HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirments of the Conditions of Participation for patients rights as evidenced by:

1. Failing to ensure the right of the patient to receive care in a safe setting by: a) failing to protect vulnerable psychiatric patients from behaviors of aggression and sexually inappropriate behavior exhibited by Patient #3 for 3 (#1, #5, #6) of 6 sampled patients; b)
failing to ensure the RN assessed the patient exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff for 1 of 1 (#3) sampled patients reviewed for aggressive and inappropriate sexual behaviors out of a total sample of 6, and; c) failing to document incidents of patient and staff attacks and sexually inappropriate behavior towards other patients and staff according to hospital policy for 1 of 1 sampled patients reviewed for behaviors of aggression and sexually inappropriate behavior (See findings at A-0144).

2. Failing to ensure less restrictive interventions were implemented and determined to be ineffective before initiating the use of patient seclusion for 1 of 1 (Patient #3)sampled patients reviewed for the use of seclusion out of a total sample of 6 (See findings at A-0164).

3. Failing to develop and implement policies and procedures for the use of seclusion as evidenced by a) failing to include specific directives on the implementation of seclusion in the restraint/seclusion policy, and; b) failing to develop and implement a policy and procedure for the use of time out (See findings at A-0167).

4. Failing to ensure orders for the use of seclusion were not written on an as needed basis as evidenced by a) failing to clarify physician's orders for the use of time out or seclusion; b) the use of trial release from seclusion, and; c) failing to obtain a new order for seclusion after a recent release from seclusion for 1 of 1 (#3) sampled patients reviewed for the use of seclusion out of a total sample of 6 (See findings at A-0169).

5. Failing to ensure that a face-to-face evaluation of the patient within one hour of the initiation of seclusion was conducted by a physician or a licensed independent practitioner for 1 of 1 (#3) patients reviewed for the use of seclusion out of a total sample of 6 (See findings at A-0178 and A-0184).

6. Failing to ensure an evaluation of the patient in seclusion was conducted within 1 hour after initiation of seclusion and included an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the seclusion for 1 of 1 (#3) sampled patients reviewed for the use of seclusion out of a total sample of 6 (See findings at A-0179).

7. Failing to ensure the patient's medical record included a description of the patient's behavior that warranted placing the patient in seclusion for 1 of 1 (#3) sampled patients reviewed for the use of seclusion out of a total sample of 6 (See findings at A-0185).

8. Failing to ensure the staff on the psychiatric unit had education and training on techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraint or seclusion and specific behavioral changes that indicate seclusion is no longer necessary. (See findings A-199 and A-204).

9. Failing to ensure the entire staff of the psychiatric unit had education and training in the use of nonphysical intervention skills. (See findings A-200).

10. Failing to ensure staff personnel records contained documentation that demonstrated competencies had been successfully completed during orientation. (See findings A-208).

Based on record review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:


1. Failing to ensure a registered nurse supervised and evaluated the nursing care for each patient by a) failing to ensure the RN assessed the patient exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff; b) failing to notify the physician, the Director of Nursing and the unit Director in a timely manner of a patient being sexually inappropriate with another patient; c) failing to ensure less restrictive interventions were implemented and determined to be ineffective before initiating the use of patient seclusion, and; d) failing to ensure all nursing entries entered into the medical record were a complete and/or accurate account of the patient's behavior (See findings at A-0395).

2. Failing to ensure the nursing staff developed and kept current a nursing care plan as evidenced by failing to ensure nursing interventions and goals were identified and implemented to address physically aggressive and/or sexually-inappropriate behavior (See findings at A-0396).

3. Failing to ensure a Registered Nurse (RN) assigned the nursing care of each patient according to the needs of the patient and the qualifications and competency of the nursing staff as evidenced by: a) failing to ensure the Behavioral Health Unit Director met the job description qualifications; b) failing to ensure an RN assigned as Charge Nurse met the job description experience requirements and was assessed as competent, and; c) failing to ensure the nursing staff of the psychiatric unit (Behavioral Health Unit) were oriented to the unit, assessed for competency prior to providing patient care, and were trained in CPI (Crisis Prevention Institute) and Seclusion (See findings at A-0397).

Based on record review and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by:
a) failing to protect vulnerable psychiatric patients from behaviors of aggression and sexually inappropriate behavior exhibited by Patient #3 for 3 (#1, #5, #6) of 6 sampled patients;
b) failing to ensure the RN assessed the patient exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff for 1 of 1 (#3) sampled patients reviewed for aggressive and inappropriate sexual behaviors out of a total sample of 6, and:
c) failing to document incidents of patient and staff attacks and sexually inappropriate behavior towards other patients and staff according to hospital policy for 1 of 1 sampled patients reviewed for behaviors of aggression and sexually inappropriate behavior.

Findings:

a) Failing to protect vulnerable psychiatric patients from behaviors of aggression and sexually inappropriate behavior:

Patient #3
Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia. Review of the Psychiatric Evaluation dated 09/01/12 revealed the patient's chief complaint was, "I had a knife to kill her (sister)". The problem list included Bizarre delusions about being married to God and having immense powers, Tendency to thoughts of violence, Lability of mood, and Non-compliance with medications....

Review of the nurse's notes, dated 09/14/12 revealed no documented evidence that the patient was found in bed with another patient. Review of the Observation Flow Sheets dated/timed 09/15/12 at 00:15 (12:15 a.m.) revealed the patient was in another patient's room, was non-compliant, and was redirected out of patient's room. Review of Incident Report #378 confirmed Patient #3 was found in bed with a male patient (Patient #6) on 09/15/12 at 12:45 a.m. Review of the treatment plan for Patient #3 revealed no documented evidence that the plan was updated with any interventions to address the inappropriate behavior by Patient #3.

Review of the nurse's notes, dated 09/24/12 at 9:30 a.m. revealed Patient #3 took another patient's cane (Patient #1) and attempted to hit him with it. The nurse's note revealed, "She put herself in time out." Further review of the notes dated 09/24/12 revealed the following: "2200 (10:00 p.m.) Patient was into another patient's room (Patient #1) and had to be redirected out. Patient did not have clothing on. Patient returned to own room, patient redirected for physical contact with another patient." There was no documented evidence of any increased supervision of Patient #3 and there was no documented evidence the treatment plan was updated with any interventions to protect other patients from Patient #3. There was no documented evidence the physician was notified of the incident.

Review of Incident Report #415 revealed Patient #3 lunged toward a staff member. Another staff member and Patient #5 came to assist. Patient #3 was swinging arms and scratched Patient #5. Review of the patient's treatment plan revealed the plan was not updated when the patient injured another patient and was placed on 1:1 observation

Review of the nurse's notes, dated 09/29/12 revealed no documented evidence that Patient #3 scratched another patient (Patient #5). Further review of the nurse's note revealed the following: "1750 (5:50 p.m.) Patient received Haldol 10 mg. at 1750 for psychosis. She has attacked the staff several times. She is also now a 1:1 by a female, Caucasian tech because the doctor doesn't want her to feel rewarded with special behaviors, such as being watched by an AA (African American) tech."


Patient #1
Review of the medical record for Patient #1 revealed he was a 66 year old male who had been admitted to the facility on 9/7/12. Review of the Psychiatric evaluation for Patient #1 revealed his diagnosis included Schizoaffective disorder, bipolar type, with the most recent episode being manic.
Review of a Psychiatrist note dated 9/24/12 revealed Patient #1 was hit his with walking stick by another patient (Patient #3). Further review of Patient #1's medical record revealed no incident report had been completed, no nursing notes about the incident had been recorded, and nothing about the incident had been documented in the Mental Health Technician (MHT) observation notes. This was verified on 10/11/12 at 11:25 a.m. by Registered Nurse S5.

In an interview on 10/11/12 at 11:30 a.m., Registered Nurse (RN) S5 said on 9/24/12, Patient #3 tried to hit Patient #1 with a cane. She said nothing had been done to further protect Patient #1 from Patient #3. RNS5 said no incident report had been filled out because Patient #1 had not actually been hit.

Review of a Staffing Note by Medical Director S9 for Patient #1 dated 9/25/12 revealed the following in part: a female patient who was psychotic who is in a room across from him was found naked in his room. As far as the judgment of the patient is concerned, he always brags about wanting to do the right thing, but he did not alert anybody nor did he ask the woman to leave. So he was reprimanded about it and then instead of expressing remorse, he reacted ugly to one of the staff members requiring a shot.

Review of Patient #1's medical record revealed no Social Service notes related to the incident on 9/24/12 when Patient #3 went into his room during the night. Further review revealed the treatment plans for Patient #1 had not been updated after Patient #3 entered his room and was found naked in his bed.

Review of the nurse's notes for Patient #1 dated 9/24/12 revealed no mention of notifying the physician about Patient #3 entering his room.

Record review revealed no incident report had been documented for the incident on 9/24/12 about Patient #3 entering Patient #1's room. This was verified by Director of Nursing S1 on 10/10/12 at 3:30 p.m.

In an interview on 10/10/12 at 3:35 p.m. with Director of Nursing (DON) S1, she said Patient #3 had multiple attacks on staff and other patients and sexual behaviors which increased after about a week of being at the hospital. She said she did not know why Patient #3 was not placed on 1:1 observation sooner than 9/29/12.

In an interview on 10/11/12 at 12:50 p.m. with RN S6, he stated on the night of 9/24/12, one of the Mental Health Technicians (MHT) told him Patient #3 had gone into Patient #1's room. RNS6 said the patients were attempting to have sex. When discovered by the MHT, Patient #3 ran out of Patient #1's room and back to her own room across the hall. RNS6 said no revisions had been added to either patients care plan. RNS6 also said the physician was not notified about the incident that night. RNS6 verified there was no documentation in the nursing notes of the patients attempting to have sex. RNS6 also said no incident report had been filled out, but one should have been completed. RNS6 said they increased Patient #3's supervision, but nothing was documented. He said Patient #3 was not monitored on paper any more than every 15 minutes. He said he could not have guaranteed that Patient #3 could not have gone into another patient's room in the future. RNS6 said Patient #3 had gone into another patient's room (Patient #6) in the past and got in bed with him, but nothing different had been done after that incident to protect other patients from Patient #3.

An interview was conducted on 10/11/12 at 3:20 p.m. with Medical Director S9. He said he did not recall if Patient #3 had ever been into Patient #1's room in a sexual manner. He said he was never notified of an incident between Patient #1 and Patient #3. When asked about the Staffing Note for Patient #1 he had written dated 9/25/12, he said he must have been notified that day, but he could not remember. When asked if Patient #1 was a victim of Patient #3, S9 said you would think so, but Patient #1 did not ask her to leave. When S9 was asked if anything was done to keep Patient #3 away from other male patients, he replied no. S9 also said Patient #3 had tried to choke another female patient, had previously been found in another male patient's room, and attacked the staff on multiple occasions. When asked why Patient #3 had not been placed on 1:1 sooner than 9/29/12, he said she was paranoid and may feel like it was a personal attack against her because she was black.

An interview was held on 10/12/12 at 8:35 a.m. with Director of Nursing S1. She said she had never been made aware of Patient #3 crawling into the bed naked with Patient #1. She said she was aware of the first instance of Patient #3 in bed with another patient, but not Patient #1. DONS1 said an incident report should have been filled out and she should have been notified.

In an interview on 10/12/12 at 9:05 a.m. with Licensed Practical Nurse (LPN) S10, she said she had come to the psych unit about a year ago. She said her job was to take care of patients and pass medications. She said after Patient #3 was caught in Patient #6's room, Patient #1 was switched into Patient #6's room because the staff thought he would be safe to put across from Patient #3 because he was older and meek. LPNS10 said Patient #3 was unpredictable when she would attack other patients. LPNS10 said after Patient #3 was found in Patient #1's room, he was agitated. She obtained an order from the physician to give 2 mg Ativan IM for Patient #1 because he was angry. She did not tell Medical Director S9 that Patient #3 was naked in Patient #1's room. LPNS10 said she did not remember what they did, if anything for Patient #1's safety.

In an interview on 10/12/12 at 10:15 a.m. with MHT S8, she said on 9/24/12 at 2200, Patient #3 was found in Patient #1's room. She said Patient #3 was in Patient #1's bed naked. She said Patient #1 was saying he was her husband, and she was not leaving. MHTS8 said she went to get the RN, and on their way back, Patient #3 ran out of Patient #1's room back to her own room while still naked. Then, MHTS8 said the staff basically did nothing. She said Patient #1 started cussing, and they moved his room, so he started cussing more. MHTS8 said more males have been placed in that room across from Patient #3 since Patient #1 and Patient #6 had been moved. She said nothing was done differently to protect Patient #1 or the male patient that was in that room afterward. MHTS8 said Patient #3 even tried to get to Patient #6's room and Patient #1's room after they were moved away from her room. She said Patient #3 was obsessed with both patients and still tried to talk to them and even wrote Patient #6 letters. She said nothing was done differently with Patient #3's observation level until several days after the incidents. She said the director of the unit, the DON or the Physician never asked her about the incident.

In an interview on 10/12/12 at 12:15 p.m. with Director of Behavioral Health S3, she said she was not aware that Patient #3 had been found in Patient #1's room naked on 9/24/12. S3 said after being caught in Patient #1's room, she would have expected Patient #3 to have been placed on 1:1 observation and Patient #1 to have been counseled. She said the other patients were placed at risk by not putting Patient #3 on 1:1 observation earlier than 9/29/12.

Patient #6
Record review revealed Patient #6 was a 40 year old male that had been admitted to the facility on 9/12/12 for Psychosis.

In an interview on 10/11/12 at 12:50 p.m. with RN S6, he stated S6 said Patient #3 had gone into Patient #6's room on 9/14/12 and got in bed with him, but nothing different had been done after that incident to protect him or other patients from Patient #3.

In an interview on 10/12/12 at 10:15 a.m. with MHT S8, she said after Patient #3 went into Patient #6's room on 9/14/12, he was moved down the hall. MHTS8 said Patient #3 tried to get into Patient #6's room after he was moved away from her room. She said Patient #3 was obsessed with Patient #1 and Patient #6 and even wrote Patient #6 letters.

Record review revealed no updates had been made to Patient #6's treatment plan after Patient #3 was found in his room on 9/14/12. Also, no nursing notes about the incident were located in his medical record on 9/14/12.

Review of Patient #3's medical record revealed she was not placed on 1:1 observation until 9/29/12.

Patient #5
Record review revealed Patient #5 was a 56 year old male admitted to the psychiatric unit on 9/12/12. His diagnosis included depression.

