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.

CEDAR HILLS HOSPITAL 10300 SW EASTRIDGE STREET PORTLAND, OR 97225 Dec. 13, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on interview, review of restraint training documentation for 1 of 5 hospital staff (Employee 3), and review of policies and procedures, and other documentation it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* During orientation staff did not receive training and did not demonstrate competency related to monitoring, assessment, and provision of care of patients in seclusion in accordance with hospital policies and procedures.

Findings include:

1. Refer to the deficiency cited at Tag A202, CFR 482.13(f) Patient Rights: Restraint or Seclusion. That deficiency reflects the hospital's failure to ensure Employee 3 was trained in the use of seclusion during orientation in accordance with hospital policies and procedures.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on interview, review of training documentation for 5 of 5 hospital staff (Employees 1, 2, 3, 4, and 5), review of policies and procedures, and review of other documentation it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* Staff were not trained and did not demonstrate competency in the use of seclusion; and
* Staff were not trained and did not demonstrate competency in the safe application and use of the types of restraints approved for use in the hospital.

Findings include:

1. The policy and procedure titled "Seclusion and Restraint and Seclusion" dated last revised "9/28/16" was reviewed. It stipulated:
* "The focus of these interventions is the safety of the patient and the staff."
* "All nursing and clinical staff receive training in prevention and management of aggressive behavior, the use of seclusion and restraint, strategies to minimize and/or prevent the use of seclusion and restraint, and the requirements of this policy during new employee orientation and at least annually thereafter..."
* The "Definitions" reflected "...'Mechanical Restraints': Any physical device used to restrict the movement of a portion or the entirety of a patient's body...'Anklets': Cloth or leather band around the ankle or leg secured to a stationary object. Acceptable fasteners include Velcro and buckle type devices. The device must not be secured so tightly as to cause chafing of the skin or constriction of circulation...'Wristlets': A cloth or leather band fastened around the waist or arm and secured to a stationary object. Acceptable fasteners include Velcro and buckle type devices...'Physical Hold': The application of physical body pressure by another person to the body of a patient in such a way as to limit or control the physical activity of the patient. The various techniques for prevention and management of aggressive behavior including - but not limited to - holding or containing the patient are considered forms of physical restraint...'Seclusion': is the involuntary confinement of a patient alone in a room or area away from which the patient is physically prevented from leaving...Qualified RN': An RN who has clinical knowledge/skills/experience and who has demonstrated assessment of the patient's medical or behavioral status competency in the use of restraint and the assessment of patients placed in restraint."
* The "Procedure(s) reflected "...Use of Seclusion or Restraint is limited to emergencies in which there is an imminent risk of a patient physically harming themselves, staff, or others, and in which all non-physical, less restrictive interventions have not been found to be effective."
* "During seclusion or restraint interventions the Registered Nurse is responsible (sic) reassess the patient at a minimum of every hour to...Determine if continuation of the intervention is warranted and...Assure that the patient's physiological needs are being met including but not limited to food, hydration, elimination, pain, range of motion, and circulation."
* "Staff Training/Competence...Staff demonstrate competency via demonstration of skills learned from the facility's 'Handle with Care' Program training. Skills include the following elements...use of de-escalation, mediation, self-protection and other non-physical techniques...signs of physical distress during a physical intervention...When and how to initiate an intervention...monitoring of patients in seclusion or restraint and when/how to end the intervention...management of emergency conditions, including CPR, relief of airway obstruction, and first aid...Proper documentation of interventions, including making needed adjustments to the patient's treatment plan."
* "Performance Improvement...Seclusion, Physical Restraint, and Mechanical Restraint data is collected and aggregated monthly and reported to the Performance Improvement Committee...data is reviewed quarterly at the hospital's Seclusion/Restraint Committee. Data and opportunities for improvement (if identified), are reported to the hospital's Performance Improvement Committee for on-going analysis and improvement efforts."

2. A document titled "Posey soft locking ankle and wrist restraints" dated "2018" was provided by the ADON on 11/09/2018 at 1530. He/she stated the document reflected a current list of the hospital's approved restraint devices. The document was reviewed and reflected the following:
* Approved restraint type: Posey Locking Twice-as-Tough Cuffs - Wrist Cuffs, lock on connecting strap. Wrist Cuffs, lock on connecting strap"
* "Neoprene Cuffs gentle on patient's skin."
* "Two models available: Ankle restraints are (red) and Wrist restraints are (blue) cuffs with lock on connecting strap Models (2392, 2793), and (2798, 2799)."
* "Cuffs adjust to fit most limb sizes. Ankle cuffs may also be used on larger wrists."
* "Machine washable."
The restraints identified on the list of approved restraints were inconsistent with the restraints identified in the hospital's policy and procedure in finding 1. For example, the policy and procedure referenced arm, leg and leather band restraints. Whereas, the list of approved restraints did not include arm, leg, and leather band restraints.

3. During an interview with the DON on 11/09/2018 at 1530, he/she confirmed finding 2.

4. Review of Manufacturer Application Instructions titled "Posey Twice-As-Tough Cuffs - Key Lock" dated 2016 provided for the approved restraints in finding 2 reflected:
* "Staff Training: Staff must have on going training and be able to demonstrate competency to use this device in accord with: Posey instructions; your facility policies; and state and federal regulations..."
* "Before Applying Any Restraint...Make a complete assessment of the patient to ensure restraint use is appropriate...A restraint must only be used in accord with the patient's individualized care plan..."
* The manufacturer instructions additionally included information related to: Indications for Use, Contraindications, Application Instructions, Adverse Reactions, Patient Monitoring, Patient Monitoring Per Facility Policy, Bed Safety, Additional Warnings, Storage and Handling, and Laundering.

5. Staff orientation and annual training materials provided were reviewed and did not include staff training and demonstrated competencies for the hospital's approved restraint types reflected in finding 2. For example
* Documentation in NEO training materials titled "Nursing Orientation RN, LPN, MHT" reflected no information related to the specific hospital approved restraint devices.
* Documentation in the "Risk Management Performance Improvement Regulatory Compliance" all staff NEO training materials provided reflected only "Seclusion/Restraint...3 Types of Restraints/Restrictive Interventions...Physical-Handle with Care Techniques...Mechanical-Last resort if physical holds do not work...Chemical-Never done at Cedar Hills Hospital." There was no information related to the hospital's approved restraint devices.
* Documentation in the annual staff training materials titled "The Handle With Care Story" dated 2006 reflected no information related to the hospital's approved restraint devices.
* Review of a restraint/seclusion competency attestation used to demonstrate restraint/seclusion training and competency reflected only "...I have been exposed to, trained, and competently demonstrated safe techniques for the use of seclusion, physical restraint, and mechanical restraint at Cedar Hills Hospital." The document included no information related to the specific hospital approved restraint devices.

Due to the unclear and inconsistent information related to the types of restraint devices approved for use at the hospital, there was no assurance staff were appropriately trained and demonstrated competency in the specific types of restraints used.

6. During an interview with the DPI on 11/09/2018 at the time of the staff training materials review, he/she confirmed finding 5.

7. Review of employee training documentation reflected the following:
* Employee 1 (Security) with hire date 03/12/2018 reflected no evidence of restraint education or demonstrated restraint competency specific to the hospital's approved restraint devices on hire.
* Employee 2 (Security) with hire date 05/14/2018 reflected no evidence of restraint education or demonstrated restraint competency specific to the hospital's approved restraint devices on hire.
* Employee 3 (RN) with hire date 01/08/2015 reflected no evidence of seclusion training on hire; and no restraint education or demonstrated restraint competency specific to the hospital's approved restraint devices, including on hire and annually.
* Employee 4 (RN) with hire date 06/12/2017 reflected no evidence of restraint education or demonstrated restraint competency specific to the hospital's approved restraint devices, including on hire and annually.
* Employee 5 (RN) with hire date 05/15/2017 reflected no evidence of restraint education or demonstrated restraint competency specific to the hospital's approved restraint devices, including on hire and annually.

8. On 11/09/2018 at the time of the employee training documentation review, the DPI and ADON confirmed the lack of restraint and seclusion training and demonstrated competencies in finding 7.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations, interviews, review of incident/event and medical record documentation for 45 of 49 patients reviewed for incident/events in the last twelve (12) months (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 and 58), review of grievance documentation for 4 of 6 patients selected from the grievance log (Patients 8, 53, 56, and 57), review of medical record documentation for 3 of 4 patients who experienced restraint or seclusion (Patients 25, 26, and 36), review of restraint training documentation for 5 of 5 staff (Staff 1, 2, 3, 4 and 5), review of policies and procedures, and review of other documentation related to safety and physical environment risk, it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

2. Refer to the findings cited under Tag A263, CFR 482.21 - CoP Quality Assessment and Performance Improvement.

3. Refer to the findings cited under Tag A385, CFR 482.23 - CoP Nursing Services.

4. Refer to the findings cited under Tag A700, CFR 482.41 - CoP Physical Environment
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on interview, review of restraint training documentation for 5 of 5 hospital staff (Employees 1, 2, 3, 4 and 5), and review of policies and procedures and other documentation, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* Staff were not trained and did not demonstrate competency in the use of first aid techniques.

