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.

BROOKWOOD BAPTIST MEDICAL CENTER 2010 BROOKWOOD MEDICAL CENTER DRIVE BIRMINGHAM, AL 35209 May 2, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policies, training content for restraints and Healthy Interventions (HI), video footage, facility's "Video Review of events" document, medical records and interviews; it was determined the facility failed to ensure:

1. Staff utilized methods of physical restraint according to the facility policy and training in HI material to physically restrain a patient.

2. Physician orders were obtained for all restraints.

3. Restraint orders were signed by the physician within 24 hours.

4. Staff completed a face to face assessment within 1 hour of initiation of restraints.

5. Staff conducted Post Restraint Assessments of patients after having been released from restraints.

These deficient practices affected 4 of 8 records reviewed of patients who had been restrained, including Patient Identifer (PI) # 1, PI # 7, PI # 5, and PI # 2 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Refer to A167, A168, A178, A188 for findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on review of facility policy, medical record, training content for restraints and Healthy Interventions (HI), video footage, facility's "Video Review of events"; it was determined the facility failed to ensure staff utilized methods of physical restraint according to the facility policy and training in HI material to physically restrain Patient Identifier (PI) # 1, 1 of 1 patient who was physically restrained and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Facility Policy
Subject: Restraint & Seclusion
Adopted policy: 5/16
Reviewed: 05/16, 07/17

I. Scope:
This applies to Brookwood Baptist Medical Center. It is a hospital-wide policy that would apply to any department providing patient care ...

II. Purpose:
The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety, and preserves his or her dignity, rights and well-being ...

III. Definitions:
A. "Restraint" means any method, physical or chemical, or mechanical
device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely ...

Attachment C

Definitions and Information Points

Definitions

Physical Restraint:
Holding the patient means physically holding a patient in a manner that restricts his/her movement (this would include therapeutic holds) constitutes restraint for that patient. Holding a patient can be just as restrictive and potentially dangerous as restraining methods using devices. Physically holding a patient during a force psychotropic (or other) medication procedure is considered physical restraint ...

Attachment D

Special Considerations Associated with Special / Vulnerable Populations ...

5. Restraining a patient in the prone position may predispose the patient to suffocation.

If the patient must be restrained in the prone position, ensure that the airway is unobstructed at all times (for example, do not cover or "bury" the patient's face). Also, ensure that expanse of the patient's lungs is not restricted by excessive pressure on the patient's back ..."

Review of the training content for Healthy Interventions (HI) revealed the content included, "Holds and Restraints." Review of the content for "Holds and Restraints" revealed the type of holds included, " ... Bear hug hold and basket hold ..."

Review of the "Bear hug hold" revealed the technique included a partner, whose responsibility is to distract the person to be held. The holder performs a "bear hug" from behind and locks their arms around the person to be held.

The "Basket Hold" is similar to the "Bear hug hold" with the exception the holder holds the person to be held by the wrist in an "X" position.

Both of these holds can be used to "Take down" a person using leg stabilization and moving them to a horizontal restraint. Included in this training, " ... Upper body ... Continue to roll paint to their side ... Lower body ... Slide hands up legs from feet, holding legs down at knee ... Person holding legs is communicator, and monitors respirations and positioning ... General ... Medicate in this position ... Hold until calm or ready for transport ... Re-position if rolled too far toward chest ... Never let a patient stay face down..."

Further review of the HI training revealed, " ... What is a Restraint? Block and or interfere with a person's ability to freely move their own body ... Physically holding ..."

On 4/30/18 at 12:18 PM, the surveyors reviewed the video footage of 4/19/18 involving PI # 1 in the presence Employee Identifier (EI) # 2, Vice President of Quality & Clinical Information and EI # 3, Nursing Director of Psychiatry.

Time line for 4/19/18 video footage:

1:32 PM - The patient was lying in the bed located in the seclusion room with the door open. Visible located in the hallway just outside the door is an over the bed table and chair. The patient was restless in bed.

1:35 PM - The patient arose from the bed, walked to the doorway and stepped outside the seclusion room into the hallway. The patient returned to the bed and laid down.

1:36 PM - The patient arose from bed, walked to the door of the seclusion room, returned to the bed and laid down.

1:39 PM - The patient arose from bed (third time up out of bed), returned to the doorway and backed into the seclusion room. EI # 4, Mental Health Assistant (MHA) stepped into the seclusion room. The patient sat on the bed and appeared to be talking with EI # 4. EI # 4 turned his back to the patient to walk away. The patient stood up from the bed and moved toward EI # 4. At this point, there appeared to be a scuffle between PI # 1 and EI # 4. EI # 4 and PI # 1 backed into the room with their arms intertwined. EI # 4 moved the patient toward the bed. Two other MHAs (identified as EI # 5 and EI # 6) entered the seclusion room. EI # 6 was holding the patient's right arm, EI # 5 was holding the patient's left arm and EI # 4 was positioned to the patient's back. The patient was placed cross-wise on the bed in a prone position with his/her feet hanging over the side of the bed. EI # 4, EI # 5 and EI # 6 (MHAs) were attempting to hold the patient. At this point, the patient was fighting the hold and the MHAs were having a difficult time holding the patient down on the bed.

1:40 PM - EI # 8, MHA entered the seclusion room and went around to the patient's head, leaned over and appeared to be checking on the patient. The patient continued to resist the physical hold by the three MHAs. EI # 4's weight was resting on his left knee for the most part with EI # 4 occasionally being lifted off the bed by the patient's resistance. All three MHAs were struggling to hold the patient.

The patient continued to struggle for several minutes. EI # 8 continued to check the patient's head and face during this time. At 1:43 PM, the patient's legs stopped moving and his/her toes were touching the floor. The patient was held by the arm, back and/or upper body area by one or two of the MHAs after the patient stopped struggling until 1:46 PM at which time the patient was released by all MHAs.

1:49 PM - EI # 7, Registered Nurse (RN) entered the room. EI # 7 went to the patient's head to assess the patient. The patient was rolled to his/her left side. EI # 4 checked the patient's carotid pulse.

1:50 PM - the patient was positioned onto his / her back on the bed. EI # 7 initiated cardiopulmonary resuscitation (CPR).

Review of PI # 1's medical record revealed the Cardiopulmonary Resuscitation Record dated 4/19/18 revealed CPR was initiated at 1:45 PM with chest compressions and Ambubag (mask to assist with ventilation of the patient's lungs).

Advanced Cardiopulmonary Resuscitation (ACLS) was conducted by the Code team from 1:50 PM until 2:49 PM at which time, resuscitative measures ended due to "no sustained return of circulation."