Review of Incident Report #415 revealed Patient #3 lunged toward a staff member. Another staff member and Patient #5 came to assist. Patient #3 was swinging arms and scratched Patient #5.

A review was made of a Nursing Note dated 9/29/12 at 0930 (9:30 a.m.) for Patient #5. The note revealed: AA&O x 3 (awake, alert, and oriented x 3). Pleasant mood. Appropriate behavior. Compliant with all meds. Ate well at breakfast. The note was signed by S5 Registered Nurse (RN). Further review revealed an entry time for 1800 (6:00 p.m.) by S5 that indicated Pt. (patient) scratched his hand earlier today and the nurse, S11, cleaned it and put a dressing on it. He was compliant with all his meds. Ate well at meals and attended groups.

Review of the medical record for Patient #5 revealed no mention of Patient #3 scratching him in the Physician's Progress Notes, no Physician's Orders to clean the wound, and no Nursing Notes indicating the physician had been notified. Further review revealed no documentation as to how the facility planned to protect Patient #5 from future altercations involving Patient #3.

b) Failing to ensure the RN assessed the patient exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff:
Patient #3
Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia. Review of the Psychiatric Evaluation dated 09/01/12 revealed the patient's chief complaint was, "I had a knife to kill her (sister)". The problem list included Bizarre delusions about being married to God and having immense powers, Tendency to thoughts of violence, Lability of mood, Non-compliance with medications....

Review of the Nursing 24-Hour BH (Behavioral Health) Assessments revealed in part the following:
09/07/12 at 2000 (8:00 p.m.).....Attempted to burn female peer with her cigarette on smoke break, but attempt was aborted by MHT....Placed in time out/attempted to leave time out requiring redirection...
09/08/12 at 1800 (6:00 p.m.) - Patient is compliant with meds. She needed time in quiet room today due to her aggressive type behavior with female peer.... 2010 (8:10 p.m.)....Pulled her jacket off and threw it on the floor and attempted to go in day room but was redirected....Patient attempting to harm female peer....Haldol 10 mg. given IM (Intramuscular injection)......
09/09/12 at 0025 (12:25 a.m.) - Was asleep in time out room. Left time out room and went to peer's room (female) and put her hands around peer's neck requiring redirection...
09/12/12 at 1945 (7:45 p.m.) - ....Hit male peer. Stated, "God and I needed some leverage.".... 2330 (11:30 p.m.) - Running in hall in bra and shirt and nude from waist down requiring redirection.
09/14/12 at 0930 (9:30 a.m.) - Patient is not getting along well on the unit. She has attempted to attack the activity director and one of the MHTs. She went in time out to calm down....
( Incident Report revealed Patient #3 was found in bed with a male patient on 09/15/12 at 12:45 a.m.)

Review of the physician orders and observation flow sheets revealed the observation level order for Patient #3 was Q 15 minutes (Special Precautions I) from admission until 09/29/12.

Review of the Master Treatment Plan, dated 09/04/12 revealed the patient's problem list indicated Psychosis and Noncompliance with medications were the only problems identified. Review of the care plan for psychosis revealed the patient had Disorganized Thoughts, Paranoid Ideations, and Negative Symptoms. Bizarre Behaviors was not checked. There was no documented evidence that the patient's violent thoughts and potential for violent behavior was addressed on the treatment plan. There was no documented evidence that the patient's aggressive, threatening behavior and sexually inappropriate behavior toward other patients and staff was identified on the treatment plan, and there were no interventions identified to address the patient's behaviors to protect other patients.

Further review of the patient's record revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m., after hitting the charge nurse. The record also revealed the patient was placed in seclusion again on 09/16/12 at 5:45 a.m. for physically attacking the staff, and again at 7:30 p.m for attacking staff. Review of the Treatment Plan revealed that the plan was updated to include the seclusion for an Alteration in Behavior, Sexually Inappropriate, and Combative towards staff. There were no other interventions identified on the treatment plan to address the patient's aggressive behavior, sexually inappropriate behavior, and combative behavior towards other patients and staff, other than seclusion.

Further review of the Nursing 24-Hour BH Assessments revealed in part the following:
09/20/12 at 1200 (12:00 p.m.) - Patient attacked a MHT (Mental Health Technician) for no apparent reason. she was given a quiet area to calm down..... 1400 (2:00 p.m.) - Patient attacked the MHT and was placed in a quiet area to be watched closely by a different MHT while she calmed down. She eventually agreed to behave and was allowed to go back among the general population. 2000 (8:00 p.m.) - ...Delusional, Paranoid, accepting redirection. Attempts to have physical contact with male patient.....
09/24/12 at 0930 (9:30 a.m.) - ...Patient is easily agitated. She took another patient's cane and attempted to hit him with it. She put herself in time out.....2200 (10:00 p.m.) - Patient was in another patient's room and had to be redirected out. Patient did not have clothing on. Patient returned to own room. Patient redirected for physical contact with other patients.
09/25/12 at 0930 (9:30 a.m.) - ....She has been acting out today and tried to burn me with her cigarette.....2145 (9:45 p.m.) - Patient attempting to go into male patient's room, noted firm redirection and was difficult to redirect...
09/29/12 at 1200 (12:00 p.m.) - .....She walked up being me when I walked into the contraband room and she tried to hit me, but I blocked it and she walked away to her room..... 1750 (5:50 p.m.) - Patient received Haldol 10 mg IM at 1750 for psychosis. She has attacked the staff several times. She is also now a 1:1 by a female, Caucasian tech because the doctor doesn't want her to feel rewarded with special behaviors, such as being watched by an AA (African American) tech.

Further review of the treatment plan revealed no documented evidence that the plan was updated with the patient's behaviors and there were no interventions to address the patient's behavior or the protection of other patients and staff. The change in the observation status on 09/29/12 was not included in the treatment plan.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on the 7 a.m. to 7 p.m. shift. S5RN verified she had placed Patient #3 in seclusion on 09/15/12. S5 stated the patient had multiple occurrences of attacking the staff and other patients prior to this date . S5 indicated the patient's behaviors increased after she had been on the unit about a week. S5 stated the attacks were unprovoked and the patient was unpredictable. S5 stated, "We don't know when she will attack". S5 reviewed the patient's treatment plan and verified the only update to the plan of care was on 09/15/12 when the patient was placed in seclusion. S5 verified the patient's aggressive, attacking behavior toward other patients and the staff had not been identified as a problem, and there were no interventions identified to address the behavior and protect the other patients and staff. S5 also verified the patient had demonstrated multiple incidents of sexually inappropriate behavior and this was not identified as a problem on the treatment plan and there were no interventions identified to address this problem, except seclusion. S5 confirmed 1:1 observation was not implemented for Patient #3 until 09/29/12. S5 stated, "We could have put her on 1:1 earlier and that may have prevented seclusion." When asked if any patients were injured by Patient #3, S5 stated yes, Patient #5, and S11LPN were both scratched by Patient #3.

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he was the Charge Nurse on the 7:00 p.m. to 7 a.m. shifts on 09/14/12 and 09/24/12 when Patient #3 was found in bed with male patients. S6 stated Patient #3 was found in bed with Patient #6 on the 15 minute round check. S6 stated both patients had their clothes on and were asleep. S6 stated they escorted the patient back to her room and he completed an incident report. S6 verified the treatment plan was not updated after this incident. S6 stated S8MHT found Patient #3 naked in bed with Patient #1 and they were trying to have sex. S6 stated he went to Patient #1's room and Patient #3 ran out naked. S6 stated he moved Patient #1 to another room that night and they watched Patient #3 closer. S6 verified he did not document an incident report, did not update the treatment plan for either patient, and did not notify the physician of the incident, "Because nothing happened." S6 confirmed 1:1 monitoring was not implemented after this incident and stated it should have been. S6 stated, "Always possible she could do it again. 1:1 monitoring should ensure she did not go into another room."

On 10/11/12 at 3:25 p.m., in a face-to-face interview, the Medical Director (and Patient #3's psychiatrist), S9 confirmed Patient #3 had multiple instances of attacking the staff and her behavior had been difficult to control. S9 stated Patient #3 has an inferiority complex and he did not want to put her on 1:1 observation. S9 stated he thought he could control her with medication and did not think she was a danger to others. S9 stated Patient #3 had attacked other patients by attempting to burn a patient with a cigarette and choke another patient. S9 stated he was not aware that Patient #3 had attempted to have sex with a male patient. S9 verified he had no orders to address interventions to prevent Patient #3 from going into other patient's rooms. When asked about the use of 1:1 observation to prevent Patient #3 from attacking staff and patients, S9 stated he did not want Patient #3 to feel a personal attack since she was black.

On 10/12/12 at 12:20 p.m. the Behavioral Health Unit Director, S3 was interviewed. S3 indicated she was aware that 1:1 observation had not been implemented for Patient #3 when the patient had attacked other patients or staff. S3 indicated the other patients on the unit were placed at risk by not implementing preventative measures to protect them from Patient #3's behaviors. S3 indicated she was not aware of the second incident where Patient #3 was found naked in a male patient's bed. S3 stated 1:1 observation should have been implemented after the first incident where the patient was found in another patient's bed. S3 stated "Watch closer" was not enough. S3 verified an incident report and an investigation should have been done for the incident where Patient #3 was naked in bed with a male patient. S3 indicated she had identified the need for staff training on seclusion, managing patient behavior and 1:1 observation. S3 stated the training had not been done yet.

Review of the hospital policy titled Special Precautions and Observation Levels, revision date 04/20/11 and reviewed date 02/15/12, provided as current policy by S1 Director of Nursing, revealed in part the following:
I. Policy: The hospital shall institute staff monitoring as required to prevent patients from harming themselves or others. Indications of suicidal intent, a desire to elope, or increasing agitation will be immediately evaluated by the staff member as observed......In order to provide protection to psychiatric patients, three levels of observation monitoring is provided by a train staff member under the direction of the Physician and Registered Nurse. A. Special Precautions I - monitoring every 15 minutes. Special Precautions II - monitoring on a constant basis. C. A Registered Nurse may place a patient on a Special Precautions and increased the level of the observation in all cases the least restrictive clinically appropriate intervention will be made. The Attending Physician is always contacted to give a specific order for the level of monitoring. Any discontinuation of monitoring or lessening of the level of monitoring must be by Physician order.
II. Procedure:
A. A written physician's order is obtained for Special Precautions.
1. After evaluation and assessment, staff monitoring may be instituted by the Attending Physician or Registered Nurse.

Review of the hospital policy titled Initial Plan of Care revision date of 12/08/11, provided by S1 Director of Nursing and current policy, revealed in part the following:
I. Policy: All patient will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professionals through licensure, training and experience.
II. Purpose: To establish a comprehensive, goal-oriented, individualized plan for each patient served based on assessment of patient physical, cognitive, behavioral communicative, emotional, pharmacological, pain management, and social needs.
III. Procedure: Each individualized treatment plan is developed through the initial evaluation and team conference process in coordination with the attending physician and treatment team. The individual treatment plan include the following information presently behavioral: The type of treatment and/or services to be provided, and revised when appropriate....

Review of the hospital policy titled Plan of Care revision date of 08/21/12, provided by S1 Director of Nursing and current policy, revealed in part the following:
I. Policy: To ensure that the needs of the patient and family/significant other(s) are met and have access to the appropriate setting and level of care, health care professionals, and type of medical health and social services needed.
A.1. After a thorough nursing assessment is done, care plans are completed by an RN. The care plan will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals. All interventions should be patient specific...The admission assessment data and physician orders are the basis for the selection and individualization of the patient plan of care. Patients receive care based on documented assessment of their need....Additional problems unique to the patient may be included and reassessed whenever warranted by the patient's condition.....Patients are evaluated on a regular basis as delegated by the Registered Nurse. Patient outcomes and response to treatment/implementation of patient care planning is evaluated and documented daily....All nurses are responsible for up dating care plans with specific changes in patient's condition, as new orders are written and as treatment changes.

c) Failing to document incidents of patient attacks and sexually inappropriate behavior towards other patients and staff according to hospital policy:

Patient #3
Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia. Review of the Psychiatric Evaluation dated 09/01/12 revealed the patient's chief complaint was, "I had a knife to kill her (sister)". The problem list included Bizarre delusions about being married to God and having immense powers, Tendency to thoughts of violence, Lability of mood, Non-compliance with medications....

Review of the patient's record revealed Patient #3 had attacked other patients on the following dates: 09/07/12, 09/08/12, 09/12/12, 09/24/12, and 09/29/12. The patient's record also revealed the patient had physically attacked the staff on the following dates: 09/14/12, 09/15/12, 09/16/12, 09/20/12, 09/25/12, and 09/29/12. The patient's record revealed Patient #3 had demonstrated sexually inappropriate behavior on the following dates: 09/12/12, 09/14/12, 09/20/12, and 09/24/12.

Review of the hospital's incident report log revealed only 3 incidents involving Patient #3 were documented. Review of the incident reports revealed the following:
Incident #378 occurred on 09/15/12 at 12:45 a.m. with Patient #3 found in bed with male patient. Both fully dressed, no sexual contact noted. The immediate actions taken were documented as female patient sent back to room. MHT to closely monitor.

Incident #408 occurred on 09/24/12 at 7:45 a.m. with Patient #3 attacking MHT on 2 occasions. Patient was angry/nervous/anxious because of treatment plan and made an irrational behavior decision. Immediate actions taken were documented as patient privileges were revoked for a time. Redirected behavior. Continuous careful monitoring of patient's actions.

Incident #415 occurred on 09/29/12 at 5:00 p.m. with Patient #3 lunging toward staff member. Another staff member and patient (Patient #5) came to assist. Patient #3 was swinging arms and scratched Patient #5. PRN (As needed) injection was given for behavior. Immediate actions taken were documented as PRN injections and quiet time, 1:1 monitoring in place. Staff attended to Patient #5's scratch/skin tear.

On 10/11/12 at 9:45 a.m., S5RN was interviewed. After reviewing the record for Patient #3, S5 verified the patient had multiple instances of attacking other patients and staff, and had sexually inappropriate behaviors. S5 stated Patient #3 had attempted to burn her with a cigarette, had hit her, and had lunged at her. S5 stated Patient #3 had scratched S11 on her face this month. S5RN verified she had not documented incident reports on these occurrences. S5 stated she documented incident reports for, "really significant" incidents. S5 then indicated significant incidents were patient falls or patient-to-patient contact. S5 verified the patient attacked her on 09/29/12 and she administered Haldol 10 mg. injection to the patient. S5 stated she did not document an incident report for this occurrence because, "nobody got hurt". S5 stated, "When you have incident reports for that type of behavior we don't keep doing them. We would be doing incident reports all day."