Findings include:

1. The policy and procedure titled "Seclusion and Restraint and Seclusion" dated last revised "9/28/16" was reviewed. It stipulated:
* "All nursing and clinical staff receive training in prevention and management of aggressive behavior, the use of seclusion and restraint, strategies to minimize and/or prevent the use of seclusion and restraint, and the requirements of this policy during new employee orientation and at least annually thereafter..."
* "Staff Training/Competence...Staff demonstrate competency via demonstration of skills learned from the facility's 'Handle with Care' Program training. Skills include the following elements...relief of airway obstruction, and first aid..."

2. Staff orientation and annual training materials provided were reviewed and did not include staff training that addressed restraint related first aid techniques. For example:
* Documentation in NEO training materials titled "Nursing Orientation RN, LPN, MHT" reflected no information regarding restraint related first aid techniques.
* Documentation in the all staff NEO training materials provided reflected only "Seclusion/Restraint...3 Types of Restraints/Restrictive Interventions...Physical-Handle with Care Techniques...Mechanical-Last resort if physical holds do not work...Chemical-Never done at Cedar Hills Hospital." There was no information regarding restraint related first aid techniques.
* Documentation in the annual staff training materials titled "The Handle With Care Story" dated 2006 reflected no information regarding restraint related first aid techniques.
* Review of a restraint/seclusion competency attestation used to demonstrate restraint/seclusion training and competency reflected only "...I have been exposed to, trained, and competently demonstrated safe techniques for the use of seclusion, physical restraint, and mechanical restraint at Cedar Hills Hospital." The documentation included no information regarding restraint related first aid techniques.

3. Review of employee training documentation for first aid techniques related to patients who were restrained or secluded, including appropriate first aid required if a restrained or secluded patient was in distress or injured, reflected no evidence of the training for the following employees:
Employee 1 (Security) with hire date 03/12/2018.
Employee 2 (Security) with hire date 05/14/2018.
Employee 3 (RN) with hire date 01/08/2015.
Employee 4 (RN) with hire date 06/12/2017.
Employee 5 (RN) with hire date 05/15/2017.

4. On 11/09/2018 at the time of the employee training documentation review, the DPI confirmed the lack of employee first aid training in finding 3.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, interviews, review of incident/event and medical record documentation for 45 of 49 patients reviewed for incident/events in the last twelve (12) months (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 and 58), review of grievance documentation for 4 of 6 patients selected from the grievance log (Patients 8, 53, 56, and 57), review of medical record documentation for 3 of 4 patients who experienced restraint or seclusion (Patients 25, 26, and 36), review of restraint training documentation for 5 of 5 staff (Staff 1, 2, 3, 4 and 5), review of policies and procedures, and review of other documentation related to safety and physical environment risk, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* Physical environment and security measures to ensure safe care and prevent patients from inappropriate departure, or elopement, from the secured facility and from secured units were not effective. Patient 44 eloped from the hospital to a nearby freeway overpass, jumped onto the freeway below and died .
* Patients were not provided care in a safe physical environment that was free of ligature risks, unsafe items, and fire hazards.
* Patients were not supervised to ensure safe care when in high risk areas and during high-risk activities that included smoking.
* Patients were not supervised when experiencing aggressive behaviors to ensure safe care and prevent patient to patient altercations.
* Patients were not ensured safe care during medication administration.
* All components of an effective abuse prevention program were not evident, including timely and complete investigations of and response to actual or potential or alleged abuse or neglect to ensure those incidents and events did not recur.
* Restraint and seclusion requirements were not met for those patients who experienced restraint or seclusion.
* Restraints and seclusion were not implemented by staff who met the restraint and seclusion training requirements.
* Response to patient's complaints and grievances were not timely or complete.
* Patients were not informed of their rights as required.
* Medicare beneficiaries did not receive the Important Message from Medicare (IM) as required.
* Patients did not received AD information as required.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under Tags A144 and A145, CFR 482.13(c) - Standard: Privacy and Safety.

2. Refer to the findings cited under Tags A166 and A168, CFR 482.13(e) - Standard: Restraint or seclusion.

3. Refer to the findings cited under Tags A196, A202 and A206, CFR 482.13(f) - Standard: Restraint or seclusion: Staff training requirements.

4. Refer to the findings cited under Tags A117 and A123, CFR 482.13(a) - Standard: Notice of Rights.

5. Refer to the findings cited under Tag A132, CFR 482.13(b) - Standard: Exercise of Rights.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, documentation in 11 of 11 medical records reviewed for notification of patient's rights (Patients 21, 25, 26, 36, 38, 40, 41, 43, 45, 46 and 49), documentation in 5 of 5 medical records of Medicare beneficiaries reviewed for the IM (Patients 21, 36, 38, 45 and 46) and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* The written document provided to patients or their representatives contained incomplete and unclear language related to the patient's rights stipulated by the Patient's Rights COP, and documentation that patients had received information about their rights was incomplete and unclear.
* Medicare beneficiaries or their representatives did not receive the IM as required by CFR 489.27(a) and CFR 405.1205. The IM form in use was not the current and un-altered IM form, and documentation that patients received the IM information was incomplete and unclear.

Findings include:

1. a. Review of the policy and procedure titled "Rights and Responsibilities of Patients" dated as last revised 08/18/2017 reflected that "Patients at Cedar Hills are educated and informed prior to admission that they have the following rights while receiving services from the organization..." Twenty-seven (27) rights were listed as A through Z and AA. The policy and procedure included three (3) other "Rights Specific To Involuntary Patients (inpatient only)" that were listed A through C. In addition, it contained twenty-two (22) other "Rights afforded to Outpatient Clients" listed as (a) through (v). The policy and procedure contained a section titled "Patient Notification of Personal Rights" that stipulated that "Prior to admitting to a program at Cedar Hills, facility staff give the individual, guardian, and/or supporting others (as appropriate) a written document outlining and describing patient rights while receiving services from Cedar Hills...The patient and/or guardian indicates receipt of the 'Patient rights' document when they sign the 'Consent To Treatment' form at the time of admission. The patient / guardian also indicates that they understand the process for exercising their rights and for filing complaints about possible rights violations...In addition to the 'Patient Rights' handout received at admission, patients are informed of their rights and the grievance process in the Patient Handbook that all patients receive at admission."

The policy and procedure did not clearly or completely specify the rights required by CFR 482.13. Examples include:
* The right to receive care in a safe setting was not clearly addressed. The policy and procedure included "The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned." However, it was unclear what "reasonable safety" was defined as in terms of hospital practices and the environment.
* The right be free from harassment was not included.
* The right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital was not included.
* The right to safe implementation of restraint or seclusion by trained staff was not included.
* Visitation rights were not included.

b. The document titled "Your Rights As A Patient" was provided and described as the patient's rights document given to patients on admission and contained in the hospital's admission packet. It did not contain an implementation date, a review or revision date, nor did it reflect a document or version number.

The document did not clearly or completely specify the rights required by CFR 482.13. Examples include:
* The right to receive care in a safe setting was not clearly addressed. The document included "...you...have the right to...a humane treatment environment that affords reasonable protection from harm..." It was unclear what "reasonable protection from harm" was defined as.
* The right be free from harassment was not included.
* The right to file a complaint or grievance and to be informed who to file a complaint or grievance with. The "Patient Rights and Responsibilities" document provided with the "Your Rights As A Patient" document contained a list of five agencies to contact to file a complaint. For the CMS SA it reflected "To report concerns or complaints to the State of Oregon - Oregon Department of Healthcare Licensing and Certification...800 NW Oregon Street Suite 305..." The name and the address of the CMS SA were incorrect.
* The right to formulate an advance directive was not included.
* The right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital was not included.
* The right to personal privacy was not included.
* The right to the confidentiality of his or her clinical records was not included.
* The right to be free from restraint and seclusion was not included.
* The right to safe implementation of restraint or seclusion by trained staff was not included.
* Visitation rights were not complete and were identified as only "...you...have the right to...visit with family members, friends, advocates and legal / medical professionals."

c. Review of patient medical records reflected:

* Patient 21 was admitted on [DATE] at 2147. Although the patient signed the "Consents and Conditions of Treatment" form and initialed the receipt of the patient rights document on the form, the patient had not been informed of his/her rights as a hospital patient as the patient's rights form was incomplete and unclear as identified in #1.b. above in this deficiency. In addition, the date and time spaces next to the patient's signature were blank.

* Patient 25 was admitted on [DATE] at 1442. Although the patient signed the "Consents and Conditions of Treatment" form on 08/16/2018 at 1507 and initialed the receipt of the patient rights document on the form, the patient had not been informed of his/her rights as a hospital patient as the patient's rights form was incomplete and unclear as identified in #1.b. above in this deficiency.

* Patient 26 was admitted on [DATE] at 2335. The date on which the patient signed the "Consents and Conditions of Treatment" form was illegible.

* Patient 36 was admitted on [DATE] at 2356. The patient signed the "Consents and Conditions of Treatment" form on 09/09/2018 at 1800 and initialed the receipt of the patient rights document on the form. However, the documentation was unclear as at the top of each page of the form a hand-written, undated and unsigned entry reflected "*Pt. refused to sign."

* Patient 38 was admitted on [DATE] at 2047. The patient had not initialed receipt of the patient's right document on the "Consents and Conditions of Treatment" form. Although a patient's signature was noted in the signature space of the form the last name did not match the last name of Patient 38 and the date and time spaces next to the signature were blank.

