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.

NORTHERN HOSPITAL OF SURRY COUNTY 830 ROCKFORD ST MOUNT AIRY, NC 27030 March 1, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, observation, medical record review and staff and patient interview the facility staff failed to treat patients with dignity and respect by use of seclusion on Involuntary Committed (" IVC") patients without evaluating the need for the restrictive intervention and discontinuing the restrictive intervention at the earliest possible time for 2 of 4 sampled Involuntary Committed ("IVC") patients. (Patients # 9 and #12)

The findings include:

Review on February 28, 2018 of the policy and procedure "Patient Rights" (Version 11) revealed,"... U. FREE FROM SECLUSION AND RESTRAINT Patients have the right to be free form seclusion, physical restraints, and drugs that are used as a restraint that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. ...".

Review on February 27, 2018 of the policy titled "Restraints" facility "Reference: 511, Version: 8,"revealed "Policy ... The hospital uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others. Restraints should be considered once less restrictive interventions have been considered/tried, and are determined to be inadequate for the clinical purpose. Any use of restraint will be discontinued at the earliest possible time, based on reassessment of the patient's continuing need for the restraint ...Responsibility Physicians and nursing clinical staff ...Orders ...The order for restraint must be given by a Physician. If the restraint is initiated by a nurse based on the immediate need, the attending physician is to be informed immediately to see the patient within one hour. The nurse will document an order for restraint. The physician must do an in-person evaluation of the patient within one hour of the initiation of restraint or seclusion ...Monitoring ...Patients who secluded (sic) are continually monitored either in person or through the use of both video and audio equipment. (continually (sic) means ongoing without interruption). Documentation of patient activity/observations will be made every 15 minutes. Documentation of respiratory and circulatory status and assessment of nourishing and toileting will be every 2 hours ..."

Review on February 27, 2018 of the policy titled "Processing of Involuntary Commitment and Behavioral health Patients" facility "Reference: 1766, Version: 16," revealed "Policy ...This policy outlines the steps for processing patients under involuntary commitment petitions and orders ...B ...The involuntary Commitment Patient will not go to Triage. 1. The patient will be placed in one of the ED designated observation rooms. If these rooms are occupied ..."

Review on February 27, 2018 revealed of the policy titled "Guidelines for Use of ED (Emergency Department) Observation Rooms" facility "Reference: 2422, Version: 2," "Policy: The Emergency Department Rooms will be utilized for mental health Patients who are under Involuntary Commitment order. Priority for occupancy of the Observation Rooms will be given to Involuntary Commitment patients who are combative, uncooperative or who present a threat to the safety and well-being of other patients, visitors, and staff. An ED physician must order the assignment of an Involuntary Commitment patient to an Observation Room. No other categories of patients are to be assigned to the Observation Rooms at any time. Procedure...F. The door to the Observation Room will be locked at all times when an Involuntary Commitment patient is placed in the room ..."

Review on February 27, 2018 of the "Restraint Order Form" for "Management of Violent or Self-destructive Behavior" with a form review update of 6/27/14 revealed "ASSESSMENT", "ALTERNATIVES TRIED/INEFFECTIVE" and nine check boxes listing strategies attempted. The ninth box indicated: "N/A-IVC Status-locked observation necessary. The remainder of the assessment options included check box options for "EDUCATION ATTEMPTED ...CLINICAL JUSTIFICATION ...and ...TYPE OF RESTRAINT INITIATED." The form included a signature line with date and time areas for the assessing staff, and an "ORDER" signature line with date and time areas for the ordering physician staff.

Observation of the emergency department (ED) on February 28, 2018 beginning at 1600 revealed two seclusion rooms labeled "Observation 1 and Observation 2" (seclusion room for behavioral health patients). Observation revealed the rooms were empty and the doors were secured with a magnetic lock. Observation revealed the room rooms were locked and could only be accessed by badge entry. Continued observation revealed a toggle switch on an exterior wall that could disengage the magnetic locks in an emergency.