On 10/11/12 at 12:05 p.m., S6RN was interviewed. S6 verified he had documented the incident report on 09/15/12 when Patient #3 was found in a male patient's bed asleep with her clothes on. S6 also verified that he did not document an incident report on 09/24/12 when Patient #3 was found naked in bed with a male patient and stated, "I probably should have."

On 10/12/12 at 11:35 a.m. S11LPN was interviewed and stated she had not been attacked by Patient #3 until about 1 week ago. S11 indicated the patient had scratched her on her face and pointed to an area to the right side of her mouth. S11 stated S5RN had documented an incident report on this occurrence.

On 10/12/12 at 8:35 a.m., in a face-to-face interview the Director of Nursing confirmed the only incident reports involving Patient #3 were the 3 incidents referred to above. S1 stated incident reports should be completed for unusual occurrences such as patient falls, medication errors, change in condition, treatment errors, transfer to acute care, harm to patient. S1 indicated an incident report should be documented if a patient was found attempting to have sex with another patient, and if a patient attacked the staff or other patients with or without injury.

On 10/12/12 at 12:20 p.m., in a face-to-face interview the Behavioral Health Unit Director, S3 confirmed incident reports had not been documented on all the occurrences involving Patient #3. S3 confirmed the incident report was the method used to inform her of occurrences on the unit. S3 verified she was not aware

Based on record review and interview, the hospital failed to ensure less restrictive interventions were implemented and determined to be ineffective before initiating the use of patient seclusion for 1 of 1 (Patient #3) sampled patients reviewed for the use of seclusion out of a total sample of 6. Findings:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the Nursing 24-Hour BH (Behavioral Health) Assessment dated 09/15/12 revealed the following: "0930 (9:30 a.m.) Pt. (Patient) is AA&O X3 (Awake, Alert & Oriented to person, place, and time), but she is delusional. She snuggled into another patient's bed last night and got a time out for the behavior. She believes that the other patient is God. She hit me when I told her to go to time out. She is paranoid and combative. Non-cooperative, but she does take her meds and ate well at breakfast.
1800 (6:00 p.m.) Patient refused 1800 vital signs. She is combative and threw the thermometer on the floor. She has been compliant with her meds through the day and ate well at meals." The above entries were signed by S5RN and were the only entries documented in the nurse's notes for 09/15/12, 7 a.m. to 7 p.m. shift.

Review of the physician's orders dated 09/15/12 revealed the following verbal orders:
"1215 (12:15 p.m.) Place patient in seclusion/time out for sexual inappropriate behavior and combative behavior towards staff and other patients for 4 hours.
1615 (4:15 p.m.) Continue seclusion/time out for an additional 4 hours for continued behavioral problems." The verbal orders were documented by S5RN.

Review of the restraint/seclusion form revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m.. The following alternative or less restrictive measures were checked as used: determine internal/external causes of behavior, re-direct the individual's focus, suggest privacy/voluntary time-out, one-to-one session; verbal de-escalation, clear, firm limit setting, and psychotropic medications/MD order obtained.
The form also revealed the specific patient behavior warranting seclusion was, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue."
The section for the criteria for release from seclusion was left blank. The section for the date and time the physician was notified was left blank.
Further review of the form revealed the exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.


There was no documented evidence of an incident where the patient was combative to other patients and staff, and sexually inappropriate, requiring seclusion at 12:15 p.m. There was no documented evidence that a time out was used, that verbal de-escalation was attempted, that firm limit setting was attempted, and there was no documented evidence that any medication orders were requested or obtained.


On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12. S5 indicated Patient #3 had occurrences prior to 09/15/12 where she had attacked the staff, but was re-directable. S5 stated on 09/15/12 she went to the smoking area to speak to the patient about her behavior the night before where she was sexually inappropriate and attacking the staff. S5 stated she asked the patient if she understood what she (S5RN) said. S5 stated Patient #3 sat quietly and then came at her with a cigarette. S5 stated she and S13 MHT walked the patient to the seclusion room and shut the door. S5 stated, "There's been so many incidents with this patient, I don't know all the dates." When asked what was different about this incident that required the patient to be placed in seclusion, S5 stated the cigarette had more potential for injury. S5 stated, "I felt like the behavior had gone on long enough." S5 indicated there were no other threatening behaviors demonstrated by Patient #3 that morning. When asked to find documentation that the patient attempted to burn her, S5 reviewed the patient's record and verified the incident was not documented in the record. After reviewing the restraint/seclusion form, S5 verified she had checked the above less restrictive measures were attempted. S5 verified 1:1 observation was not attempted on 09/15/12, Time Out was not attempted on 09/15/12, and there was no request for psychotropic medications on 09/15/12. S5 indicated she checked those measures since they had been attempted in the past. S5 verified less restrictive measures were not attempted after this incident. S5 also verified she had documented on the restraint/seclusion form that the behavior warranting seclusion was the patient hit her and was sexually inappropriate towards another patient. S5 confirmed the sexually inappropriate behavior had occurred the night before. S5 stated she put Patient #3 in seclusion due to she felt like the behavior had gone on long enough and she was a threat to the staff and patients on the unit. S5RN stated, "1:1 observation should have been used first."

On 10/12/12 at 9:30 a.m., in a face-to-face interview, S7MHT confirmed she was assigned to monitor Patient #3 when she was placed in the seclusion room. S7 stated she was in the hallway when S5RN brought the patient in from the smoking area. S7 stated it was around 9:30 a.m. and S5RN put the patient in time out. S7 stated when the patient wanted to leave the room, S5RN locked the door. S7 indicated the patient tried to burn the nurse while in the smoking area. S7 verified she had documented the patient was in her room and not in the seclusion room. S7 stated the patient was calm and cooperative all day, but was not in her room. S7 confirmed the patient was in the seclusion room all day. S7 stated she did not know why the patient was in seclusion all day.

Review of the hospital's policy titled, Patient Rights, revision date of 10/18/2011, and provided by S1 Director of Nursing as the current Restraint/Seclusion Policy, revealed in part the following: ....All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restrain or seclusion may only imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time.....1. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. A0164. 2. The type or technique of restraint or seclusion used shall be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. A-0165......

Based on record review and interview, the hospital failed to develop and implement policies and procedures for the use of seclusion as evidenced by a) failing to include specific directives on the implementation of seclusion in the restraint/seclusion policy, and; b) failing to develop and implement a policy and procedure for the use of time out. Findings:

a) Failing to include specific directives on the implementation of seclusion in the restraint/seclusion policy:

Review of the hospital policy titled Patient Rights revision date of 10/18/11 and provided as current policy by S1 Director of Nursing, revealed in part the following:
Reference: CMS - Restraint or Seclusion...
I. Policy: The hospital provides all patient with the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinues at the earliest possible time.....
Standards shall be followed for guidance prior to the use of restrain or seclusion: A-0160-A-0188.

Further review of the policy revealed that the CMS standards were stated and the data tag number referenced for A0164 through A0188. There were no specific directives for how the facility staff were to implement the policy. There were no directives for less restrictive interventions or alternatives to restraint/seclusion identified in the policy. There were no directives regarding the supervision/observation of the patient in seclusion. There were no directives on how the staff was to assess and document the patient behavior and the patient response to the interventions. The policy indicated a Registered Nurse or a Physician Assistant could conduct the face-to-face 1 hour evaluation of the patient in restraint/seclusion if trained, but failed to indicate the training required. The policy failed to include specific directives on how the 1 hour evaluation was to be documented. The policy did not include directives on the use of the restraint/seclusion form or the Behavioral Restraint and Seclusion Flowsheet. There was no documentation of directives in the policy on the criteria for the release of the patient from restraint/seclusion.

On 10/10/12 at 4:10 p.m., a face-to-face interview was conducted with S1 Director of Nursing. After reviewing the policy and procedure for patient rights, restraint/seclusion, S1 verified that policy was written with the CMS standards for the use of restraint/seclusion including a reference to the standards. S1 verified there were no specific directives for the staff on how to implement the policy and verified the staff did not have access to the CMS standards. S1 verified the above policy indicated a registered nurse or physician assistant could conduct the 1 hour face-to-face evaluation, but stated there were no staff at this facility who had that training.


b) Failing to develop and implement a policy and procedure for the use of time out:

Review of the medical record for Patient #3 revealed "Time Out" and "Quiet Room" had been used to address the patient's behavior. Review of the record also revealed the patient was placed in seclusion on 09/15/12 and 09/16/12.

On 10/10/12 at 4:10 p.m., S1 Director of Nursing was interviewed. When asked to explain the difference between "Time Out" and seclusion, S1 stated seclusion is when the door is closed and time out is when the door is open. S1 indicated the seclusion room on the behavioral health unit was used for seclusion, time out, and the quiet room. S1 stated there was no policy and procedure for the use of "Time Out" or "Quiet Room".

Based on record review and interview, the hospital failed to ensure orders for the use of seclusion were not written on an as needed basis as evidenced by a) failing to clarify physician's orders for the use of time out or seclusion; b) the use of trial release from seclusion, and; c) failing to obtain a new order for seclusion after a recent release from seclusion for 1 of 1 (#3) sampled patients reviewed for the use of seclusion out of a total sample of 6 (#1-#6). Findings:

a) Failing to clarify physician's orders for the use of time out or seclusion:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the physician's orders revealed the following verbal orders:
"09/15/12 - 1215 (12:15 p.m.) Place patient in seclusion/time out for sexual inappropriate behavior and combative behavior towards staff and other patients for 4 hours.
09/15/12 - 1615 (4:15 p.m.) Continue seclusion/time out for an additional 4 hours for continued behavioral problems." The above verbal orders were documented by S5RN.
"09/16/12 - 0545 (5:45 a.m.) Place patient in seclusion/time out for combative behavior, attacking staff for up to 4 hours.

Review of the patient's medical record revealed Patient #3 was placed in seclusion on the following dates and times:
09/15/12 at 12:15 p.m. with the specific patient behavior warranting seclusion documented as, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue." The exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.
09/16/12 at 5:45 a.m. with the specific behavior warranting seclusion documented as, "Attacking staff, patient impulsive, unable to control behavior, physically attacking staff." The exit date and time from seclusion was 09/16/12 at 9:45 a.m.
09/16/12 at 7:30 p.m. with the specific behavior warranting seclusion documented as "Attacking staff, sneaks up behind staff and physically hits/grabs. Patient impulsive/combative." The exit date and time from seclusion was 09/16/12 at 10:45 p.m.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12. S5 stated on 09/15/12 she went to the smoking area to speak to the patient about her behavior the night before where she was sexually inappropriate and attacking the staff. S5 stated she asked the patient if she understood what she (S5RN) said. S5 stated Patient #3 sat quietly and then came at her with a cigarette. S5 stated she and S13 MHT walked the patient to the seclusion room and shut the door. S5 verified the patient was placed in seclusion on 09/15/12 at 12:15 p.m. S5 verified she had written the verbal order for "seclusion/time out" and verified the order indicated either seclusion or time out could be used.

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he was the charge nurse on the 7:00 p.m. to 7:00 a.m. shift on 09/15/12 and 09/16/12. S6 verified Patient #6 was placed in seclusion on 09/16/12 at 5:45 a.m. and again at 7:30 p.m. S6 verified the verbal order he had received on 09/16/12 at 5:45 a.m. indicated seclusion or time out could be used.

On 10/12/12 at 8:35 a.m., in a face-to-face interview, the Director of Nursing, S1 confirmed the verbal orders written as seclusion/time out, indicated the nurse could determine which intervention to implement for the patient. S1 indicated the order for seclusion should have been specific to seclusion and not seclusion or time out.

b) The use of Trial Release from Seclusion:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the restraint/seclusion form revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m.. The form also revealed the specific patient behavior warranting seclusion was, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue."
Review of the section, "Continuation of Restraint and Seclusion" revealed a written order was obtained on 09/15/12 at 1615 (4:15 p.m.) to continue seclusion, but there was no documented evidence of the behavior warranting continuation of the seclusion.
Further review of the form revealed the exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.

Review of the physician's orders dated 09/15/12 revealed the following verbal orders:
"1215 (12:15 p.m.) Place patient in seclusion/time out for sexual inappropriate behavior and combative behavior towards staff and other patients for 4 hours.
1615 (4:15 p.m.) Continue seclusion/time out for an additional 4 hours for continued behavioral problems." The verbal orders were documented by S5RN.

Review of the Behavioral Restraint and Seclusion Flowsheet, dated 09/15/12, documented by S5RN revealed the nurse documented a Trial Release at 12:45 p.m., 3:30 p.m., and 6:15 p.m. S5RN stated she considered a trial release from seclusion was when the patient was allowed to go to the bathroom.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she had documented the trial release from seclusion at 12:45 p.m., 3:30 p.m., and 6:15 p.m. S5RN stated she took the patient to the bathroom at these times and the patient lunged at her so she put her back in seclusion.


c) Failing to obtain a new order for seclusion after a recent release from seclusion:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the physician's orders revealed the following verbal order:
"09/16/12 - 1930 (7:30 p.m.) Haldol 10 mg. IM stat, Seclusion for up to 4 hours for physically attacking staff/combative behavior/agitation.

Review of the patient's medical record revealed Patient #3 was placed in seclusion on 09/16/12 at 7:30 p.m. with the specific behavior warranting seclusion documented as "Attacking staff, sneaks up behind staff and physically hits/grabs. Patient impulsive/combative." The exit date and time from seclusion was 09/16/12 at 10:45 p.m.

Review of the Behavioral Restraint and Seclusion Flowsheet, dated 09/16/12, documented by S6RN revealed the nurse documented a Trial Release at 8:30 p.m. Review of the flow sheet revealed the patient was returned to seclusion.

Review of the Observation Flow Sheet dated 09/16/12 revealed S8MHT documented the patient was in the hall at 21:00 and 21:15 (9:00 p.m. and 9:15 p.m.).

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he had attempted a trial release from seclusion for Patient #3 at 8:30 p.m. S6 stated the patient was removed from seclusion on a trial basis. S6 stated after the patient was released from seclusion, Patient #3 began stalking the staff and tried to go into Patient #6's room. S6 stated he placed the patient back in seclusion, but did not obtain a physician's order to do so. S6 stated he thought he could put the patient back in seclusion under the previous order.

