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.

HILL CREST BEHAVIORAL HEALTH SERVICES 6869 FIFTH AVENUE SOUTH BIRMINGHAM, AL Dec. 27, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, review of medical records (MR), policies and procedures, facility incident report documentation, Acute Services Safety documentation, Form CMS-(Centers for Medicare and Medicaid) , hospital medical record, facility Seclusion/Restraint for Patients policy and procedure, facility Restraint and Seclusion log, facility death investigation documentation, facility video review and staff interviews, it was determined the hospital failed to the ensure:

1) staff identified and corrected environmental safety concerns on the acute patient units.

2) the nurse completed and documented an assessment of patient injuries.

3) incident reports were completed for all patient injuries which included patient/staff physical alterations documented in the medical record.

4) the patient death report completed by the staff contained accurate findings regarding the use of restraints.

5) staff followed its own policy for use of restraint and documented a patient had been placed in a physical restraint.

6) staff followed its own policy for use of restraint and obtained a physician's order for a patient restraint.

7) staff followed its own policy for use of restraint and documented results of 5-minute patient observations during patient restraint.

8) staff followed its own policy for use of restraint and completed and documented the One Hour Face to Face Evaluation findings within one hour.

This had the potential to affect all patients treated at the psychiatric hospital.

Findings include:

Refer to A-144, A-167, A-168, A-175, A-178, and A -213 for findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, review of medical records, policies and procedures, facility incident report documentation, Acute Services Safety documentation, Form CMS-(Centers for Medicare and Medicaid) , hospital medical record and staff interviews, the hospital failed to the ensure:

1) staff identified and corrected environmental safety concerns on the acute patient units.

2) the nurse completed and documented an assessment of patient injuries.

3) incident reports were completed for all patient injuries which included patient/staff physical alterations documented in the patient medical record.

4) the patient death report completed by the staff contained accurate findings regarding the use of restraints.

This affected Patient Identifier (PI # 1), 1 of 1 death record reviewed and had the potential to affect all patients treated at the psychiatric hospital.

Findings include:

Subject: Safety Checks
Policy: IX-0.0001
Revision Date: 6/11

I. Policy
All Units...will do safety checks every shift.

II. Purpose
This policy is to ensure that a safe environment will be provided for all patients and staff.

III. Procedure
1. Unit nursing staff will assess each patient room and public area. Any unauthorized items (i.e. sharps, hazardous items) will be disposed of in the correct manner.

2. Unit nursing staff will ensure that:
b. Any needed unit maintenance will be noted and reported to maintenance.
c. No cord are on my unit.( Personal equipment may be used at the therapist's discretion).

Subject: Incident Reporting
Policy: I-0.0001
Revision Date: 6/11

I. Policy
It shall be the policy...that a Healthcare Peer Review Report (H.P.R.) be completed whenever an unexpected occurrence happens with a patient, staff member...reports shall be retained...no less than 5 (5) years...

II. Purpose
...reporting is the foundation of the Risk Management Program. In order that action may be taken to investigate an unexpected occurrence, a properly prepared HPR must be completed to assure thorough and timely documentation for reporting of all hospital-related variances/incidents.

III. Procedure
A. The staff member who has knowledge or observes an unusual incident shall complete the HPR...the shift ...the incident occurred.
B. If a patient is involved, complete all patient identification areas.
E. Describe the person's condition before and after the incident, and the action taken.
F. Notify the patient's physician of any injury...
I ...Occurrences which indicate potential liability shall immediately be brought to the attention of the Risk Manager.

IV. HPR Required For:
A. Deaths
C. Physical Altercation (staff, patient, other)
D. Any injury or Potential for Injury
N. ER (emergency room ) visits
O. Restraints/Seclusions
W. hospitalization
V. Responsibilities

A. Hospital staff- as per policy and procedure outlined above.
B. Nurse/Physician-assesses person's condition and documents action taken...If a patient is involved, document this information in the patient's medical record. Immediately notify immediate supervisor and Risk Manager...
C. Risk Manager-reviews all HPR's...initiates investigation...report any..problem areas... to administrative staff...

A tour of the psychiatric acute hospital units for adolescents boys, girls and adults was conducted on 12/21/17 at 9:30 AM with Employee Indentifer (EI) # 1, Director of Nursing (DON). During the facility tour, the survey staff observed the following:

Adult unit
Room 300- wardrobe not secured to floor/wall, sheet rock damage, graffiti writing inside window sill.
Room 301-heating/cooling vent with loose screw/bolt, wardrobe not secured.
Rooms 303, 304- large amount of dust/dirt in air conditioner vents.
Room 305- wardrobe not secured to wall.
Room 307-wardrobe not secured.
Room 308- wardrobe not secured to wall, large stain on ceiling.
Room 309- wardrobe not secured.
Room 310- both wardrobes not secured to wall.
Room 312- both wardrobes not secured to wall.
Room 313- wardrobes and psychiatric beds not secured.
Room 315- sheet rock damage in corner of room.
Room 316- 2 holes in sheet rock around window.
Room 317- bathroom sink has sharp metal edge underneath.
Adult outside recreation area/smoking area- one cup overflowing with cigarette butts

