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.

VIA CHRISTI HOSPITALS WICHITA, INC 929 NORTH ST FRANCIS STREET WICHITA, KS 67214 Feb. 15, 2018
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and document review the hospital's governing body failed to ensure an effective operation of the grievance process. This deficient practice puts all staff and patients at risk for failing to have their complaints and grievances resolved, to assure the appropriate interventions, safety measures, changes and resolutions occurred.

Findings include:

Interview on 2/15/2018 at 6:53 pm, Administrative Staff B explained that facility grievances are the responsibility of the Risk Manager. The Risk Manager presents grievances to the Quality Patient Committee (QPIC). The QPIC is not considered a grievance committee. The hospital board (governing body) does not currently oversee, approve or provide oversight of the grievance process.

- Document titled "Governing Body/Board of Directors By-Laws" failed to address the development and implementation of the grievance process including delegating in writing the committee responsible for handling the grievance process. The hospital did not provide any further documents showing the the governing body was responsible for the effective operation of the grievance process.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on interview and document review the hospital's governing body failed to assume responsibility of the grievance process included timely referral of patient concerns regarding quality of care to a Quality Improvement Organization. Failure of the Governing Body's to oversee the grievance process and ensure timely referral of quality of care concerns to the Quality Improvement Organization puts all patients at risk for receiving substandard care and treatment.

Findings include:

Interview on 2/15/2018 at 6:53 pm, Administrative Staff B explained the facility has an Ad Hoc (for a particular purpose) committee whose members are appointed and meet only in response to a grievance that is not satisfactorily resolved. The Governing Body/Board of Directors currently do not provide oversight of the Quality Committee to address resolution of grievances.

- Document titled "Governing Body/Board of Directors By-Laws" lacked a mechanism for timely referral of patient concerns to the Quality Improvement Organization.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record, policy and procedure review the hospital failed to prevent mental and physical abuse when the staff used restraints as a matter of retaliation, discipline, and convenience for 1 of 12 records reviewed (Patient #1) of patients who were restrained. This deficient practice puts all patients at risk for emotional and physical abuse and at risk for injury.

Findings include:

- Patient #1's record review on 2/14/2018 revealed a date of birth of 4/18/2004 ([AGE] years old) and admission to the hospital on [DATE] with a diagnosis of drug overdose and suicide attempt. On 1/30/2018 around 6:45 pm, Staff applied Nylon 4 point, locked restraints (to both lower and both upper limbs), a C-collar (brace to prevent neck movement), a spit mask (a mesh head covering to prevent patient from spraying spit), and a cross restraint (a rolled sheet placed over a patient's chest, pulled up under the arms, and tied to bed) to Patient #1 after an altercation where she bit, scratched, spit, pulled hair, cursed at the nursing staff, and threatened self harm.

- Interview on 2/14/2018 at 8:40 am Employee Registered Nurse (RN) Staff P Burn Unit /Pediatric Intensive Care Unit (PICU) stated, "At 6:00 pm on 1/30/2018, Patient #1 went to the shower and we realized the "hugs bracelet" (safety ankle/wrist bracelet that protects from elopement) was off. I told her that she would have to put it back on, that it is required for all pediatric patients even though she was older. The female tech tried to get her to put the bracelet back on and she said she did not want to wear the bracelet. I took the bracelet to the shower room and she became very loud and refused to do so. We walked to her room, she was defiant and walked down the hall with her arms crossed. When we got to the room she would not get into the bed. She continued to be loud and was cussing at me, refusing to get into bed. I didn't want to be alone with her in the room. I knew it was escalating and I called security. She was cursing at me and I told her again she would have to have the monitor on. I think as soon as I called security it escalated her and she started scratching herself on her arm. I told her she couldn't do that and I grabbed her hands, getting her onto the bed. She then started biting herself, breaking the skin. Certified Nurse Aide (CNA) Staff DD tried to keep her legs down and I held her at the top. I called out for help and CNA Staff BB brought the soft restraints. I'm not sure they ever really got put on. I called for more help and RN Staff U came in and grabbed Patient #1's arm and then Patient #1 grabbed my hair. I told her to let go of my hair and she would not. Then CNA Staff DD called charge nurse for more help. I was on the left at the arm. CNA Staff DD on right leg. RN Staff U was on the right side. Security brought the nylon restraints. She had on the nylon 4 point restraints, a c-collar, and a spit mask." RN Staff O contacted the Wichita police department to make a report regarding the assault. The police officer interviewed Patient #1 and myself. Then he had her apologize to me. I told her the behavior was inappropriate. When Patient #1 apologized I don't think she was genuine. "I had her as a patient on Jan. 30, 31, and [DATE]st. I felt fine taking care of her because she was calm and I did not feel threatened. The sitter was a larger size and she was at a level 3 suicide watch (sitter at arm's length away from the patient) at that point. We kept her in restraints because she wanted to pull the IV out and she did remove the hugs bracelet. I just don't think taking the restraints off was appropriate because she continued to say she would kill herself if they came off. On day two I was going to take the restraints off but she was being so mouthy.