On 10/12/12 at 8:35 a.m., in a face-to-face interview, the Director of Nursing, S1 verified trial release from seclusion was not permissible, and a new order was required when a patient was placed back in seclusion. When asked to explain the difference between "Time Out" and seclusion, S1 stated seclusion is when the door is closed and time out is when the door is open. S1 indicated the seclusion room on the behavioral health unit was used for seclusion, time out, and the quiet room. S1 stated there was no policy and procedure for the use of "Time Out" or "Quiet Room".


Review of the hospital's policy titled, Patient Rights, revision date of 10/18/2011, and provided by S1 Director of Nursing as the current Restraint/Seclusion Policy,revealed in part the following: ....All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time..... 6. Orders for the use of restraint or seclusion shall never be written as a standing order or on an as needed basis (PRN). A-0169.

Based on record review and staff interview, the hospital failed to ensure that a face-to-face evaluation of the patient within one hour of the initiation of seclusion was conducted by a physician or a licensed independent practitioner for 1 of 1 (#3) patients reviewed for the use of seclusion out of a total sample of 6 (#1-#6). Findings:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the Nursing 24-Hour BH (Behavioral Health) Assessment dated 09/15/12 revealed the following: "0930 (9:30 a.m.) Pt. (Patient) is AA&O X3 (Awake, Alert & Oriented to person, place, and time), but she is delusional. She snuggled into another patient's bed last night and got a time out for the behavior. She believes that the other patient is God. She hit me when I told her to go to time out. She is paranoid and combative. Non-cooperative, but she does take her meds and ate well at breakfast.
1800 (6:00 p.m.) Patient refused 1800 vital signs. She is combative and threw the thermometer on the floor. She has been compliant with her meds through the day and ate well at meals." The above entries were signed by S5RN and were the only entries documented in the nurse's notes for 09/15/12, 7 a.m. to 7 p.m. shift.

Review of the physician's orders dated 09/15/12 revealed the following verbal orders:
"1215 (12:15 p.m.) Place patient in seclusion/time out for sexual inappropriate behavior and combative behavior towards staff and other patients for 4 hours.
1615 (4:15 p.m.) Continue seclusion/time out for an additional 4 hours for continued behavioral problems." The verbal orders were documented by S5RN.

Review of the restraint/seclusion form revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m.. The form also revealed the specific patient behavior warranting seclusion was, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue." The section for the criteria for release from seclusion was left blank. The section for the date and time the physician was notified was left blank.
Physician evaluation within 1 hour was left blank.
Further review of the form revealed the exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.

Review of the physician's progress notes revealed that the only progress note documented on 09/15/12 was at 11:20 a.m. and did not include an evaluation of the patient while in seclusion.

Review of the restraint/seclusion form revealed Patient #3 was again placed in seclusion on 09/16/12 at 5:45 a.m. The specific behavior warranting seclusion was documented as attacking staff, patient impulsive, unable to control behavior, physically attacking staff. Review of the "Physician Evaluation within 1 hour" section revealed it was left blank. Review of the form revealed the physician was notified on 09/16/12 at 0550 (5:50 a.m.). Further review of the form revealed the exit date and time from seclusion was 09/16/12 at 9:45 a.m.
Review of the physician's progress notes revealed no documented evidence of a progress note dated 09/16/12.

Review of the restraint/seclusion form revealed Patient #3 was again placed in seclusion on 09/16/12 at 7:30 p.m. The specific behavior warranting seclusion was documented as attacking staff, sneaks up behind staff and physically hits/grabs. Patient impulsive/combative. Review of the "Physician Evaluation within 1 hour" section revealed S14 Nurse Practitioner signed on the physician signature line. Further review of the form revealed the exit date and time from seclusion was 09/16/12 at 10:45 p.m.
Review of the physician's progress notes revealed no documented evidence of a progress note dated 09/16/12. There was no documentation of the nurse practitioner's evaluation of the patient in seclusion.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12. S5 verified the patient was placed in seclusion on 09/15/12 at 12:15 p.m. When asked if the physician evaluated the patient within 1 hour of placing her in seclusion, S5 stated, "He was on the unit". S5 verified the restraint/seclusion form indicated there was no 1 hour evaluation by the physician or nurse practitioner.

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he was the charge nurse on the 7:00 p.m. to 7:00 a.m. shift on 09/15/12 and 09/16/12. S6 verified Patient #6 was placed in seclusion on 09/16/12 at 5:45 a.m. and again at 7:30 p.m. S6 verified the physician did not see the patient within 1 hour of initiating the seclusion. S6 stated he had not seen the policy at this facility, but thought it was ok for the RN to evaluate the patient in one hour.

On 10/11/12 at 3:25 p.m. in a face-to-face interview, S9 Medical Director confirmed he was the patient's psychiatrist and was familiar with the patient. When asked what the procedure was to evaluate a patient after the patient was placed in seclusion, S9 stated the patient should be evaluated in 4 hours. After reviewing the hospital's Patient Rights policy including Restraint/Seclusion, S9 verified the policy indicated the physician or licensed independent practitioner was to evaluate the patient within 1 hour of placement in seclusion. S9 stated he was not aware of this requirement and verified this had not been done for Patient #3.

On 10/11/12 at 4:00 p.m., in a face-to-face interview, S1 Director of Nursing confirmed the hospital policy was for a physician or licensed independent practitioner to conduct the 1 hour evaluation of the patient in seclusion. S1 stated there were no nurses or physician assistants at the facility that had been trained to perform the evaluation. S1 stated that S14 was the nurse practitioner for S15 Internal Medicine Physician. S1 confirmed there was no documentation of an evaluation of the patient by the physician or the nurse practitioner within 1-hour after the patient was placed in seclusion.


Review of the hospital's policy titled, Patient Rights, revision date of 10/18/2011, and provided by S1 Director of Nursing as the current Restraint/Seclusion Policy,revealed in part the following: ....All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restrain or seclusion may only imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time.....15. When a restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient shall be seen face-to-face within 1 hour after the initiation of the intervention. By a -
a) Physician or other licensed independent practitioner; or b) Registered nurse or physician assistant who has been trained in accordance with the requirements specified in paragraph (f) of this section.

Based on record review and interview, the hospital failed to ensure an evaluation of the patient in seclusion was conducted within 1 hour after initiation of seclusion and included an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the seclusion for 1 of 1 (#3) sampled patients reviewed for the use of seclusion out of a total sample of 6 (#1-#6). Findings:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the restraint/seclusion form revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m.. The form also revealed the specific patient behavior warranting seclusion was, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue." The section for the criteria for release from seclusion was left blank. The section for the date and time the physician was notified was left blank.
Physician evaluation within 1 hour was left blank.
Further review of the form revealed the exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.

Review of the physician's progress notes revealed that the only progress note documented on 09/15/12 was at 11:20 a.m. and did not include an evaluation of the patient while in seclusion.

Review of the restraint/seclusion form revealed Patient #3 was again placed in seclusion on 09/16/12 at 5:45 a.m. The specific behavior warranting seclusion was documented as attacking staff, patient impulsive, unable to control behavior, physically attacking staff. Review of the "Physician Evaluation within 1 hour" section revealed it was left blank. Review of the form revealed the physician was notified on 09/16/12 at 0550 (5:50 a.m.). Further review of the form revealed the exit date and time from seclusion was 09/16/12 at 9:45 a.m.
Review of the physician's progress notes revealed no documented evidence of a progress note dated 09/16/12.

Review of the restraint/seclusion form revealed Patient #3 was again placed in seclusion on 09/16/12 at 7:30 p.m. The specific behavior warranting seclusion was documented as attacking staff, sneaks up behind staff and physically hits/grabs. Patient impulsive/combative. Review of the "Physician Evaluation within 1 hour" section revealed S14 Nurse Practitioner signed on the physician signature line. Further review of the form revealed the exit date and time from seclusion was 09/16/12 at 10:45 p.m.
Review of the physician's progress notes revealed no documented evidence of a progress note dated 09/16/12. There was no documentation of the nurse practitioner's evaluation of the patient in seclusion.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12 from 7 a.m. to 7 p.m.. S5 verified the patient was placed in seclusion on 09/15/12 at 12:15 p.m. When asked if the physician evaluated the patient within 1 hour of placing the patient in seclusion, S5 stated, "He was on the unit". S5 verified the restraint/seclusion form indicated there was no 1 hour evaluation by the physician or nurse practitioner.

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he was the charge nurse on the 7:00 p.m. to 7:00 a.m. shift on 09/15/12 and 09/16/12. S6 verified Patient #6 was placed in seclusion on 09/16/12 at 5:45 a.m. and again at 7:30 p.m. S6 verified the physician did not see the patient within 1 hour of initiating the seclusion. S6 stated he had not seen the policy at this facility, but thought it was ok for the RN to evaluate the patient in one hour.

On 10/11/12 at 3:25 p.m. in a face-to-face interview, S9 Medical Director confirmed he was the patient's psychiatrist and was familiar with the patient. When asked what the procedure was to evaluate a patient after the patient was placed in seclusion, S9 stated the patient should be evaluated in 4 hours. After reviewing the hospital's Patient Rights policy including Restraint/Seclusion, S9 verified the policy indicated the physician or licensed independent practitioner was to evaluate the patient within 1 hour of placement in seclusion. S9 stated he was not aware of this requirement and verified this had not been done for Patient #3.

On 10/11/12 at 4:00 p.m., in a face-to-face interview, S1 Director of Nursing confirmed the hospital policy for a physician or licensed independent practitioner to conduct the 1 hour evaluation of the patient in seclusion. S1 stated there were no nurses or physician assistants at the facility that had been trained to perform the evaluation. S1 stated that S14 was the nurse practitioner for S15 Internal Medicine Physician.
S1 confirmed there was no documentation of an evaluation of the patient by the physician or the nurse practitioner within 1-hour after the patient was placed in seclusion.

Review of the hospital's policy titled, Patient Rights, revision date of 10/18/2011, and provided by S1 Director of Nursing as the current Restraint/Seclusion Policy,revealed in part the following: ....All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restrain or seclusion may only imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time.....
15. When a restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient shall be seen face-to-face within 1 hour after the initiation of the intervention. By a - a) Physician or other licensed independent practitioner; or b) Registered nurse or physician assistant who has been trained in accordance with the requirements specified in paragraph (f) of this section.
16. the patient shall be seen face-to-face within 1 hour after the initiation of the intervention to evaluate - a) The patient's immediate situation; b) The patient's reaction to the intervention; c) The patient's medical and behavioral condition; and d) The need to continue or terminate the restraint or seclusion.
20. When restraint or seclusion is used, there shall be documentation in the patient's medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior; A0184.

Based on record review and interview, the hospital failed to ensure a 1 hour face-to-face medical and behavioral evaluation was conducted and documented in the medical record after the patient was placed in seclusion for 1 of 1 (#3) sampled patients reviewed for the use of seclusion out of a total sample of 6 (#1-#6). Findings:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the patient's medical record revealed Patient #3 was placed in seclusion on the following dates and times:
09/15/12 at 12:15 p.m. with the specific patient behavior warranting seclusion documented as, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue." The exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.
09/16/12 at 5:45 a.m. with the specific behavior warranting seclusion documented as, "Attacking staff, patient impulsive, unable to control behavior, physically attacking staff." The exit date and time from seclusion was 09/16/12 at 9:45 a.m.
09/16/12 at 7:30 p.m. with the specific behavior warranting seclusion documented as "Attacking staff, sneaks up behind staff and physically hits/grabs. Patient impulsive/combative." The exit date and time from seclusion was 09/16/12 at 10:45 p.m.

Review of the physician progress notes, restraint/seclusion forms, Behavioral Restraint and Seclusion Flowsheets, and the Nursing 24-hour BH (Behavioral Health) Assessments revealed no documentation of a face-to-face, 1-hour evaluation of the patient's immediate situation, reaction to the seclusion, the patient's medical and behavioral condition, and the need to continue or terminate the seclusion

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12. S5 verified the patient was placed in seclusion on 09/15/12 at 12:15 p.m. S5 verified the restraint/seclusion form indicated there was no 1 hour evaluation by the physician or nurse practitioner.

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he was the charge nurse on the 7:00 p.m. to 7:00 a.m. shift on 09/15/12 and 09/16/12. S6 verified Patient #6 was placed in seclusion on 09/16/12 at 5:45 a.m. and again at 7:30 p.m. S6 verified the physician did not see the patient within 1 hour of initiating the seclusion. S6 stated he had not seen the policy at this facility, but thought it was ok for the RN to evaluate the patient in one hour.

On 10/11/12 at 3:25 p.m. in a face-to-face interview, S9 Medical Director confirmed he was the patient's psychiatrist and was familiar with the patient. When asked what the procedure was to evaluate a patient after the patient was placed in seclusion, S9 stated the patient should be evaluated in 4 hours. After reviewing the hospital's Patient Rights policy including Restraint/Seclusion, S9 verified the policy indicated the physician or licensed independent practitioner was to evaluate the patient within 1 hour of placement in seclusion. S9 stated he was not aware of this requirement and verified this had not been done for Patient #3.

On 10/11/12 at 4:00 p.m., in a face-to-face interview, S1 Director of Nursing confirmed the hospital policy was for a physician or licensed independent practitioner to conduct the 1 hour evaluation of the patient in seclusion. S1 stated there were no nurses or physician assistants at the facility that had been trained to perform the evaluation. S1 confirmed there was no documentation of an evaluation of the patient by the physician or the nurse practitioner within 1-hour after the patient was placed in seclusion.


Review of the hospital's policy titled, Patient Rights, revision date of 10/18/2011, and provided by S1 Director of Nursing as the current Restraint/Seclusion Policy,revealed in part the following: ....All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restrain or seclusion may only imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time.....15. When a restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient shall be seen face-to-face within 1 hour after the initiation of the intervention. By a -
a) Physician or other licensed independent practitioner; or b) Registered nurse or physician assistant who has been trained in accordance with the requirements specified in paragraph (f) of this section.