1. Review on February 27, 2018 of the medical record for Patient #12 revealed the patient was admitted on [DATE] with a diagnosis of "Conduction Disorder unspecified". Past medical history included depression paranoia and HI (homicidal ideations). Review revealed patient # 12 was admitted to Exam Room #7 at 1209 on January 30, 2018. Review of nursing notes revealed Patient#12's initial behavior was calm and cooperative. Review of a nurse's note dated January 30, 2017 at 1430 revealed Patient #12's behavior became violent and argumentative. The patient then "...ran from room pushing past security and slamming open ED (emergency department) doorway, at which time she was stopped by hospital security and returned to E7 (exam room 7)... one-one supervision in place for patient safety." Review of every 15 minute observation revealed behavior as calm and/or cooperative from 1500 through 2241 with the exception of 1800, 2015, and 2115 at which time the behavior was agitated. Review of a "Restraint Order From" dated January 30, 2018 at 2245 revealed, a section called "ASSESSMENT" and a checked box indicating, "N/A--IVC Status-locked observation necessary." Review revealed on January 30, 2018 at 2241, patient #12 was transferred to seclusion (Observation room 1). Review revealed Patient #12 remained in the locked seclusion room until transfer to another facility on February 01, 2018 at 1958. Review revealed Patient #12 remained in the locked observation (seclusion) room for 55 hours and 57 minutes. Every 15 minute observation revealed Patient #12's behavior from January 30, 2018 at 2241 through discharge as calm, cooperative, suspicious, pacing or sleeping. Review revealed no documented violent or harmful behavior to self or others that would indicate the need for the seclusion. Continued review revealed no evidence of seclusion being discontinued at the earliest possible time. Review revealed no evidence that Patient #12 exhibited violent behaviors or behaviors indicating the necessity for seclusion after 1500 on January 30, 2017.

Interview on February 28, 2018 at 0840 with MD #6 revealed IVC patients went to the seclusion room if commitment proceedings were on-going. When the magistrate brought the patient to the facility, they were automatically taken to the seclusion room. Interview revealed an IVC patient could go to a regular exam room, if both seclusion rooms were occupied, but in order to have the ability to monitor the patients with video, control external stimuli, dim the lights to encourage rest and provide sitters the necessary tools toobserve and document behaviors, patients were assigned to the seclusion rooms. Interview revealed the seclusion rooms remained in a locked position while occupied and security would be called to assist anytime the doors were opened. Interview confirmed when a patient was placed in the observation room, "they are secluded." Continued interview revealed the IVC paperwork was the rationale for placing IVC patients in seclusion because the paperwork indicated the patient was a harm to self and/or others.

Interview on February 28, 2018 with RN #11 revealed the seclusion rooms had a sitter sitting outside to observe and document the patient's behaviors. When the patient needed to use the bathroom, nursing entered to perform assessments or the door was opened/unlocked for any reason, security was present to provide standby assistance.

Interview on February 28, 2018 at 1015 with administrative Staff (AS ) #2 and AS #4 revealed if observation room #1 and #2 were occupied, IVC patients in the ED (emergency department) would be triaged for risk and assigned to specific exam rooms in the department that were equipped with ports to connect cameras for monitoring. A sitter was placed outside of the room, but, the patients were not secluded because the exam room doors did not have locks. Only the two seclusion rooms were secured with a magnetic lock and they were always on in the locked position. Entry to and exit from the rooms required badge access. Continue interview revealed the two seclusion rooms were "never used for general ED patients" and were designated to be used for IVC patients. The seclusion rooms were used first, then the other rooms were utilized if the number of IVC patient exceeded two.

Interview with AS #2 on February 28, 2018 at 1420 and March 01, 2018 at 1030 revealed when a patient is IVC'd they were placed in seclusion due to the risk of eloping. The seclusion room door automatically locked. There was an emergency switch that could override the locking mechanism if needed. Interview revealed AS #2 could not recall a recent event occasion when the need to use the toggle switch to turn off the magnetic locks had occurred. Continued interview revealed if a patient came in under voluntary commitment, the patient was placed in a regular exam room. Once the IVC paperwork arrived, the patient would be placed in seclusion until the IVC was removed, placement was obtained or a change in medical condition warranted transfer to a medical exam room. Further interview revealed if both seclusion rooms were in use, and a patient came and was determined to be a higher safety risk, the patients in observation would be reassessed and one of them would be moved to an exam room to allow the higher risk patient to be placed in seclusion. Interview revealed the seclusion rooms were not equipped to manage medical emergencies, but, there was a crash cart outside of the room.