The medical record lacked evidence that the hospital attempted to reassign the nurse responsible for caring for Patient #1 on the days following this altercation. RN Staff O continued to care for Patient #1 on 1/31/2018 and 2/1/2018 even though Patient #1 had bit her, scratched her, and pulled her hair on the evening of 1/30/2018, and RN Staff O filed an assault report against Patient #1 with the police. Placing RN Staff O in charge of Patient #1 after this incident, when she is tied down with restraints gives RN Staff O "power" over Patient #1.

The record lacked documentation that nursing staff attempted any deescalation techniques (avoid overreacting, remain calm, rational, choose wisely what you insist on, allow time for decisions) or spoke to the patient's guardian about signing a waiver for the Hugs bracelet.

Policy titled "Child Security" read, All children will be assigned a security sensor number during the admission process. If a parent/guardian chooses not to have the child wear a security sensor a waiver will be signed.

Nursing Documentation showed the patient in Nylon 4 point locked wrist restraints every 12 hour check that was completed from restraint initiation up though discharge even though interview with staff indicated that the patient was only in nylon locked wrist restraints from sometime in the morning on 1/31/2018 until she discharged on [DATE] at 12:32 pm.

Interview on 2/13/2018 at 5:10 pm, RN Staff O stated, I assessed the restraints and asked how Patient #1 was feeling. She was wearing nylon wrist restraints and leg restraints. I took the leg restraints off during the night (1/31/2018). She had the neck brace and I removed that as well. She had a sheet across her chest and I removed that as well. Every time I talked with her she would ask if she could have the restraints removed and I said I needed to make sure she was safe first. Patient #1 said she would hurt herself if they came off.

- Even though there was numerous documentation in the medical record that said the patient was calm, cooperative, sleeping, playing cards and cognitive status improved and no longer interferes with care, the medical record lacked evidence hospital staff attempted to use restraint alternatives past 5:07 am on 1/31/2018.

Nurse Progress note dated 2/1/2018 at 7:36 pm authored by RN Staff P read, Pt (Patient #1) verbalizes throughout shift desire to kill herself to RN. Pt states multiple times "As soon as I get out of these restraints, I'm going to kill myself:. RN discusses pt status with Resident Physician Staff L, Pediatric Hospitalist Staff M, and House Supervisor RN Staff PP. All agree to keeping patient in restraints to keep patient and staff safe, even though the medical record showed that the patient was on a level 3 behavioral health status watch (person sitting within arm's reach) and had suicide precautions in place (every 15 minute checks).

Interview on 2/12/2018 at 10:03 am with Patient's Guardian, "I just feel like they failed my girl." He felt like no one listened to them about the medications and restraints. The Guardian shared he felt like the restraints were not necessary and that because Patient #1 hurt a nurse she would pay for it. The Guardian recalled he asked for the policy and procedure about restraints and was not given a copy. The Guardian indicated when Patient #1 was discharged she was very weak and could hardly walk and that she could not feel her fingers as they were tingling. He remembers her hands as being swollen and she had difficulty gripping. The Guardian shared that Patient #1 is back home now, she felt trapped while at the hospital and is trying to sort through it all.

- The medical record lacked documentation the hospital staff used less restrictive restraints (for example: soft wrist restraints). The record indicated the type of restraint used from initiation on 1/30/2018 to discharge on 2/2/2018 was "hard" nylon, locked restraints.

- The record rarely documented evidence hospital staff removed the restraints during care to assess the ongoing need for them or at least every 12 hours as a trial.