Based on record review and interview, the hospital failed to ensure the patient's medical record included a description of the patient's behavior that warranted placing the patient in seclusion for 1 of 1 (#3) sampled patients reviewed for the use of seclusion out of a total sample of 6 (#1-#6). Findings:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the Nursing 24-Hour BH (Behavioral Health) Assessment dated 09/15/12 revealed the following: "0930 (9:30 a.m.) Pt. (Patient) is AA&O X3 (Awake, Alert & Oriented to person, place, and time), but she is delusional. She snuggled into another patient's bed last night and got a time out for the behavior. She believes that the other patient is God. She hit me when I told her to go to time out. She is paranoid and combative. Non-cooperative, but she does take her meds and ate well at breakfast.
1800 (6:00 p.m.) Patient refused 1800 vital signs. She is combative and threw the thermometer on the floor. She has been compliant with her meds through the day and ate well at meals." The above entries were signed by S5RN and were the only entries documented in the nurse's notes for 09/15/12, 7 a.m. to 7 p.m. shift.

Review of the physician's orders dated 09/15/12 revealed the following verbal orders:
"1215 (12:15 p.m.) Place patient in seclusion/time out for sexual inappropriate behavior and combative behavior towards staff and other patients for 4 hours.
1615 (4:15 p.m.) Continue seclusion/time out for an additional 4 hours for continued behavioral problems." The verbal orders were documented by S5RN.

Review of the restraint/seclusion form revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m.. The form also revealed the specific patient behavior warranting seclusion was, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue." The section for the criteria for release from seclusion was left blank. The section for the date and time the physician was notified was left blank.
Further review of the form revealed the exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.

There was no documented evidence of an incident where the patient was combative to other patients and staff, and sexually inappropriate, requiring seclusion at 12:15 p.m. There was no documented evidence of an incident report involving Patient #3 on 09/15/12.

Review of the Observation Flow Sheet dated, 09/15/12 and documented by S7MHT (Mental Health Technician) revealed the patient was calm and cooperative, eating, or sleeping from 6:45 a.m. to 9:00 p.m. There was no documented evidence on the observation form that the patient was in seclusion.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12. S5 indicated Patient #3 had occurrences prior to 09/15/12 where she had attacked the staff, but was re-directable. S5 stated on 09/15/12 she went to the smoking area to speak to the patient about her behavior the night before where she was sexually inappropriate and attacking the staff. S5 stated she asked the patient if she understood what she (S5RN) said. S5 stated Patient #3 sat quietly and then came at her with a cigarette. S5 stated she and S13 MHT walked the patient to the seclusion room and shut the door. S5 stated, "There's been so many incidents with this patient, I don't know all the dates." When asked what was different about this incident that required the patient to be placed in seclusion, S5 stated the cigarette had more potential for injury. S5 stated, "I felt like the behavior had gone on long enough." S5 indicated there were no other threatening behaviors demonstrated by Patient #3 that morning. When asked to find documentation that the patient attempted to burn her, S5 reviewed the patient's record and verified the incident was not documented in the record. S5 verified less restrictive measures were not attempted after this incident. S5 also verified she had documented on the restraint/seclusion form that the behavior warranting seclusion was the patient hit her and was sexually inappropriate towards another patient. S5 confirmed the sexually inappropriate behavior had occurred the night before. S5 stated she put Patient #3 in seclusion due to she felt like the behavior had gone on long enough and she was a threat to the staff and patients on the unit.

On 10/12/12 at 9:30 a.m., in a face-to-face interview, S7MHT confirmed she was assigned to monitor Patient #3 when she was placed in the seclusion room. S7 stated she was in the hallway when S5RN brought the patient in from the smoking area. S7 stated it was around 9:30 a.m. and S5RN put the patient in time out. S7 stated when the patient wanted to leave the room, S5RN locked the door. S7 indicated the patient tried to burn the nurse while in the smoking area. S7 stated the patient was calm and cooperative all day. S7 confirmed the patient was in the seclusion room all day. S7 stated she did not know why the patient was in seclusion all day.

Review of the hospital's policy titled, Patient Rights, revision date of 10/18/2011, and provided by S1 Director of Nursing as the current Restraint/Seclusion Policy,revealed in part the following: ....All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restrain or seclusion may only imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time..... 21. When restrain or seclusion is used, there shall be documentation in the patient's medical record of the following: A description of the patient's behavior and the intervention used. A-0185.

Based on record review and interviews, the hospital failed to ensure the staff on the psychiatric (Behavioral Health) unit had education and training on techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of seclusion for 7 (S3, S5, S6, S7, S8, S10, S11) of 7 staff members reviewed.
Findings:

Review of the Personnel record for Registered Nurse S6 revealed no documented training for the use of patient seclusion.

Review of the personnel record for Mental Health Technician (MHT) S8 revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, and no documented seclusion training.

Review of the personnel record for S5RN revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, no documented seclusion training, and no documented CPI training.

Review of the personnel record for S3, Behavioral Unit Director, revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, no documented seclusion training, and no documented CPI training.

In an interview on 10/11/12 at 9:00 a.m. with Registered Nurse S5, she said she started on 7/18/12 at the facility. She said she worked at another psychiatric facility from January through May. S5 said her rotation at nursing school and her few months at the other psychiatric facility was her only training in psychiatric nursing. She said she had not had CPI (Crisis Prevention Institute) training yet. She said her orientation to the psychiatric unit at the facility included two days following the charge nurse on the other rotation. S5 also said she had no formalized orientation where she was shown all of the policies and procedures of the hospital. She stated she had just an explanation about seclusion, but no real training.

In an interview on 10/11/12 at 12:50 p.m. with Registered Nurse S6, he stated he had worked at the hospital since 7/11. He said the facility has had an annual competency since he has been here, but he does not remember any training about seclusion.

In an interview on 10/12/12 at 8:25 a.m. with Director of Nursing (DON) S1, she said the staff received a general hospital orientation when hired, but none specific to the psychiatric unit. S1 said there was no training related to seclusion for the staff. S1 also said the staff was not assessed for their competencies upon hire. She said RN S5 only working two shifts with a preceptor was not the normal routine. She said MHTs work 6 shifts with a preceptor, but she had no documentation of their training.

In an interview on 10/12/12 at 9:05 a.m. with Licensed Practical Nurse (LPN) S10, she said she had started working in the psychiatric unit about a year ago. S10 said she received no training on seclusion.

In an interview on 10/12/12 at 9:30 a.m. with MHT S7, she said she had been on the psychiatric unit for two years. She said she did not get any training when she started. She said for 3 days, she followed another MHT. S7 said she received no formalized orientation.

In an interview on 10/12/12 at 11:35 a.m. with LPN S11, she said she had been on the psychiatric unit since 2/10/11. She said the facility had not provided any formalized training on seclusion.

In an interview on 10/12/12 at 12:15 p.m. with Director of Behavioral Health LPN S3, she said she was a supervisor of the staff and a coordinator of the unit. She stated she had not received any orientation to the psychiatric unit when she began as manager. Since there was no director when she took over the unit, she was trained by the staff. S3 stated there needed to be more training to the staff about seclusion.

Review of the Restraint Guideline/Staff Training document provided by S1 Director of Nursing as the staff training used for Restraint/Seclusion training, revealed no documented evidence that seclusion was included in the training.

Review of the hospital policy titled Patient Rights, Reference: CMS-Restraint or Seclusion: Staff Training Requirements, Policy Number III.F., revision date of 10/18/2011, and provided as current policy by the Director of Nursing, S1, revealed in part the following:
I. Policy: The hospital shall provide patients with the right to safe implementation of restraint or seclusion by trained staff.
II. Procedure: The Hospital Administration and/or designee and medical staff shall:
A. Provide the hospital staff (as applicable) and medical staff - Training re: Restraint or Seclusion; following the guidance below.
1. Training Intervals - Staff shall be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restrain or seclusion - a) Before performing any of the actions specified in this paragraph; b) As part of orientation; and c) Subsequently on a periodic basis consistent with hospital policy. A-0196.
2. Training Content - The hospital shall require appropriated staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: a) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. A-0199.

Based on record review and interviews, the hospital failed to ensure the entire staff of the psychiatric unit (Behavioral Health) had education and training in the use of nonphysical intervention skills for 2 of 4 sampled psychiatric unit staff (S3 Behavioral Unit Director, S5RN).
Findings:
Review of the personnel record for S3 Behavioral Health (Psychiatric unit) Director revealed she had no documented Crisis Prevention Institute (CPI) training.

Review of the personnel record for Registered Nurse S5 revealed no documented evidence of CPI training.

In an interview on 10/11/12 at 9:00 a.m. with Registered Nurse S5, she said she started on 7/18/12 at the facility. She said she had not had CPI training yet. She said her orientation to the psychiatric unit at the facility included two days following the charge nurse on the other rotation. S5 also said she had no formalized orientation.

On 10/12/12 at 8:35 a.m., in a face-to-face interview, S1 Director of Nursing confirmed CPI was the training the hospital used for non-physical intervention and behavior management. S1 verified S5 and S3 had not had CPI training at this time.

Review of the hospital policy titled Patient Rights, Reference: CMS-Restraint or Seclusion: Staff Training Requirements, Policy Number III.F., revision date of 10/18/2011, and provided as current policy by the Director of Nursing, S1, revealed in part the following:
I. Policy: The hospital shall provide patients with the right to safe implementation of restraint or seclusion by trained staff.
II. Procedure: The Hospital Administration and/or designee and medical staff shall:
A. Provide the hospital staff (as applicable) and medical staff - Training re: Restraint or Seclusion; following the guidance below.
1. Training Intervals - Staff shall be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restrain or seclusion - a) Before performing any of the actions specified in this paragraph; b) As part of orientation; and c) Subsequently on a periodic basis consistent with hospital policy. A-0196.
2. Training Content - The hospital shall require appropriated staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: ....b) The hospital shall require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: The use of nonphysical intervention skills. A-0200....

Based on record review and interviews, the hospital failed to ensure the appropriate staff had education and training in clinical identification of specific behavioral changes that indicate seclusion is no longer necessary for 7 (S3 Behavioral Unit Director, S5RN, S6RN, S7MHT, S8MHT, S10LPN, S11LPN) of 7 sampled psychiatric unit staff members reviewed.
Findings:
Review of the Personnel record for Registered Nurse S6 revealed no documented training for the use of patient seclusion.

Review of the personnel record for Mental Health Technician (MHT) S8 revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, and no documented seclusion training.

Review of the personnel record for S5RN revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, no documented seclusion training, and no documented CPI training.

Review of the personnel record for S3, Behavioral Unit Director, revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, no documented seclusion training, and no documented CPI training.

In an interview on 10/11/12 at 9:00 a.m. with Registered Nurse S5, she said she started on 7/18/12 at the facility. She said she worked at another psychiatric facility from January through May. S5 said her rotation at nursing school and her few months at the other psychiatric facility was her only training in psychiatric nursing. She said her orientation to the psychiatric unit at the facility included two days following the charge nurse on the other rotation. S5 also said she had no formalized orientation where she was shown all of the policies and procedures of the hospital. She stated she had just an explanation about seclusion, but no real training.

In an interview on 10/11/12 at 12:50 p.m. with Registered Nurse S6, he stated he had worked at the hospital since 7/11. He said the facility has had a competency since he has been here, but he does not remember having any training about seclusion.

In an interview on 10/12/12 at 8:25 a.m. with Director of Nursing (DON) S1, she said the staff received a general hospital orientation when hired, but none specific to the psychiatric unit. S1 said there was no training related to seclusion for the staff. S1 also said the staff was not assessed for their competencies upon hire. She said RN S5 only working two shifts with a preceptor was not the normal routine. She said MHT's work 6 shifts with a preceptor, but she had no documentation of their training.

In an interview on 10/12/12 at 9:05 a.m. with Licensed Practical Nurse (LPN) S10, she said she had started working in the psychiatric unit about a year ago. S10 said she received no training on seclusion.

In an interview on 10/12/12 at 9:30 a.m. with MHT S7, she said she had been on the psychiatric unit for two years. She said she did not get any training when she started. She said for 3 days, she followed another MHT. S7 said she received no formalized orientation and had not received training on seclusion.

In an interview on 10/12/12 at 11:35 a.m. with LPN S11, she said she had been on the psychiatric unit since 2/10/11. She said the facility had not provided any formalized training on seclusion.

In an interview on 10/12/12 at 12:15 p.m. with Director of Behavioral Health LPN S3, she said she was a supervisor of the staff and a coordinator of the unit. She stated she had not received any orientation to the psychiatric unit when she began as manager. Since there was no director when she took over the unit, she was trained by the staff. S3 stated that there needed to be more training to the staff about seclusion. S3 verified she had not received CPI training or training on seclusion.

Review of the hospital policy titled Patient Rights, Reference: CMS-Restraint or Seclusion: Staff Training Requirements, Policy Number III.F., revision date of 10/18/2011, and provided as current policy by the Director of Nursing, S1, revealed in part the following:
I. Policy: The hospital shall provide patients with the right to safe implementation of restraint or seclusion by trained staff.
II. Procedure: The Hospital Administration and/or designee and medical staff shall:
A. Provide the hospital staff (as applicable) and medical staff - Training re: Restraint or Seclusion; following the guidance below.
1. Training Intervals - Staff shall be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restrain or seclusion - a) Before performing any of the actions specified in this paragraph; b) As part of orientation; and c) Subsequently on a periodic basis consistent with hospital policy. A-0196.
2. Training Content - The hospital shall require appropriated staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: ....b) The hospital shall require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: The use of nonphysical intervention skills. A-0200.....iii) Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. A-0204.

Based on record review and interviews, the hospital failed to ensure staff personnel records contained documentation that demonstrated competencies had been successfully completed during orientation for 4 of 4 sampled Behavioral Unit staff (S6RN, S8MHT, S5RN, S3Behavioral Health Unit Director).
Findings:
Review of the Personnel record for Registered Nurse S6 revealed he had no documented job specific competency demonstrations when he was hired in the unit.

Review of the personnel record for Mental Health Technician (MHT) S8 revealed she had no documented job specific competencies.

Review of the personnel record for S5RN revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, no documented seclusion training, and no documented CPI training.

Review of the personnel record for S3, Behavioral Unit Director, revealed she had no documented job specific competencies, no documented orientation to the psychiatric unit, no documented seclusion training, and no documented CPI training.

In an interview on 10/11/12 at 9:00 a.m. with Registered Nurse S5, she said she started on 7/18/12 at the facility. She said she worked at another psychiatric facility from January through May. S5 said her rotation at nursing school and her few months at the other psychiatric facility were her only training in psychiatric nursing. S5 also said she had no formalized orientation to the psychiatric unit.

In an interview on 10/12/12 at 8:25 a.m. with Director of Nursing (DON) S1, she said the staff received a general hospital orientation when hired, but none specific to the psychiatric unit. S1 also said the staff was not assessed for their competencies upon hire.