Adolescent unit:
Rooms 210 and 211-ceiling sheet rock damage (2 holes)
Room 211- heating/cooling vent rusted.
Room 213-peeling paint on ceiling and window sill. Covered electrical box had sharp edges.
Room 214-vent approximately 1/2 foot (width) by 1 foot (length) uncovered.
Adolescent boys dayroom- one telephone cord approximately 2 1/2 to 3 foot long (greater than 12 inches)
Room 215- uncovered vent with visible rust.
Rooms 219-bathroom vent uncovered.
Room 220- wardrobe metal fasteners separated from wall (ligature/self injury risk), bathroom vent uncovered and rusted.
Room 221-bathroom vent cover rusted, peeling paint and separated sheet rock around shower.
Room 225-bathroom vent uncovered.
Rooms 227-wardrobe not secured, metal fasteners with no screws to top bolt ( (ligature/self injury risk)
Room 230- wardrobe not secured to wall, bracket on floor loose, no bolts or screws.
Room 232- three holes in ceiling.
Room 233-wardrobe not secured, metal fasteners with no screws to top bolt.
Rooms 247, 249, 251 -vents approximately 1 foot (W) by 1 foot (L) uncovered.
Room 249- wardrobe metal fasteners separated from wall (ligature/self injury risk)
Room 250- 2 ceiling vents not covered, 1 hole in ceiling.
Room 252-uncovered vent separated at one end from the ceiling, door frame loose from the wall and an uncovered shower head.
Room 295-vent not secured and uncovered.
Adolescent common bathroom-exposed sprinkler, visible open area in ceiling

In an interview on 12/19/17 at 10:10 AM, EI # 1 reported Mental Health Technicians (MHT) complete daily shift rounds at the start of the shift for contraband and sharps and "notable things broken are reported to maintenance staff".

On 12/22/17, review of the Acute Services Safety Check documentation for all acute units for 12/18/17 and 12/19/17 failed to include the above observations. There was no documentation the findings were reported and maintenance requests completed.

1. PI # 1 was admitted on [DATE] with a diagnosis of Schizophrenia and Alcohol Abuse. PI # 1's medical history revealed Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Stage 3 (1-6, 6 is end stage).

Review of the 5/8/15 11-7 (11:00 PM-7:00 AM) shift MHT progress note entry at 6:00 AM revealed "slept 2 1/4 hours, monitored 4 (for) safety 15 mins (minutes)...fighting w/staff (with staff)- failure to re-direct-fopping (flopping) on floor, escorted to PR (patient room) twice agitated most of the night..." At 7:45 AM the 7-3 (7:00 AM-3:00 PM) shift MHT documented patient was combative, aggressive throwing punches at staff and attempted to kick staff and placed in a physical hold, broke loose, hitting staff, nurse aware of behaviors. At 8:00 AM, "the patient continues to be aggressive and assaultative, cursing, spitting and kicking. Pt flopped on the floor hitting head against the tile. Nurse aware of behaviors".

Record review revealed physician orders dated 5/8/15 at 7:30 AM for use of patient restraint for aggressive and combative behaviors.

There was no documentation the nurse was notified the patient hit his/her head. There was no documentation the nursing staff completed a patient assessment after PI #1 hit his/her head against the tile and no documentation the physician was notified. There was no incident report documentation provided to the surveyor.

At 8:15 AM the MHT's documented, pt. refused to calm down, fists clenched lunged at staff. At 8:45 AM, running at staff, fists clenched when staff approached, pt. slumped over bed landing in corner, hitting head on wall, refused to get up. The MHT documented nurse aware of behaviors.

There was no documentation the nurse assessed the patient after hitting his/her head on the wall and no documentation the physician was notified. There was no incident report regarding physical altercation (fighting with staff) on 5/8/15 and no documentation of an injury/potential injury of the patient hitting his/her head on 2 separate occasions the morning of 5/8/15.

Record review revealed the 11-7 shift RN documented on 5/8/15 at 7:10 AM the patient was loud, disruptive, combative, aggressive and non-compliant with staff and physical restraint implemeted. At 7:15 AM the nurse documented Haldol 5 mg (milligram) and Benadryl 50 mg IM given, continued to resist cooperating with staff. At 7:30 AM, the nurse documented the physician was notified concerning patient behaviors, orders obtained for physical restraints up to one hour for aggressive and combative behavior, (patient) continues to resist and remains in physical hold, no respiratory distress noted and or injury.

Further review on 5/8/15 at 7:35 AM contained nurse documentation "transported from day areas and (patient) dropped to floor when arriving at nurse station, refused again to comply with staff." At 7:40 AM PICU (psychiatric intensive care unit) notified concerning transfer and the patient walked without resistance with social worker to PICU.

Review of the 7-3 (7:00 AM-3:00 PM ) shift RN progress note documentation dated 5/8/15 at 7:30 AM revealed PI # 1 was transferred to PICU from adult unit, violent, combative, yelling and cursing. At 9:30 AM, the patient accepted po (oral) medications after much coaxing and was given 2 (tablets) Tylenol 325 mg with regular schedule medications. There was no reason documented why Tylenol was administered. At 11:50 AM, the RN documented an ice pack was given to patient for L (left) eye swelling possibly from earlier altercation with staff. Area is intact with no redness.

There was no incident report documentation for PI # 1's swollen left eye and no documentation the physician was notified.