* Patient 40 was admitted on [DATE] at 2310. Although the patient's legal guardian had signed the "Consents and Conditions of Treatment" form on 09/24/2018 at 2300 and initialed the receipt of the patient rights document on the form, the guardian had not been informed of the patient's rights as a hospital patient as the patient's rights form was incomplete and unclear as identified in #1.b. above in this deficiency.

* Patient 41 was admitted on [DATE] at 1758. The "Consents and Conditions of Treatment" form was blank and not signed or initialed by the patient or by a legal guardian.

* Patient 43 was admitted on [DATE]. Although the patient signed the "Consents and Conditions of Treatment" form on 10/04/2018 at 1300 and initialed the receipt of the patient rights document on the form, the patient had not been informed of his/her rights as a hospital patient as the patient's rights form was incomplete and unclear as identified in #1.b. above in this deficiency.

* Patient 45 was admitted on [DATE] at 2339. Although the patient signed the "Consents and Conditions of Treatment" form on 10/25/2018 at 1156 and initialed the receipt of the patient rights document on the form, the patient had not been informed of his/her rights as a hospital patient as the patient's rights form was incomplete and unclear as identified in #1.b. above in this deficiency.

* Patient 46 was admitted on [DATE] at 1859. The patient signed the "Consents and Conditions of Treatment" form on 10/25/2018 at 1845 and initialed the receipt of the patient rights document on the form. However, there was no documentation to reflect why the patient didn't receive written notice of rights prior to admission, two days earlier. In addition, the patient had not been informed of his/her rights as a hospital patient as the patient's rights form was incomplete and unclear as identified in #1.b. above in this deficiency.

* Patient 49 was admitted on [DATE] at 1944. The "Patient Signature" line on the "Consents and Conditions of Treatment" form was blank.

2. a. The policy and procedure titled "Important Message from Medicare, IP" dated as last reviewed 03/10/2017 reflected "Cedar Hills Hospital complies with the requirements of the CMS IMPORTANT MESSAGE FROM MEDICARE and the DETAILED NOTICE OF DISCHARGE...Patients are given no more than two days and at least four hours prior to discharge to consider whether or not they want to appeal. Routine delivery of the second notification during the rush to make discharge arrangements must be avoided...Medicare beneficiaries are given the initial [IM] on admission and the follow up [IM] in writing, as soon as possible when the discharge is planned (not more than two days before discharge). Patients must sign the documents and receive a copy of the signed documents...On admission, patients are given the [IM]...The signature of the beneficiary (or representative) on the form must be obtained at that time. The patient must receive a copy of the document at the time of signing...A second notification [IM] must be given to the beneficiary...not more than two days prior to discharge, this will be a new [IM] signed by the patient or patient's representative. The patient must have at least four hours to consider and review the [IM] prior to discharge...The second notification also requires the patient (or representative) signature. The patient must receive a copy of the signed document...If the patient does not receive the [IM] upon admission (due to severity of medical condition, etc), the patient or representative must receive, sign the [IM], and receive a copy within two calendar days of admission."

b. Review of the "CMS.gov" webpage titled "Hospital Discharge Appeal Notices" stipulated that the IM form "CMS-R-193 (Exp. 03/31/2020)" was the current form in effect. Previous "CMS.gov" information reflected that all hospitals were required to begin using the current form effective "60 days from June 29, 2017." The "Completing The Notice" section of the form required that the patient's full name, an ID number that identifies the patient, and the patient's physician name be recorded on the form.

c. Review of patient medical records reflected:

* Patient 21 was a Medicare beneficiary admitted on [DATE] at 2147 and discharged on [DATE] at 1720. Only one page of the two-page IM form, outdated version CMS-R-193 (approved 07/10), was provided. The form did not include the patient's middle name or initial as part of a full name, a patient ID number or the patient's physician name. The documentation did not reflect that the patient or representative signed, dated and received a copy of the form within two days of admission. Initials that did not match the patient's first and last name were recorded on the signature line and the "Date/Time" space was blank. In addition, there was no evidence that a second notification had been signed and a copy provided in advance of discharge, but not more than two calendar days before the discharge.

* Patient 36 was a Medicare beneficiary admitted on [DATE] at 2356 and discharged on [DATE] at 1207. Only one page of the two-page IM form, outdated version CMS-R-193 (approved 07/10), was provided. The form did not include the patient's middle name or initial as part of a full name or the patient's physician name. The documentation did not reflect that the patient or representative signed, dated and received a copy of the form within two days of admission. The signature line was covered with a label that denoted only "NMI" and the "Date/Time" space was blank. At the top of the form was a handwritten, undated and unsigned entry that read "*Pt refused to sign." In addition, there was no documentation to reflect that the patient had been presented with a copy of a signed IM form in advance of discharge, but not more than two calendar days before the discharge.

* Patient 38 was a Medicare beneficiary admitted on [DATE] at 2047 and discharged on [DATE] at 1417. Only one page of the two-page IM form, outdated version CMS-R-193 (approved 07/10), was provided. The form did not include the patient's middle name or initial as part of a full name, a patient ID number or the patient's physician name. The documentation did not reflect that the patient or representative signed, dated and received a copy of the form within two days of admission. The signature line was covered with a label that denoted only "NMI" and the "Date/Time" space was blank. At the top of the form was a handwritten, undated and unsigned entry that read "*Pt refused to sign." In addition, there was no documentation to reflect that the patient had been presented with a copy of a signed IM form in advance of discharge, but not more than two calendar days before the discharge.

* Patient 45 was a Medicare beneficiary admitted on [DATE] at 2339 and discharged on [DATE] at 1236. Only one page of the two-page IM form, outdated version CMS-R-193 (approved 07/10), was provided. The form did not include the patient's physician name. The documentation did not reflect that the patient or representative signed, dated and received a copy of the form within two days of admission. A signature was recorded and only a date was recorded in the "Date/Time" space. There was no documentation to reflect that the patient had been presented with a copy of the signed IM form in advance of discharge, but not more than two calendar days before the discharge.

* Patient 46 was a Medicare beneficiary admitted on [DATE] at 1859 and discharged on [DATE] at 1354. Only one page of the outdated two-page IM form, version CMS-R-193 (approved 07/10), was provided. The form did not include the patient's middle name or initial as part of a full name, a patient ID number or the patient's physician name. The documentation did not reflect that the patient or representative signed, dated and received a copy of the form within two days of admission. The signature line was covered with a label that denoted only "NMI" and the "Date/Time" space was blank. At the top of the form was a handwritten, undated and unsigned entry that read "*Pt refused to sign." In addition, there was no documentation to reflect that the patient had been presented with a copy of a signed IM form in advance of discharge, but not more than two calendar days before the discharge.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview, review of grievance documentation for 4 of 6 patients selected from the grievance log (Patients 8, 53, 56 and 57), and review of policies and procedures, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* A written grievance notice that contained the required elements including the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was not provided to each patient/patient representative who filed a complaint or grievance with the hospital.

Findings include:

1. The hospital policy and procedure titled "Patient and Family Grievances/The Role of the Patient Advocate" dated as last revised "10/16" reflected:
* "...Cedar Hills Hospital...will provide an effective mechanism for timely, reasonable, and consistent resolution of patient/family grievances as an important part of providing quality care and service to our patients...Grievances will be documented and all timelines met per policy."
* "...It is the responsibility of each staff member to respond promptly to any concern or grievance voiced by patients and their families no matter how trivial the complaint may be. The staff member receiving the complaint should notify his/her supervisor when the issue cannot be immediately resolved...If a patient concern cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, then the complaint is a grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf...Complaints received in written form, abuse or neglect, issues related to Cedar Hill's compliance with the CMS Hospital Conditions of Participation (CoPs)...will be forwarded directly to the Patient Advocate or designee who should delegate investigation to the appropriate staff members. If a complaint received is from legal counsel or regulatory authority, it should be referred to Corporate Risk Management or Legal Department for appropriate action...A written complaint is always considered a grievance. This includes written complaints from an inpatient, an outpatient, a released/discharged patient, or a patient's representative regarding the patient care provided, appeals of treatment decisions, abuse or neglect, or the hospital's compliance with CoPs. An email or fax is considered 'written'."
* "...All verbal or written complaints regarding abuse, neglect, patient harm, or compliance with CMS requirements are considered grievances and are responded to immediately."
* "...If the concern/complaint issue cannot be resolved with staff present, if the patient contacts the patient advocate directly, if the grievance is written, or if the grievance is regarding abuse or neglect issues related to the Cedar Hill's compliance with the CMS Hospital Conditions of Participation...patient will have access to the following persons to facilitate immediate resolution of the grievance: Patient Advocate, Medical Director...and/or CEO."
* "...All grievances, investigations, and outcomes will be documented on the Grievance Form."
* "...Each patient, patient representative and/or family member voicing a grievance will receive a response from the facility that addresses the complaint in a timely manner..."
* "...The grievance resolution/follow up will be documented completely and accurately in a timely manner as follows...The first respondent to the grievance will document the date and time the patient was seen and the steps immediately taken to resolve the grievance...The grievance form will be forwarded to the Patient Advocate within 24 hours...The Patient Advocate will respond to the patient within 1 working day of receiving the Grievance Form and document additional investigations and outcomes; then, draft a written notice to the patient...The written notice will be sent to the patient within 7 days of the grievance and will include the Written Notice documentation stated above...If not resolved within 7 days, another decision letter will be sent within 30 days...This documentation will include...Name of person voicing a grievance/how to contact...Patient name and record number...Nature of Grievance...Pertinent Investigational Information...Resolution of Grievance/Follow Up...Signature of all staff addressing the grievance...Written notice of the facility's decision contains...The name of the facility contact person...The steps taken on behalf of the patient to investigate the grievance...The results of the grievance process...The date of completion."
* "...Performance Improvement activities...Documentation will be forwarded to the Program Directors or designated staff member for review to implement improvement actions...This information should be forwarded at least quarterly to the Risk Manager/PI Director for integration in Risk Management/Performance Improvement Program...Trends should be identified and addressed as indicated...'Complaints' will be tracked, trended, and reported along with 'grievances'..."
* "...The Patient Advocate is selected by the CEO or designee...Patient Advocate responsibilities...Responds to patient/family grievances promptly...Investigates grievances within 1 working day of receiving the Grievance Form and assists in providing resolution of the issue utilizing facility resources...Note: Any verbal or written grievance regarding abuse, neglect, patient harm, or patient rights will be addressed by the DON and/or Administrator on Call immediately and will not wait until the next working day...Reports to the CEO or designee about grievances, investigations and results on an ongoing basis...Maintains a log or file of grievances and complaints for tracking and trending. Shares this information with the Performance Improvement Committee at least quarterly or as otherwise appropriate."