Interview on February 28, 2018 at 1620 with RN #13 revealed, all medically stable IVC patients were secluded unless there were more than two IVC patients in the ED at the same time. The interview revealed all IVC patients were not violent or self-destructive. Interview revealed many IVC patients were calm and cooperative. Interview revealed, nursing documentation and restraint education was provided during initial hospital orientation. Continued interview revealed restraint training occurred at an annual skills fair. RN #13 revealed, retraint/seclusion orders were obtained every 4 hours for adults and patients were continuously observed. Documentation by the sitter occurred every 15 minutes and nursing observation and documentation occurred "every hour."








2. Review of the medical record on February 27, 2018 for Patient #9 who arrived in the ED of a local facility accompanied by local law enforcement officers at 1904 PM, and under involuntary commitment orders initiated by her crisis worker on May 25, 2017, after leaving an outpatient treatment facility earlier in the day revealed Patient #9 was assigned to and placed in Observation Room #1 (one of two dedicated behavioral health rooms) on arrival. Medical record review revealed Patient #9 was a thirty-eight year old female whose history included diagnoses of asthma, substance abuse, hallucinations, paranoia, and suicidal ideation without a plan of action. Review of a nursing assessment on May 25, 2017 at 1906 indicated the patient was awake, alert and had a regular respiratory pattern. Continued review of the initial assessment revealed Patient #9's "Speech Pattern" was described as "Rambling" and "Excessive," and "Patient Behavior/Mood" was noted to be "Cooperative," "Anxious," and "Suspicious." Medical record review revealed Patient #9 was medically screened by an ED physician, MD #6, on May 25, 2017 at 1910, and a tele-psychiatry evaluation was ordered. Further medical record review revealed a tele-psychiatry assessment on May 26, 2017 at 1238 which noted "Patient presents calm cooperative ...states she has been experiencing psychotic symptoms ...denies plan or intent to harm herself because of her 6 y/o (year old) daughter." Review of 15 minute staff observations revealed Patient #9's behavior was described as agitated or pacing from 1936 through 2215 on May 25, 2017 except at 2000, 2045, and 2115 at which time the behavior was noted to be calm or sleeping. Review of observer documentation beginning at 2330 on May 25, 2017 until 0745 on May 29, 2017 revealed Patient #9's behavior was noted as calm or sleeping except for agitation or pacing at 1115, 1145, 1245, 1530 and 2145 on May 26, 2017. Review revealed calm or resting observations except for 1345 on May 27, 2017, and 0043, and 1130 through 1200 on May 28, 2017 when she was noted to be agitated or pacing. Review beginning at 0800 on May 29, 2017 revealed increasingly frequent observations of pacing or agitated behaviors with fewer calm periods until observer staff noted persistent agitated or pacing behaviors beginning at 1230 and until she was noted to be unresponsive at 1628. Record review revealed no documented violent or harmful behavior directed toward others requiring seclusion during the admission. Review of a nursing note dated May 29, 2017 at 1350 revealed Patient #9 had been placed in a restraint chair within Observation Room #1 " ...for her own safety due to multiple times of rolling off bed and falling against wall." Review revealed Patient #9 was released from the restraint chair on May 29, 2017 at 1548. Continued review revealed no evidence of consideration for seclusion being discontinued, or a face to face encounter between Patient #9 and a physician within one hour of being placed in the restraint chair on May 29, 2017 and Patient #9's transfer to Critical Care Room #1 at 1633. Review revealed no documented evidence that Patient #9 exhibited violent behaviors toward self or others, or behaviors potentially indicating the need for seclusion from May 25, 2017 through May 29.

Interview on February 28, 2018 at 0840 with MD #6 who admitted Patient #9 on May 25, 2017, revealed IVC patients were taken to the seclusion room if commitment proceedings were on-going. When a patient was brought to the facility with completed or pending magistrate orders, they were automatically taken to an unoccupied seclusion room if one was available. Interview revealed an IVC patient could go to a regular exam room if both seclusion rooms were already occupied, but a more complex process was used in order to have the ability to monitor the patient with video, control stimulus, dim the lights and provide a sitter the necessary tools to document behaviors. Interview revealed the observation room doors remained in the locked position when occupied and security would be called to assist anytime the doors were opened. Interview confirmed when a patient was placed in the observation room, "they are secluded." Continued interview revealed the IVC paperwork provided the rationale for placing IVC patients in seclusion because the paperwork indicated the patient had a potential risk of harm to self and/or others.