Medical record review revealed on 5/8/15 at 1:30 PM, the RN assigned to the patient's care documented "the patient was...standing on the bed swinging object at staff... attempted to redirect and process patient with pt (patient) to get down. Writer contacted Dr. (doctor) ...informed of behavior and status...ordered prn medications as well as pt med status. MD (medical doctor) stated to give Thorazine 100 mg IM (intramuscular), now dose, along with prn's" (as needed). Thorazine 100 mg IM, Benadryl 50 mg IM and Haldol 5 mg IM was given per MD orders. Approx (approximately) 1400 (2:00 PM), this nurse and the other unit nurse were called to pt room, by MHT for help. Pt was observed lying on the floor unresponsive, pulse and respirations noted to be absent. CPR (cardiopulmonary resuscitation) was initiated..."

Review of a 5/8/15 Rapid Response Team Record document contained RN documentation "...approximately 2:00 PM nurses called to room where pt. was unrespons. (unresponsive) Pt. placed from side lying pos (position) to back. This nurse retrieved the AED (automated external defibrillator) and emerg (emergency) bag. Paramedics called code blue (respiratory/cardiac arrest). Pt had no stable rhythm (after) sev (several) attempts. Pt placed on backboard and transferred to stretcher. pt left building at approx (approximately) 3:00 PM." At 5:20 PM, an RN documented contact with local hospital ED department which reported PI # 1 was being admitted to a critical care unit.

Review of the patient's hospital medical record revealed discharge diagnoses were cardiac arrest, severe cerebral anoxia and hyperkalemia. The time of death was 11:30 AM on 5/9/15.

There was no incident report documentation provided to the surveyor for the altercation with staff, the swollen left eye and no documentation of any report of head injury. There was no nurse assessment of the documented head injuries or physician notification of eye or head injuries.

A phone interview was conducted on 12/20/17 at 3:57 PM with the attending physician, EI # 11. EI # 11 reported he/she never formally saw the patient but had spoken to nursing staff over the night regarding combative behavior. EI # 11 reported the day the patient was transferred to the medical center for medical care the patient had been aggressive and may have even fashioned a weapon.

During the interview, the physician, EI # 11 stated he/she was not aware of any injuries the patient sustained while in the psychiatric hospital. When asked about underlying health conditions that would make physical restraint dangerous for this patient, EI # 11 remarked 'literally this patient was threatening other patients, so of course we would order them (staff) to do something".

An interview was conducted on 12/21/17 at 8:39 AM to 9:18 AM with EI # 6, MHT who was on duty 5/8/15 on the 7-3 shift. EI # 6 confirmed she/he completed 5 minute observations entries and documented MHT progress note entries from 7:45 AM to 2:00 PM. EI # 6 reported the MHT staff attempted to keep the patient from harming himself and others and were attempting to get a plastic bottle away from the patient. EI # 6 reported the patient had "hit me in the face". EI # 6 reported the patient was on his/her back or on either side in a physical hold for about 4-5 minutes by two MHT's, EI # 7 and EI # 9. EI # 6 reported the patient was in the physical hold before the 2 RN's gave the patient a "shot" (injection), then the patient was released. A few minutes later the MHT's called for help as it looked like the patient wasn't breathing. According to EI # 6, a code blue was called.

The surveyor asked EI # 6 if staff document all physical holds in the medical record? EI # 6 responded, "yes."

In an interview on 12/21/17 at 10:06 AM, EI # 7, Lead MHT, confirmed he/she was on duty 5/8/15 on the 7-3 shift. EI # 7 reported he/she assisted EI # 9, MHT, who was assigned to the patient that shift. EI # 7 reported the patient had psychotic behaviors, threatening patients and staff and made a weapon out of a plastic bottle. EI # 7 reported PI # 1 jumped from the bed with the homemade weapon, the nurse entered the room and gave PI # 1 a shot while he/she and the MHTs held PI # 1 on the floor in a therapeutic hold for about 10-15 minutes, on his/her stomach on the floor, arms extended, EI # 7 and EI # 9 on either side. When PI # 1 was calm and was talking to the MHT's, they exited the room.

EI #7 reported to the surveyor staff was required to document a physical hold in the patient's medical record. EI # 7 responded "someone should have done that, a restraint was performed."

EI # 7 reported EI # 13, MHT who was assigned to the adolescent unit on 5/8/15 on 7-3 shift and had responded to the "show of force" for PICU returned to the patient's room a few minutes later and reported to the nurse the patient was not breathing, the code blue was called.

In an interview on 12/21/17 at 10:42 AM, EI # 8, Assistant Director of Nursing, then PICU Unit Nurse Manager. EI # 8 reported she/he completed the patient admission on 5/7/15 and she/he entered the unit while the code was in progress on 5/8/15. EI # 8 confirmed she/he completed the incident report on 5/8/15 to "basically close up the chart" following the patient condition change.

Review of the incident report completed 5/8/15 2:00 PM revealed EI # 8 documented the injury type, loss of consciousness. There were no documented physical injuries, no documentation of a staff/patient physical confrontation, no documentation a physical restraint was used prior to the patient condition change and no documentation of chemical restraint use (unscheduled medications). EI # 8 reported the documentation was not an investigation of the incident, that was done by the Risk Manager.