Review of the facility's Video Review of events on 4/19/18 revealed, " ... 4-19-18 PICU (Psychiatric Intensive Care Unit) 1 Seclusion "timeout" ...

1339 (1:39 PM) OOB (Out of bed) to hallway; Returns to door way; Backs into room - MHA in front of pt (patient); Seated on bed talking to MHA who is standing in doorway; MHA turns to walk away; Pt stands up and moves toward MHA; Patient backed into room-arms locked with MHA; MHA moves patient towards bed; Other MHAs arrive to doorway; Positioned across bed prone with MHA 1 (EI # 4) lying on top of patient; MHA 2 (EI # 6) at patient's RUE (right upper extremity) and MHA 3 (EI # 5) at patient's LUE (left upper extremity) ...

1340 (1:40 PM) MHA 4 (EI # 8) enters room goes around bed to patients head; MHA 1"s weight supported by his left knee on bed mattress; Pt resisting - moving all three MHAs; MHA 4 leaves room ...

1341 (1:41 PM) MHA 1 wipes his faces (injury); MHA 4 returns to room briefly and exits again ... 1342 (1:42 PM) MHA 4 returns and hold patients left leg; MHA 4 exits room again; MHA 4 re-enters room to bring gloves to MHA 2 and 3. Pt continues to resist ... 1343 (1:43 PM) MHA 3 applies gloves while MHA 4 holds patient's left arm. MHA 4 then checks patient's head and face; Pt's legs stop moving; toes down to floor and feet relaxed; MHA 4 at patient's head; MHA 2 putting on other glove ... 1349 (1:49 PM) RN (Registered Nurse) (EI # 7) enters room; goes to far side of room to assess patient; patient turned to side-lying position; MHA 1 checks for carotid pulse ... 1350 (1:50 PM) Pt positioned to back parallel to bed mattress ... mattress wet near patient's head / mouth when prone across mattress ... CPR started by Psych RN ..."

On 4/30/18 at 12:18 PM, during the review of the above video, EI # 1 was giving a verbal narrative of the above events and verified the patient was restrained in the prone position on the bed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility policy, video footage, and interviews with staff, it was determined the facility failed to ensure:

1. Restraint orders were obtained for all restraints.

2. Restraint orders were signed by the physician within 24 hours.

This affected 3 of 8 records reviewed, including Patient Identifier (PI) # 1, PI # 7, and PI # 5 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Policy: Restraint and Seclusion
Policy Number: Tenet CQ_4.004
Date Reviewed: 07/17

Procedure:

A. Methodology:

...2. Document the physician's order for restraint on the Physician's Order Sheet for Restraint or Seclusion...

B. Authorization and Ordering of Restraints:

1. Restraint is initiated only upon the order of a physician...

a) In an emergent situation... Registered Nurse competent in restraint usage may initiate restraint use based on an appropriate assessment of patient needs... The order must be obtained either during the emergency application of the restraint or immediately (defined as without time interval) after the restraint has been applied.

b) ...Restraint orders must be dated and timed when signed by physician...

3. Restraint orders are never written on as "as needed" basis or as PRN (as needed) orders or standing orders. Trial releases are not permitted as the release of the patient is considered as discontinuation or the restraint order...

1. PI # 1 presented to the facility's Emergency Department (ED) on 4/15/18 at 2:05 PM with Chief Complaint of Combative Behavior and seen by the ED physician at that time.

The ED Physician documented the patient's History of Present Illness: "... patient has stopped taking psychiatric medicines... has become more and more agitated over the last few days... now yelling, screaming, cussing... has threatened people at the house. Mother states... (he/she) is a threat to (him/herself) and others..."

Review of Systems revealed: "... Psych: The patient is agitated, combative... screaming and yelling in the halls... left triage... running down the halls... cussing people... had to be physically restrained. I talked with... mother... wanted us to restrain (patient) and get (him/her) help... Patient appears to be psychotic, agitated, combative and danger to (him/herself) and others..."

Medical Decision Making and Plan: "... Patient had to be given a shot of Geodon, Ativan, physically restrained in four-point restraints. I did discuss all this with the mother. She is agreeable to all of this. I was able to a physical examination after (he/she) was chemically restrained... no obvious acute abnormality that would not make (patient) eligible to go to psychiatry..."

Review of the medical record documentation revealed the patient was placed in four-point, Neoprene restraints at 2:15 PM. The surveyor was unable to determine how long the four-point restraints remained in place.

There was no documentation of a physician's order for the use of four-point restraints.

The patient was discharged from the ED on 4/15/18 at 6:37 PM and admitted to psychiatric services at that time with diagnosis including Schizophrenia.

Review of the Restraint Order Sheet dated 4/16/18 at 5:05 AM revealed physician orders for 4 point soft restraints to bilateral wrists and ankles due to the patient combative, hitting and kicking staff. Alternative measures taken included redirection, decreased stimuli and limit setting.

Review of the Restraint Flowsheet dated 4/16/18 revealed the patient's Velcro restraints were as follows:
5:05 AM - bilateral wrists and ankles
8:50 AM - bilateral ankles. There was no documentation bilateral wrist restraints were on at that time.
9:00 AM - left wrist and left ankle.

Review of the Restraint Order Sheet dated 4/16/18 at 9:05 AM revealed physician orders for Velcro restraints to bilateral wrists and right ankle due to the patient combative with staff, punching. Alternative measures taken included verbal redirection, decreased stimuli and limit setting.

Review of the 1 Hr Assessment Seclusion / Behavior Restraint dated 4/16/18 at 9:50 AM revealed the nurse documented the patient's status, " ... Restraints ... Type: 4 point Velcro ... Patient's reaction to the intervention ... Pt observed lying supine with restraints (Velcro X {times} 4) to upper & lower extremities. Restraints applied appropriately with good circulation noted ... I have performed a face-to-face (re)assessment of the patient and the patient requires restraint ..."

There was no documentation of a physician's order for 4 point restraints as per the documentation by the nurse in the 1 hour face to face assessment of the patient.

Review of the Restraint Flowsheet dated 4/16/18 revealed the patient's Velcro restraints were as follows:
9:15 AM - left wrist and left ankle.
9:30 AM through 10:45 AM - bilateral wrists and left ankle.
11:00 AM - bilateral wrists
11:15 AM - bilateral wrists and left ankle.
11:30 AM and 11:45 AM - bilateral wrists and right ankle
12:00 PM and 12:15 PM - right wrist and right ankle.
12:30 PM and 12:45 PM - bilateral wrist and right ankle.