2. Patient 57: Grievance log documentation for the patient was reviewed and reflected the "Date of Complaint" was 10/22/2018 and the "Intervention Date" was 10/23/2018. The grievance was categorized as "Patient Care." The "Complaint Details" reflected "Pt states [he/she] has not met with case worker and met with MD 2 days late. Also had complaints regarding HIPPA in relation to provider/patient conversations being held in patient bedrooms and hallways..." The undated "Resolution Details" entry reflected "Informed care team of patient's complaints and they will follow up. Will meet with patient for second check in. 7 Day Letter due."

There was no documentation reflecting the hospital contacted or attempted to contact the patient either verbally or in writing after 10/22/2018, including no written notice of follow-up investigation and resolution submitted to the patient as required by the hospital's grievance policy and procedure.

3. Patient 8: Grievance log documentation for the patient was reviewed and reflected the "Date of Complaint" and "Intervention Date" was 02/26/2018. The grievance was categorized as "Rights." The "Complaint Details" reflected "Pt called stating that [his/her] rights have been violated several times. The "Resolution Details" reflected "PA has not been able to contact pt...will you please speak with [him/her]? 2/27/18 - I...spoke with [physician] regarding this patient. [He/she] said that the patient is wanting to be on a different unit. [He/she] eloped recently and is now on a hold. Due to [his/her] high elopement risk [he/she] can't be taken off." There was no documentation reflecting the hospital contacted or attempted to contact the patient either verbally or in writing after 02/27/2018, including no documentation reflecting a written notice of follow-up investigation and resolution submitted to the patient. Refer to Tag A144, 2.b., for the findings related to Patient 8's elopement and lack of investigation to prevent recurrence.

4. Patient 56: Grievance log documentation for the patient was reviewed and reflected the grievance was submitted by the patient. The "Date of Complaint" was 08/28/2018 and the "Intervention Date" was 08/29/2018. The grievance was categorized as "Lost Belonging." The "Complaint Details" reflected "Patient called multiple staff members stating that [his/her] acordian (sic) file folder with important documents went missing. This included [his/her] original birth certificate, social security card, housing documents, storage key..."

The undated "Resolution Details" reflected "Multiple staff members searched...and could not locate the item. PA called the patient to let [him/her] know that it hadn't been found and get more information. Pt informed PA that [he/she] had contacted the police and multiple agencies about this grievance..." There was no documentation reflecting a written notice of follow-up investigation and resolution was submitted to the patient.

5. Patient 53: Grievance log documentation for the patient was reviewed. The "Date of Complaint" was 04/28/2018 and the "Intervention Date" was 05/02/2018. The grievance was categorized as "Clinical Care." The "Complaint Details" reflected "Pt claimed that an RN...dropped pt on floor. Pt also claimed [he/she] was threatened with no visitation access if [he/she] did not fully cooperate..."

A written response submitted to the patient in response to the grievance, was reviewed. The written response was dated 05/08/2018, 10 days after the "Date of complaint." There was no documentation reflecting that the patient was provided a written notice within 7 days in accordance with the hospital's policy and procedure.

6. During an interview with the DPI on 11/09/2018 at the time of the grievance documentation review, he/she confirmed findings 2, 3, 4 and 5.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, documentation in 7 of 9 medical records of patients reviewed for AD information (Patients 26, 36, 38, 41, 43, 46 and 49) and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* Documentation to reflect whether patients had formulated an AD, were provided AD information, and compliance with all aspects of AD requirements was incomplete and unclear.

Findings include:

1. Review of an undated document titled "Your Rights As A Patient," referred to as 'Patient Bill of Rights' in finding 3 below, reflected it failed to include the patient's right to formulate advance directives and to have hospital staff and practitioners who provided care in the hospital comply with those directives. Refer also to the findings under Tag A117, at 1.b., that described the omissions contained in the patient's rights document provided to patients.

2. Review of the policy and procedure titled "Advance Directives" dated as revised "12/2014" reflected "The Advance Directive Acknowledgment Form is a permanent part of the medical record...At the time of admission, the Admission Counselor will give the patient written information concerning his or her right...to accept or refuse treatment and the right to formulate advance medical directives. The written information will include...An Advance Medical Directives Acknowledgement Form which contains a summary of the facility policy on advance medical directives. A copy of patient's rights...Upon admission, the attending physician and the unit / program nurse reviews the medical record to ascertain whether the patient has indicated that he or she has an advance directive..."

Although the policy indicated the patient would receive a copy of the patient's rights it was noted that the patient's rights document provided did not include the right to formulate an advance directive. In addition, the policy required that the physician and the nurse review the medical record to determine the patient's advance directive status. However, based on the findings from the records below that review had not been conducted or was not effective as the patients' advance directive status were not documented or were unclear in those cases.

3. The medical record of Patient 36 was reviewed and reflected he/she was admitted on [DATE] at 2356. The "Reason For Admission" was "Psychosis and suicidal ideation." The record was unclear, incomplete and contradictory with regard to the patient's right to formulate an advanced directive. For example:
The "Advance Directive / Healthcare Proxy Acknowledgement" form reflected:
* "I currently have an executed Advance Directive for Medical Care." This was preceded by a check mark indicating a "Yes" response.
* "I currently have an executed Advance Directive for Mental Health Treatment." This was preceded by a check mark indicating a "Yes" response.
* "I have identified a Health Care Proxy / Surrogate Decision Maker to make decisions on my behalf. If yes, name of healthcare proxy/surrogate decision maker: [line with name on it] Phone #: [line with phone number on it] Patient has a legal guardian: Name: [blank line] Phone #: [blank line]. There was no "Yes" or "No" response marked. The space for indicating a "Yes" or "No" response was blank.
* "If you answered 'yes' to any of the above, are you able to provide the facility with a copy of these Advance Directive Documents?" There was no "Yes" or "No" response marked. The space for indicating a "Yes" or "No" response was blank.
* "If you do not have an Advance Directive or Healthcare Proxy, do you wish to execute an advance directive or healthcare proxy or name a surrogate decision maker?" There was no "Yes" or "No" response marked. The space for indicating a "Yes" or "No" response was blank.
* The form had a "Patient Signature" line with a signature on it dated 09/09/2018 at 1800. However, the top of the form had an undated hand written note that reflected "*Pt. refused to sign."
* The form was signed by a staff person and dated 09/08/2018 at 0452, the day before the patient signature.
The record contained a 4-page "Consents and Conditions of Treatment" form that reflected:
* Page 1 of the form reflected "I understand that I have the responsibility to provide Cedar Hills with copies of any current 'Advance Directives' that I may have, including 'Medical' and 'Mental Health' Advance Directives. Furthermore, I acknowledge receipt of written materials concerning each type of Advance Directive and how they can be obtained." This was preceded by a line with the patient's initials handwritten on it.
"I acknowledge receipt of a copy of Cedar Hills 'Patient Bill of Rights' and that I understand that I have these rights as a patient..." This was preceded by a line with the patient's initials handwritten on it.
* Page 3 of the form had a "Patient Signature" line with a signature on it dated 09/09/2018 at 1800." However, the tops of all 4 pages of the form had an undated hand written note that reflected "*Pt. refused to sign."
* Page 4 of the form was signed by a staff "witness" and dated 09/08/2018 at 0450, the day before the patient signature.
Due to the incomplete, unclear and contradictory information, there was no assurance that the patient's right to formulate an advanced directive was upheld and that hospital staff who provided care to the patient would comply with those directives.

During an interview with the ADON on 11/09/2018 at the time of the medical record review he/she confirmed the findings for Patient 36.

4. The medical record of Patient 38 reflected he/she was admitted on [DATE]. A form titled "Advance Directive / Healthcare Proxy Acknowledgement" was incomplete as the spaces for responses to the following questions and information were blank:
* "I have identified a Health Care Proxy / Surrogate Decision Maker to make decisions on my behalf."
* "If you answered 'yes' to any of the above, are you able to provide the facility with a copy of these Advance Directive Documents?"
* "If you do not have an Advance Directive or Healtthcare Proxy, do you wish to execute an advance directive or healthcare proxy or name a surrogate decision maker?"
* "Date" and "Time" of the patient's signature.