In an interview on 12/21/17 at 10:58 AM, EI # 3, Utilization Management Director and Licensed Professional Counselor reported she/he was the Risk Manager (RM) during the events of 5/8/15. EI # 3 reported as the RM, duties included investigation of all facility incidents. EI # 3 reported she/he responded to the code, interviewed staff including the RN and MHT assigned to PI # 1's care. EI # 3 reported afterwards video and digital photography were reviewed of the patient room (requested and not provided to surveyor) and the death investigation was completed on May 28, 2015. A Root Cause Analysis (RCA) was conducted. EI # 3 was asked by the surveyor if the fact the patient was in restraints was discussed in the RCA meeting, EI # 3 reported "I don't recall it came up, I knew the patient was in restraints, I didn't think it was necessary and relevant to the fact the patient expired."

During the interview on 12/21/17 at 10:58 AM, EI # 3 confirmed she/he failed to complete the Form CMS- and notify CMS about the patient death following use of a restraint. EI # 3 reported she/he was relieved of Risk Manager duties in September 2015.

Review of the Form CMS- , Report of a Hospital Death Associated with Restraint or Seclusion completed by the facility on 10/16/17 revealed documentation a physical restraint (therapeutic hold) was performed "within 1 week..."

The documentation above submitted to CMS on 10/16/17 contained inaccurate information as the patient death occurred within 24 hours of removal of restraint.

Facility staff failed to ensure PI # 1 was safe from self injurious harm, that nurse assessments were performed after injuries documented and all patient/staff incidents were documented in the facility HPS report. There was no medical record documentation staff placed the patient in a physical restraint minutes prior to a code blue and no documentation the facility death investigation included accurate facts that the patient was in a physical restraint minutes prior to a code blue.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital Seclusion/Restraint for Patients policy and procedure, Restraint and Seclusion log, medical records (MR), death investigation documentation, facility video review and staff interviews, it was determined the hospital failed to follow its own policy for use of restraint and document that a patient had been placed in a physical restraint.

This affected Patient Identifier (PI) # 1, 1 of 1 death record reviewed with a patient placed in a physical restraint. This had the potential to negatively affect all patients treated at the psychiatric hospital.

Findings include:

Subject: Seclusion/Restraint for Patients
Policy: X-0.0005
Revised Date: 06/14

1. Policy
Policy Statement:
Patients are assessed upon admission and... a continual basis throughout their hospitalization at Hill Crest Behavioral Health Services (HCBHS) for behaviors... potentially dangerous to self and others. Seclusion and Restraint (S/R) use is implemented as a last resort to ensure safety of patients and others. S/R shall not be used in place of appropriate mental health treatment. S/R must not result in harm or injury to the patient or others during an emergency safety situation.

Restraint:
Physical Restraint/Hold:
Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body...only used when there is immediate/imminent risk of harm to patients or others and all less restrictive treatment alternative...unsuccessful. Therapeutic physical intervention/hold is used a Hill Crest Behavioral Health Services for a substitution of the word restraint...

Scope:
All clinical staff.

Procedure:

14. The RN/MHT (mental health technician) demonstrates through their documentation in the patients chart... interventions that protects the patient's safety... Documents S/R information on the Seclusion/Restraint Clinical Note... condition or symptoms... detailed description of the patient's physical and mental status and an assessment of any environmental factors... contributed to the situation at... intervention... Ensures that S/R information is documented on the Seclusion/Restraint Log.
Assessed the patient's medical and psychological status and readiness for discontinuation... Documents... response to intervention used... Ensures... Seclusion/Restraint Patient/Staff Debriefing form is completed is completed within 24 hours of patient release... filed in... chart.


1. PI # 1 was admitted on [DATE] with a diagnosis of Schizophrenia and Alcohol Abuse. PI # 1's medical history revealed Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Stage 3 (1-6, 6 is end stage).

Medical record documentation by the Mental Health Technicians (MHT) revealed the patients' behaviors, aggression, assaultitive and combative, cursing spitting and threatening on 5/8/15 and at 1:45 PM the patient talked to social worker and retreated to patient room when approached by staff.

Medical record review revealed on 5/8/15 at 1:30 PM, RN documentation the patient was jumping on bed, swinging a home-made object at MHTs and acting out since 7:30 AM. The documentation revealed IM (intramuscular) Benadryl 50 mg (milligram), Haldol 5 mg and Thorazine 100 mg was administered by the RN at 1:50 PM. At approximately 2:00 PM, the patient was found unresponsive by MHT staff according to RN documentation.

The surveyors requested and reviewed the facility video documentation provided by Employee Identifier (EI) # 2, Director of Risk Management on 12/20/17 at 1:45 PM. Observations included 4 MHT and 2 RN 's (RN's no longer employed) enter and exit PI # 1's patient room prior to and around the time PI # 1 was found unresponsive.

Interviews were conducted with the MHT staff, EI's # 6, # 7 and # 9 on 12/21/17 between 8:30 AM and 10:30 AM. All MHT's reported they were on duty on 5/8/15 and assisted with PI # 1's care. EI # 6, # 7 and # 9 reported to the surveyors because of threatening behaviors, the patient had been placed in a physical restraint within minutes prior to being found unresponsive.