Telephone interview on February 28, 2018 at 1025 with MD #8 revealed she remembered Patient #9, but currently did not have access to the record, and had been the attending of record in the ED on May 29, 2017. Interview revealed Patient #9 " ...had been medically cleared for several days, and she had been waiting for placement." MD #8 revealed she had prescribed ziprasidone (a psychoactive medication for treating acute agitation in schizophrenia) earlier in the day for Patient #9 because "She was beating on the door, and yelling and banging. I was concerned she might hurt herself." Interview revealed the ED physicians typically round on behavioral health patients who were not discharged or transferred from the ED twice a day, but she had not rounded on Patient #9 that day. Interview revealed MD #8 had observed the patient earlier in the day through an observation window when she was "so agitated I didn't think it was a good time," and had been in a sterile procedure when she had approved use of the restraint chair. Interview revealed "I've run this case over in my mind many times and can't think of anything that indicated a medical problem."

Interview on February 28, 2018 at 1030 with RN #11 who had provided care to Patient #9 on two occasions revealed the observation rooms had a staff member sitting in an alcove outside the rooms to observe and document patient behaviors. When a patient needed to use the bathroom, nursing needed to enter to perform assessments, or the door was opened/unlocked for any reason, security was called to provide standby assistance. Interview revealed nurses could enter the observation room unaccompanied by security staff, but security needed to be present if a patient crossed the alcove from the observation room to the bathroom. Interview revealed RN #11 had requested use of intramuscular ziprasidone because of patient agitation on the morning of May 29, 2017, and later in the day, the restraint chair because Patient #9 " ...would get up and walk around the room, and flop back across the bed. Almost hit her head, and we were worried she would injure herself." RN #11 remembered security staff were in the area, but did not recall any problems requiring close proximity of security staff during her care of Patient #9.

Interview on February 28, 2018 at 1510 with patient care technician (PCT) #16 revealed she had been an observer on three shifts during Patient #9's stay in the ED. Interview revealed PCT #16 had worked with Patient #9 on Saturday and Sunday, and had agreed to work an additional eight hours on the Monday holiday. PCT #16 remembered the patient as " ...mainly calm, sometimes pacing, and sometimes violently cussing ..." Interview revealed Patient #9 was already restrained in the restraint chair when PCT #16 arrived to work, and she had observed staff help the patient out of the chair. PCT #16 indicated it seemed " ...like she could not walk by herself ..." and it was " ...different from the weekend."

Interview with RN #10 on February 28, 2018 at 1100 during a tour of the ED revealed part of his duties was as a facility restraint trainer, and he had provided initial and annual training renewal for many of the ED staff. Interview revealed the observation rooms' doors automatically locked, and required badge access to enter or exit the rooms, or attached entry alcove. Interview revealed there were emergency switches in the entry alcove, and at the nursing station to override the locking mechanism in an emergency if needed. Interview confirmed IVC patients were placed in one of two locked observation rooms until IVC was vacated, patient placement was obtained, or change in patient medical condition warranted transfer to a medical room. Further interview revealed if both observation rooms were already in use, but a patient came in who was determined to be a higher safety risk, the patients currently in observation rooms would be reassessed and one of them would be moved to an exam room for monitoring to allow the highest risk patient to be placed in seclusion.

Interview on February 28, 2018 at 1015 with administrative staff (AS) #2 and AS #4 revealed that if observation rooms #1 and #2 were already occupied, newly arriving behavioral health patients under IVC orders were assigned to other specific exam rooms in the ED that were equipped with ports to connect cameras for monitoring. A sitter was placed outside of the room, but, the patients were not considered seclusion rooms because the exam room doors did not have locks. Only observation rooms #1 and #2 were secured with magnetic locks and they were always in the locked position during routine use. Entry to and exit from the rooms required badge access. Continue interview revealed the seclusion rooms were "never used for general ED patients" and were designated to be used for IVC patients. Interview revealed the two observation rooms were used first, then the other designated rooms were utilized if the number of IVC patients exceeded two.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of restraint policy and procedure, QAPI data, ED Restraint Log data, medical record review and staff interview the facility failed to have a system in place to evaluate the quality of care provided to patients in seclusion and other restrictive interventions. (Patients #5, #8, # 9 and #12)

