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Based on record review and facility policy/procedure review, the Hospital failed to implement seclusion in accordance with safe and appropriate techniques as determined by hospital policy for 1 of 1 closed record adult patient (Patient #1) in seclusion on September 28-29, 2018. Failure to monitor, evaluate, and document assessments of patients in seclusion has the potential to result in physical or psychological harm.

Findings include:

Review of the Hospital policy titled "Restraint and Seclusion" occurred on 10/03/18. This policy, dated 11/28/16, stated, ". . . Policy . . . C. Monitoring and Evaluating Patients in Restraint or Seclusion. . . 7. A trained staff member assesses the patient at the initiation of . . . seclusion at scheduled intervals as identified in this policy, assessing: a. Sign of any injury associated with utilization of . . . seclusion. b. Nutrition and hydration - offer food and/or fluids, provide meals at regular times. . . . f. Hygiene and elimination - offer as needed. g. Physical and psychological status and comfort - provide the opportunity for the patient to discuss feeling, etc. h. Readiness for discontinuation of restraint or seclusion i. Meeting criteria for release. . . . 9. Staff will help the patient meet behavior criteria for discontinuing . . . the intervention. 10. Staff will conduct safety checks at a minimum of every 15 minutes. 11. Monitoring is done through continuous in-person observation by an assigned staff member trained to do so. . . . F. Medical record documentation requirements are as follows: . . . 4. Nurses notes, Restraint and Seclusion Flowsheet documents a. Each in-person evaluation and reevaluation of the patient. b. 15-minute assessments of the patient's status. c. Assistance given to the patient to help him/her meet the behavior criteria for discontinuing restraint and seclusion d. continuous monitoring. . . ."

Review of Patient #1's medical record occurred on October 2-3, 2018. Patient #1's "Daily Notes (Nursing)" on 09/29/18 stated, ". . . Discontinue seclusion at 0925 [9:25 a.m.]. . . . Will continue to monitor and will update to MD as needed."

The medical record identified Patient #1 in seclusion from 4:18 p.m. on 09/28/18 until 9:25 a.m. on 09/29/18. The record lacked documentation of monitoring and evaluating Patient #1 for the time period of 8:18 a.m. until 9:25 a.m. (67 minutes) on 09/29/18.

Based on record review and facility policy/procedure review, the Hospital failed to ensure a physician or licensed independent practitioner renewed orders for seclusion every four hours for 1 of 1 closed record adult patient (Patient #1) in seclusion for a excess of 4 hours on September 28-29, 2018. Failure to review and renew seclusion orders at specified times has the potential for inappropriate use of seclusion.

Findings include:

Review of the Hospital policy titled "Restraint and Seclusion" occurred on 10/03/18. This policy, dated 11/28/16, stated, ". . . Policy . . . All patients have the right to be free from any . . . . restraint and seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. . . . When the use of restraint or seclusion is determined to be necessary, the type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm and is selected considering information learned from the initial and ongoing assessments. They are to be utilized in a manner that preserves the patient's safety and dignity. . . . The use of seclusion or physical/chemical restraint . . . Is in accordance with the order of the attending or on-call physician or trained NP [nurse practitioner], PA [physician's assistant] or RN [registered nurse]. . . . Definitions . . . Seclusion is the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. . . . Prolonged restraint/seclusion: The organization has defined a prolonged restraint/seclusion to be over 1 hour. Any restraint/seclusion exceeding 1 hour will require notification of the attending provider. . . . Responsibilities A. The attending or on-call physician who is responsible for the patient's care must evaluate the need for restraint or seclusion within the required timeframes and conduct in person assessment as required for both adults and adolescents. Physicians are responsible for supplying the initial order and giving or confirming (if ordered by trained licensed RN, NP, or PA) all subsequent re-orders for the use of restraint or seclusion. B. Registered nurses are responsible to monitor the length of time a restraint/seclusion is utilized and notify the attending provider of all prolonged restraints/seclusions. . . . Procedures . . . . 3. Each order for restraint or seclusion must be time-limited and may only be renewed in accordance with the following limits for up to a total of 24 hours: a: 4 hours for adults 18 years or older . . . 4. A new order is to be obtained when reapplying/reinitiation a restraint or seclusion if the patient is at imminent risk of physically harming self or others, and nonphysical interventions are ineffective. . . . 6. If restraint or seclusion use needs to continue beyond the expiration of the time-limited order, a new order is obtained from the attending or on-call physician. . . ."

Review of Patient#1's medical record occurred on October 2-3, 2018. Patient #1's Restraint/Seclusion Physician Orders identified an initial order for seclusion on 09/28/18 at 4:18 p.m. and renewal orders for seclusion every 4 hours until 8:18 a.m. on 09/29/18.

Patient #1's "Daily Notes (Nursing)" on 09/29/18 stated, ". . . Discontinue seclusion at 0925 [9:25 a.m.]. . . . Will continue to monitor and will update to MD as needed."

The medical record identified Patient #1 in seclusion from 4:18 p.m. on 09/28/18 until 9:25 a.m. on 09/29/18. The record lacked a physician or licensed independent practitioner order for seclusion for the time period of 8:18 a.m. until 9:25 a.m. (67 minutes) on 09/29/18.