Review of the facility death investigation documentation revealed one RN, EI # 16 on duty and assisted with PI # 1's care completed a written statement of the events which documents the "...Patient Care Techs (technicians) had to restrain pt (patient)..."

Review of the facility Restraint and Seclusion log failed to include documentation that PI # 1 was placed in a physical restraint between 1:30 PM and 2:00 PM on 5/8/15.

There was no documentation in the medical record the patient was restrained.

In an interview on 12/21/17 at 3:00 PM, EI # 1, Director of Nursing confirmed the above finding.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital Seclusion/Restraint for Patients policy and procedure, medical records, facility video review, death investigation documentation and staff interviews, it was determined the hospital failed to follow its own policy for use of restraint, specifically a physical hold restraint, which included obtaining a physician's order for a patient restraint.

This affected Patient Identifiers' (PI) # 1, 1 of 4 records reviewed for patients who required restraints. This had the potential to negatively affect all patients treated at the psychiatric hospital.

Findings include:

Subject: Seclusion/Restraint for Patients
Policy: X-0.0005
Revised Date: 06/14

1. Policy
Policy Statement:
Patients are assessed upon admission and..a continual basis throughout their hospitalization at Hill Crest Behavioral Health Services (HCBHS) for behaviors... potentially dangerous to self and others. Seclusion and Restraint (S/R) use is implemented as a last resort to ensure safety of patients and others. S/R shall not be used in place of appropriate mental health treatment. S/R must not result in harm or injury to the patient or others during an emergency safety situation.

Philosophy ...HCBHS promotes a violence and coercion-free treatment philosophy... S/R should not cause undue physical discomfort, harm, or pain to the patient... S/R procedures... considered to be unusual, high risk events... warrant timely assessment and continuous monitoring... The Risk Manager, along with each unit manager reviews and monitors each episode, provides an educational resource for hospital staff, and makes recommendations related to opportunities for reduction of seclusion/restraint...

Restraint:
Physical Restraint/Hold:
Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body... Therapeutic physical intervention/hold is used a Hill Crest Behavioral Health Services for a substitution of the word restraint...

Scope:
All clinical staff.

Procedure:
3. The RN (Registered Nurse) and unit staff implement the least restrictive, non-physical interventions... utilizing patient identified preferred de-escalation preferences... including Redirecting... de-escalation, Separating patient from group or community, Engaging the patient in 1:1 (one on one)...offering food or drinks... Administering medications as ordered by physician... Documents the alternative attempted...

4. The Physician/RN assessed the need for restrictive intervention and a written or telephonic order is obtained from the physician for the S/R Order form as follows:
Adults 18 and older up to 1 hour
...The physicians' orders specify the reason for restraint... usage, the type of restraint, specific behaviors required to terminate the S/R, and their duration... The length of the S/R is limited by the continued need... rather than the length of the order; the name of the ordering physician is included... the date and time the order was obtained... In an emergency, the Clinical staff may initiate a seclusion/restraint as a protective measure provided that a physician order is obtained as soon as possible, but no longer that 1 hour after the initiation of the seclusion/restraint.

1. PI # 1 was admitted on [DATE] with a diagnosis of Schizophrenia and Alcohol Abuse. PI # 1's medical history revealed Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Stage 3 (1-6, 6 is end stage).

Medical record documentation by the Mental Health Technicians (MHT) revealed the patients' behaviors, aggression, assaultive and combative, cursing spitting and threatening on 5/8/15 and at 1:45 PM the patient talked to social worker and retreated to patient room when approached by staff.

Medical record review revealed on 5/8/15 at 1:30 PM, RN documentation the patient was jumping on bed, swinging home-made object at MHTs and acting out since 7:30 AM. The documentation revealed IM (intramuscular) Benadryl, Haldol and Thorazine was administered by the RN at 1:50 PM. At approximately 2:00 PM, the patient was found unresponsive by MHT staff according to RN documentation.

The surveyors requested and reviewed the facility video which was provided by Employee Identifier (EI) # 2, Director of Risk Management on 12/20/17 at 1:45 PM. Observations included 4 MHT (EI # 6, EI #7, EI # 9 and EI # 13) and 2 RNs (RN's no longer employed) enter and exit PI # 1's patient room prior to and around the time PI # 1 was found unresponsive.

Interviews were conducted with the MHT staff, EI's # 6, # 7 and # 9 on 12/21/17 between 8:30 AM and 10:30 AM. All MHT's reported they were on duty on 5/8/15 and assisted with PI # 1's care. EI # 6, # 7 and # 9 reported to the surveyors because of threatening behaviors, the patient had been placed in a physical restraint within minutes prior to being found unresponsive.

Review of the facility death investigation documentation revealed one RN, EI # 16 on duty who assisted with PI # 1's care completed a written statement of the events which documents the "...Patient Care Techs (technicians) had to restrain pt (patient)..."

There was no MHT or nursing documentation in the medical record the patient was restrained and no physician order for restraint/physical hold.

In an interview on 12/21/17 at 3:00 PM, EI # 1, Director of Nursing confirmed the above findings, staff failed to comply with facility policy for patient restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital Seclusion/Restraint for Patients policy and procedure, medical records, and staff interviews, it was determined the hospital failed to follow its own policy for use of restraint and document results of 5-minute patient observations during patient restraint.

