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Based on policy and procedure review, medical record review and staff interviews, hospital staff failed to obtain a physician order for restraints in 2 of 5 restrained patients (Patient #1 & #2).

The findings include:

Review of the policy and procedure titled "Seclusion and Physical or Chemical Restraint" reviewed 04/28/2020 revealed "Justification, Psychiatrist's Order, and Documentation...2. Restraint or seclusion and Orders. a. A written order from the Psychiatrist or LIP (licensed independent practitioner) is required for the use of a chemical or physical restraint or a seclusion episode..."

Review of the medical record for Patient #1 revealed he was a 14-year-old male admitted on 03/15/2021 for "agitation and aggression at home." Review of the medical record revealed a restrictive intervention packet was completed for a manual hold on 03/18/2021 at 1346, 04/03/2021 at 1100, 04/03/2021 at 1312, and 04/12/2021 at 1100. Review of the restraint packet failed to reveal a physician or LIP order for the restrictive intervention.

Interview on 07/07/2021 at 1418 with the Chief Nursing Officer (CNO) revealed a restrictive intervention required a physician or LIP's order. Interview revealed the order sheet was included in the restraint packet.

Interview on 07/07/2021 at 1011 with RN #1 revealed she recalled patient #2. Interview revealed the verbal orders were to be recorded on the order form found in the "restraint packet." Review of record during interview revealed there was no order for patient #2's restrictive intervention. Interview revealed "the order should be in the packet, it could be an oversight, something that I missed." Interview revealed the verbal order for the restrictive intervention was not completed. Interview revealed if a manual hold was initiated by an RN facility process was to notify the physician, receive a verbal order, and fill out the order form for the physician to sign.


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A closed medical record review on 07/06/2021 for Patient #2 revealed a 14-year-old female admitted on 04/03/2021 for suicidal ideation and attempt. Review of the "Restraint/Seclusion/Manual Hold Initial Assessment by RN (Registered Nurse) #1 dated 04/21/2021 at 1240 revealed " ...Behavior requiring Seclusion/Restraint/Manual Hold: Violent or self-destructive behavior ... Patient Assault ... Type of Intervention: ... Chemical ..." Review of the restraint packet failed to reveal a physician or LIP order for the restrictive intervention.

Telephone interview on 07/07/2021 at 1011 with RN #1 revealed she recalled patient #2. Interview revealed RN's could initiate the restraint process when a patient required an intervention such as a manual hold. Interview revealed the providers were then notified, and verbal orders were received if a patient required medications. Interview revealed the verbal orders were to be recorded on the order form found in the "restraint packet" Review of record during interview revealed there was no order for patient #2's restrictive intervention. Interview revealed "the order should be in the packet, it could be an oversight, something that I missed." Interview revealed the verbal order for the restrictive intervention was not completed. Interview revealed if a manual hold was initiated by an RN facility process was to notify the physician, receive a verbal order, and fill out the order form for the physician to sign.

Interview on 07/07/2021 at 1418 with the Chief Nursing Officer (CNO) revealed a restrictive intervention required a physician or LIP's order. Interview revealed the order sheet was included in the restraint packet.

Based on policy and procedure review, medical record review and staff interviews, hospital staff failed to notify the attending provider of a restrictive intervention in 3 of 5 patients requiring a restrictive intervention (Patient #1, #3, # 10).

The findings included:

Review of the policy and procedure titled "Seclusion and Physical or Chemical Restraint" reviewed 04/28/2020 revealed "Justification, Psychiatrist's Order, and Documentation ... 2. Restraint or seclusion and Orders ...If the patient primary psychiatrist (is available, only he or she can order physical, chemical restraint or seclusion. If the psychiatrist is not in the facility to order the use of a restraint or seclusion, the registered nurse provides an emergency assessment, and for physical restraint or seclusion, obtains the psychiatrist's telephone order at the time the emergency safety intervention is initiated by staff) ..."

1. Closed medical record review for Patient #1 revealed he was a 14-year-old male admitted on 03/15/2021 for "agitation and aggression at home." Review of the "Behavioral Health MD (medical doctor) Order Form" dated 03/23/2021 at 1726, 04/01/2021 at 1641, 04/03/2021 at 1010, 04/05/2021 at 1156, 04/09/2021 at 1046, 04/09/2021 at 1237, and 04/15/2021 at 0938, and 04/19/2021 at 0922 revealed "Attending physician notified if not MD ordering intervention Name:________ (the Name of the attending physician was blank, therefore not notified)..." Further review of the order form revealed the restraint orders were telephone orders received by a LIP and not the patients attending MD.

