signed and dated 6/26/11 but not dated at the top and timed 10:45 a.m. Therefore was completed while pt. #3 was restrained in the body wrap.
The 1 hour face to face document was also completed at 10:45 a.m. while pt. #3 was restrained in the body wrap. " No " is circled as an answer to the question, " Currently in restraint/seclusion " . Under question #1, " Known medical conditions or physical disabilities increasing risk of injury " " Yes " is checked and " seizures " is listed. Under " Known history of physical or sexual abuse increasing risk of stress/trauma: " yes " is checked and states, " physical abuse at Mendota " .

On 6/26/11 patient #3 was restrained in a body wrap from 1120 - 1150 (11:20 a.m. - 11:50 a.m.). The restraint flow sheet shows pt. #3 was in a body wrap but fails to show what time pt. #3 was put in the body wrap and what time the body wrap was removed.
The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.

Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.
No psychological assessment during or after the restraint event was documented.
The 1 hour face to face document was completed at 12:00 p.m. Under question #1, " Known medical conditions or physical disabilities increasing risk of injury " " Yes " is checked and " seizures " is listed. Under " Known history of physical or sexual abuse increasing risk of stress/trauma: " yes " is checked and states, " physical abuse at Mendota " .

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.


Patient #4 was an [AGE] year old child.

8 Restraint/seclusion events for Patient #4 as follows:
On 11/19/11 Patient #4 was in a body wrap from 1620 - 1715 (4:20 p.m. - 5:15 p.m.)
No psychological assessment during or after the restraint event was documented.
The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.

Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.

On 11/19/11 from 1920-2010 (7:20 p.m.- 8:10 p.m.) Patient #4 was restrained in a body wrap. Documentation on the restraint flow sheet is not clear as to when the body wrap was applied and removed.
Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.
No psychological assessment during the restraint event was documented.
The 1 hour face to face documentation shows pt. #4 refused vital signs. The space for documentation is blank next to the question, " Is the patient able to be released from restraints/seclusion yet? "
Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.

On 11/20/11 from 1150-1220 (11:50 a.m. - 12:20 p.m.), patient #4 was restrained in a body wrap. Documentation on the restraint flow sheet shows the body wrap was applied at 1205 (12:05 p.m.) and removed at 1208 (12:08 p.m.) and " changed to locked seclusion until 1220 (12:20 p.m.). There is no physician order for locked seclusion.
The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.

Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.
No psychological assessment during the restraint event was documented.

On 11/25/11 from 1443-1448 (2:43 p.m.- 2:48 p.m.) Patient #4 was restrained in a body wrap. Documentation on the restraint flow sheet shows at 1444 (2:44 p.m.) pt. #4 was " wheeled into comfort room. " The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and what the patient was wheeled on.

No psychological assessment during the restraint event was documented.
The debriefing form is dated 11/25/11 at 1505 (3:05 p.m.). This is the third episode of restraint or seclusion for this pt. The debriefing form states, " after the 3rd episode of restraint or locked seclusion during this level of care schedule a multidisciplinary team meeting immediately. Meeting date: " the space after meeting date is blank. The record does not show a special multidisciplinary team meeting until 11/29/11.
The 1 hour face to face document is dated 11/25/11 and timed 1515 (3:15 p.m.) at the top. Documentation shows pt. #4 was complaining of 4/10 pain related to a bump on forehead and lists, " swelling + bruising on forehead " . However the restraint flow sheet does not indicate a head injury of any kind.
On 11/25/11 from 1448 - 1456 (2:48 p.m. - 2:56 p.m.) patient #4 was in locked seclusion. Comments section states, " patient tied shirt around neck " . The restraint flow sheet does not have documentation to show how the patient was taken to the locked seclusion, which staff were involved.


The 1 hour face to face document is dated 11/25/11 and timed 1515 (3:15 p.m.) at the top. Documentation shows pt. #4 was complaining of 4/10 pain related to a bump on forehead. However the restraint flow sheet does not indicate a head injury of any kind.
Any injury from the patient ' s shirt around the neck is not addressed. The debriefing form is identical to the form for the incident immediately pre-ceding this locked seclusion.
Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period.

On 11/26/11 from 1835-1905 (6:35 p.m.- 7:05 p.m.) Patient #4 was restrained in a body wrap. Documentation on the restraint flow sheet shows at 1842 (7:42 p.m.) pt. #4 was " re-wrapped. " There is no physician order for the second time pt. #4 was put in a body wrap. Release criteria met section is not answered. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.
Documentation does not show what time the body wrap was first applied. Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked.
No psychological assessment during the restraint event was documented.
Patient debriefing form to be completed within 24 hours of the event is dated 11/28/11 at 1700 (5:00 p.m.).