The above documentation revealed multiple removals and reapplications of restraints, which require physician orders; nevertheless, there was no documentation of a physician's order for the restraints to be reapplied.

Review of the Restraint Order Sheet dated 4/16/18 at 1:05 PM revealed physician orders for Velcro restraints to bilateral wrists and right ankle due to the patient continues to verbally threaten and cussing. Alternative measures taken included verbal redirection, decreased stimuli and limit setting.

Review of the 1 Hr Assessment Seclusion / Behavior Restraint dated 4/16/18 at 1:50 PM revealed the nurse documented the patient's status, " ... Restraints ... Type: 4 point Velcro ... Patient's reaction to the intervention ... Pt observed lying supine with (Velcro) X 3 observed at upper and lower extremities ... I have performed a face-to-face (re)assessment of the patient and the patient requires restraint ..."

The above documentation was conflicting, in that, both 4 point Velcro restraints and 3 observed Velcro restraints were documented.

There was no documentation of a physician's order for 4 point restraints as per the documentation by the nurse in the 1 hour face to face assessment of the patient.

Review of the Restraint Flowsheet dated 4/16/18 revealed the patient's Velcro restraints were documented to bilateral wrists and right ankle from 1:00 PM through 4:45 PM.

Review of the Case Management / Social Services note dated 4/16/18 at 5:05 PM revealed, " ... Patient ... on 1:1 with staff ... is in 3 point restraint. Both arms and right leg ... is quiet and when spoken to ... is soft spoken and answers in 1 word answers ..."

Review of the medical record revealed no documentation of when the patient was released from restraints.

On 4/30/18 at 12:18 PM, the surveyors reviewed the video footage of 4/19/18 involving PI # 1 in the presence Employee Identifier (EI) # 2, Vice President of Quality & Clinical Information and EI # 3, Nursing Director of Psychiatry.

Time line for 4/19/18 video footage:

1:32 PM - The patient was lying in the bed located in the seclusion room with the door open. Visible located in the hallway just outside the door is an over the bed table and chair. The patient was restless in bed.

1:35 PM - The patient arose from the bed, walked to the doorway and stepped outside the seclusion room into the hallway. The patient returned to the bed and lay down.

1:36 PM - The patient arose from bed, walked to the door of the seclusion room, returned to the bed and laid down.

1:39 PM - The patient arose from bed (third time up out of bed), returned to the doorway and backed into the seclusion room. EI # 4, MHA stepped into the seclusion room. The patient sat on the bed and appeared to be talking with EI # 4. EI # 4 turned his back to the patient to walk away. The patient stood up from the bed and moved toward EI # 4. At this point, there appeared to be a scuffle between PI # 1 and EI # 4. EI # 4 and PI # 1 backed into the room with their arms intertwined. EI # 4 moved the patient toward the bed. Two other MHAs (identified as EI # 5 and EI # 6) entered the seclusion room. EI # 6 was holding the patient's right arm, EI # 5 was holding the patient's left arm and EI # 4 was positioned to the patient's back. The patient was placed cross-wise on the bed on his/her in a prone position with his/her feet hanging over the side of the bed. EI # 4, EI # 5 and EI # 6 (MHAs) were attempting to hold the patient. At this point, the patient was fighting the hold and the MHAs are having a difficult time holding the patient down on the bed.

1:40 PM - EI # 8, MHA entered the seclusion room and around to the patient's head, leaned over and appeared to be checking on the patient. The patient continued to resist the physical hold by the three MHAs. EI # 4's weight was resting on his left knee for the most part with EI # 4 occasionally being lifted off the bed by the patient's resistance. All three MHAs are struggling to hold the patient.

The patient continued to struggle for several minutes. EI # 8 continued to check the patient's head and face during this time. At 1:43 PM, the patient's legs stopped moving and his/her toes were touching the floor. The patient was held by the arm, back and/or upper body area by one or two of the MHAs after the patient stopped struggling until 1:46 PM at which time the patient was released by all MHAs.

1:49 PM - EI # 7, Registered Nurse (RN) entered the room. EI # 7 went to the patient's head to assess the patient. The patient was rolled to his/her left side. EI # 4 checked the patient's carotid pulse.

1:50 PM - the patient was positioned onto his / her back on the bed. EI # 7 initiated cardiopulmonary resuscitation (CPR).

Review of the Cardiopulmonary Resuscitation Record dated 4/19/18 revealed CPR was initiated at 1:45 PM with chest compressions and Ambubag (mask to assist with ventilation of the patient's lungs).

Advanced Cardiopulmonary Resuscitation (ACLS) was conducted by the Code team from 1:50 PM until 2:49 PM at which time, resuscitative measures ended due to "no sustained return of circulation."

There was no documentation in the medical record the patient was restrained using a physical hold, nor was there documentation of a physician's order for the use of the physical restraint of the patient on 4/19/18.

An interview was conducted on 5/2/18 at 1:32 PM with EI # 1, Accreditation Manager / Safety Manager who verified the above findings.

2. PI # 7 was admitted to the facility on [DATE] with admitting diagnoses including Alzheimer's Dementia with Behavioral Disturbances, Agitation, and Delirium.

Review of the MR revealed a Restraint Order Sheet (Medical) dated 12/2/17 at 6:00 AM. The order was signed by the physician on 12/7/17 at 9:30 AM, which was 5 days after the ordered restraint.

Further review of the MR revealed a Restraint Order Sheet (Medical) dated 12/4/17 at 7:50 PM. The order was signed by the physician on 12/14/17 at 4:10 PM, which was 10 days after the ordered restraint.

A Restraint Flowsheet (Violent)(Behavioral) dated 12/9/17 at 2:30 AM was observed in the MR. There was no restraint order documented for the restraint.

An interview was conducted on 5/2/18 at 2:09 PM with EI # 1, who confirmed the above findings, and confirmed physician orders for restraints should have been signed within 24 hours.





3. PI # 5 was admitted to the facility's Psychiatric Adult Unit on 4/1/18 with diagnoses including Autism, Psychosis and Agitation.

Review of the MR revealed a Restraint Order dated 4/1/18 at 8:45 PM with no physician's signature, date and time. The Restraint Order was for Velcro Wrist Right and Velcro Wrist Left.

Review the Restraint Flowsheet dated 4/1/18 revealed PI # 5 was in Velcro wrist restraints (right and left) and Velcro ankle restraints (right and left) from 8:45 PM to 9:45 PM.

Review of the 1 Hour Assessment Seclusion/Behavior Restraint form dated 4/1/18 at 9:00 PM revealed the type of restraint as 4 point Velcro.