Interview on 07/07/2021 at 1020 with RN #2 revealed she calls the LIP on call for orders for restraints/seclusion. Interview revealed it is not always the attending physician. Interview revealed if it is the nurse practioner or physician assistant she does not make an additional phone call to the attending physician to notify them of the restraint/seclusion episode.

Interview on 07/07/2021 at 1415 with Physician #10 revealed he is an attending physician. Interview revealed he does not recall receiving notification of his patients being placed in restraints/seclusion unless he is giving the order himself. Interview revealed if it is an expectation then it should be done.

2. Closed medical record review for Patient #3 revealed he was a 13-year-old male Involuntarily committed on 04/02/2021 for assaulting and communicating homicidal threats to other peers in his group home. Review of the "Behavioral Health MD (medical doctor) Order Form" dated 04/05/2021 at 1413, 04/10/2021 at 2145, and 04/21/2021 at 1606 revealed "Attending physician notified if not MD ordering intervention Name:________ (the Name of the attending physician was blank, therefore not notified)..." Further review of the order form revealed the restraint orders were telephone orders a nurse received by a LIP and not the patients attending MD. Review of an additional "Behavioral Health MD (medical doctor) Order Form" dated 04/08/2021 at 2218 revealed "Attending physician notified if not MD ordering intervention Name:________(the LIP that provided the telephone order was the name listed as the attending physician notified) ..."

Interview on 07/07/2021 at 1020 with RN #2 revealed she calls the LIP on call for orders for restraints/seclusion. Interview revealed it is not always the attending physician. Interview revealed if it is the nurse practioner or physician assistant she does not make an additional phone call to the attending physician to notify them of the restraint/seclusion episode.

Interview on 07/07/2021 at 1415 with Physician #10 revealed he is an attending physician. Interview revealed he does not recall receiving notification of his patients being placed in restraints/seclusion unless he is giving the order himself. Interview revealed if it is an expectation then it should be done.


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3. Closed medical record review for Patient #10 revealed he was a 16-year-old male admitted on 03/16/2021 for "aggression and suicidal and homicidal thoughts." Review of the "Behavioral Health MD (medical doctor) Order Form" dated 04/01/2021 at 1212, 04/02/2021 at 1835, 04/03/2021 at 1310 and 04/10/2021 at 1836 revealed "Attending physician notified if not MD ordering intervention Name:________ (the Name of the attending physician was blank, therefore not notified)..." Further review of the order form revealed the restraint orders were telephone orders received by a LIP and not the patients attending MD.

Interview on 07/07/2021 at 1020 with RN #2 revealed she calls the LIP on call for orders for restraints/seclusion. Interview revealed it is not always the attending physician. Interview revealed if it is the nurse practioner or physician assistant she does not make an additional phone call to the attending physician to notify them of the restraint/seclusion episode.

Interview on 07/07/2021 at 1415 with Physician #10 revealed he is an attending physician. Interview revealed he does not recall receiving notification of his patients being placed in restraints/seclusion unless he is giving the order himself. Interview revealed if it is an expectation then it should be done.

Based on policy and procedure review, medical record review, and staff interviews hospital staff failed to obtain the ordering providers signature verifying a telephone order in 4 of 5 patients who received telephone orders to initiate restraints (Patient #1, #3, #8, #10).

The findings included:

Review of the policy and procedure titled "Seclusion and Physical or Chemical Restraint" reviewed 04/28/2020 revealed "Justification, Psychiatrist's Order, and Documentation ... 2. Restraint or seclusion and Orders ...obtains the psychiatrist's telephone order at the time the emergency safety intervention is initiated by staff ...f. The psychiatrist's or LIP's (licensed independent practitioner) telephone order for physical or chemical restraint or seclusion must be followed with the psychiatrist's signature verifying the telephone order within 24 hours of receipt of the order ..."