- The record lacked documentation the hospital staff contacted the consulted Psychiatrist to see the patient after this altercation to re-evaluate the need for her home medications, which were on hold, and for further psychological support. The patient was taking medications at home: Aripiprazole and Lexapro. Aripiprazole is used to treat major depressive disorders and discharge documentation has the following warning: You should not stop this medication suddenly. Stopping suddenly may make your condition worse. Lexapro is used to treat major depressive disorders and Discharge Documentation has the following warning: Do not stop using Lexapro suddenly, or you could have unpleasant withdrawal symptoms.

- Some documentation in the medical record showed the patient was in soft restraints when in fact she was in "hard" nylon-locked restraints.

- The medical record lacked documentation when the C-collar, spit mask and cross restraints were removed.

Email from House Supervisor Staff PP dated February 1, 2018 at 4:07 pm with Subject: family compliment read, I got a call from the guardian of Patient #1, who was the biter/hair puller. The guardian could not say enough nice things about RN staff P, "she managed Patient #1 with fairness" (everything except the restraints).

The hospital staff failed to even try to remove the restraints from Patient #1, they labeled her the biter and hair puller and did not use their current assessments of her to make decisions about removing the restraints. The hospital staff made decisions based on past behavior and what might happen if the restraints were removed. It was convenient for the staff to leave her restrained so they did not have to be concerned.

- The hospital's document titled "Annual Education Clinical 2017" directed, use alternatives to restraints such as a tele-sitter or human sitter. Restraints should be discontinued at the earliest opportunity and released no less than every 12 hours as a trial. Restraints are never used to discipline a patient, make patient care tasks more convenient for staff and make a patient do something against their will.

The record showed that the patient had a human sitter with her within arm's reach and the record showed 15 minute documentation from the sitter's of the patient's status from 1/30/2018 at 6:45 pm through discharge at 2/2/2018 at 12:32 pm. The overwhelming majority (over 90%) of these checks indicated that the patient was calm, visiting calmly, and playing cards. Even though the patient was verbalizing occasionally that she would kill herself when the restraints came off, the threat was empty in the environment of the hospital with a sitter and precautions in place as the patient showed no further violence towards herself or staff. Documentation also indicated one of Patient #1's guardians present for the entire hospital stay.

- The hospital's document outline titled "New Hire Orientation Educational Power Point directed, restraint or seclusion use is: not driven by diagnosis, but by comprehensive, individual, patient assessment. The goal is to strive toward a restraint-free environment, to preserve each patient's right to care that maintains personal dignity and well-being, restraint and seclusion are used to protect the immediate safety of the patient, staff, and others. The document lacked evidence of education directing staff when to use soft restraints versus nylon locked restraints.


- The hospital's policy titled "Restraints and Seclusion Policy" directed, the use of the restraint or seclusion is not driven by diagnosis, but by a comprehensive, individual, patient assessment...restraint or seclusion is discontinued at the earliest possible time and when the unsafe condition has been resolved. Restraint or seclusion may only be used while the unsafe situation continues and will be discontinued when the patient is no longer harmful to self or others. The decision to discontinue restraint may be made by the registered nurse or a physician, physician assistant, or Advanced Practice Registered Nurse. The decision to discontinue is based on the determination that the need for restraint/seclusion is no longer present, or that the patient's need can be addressed using less restrictive methods.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0159
Based on interview, record, policy and procedure review the hospital failed to ensure staff documented application and removal of items that were used as restraints in 1 of 12 records reviewed (Patient #1) of patients who were restrained. This deficient practice puts all patients at risk for physical and psychological harm due to unsafe and inappropriate restraints.

Findings include:

- Patient #1's record review on 2/12/2018 revealed documentation in the nursing notes the patient was in 4 point nylon locked restraints (both wrists and ankles) starting on 1/30/2018 at 6:45 pm through discharge on 2/2/2018. The nursing progress note from 1/30/2018 at 7:10 pm revealed Staff P recording a spit mask was applied to the patient on 1/30/2018 around 6:00 pm.

Interview on 2/14/2018 at 7:45 am, Security Officer Staff JJ recalled, "Security was called to the unit and when we arrived there were several staff holding the patient down. When we put her in restraints she was also put in a c-collar to keep him/her from biting herself. S/he was able to sit up and slam herself down so we restrained her torso with a sheet and tied it to the bed "cross restraint". Her ankles were restrained. She was spitting and they tried a regular mask which didn't work. I am not sure if they got a spit hood.