5. The medical record of Patient 41 reflected he/she was admitted on [DATE]. A form titled "Advance Directive / Healthcare Proxy Acknowledgement" was not completed except for the "Staff Signature" line and the "Date" and "Time" space next to the staff signature.
The spaces for responses to the following questions and information were blank:
* "I currently have an executed Advance Directive for Medical Care."
* "I currently have an executed Advance Directive for Mental Health Treatment."
* "I have identified a Health Care Proxy / Surrogate Decision Maker to make decisions on my behalf."
* "If you answered 'yes' to any of the above, are you able to provide the facility with a copy of these Advance Directive Documents?"
* "If you do not have an Advance Directive or Healtthcare Proxy, do you wish to execute an advance directive or healthcare proxy or name a surrogate decision maker?"
* "Patient Signature"
* "Date" and "Time" of the patient's signature.

6. The medical record of Patient 43 reflected he/she was admitted on [DATE]. A form titled "Advance Directive / Healthcare Proxy Acknowledgement" was signed and dated by the patient on 10/04/2018 at 1300. However, the form was incomplete as the spaces for responses to the following questions were blank:
* "I currently have an executed Advance Directive for Medical Care."
* "I currently have an executed Advance Directive for Mental Health Treatment."
* "I have identified a Health Care Proxy / Surrogate Decision Maker to make decisions on my behalf."
* "If you answered 'yes' to any of the above, are you able to provide the facility with a copy of these Advance Directive Documents?"
* "If you do not have an Advance Directive or Healtthcare Proxy, do you wish to execute an advance directive or healthcare proxy or name a surrogate decision maker?"

7. The medical record of Patient 49 reflected he/she was admitted on [DATE]. A form titled "Advance Directive / Healthcare Proxy Acknowledgement" was signed and dated by the patient on either 10/13/2018 or 11/13/2018 as the month of the date was not clear. In addition, the "Time" space next to the patient's signature was blank.

8. Similar findings related to unclear, incomplete and/or contradictory information with regard to the patient's right to formulate an advanced directive was identified during review of the medical record for Patient 26 with admitted [DATE]; and Patient 46 with admitted [DATE]. During an interview with the ADON on 11/09/2018 at the time of the medical record review, he/she confirmed the findings for Patients 26 and 46.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, interviews, review of incident/event and medical record documentation for 45 of 49 patients reviewed for incident/events in the last twelve (12) months (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 and 58), review of policies and procedures, and review of other documentation related to safety and physical environment risk, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights to safe care were recognized, protected and promoted as follows:
* Physical environment and security measures to ensure safe care and prevent patients from inappropriate departure, or elopement, from the secured facility and from secured units were not effective. Patient 44 eloped from the hospital to a nearby freeway overpass, jumped onto the freeway below and died .
* Patients were not provided care in a safe physical environment that was free of ligature risks, unsafe items, and fire hazards.
* Patients were not supervised to ensure safe care when in high risk areas and during high-risk activities that included smoking.
* Patients were not supervised when experiencing aggressive behaviors to ensure safe care and prevent patient to patient altercations.
* Patients were not ensured safe care during medication administration.

Findings include:

1. Elopement prevention procedures related to facility and unit door security had not been implemented and enforced to ensure that patients received care in a safe setting and were protected from elopement and the associated safety risks.

a. During interview with the CEO and the DPI on 11/06/2018 at 1545 they provided the following information:
* New patient admission assessments are conducted in I&A rooms adjacent to the hospital's lobby. The lobby is considered "secure" as the lobby door is locked with access by electronic key fob entry 24/7. Only staff issued an electronic key fob can open the lobby front door, the secured unit doors and all other secure doors throughout the hospital. Visitors must push a buzzer on the outside of the building to enter. The door is answered and opened electronically for visitors by the receptionist when one is at the front desk, and by security after hours.
* On 10/17/2018 Patient 44 eloped from the hospital through the secure lobby front door by following a staff member out the door. Patient 44 ran down the street to the nearby freeway overpass and jumped onto the freeway below. [He/she] was taken to the hospital where he/she died .
* Patient 44 had been transferred to CHH and was in the process of admission assessment with the QMHP. Patient 44 was unattended in the unsecured I&A room #2 at times. An LPN walked through the lobby and exited the hospital through the front lobby door using his/her key fob. The LPN went through the door, "did not make sure the door was shut" behind him/her and Patient 44 ran through the lobby and through the closing door behind the LPN.
* During training staff are directed to ensure the doors are shut fully behind them. "The [LPN] did not do that."

b. The record of Patient 44 reflected he/she was transferred to the hospital from another hospital's ED on 10/17/2018 via secure transport secondary to SI. The record reflected the following:
* A "Patient Observation Rounds, IP" form reflected the patient status was "arrive 1434." The documentation reflected the patient was in I&A room #2 on 10/17/2018 at 1500, 1515, 1530, 1545, 1600, 1615, 1630, and 1645. There was no further observation documentation on the form.
* On 10/17/2018 at 1520 an RN signed and dated a "Medical Screen" form.
* On 10/17/2018 at 1603 QMHP documentation reflected a "Clinical Assessment" was initiated. The 23 page "Clinical Assessment" form was signed and dated by the QMHP at 1914 on 10/17/2018, after Patient 44's elopement and suicide. The form included the following documentation by the QMHP:
- The patient was on a mental health "hold" effective 10/16/2018.
- Under the "Reason for Admission" section of the form the patient stated "'I was getting ready to (kill self)'...Pt was intending on committing suicide on 10/16/18, plan to shoot self [with] gun or jump off a bridge...gun was taken away by [family member]. When EMS arrived Pt attempted to run in front of traffic when they were getting [him/her] into the EMS - unsuccessful attempt."
- Under the "Risk of Suicide" section of the form the patient expressed SI on 10/17/2018 and was assessed as "High Risk" secondary to "Intent/Plan to die...Clear Intent;" "Lethality of attempt or plan...Potentially Lethal Attempt;" and "Prior attempts...[less than] 6 months ago or multiple attempts."
* There was no documentation in the record after the "Clinical Assessment." There was no inpatient documentation, no discharge summary, no progress notes, and no other documentation to reflect the patient's location, status or condition.

c. Video recordings of the lobby, admission assessment area and parking lot were reviewed with the DPO on 11/06/2018 beginning at approximately 1730. The DPO indicated that the lobby, admission assessment area and parking lot were monitored by interior cameras 16 and 17, and exterior camera 18. The review of the recordings from the three cameras revealed the following sequence of events in the minutes prior to Patient 44's elopement on 10/17/2018. It was observed that the time stamps on the interior camera views were not fully synchronized. Therefore, beginning at either 1700 or at 1705, depending on the camera view, the following events were observed after Patient 44 and the QMHP had already entered the I&A room #2:
* QMHP exited I&A room #2 and entered another room with a closed door across the hall.
* Patient 44 exited I&A room #2 and unescorted and unobserved turned a corner in the direction of the public bathroom in the assessment area and is out of view of the camera.
* A staff person exited North Unit secure door into the lobby/assessment area and did not ensure the North Unit door was closed and latched behind him/her.
* Patient 44 came back into camera view and returned to I&A room #2.
* Patient 44 appeared in the doorway of I&A room #2 and stood looking out at the lobby area.
* The LPN exited North Unit secure door into the lobby/assessment area and did not ensure the North Unit door was closed and latched behind him/her.
* The LPN walked through the lobby and used the key fob to open the secure lobby front door.
* The LPN exited the building and did not ensure the secure lobby door was closed and latched behind him/her.
* Patient 44 left the doorway of I&A room #2, walked a few steps into lobby, then ran through the open secure lobby door and past the LPN into the parking lot, and continued to run in a NE direction down the street out of view of the exterior camera.
* Thereafter the video reflected that numerous staff are observed to run out of the lobby front door and some ran down the street in the same direction that Patient 44 ran.

d. On 11/06/2018 at approximately 1500 observations of the route from the hospital's front door to the nearby freeway overpass revealed that the distance between those two points was not greater than one and one/half blocks (1 1/2).

e. Review of incident/event documentation for Patient 44's elopement and suicide event on 10/17/2018 reflected the hospital initiated an investigation and immediate actions on that date. Those actions included:
* An "Immediate/Intermediate Action Plan" included that "Effective 10/17/18, education was provided to working staff related to the risk of patient's 'tailgating' behind unsuspecting staff exiting units or the building. Email communication was sent to all staff describing the risk and informing them of the expectation that they will ensure doors are fully closed behind them before proceeding on their way. Hospital managers were given the assignment to obtain a written attestation from all staff acknowledging the receipt of education about the Door Security policy."
* In an email from the CEO to "Cedar Hills Employees" dated 10/17/2018 at 2137 staff were directed to "Effective immediately, we must ask all staff to exit and enter the building through the door off the West 1 hallway on the far west side of the parking lot. All staff must use this door for any entering and exiting of the building, including lunch breaks. All staff must ensure any doors fully close behind them as they walk throughout the facility. Do not let anyone through a door without a badge. It is essential that we all practice door safety."

f. The policy and procedure titled "Facility Access, Door Security and Key Control" with "Original Policy Date: 16 May 2018" was reviewed. It had been revised the day after Patient 44's elopement and suicide and reflected a "Revision Date(s): 10/18/18. It included a section titled "Workforce Traffic Flow and Door Awareness" that stipulated "Workforce members will...Access the hospital through the West One Stairwell door when coming to and from the hospital at shift change or while going on breaks or meal periods...Exercise door awareness and survey their surroundings on both sides of all doors prior to opening a door. They will not open a door if patients are in the immediate area...Ensure doors close completely prior leaving (sic) the immediate vicinity of the door...Not use the front lobby doors or direct admit hall from the south unit...Pay particular attention when opening the main entrance door and survey the lobby or any area prior to opening a door to ensure only intended visitors are allowed through the door."

g. Incident/event and medical record documentation reviewed for the last twelve (12) months, since November 2017, revealed there had been 14 documented instances of neglect that resulted in patient elopement from the secure facility or from secure units secondary to failed door security procedures. Ten (10) of those instances occurred prior to Patient 44's elopement and suicide on 10/17/2018 and five (5) of those involved the secure lobby front door. The hospital's investigations and corrective actions for those ten cases were not adequate to ensure the prevention of Patient 44's elopement through the secure lobby front door. Three (3) more instances occurred after Patient 44's elopement and suicide, one (1) of which involved the secure lobby front door. Those reflect that the actions the hospital had taken in response to Patient 44's elopement continued to be ineffective.