The Findings Include:

Review on February 27, 2018 of the policy titled "Restraints" facility "Reference: 511, Version: 8,"revealed "Policy ... The hospital uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others. Restraints should be considered once less restrictive interventions have been considered/tried, and are determined to be inadequate for the clinical purpose. Any use of restraint will be discontinued at the earliest possible time, based on reassessment of the patient's continuing need for the restraint ..."

Review on February 28, 2018 of the policy and procedure "Patient Rights" (Version 11) revealed,"... U. FREE FROM SECLUSION AND RESTRAINT Patients have the right to be free form seclusion, physical restraints, and drugs that are used as a restraint that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. ...".

Review on February 28, 2018 of QAPI data revealed no evidence of monitoring IVC (Involuntary Commitment) patients for behaviors that would necessitate seclusion and no evidence of the assessment or monitoring of IVC (Involuntary Commitment) patients for the earliest possible release from a restrictive intervention.

1. Review of a ED (emergency department) restraint log May 15, 2017 through June 15, 2017 revealed, Patient # 5 (an IVC'd Patient) was secluded from May 21, 2017 at 2131 through May 23, 2017 at 1543 (97 hours and 36 minutes).

Interview on February 28, 2018 at 0840 with MD #6 revealed IVC patients were automatically taken to the seclusion room. Interview revealed an IVC patient could go to a regular exam room, but in order to have the ability to monitor the patients with video, control external stimuli, dim the lights to encourage rest and provide sitters the necessary tools to observe and document behaviors, patient were assigned to the seclusion rooms. Interview the seclusion rooms remained in a locked position while occupied and security would be called to assist anytime the doors were opened. Interview confirmed when a patient was placed in the seclusion room, "they are secluded." Continued interview revealed the IVC paperwork was the justification for placing the IVC patient in seclusion because the paperwork indicated the patient was a risk of harm to self and/or others.

Interview with AS #2 February 28, 2018 at 1040 revealed, Continued interview revealed the monitoring that occurred regarding seclusion of IVC patients included review of the orders, and documentation for completeness.

Interview on February 28, 2018 at 1620 with RN #13 revealed, all medically stable IVC patients were secluded unless there were more than two IVC patients in the ED at the same time. The interview revealed not all IVC patients exhibited behaviors that were violent or self-destructive. Interview revealed many IVC patients were calm and cooperative.

2. Review of a ED (emergency department) restraint log May 15, 2017 through June 15, 2017 Patient #8 (an IVC'd patient) was secluded from May 16, 2017 at 1211 through May 20, 2017 at 1036 (97 hours and 53 minutes).
Interview on February 28, 2018 at 0840 with MD #6 revealed IVC patients were automatically taken to the seclusion room.

Interview revealed an IVC patient could go to a regular exam room, but in order to have the ability to monitor the patients with video, control external stimuli, dim the lights to encourage rest and provide sitters the necessary tools to observe and document behaviors, patient were assigned to the seclusion rooms. Interview the seclusion rooms remained in a locked position while occupied and security would be called to assist anytime the doors were opened. Interview confirmed when a patient was placed in the seclusion room, "they are secluded." Continued interview revealed the IVC paperwork was the justification for placing the IVC patient in seclusion because the paperwork indicated the patient was a risk of harm to self and/or others.

Interview with AS #2 February 28, 2018 at 1040 revealed, Continued interview revealed the monitoring that occurred regarding seclusion of IVC patients included review of the orders, and documentation for completeness.

Interview on February 28, 2018 at 1620 with RN #13 revealed, all medically stable IVC patients were secluded unless there were more than two IVC patients in the ED at the same time. The interview revealed not all IVC patients exhibited behaviors that were violent or self-destructive. Interview revealed many IVC patients were calm and cooperative.

3. Review of an ED restraint log dated January 30, 2018 at 2241 through February 01, 2018 at 1958 revealed Patient #12 (an IVC'd patient) was secluded for 55 hours and 57 minutes.