An interview conducted 5/2/18 at 1:48 PM with EI # 1 confirmed the restraint order dated 4/1/18 was not signed by the physician. EI # 1 stated the expectation was that all restraint orders are signed within 24 hours. EI # 1 further confirmed there was no physician's order for 4 point restraints.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of facility policies and procedures, medical records, Violent/Behavior Restraint Log, Safety Event Entry documentation, training content for restraints and Healthy Interventions (HI), video footage, facility's "Video Review of events" document, medical records and interviews; it was determined the CEO failed to ensure:

1. Staff utilized methods of physical restraint according to the facility policy and training in HI material to physically restrain a patient.

2. Physician orders were obtained for all restraints.

3. Restraint orders were signed by the physician within 24 hours.

4. Staff completed a face to face assessment within 1 hour of initiation of restraints.

5. Staff conducted Post Restraint Assessments of patients after having been released from restraints.

6. Staff kept a document of all restraint events to be included in quality monitoring.

7. A Suicide Risk Assessment was completed after a suicide attempt.

8. The staff completed the Psychiatric Precaution Rounding Sheets with complete and accurate documentation of all events and observations.

9. Medical record documentation included all events including the use of restraints.

10. Medical record documentation was complete and accurate with patients' location of care being provided.

These deficient practices had the potential to negatively affect all patients admitted to this facility.

Findings include:

Refer to A167, A168, A178, A188, A 273, A 392, A 395, and A 449 for findings.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility policies and procedures, medical records, Violent/Behavior Restraint Log, Safety Event Entry documentation, training content for restraints and Healthy Interventions (HI), video footage, facility's "Video Review of events" document, medical records and interviews; it was determined the Governing Body failed to ensure:

1. Staff utilized methods of physical restraint according to the facility policy and training in HI material to physically restrain a patient.

2. Physician orders were obtained for all restraints.

3. Restraint orders were signed by the physician within 24 hours.

4. Staff completed a face to face assessment within 1 hour of initiation of restraints.

5. Staff conducted Post Restraint Assessments of patients after having been released from restraints.

6. Staff kept a document of all restraint events to be included in quality monitoring.

7. A Suicide Risk Assessment was completed after a suicide attempt.

8. The staff completed the Psychiatric Precaution Rounding Sheets with complete and accurate documentation of all events and observations.

9. Medical record documentation included all events including the use of restraints.

10. Medical record documentation was complete and accurate with patients' location of care being provided.

These deficient practices had the potential to negatively affect all patients admitted to this facility.

Findings include:

Refer to A167, A168, A178, A188, A 273, A 392, A 395, and A 449 for findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on review of medical records and interview, it was determined the facility failed to ensure a face to face assessment was completed within 1 hour of initiation of restraints for 1 of 8 medical records reviewed. This affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 1 presented to the facility's Emergency Department (ED) on 4/15/18 at 2:05 PM with Chief Complaint of Combative Behavior and seen by the ED physician at that time.

The ED Physician documented the patient's History of Present Illness: "... yelling, screaming, cussing... has threatened people at the house. Mother states... (he/she) is a threat to (him/herself) and others..."

Review of Systems revealed: "... Psych: The patient is agitated, combative... screaming and yelling in the halls... left triage... running down the halls... cussing people... had to be physically restrained. I talked with... mother... wanted us to restrain (patient) and get (him/her) help... Patient appears to be psychotic, agitated, combative and danger to (him/herself) and others..."

Medical Decision Making and Plan: "... Patient had to be given a shot of Geodon, Ativan, physically restrained in four-point restraints. I did discuss all this with the mother. She is agreeable to all of this. I was able to a physical examination after (he/she) was chemically restrained... no obvious acute abnormality that would not make (patient) eligible to go to psychiatry..."

Review of the medical record documentation revealed the patient was placed in four-point, Neoprene restraints at 2:15 PM. The surveyor was unable to determine how long the four-point restraints remained in place.

There was no documentation a face to face assessment of the patient was completed.

The patient was discharged from the ED on 4/15/18 at 6:37 PM and admitted to psychiatric services at that time with diagnosis including Schizophrenia.

Review of the Restraint Order Sheet dated 4/16/18 at 5:05 AM revealed physician orders for 4 point soft restraints to bilateral wrists and ankles due to the patient combative, hitting and kicking staff. Alternative measures taken included redirection, decreased stimuli and limit setting.

Review of the 1 Hr (Hour) Assessment Seclusion / Behavior Restraint dated 4/16/18 revealed the 1-Hr assessment was completed at 6:30 AM, which was 1 hr and 25 minutes after the patient had been restrained.

An interview was conducted on 5/2/18 at 1:32 PM with Employee Identifier # 1, Accreditation Manager / Safety Manager who verified the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedure, medical records (MR) and interviews with facility staff, it was determined the facility staff failed to conduct a Post Restraint Assessment for 3 of 8 patients after having been released from restraint.

This affected Patient Identifier (PI) # 7, PI # 1, PI # 2 and has the potential to negatively affect all patients admitted to facility.

Findings include:

Policy: Restraint and Seclusion
Policy Number: Tenet CQ_4.004
Date Reviewed: 07/17

I. Scope:

This policy applies to Brookwood Baptist Medical Center. It is a hospital-wide policy that would apply to any department providing patient care.

II. Purpose:

The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety, and preserves his or her dignity, rights and well-being.

...V. Procedure:

A. Methodology:

...4. As early as feasible in the restraint process, make the patient aware of the rational for the intervention.

5. RN (Registered Nurse) assessments are documented on the Restraint and Seclusion Flowsheet following the Observation and Monitoring guidelines.

...C. Documentation

1. Each episode of restraint use shall be documented in the patient's medical record and shall included but not be limited to:

a) Assessment and reassessment, including:

1. Significant changes in the patient's condition that warranted restraint use.

2. Patient's response to restraint...

3. Monitoring and Reassessment:

a) The restrained patient is assessed, monitored, and reassessed.

...c) Monitoring is accomplished by observation, direct face-to-face interaction with the patient or related direct examination of the patient by trained and competent staff...

Attachment A: Restraint Flowchart

...Once restraint / seclusion is discontinued, re-assess patient status.


1. PI # 7 was admitted to the facility on [DATE] with admitting diagnoses including Alzheimer's Dementia with Behavioral Disturbances, Agitation, and Delirium.

Review of the MR revealed a Restraint Order Sheet (Medical) dated 12/2/17 at 6:00 AM. The Restraint Flowsheet dated 12/2/17 contained no documentation the Post Restraint Assessment/ Debriefing had been performed. The form's instructions state: "Complete at the time of restraint removal." The last documented monitor check was at 8:00 PM. The form contained initials only, and was not signed by the Nurse.