* On 11/05/2017 Patient 5 eloped from the hospital through the secure lobby front door by following a staff person through the closing door that had not been closed and latched, into the parking lot. The patient was pursued by staff down the street in a NE direction towards the nearby freeway overpass and then into a nearby shopping center. Staff called 911 and returned to the facility without the patient.

An "Incident Report Summary" had not been completed, there was no documented investigation with causes identified and actions taken to prevent recurrence, and that included whether the patient was subsequently found or returned to the facility.

* On 02/07/2018 Patient 7 eloped from the hospital through the secure lobby front door when he/she was "accidentally let out by reception staff." Staff were unable to locate the patient.

An "Incident Report Summary" had been completed, however, the "Management Follow-Up" section dated 02/08/2018 reflected only "Continue to Monitor Patient for Safety." There was no documented investigation with causes identified and actions taken to prevent recurrence, and that included whether the patient was subsequently found or returned to the facility.

* On 03/13/2018 Patient 9 eloped from the hospital through the secure lobby front door and left the hospital's unsecured exterior premises. During interview on 11/08/2018 at 1315 the DPI confirmed that there was no other incident/event documentation related to this elopement.

An "Incident Report Summary" had not been completed, there was no documented investigation with causes identified and actions taken to prevent recurrence, and that included whether the patient was subsequently found or returned to the facility.

* On 03/27/2018 Patient 10 eloped from the hospital through the secure lobby front door when he/she "ran out after door was unlocked for person leaving the hospital grounds." The patient left the hospital's unsecured exterior premises and was later found and returned to the hospital by police.

An "Incident Report Summary" had been completed, however, the "Management Follow-Up" section dated 03/28/2018 reflected only "Notify Director of AC for Staff Performance Follow-Up." And "Refer to Patient Safety Committee for Analysis/Further Follow-Up." There was no other documented investigation with causes identified and actions taken to prevent recurrence.

* On 04/04/2018 Patient 11 eloped from the secure CSU to the North Unit by following a staff person through the closing door that had not been closed and latched. A physical hold restraint was initiated, the patient returned to the CSU, and received "PRN medication."

A "Washington County Adult Abuse/Neglect Reporting Form for Mental Health" had been completed and dated by the DPI on 04/06/2018, however, it's purpose was to report that staff had "placed hands on the patient (a physical hold intervention)" and it did not include an investigation into the patient's elopement. An "Incident Report Summary had not been completed, and there was no documented investigation with causes identified and actions taken to prevent recurrence.

* On 04/20/2018 Patient 12 eloped from secure North Unit by following a staff person who was exiting the unit and "pushed the staff...got through the doors and into the lobby." A physical hold restraint was initiated, and the patient returned to the North Unit.

An "Incident Report Summary" had been completed and the "Manager Investigation Notes" dated 04/20/2018 reflected that video was reviewed and staff interviewed, and it was determined that the patient had "tailgated staff..." through the door. However, the investigation was incomplete and there was no documentation with causes identified and actions taken to prevent recurrence.

* On 04/29/2018 patient 13 eloped from the hospital through the secure "lobby" and left the hospital's unsecured exterior premises. The documentation reflected only that the patient was "not returned." The DPI confirmed that there was no other incident/event documentation related to this elopement.

An "Incident Report Summary" had not been completed and there was no documented investigation with causes identified and actions taken to prevent recurrence.

* On 07/09/2018 Patient 18 eloped from the secure North Unit to the interior courtyard by walking past staff through the open door through which staff were entering the North Unit. The patient did cooperate with staff and was returned to the North Unit.

An "Incident Report Summary" had been completed. However, the "Manager Investigation Notes" dated 07/10/2018 reflected only "Staff aware to be mindful of patients trying to leave when they are entering/exiting the unit." There was no other investigation documentation with causes identified and actions taken to prevent recurrence.

* On 09/25/2018 Patient 39 eloped from the hospital by running past a staff person who was exiting the interior courtyard through a secure door to the outside. Patient 39 had been in the courtyard with another staff person who documented "[Patient 39] was attending an outside break with this staff. While talking with another pt, I looked at the grass and realized [Patient 39] was no longer laying where [he/she] had been. I searched the immediate courtyard area, and behind the bushes in the courtyard. When [he/she] was not located, all patients returned to the unit, where a search was already underway. [Patient 39] was returned by police."

Two "Incident Report Summary" forms had been completed. However, the undated and unsigned "Manager Investigation Notes" on the forms reflected only "Staff educated on pt. management" and "Staff educated on awareness of surrounding at exit doors." There was no other investigation documentation with causes identified and actions taken to prevent recurrence.

* On 09/27/2018 Patient 40 eloped from the hospital through a secure South Unit door to the hospital's unsecured exterior premises. A staff person documented "I used the South side door to go onto the South Unit. I encountered a [gender] person who I assumed was a Cedar Hills staff person. I greeted [him/her] and then [he/she] slipped out the door. I then entered South Unit and didn't think there was a problem."

Two "Incident Report Summary" forms had been completed. However, undated and unsigned "Manager Investigation Notes" on the forms reflected only "Staff educated re: Door awareness and need for staff identification" and "Staff involved educated in door awareness and looking for ID badges." There was no other investigation documentation with causes identified and actions taken to prevent recurrence.

* On 10/25/2018 at 2230 Patient 45 eloped from the hospital through the secure lobby front door, eight (8) days after Patient 44's elopement and death. When staff opened the secure front door to let out the secure transport driver who brought Patient 45 to the hospital, the patient pushed through the open door, exited into the parking lot and ran into the street. The staff person exited the building to follow the patient. The staff person's documentation of the incident included other patient safety problems including "Pt. tried to run into the street as an oncoming truck was approaching," the staff person physically grabbed and held the patient on multiple occasions and the patient "struggled to try to free [him/herself] from this writer's grasp," the staff person allowed the patient to smoke in the parking lot after the elopement and physical altercation, and the staff person's lack of a communication device to call other hospital staff for help during the encounter. The staff person wrote "Throughout this incident other CHH staff on duty were unaware that these events were taking place out in the parking lot thus explaining why no other CHH staff aided this writer."

Video recording of the incident was reviewed with the DPO on 11/07/2018 at approximately 1305. The video of the front lobby and the hospital's front exterior from cameras 17, 18 and 21 showed that on 10/25/2018 at 2330 a patient, the driver that brought the patient to the hospital and a staff person were inside the hospital in the hospital lobby near the secure lobby front door. Although the patient was observed to be standing between the staff person and the secure lobby front door, the staff person used the key fob to open the secure lobby front door. When the staff person opened the door the patient quickly and easily exited the building into the parking lot. The camera views showed that the patient eloped into the street in front of the hospital with the staff person and the driver in pursuit. The staff person made physical contact with the patient and a visible physical struggle or altercation between the two was observed during which the staff person was seen to attempt to physically hold or restrain the patient. The staff person was observed to eventually direct the patient back into an area of the parking lot at the opposite end of the building from the main front door. The patient and the staff person stopped in that area for several minutes where it appeared (secondary to nighttime and inadequate outdoor lighting conditions for the camera) that the patient was smoking. The patient and the staff person reentered the building through the secure lobby front door at 2241, ten (10) minutes after the patient eloped. The staff person was observed to physically hold the patient during escort back into the building. During the entire episode there was no observation on the video of other staff response to the elopement and physical altercation.

An "Incident Report Summary" had been completed. However, the unsigned and undated "Manager Investigation Notes" reflected only "Incident reviewed with staff involved. Staff re-trained on revised patient admission process." An untitled and unsigned document dated 10/25/2018 had a list of eight (8) items that appeared to be observations or concerns about the events of the incident, a list of "Staff involved' and five items listed under "Action Plan." The author of the document was not evident, and the documentation was not complete or clear. For example: There was no reference to the patient getting through the door opened by staff, there was no reference to the staff's lack of a communication device to call for help, there was no reference to the physical altercation between the patient and the staff person, there was no reference to the use of physical restraint applied by the staff person, there was no reference to the fact that staff allowed the patient to smoke in the parking lot on the hospital's premises when no one else in the hospital knew this event had occurred, there was no reference to the fact that staff allowed the patient to smoke on the hospital's premises in violation of the hospital's policy identified below under #4 of this deficiency, and no reference to the increased risk for the patient to elope again while smoking in the unsecured parking lot with a staff member who had no communication device. Under "Action Plan" an entry reflected "[Male name] to do skin checks with female witness unless pt requests female nurse." It was not clear how this related to the elopement of Patient 45. There was no other investigation documentation provided.