Interview on February 28, 2018 at 0840 with MD #6 revealed IVC patients were automatically taken to the seclusion room. Interview revealed an IVC patient could go to a regular exam room, but in order to have the ability to monitor the patients with video, control external stimuli, dim the lights to encourage rest and provide sitters the necessary tools to observe and document behaviors, patient were assigned to the seclusion rooms. Interview the seclusion rooms remained in a locked position while occupied and security would be called to assist anytime the doors were opened. Interview confirmed when a patient was placed in the seclusion room, "they are secluded." Continued interview revealed the IVC paperwork was the justification for placing the IVC patient in seclusion because the paperwork indicated the patient was a risk of harm to self and/or others.

Interview with AS #2 February 28, 2018 at 1040 revealed, Continued interview revealed the monitoring that occurred regarding seclusion of IVC patients included review of the orders, and documentation for completeness.

Interview on February 28, 2018 at 1620 with RN #13 revealed, all medically stable IVC patients were secluded unless there were more than two IVC patients in the ED at the same time. The interview revealed not all IVC patients exhibited behaviors that were violent or self-destructive. Interview revealed many IVC patients were calm and cooperative.







4. Review of an emergency department (ED) "Room History Log" (Restraint log) for the period May 15, 2017 through June 15, 2017 revealed Patient #9 (an IVC'd patient) was assigned to Observation #1 for 98 hours and 25 minutes.

Interview on February 28, 2018 at 0840 with MD #6 who admitted Patient #9 on May 25, 2017, revealed patients were taken to the seclusion room if IVC proceedings were on-going. When a patient was brought to the facility with completed or pending magistrate orders, they were automatically taken to an unoccupied seclusion room if one was available. Interview revealed an IVC patient would go to a regular exam room if both seclusion rooms were already occupied, but a more complex process was used in order to have the ability to monitor the patient with video, control stimulus, dim the lights and provide a sitter the necessary tools to document behaviors. Interview revealed the observation room doors remained in the locked position when occupied and security would be called to assist anytime the doors were opened. MD #6 confirmed that when a patient was placed in the observation room, "they are secluded." Continued interview revealed IVC paperwork provided the justification for placing IVC patients in seclusion because the IVC paperwork stated a patient had a potential risk of harm to self and/or others.

Interview on February 28, 2018 at 1030 with RN #11 who had provided care to Patient #9 on two occasions revealed the observation rooms had a staff member sitting in an alcove outside the rooms to observe and document patient behaviors. When a patient needed to use the bathroom, nursing needed to enter to perform assessments, or the door was opened/unlocked for any reason, security was called to provide standby assistance. Interview revealed nurses could enter the observation room unaccompanied by security staff, but security needed to be present if a patient crossed the alcove from the observation room to the bathroom. Interview revealed RN #11 had requested use of intramuscular ziprasidone (a psychoactive medication for treating acute agitation in schizophrenia) because of patient agitation on the morning of May 29, 2017, and later in the day, the restraint chair because Patient #9 " ...would get up and walk around the room, and flop back across the bed. Almost hit her head, and we were worried she would injure herself." Interview revealed RN #11 had obtained renewal orders for continued use of the seclusion room, and the restraint chair on May 29, 2017.

Interview with RN #10 on February 28, 2018 at 1100 during a tour of the ED revealed part of his duties was as a facility restraint trainer, and he had provided initial and annual training renewal for many of the ED staff. Interview revealed the observation rooms' doors automatically locked, and required badge access to enter or exit the rooms. Interview confirmed IVC patients were placed in one of two locked observation rooms until IVC was vacated, patient placement was obtained, or a change in patient medical condition warranted transfer to a medical room or outside facility. Further interview revealed if both observation rooms were already in use, and an IVC patient came in who was determined to be a higher safety risk, the IVC patients currently in observation rooms would be reassessed and one of them would be moved to an exam room for monitoring to allow the highest risk patient to be placed in seclusion.