Further review of the MR revealed a Restraint Order Sheet (Medical) dated 12/3/17 at 9:00 PM. The surveyor requested a copy of the Restraint Flowsheet and Post Assessment/ Debriefing for this restraint. None was provided.

A Restraint Order Sheet (Medical) was observed in the MR dated 12/4/17 at 7:50 PM. There was no documented Post Assessment/ Debriefing.

Further review of the MR revealed a Restraint Flowsheet (Violent) (Behavioral) dated 12/9/17 at 2:30 AM. There was no physician's order or Post Assessment/ Debriefing documented with this date, and none was provided upon request.

Further review of the MR revealed a Restraint Order Sheet (Medical) dated 12/9/17 at 8:00 PM. There was no documented Post Assessment/ Debriefing.

Review of the MR revealed a Restraint Order Sheet (Medical) dated 12/14/17 at 4:30 AM. The Post Assessment/ Debriefing only contained the "Time Device Removed: 10:05 AM." All other assessment information was left blank, as well as the Nurses signature.

Further review of the MR revealed 2 Restraint Order Sheets (Medical) dated 12/21/17 at 10:30 PM, and 12/27/17 at 9:55 AM. Neither Restraint occurrence included a documented Post Assessment/ Debriefing.

An interview was conducted on 5/2/18 at 2:09 PM with Employee Identifier (EI) # 1, Accreditation Manager and Safety Officer, who confirmed the above findings.





2. PI # 1 presented to the facility's Emergency Department (ED) on 4/15/18 at 2:05 PM with Chief Complaint of Combative Behavior and seen by the ED physician at that time.

The ED Physician documented the patient's History of Present Illness: "... patient has stopped taking psychiatric medicines... has become more and more agitated over the last few days... now yelling, screaming, cussing... has threatened people at the house. Mother states... (he/she) is a threat to (him/herself) and others..."

Review of Systems revealed: "... Psych: The patient is agitated, combative... screaming and yelling in the halls... left triage... running down the halls... cussing people... had to be physically restrained. I talked with... mother... wanted us to restrain (patient) and get (him/her) help... Patient appears to be psychotic, agitated, combative and danger to (him/herself) and others..."

Medical Decision Making and Plan: "... Patient had to be given a shot of Geodon, Ativan, physically restrained in four-point restraints. I did discuss all this with the mother. She is agreeable to all of this. I was able to a physical examination after (he/she) was chemically restrained... no obvious acute abnormality that would not make (patient) eligible to go to psychiatry..."

Review of the medical record documentation revealed the patient was placed in four-point, Neoprene restraints at 2:15 PM. The surveyor was unable to determine how long the four-point restraints remained in place.

There was no documentation in the medical record of the discontinuation of the restraint, no documentation the patient was assessed every 15 minutes after 5:00 PM and there was no documentation of a post-restraint assessment of the patient.

The patient was discharged from the ED on 4/15/18 t 6:37 PM and admitted to psychiatric services at that time with diagnosis including Schizophrenia.

Review of the Restraint Order Sheet dated 4/16/18 at 5:05 AM revealed physician orders for 4 point soft restraints to bilateral wrists and ankles due to the patient combative, hitting and kicking staff. Alternative measures taken included redirection, decreased stimuli and limit setting.

Review of the Restraint Order Sheet dated 4/16/18 at 9:05 AM revealed physician orders for Velcro restraints to bilateral wrists and right ankle due to the patient combative with staff, punching. Alternative measures taken included verbal redirection, decreased stimuli and limit setting.

Review of the Restraint Order Sheet dated 4/16/18 at 1:05 PM revealed physician orders for Velcro restraints to bilateral wrists and right ankle due to the patient continues to verbally threaten and cussing. Alternative measures taken included verbal redirection, decreased stimuli and limit setting.

Review of the Case Management / Social Services note dated 4/16/18 at 5:05 PM revealed, " ... Patient ... on 1:1 with staff ... is in 3 point restraint. Both arms and right leg ... is quiet and when spoken to ... is soft spoken and answers in 1 word answers ..."

Review of the medical record revealed the patient was in mechanical restraints on 4/16/18 from 5:05 AM and the last documentation of restraints was at 4:45 PM. There was no documentation of the time the patient was released from restraints and no documentation of a post restraint assessment for the above restraints.

3. PI # 2 was admitted on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type and Borderline Intellectual Functioning.

Review of the Restraint Order Sheet dated 3/4/18 at 2:45 PM revealed orders for 4-point bilateral wrist and ankle Velcro restraints.

Review of the Restraint Flowsheet dated 3/4/18 the patient was restrained with bilateral wrist and bilateral ankle restraints at 2:45 PM and 3:00 PM and discontinued at 3:15 PM. There was no documentation of an assessment of the patient's vital signs post removal of the restraints.

A list of the above concerns was given to the facility staff on 5/1/18. An email response was received on 5/3/18 from EI # 1, who verified the above findings
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, Violent/Behavior Restraint Log, video footage and interview, it was determined the facility staff failed to keep a document of all restraint events to be included in quality monitoring. This affected 2 of 8 records reviewed of patients who were restrained, including Patient Indentifer (PI) # 1 and PI # 7 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

1. PI # 1 was admitted on [DATE] at 6:37 PM with diagnosis including Schizophrenia.

On 4/30/18 at 12:18 PM, the surveyors reviewed the video footage of 4/19/18 involving PI # 1 in the presence of Employee Identifier (EI) # 2, Vice President of Quality & Clinical Information and EI # 3, Nursing Director of Psychiatry.

Time line for 4/19/18 video footage:

1:32 PM - The patient was lying in the bed located in the seclusion room with the door open. Visible located in the hallway just outside the door is an over the bed table and chair. The patient was restless in bed.

1:35 PM - The patient arose from the bed, walked to the doorway and stepped outside the seclusion room into the hallway. The patient returned to the bed and lay down.

1:36 PM - The patient arose from bed, walked to the door of the seclusion room, returned to the bed and laid down.

1:39 PM - The patient arose from bed (third time up out of bed), returned to the doorway and backed into the seclusion room. EI # 4, MHA stepped into the seclusion room. The patient sat on the bed and appeared to be talking with EI # 4. EI # 4 turned his back to the patient to walk away. The patient stood up from the bed and moved toward EI # 4. At this point, there appeared to be a scuffle between PI # 1 and EI # 4. EI # 4 and PI # 1 backed into the room with their arms intertwined. EI # 4 moved the patient toward the bed. Two other MHAs (identified as EI # 5 and EI # 6) entered the seclusion room. EI # 6 was holding the patient's right arm, EI # 5 was holding the patient's left arm and EI # 4 was positioned to the patient's back. The patient was placed cross-wise on the bed on his/her in a prone position with his/her feet hanging over the side of the bed. EI # 4, EI # 5 and EI # 6 (MHAs) were attempting to hold the patient. At this point, the patient was fighting the hold and the MHAs are having a difficult time holding the patient down on the bed.