Further review revealed Patient #1's record lacked documentation of placement or removal of the c-collar or the cross restraint. The record indicated patient #1 remained in 4 point restraints from this incident until discharge on 2/2/2018, even though staff indicate through interview that Patient #1 only remained in bilateral wrist restraints after sometime in the early morning of 1/31/2018.

Staff used methods to restrain the patient besides the 4 point nylon locked limb restraints including the c-collar, the spit mask, and the "cross restraint".

- The hospital failed to develop and implement a policy and procedure including instructions for use of these items as restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and document review, the hospital failed to ensure that the plan of care was updated for 1 of 12 medical records reviewed (Patient #1) of patients who were restrained. Failure to update the plan of care places patients at risk for injury, both psychological and physical.


Findings include:

- Patient #1's record review on 2/12/2018 indicated that Patient #1 was placed in 4 point nylon, locking restraints after an altercation on 1/30/2018 around 6:45 pm. The patient's care plan was not modified after initiation of the restraints. The record lacked documentation hospital staff created a "Risk for Injury" POC (plan of care) related to restraint usage. The record showed Patient #1 remained in nylon, locking restraints until discharge on 2/2/2018, and the staff failed to add a care plan related to restraints.


Policy titled "Restraints and Seclusion" directed, the plan of care is revised within the shift when restraints are applied to include Risk for Injury POC and should reflect need for restraint as well as note the goal of intervention...should be reviewed as long as patient is in restraints.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy and procedure review, and staff interview, the hospital failed to prevent mental and physical abuse when the staff used restraints as a matter of retaliation, discipline, and convenience for 1 of 12 records reviewed (Patient #1) of patients who were restrained.

The cumulative effect of the facility's failure to only use restraints to ensure the immediate physical safety patients, staff members, or others placed all restrained patients at risk of psychological or physical harm.

Findings include:

- Patient #1 ([AGE] years old) demonstrated violent and self-destructive behaviors including biting, scratching, hair pulling, and threats of self-harm, and hospital staff placed her in 4 point nylon, locked restraints (both wrists and both ankles), a spit guard (a mesh head covering to prevent patient from spraying spit), c-collar (brace used to restrict neck movement), and a cross restraint (a rolled sheet placed over a patient's chest, pulled up under the arms, and tied to bed) on 1/30/2018 around 6:45 pm. The medical record lacked documentation staff removed the spit guard, the c-collar, or the cross restraint. Staff documentation showed the Patient #1 had the 4 point nylon locked wrist restraints on from the time of this incident until the patient discharged on [DATE] at 12:32 pm. Although Patient #1 showed no further violent or self-destructive behaviors and only had an occasional verbal threat of self-harm, hospital staff failed to attempt to remove the restraints. The hospital staff continued to restrain Patient #1 as a matter of retaliation, for discipline and for their convenience. (Refer to A-0154 fur further details).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on medical record and policy review, the hospital failed to ensure that orders for restraints were renewed within the time limit allowed based on patient age in 1 of 12 medical records reviewed (Patient #1). Failure to renew the restraint order per policy for the use of nylon, locked restraints based on patient age could result in mental anguish and injury.


Findings include:

- Patient #1's medical record review performed on 2/12/2018 indicated hospital staff placed her in 4 point nylon, locked restraints to both lower and both upper limbs, a C-collar (neck brace to prevent neck movement), a spit mask (a mesh head covering to prevent patient from spraying spit), and a cross restraint (a rolled sheet applied over patient's chest, pulled under the arms, and tied to bed), after an altercation on 1/30/2018 involving biting, scratching hair pulling, and threatening self-harm. Patient #1 demonstrated violent and self destructive behaviors and the hospital staff restrained her accordingly. There is no documentation stating when the C-collar, spit mask, or cross restraints were removed. Dcoumentation revealed she remained in nylon locked restraints to all four limbs until discharge on 2/2/2018. Documentation showed that after restraint initiation, physician staff failed to give renewal orders for violent/self-destructive restraints every 2 hours per hospital policy. Hospital staff failed to identify the restraint usage for violent/self-destructive behaviors, and thus did not carry out the requirments.