On 11/28/11 from 1130 - 1200 (11:30 a.m. - 12:00p.m.) patient #4 was restrained in a body wrap. Restraint flow sheet documentation shows at 1140 (11:40 a.m.) pt. #4 was " re wrapped " and released at 1200 (12:00 p.m.). Physician orders show one order for a body wrap restraint. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.
Personal cares were not documented that included the 15 minute vital signs, elimination, and hydration. The section for " continues to need restraint " is not filled in. The patient debriefing form is not dated or timed at the top, therefore there is no way to determine when the debriefing was completed.
The 1 hour face to face document is dated 11/28/11 and timed 1215 (12:15 p.m.), the physical assessment area states, " multiple very superficial scratches, she states are from yesterday. " Documentation does not state where the scratches are. Record does not have documentation to show how patient #4 sustained scratches.

Per policy # 04-087-0911, no team case review was found after 2 episodes that occurred within a 12 hour period

On 1/8/12 from 2110 - 2150 (9:10 p.m. - 9:50 p.m.) patient #8 was restrained in a body wrap. Restraint flow sheet shows in comment section, " control hold transition " and in the precipitating events section states, " inability to calm after attempt at release from physical hold " . The record shows no order for a therapeutic hold. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.
Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked. Flow sheet states at 2150 (9:50 p.m.) vitals checked but results are not documented.
The 1 hour face to face document shows under Physical Summary: 1. Known medical conditions or physical disabilities increasing risk of injury: box No is checked and a hand written note is made, " Non noted on medical or nursing eval though Mother states history of heart problem " . The nursing admission assessment dated [DATE] states, " had ECCO 9/11- result pulmonary hypertension, since Concerta was increased, pt. complained of chest pressure, tingling in chest. "

On 1/9/12 from 2035 - 2105 (8:35 p.m. - 9:05 p.m.) patient #8 was restrained in a body wrap. Personal cares were not documented that included the 15 minute vital signs, elimination, hydration, and pressure points were not checked. The restraint flow sheet does not have documentation showing where the patient was when put in the body wrap, which staff were involved and the locations of the patient while restrained.
No psychological assessment during the restraint event was documented. The 1 hour face to face documentation dated 1/9/12 at 2130 (9:30 p.m.) states, " no " for any known medical condition, increasing risk of injury. The nursing admission assessment dated [DATE] states, " had ECCO 9/11- result pulmonary hypertension, since Concerta was increased, pt. complained of chest pressure, tingling in chest. " Physical assessment shows pt. #8 refused a blood pressure check.
Surveyor # reviewed and confirmed Patient's # 1, 2, 3, 4 and 8's findings with RN Informatics-C between 12:17 p.m. and 12:45 p.m.on 2-21-12.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0207
Based on staff interview, regulatory staff interview and personnel file review the staff providing training for restraint/seclusion and self defense are not qualified.

Findings include:

On 2-20-12 at 10:37 AM an interview with ES/SE, L was completed with Dir. PI A and RN Informatics C present. ES/SE L explained that the staff that work directly with the patients receive S.A.F.E. training at orientation and on an annual basis. The training is 7-8 hours long. The training includes all restraints, de-esculation techniques, self defense and hands on techniques. The training materials used are a video created by the hospital, based on the current policy & procedure, and a set of power point information slides. ES/SE L stated the training is completed by SDT M and SED N. SDT M and SED N complete the hands on demonstration and the return demonstration from staff.

On 2-20-12 at 2:15 PM a review of SED N ' s personnel file was completed with ES/SE L. The file shows SED N completed the same S.A.F.E training as all other staff and doesn ' t hold a professional license or certification. ES/SE L stated that SED N was trained by SDT M and ES/SE L to provide restraint/seclusion and self defense training to staff.

On 2-22-12 at 2:28 PM a review of SDT M ' s personnel file was completed with ES/SE L. The file shows SDT M was approved through the State of WI for training CBRF (community based residential facility) staff first aid/choking, fire safety and standard precautions.

During a telephone interview conducted on 02/23/12 at 9:28 a.m. Surveyor # inquired about the CBRF training the hospital was using to structure their restraint/seclusion training. Division of Quality Assurance (DQA) Nurse Consultant (NC) II -O for the Bureau of Assisted Living that also over sees CBRFs told Surveyor # , DHS - approved training is required for CBRF employees, that consists of Standard Precautions, Fire Safety, First Aid and Choking, and Medication Administration and Management. (This training is deptartment approved, meaning DHS approves the curriculum developed by UW Oshkosh who coordinates the content and trainers of those courses.)
DQA NCII-O told Surveyor # ,additional training required of all employees includes Resident Rights, Client Group and Recognizing, Preventing, Managing and Responding to Challenging Behaviors. The content of those programs does not require department approval. The rule states that the CBRF must provide, obtain or ensure adequate training for all employees in those areas.
DQA NCII-O told Surveyor # ,in approving the use of a restrictive measure for a specific resident the Department would approve the restrictive measure being used (i.e., a 2-person basket hold) and in doing so would review the source of their training.
DQA NCII-O reviewed a a memo with Surveyor # , published by the State (Department of Long Term Care (DLTC), Department of Mental Health Substance Abuse Services (DMHSAS) and the Division of Quality Assurance (DQA) dated 09-21-2010.
The memo #DQA 10-26 entitled "Practices Not to be Used in Community Based programs or Facilities", noted in the last bullet under prohibited practices: "Any maneuver or technique that forcibly takes an individual face forward from a standing position to a prone position".