1:40 PM - EI # 8, MHA entered the seclusion room and around to the patient's head, leaned over and appeared to be checking on the patient. The patient continued to resist the physical hold by the three MHAs. EI # 4's weight was resting on his left knee for the most part with EI # 4 occasionally being lifted off the bed by the patient's resistance. All three MHAs are struggling to hold the patient.

The patient continued to struggle for several minutes. EI # 8 continued to check the patient's head and face during this time. At 1:43 PM, the patient's legs stopped moving and his/her toes were touching the floor. The patient was held by the arm, back and/or upper body area by one or two of the MHAs after the patient stopped struggling until 1:46 PM at which time the patient was released by all MHAs.

1:49 PM - EI # 7, Registered Nurse (RN) entered the room. EI # 7 went to the patient's head to assess the patient. The patient was rolled to his/her left side. EI # 4 checked the patient's carotid pulse.

1:50 PM - the patient was positioned onto his / her back on the bed. EI # 7 initiated cardiopulmonary resuscitation (CPR).

Review of the Cardiopulmonary Resuscitation Record dated 4/19/18 revealed CPR was initiated at 1:45 PM with chest compressions and Ambubag (mask to assist with ventilation of the patient's lungs).

Advanced Cardiopulmonary Resuscitation (ACLS) was conducted by the Code team from 1:50 PM until 2:49 PM at which time, resuscitative measures ended due to "no sustained return of circulation."

There was no documentation in the medical record the patient was restrained using a physical hold, nor was there documentation of a physician's order for the use of the physical restraint of the patient on 4/19/18.

Review of the Violent / Behavioral Restraint Log revealed no documentation the patient was physically restrained on 4/19/18.

An interview was conducted on 5/2/18 at 1:32 PM with EI # 1, Accreditation Manager and Safety Officer, who verified the above findings.

An interview was conducted on 5/2/18 at 10:10 AM with EI # 3, Nursing Director Psychiatry. During this interview, the surveyor asked what was the purpose of the Restraint / Seclusion Log. EI # 3 stated that it was a way to know who had been restrained / secluded and that every restraint is discussed at "Huddle" the next morning.






2. PI # 7 was admitted to the facility on [DATE] with admitting diagnoses including Alzheimer's Dementia with Behavioral Disturbances, Agitation, and Delirium.

Review of the Violent/Behavioral Restraint Log located on the Geriatric Psychiatric unit, revealed 5 occurrences of PI # 7 in restraints.

Review of PI # 7's MR revealed 6 additional occurrences, dated 12/10/17, 12/12/17, 12/14/17, 12/20/17,12/21/17 and 12/27/17, where PI # 7 was placed in restraints, and not entered in the log book.

An interview was conducted on 5/2/18 at 2:09 with EI # 1, who confirmed the above findings.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of facility policies, medical records, training content for restraints and Healthy Interventions (HI), video footage, facility's "Video Review of events", and interviews; it was determined the facility failed to ensure:

1. Staff utilized methods of physical restraint according to the facility policy and training in HI material.

2. Restraint orders were obtained for all restraints.

3. Restraint orders were signed by the physician within 24 hours.

4. A face to face assessment was completed within 1 hour of initiation of restraints.

5. The staff conducted a Post Restraint Assessment after a patient was released from restraints.

6. A Suicide Risk Assessment was completed after each suicide attempt.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Refer to A 167, A 168, A 178, A 188, and A 395 for findings.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of facility policies, medical records, training content for restraints and Healthy Interventions (HI), video footage, facility's "Video Review of events", and interviews; it was determined the facility failed to ensure:

1. Staff utilized methods of physical restraint according to the facility policy and training in HI material.

2. Restraint orders were obtained for all restraints.

3. Restraint orders were signed by the physician within 24 hours.

4. A face to face assessment was completed within 1 hour of initiation of restraints.

5. The staff conducted a Post Restraint Assessment after a patient was released from restraints.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Refer to A 167, A 168, A 178, and A 188 for findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on facility policy and procedure, review of medical records (MR), Safety Event Entry documentation and interviews with staff it was determined the facility failed to ensure a Suicide Risk Assessment was completed after a suicide attempt by Patient Identifier (PI) # 8. This deficient practice affected 1 of 8 records reviewed and had the potential to negatively affect all patients admitted to the facility's psychiatric services.

Findings include:

Policy and Procedure Directive
Subject: Suicide Risk Assessment
Date Reviewed: 07/17

II. Purpose: The purpose of this policy is to describe the process for assessing for risk and developing a plan of care for patients thirteen years of age or older with suicidal ideation.

III. Definitions:

A. "Suicidal Patient" is one who has recently made an attempt in the last 12 months...

IV. Policy:

A. ...all patients aged thirteen years or older...who present with a behavioral health related complaint...will be screened using the following three screening questions...

3. Have you attempted suicide or had a plan to attempt within the last 12 months?

B. A "yes" answer...puts the patient at risk of suicide and will require further assessment...The suicide risk assessment...will determine the interventions and monitoring necessary to maintain patient safety...

V. Procedure:

B. Inpatient Procedure:

2...The nursing staff will place the patient under the designated level of observation at all times by a competent health care provider who is monitoring the patient...

9. Inpatient Documentation:

c. The nursing staff will document the patient's behavior and activity on the Constant Observation Flowsheet...

e. Clinical status of the patient will be documented along with changes in physical or emotional condition on the Constant Observation Flowsheet...

C. Auditing and Monitoring:
The Clinical Quality Department shall audit adherence to this policy in its Comprehensive Clinical Audits.

D. Responsible Person:
The Nursing Department Directors are responsible for ensuring that all individuals adhere to the requirements of this policy that these procedures are implemented and followed...

E. Enforcement:
All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy...

1. PI # 8 was admitted to the facility's Psychiatric Services on 11/2/17 with diagnoses including Schizophrenia, Psychosis and Agitation.

Review of the MR revealed PI # 8's Suicide Risk Assessment completed on 11/2/17 was moderate risk with a score of 25.

Review of Safety Event Entry documentation (PI # 8) dated 11/24/17 at 4:50 PM revealed PI # 8 attempted to hang self in the patient room on psychiatric intensive care unit 2.