In an interview on 10/12/12 at 12:15 p.m. with Director of Behavioral Health LPN S3, she said she was a supervisor of the staff and a coordinator of the unit. She stated she had not received any orientation to the psychiatric unit when she began as manager. Since there was no director when she took over the unit, she was trained by the staff.

Review of the hospital policy titled Patient Rights, Reference: CMS-Restraint or Seclusion: Staff Training Requirements, Policy Number III.F., revision date of 10/18/2011, and provided as current policy by the Director of Nursing, S1, revealed in part the following:
I. Policy: The hospital shall provide patients with the right to safe implementation of restraint or seclusion by trained staff.
II. Procedure: The Hospital Administration and/or designee and medical staff shall:
A. Provide the hospital staff (as applicable) and medical staff - Training re: Restraint or Seclusion; following the guidance below.
1. Training Intervals - Staff shall be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restrain or seclusion - a) Before performing any of the actions specified in this paragraph; b) As part of orientation; and c) Subsequently on a periodic basis consistent with hospital policy. A-0196.
4. Training Documentation - The hospital shall document in the staff personnel records that the training and demonstration of competency were successfully completed. A-0208....

30364

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient by: a) failing to ensure the RN assessed the patient exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff for 1 of 1 (#3) sampled patients reviewed for aggressive and inappropriate sexual behaviors out of a total sample of 6; b) failing to notify the physician, the Director of Nursing and the unit Director in a timely manner of Patient #3 being sexually inappropriate with 1 (#1) of 5 (#1, #2, #4, #5, #6) sampled patients; c) failing to ensure less restrictive interventions were implemented and determined to be ineffective before initiating the use of patient seclusion for 1 of 1 (Patient #3) sampled patients reviewed for the use of seclusion out of a total sample of 6, and; d) failing to ensure all nursing entries entered into the medical record were a complete and/or accurate account of the patient's behavior for 1 of 1 (#3) sampled patients reviewed for use of seclusion.
Findings:
a) Failing to ensure the RN assessed the patient exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff:
Patient #3
Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia. Review of the Psychiatric Evaluation dated 09/01/12 revealed the patient's chief complaint was, "I had a knife to kill her (sister)". The problem list included Bizarre delusions about being married to God and having immense powers, Tendency to thoughts of violence, Lability of mood, Non-compliance with medications....

Review of the Nursing 24-Hour BH (Behavioral Health) Assessments revealed in part the following:
09/07/12 at 2000 (8:00 p.m.).....Attempted to burn female peer with her cigarette on smoke break, but attempt was aborted by MHT....Placed in time out/attempted to leave time out requiring redirection...
09/08/12 at 1800 (6:00 p.m.) - Patient is compliant with meds. She needed time in quiet room today due to her aggressive type behavior with female peer.... 2010 (8:10 p.m.)....Pulled her jacket off and threw it on the floor and attempted to go in day room but was redirected....Patient attempting to harm female peer....Haldol 10 mg. given IM (Intramuscular injection)......
09/09/12 at 0025 (12:25 a.m.) - Was asleep in time out room. Left time out room and went to peer's room (female) and put her hands around peer's neck requiring redirection...
09/12/12 at 1945 (7:45 p.m.) - ....Hit male peer. Stated, "God and I needed some leverage.".... 2330 (11:30 p.m.) - Running in hall in bra and shirt and nude from waist down requiring redirection.
09/14/12 at 0930 (9:30 a.m.) - Patient is not getting along well on the unit. She has attempted to attack the activity director and one of the MHTs. She went in time out to calm down....
( Incident Report revealed Patient #3 was found in bed with a male patient on 09/15/12 at 12:45 a.m.)

Review of the physician orders and observation flow sheets revealed the observation level order for Patient #3 was Q 15 minutes (Special Precautions I) from admission until 09/29/12.

Review of the Master Treatment Plan, dated 09/04/12 revealed the patient's problem list indicated Psychosis and Noncompliance with medications were the only problems identified. Review of the care plan for psychosis revealed the patient had Disorganized Thoughts, Paranoid Ideations, and Negative Symptoms. Bizarre Behaviors was not checked. There was no documented evidence that the patient's violent thoughts and potential for violent behavior was addressed on the treatment plan. There was no documented evidence that the patient's aggressive, threatening behavior and sexually inappropriate behavior toward other patients and staff was identified on the treatment plan, and there were no interventions identified to address the patient's behaviors to protect other patients.

Further review of the patient's record revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m., after hitting the charge nurse. The record also revealed the patient was placed in seclusion again on 09/16/12 at 5:45 a.m. for physically attacking the staff, and again at 7:30 p.m for attacking staff. Review of the Treatment Plan revealed that the plan was updated to include the seclusion for an Alteration in Behavior, Sexually Inappropriate, and Combative towards staff. There were no other interventions identified on the treatment plan to address the patient's aggressive behavior, sexually inappropriate behavior, and combative behavior towards staff, other than seclusion.

Further review of the Nursing 24-Hour BH (Behavioral Health) Assessments revealed in part the following:
09/20/12 at 1200 (12:00 p.m.) - Patient attacked a MHT (Mental Health Technician) for no apparent reason. she was given a quiet area to calm down..... 1400 (2:00 p.m.) - Patient attacked the MHT and was placed in a quiet area to be watched closely by a different MHT while she calmed down. She eventually agreed to behave and was allowed to go back among the general population. 2000 (8:00 p.m.) - ...Delusional, Paranoid, accepting redirection. Attempts to have physical contact with male patient.....
09/24/12 at 0930 (9:30 a.m.) - ...Patient is easily agitated. She took another patient's cane and attempted to hit him with it. She put herself in time out.....2200 (10:00 p.m.) - Patient was in another patient's room and had to be redirected out. Patient did not have clothing on. Patient returned to own room. Patient redirected for physical contact with other patients.
09/25/12 at 0930 (9:30 a.m.) - ....She has been acting out today and tried to burn me with her cigarette.....2145 (9:45 p.m.) - Patient attempting to go into male patient's room, noted firm redirection and was difficult to redirect...
09/29/12 at 1200 (12:00 p.m.) - .....She walked up being me when I walked into the contraband room and she tried to hit me, but I blocked it and she walked away to her room..... 1750 (5:50 p.m.) - Patient received Haldol 10 mg IM at 1750 for psychosis. She has attacked the staff several times. She is also now a 1:1 by a female, Caucasian tech because the doctor doesn't want her to feel rewarded with special behaviors, such as being watched by an AA (African American) tech.

Further review of the treatment plan revealed no documented evidence that the plan was updated with the patient's behaviors and there were no interventions to address the patient's behavior or the protection of other patients and staff.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on the 7 a.m. to 7 p.m. shift. S5RN verified she had placed Patient #3 in seclusion on 09/15/12. S5 stated the patient had multiple occurrences prior to this date of attacking the staff and other patients. S5 indicated the patients behaviors increased after she had been on the unit about a week. S5 stated the attacks were unprovoked and the patient was unpredictable. S5 stated, "We don't know when she will attack". S5 reviewed the patient's treatment plan and verified the only update to the plan of care was on 09/15/12 when the patient was placed in seclusion. S5 verified the patient's aggressive, attacking behavior toward other patients and the staff had not been identified as a problem, and there were no interventions identified to address the behavior and protect the other patients and staff. S5 also verified the patient had demonstrated multiple incidents of sexually inappropriate behavior and this was not identified as a problem on the treatment plan and there were no interventions identified to address this problem, except seclusion. S5 confirmed 1:1 observation was not implemented for Patient #3 until 09/29/12. S5 stated, "We could have put her on 1:1 earlier and that may have prevented seclusion." When asked if any patients were injured by Patient #3, S5 stated yes, Patient #5, and S11LPN were both scratched by Patient #3.

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he was the Charge Nurse on the 7:00 p.m. to 7 a.m. shifts on 09/14/12 and 09/24/12 when Patient #3 was found in bed with male patients. S6 stated Patient #3 was found in bed with Patient #6 on the 15 minute round check. S6 stated both patients had their clothes on and were asleep. S6 stated they escorted the patient back to her room and he completed an incident report. S6 verified the treatment plan was not updated after this incident. S6 stated on 09/24/12 S8MHT found Patient #3 naked in bed with Patient #1 and they were trying to have sex. S6 stated he went to Patient #1's room and Patient #3 ran out naked. S6 stated he moved Patient #1 to another room that night and they watched Patient #3 closer. S6 verified he did not document an incident report, did not update the treatment plan for either patient, and did not notify the physician of the incident, "Because nothing happened." S6 confirmed 1:1 monitoring was not implemented after this incident and stated it should have been. S6 stated, "Always possible she could do it again. 1:1 monitoring should ensure she did not go into another room."

On 10/11/12 at 3:25 p.m., in a face-to-face interview, the Medical Director (and Patient #3's psychiatrist), S9 confirmed Patient #3 had multiple instances of attacking the staff and her behavior had been difficult to control. S9 stated Patient #3 has an inferiority complex and he did not want to put her on 1:1 observation. S9 stated he thought he could control her with medication and did not think she was a danger to others. S9 stated Patient #3 had attacked other patients by attempting to burn a patient with a cigarette and choke another patient. S9 stated he was not aware that Patient #3 had attempted to have sex with a male patient. S9 verified he had no orders to address interventions to prevent Patient #3 from going into other patient's rooms. When asked about the use of 1:1 observation to prevent Patient #3 from attacking staff and patients, S9 stated he did not want Patient #3 to feel like it was a personal attack since she was black.

On 10/12/12 at 12:20 p.m. the Behavioral Health Unit Director, S3 was interviewed. S3 indicated she was aware that 1:1 observation had not been implemented for Patient #3 when the patient had attacked other patients and/or staff. S3 indicated the other patients on the unit were placed at risk by not implementing preventative measures to protect them from Patient #3's behaviors. S3 indicated she was not aware of the second incident where Patient #3 was found naked in a male patient's bed. S3 stated 1:1 observation should have been implemented after the first incident where the patient was found in another patient's bed. S3 stated "Watch closer" was not enough. S3 verified an incident report and an investigation should have been done for the incident where Patient #3 was naked in bed with a male patient. S3 indicated she had identified the need for staff training on seclusion, managing patient behavior and 1:1 observation. S3 stated the training had not been done yet.

Review of the hospital policy titled Special Precautions and Observation Levels, revision date 04/20/11 and reviewed date 02/15/12, provided as current policy by S1 Director of Nursing, revealed in part the following:
I. Policy: The hospital shall institute staff monitoring as required to prevent patients from harming themselves or others. Indications of suicidal intent, a desire to elope, or increasing agitation will be immediately evaluated by the staff member as observed......In order to provide protection to psychiatric patients, three levels of observation monitoring is provided by a trained staff member under the direction of the Physician and Registered Nurse. A. Special Precautions I - monitoring every 15 minutes. Special Precautions II - monitoring on a constant basis. C. A Registered Nurse may place a patient on a Special Precautions and increased the level of the observation in all cases the least restrictive clinically appropriate intervention will be made. The Attending Physician is always contacted to give a specific order for the level of monitoring. Any discontinuation of monitoring or lessening of the level of monitoring must be by Physician order.
II. Procedure:
A. A written physician's order is obtained for Special Precautions.
1. After evaluation and assessment, staff monitoring may be instituted by the Attending Physician or Registered Nurse.

Review of the hospital policy titled Initial Plan of Care revision date of 12/08/11, provided by S1 Director of Nursing and current policy, revealed in part the following:
I. Policy: All patient will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professionals through licensure, training and experience.
II. Purpose: To establish a comprehensive, goal-oriented, individualized plan for each patient served based on assessment of patient physical, cognitive, behavioral communicative, emotional, pharmacological, pain management, and social needs.
III. Procedure: Each individualized treatment plan is developed through the initial evaluation and team conference process in coordination with the attending physician and treatment team. The individual treatment plan include the following information presently behavioral: The type of treatment and/or services to be provided, and revised when appropriate....

Review of the hospital policy titled Plan of Care revision date of 08/21/12, provided by S1 Director of Nursing and current policy, revealed in part the following:
I. Policy: To ensure that the needs of the patient and family/significant other(s) are met and have access to the appropriate setting and level of care, health care professionals, and type of medical health and social services needed.
A.1. After a thorough nursing assessment is done, care plans are completed by an RN. The care plan will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals. All interventions should be patient specific...The admission assessment data and physician orders are the basis for the selection and individualization of the patient plan of care. Patients receive care based on documented assessment of their need....Additional problems unique to the patient may be included and reassessed whenever warranted by the patient's condition.....Patients are evaluated on a regular basis as delegated by the Registered Nurse. Patient outcomes and response to treatment/implementation of patient care planning is evaluated and documented daily....All nurses are responsible for up dating care plans with specific changes in patient's condition, as new orders are written and as treatment changes.

b) Failing to notify the physician, the Director of Nursing, and unit Director in a timely manner of Patient #3 being sexually inappropriate with Patient #1.
Review of the medical record for Patient #1 revealed he was a 66 year old male who had been admitted to the facility on 9/7/12. Review of the Psychiatric evaluation for Patient #1 revealed his diagnosis included Schizoaffective disorder, bipolar type, with the most recent episode being manic.
In an interview on 10/11/12 at 12:50 p.m. with Registered Nurse S6, he stated on the night of 9/24/12, one of the Mental Health Technicians (MHT) told him Patient #3 had gone into Patient #1's room. S6 said the patients were attempting to have sex. S6 said when they were discovered, Patient #3 ran from Patient #1's room back into her own room. S6 said the physician was not notified because Patient #1 and Patient #3 did not actually have sex. S6 stated no incident report had been filled out, but should he have done one.
Record review revealed no incident report had been written about Patient #3 being found naked in the bed with Patient #1 on 9/24/12.
An interview was held on 10/12/12 at 8:35 a.m. with Director of Nursing S1. She said she had never been made aware of Patient #3 crawling into the bed naked with Patient #1. She said she was aware of the first instance of Patient #3 being found in bed with another patient, but not with Patient #1. She said an incident report should have been filled out and she should have been notified.

In an interview on 10/12/12 at 12:15 p.m. with Director of Behavioral Health S3, she said she was not aware that Patient #3 had been found in Patient #1's room naked on 9/24/12. S3 said after being caught in Patient #1's room, she would have expected Patient #3 to have been placed on 1:1 observation and Patient #1 to have been counseled. She said the other patients were placed at risk by not putting Patient #3 on 1:1 observation earlier than 9/29/12.