Policy titled "Restraints and Seclusion Policy" directed, for violent, self-destructive restraint use, if continuous restraint/seclusion is required a renewal order for restraint/seclusion is required every: Two (2) hours, ages 9-17 years.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0172
Based on medical record review and document review, the hospital failed to ensure that a physician saw and assessed the patient prior to renewing restraint orders for 1 of 12 patient records reviewed (Patient #1). This deficient practice places the patient at risk of unnecessary confinement and injury.

Findings include:

- Patient #1's medical record review on 2/12/2018 revealed that Patient #1 was placed in 4 point nylon, locked restraints after an altercation on 1/30/2018 around 6:45 pm. The medical record lacked documentation a provider saw and performed an assessment of Patient #1 prior to renewing restraint orders on 1/31/2018, 2/1/2018, and 2/2/2018. Nursing staff obtained all restraint renewal orders verbally and by phone around 5:00 am.


The policy titled "Restraints and Seclusion" reviewed on 2/12/2018 under violent, self-destructive restraint use directed, after 24 hours of continuous restraint use, the patient must be seen and assessed by the Physician, Physician Assistant, or Advanced Practice Registered Nurse who is responsible for the care of the patient...before a new order is obtained.

- Hospital staff failed to recognize Patient #1's restraint usage was for violent and self-destructive behaviors and continued to complete documentation and renewal orders for restraints used for non-violent, non-self-destructive behaviors.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on medical record, staff interviews and document review, the hospital failed to document any attempts to discontinue restraints at the earliest possible time per hospital policy.

This deficient practice puts the restrained patient at risk for psychological and physical harm.

Findings include:

- Policy titled "Restraints and Seclusion Policy" reviewed on 2/12/2018 directed, attempt to remove restraints or replace with less restrictive at the earliest possible time. Release restraints while providing care to assess the continued need for restraints.

- Patient #1's record review on 2/12/2018 revealed Patient #1 was placed in 4 point nylon locked restraints (both wrists and both ankles). It was documented that the restraints remained on throughout her hospital stay from 1/30/2018 at 6:45 pm until 2/2/2018 at 9:00 am. Restraint Alternative documentation began at 6:45 pm on 1/30/2018 and ended at 1/31/2018 at 5:07 am. Although there was numerous documentation in the medical record that said the patient was calm, cooperative, sleeping, playing cards and cognitive status improved and no longer interferes with care, the medical record lacked evidence staff attempted to use restraint alternatives past 5:07 am on 1/31/2018; used less restrictive restraints; removed the restraints during care to assess the ongoing need; and/or provided further psychological support.

- RN Staff P, Burn Unit /PICU, interviewed on 2/14/2018, 8:40 am stated, "I just don't think taking the restraints off was appropriate because she continued to say she would kill herself if they came off. On day two I was going to take the restraints off but she was being so mouthy.

- Pediatric hospitalist Staff H, interviewed on 2/13/2018 2:00 pm said that, The decision to continue the restraints was totally dependent on the nursing staff.

Document titled "Annual Education Clinical 2017", reviewed on 2/14/2018 directed, Every 24 hours, the healthcare provider must re-evaluate the need for the restraints and provide a new order. Restraints should be discontinued at the earliest opportunity and released no less than 12 hours as a trial.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on interview, medical record review, and policy review, the hospital failed to ensure that a restrained patient was monitored by staff who have completed required restraint training for 1 of 12 records reviewed of restrained patients (Patient #1). This deficient practice places restrained patients at risk for psychological or physical harm.

Findings include:

- Patient #1's record review on 2/12/2018 revealed Patient #1 was placed in 4 point nylon locked restraints (both wrists and both ankles) on 1/30/2018 at 6:45 pm. Patient #1 was biting, scratching herself and staff, pulling staff's hair, fighting, kicking and threatening to kill herself. MD Resident Staff I initiated restraint orders at that time that read, Restraint initiate non-violent behavior; interfering with medical care devices, nylon locked 4 point. Order valid for one calendar day. The medical record showed that the restraints remained on Patient #1 throughout her hospital stay from 1/30/2018 at 6:45 pm until 2/2/2018 at 9:00 am. Pediatrician Staff M ordered the renewal of restraints on 1/31/2018, 2/1/2018, and 2/2/2018.