Review of the Constant Observer Request Form dated 11/24/17 at 1705 (5:05 PM) revealed no signature of approval by the Director/Supervisor.

Review of the Psychiatric Precaution Round Sheet dated 11/24/17 revealed no documentation of the type of monitoring PI # 8 required. Further review revealed no documentation of the attempted hanging event that occurred at 1650 (4:50 PM) and no documentation that Constant Observation was initiated as requested at 5:05 PM.

Further review of the MR revealed the Suicide Risk Assessment was next completed on 11/27/17 which was 3 days after the attempted hanging event (see Safety Event Entry documentation below).

An interview conducted on 5/2/18 at 1:50 PM with Employee Indentifer # 1, Accreditation Manager and Safety Officer, confirmed the above findings.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedure and interviews, it was determined the facility staff failed:

1. To complete the Psychiatric Precaution Rounding Sheets with complete and accurate documentation of all events and observatons, incluing 1:1 observations.

2. To ensure medical record documentation included all events including the use of restraints.

3. To ensure medical record documentation was complete and accurate with patients' location of care being provided.

This affected 8 of 8 records reviewed, including Patient Identifier (PI) # 1, PI # 3, PI # 2, PI # 4, PI # 5, PI # 8, PI # 7, PI # 6 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 1 presented to the facility's Emergency Department (ED) on 4/15/18 at 2:05 PM with Chief Complaint of Combative Behavior and seen by the ED physician at that time.

The ED Physician documented the patient's History of Present Illness: "... patient has stopped taking psychiatric medicines... has become more and more agitated over the last few days... now yelling, screaming, cussing... has threatened people at the house. Mother states... (he/she) is a threat to (him/herself) and others..."

Medical Decision Making and Plan: "... Patient had to be given a shot of Geodon, Ativan, physically restrained in four-point restraints. I did discuss all this with the mother. She is agreeable to all of this. I was able to a physical examination after (he/she) was chemically restrained... no obvious acute abnormality that would not make (patient) eligible to go to psychiatry..."

Review of the medical record documentation revealed the patient was placed in four-point, Neoprene restraints at 2:15 PM. The surveyor was unable to determine how long the four-point restraints remained in place.

There was no documentation in the medical record of the discontinuation of the restraints, nor was there documentation the patient was assessed every 15 minutes after 5:00 PM.

Review of the Physician orders dated 4/15/18 at 3:38 PM revealed orders for 1 to 1 observation, which was discontinued on 4/15/18 at 4:43 PM. There was no documentation 1 to 1 observation was performed while the patient was in the ED from 3:38 PM until 4:43 PM.

The patient was discharged from the ED on 4/15/18 t 6:37 PM and admitted to psychiatric services at that time with diagnosis including Schizophrenia.

Review of the Physician Orders dated 4/15/18 at 7:32 PM revealed orders for close observation every 15 minute rounds on all patients unless orders reflect different from physician.

Review of the Physician Order dated 4/15/18 at 8:00 PM revealed orders for Self Harm Interventions of one to one (1:1) observation. Review of the Physician Order dated 4/16/18 at 5:08 PM revealed orders to continue 1:1 observation, until seen by provider.

These orders were discontinued on 4/19/18 at 7:07 PM (after discharge), which indicated the patient was 1:1 observation for the entire hospitalization .

Review of the medical record revealed the document entitled, "Psychiatric Precaution Round Sheet". This document was undated and the surveyor was unable to determine the room, or type of monitoring that was completed for this patient.

Review of the medical record revealed the patient was in mechanical restraints on 4/16/18 from 5:05 AM and the last documentation of restraints was at 4:45 PM. There was no documentation of the time the patient was released from restraints.

Review of the Constant Observation Flow Sheet dated 4/17/18 revealed the Mental Health Assistant (MHA) documented the type of monitoring was, "Every 15 Minutes" not the 1:1 observation as ordered by the physician.

Review of the Psychiatric Precaution Round Sheet dated 4/18/18 from 12:00 AM to 1:00 PM revealed the MHAs documented the type of monitoring was "Every 15 Minutes" not the 1:1 observation as ordered by the physician.

Review of the Constant Observation Flow Sheet dated 4/19/18 from 12:00 AM to 2:30 PM revealed the MHAs documented the type of monitoring was "Close Observation" not the 1:1 observation as ordered by the physician.

On 4/30/18 at 12:18 PM, the surveyors reviewed the video footage of 4/19/18 involving PI # 1 in the presence of Employee Identifier (EI) # 2, Vice President of Quality & Clinical Information and EI # 3, Nursing Director of Psychiatry. It was determined through the review of the video footage the patient was physically restrained by (3) three MHAs from 1:39 PM to 1:46 PM.

There was no documentation in the medical record the patient was restrained using a physical hold, nor was there documentation of a physician's order for the use of the physical restraint of the patient on 4/19/18.

An interview was conducted on 5/2/18 at 1:32 PM with EI # 1, Accreditation Manager & Safety Officer, who verified the above.

2. PI # 3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Anxiety and Bipolar 1 Disorder.

Review of the Order Sheet dated 4/18/18 revealed orders for behavioral health monitoring every 15 minutes unless orders reflect different from physician.

Review of the Restraint Order Sheet dated 4/19/18 at 8:27 PM revealed orders for 4-point bilateral wrist and ankle Velcro restraints. Review of the Constant Observer Request Form dated 4/19/18 at 8:33 PM revealed, " ... patient place in 4 point restraints ... 1:1 until restraints discontinued per protocol ..."

Review of the medical record revealed no documentation of a Constant Observation Flowsheet for the time the patient was restrained, including 1:1 observation.

Review of the medical record revealed (2) two Psychiatric Precaution Round Sheets with no documentation of the date, Type of Monitoring.

Review of the Psychiatric Precaution Round Sheet dated 4/30/18 revealed no documentation of the "Type of Monitoring".

A list of questions related to the above identified medical record problems was given to the facility.

On 5/2/18 at 1:24 PM, an interview was conducted with EI # 1, who presented the aforementioned undated documents and stated the documents should have been dated 4/28/18 and 4/29/18. These two documents were altered with the dates and the "Type of Monitoring."

During the above interview, EI # 1 verified the "Type of Monitoring" for the 4/30/18 Psychiatric Precaution Round sheet was not documented.

3. PI # 2 was admitted on [DATE] with diagnoses including Schizoaffective d
Disorder, b
Bipolar Type and Borderline Intellectual Functioning.

Review of the Physician Order dated 1/27/18 revealed the behavioral health (BH) monitoring included, "Routine ... Elopement Precautions, Continuous and Combative ..."