Interview with AS #2 February 28, 2018 at 1040 revealed, there was no QAPI data available for review to show increased incidents of elopement, violence or self-destructive behavior by IVC patients who were placed in an exam room without locking mechanisms when Observation Rooms #1 and #2 were already occupied. Further interview revealed AS #2 could not recall instances of increased elopement, violence, or self-destructive behaviors as a result of placing IVC patients in a regular exam room. Continued interview revealed the monitoring that occurred regarding seclusion of IVC patients included review of orders, and required staff documentation for completeness. Interview revealed there had been no monitoring of necessity for seclusion, and there was no QAPI data available for review regarding reassessment and discontinuation of seclusion at the earliest possible time. Interview revealed it had been standard practice to place medically cleared IVC patients in seclusion for the duration of their stay in the ED until transfer to a behavioral health facility.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, medical record review and staff interview, the facility staff failed to assess patients for violent behaviors warranting seclusion, to reassess patients for the earliest release from seclusion and staff failed to obtain renewal orders and perform and document every two hour respiratory and circulatory assessments per policy on secluded patients in 2 of 4 sampled patients. (Patients #9 and #12)

The findings include:

Review on February 27, 2018 of the policy titled "Restraints" facility "Reference: 511, Version: 8, "revealed "Policy ...Orders ...Orders for restraint or seclusion used for management of violent or self-destructive behavior may be renewed with the following limits: 4 hours for adults 18 years and older: ...Monitoring ...Patients who secluded (sic) are continually monitored either in person or through the use of both video and audio equipment. (continually (sic) means ongoing without interruption). Documentation of patient activity/observations will be made every 15 minutes. Documentation of respiratory and circulatory status and assessment of nourishing and toileting will be every 2 hours ..."

1. Review on February 27, 2018 of the medical record for Patient #12 revealed the patient was admitted on [DATE] with a diagnosis of "Conduction Disorder unspecified". Past medical history included depression paranoia and HI (homicidal ideations). Review revealed Patient #12 was admitted to Exam Room #7 at 1209 on January 30, 2018. Review revealed Patient #12's behavior was calm and cooperative. Review of a nursing note revealed at 1430 behavior was violent and argumentative. The patient then "...ran from room pushing past security and slamming open ED (emergency department) doorway, at which time she was stopped by hospital security and returned to E7 (exam room 7)... one-one supervision in place for patient safety. Continued review revealed the order was renewed every four hours through January 31, 2018 at 1845. Review revealed the seclusion order expired on [DATE] at 2245. Continued review revealed the patient remained in seclusion until discharge on February 02, 2018 at 1958 without documented violent or self destructive behaviors. Further review revealed the seclusion order was not renewed, and there were no additional orders for seclusion in the medical record after January 31, 2018 at 1845. Review of the Electronic Medical Record (EMR) forms "Seclusion Observ (sic) Tool-Nurse" and "General observation, nursing notes and vital sign flow sheets revealed, every two hour "respiratory and circulatory status" checks were not documented on January 31, 2018 from 0727 through 1030 (3 hours and 3 minutes), from 1030 through 1812 (7 hours and 42 minutes) and on February 01, 2018 from 0513 through 0835 ( 3 hours and 22 minutes) and from 0835 through 1150 ( 3 hours and 15 minutes). Review revealed every two hour respiratory and circulatory status checks could not be verified based on gaps in documentation.

Interview on February 28, 2018 at 1420 with AS (Administrative Staff) #4 while reviewing Patient #12's chart confirmed the inability to verify all respiratory or circulatory status check occurred every two hours per policy due to gaps in the documentation. Continued interview revealed there were no restraint orders in Patient #12's medical record after January 31, 2018 at 1845. Further interview revealed the policy and procedure was not followed.

Interview on February 28, 2018 at 1620 with RN #13 revealed, nursing documentation and restraint education was provided during initial hospital orientation. Continued interview revealed restraint training occurred at an annual skills fair. RN #13 revealed, orders should have been obtained every 4 hours for adults and patients were continuously observed, documentation by the sitter occurred every 15 minutes and nursing observation and documentation occurred "every hour."