* On 10/27/2018 Patient 46 eloped from the South Unit through a secure exit door into a "sally port" that led to another secure door to the hospital's unsecured exterior premises. The documentation of the incident in the medical record reflected the patient was on "medical precaution, aggression precaution, elopement precaution, fall precaution and suicide precaution...every 15 minute safety checks." The documentation reflected a housekeeper found the patient "hiding behind a curtain near the exit door at South Unit hallway...When asked how [Patient 46] was able to go through the door without a key fob, pt responded 'I just keep pushing and pushing the door and it opened by itself.'"

The review of video recording of the incident on 11/07/2018 at 1245 with the DPO revealed that the events observed were inconsistent with those recorded in the medical record. The video from camera 39 of the interior of the South Unit "sally port" showed that on 10/27/2018 at 1427 a housekeeper exited the South Unit with his/her housekeeping cart through the South Unit secure door into the "sally port." At 1428 the housekeeper reentered the South Unit through that same door and did not ensure the door was closed and latched behind him/her. Patient 46 was observed to slip through the closing door from the South Unit into the "sally port" and the South Unit door then closed and latched behind him/her secluding him/her in the "sally port." Patient 46 was observed to proceed to the other "sally port" door that led to the unsecured exterior of the building from the "sally port" and was seen to attempt to open that secure door unsuccessfully. The patient was observed to then position him/herself in a corner of the "sally port" behind a "privacy curtain" that is installed in that space. The housekeeper was observed to reenter the "sally port" from the South Unit, walk past Patient 47 who was positioned behind the curtain, use a key fob to open the secure exterior door and began to open that door. The housekeeper was observed to turn around quickly in the direction of where the patient has hidden and was then seen to exit the "sally port" back onto the South Unit. Other staff are then observed to enter the "sally port" and the patient was subsequently escorted back onto the unit.

An "Incident Report Summary" had not been completed and there was no documented investigation with causes identified and actions taken to prevent recurrence.

* On 11/04/2018 Patient 49 eloped from the South Unit through a secure door "into the courtyard following a staff member out the door." There was no other detail or information about the incident.

An "Incident Report Summary" had not been completed and there was no documented investigation with causes identified and actions taken to prevent recurrence.

h. During tours of the hospital with the ADON, the DPI and the DPO the following observations were made:

* On 11/08/2018 at 1015 on the West 1 Unit a staff person was observed to use a key fob to open the West 1 Unit secure door that led into the West 1 Unit "sally port." The staff person was observed to open the door and exit the unit from the hallway into the "sally port" without looking back to ensure the door was closed and latched behind him/her. This failure was observed by the ADON, the DPI and the DPO who confirmed that the staff person failed to follow door security procedures.

During interview at that time the leadership staff also confirmed that if a patient were to elope into the West 1 Unit "sally port" they would be unable to get through the second door that led to the unsecured exterior premises as that door was also secure and required a key fob to open. They also confirmed the patient would be able to exit back into the West 1 Unit through the secure door.

Observations in the West 1 Unit "sally port" revealed a number of risks and items that could be used by a patient secluded in the "sally port" to do harm to self or others. Those included a long umbrella placed on the top of a row of cabinets, and a number of paints and biologicals in a container inside of one of the unlocked cabinets including liquid leather dye that was identified as "flammable" on it's label. A door inside the "sally port" was open and led into a large stairwell with a flight of stairs that led up to the West 2 Unit above. This area contained numerous ligature risks that included the steel open stair rails. A large blind spot was observed underneath the staircase in which a patient who was secluded in the "sally port" could hide from detection.

* On 11/08/2018 at 1105 a staff person was observed to use the key fob to go through the secure West 1 Unit entrance door. The staff person was observed to open and walk through the door without looking back to ensure the door was closed and latched behind him/her. This failure was observed by the ADON, the DPI and the DPO who confirmed that the staff person failed to follow door security procedures.

i. Review of the hospital's "Elopement Risk Assessment" dated "baseline 10/27/17" reflected that plans for mitigating that risk were unclear and incomplete. Examples include:
* Regarding "Lobby front doors" the "Mitigation" of "Add mag lock" was identified as "complete, and the "Mitigation" of "add secure assessment area" was identified as "[estimate] 1 Qtr 2019."
* Regarding "West court yard low wall by gym...trees by [conference] room...exterior door" the "Mitigation" was "Staff education" identified as "status ongoing."
* Regarding "West one Hall exterior door" and "South Hall exterior door" the "Mitigation" of "sally port interlock installed" was identified as "complete" and there were no other mitigation plans identified.

2. The physical environment had not been maintained to ensure that patients received care in a safe setting. The hospital had not mitigated ligature risks, unsafe items, and physical environment features and disrepair that created risk for self-harm, fire, passing of contraband and elopement. As a result, patients experienced actual and potential harm.

a. Incident/event and medical record documentation was reviewed for 16 patients who experienced 25 incidents/events of neglect that included suicide attempts, self-harm, contraband use/possession and elopement secondary to access to the hospital's roof in the previous six months since May of 2018. Those cases included the following incidents/events:

* On 05/17/2018 Patient 15 was identified in a note in the medical record to have endorsed SI with a plan to "cut wrist or hit my head really hard". On that date Patient 15 was found on his/her bathroom floor "self harming" with a broken plastic butter-knife on his/her wrist. The patient sustained a "superficial cut" and required "first aid."

An "Incident Report Summary" had been completed. However, the "Manager Investigation Notes" dated 05/18/2018 reflected only "Pt assessed by nursing and plastic knife secured. Room searched for other contraband with none found. Pt place on self-harm precautions per nurse report." There was no identification of the length or dimensions of the wound, there was no documented investigation of how the patient who expressed SI that included cutting his/her wrist had obtained the plastic knife, nor was there investigation of whether patient observations had been carried out prior to the incident/event and whether those were adequate.

* On 06/17/2018 Patient 16 was identified in a note in the medical record to be on "suicide, self-harm...precautions." On that date the patient was found under a blanket to be scratching him/herself with a plastic med cup used to give oral meds and required "first aid." Although the documentation did not specify where on the patient's body he/she was self-harming, a note reflected the patient's right knee was cleansed.

An "Incident Report Summary" had not been completed and there was no documented investigation with causes identified and actions taken to prevent recurrence. There was no description of the "scratch," there was no documented investigation of how the patient who was on suicide and self-harm precautions had obtained the plastic med cup in consideration of proper medication administration practices, nor was there investigation of whether patient observations had been carried out prior to the incident/event and whether those were adequate.

* On 06/19/2018 Patient 16 attempted self-harm again. Medical record documentation reflected he/she was found in the bathroom tightening a pillowcase around his/her neck.

An "Incident Report Summary" had not been completed and there was no documented investigation with causes identified and actions taken to prevent recurrence. There was no documented investigation of how the patient who was on suicide and self-harm precautions and had self-harmed two days prior had obtained the pillowcase and was able to fashion a ligature without detection by staff, nor was there investigation of whether patient observations had been carried out prior to the incident/event and whether those were adequate.

* On 07/31/2018 Patient 21 attempted self-harm. The patient was found in his/her room with an elastic waistband ligature around his/her neck and sustained "circular redness around neck." The documentation reflected that "1 to 1 observation" was initiated.

An "Incident Report Summary" had been completed, however, the "Manager Investigation Notes" section was blank and there was no documented investigation with causes identified and actions taken to prevent recurrence. There was no investigation of how the patient had obtained the elastic ligature, nor was there investigation of whether patient observations had been carried out prior to the incident/event.

* On 08/01/2018 Patient 21 attempted self-harm again that resulted in a transfer to another hospital's ED. Medical record documentation reflected that the "Pt has long oblong piece off (sic) chair stuck on left pointer finger. Unable to remove after many attempts. Called [Washington County] non-emergency #. Fire came stating after eval '[patient] needs to go to hospital it is to (sic) hard metal to cut off without hurting [him/her].' Pt transported to [PSVMC]...Pt returned...Safety (sic) check done in room and bolt found hidden in bed. Pt reports was going to try to swallow them...Pt will continue on 1 to 1 observation, suicide, self harm, sexual victim, and elopement precautions."