Review of the Psychiatric Precaution Round Sheets dated 2/24/18 and 2/25/18 revealed no documentation of the "Type of Monitoring."

Review of the Restraint Order Sheet dated 3/4/18 at 2:45 PM revealed orders for 4-point bilateral wrist and ankle Velcro restraints.

Review of the Restraint Flowsheet dated 3/4/18 (page 1) revealed no documentation of the person who completed the document. Review of the Restraint Flowsheet dated 3/4/18 (page 2) revealed no documentation of the patient's vital signs post removal of the restraints.

Review of the Physician Order dated 3/4/18 at 4:45 PM revealed orders for " ... BH Constant Observer Self Harm ... One to One (1:1) Observation ..."

Review of the Psychiatric Precaution Round Sheet dated 3/5/18 revealed no documentation of the "Type of Monitoring."

Review of the Psychiatric Precaution Round Sheet dated 3/9/18 revealed no documentation the patient was observed at 5:45 AM.

Review of the Psychiatric Precaution Round Sheet dated 3/11/18 revealed no documentation the patient was observed from 2:00 AM to 3:00 AM.

Review of the Psychiatric Precaution Round Sheets dated 3/11/18 and 3/12/18 revealed no documentation of the "Type of Monitoring."

Review of the Psychiatric Precaution Round Sheet dated 3/15/18 revealed no documentation the patient was observed at 2:00 PM and 4:00 PM.

Review of the Psychiatric Precaution Round Sheets dated 3/17/18, 3/19/18, 3/24/18, 3/25/18, 4/1/18, 4/2/18, 4/8/18 and 4/11/18 revealed no documentation of the "Type of Monitoring."

Review of the Psychiatric Precaution Round Sheets revealed one of the documents was undated with no documentation of the type of monitoring that was completed. There was no documentation of the Psychiatric Round Sheet dated 3/31/18.

Review of 27 of 27 Psychiatric Precaution Round Sheets dated between 3/6/18 to 4/12/18 revealed no documentation of 1:1 observation of the patient.

A list of the above concerns was given to the facility staff on 5/1/18. An email response was received on 5/3/18 from EI # 1, who verified the above findings.






4. PI # 4 was admitted to the facility's Psychiatric Services on 4/19/18 with diagnoses including Bipolar I Disorder and Schizophrenia and exhibiting hallucinations and suicidal ideations with a plan.

Review of the Psychiatric Precaution Round Sheet (PPRS) dated 4/23/18 revealed no documentation of the type of monitoring PI # 4 required. Further review of the PPRS dated 4/23/18 revealed no documentation of PI # 4's location/room number. The medical record revealed PI # 4 was transferred within the facility's psychiatric units 8 times from 4/19/18 to 5/2/18 due to behavior problems. The surveyor was unable to determine what unit PI # 4 was in on 4/23/18 and what level of observation was needed.

Review of the PPRS dated 4/28/18 revealed no documentation of the type of monitoring PI # 4 required.

An interview was conducted 5/2/18 at 1:45 PM with Employee Identifier # 1 who confirmed the above findings.

5. PI # 5 was admitted to the facility's Psychiatric Services on 4/1/18 with diagnoses including Autism, Psychosis and Agitation.

Review of the Restraint Flowsheet dated 4/2/18 Post Restraint Assessment revealed PI # 5 was to remain on 1:1 (one to one) observation for safety.

Review of the PPRS dated 4/2/18 revealed no documentation PI # 5 was on 1:1 observation.

Review of the PPRS dated 4/14/18 revealed no documentation of the type of monitoring PI # 5 required.

An interview conducted 5/2/18 at 1:48 PM with EI # 1 confirmed the above findings.

6. PI # 8 was admitted to the facility's Psychiatric Services on 11/2/18 with diagnoses including Schizophrenia, Psychosis and Agitation.

Review of the PPRS's dated 11/6/17, 11/7/17, 11/8/17, 11/9/17, 11/11/17, 11/12/17, 11/13/17, 11/14/17, 11/17/17, 11/19/17, 11/22/17, 11/23/17, 11/24/17, 11/25/17, 12/1/17, 12/2/17, and 12/3/17 revealed no documentation of the Type of Monitoring PI # 8 required and/or the room location.

Further review of the PPRS dated 11/24/17 revealed no documentation of the Record of Event at 1650 (4:50 PM) of attempted hanging. Further, there was no documentation on the PPRS of the type of monitoring PI # 8 required after the attempted hanging event on 11/24/17.

Review of the Constant Observer Request Form dated 11/24/17 at 1705 (5:05 PM) revealed Step 5: Signature for Approval of Constant Observer was incomplete.

Review of the PPRS dated 11/25/17 revealed no documentation 1 to 1 observation was completed and no documentation of the room location.

Review of the Suicide Risk Initial assessment dated [DATE] at 2030 (8:30 PM) revealed PI # 8's observation level was Line of Sight Observation.

Review of the PPRS dated 11/27/17 revealed no documentation PI # 8 was placed on Line of Sight Observation.

An interview conducted on 5/2/18 at 1:50 PM with EI # 1 confirmed the above findings.





7. PI # 7 was admitted to the facility on [DATE] with admitting diagnoses including Alzheimer's Dementia with Behavioral Disturbances, Agitation, and Delirium.

Review of the MR revealed a Constant Observation Flow Sheet (COFS) used to document PI # 7's location and behavior. The surveyor was unable to determine the level of observation provided to PI # 7 on the COFS for the following dates: 12/7/17, 12/8/17, 12/13/17, 12/14/17, and 12/26/17.

An interview was conducted on 5/2/18 at 2:09 PM with EI # 1, who confirmed the forms were incomplete.

8. PI # 6 was admitted to the facility on [DATE] with admitting diagnoses including Bipolar Disorder, PTSD (Post Traumatic Stress Disorder), and Alcohol Dependence.

Review of the MR revealed a Restraint Flowsheet (Violent) (Behavioral) dated 4/2/18. On the form, from 2:30 PM until 3:15 PM, there is no documentation of what device was used for the restraint, or what PI # 6's behavior was during that time. During the Post Assessment/ Debriefing at 3:15 PM, there was no Level of Consciousness documented.

Further review of the MR revealed a 1 Hour Assessment Seclusion/ Behavior Restraint form dated 4/2/18 at 2:50 PM. There was no documentation of the patient's reaction to the intervention, this area of the form was left blank. There was no documentation related to a change, or no change in the patient's medical/ behavioral condition from baseline.

An interview was conducted on 5/2/18 at 2:05 PM, with EI # 1 who confirmed the above records were incomplete.