An interview was conducted on 10/11/12 at 3:20 p.m. with Medical Director S9 about Patient #3 being found naked in Patient #1's bed on 9/24/12. He said he did not recall if Patient #3 had ever been into Patient #1's room in a sexual manner. He said if so, he was never notified. When asked about the Staffing Note for Patient #1 discussing the incident he had written on 9/25/12, he said he must have been notified that day, but he could not remember.


c) Failing to ensure less restrictive interventions were implemented and determined to be ineffective before initiating the use of patient seclusion:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.

Review of the Nursing 24-Hour BH (Behavioral Health) Assessment dated 09/15/12 revealed the following: "0930 (9:30 a.m.) Pt. (Patient) is AA&O X3 (Awake, Alert & Oriented to person, place, and time), but she is delusional. She snuggled into another patient's bed last night and got a time out for the behavior. She believes that the other patient is God. She hit me when I told her to go to time out. She is paranoid and combative. Non-cooperative, but she does take her meds and ate well at breakfast.
1800 (6:00 p.m.) Patient refused 1800 vital signs. She is combative and threw the thermometer on the floor. She has been compliant with her meds through the day and ate well at meals." The above entries were signed by S5RN and were the only entries documented in the nurse's notes for 09/15/12, 7 a.m. to 7 p.m. shift.

Review of the physician's orders dated 09/15/12 revealed the following verbal orders:
"1215 (12:15 p.m.) Place patient in seclusion/time out for sexual inappropriate behavior and combative behavior towards staff and other patients for 4 hours.
1615 (4:15 p.m.) Continue seclusion/time out for an additional 4 hours for continued behavioral problems." The verbal orders were documented by S5RN.

Review of the restraint/seclusion form revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m.. The following alternative or less restrictive measures were checked as used: determine internal/external causes of behavior, re-direct the individual's focus, suggest privacy/voluntary time-out, one-to-one session; verbal de-escalation, clear, firm limit setting, and psychotropic medications/MD order obtained. The form also revealed the specific patient behavior warranting seclusion was, "Patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue." The section for the criteria for release from seclusion was left blank. The section for the date and time the physician was notified was left blank.
Further review of the form revealed the exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.

There was no documented evidence of an incident where the patient was combative to other patients and staff, and sexually inappropriate, requiring seclusion at 12:15 p.m. There was no documented evidence that a time out was used, that verbal de-escalation was attempted, that firm limit setting was attempted, and there was no documented evidence that any medication orders were requested or obtained.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12. S5 indicated Patient #3 had occurrences prior to 09/15/12 where she had attacked the staff, but was re-directable. S5 stated on 09/15/12 she went to the smoking area to speak to the patient about her behavior the night before where she was sexually inappropriate and attacking the staff. S5 stated she asked the patient if she understood what she (S5RN) said. S5 stated Patient #3 sat quietly and then came at her with a cigarette. S5 stated she and S13 MHT walked the patient to the seclusion room and shut the door. S5 stated, "There's been so many incidents with this patient, I don't know all the dates." When asked what was different about this incident that required the patient to be placed in seclusion, S5 stated the cigarette had more potential for injury. S5 stated, "I felt like the behavior had gone on long enough." S5 indicated there were no other threatening behaviors demonstrated by Patient #3 that morning. When asked to find documentation that the patient attempted to burn her, S5 reviewed the patient's record and verified the incident was not documented in the record. After reviewing the restraint/seclusion form, S5 verified she had checked the above less restrictive measures were attempted. S5 verified 1:1 observation was not attempted on 09/15/12, Time Out was not attempted on 09/15/12, and there was no request for psychotropic medications on 09/15/12. S5 indicated she checked those measures since they had been attempted in the past. S5 verified less restrictive measures were not attempted after this incident. S5 also verified she had documented on the restraint/seclusion form that the behavior warranting seclusion was the patient hit her and was sexually inappropriate towards another patient. S5 confirmed the sexually inappropriate behavior had occurred the night before. S5 stated she put Patient #3 in seclusion due to she felt like the behavior had gone on long enough and she was a threat to the staff and patients on the unit. S5RN stated, "1:1 observation should have been used first."


Review of the hospital's policy titled, Patient Rights, revision date of 10/18/2011, and provided by S1 Director of Nursing as the current Restraint/Seclusion Policy, revealed in part the following: ....All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restrain or seclusion may only imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time.....1. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. A0164. 2. The type or technique of restraint or seclusion used shall be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. A-0165......


d) Failing to ensure all nursing entries entered into the medical record were a complete and/or accurate account of the patient's behavior:

Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia.


Review of the Nursing 24-Hour BH (Behavioral Health) Assessment dated 09/15/12 revealed the following: "0930 (9:30 a.m.) Pt. (Patient) is AA&O X3 (Awake, Alert & Oriented to person, place, and time), but she is delusional. She snuggled into another patient's bed last night and got a time out for the behavior. She believes that the other patient is God. She hit me when I told her to go to time out. She is paranoid and combative. Non-cooperative, but she does take her meds and ate well at breakfast.
1800 (6:00 p.m.) Patient refused 1800 vital signs. She is combative and threw the thermometer on the floor. She has been compliant with her meds through the day and ate well at meals." The above entries were signed by S5RN and were the only entries documented in the nurse's notes for 09/15/12, 7 a.m. to 7 p.m. shift.


Review of the physician's orders dated 09/15/12 revealed the following verbal orders:
"1215 (12:15 p.m.) Place patient in seclusion/time out for sexual inappropriate behavior and combative behavior towards staff and other patients for 4 hours.
1615 (4:15 p.m.) Continue seclusion/time out for an additional 4 hours for continued behavioral problems." The verbal orders were documented by S5RN.


Review of the restraint/seclusion form revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m. due to "patient attacked charge nurse. She hit her. Also sexually inappropriate towards another patient with intent to continue."
Further review of the form revealed the exit date and time from the seclusion was 09/15/12 at 2005 (8:05 p.m.), 7 hours and 50 minutes in seclusion.


Review of the Behavioral Restraint and Seclusion Flowsheet dated 09/15/12 and documented by S5RN revealed the following behavior was checked as occurring every hour on the hour from 12:15 p.m. to 6:00 p.m.: Agitated/restless, Inability to comply with safe treatment/Poor judgement, Combative, Physically threatening self or others, Elopement risk with potential harm to self/others, and Impulsive.


Review of the Observation Flow Sheet dated, 09/15/12 and documented by S7MHT (Mental Health Technician) revealed the patient was calm and cooperative, eating, or sleeping from 6:45 a.m. to 9:00 p.m. There was no documented evidence on the observation form that the patient was in seclusion.


On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on 09/15/12. S5 indicated Patient #3 had occurrences prior to 09/15/12 where she had attacked the staff, but was re-directable. S5 stated on 09/15/12 she went to the smoking area to speak to the patient about her behavior the night before where she was sexually inappropriate and attacking the staff. S5 stated she asked the patient if she understood what she (S5RN) said. S5 stated Patient #3 sat quietly and then came at her with a cigarette. S5 stated she and S13 MHT walked the patient to the seclusion room and shut the door. S5 stated, "There's been so many incidents with this patient, I don't know all the dates." When asked what was different about this incident that required the patient to be placed in seclusion, S5 stated the cigarette had more potential for injury. S5 stated, "I felt like the behavior had gone on long enough." S5 indicated there were no other threatening behaviors demonstrated by Patient #3 that morning. When asked to find documentation that the patient attempted to burn her, S5 reviewed the patient's record and verified the incident was not documented in the record. After reviewing the restraint/seclusion form, S5 verified she had documented on the restraint/seclusion form that the behavior warranting seclusion was the patient hit her and was sexually inappropriate towards another patient. S5 confirmed the sexually inappropriate behavior had occurred the night before. S5 stated she put Patient #3 in seclusion due to she felt like the behavior had gone on long enough and she was a threat to the staff and patients on the unit. After reviewing the Observation Flow Sheet dated 09/15/12 and documented by S7MHT, S5 verified the MHT documented the patient was either asleep, eating, or calm and cooperative all day. S5 verified the MHT had documented the patient was either in her room, activity room, or dining room on 09/15/12, and not in seclusion. S5RN confirmed the above inaccuracies in the medical record.

On 10/12/12 at 9:30 a.m., in a face-to-face interview, S7MHT confirmed she was assigned to monitor Patient #3 when she was placed in the seclusion room. S7 stated she was in the hallway when S5RN brought the patient in from the smoking area. S7 stated it was around 9:30 a.m. and S5RN put the patient in time out. S7 stated when the patient wanted to leave the room, S5RN locked the door. S7 indicated the patient tried to burn the nurse while in the smoking area. S7 stated she was assigned 1 on 1 with Patient #3. S7 verified she had documented the patient was in her room and not in the seclusion room. S7 stated the patient was calm and cooperative all day, but was not in her room. S7 confirmed the patient was in the seclusion room all day.

30364

Based on record review and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan as evidenced by failing to ensure nursing interventions and goals were identified and implemented to address physically aggressive and/or sexually-inappropriate behavior for 3 (#1, #3, #6) of 6 (#1, #2, #3, #4, #5, #6) sampled patients.

Findings:

Patient #3
Review of the patient's medical record revealed Patient #3 was a 53 year old female admitted to the hospital on 08/31/12 as a full voluntary admit with a diagnosis of Chronic Paranoid Schizophrenia. Review of the Psychiatric Evaluation dated 09/01/12 revealed the patient's chief complaint was, "I had a knife to kill her (sister)". The problem list included Bizarre delusions about being married to God and having immense powers, Tendency to thoughts of violence, Lability of mood, Non-compliance with medications....

Review of the Master Treatment Plan, dated 09/04/12 revealed the patient's problem list indicated Psychosis and Noncompliance with medications were the only problems identified. Review of the care plan for psychosis revealed the patient had Disorganized Thoughts, Paranoid Ideations, and Negative Symptoms. Bizarre Behaviors was not checked. There was no documented evidence that the patient's violent thoughts and potential for violent behavior was addressed on the treatment plan.

Review of the Nursing 24-Hour BH (Behavioral Health) Assessments revealed in part the following:
09/07/12 at 2000 (8:00 p.m.).....Attempted to burn female peer with her cigarette on smoke break, but attempt was aborted by MHT....Placed in time out/attempted to leave time out requiring redirection...
09/08/12 at 1800 (6:00 p.m.) - Patient is compliant with meds. She needed time in quiet room today due to her aggressive type behavior with female peer.... 2010 (8:10 p.m.)....Pulled her jacket off and threw it on the floor and attempted to go in day room but was redirected....Patient attempting to harm female peer....Haldol 10 mg. given IM (Intramuscular injection)......
09/09/12 at 0025 (12:25 a.m.) - Was asleep in time out room. Left time out room and went to peer's room (female) and put her hands around peer's neck requiring redirection...
09/12/12 at 1945 (7:45 p.m.) - ....Hit male peer. Stated, "God and I needed some leverage.".... 2330 (11:30 p.m.) - Running in hall in bra and shirt and nude from waist down requiring redirection.
09/14/12 at 0930 (9:30 a.m.) - Patient is not getting along well on the unit. She has attempted to attack the activity director and one of the MHTs. She went in time out to calm down....
( Incident Report revealed Patient #3 was found in bed with a male patient on 09/15/12 at 12:45 a.m.)

There was no documented evidence that the patient's aggressive, threatening behavior and sexually inappropriate behavior toward other patients and staff was identified on the treatment plan, and there were no goals or interventions identified to address the patient's behaviors to protect other patients.

Further review of the patient's record revealed Patient #3 was placed in seclusion on 09/15/12 at 12:15 p.m., after hitting the charge nurse. The record also revealed the patient was placed in seclusion again on 09/16/12 at 5:45 a.m. for physically attacking the staff, and again at 7:30 p.m for attacking staff. Review of the Treatment Plan revealed that the plan was updated to include the seclusion for an Alteration in Behavior, Sexually Inappropriate, and Combative towards staff. There were no other interventions identified on the treatment plan to address the patient's aggressive behavior, sexually inappropriate behavior, and combative behavior towards staff, other than seclusion.

Further review of the Nursing 24-Hour BH (Behavioral Health) Assessments revealed in part the following:
09/20/12 at 1200 (12:00 p.m.) - Patient attacked a MHT (Mental Health Technician) for no apparent reason. she was given a quiet area to calm down..... 1400 (2:00 p.m.) - Patient attacked the MHT and was placed in a quiet area to be watched closely by a different MHT while she calmed down.... 2000 (8:00 p.m.) - ...Delusional, Paranoid, accepting redirection. Attempts to have physical contact with male patient.....
09/24/12 at 0930 (9:30 a.m.) - ...Patient is easily agitated. She took another patient's cane and attempted to hit him with it. She put herself in time out.....2200 (10:00 p.m.) - Patient was in another patient's room and had to be redirected out. Patient did not have clothing on. Patient returned to own room. Patient redirected for physical contact with other patients.
09/25/12 at 0930 (9:30 a.m.) - ....She has been acting out today and tried to burn me with her cigarette.....2145 (9:45 p.m.) - Patient attempting to go into male patient's room, noted firm redirection and was difficult to redirect...
09/29/12 at 1200 (12:00 p.m.) - .....She walked up being me when I walked into the contraband room and she tried to hit me, but I blocked it and she walked away to her room..... 1750 (5:50 p.m.) - Patient received Haldol 10 mg IM at 1750 for psychosis. She has attacked the staff several times. She is also now a 1:1....

Further review of the treatment plan revealed no documented evidence that the plan was updated with the patient's behaviors and there were no interventions to address the patient's behavior or the protection of other patients and staff. The plan of care was not updated with the 1:1 observation status change on 09/29/12.

On 10/11/12 at 9:45 a.m., in a face-to-face interview, S5RN verified she was the Charge Nurse on the 7 a.m. to 7 p.m. shift. S5 stated the patient had multiple occurrences of attacking the staff and other patients. S5 indicated the patients behaviors increased after she had been on the unit about a week. S5 stated the attacks were unprovoked and the patient was unpredictable. S5 stated, "We don't know when she will attack". S5 reviewed the patient's treatment plan and verified the only update to the plan of care was on 09/15/12 when the patient was placed in seclusion. S5 verified the patient's aggressive, attacking behavior toward other patients and the staff had not been identified as a problem, and there were no interventions or goals identified to address the behavior and protect the other patients and staff. S5 also verified the patient had demonstrated multiple incidents of sexually inappropriate behavior and this was not identified as a problem on the treatment plan and there were no interventions identified to address this problem, except seclusion.