This affected Patient Identifiers' (PI) # 2, # 5 and # 9, 3 of 4 records reviewed for patients who required restraints. This had the potential to negatively affect all patients treated at the psychiatric hospital.

Findings include:

Subject: Seclusion/Restraint for Patients
Policy: X-0.0005
Revised Date: 06/14

1. Policy
Policy Statement:
Patients are assessed upon admission and... a continual basis throughout their hospitalization at Hill Crest Behavioral Health Services (HCBHS) for behaviors... potentially dangerous to self and others. Seclusion and Restraint (S/R) use is implemented as a last resort to ensure safety of patients and others... must not result in harm or injury to the patient or others during an emergency safety situation.

Philosophy... HCBHS promotes a violence and coercion-free treatment philosophy... S/R should not cause undue physical discomfort, harm, or pain to the patient... S/R procedures... considered to be unusual, high risk events... warrant timely assessment and continuous monitoring...

Restraint:
Physical Restraint/Hold:
Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body... only used when there is immediate/imminent risk of harm to patients or others and all less restrictive treatment alternative... unsuccessful. Therapeutic physical intervention/hold is used a Hill Crest Behavioral Health Services for a substitution of the word restraint...

Scope:
All clinical staff.

Procedure:
8. If physical restraint is indicated, 2 staff must participate in the physical hold application...

11. Nurse/designee assigns a staff member, competent in CPR (cardiopulmonary resuscitation) and non-violent crisis intervention... to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode...

12. Assigned staff conducts 5-minute patient observation on the Seclusion/Restraint Hourly Flow Sheet that includes the following:
Reviews for signs of injury related to restraint application
Evaluates patient behavior, staff interventions and patient responses
Evaluates for breathing
Monitors for circulation and skin integrity
...Obtains vital signs
Notifies RN (Registered Nurse) of any changes in physical or psychological status/comfort needs...







1. PI # 2 was admitted on [DATE] with a diagnosis of Paranoid Schizophrenia.

Review of Nurses' Progress Note documentation dated 6/29/15 revealed at 3:20 PM the patient was agitated, combative and assaultive toward staff. At 3:40 PM the nurse documented patient retained per policy for his/her safety due to harm to self and others. At 3:45 PM (20 minutes after restraint initiated), the nurse documented patient released from restraint and offered liquids.

There was no documentation staff monitored the patient every 5 minutes during the 25 minute period. There was no documentation of patient observations for signs of injury related to restraint application, evaluation of breathing, monitoring of circulation, skin integrity and no vital signs were documented every 5 minutes per facility policy.

In an interview on 12/21/17 at 3:07 PM, Employee Identifier (EI) # 1, Director of Nursing confirmed the above findings.

2. PI # 5 was admitted to the facility on [DATE] with the diagnosis of Bipolar Disorder.

Review of the MR revealed a physician's order on 9/28/17 at 2:00 PM which stated: "Restrain pt (patient) up to 1 hour to prevent harm to self and others. Release pt when no longer attempting to harm self or others."

Further review of the MR revealed a Seclusion/Restraint Record dated 9/28/17 at 1:50 PM. The documentation on the record revealed "...staff had to physically restrain pt from 1350 (1:50 PM) 1400 (2:00 PM) ." There was no documentation during the physical hold/restraint PI # 5 was monitored every 5 minutes for injury, behavior, breathing, circulation and skin integrity.

Review of the MR revealed a physician's order dated 10/18/17 at 2:00 PM which stated: "Restrain patient for up to 1 hour for attacking staff. Release patient when she/he is no longer combative."

Review of the Hill Crest Behavioral Health Services Seclusion/Restraint Log revealed on 10/18/17 PI # 5 was restrained from 1:45 PM to 1:55 PM. There was no Seclusion/Restraint record documentation the patient was monitored every 5 minutes for injury, behavior, breathing, circulation and skin integrity.

During an interview on 12/21/17 at 3:15 PM with EI # 1, the above findings were confirmed.

3. PI # 9 was admitted to the facility on on 9/19/17 with the diagnoses of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder.

Review of the MR revealed a physician's order dated 10/23/17 at 10:00 AM which stated: "Restrain patient for up to 1 hour to prevent harm to self and others. Release when patient no longer threatening or aggressive towards others."

During an interview on 12/21/17 at 2:05 PM, EI # 14, Registered Nurse, stated the order date was incorrect, and should read 10/25/17.

Further review of the MR revealed a Seclusion/Restraint Record dated 10/25/17, which documented PI # 9 was restrained from 10:00 AM to 10:20 AM. There was no documentation the patient was monitored every 5 minutes for injury, behavior, breathing, circulation, and skin integrity.

Further review of the MR revealed a physician's order dated 10/31/17 at 2:30 PM which stated: "Place pt (patient) in physical restraint for up to 1 hour to prevent harm to self/staff."

Review of the Seclusion/Restraint Record dated 10/31/17 at 2:30 PM revealed "...the patient was held in restraint for approximately 20 minutes until he/she was calm enough to be released." There was no documentation the patient was monitored every 5 minutes for injury, behavior, breathing, circulation and skin integrity.

The MR revealed a physician's order dated 12/4/17 at 3:15 PM which read: "Place patient in physical restraint for up to 1 hour to prevent harm to self and others, release when pt is no longer a threat to self and others."