Although Patient #1 showed violent and self destructive behaviors, Staff I indicated the reason for ordering restraints for Patient #1 was for protection of medical care devices and non-violent behavior. Thus, Physician staff did not follow the policy for the management of a patient with violent and self-destructive behaviors including a one hour face-to face assessment and renewal orders every two (2) hours for pediatric patients age 9-17.

- Policy titled "Restraints and Seclusion" reviewed on 2/12/2018 directed staff, assessment and monitoring of the patient in restraint or seclusion is the responsibility of physicians, other licensed independent practitioners, and the RN/LPN or trained designee who have been trained to monitor the condition of patients in restraint or seclusion.

Interview on 2/13/2018 at 12:30 pm, Staff I, MD Resident, Family Medicine stated, "I have been here since 7/1/2017. "I have not received anything formal for restraint training."

Interview on 2/14/2018 at 2:05 pm stated Staff C, RN, CNO, "Hospital restraint training for nursing includes assess the patient for risk of harm to themselves, employees, and environment." "PICU training for the staff caring for psychiatric patients includes restraint education and suicidal protocols, but nothing specific to psychiatric conditions.

- Document titled "Annual Education Clinical 2017" under Restraint and Seclusion, lacked evidence of any instruction on managing violent and self-destructive patients and the use of Nylon 4 point, locked restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review, and staff interview, the hospital failed to provide evidence that a 1 hour face-to face assessment was performed when 4 point (Both ankles and both wrists attached to bed) Nylon locked restraints were applied for three of twelve records reviewed of patients in restraints (Patient #1, 14, and 15). This type of restraint is used for the management of violent or self-destructive behavior. A one hour face-to face medical and behavioral assessment must be performed by a Physician or other licensed independent practitioner (Advanced Practice Registered Nurse) from the time the restraints were applied. A well trained RN or Physician Assistant (PA-C) may also perform assessment. The deficient practice puts all restraint patients at risk of unrecognized physical and behavioral complications as a result of restraint use.

Findings include:

- Patient #1's record review on 2/14/2018 revealed a date of birth of 4/18/2004 and admission to the hospital on [DATE] with a diagnosis of [DIAGNOSES REDACTED]'s chest, pulled up under the arms, and tied to bed) to Patient #1 after an altercation where she bit, scratched, spit, pulled hair, and cursed at the nursing staff. Resident Physician Staff I was present when restraints were applied. However, the record lacked documentation of a 1 hour face-to-face assessment performed by either a physician or trained RN. Staff I, MD stated in Generic progress note dated 1/30/2017 at 6:42 pm, that she "will follow up in a few hours when patient calmer."

- Patient #14's record review on 2/14/2018 revealed a date of birth of 2/8/1992 and admission to the hospital on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Staff placed Nylon four point locked restraints on 1/26/2018 at 9:32 pm and removed on 1/28/2018 at 11:00 am. The first Face-to Face physician assessment was performed on 1/27/2018 at 3:20 pm. The Physician or trained nurse failed to perform a one hour face-to-face assessment after 4 point violent restraints placed per policy.

- Patient #15's record review on 2/14/2018 revealed a date of birth of 8/12/1958 and admission to the hospital on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. He was found to be confused to time, place, and person. Staff applied Nylon four point locked restraints on 1/21/2018 at 12:30 am and removed 1/21/2018 at 9:00 am. First Face-to Face physician assessment was performed on 1/21/2018 at 6:21 am. The Physician or trained nurse failed to perform a one hour face-face assessment post restraint placement per policy.

Interview with Chief Nursing Officer (CNO) Staff C on 2/14/2018, 2:05 pm, "Hospital restraint training for nursing includes assess the patient for risk of harm to themselves, employees, and environment." "PICU training for the staff for caring for psychiatric patients includes restraint education and suicidal protocols, but nothing specific to psychiatric conditions. Criteria used for violent restraints is to assess for concerns about self-harm, harm to others, or harm to the environment. Nylon restraints are used when violent behavior is evident.

Interview with MD Resident Family Medicine Staff I on 2/13/18 at 12:30 pm, "I have been here since 7/1/2017. "I think I admitted "I have not received anything formal for restraint training."

Interview with MD Resident Family Medicine Staff L on 2/13/18 at 2:20 pm, "Restraint training? I have not had any formal training."