An "Incident Report Summary" had not been completed and there was no documented investigation with causes identified and actions taken to prevent recurrence. There was no clear description of the "piece of chair," there was no description of whether an injury was sustained, there was no documented investigation of whether the "1 to 1 observations
VIOLATION: QAPI Tag No: A0263
Based on observations, interviews, review of incident/event and medical record documentation for 45 of 49 patients reviewed for incident/events in the last twelve (12) months (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 and 58), review of grievance documentation for 4 of 6 patients selected from the grievance log (Patients 8, 53, 56, and 57), review of medical record documentation for 3 of 4 patients who experienced restraint or seclusion (Patients 25, 26, and 36), review of restraint training documentation for 5 of 5 staff (Staff 1, 2, 3, 4 and 5), review of policies and procedures, and review of other documentation related to safety and physical environment risk, it was determined that the QAPI program was not effective to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

2. Refer to the findings cited under Tag A385, CFR 482.23 - CoP Nursing Services.

3. Refer to the findings cited under Tag A700, CFR 482.41 - CoP Physical Environment
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, interviews, review of incident/event and medical record documentation for 45 of 49 patients reviewed for incident/events in the last twelve (12) months (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 and 58), review of medical record documentation for 3 of 4 patients who experienced restraint or seclusion (Patients 25, 26, and 36), review of restraint training documentation for 5 of 5 staff (Staff 1, 2, 3, 4 and 5), and review of policies and procedures, it was determined that nursing services had not been managed to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observations, interviews, review of incident/event and medical record documentation for 45 of 49 patients reviewed for incident/events in the last twelve (12) months (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 and 58) and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights to safe care were recognized, protected and promoted as follows:
* All components of an effective abuse prevention program were not evident, including timely and complete investigations of and response to actual, potential or alleged abuse or neglect to ensure those incidents and events did not recur. Those incidents and events included elopements from the secured facility and secured units that resulted in death for Patient 44; and actual and potential harm from ligature points, unsafe items, patient to patient altercations, lack of patient monitoring and supervision, and medication errors.

The CMS Interpretive Guideline for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guideline reflects that components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP: Patient's Rights. Those findings reflect the hospital's failure to ensure investigations of abuse and neglect were timely and complete to prevent recurrence for 45 of 49 patients reviewed who experienced incidents/events.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation reviewed in the medical records of 3 of 4 patients (Patients 25, 26 and 36) who were physically restrained or placed in seclusion for violent or self destructive behaviors, and review of policies and procedures, it was determined the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* Restraints and seclusion were not used in accordance with a written modification to the patient's plan of care.

Findings include:

1. The policy and procedure titled "Seclusion and Restraint" dated last revised "9/28/16" was reviewed. It stipulated:
* The "Definitions" section reflected "...'Mechanical Restraints': Any physical device used to restrict the movement of a portion or the entirety of a patient's body...'Physical Hold': The application of physical body pressure by another person to the body of a patient in such a way as to limit or control the physical activity of the patient...'Seclusion': is the involuntary confinement of a patient alone in a room or area away from which the patient is physically prevented from leaving."
* "The patient's Master Treatment Plan is to be updated whenever a seclusion/physical restraint/mechanical restraint intervention occurs..."

2. The medical record of Patient 36 was reviewed and reflected the patient was admitted on [DATE]. The "Reason For Admission" was "Psychosis and suicidal ideation."
* A "RN Seclusion/Restraint Assessment" dated 09/14/2018 at 1230 reflected a "Physical Hold" (physical restraint) of the patient occurred from 1042 to 1055. The "Clinical Justification for Intervention" section on the assessment reflected "...Pt used a long thumbnail in attempt to cut wrist of opposite hand. Pt repeatedly stated 'Don't kill my [family member].'"
* There was no documentation reflecting a modification to the plan of care related to the physical hold event.

* A "RN Seclusion/Restraint Assessment" dated 09/14/2018 at 2124 reflected a second "Physical Hold" of the patient occurred from 1955 to 2020. The "Clinical Justification for Intervention" section reflected the patient was a danger to him/herself and "...Pt attempting to Dig Nails into wrist to get o (sic) vein...Pt. using nails on right hand...attempt to dig into left wrist."
* There was no documentation reflecting a modification to the plan of care related to the physical hold event.

3. The medical record of Patient 26 was reviewed and reflected the patient was admitted on [DATE]. The "Reason for Admission" was "...increasing agitation with impulsivity and irritability."
* A "RN Seclusion/Restraint Assessment" dated 08/18/2018 at 1335 reflected the patient was placed in seclusion from 1215 to 1315. The "Clinical Justification for Intervention" section on the assessment reflected the patient was a danger to him/herself, a danger to others, and "...Making threatening remarks, posturing, impulsive unsafe behavior, throwing things."
* There was no documentation reflecting a modification to the plan of care related to the seclusion event.

4. The medical record of Patient 25 was reviewed and reflected the patient was admitted on [DATE] with a diagnosis of bipolar disorder.
* A "RN Seclusion/Restraint Assessment" dated 08/17/2018 at 2340 reflected the patient was placed in seclusion from "8/17" at 2330 to 0015. The "Clinical Justification for Intervention" section on the assessment reflected "...Patient would not leave [male/female] patients (sic) room, un-redirectable (sic), disruptive to [male/female] patients, potentially dangerous situation."
* There was no documentation reflecting a modification to the plan of care related to the seclusion event.

5. During an interview with the ADON on 11/09/2018 at the time of the medical record review, he/she confirmed findings 2, 3 and 4.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation reviewed in the medical records of 3 of 4 patients (Patients 25, 26 and 36) who were physically restrained or placed in seclusion for violent or self destructive behaviors, and review of policies and procedures, it was determined the hospital failed to fully develop and implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* Physician orders for physical restraints and seclusion of patients were not authenticated, dated and timed by the physician within 24 hours in accordance with hospital policies and procedures.
* Physician orders for physical restraints and seclusion of patients were not time limited in accordance with hospital policies and procedures.
* Physician orders for physical restraints and seclusion of patients were not complete and legible in accordance with hospital policies and procedures.

Findings include:

1. The policy and procedure titled "Seclusion and Restraint and Seclusion" dated last revised "9/28/16" was reviewed and reflected:
* "Physician orders...The following are necessary elements for seclusion/restraint/physical hold orders...Each and every episode requires a physician's order that is dated and timed. Orders for seclusion or restraint shall be authenticated by the physician within 24 hours..."

2. The undated "Rules and Regulations of Medical Staff" provided reflected:
* Section 5 reflected "...Member Orders...All orders for medication and/or treatment for patients admitted to the Facility shall be in writing. Orders must be written clearly and legibly and must be complete, including the date, time and justification for the order. A verbal order or telephone order shall be considered to be written if accepted by a registered nurse or licensed pharmacist and signed and dated...All orders shall be dated. In addition, all Facility personnel shall record the date and time when the order has been transcribed...All orders must be complete, signed, dated, written clearly and legibly. Orders which are illegibly or improperly written will not be carried out until rewritten and understood by the duly authorized person."
* Section 7 reflected "Seclusion and/or Restraint...Orders for seclusion and/or restraint shall...be time limited...be signed by the physician within 24 hours of initiation...Orders for seclusion and/or restraint should be given by a Physician, as permitted by Oregon state law. If a Physician is not immediately available, however, a Registered Nurse may, if specifically trained, initiate seclusion and/or restraint, and shall contact a Physician within 1 hour to obtain an order and to consult about the patient's condition."

3. The medical record of Patient 36 was reviewed and reflected the patient was admitted on [DATE]. The "Reason For Admission" was "Psychosis and suicidal ideation."
* A "RN Seclusion/Restraint Assessment" dated 09/14/2018 at 1230 reflected a "Physical Hold" (physical restraint) of the patient occurred on 09/14/2018 from 1042 to 1055.
* A telephone order for the physical hold event was dated 09/14/2018. However, the spaces on the form for documenting the time of the order, the time the physical hold was initiated, and the time the order was signed by the RN had written over, illegible entries.

* A "RN Seclusion/Restraint Assessment" dated 09/14/2018 at 2124 reflected a second "Physical Hold" of the patient occurred on 09/14/2018 from 1955 to 2020.
* A telephone order for the physical hold event was signed and dated by the RN on 09/14/2018 at 2015. The order was incomplete as there was no duration for the physical hold and it was not time limited. The space on the order for documenting the "Maximum Time" was blank. Further, the physician signature was dated 10/31/2018, 47 days after the physical hold event, and the time it was signed by the physician was scribbled and illegible.

During an interview on 11/09/2018 at 1550 the ADON confirmed the physician order for the physical hold that occurred from 1955 to 2020 was incomplete and was not time limited.

4. The medical record of Patient 25 was reviewed and reflected the patient was admitted on [DATE] with a diagnosis of bipolar disorder.
* A "RN Seclusion/Restraint Assessment" dated 08/17/2018 at 2340 reflected the patient was placed in seclusion on "8/17" from 2330 to 0015.
* The telephone order for the seclusion event reflected the date and time seclusion was initiated was 08/17/2018 at 2330. However, the order and the RN signature on the order were not dated and timed until 08/23/2018 at 2330, six days after the seclusion event; and the physician signature on the order was not dated until 08/20/2018 and the time was scribbled and illegible.

5. The medical record of Patient 26 was reviewed and reflected the patient was admitted on [DATE]. The "Reason for Admission" was "...increasing agitation with impulsivity and irritability."
* A "RN Seclusion/Restraint Assessment" dated 08/18/2018 at 1335 reflected the patient was placed in seclusion on 08/18/2018 from 1215 to 1315.
* A telephone order for the seclusion event was signed and dated by the RN on 08/18/2018 at 1215. However, the physician signature on the order was not dated and timed until 08/20/2018 at 1210, two days after the seclusion event.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations, interviews, review of incident/event and medical record documentation for 45 of 49 patients reviewed for incident/events in the last twelve (12) months (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 and 58), review of policies and procedures, and review of other documentation related to safety and physical environment risk, it was determined that the physical environment had not been maintained to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.