On 10/11/12 at 12:05 p.m., in a face-to-face interview, S6RN confirmed he was the Charge Nurse on the 7:00 p.m. to 7 a.m. shifts on 09/14/12 and 09/24/12 when Patient #3 was found in bed with male patients. S6 stated on 09/14/12 Patient #3 was found in bed with Patient #6 on the 15 minute round check. S6 stated both patients had their clothes on and were asleep. S6 stated they escorted the patient back to her room and he completed an incident report. S6 verified Patient #3's treatment plan was not updated after this incident. S6 stated on 09/24/12 S8MHT found Patient #3 naked in bed with Patient #1 and they were trying to have sex. S6 stated he went to Patient #1's room and Patient #3 ran out naked. S6 stated he moved Patient #1 to another room that night and they watched Patient #3 closer. S6 verified he did not document an incident report, did not update the treatment plan for either patient, and did not notify the physician of the incident, "Because nothing happened." S6 confirmed 1:1 monitoring was not implemented after this incident and stated it should have been. S6 stated, "Always possible she could do it again. 1:1 monitoring should ensure she did not go into another room."


Patient #1
Review of the medical record for Patient #1 revealed he was a 66 year old male who had been admitted to the facility on 9/7/12. Review of the Psychiatric evaluation for Patient #1 revealed his diagnosis included Schizoaffective disorder, bipolar type, with the most recent episode being manic.
Review of a Staffing Note by Medical Director S9 for Patient #1 dated 9/25/12 revealed the following in part: a female patient who was psychotic who is a room across from him was found naked in his room. As far as the judgment of the patient is concerned, he always brags about wanting to do the right thing, but he did not alert anybody nor did he ask the woman to leave. So he was reprimanded about it and then instead of expressing remorse, he reacted ugly to one of the staff members requiring a shot.

In an interview on 10/11/12 at 12:50 p.m. with RN S6, he stated on the night of 9/24/12, one of the Mental Health Technicians (MHT) told him Patient #3 had gone into Patient #1's room. S6 said the patients were attempting to have sex. S6 said no revisions had been added to either patient's care plan.

Record review of Patient #1's medical record revealed no problems or interventions had been added to his treatment plan after Patient #3 was found naked in his room on 9/24/12.

Patient #6
Record review revealed Patient #6 was a 40 year old male that had been admitted to the facility on 9/12/12 for Psychosis.

Review of the Nursing Notes dated 9/14/12 at 0930 (9:30 a.m.) for Patient #6 revealed the following entry: AA&O x 3 (awake, alert and oriented). Pt (patient) is calm and cooperative this morning. He says he came here because he has been making bad decisions lately. He was sexually inappropriate towards me and stated that he " wants to strip for me " so I can look at his body. I informed him that his behavior was inappropriate. He was compliant with all his meds and he ate well at breakfast. The entry was signed by Registered Nurse S5.


Review of the Nursing Notes dated 9/15/12 at 0930 (9:30 a.m.) revealed the following entry: AA&O x 3. Calm and cooperative. Pt said he was sorry for making bad decisions. He let a female pt lay down with him last night and he was told not to do that again. He said he was sorry and he will try to make better decisions. He was compliant with all his meds and ate well at breakfast. The entry was signed by Registered Nurse S5.


In an interview on 10/11/12 at 12:50 p.m. with RN S6, he stated S6 said Patient #3 had gone into Patient #6's room on 9/14/12 and got in bed with him, but nothing different had been done after that incident to protect him or other patients from Patient #3.


Record review revealed no updates had been made to Patient #6's treatment plan after Patient #3 was found in his room on 9/14/12 or when he was acting sexually inappropriate with staff on 9/14/12.


Review of the hospital policy titled Initial Plan of Care revision date of 12/08/11, provided by S1 Director of Nursing and current policy, revealed in part the following:
I. Policy: All patient will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professionals through licensure, training and experience.
II. Purpose: To establish a comprehensive, goal-oriented, individualized plan for each patient served based on assessment of patient physical, cognitive, behavioral communicative, emotional, pharmacological, pain management, and social needs.
III. Procedure: Each individualized treatment plan is developed through the initial evaluation and team conference process in coordination with the attending physician and treatment team. The individual treatment plan include the following information presently behavioral: The type of treatment and/or services to be provided, and revised when appropriate....


Review of the hospital policy titled Plan of Care revision date of 08/21/12, provided by S1 Director of Nursing and current policy, revealed in part the following:

I. Policy: To ensure that the needs of the patient and family/significant other(s) are met and have access to the appropriate setting and level of care, health care professionals, and type of medical health and social services needed.
A.1. After a thorough nursing assessment is done, care plans are completed by an RN. The care plan will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals. All interventions should be patient specific...The admission assessment data and physician orders are the basis for the selection and individualization of the patient plan of care. Patients receive care based on documented assessment of their need....Additional problems unique to the patient may be included and reassessed whenever warranted by the patient's condition.....Patients are evaluated on a regular basis as delegated by the Registered Nurse. Patient outcomes and response to treatment/implementation of patient care planning is evaluated and documented daily....All nurses are responsible for up dating care plans with specific changes in patient's condition, as new orders are written and as treatment changes.

Based on record reviews and interviews, the hospital failed to ensure a Registered Nurse (RN) assigned the nursing care of each patient according to the needs of the patient and the qualifications and competency of the nursing staff as evidenced by: a) failing to ensure the Behavioral Health Unit Director met the job description qualifications (S3); b) failing to ensure an RN assigned as Charge Nurse met the job description experience requirements and was assessed as competent (S5RN), and; c) failing to ensure the nursing staff of the psychiatric unit (Behavioral Health Unit) were oriented to the unit and assessed for competency prior to providing patient care, were trained in CPI (Crisis Prevention Institute) and Seclusion 5 of 5 (S3, S5, S6, S10, S11) nursing staff whose qualifications and training were reviewed. The nursing care of 1 of 1 (#3) sampled patients reviewed for the use of seclusion was provided by nursing staff that had not received orientation, training and were assessed as competent to provide care to patients in seclusion.
Findings:

Review of the medical record for Patient #3 revealed the patient was placed in seclusion on 09/15/12 at 12:15 p.m. and released at 8:05 p.m. The patient was again placed in seclusion on 09/16/12 at 5:45 a.m. and released at 9:45 a.m. The patient was placed in seclusion again at 7:30 p.m. and released at 10:45 p.m. on 09/16/12. S5RN and S6RN provided nursing care to Patient #3 on 09/15/12 and 09/16/12.

a) failing to ensure the Behavioral Health Unit Director met the job description qualifications:
Review of the job description for the Director of Behavioral Health, dated 10/2010 revealed the following: Responsible for the provision of effective and efficient clinical services provided in the unit. Reports directly to the Administrator and Director of Nursing for all operational responsibilities and clinical operations. Directly supervises and evaluates Behavioral Unit Registered Nurses, Licensed Practical Nurses, Mental Health Technicians, and other Clinical employees. Maintains professional licensure/certification as well as CPR and CPI. Education/Experience Requirements: Must have at least one of the following qualifications: 1. A registered nurse who has a Master's degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing and at least three years full time experience in progressively responsible management position in healthcare. 2. A master's degree in a related field such as psychology or nursing education and five years nursing experience and three years providing nursing care to the mentally ill; or 3. Bachelor's, associate degree or diploma in nursing with documented evidence of educational programs focused on treating psychiatric patients, which has occurred at intervals sufficient enough to keep the nurse current on psychiatric nursing techniques. In addition, the nurse shall have at least five years of nursing experience, three years of which were providing nursing care to the mentally ill, or receive regular, documented supervision/consultation from a master's prepared psychiatric nurse.

Review of the personnel record for S3 Behavioral Health Unit Director, revealed S3 was a LPN (Licensed Practical Nurse) since 1999. Review of S3's application dated 02/21/11 revealed S3 had been employed at a hospital as a staff nurse from 2/1999 to 9/2009. The job description and responsibilities listed at this hospital were, "varied-float nurse-all units, UR (Utilization review) nurse, Discharge nurse, rehab nurse, unit coordinator. The application also revealed S3 had been employed as a private duty nurse for a 2 year old patient from 5/2009 to present (02/21/11). A job description acknowledgement dated 08/02/12 and signed by S3 was noted in the record. There was no documented evidence of CPI certification or training.

On 10/10/12 at 10:20 a.m., S2 Administrator stated that S3 was the Director of the psychiatric unit. S2 provided an organization chart that indicated S3 was the Behavioral Health Unit Director.

On 10/12/12 at 12:20 p.m. S3 Behavioral Health Unit Director was interviewed. S3 stated she had worked in a geri-psych unit at another hospital for 3 years. S3 indicated she had not worked in a management position in that unit. S3 stated she was employed at this hospital as a nurse liaison prior to taking the current position as Director of Behavioral Health in August, 2012. After reviewing the above job description, she verified this was the job description she had signed in acknowledgement on 08/02/12. S3 verified she had not taken CPI training yet.

On 10/12/12 at 3:35 p.m., in a face-to-face interview, S1 Director of Nursing reviewed the job description for the Director of Behavioral Health and verified S3 did not meet the education/experience requirements of the position. S1 verified S3 had not had CPI training yet. S1 indicated S12 Consultant hired S3, and hired all staff for the Psychiatric Unit.

On 10/12/12 at 4:10 p.m., in a face-to-face interview, S2 Administrator stated he and S1 Director of Nursing recommended S3 Director of Behavioral Health to S12 Consultant and he agreed S3 would be a good fit. S2 stated S12 Consultant offered the position to S3. After reviewing the job description for the Director of Behavioral Health, he verified S3 did not meet the education/experience requirements of the position.

b) Failing to ensure an RN assigned as Charge Nurse met the job description experience requirements and was assessed as competent:
Review of the personnel record for S5RN revealed a date of hire of 07/05/12. Review of the resume for S5RN revealed S5 had graduated from nursing school in August 2011. Review of the work experience revealed S5 had only worked as a nurse in a psychiatric unit from January 2012 to May 2012 (5 months). The record revealed no documented evidence of an orientation to the Behavioral Health unit, no CPI certification or training, and no competency assessments.

Review of the job description for the Registered Nurse-Behavioral Health, dated 10/2010 revealed the following:
Maintains professional licensure/certification as well as CPR and CPI.
Education/Experience Requirements: ....Three years of psychiatric nursing experience in an inpatient setting preferred.

In an interview on 10/11/12 at 9:45 a.m., S5RN confirmed she was employed as charge nurse on the 7 a.m. to 7 p.m. shift on the psychiatric unit. S5 stated she had worked in a psychiatric hospital from January to May of this year and she had not worked anywhere from May until she was hired her in July. S5 stated she had not taken any CPI training yet. S5 indicated her orientation to taking care of psychiatric patients was she sat side by side with another RN for 2 days. S5 indicated the only training she had was in nursing school and she was not oriented to the facility's policies and procedures.

In an interview on 10/12/12 at 8:35 a.m., S1 Director of Nursing stated the orientation to the psychiatric unit consisted of working along side another RN for approximately 6 shifts. S1 stated there was no documentation of the orientation to the psychiatric unit. S1 indicated competency assessments were not done when an employee was hired. S1 stated competency assessments were done yearly in November. S1 indicated CPI training was required of all staff working on the psychiatric unit and stated CPI training was offered every 2 months. S1 verified S5RN had not had CPI training yet. S1 verified S5RN had only been a nurse for a year and had only 5 months experience working as a nurse on a psychiatric unit. S1 stated S5's orientation was not typical and confirmed S5 had only spent 2 shifts with another RN as her orientation. S1 stated she did not hire staff for the psychiatric unit and stated S12 Consultant was in charge of that. S1 verified she was responsible for the unit. S1 stated she did not feel S5RN was qualified to be in charge of the psychiatric unit.

c) Failing to ensure the nursing staff of the psychiatric unit (Behavioral Health Unit) were oriented to the unit and assessed for competency prior to providing patient care, were trained in CPI (Crisis Prevention Institute) and Seclusion:

Review of the Personnel record for Registered Nurse S6 revealed no documented training for the use of patient seclusion. There was no documented evidence of an orientation to the psychiatric unit. There was no documented evidence of a competency assessment for the use of seclusion. In an interview on 10/11/12 at 12:50 p.m. with Registered Nurse S6, he stated he had worked at the hospital since 7/11. He said the facility has had a competency since he has been here, but he does not remember having any training about seclusion.

Review of the personnel record for Registered Nurse S5 revealed no documented training or competency assessment for the use of patient seclusion. There was no documented evidence of an orientation to the psychiatric unit, no competency assessments, and no evidence of CPI certification or training. In an interview on 10/11/12 at 9:00 a.m. with Registered Nurse S5, she said she started on 7/18/12 at the hospital in the psych unit. She said she worked at another psychiatric facility from January through May. S5 said her rotation at nursing school and her few months at the other psychiatric facility was her only training in psychiatric nursing. She said she had not had CPI training yet. She said her orientation to the psychiatric unit at the facility included two days following the charge nurse on the other rotation. S5 also said she had no formalized orientation where she was shown all of the policies and procedures of the hospital. She stated she had just an explanation about seclusion, but no real training.

Review of the personnel record for S3 Director of Behavioral Health Unit revealed no documented evidence of a unit specific orientation. There was no evidence of CPI certification or training. There was no evidence of training or competency in care of the patient in seclusion. In an interview on 10/12/12 at 12:15 p.m. with Director of Behavioral Health LPN S3, she said she was a supervisor of the staff and a coordinator of the unit. She stated she had not received any orientation to the psychiatric unit when she began as manager. Since there was no director when she took over the unit, she was trained by the staff. S3 indicated she had not received any training in CPI yet. S3 stated there needed to be more training to the staff about seclusion.

In an interview on 10/12/12 at 8:25 a.m. with Director of Nursing (DON) S1, she said the staff received a general hospital orientation when hired, but none specific to the psychiatric unit. S1 said there was no training related to seclusion for the staff. S1 also said the staff was not assessed for their competencies upon hire. She said RN S5 only working two shifts with a preceptor was not the normal routine. S1 verified S5 and S3 had not had CPI training yet.

In an interview on 10/12/12 at 9:05 a.m. with Licensed Practical Nurse (LPN) S10, she said she had started working in the psychiatric unit about a year ago. S10 said she received no training on seclusion.

In an interview on 10/12/12 at 11:35 a.m. with LPN S11, she said she had been on the psychiatric unit since 2/10/11. She said the facility had not provided any formalized training on seclusion.


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