A review of the progress note dated 12/4/17 at 3:15 PM, revealed the following documentation by the LPN (Licensed Practical Nurse): "...Pt remained in restraint for approximately 5 minutes after injection with a total time in restraint being 10-15 minutes total." There was no documentation PI # 9 was monitored every 5 minutes during the physical hold/restraint for injury, behavior, breathing, circulation and skin integrity.

Further review of the MR revealed a physician's order on 12/11/17 at 2:00 PM which read: "Place patient in physical restraint for up to 1 hour to prevent harm to others, harm to self and staff. Release when no longer fighting, resisting."

Review of the Seclusion/Restraint Record dated 12/11/17 at 2:00 PM revealed PI # 9 was restrained for 15 minutes. There is no documentation staff monitored the patient every 5 minutes for injury, behavior, breathing, circulation and skin integrity.

In an interview on 12/22/17 at 10:45 AM, EI # 1 confirmed the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on review of hospital Seclusion/Restraint for Patients policy and procedure, medical record (MR), and staff interview, it was determined the staff failed to follow its own policy for use of restraint, conduct and document the One Hour Face to Face Evaluation findings within one hour per policy.

This affected Patient Identifiers (PI) # 9, 1 of 4 records reviewed for patients who required restraints. This had the potential to negatively affect all patients treated at the psychiatric hospital.

Findings include:

Subject: Seclusion/Restraint for Patients
Policy: X-0.0005
Revised Date: 06/14

1. Policy
Policy Statement:
Patients are assessed upon admission and..a continual basis throughout their hospitalization at Hill Crest Behavioral Health Services (HCBHS) for behaviors... potentially dangerous to self and others. Seclusion and Restraint (S/R) use is implemented as a last resort to ensure safety of patients and others. S/R shall not be used in place of appropriate mental health treatment. S/R must not result in harm or injury to the patient or others during an emergency safety situation.

Philosophy ...HCBHS promotes a violence and coercion-free treatment philosophy...

Restraint:
Physical Restraint/Hold:
Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body... only used when there is immediate/imminent risk of harm to patients or others and all less restrictive treatment alternative... unsuccessful. Therapeutic physical intervention/hold is used a Hill Crest Behavioral Health Services for a substitution of the word restraint...

Scope:
All clinical staff.

Procedure:

13. A Physician, Qualified RN (QRN), or other Licensed Independent Practitioner as allowed by law... conducts an in-person, face to face assessment on the patient in S/R within 1 hour of initiation and documents findings on the One Hour Face to Face Evaluation...also completed to ensure... use of S/R poses no undue risk to the patient's medical or psychological well-being... Evaluates the patient's medical condition, including a complete review of systems assessment...medications, most recent lab results... Assesses the safety of patients in S/R, including the appropriate implementation... of S/R interventions...






1. PI # 9 was admitted to the facility on on 9/19/17 with the diagnoses of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder.

Review of the Seclusion/Restraint Record dated 10/31/17 at 2:30 PM revealed "...the patient was held in restraint for approximately 20 minutes until he/she was calm enough to be released."

Review of the Seclusion and Restraint One Hour Face to Face Evaluation revealed the date and time, 10/31/17 at 6:00 PM. This was three and a half hours after the restraint, not 1 hour, per facility policy.

The MR revealed a physician's order dated 12/4/17 at 3:15 PM which read: "Place patient in physical restraint for up to 1 hour to prevent harm to self and others, release when pt is no longer a threat to self and others."

A review of the progress note dated 12/4/17 at 3:15 PM, revealed the following documentation by the LPN (Licensed Practical Nurse): "...Pt remained in restraint for approximately 5 minutes after injection with a total time in restraint being 10-15 minutes total." There was no additional documentation of monitoring PI # 9 every 5 minutes, per facility policy.

The One Hour Face to Face Evaluation was recorded on 12/4/17 at 5:50 PM. This was 2 hours and 35 minutes after the restraint, not within the one hour facility policy.

In an interview on 12/22/17 at 10:45 AM, Employee Identifier (EI) # 1, Director of Nursing confirmed the above findings.
VIOLATION: PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT Tag No: A0213
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, hospital policy and procedure, hospital video observation and staff interviews, it was determined the facility failed to complete and submit a report to Centers for Medicare and Medicaid Services (CMS) of a death associated with the use of a restraint that occurred within 24 hours after the patient was removed from a restraint. In addition, the documentation submitted to CMS by the facility was inaccurate.

This affected Patient Identifier (PI) # 1, 1 of 1 record reviewed with a death associated with restraint use and this had the potential to negatively affect all patients treated at this facility.

Findings include:

Subject: Seclusion/Restraint (S/R) for Patients
Policy: X-0.0005
Revised Date: 06/14

1. Policy
Policy Statement:
Patients are assessed upon admission and on a continual basis throughout their hospitalization at Hill Crest Behavioral Health Services (HCBHS) for behaviors that are potentially dangerous to self and others... S/R must not result in harm or injury to the patient or others during an emergency safety situation.

Philosophy ...HCBHS promotes a violence and coercion-free treatment philosophy... S/R should not cause undue physical discomfort, harm, or pain to the patient... S/R procedures are considered to be unusual, high risk events that warrant timely assessment and continuous monitoring... The Risk Manager, along with each unit manager reviews and monitors each episode, provides an educational resource for hospital staff, and makes recommendations related to opportunities for reduction of seclusion/restraint...

