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Based on interview and record review, the facility ' s Governing Body failed to ensure the facility adhered to its policy regarding Restraint/Seclusion usage for 2 of 7 sampled discharged patients (ID # 6, # 10). The facility failed to obtain physician orders for restraint (Patient ID # 6, # 11) and failed to include these episodes into the Quality Assurance Monitoring program.

Findings include:

Patient ID # 6

Record review on 11-09-12 of Patient ID # 6 ' s clinical record revealed she was 15 years old and admitted to the facility on 03-07-12 with a diagnosis of Mood Disorder.

Review of facility " Significant Incident Report, " dated 03-12-12 read: " pt. (patient) ID # 6 offered to go to quiet room and refused. Code is called. Pt in day room. Pt attempted to swing at Staff ID # 11, but missed... Staff grabbed pt. and took to ground after she swung at him ...pt taken to ground by Staff ID # 11, where she hit her head ... "

Review of the physician orders for Patient ID # 6 failed to reveal a physician order for the personal restraint applied on 11-09-12. In addition, review of the facility Quality Assurance data for restraints, failed to reveal the reporting of this episode of personal restraint.

Patient ID # 10

Record review on 11-09-12 of Patient ID #10 ' s clinical record revealed he was 43 years old and admitted to the facility on 05-25-12 with a diagnosis of Schizoaffective Disorder.

Review of facility " Significant Incident Report, " dated 05-26-12 read: " pt. (ID # 10) trying to attack staff. Pt taken down by staff ...later pt complained of shoulder pain ... " Record review showed x-ray disclosed a fractured clavicle; Patient ID # 10 was transported to a local hospital for evaluation and treatment. Patient ID # 10 returned to the facility the same day.

Review of the physician orders for Patient ID # 10 failed to reveal a physician order for the personal restraint applied on 11-09-12. In addition, review of the facility Quality Assurance data for restraints, failed to reveal the reporting of this episode of personal restraint. The facility policy required any injuries related to the use of restraint would be reported and reviewed.

Interview on 11-09-12 at 2:10 p.m. with the Director of Nursing (DON/ Staff ID #1), she stated the facility had not been considering the use of PMAB (Preventative Management of Aggressive Behavior) as a restraint. Upon review and discussion of the facility ' s restraint/seclusion policy, the DON (ID # 1) acknowledged that use of a " physical take- down (using PMAB) " was considered a personal restraint.

Record review in 11-09-12 of the facility policy titled " Seclusion and Restraint, " undated, read: " Definition: ....Restraint: an individual placed in restraint to be defined as personal, mechanical or any device which restrain a patient for medical ,behavioral and/or diagnostic reasons ...III. Orders. 1 ...b. All restraint and seclusion are applied and continued pursuant to an order by the physician, clinical psychologist, or other authorized licensed independent practitioner designee ,,,, " XII. QA and Performance Improvement: Data Collection is integrated into PI activities: Indicators: 1/ Staff or patient injury sustained while in seclusion or restraint. 2 orders .... "

Review of the facility preprinted form titled " Seclusion /Restraint Orders " revealed six (6) check off boxes for type of restraint, one of which was " Personal " restraint. Further review of the order form revealed a section that listed patient behaviors with " check off boxes. " The behaviors included: fighting staff ; fighting with peers; threatening to fight staff, etc ... "