2. Review of the medical record on February 27, 2018 for Patient #9 who arrived in the ED of a local facility accompanied by local law enforcement officers at 1904 PM, and under involuntary commitment orders initiated by her crisis worker on May 25, 2017, after leaving an outpatient treatment facility earlier in the day revealed Patient #9 was assigned to Observation Room #1 (one of two dedicated behavioral health rooms) at arrival. Medical record review revealed Patient #9 was a thirty-eight year old female whose history included diagnoses of asthma, substance abuse, hallucinations, paranoia, and suicidal ideation, but without a plan of action. Review of a nursing assessment was initially performed on May 25, 2017 at 1906. Review of a "Restraint Order Form" dated May 25, 2017 (smudged) at 1900 revealed, a section called "ASSESSMENT" with a series of check boxes, and a checked box indicating, "N/A--IVC Status-locked observation necessary." Record review revealed each order was valid for a " ...maximum of 24 consecutive hours" as long as staff obtained interim verbal or telephone orders from a physician to continue the intervention every four hours. Review revealed renewal of the "Restraint Order Form" was completed on May 26, 2017 at 1900, May 27, 2017 at 1900, and May 28 at 1900. Review revealed the form dated May 25, 2017 contained no documentation of interim approval after 1900 to continue the intervention, but the forms dated May 26, 2017 through May 28 2017 were correctly completed. Review of a modified "Restraint Order Form" dated May 29, 2017 at 1350 revealed, a section called "ASSESSMENT" with a series of check boxes and a checked box indicating, "N/A--IVC Status-locked observation necessary ...Clinical Justification ...Prevent harm to self ..." checked and hand written and checked "Restraint Chair." Review revealed use of the restraint chair on May 29, 2017 had been approved for a maximum two hours of use, and Patient #9 had been released at 1548. Review revealed Patient #9 remained in the locked seclusion room until 1631 on May 29, 2017. Review of the Electronic Medical Record (EMR) forms "Seclusion Observ [sic] (observation) Tool-Nurse" and "General observation, nursing notes and vital sign flow sheets revealed, every two hour "respiratory and circulatory status" check gaps greater than two hours were documented on:
May 25, 2017 at 1915 and 2214 (2 hours and 59 minutes)
May 25, 2017 at 2214 and May 26, 2017 at 0241 (4 hours and 27 minutes)
May 26, 2017 at 0300 and 0705 (4 hours and 5 minutes)
May 26, 2017 at 0705 and 1900 (11 hours and 55 minutes)
May 27, 2017 at 0500 and 0803 (3 hours and 3 minutes)
May 27, 2017 at 0803 and 1506 (7 hours and 3 minutes)
May 27, 2017 at 1506 and 2245 (7 hours and 39 minutes)
May 27, 2017 at 2245 and May 28, 2017 at 0100 (2 hours and 15 minutes)
May 28, 2017 at 0204 and 0737 (5 hours and 33 minutes)
May 28, 2017 at 0737 and 2300 (15 hours and 23 minutes)
May 29, 2017 at 0700 and 1552 (8 hours and 52 minutes)
Review revealed every two hour respiratory and circulatory status checks for Patient #9 could not be verified based on gaps in documentation.

Interview on February 28, 2018 at 1330 with Administrative Staff (AS) #3 while reviewing Patient #9's chart confirmed the inability to verify respiratory and circulatory status checks occurred every two hours per policy as a result of gaps in the documentation. Further interview revealed policy and procedures were not followed.

Interview on February 28, 2018 at 1430 with AS #2 revealed there were no restraint renewal orders in Patient #9's medical record from May 25, 2017 at 2300 until May 26, 2017 at 1900. Further interview revealed policy and procedures were not followed.

Interview on February 28, 2018 at 1030 with RN #11 who had provided care to Patient #9 on two occasions revealed she had received initial restraint training, and had participated in annual training updates. Interview with RN #11 revealed "observation rooms" had a staff member sitting in an alcove outside the rooms to observe and document patient behaviors every fifteen minutes, and nurses performed and documented general assessment and seclusion checks every two hours in the electronic record. Interview also revealed new restraint order sets needed to be signed by a physician at least every twenty-four hours, and renewed by staff every at least every four hours until another restraint order was required of the physician. Interview revealed RN #11 had requested use of intramuscular ziprasidone (a psychoactive medication for treating acute agitation in schizophrenia) because of patient agitation on the morning of May 29, 2017, and later in the day, the restraint chair because Patient #9 " ...would get up and walk around the room, and flop back across the bed. Almost hit her head, and we were worried she would injure herself," and the physician had approved use of the restraint chair for two hours. Interview revealed RN #11 had obtained renewal orders for continued use of the seclusion room on May 29, 2017.