Interview with Doctor of Osteopathy (DO) Senior Resident Family Medicine Staff J on 2/13/2018 at 2:20 pm, "Restraint training as resident there has been no formal training.



Document titled "Annual Education Clinical 2017," under Restraint and Seclusion, lacked evidence of any instruction on managing violent and self-destructive patients and the use of Nylon 4 point, locked restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
Based on medical record review, interview, and policy review, the hospital failed to provide evidence that a 1 hour medical and behavioral face to face assessment was performed when restraints were applied to violent/self-destructive patients in two of twelve (Patient #1, and #14) medical records reviewed of restrained patients. Failure to perform the 1 hour face to face assessment after restraint application placed all restrained patients at risk of unrecognized physical and behavioral complications as a result of restraint use.

Findings Include:

- Patient #1's medical record review on 2/12/2018 revealed the patient was admitted to Pediatric Intensive Care Unit (PICU) following a suicide attempt. She was placed in nylon locked four point restraints (both wrists and both ankles) on 1/31/2018 after 6:45 pm for behaviors including scratching, biting, hair pulling and threatening self-harm. The record lacked documentation that staff recognized this restraint usage for violent/self-destructive reasons. Therefore, the medical record lacked documentation of a 1-hour face-to-face medical and behavioral evaluation after the restraints were initiated. Patient #1 remained in restraints until her discharge on 2/2/2018.

- Patient #15's medical record review on 2/13/2018 revealed the patient was admitted to 4 CTI with chest pain and unstable angina (chest pain and pressure). Documentation revealed the patient was confused, threatened staff, and threatened to elope. Hospital staff applied nylon locked four point restraints on 1/21/2018 at 12:30 am and removed them on 1/21/2018 at 9:00 am. Even though the record indicated Patient #15's behaviors threatened himself and hospital staff, the medical record lacked documentation a 1-hour face-to-face medical and behavioral health assessment was performed after the restraints were initiated for these violent/self-destructive behaviors.

Interview on 2/14/2018 at 2:05 pm, Chief Nursing Officer (CNO) Staff C stated, criteria used for violent restraints is to assess for concerns about self-harm, harm to others, or harm to the environment. Nylon restraints are used when violent behavior is evident.

- Document titled "Annual Education Clinical 2017" provided to hospital wide clinical staff reviewed on 2/14/2018 included a review of non-violent, non-self-destructive restraint use as well as use of restraint and seclusion techniques. The annual training did not include the requirement for a 1-hour face-to-face medical and behavioral evaluation to be performed after restraints are applied for violent/self-destructive behaviors.

- Policy titled "Restraints and Seclusion" reviewed on 2/12/2018 directed staff, assessment and monitoring of the patient in restraint or seclusion is the responsibility of physicians, other licensed independent practitioners, and the RN/LPN or trained designee who have been trained to monitor the condition of patients in restraint or seclusion...a 1 hr. face to face assessment is not required for non-violent, non-self-destructive restraint use ...a 1 hr. face to face assessment is required for violent, self-destructive restraint use. The policy does not define criteria for non-violent, violent, or self-destructive behavior. The policy also does not indicate when staff should use the nylon locked restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0199
Based on interview and document review, the hospital failed to provide complete restraint training identifying mental and developmental patient populations including: newborn, pediatric, adolescent, adult, and frail-elderly adult. All facility staff responsible for ordering, applying, assessing, or monitoring patients requiring restraints failed to be provided with specific patient population training.

Failure of the facility to provide complete training for all staff involved in direct patient care placed all patients at risk for inappropriate use of restraints, violating the rights and safety of the patients placed in restraints and psychological and/or physical harm when restraints are used.

Findings include:

- Document titled "Annual Education Clinical 2017, Rapid Regulation Review" lacked evidence of the requirements for Violent, self-destructive restraint usage including renewal orders which are required every 3 hours for ages 18 and older, every 2 hours for ages 9-17 years of age and every 1 hour for ages less than 9 years.

- Document outline titled "Restraint/Seclusion Standards" PowerPoint Education completed by every new employee at the Facility during orientation reviewed on 2/14/2018 lacked evidence of approaches to be taken regarding specific developmental patient populations.

Interview on 2/13/2018 at 4:00 pm RN Charge Staff V stated, "Restraint training is annual on line...and is geared to adults, not pediatrics.