Restraint:
Physical Restraint/Hold:
Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body... only used when there is immediate/imminent risk of harm to patients or others and all less restrictive treatment alternative... unsuccessful. Therapeutic physical intervention/hold is used a Hill Crest Behavioral Health Services for a substitution of the word restraint...

Scope:
All clinical staff.

Procedure:

...18. The Risk Manager reports any death relating to S/R use...as sentinel event.
The hospital must report the following information to CMS (Centers for Medicare and Medicaid Services):
Each death that occurs while a patient is in restraint or seclusion.
Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint... contributed directly or indirectly to a patient's death. "Reasonable to assume"...includes, but is not limited to...deaths related restriction of moment for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.

Each death referenced above must be reported to CMS by telephone no later than close of business the next day following knowledge of the patient's death. Staff must document in the patient's medical record the date and time the death was reported to CMS...

Reporting Requirement
1. Hospital must report the following deaths with restraint and seclusion directly to CMS RO (regional office) no later than close of business on the next business day following knowledge of the patient's death:

Each death that occurs while a patient is in restraint or seclusion excluding... only 2 point soft restraints....

Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion, excluding those in which only 2 point soft wrist restraints were used...

Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death, regardless of the type(s) of restraint use on the patient during this time.

2. Hospitals must record an internal hospital log or other system deaths... The log must include the information specified... the log entry must be made no later than seven days after the date of death of the patient...

****

1. PI # 1 was admitted on [DATE] with diagnosis of Schizophrenia.

Medical record documentation revealed PI # 1 was transferred to a local medical center on 5/8/15 at 3:00 PM and admitted to the critical care unit after staff found PI # 1 unresponsive.

Further medical record review revealed Progress Note documentation completed by Employee Identifier (EI) # 2, Director of Risk Management and Regulatory Compliance (DRM/RC) dated 10/16/17. The documentation contained the following "...Sufficient evidence could not be located that report of a hospital death associated with restraint or seclusion was reported to CMS at the time of its occurrence. To ensure compliance with reporting requirement, DRMC/RC submitted to CMS via email (electronic mail) on 10/16/17 at 1703 (5:03 PM) incident recorded in HCBHS internal log on 10/16/17 at 1703..."

Review of the facility documentation presented to the surveyor included the Form CMS- which contained documentation restraint information the (death occurred) "within 1 week, where restraint, seclusion or both contributed to the patient's death" and the type physical restraint used was "therapeutic holds".

The facility internal incident reporting log documentation revealed the event was logged on 10/16/17 at 5:05 PM, and the date of death was 5/9/15.

In interviews with facility staff were conducted on 12/21/17 from 8:30 AM to 10:30 AM. The Mental Health Technician'S (MHT) who surveyors observed on the facility video were in the patient's room on 5/8/15 between 1:41 PM to 2:00 PM. MHT's,EI # 6, # 9 and # 7 all reported the patient was placed in physical restraint prior to being found unresponsive around 2:00 PM on 5/8/15.

There was no medical record documentation the hospital staff placed the patient in a restraint on 5/8/15 between 1:41 PM and 2:00 PM. There was no documentation in the patient's medical record of the date and time of death.

In an interview on 12/20/17 at 3:50 PM, EI # 3, Utilization Management Director, Risk Manager at the time of the event with PI # 1, reported the facility staff was aware on Monday following the event (which was 5/11/15) the patient had expired.

On 12/27/17, a review of the acute care hospital medical records for the transferring facility confirmed the time of death was 11:30 AM on 5/9/15.

In an interview on 12/21/17 at 10:58 AM, EI # 3, Utilization Management Director reported she/he was the Risk Manager (RM) on 5/8/15. EI # 3 confirmed no report of the patient's death was sent to CMS within the required timeframe and verbalized she/he was not aware of the requirement. EI # 3 reported she/he was relieved of Risk Management duties in September 2015.

The hospital failed to report a patient death that occurred within 24 hours after the patient had been removed from restraint to CMS no later than the close of business on the next business day following knowledge of the patient's death. The information reported to CMS on 10/16/17 was inaccurate as hospital staff had placed the patient in a restraint less than 24 hours from the time of death. The CMS Form documentation indicated the patient expired within 1 week of having been restrained.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of facility documentation of the death investigation and staff interview, it was determined the hospital failed to ensure facility monitoring data to be collected as a result a death investigation was analyzed, and if needed, the facility re-evaluated patient care processes as a result of the data analysis.

This affected Patient Identifier (PI) # 1, 1 of 1 death record review. This had the potential to affect all patients treated at the facility.

Findings include:

In an interview with Employee Identifier (EI) # 2, Director of Risk Management on 12/21/17 at 7:45 AM, the surveyor requested results of the facility monitoring of physician orders following a facility death investigation completed on 5/28/15 which involved PI # 1.

On 12/22/17 at 10:30 AM, EI # 2 reported facility monitoring and data analysis documentation could not be located.

There was no documentation facility staff completed physician orders weekly random medical record audits, collected and analyzed the data and, if needed used the findings to improve patient safety following the adverse patient event.