1. Closed medical record review for Patient #1 revealed he was a 14-year-old male admitted on 03/15/2021 for "agitation and aggression at home." Review of the "Behavioral Health MD (medical doctor) Order Form" dated 03/23/2021 at 1726, 04/01/2021 at 1641, 04/03/2021 at 1010, 04/05/2021 at 1156, 04/09/2021 at 1046, 04/09/2021 at 1237, and 04/15/2021 at 0938, 04/19/2021 at 0922 revealed a nurse obtained a telephone order for a restrictive intervention. Further review failed to reveal the ordering provider or LIP signed the order form verifying the telephone order.

Interview on 07/07/2021 at 1008 with RN #2 (registered nurse) revealed that she had obtained multiple telephone orders for Patient #1, #3 and #10 for a restrictive intervention. Interview revealed RN #2's process was to flag the order form so the provider or LIP would sign it upon coming to the unit. Interview revealed the flag was used as a visual reminder for the providers and LIPs to sign the verbal order. Interview confirmed the telephone order should be signed by the ordering provider or LIP.

Interview on 07/07/2021 at 1108 with the Director of Quality and Risk Management revealed she audited all the restraint packets within the first twenty-four hours following the restraint episode. Interview revealed it was the nurse's responsibility to ensure the verbal telephone orders got signed by the ordering provider or LIP. Interview revealed ordering providers and LIPs not signing the telephone orders was a "systemic problem and closing the loop was missing."

Interview on 07/07/2021 at 1122 with Nurse Practitioner #1 (NP) revealed she was under the impression if she was not the LIP on call that gave the telephone order for a restrictive intervention, she still could sign the telephone order form is she was on the unit performing her rounds. Interview revealed traditionally verbal telephone orders needed to be signed within 24 hours. Interview revealed several of the nurses flagged the verbal telephone orders, but that process was something "that we could be more consistent with, that is definitely an area we can work on."

2. Closed medical record review for Patient #3 revealed he was a 13-year-old male admitted under Involuntarily Commitment Petition on 04/02/2021 for assaulting and communicating homicidal threats to other peers in his group home. Review of the "Behavioral Health MD (medical doctor) Order Form" dated 04/05/2021 at 1413, 04/08/2021 at 2218, 04/10/2021 at 2145, and 04/21/2021 at 1606 revealed a nurse obtained a telephone order for a restrictive intervention. Further review failed to reveal the ordering provider or LIP signed the order form verifying the telephone order.

Interview on 07/07/2021 at 1008 with RN #2 (registered nurse) revealed that she had obtained multiple telephone orders for Patient #1, #3 and #10 for a restrictive intervention. Interview revealed RN #2's process was to flag the order form so the provider or LIP would sign it upon coming to the unit. Interview revealed the flag was used as a visual reminder for the providers and LIPs to sign the verbal order. Interview confirmed the telephone order should be signed by the ordering provider or LIP.

Interview on 07/07/2021 at 1108 with the Director of Quality and Risk Management revealed she audited all the restraint packets within the first twenty-four hours following the restraint episode. Interview revealed it was the nurse's responsibility to ensure the verbal telephone orders got signed by the ordering provider or LIP. Interview revealed ordering providers and LIPs not signing the telephone orders was a "systemic problem and closing the loop was missing."

Interview on 07/07/2021 at 1122 with Nurse Practitioner #1 (NP) revealed she was under the impression if she was not the LIP on call that gave the telephone order for a restrictive intervention, she still could sign the telephone order form is she was on the unit performing her rounds. Interview revealed traditionally verbal telephone orders needed to be signed within 24 hours. Interview revealed several of the nurses flagged the verbal telephone orders, but that process was something "that we could be more consistent with, that is definitely an area we can work on."

3. Review of the medical record for Patient #8 revealed he was a 16-year-old male admitted under Involuntarily Commitment Petition on 05/24/2021 for major depressive disorder. Review of the "Behavioral Health MD (medical doctor) Order Form" dated 06/12/2021 at 1355 revealed a nurse obtained a telephone order for a restrictive intervention. Further review failed to reveal the ordering provider signed the order form verifying the telephone order.

Interview on 07/07/2021 at 1008 with RN #2 (registered nurse) revealed that she had obtained multiple telephone orders for Patient #1, #3 and #10 for a restrictive intervention. Interview revealed RN #2's process was to flag the order form so the provider or LIP would sign it upon coming to the unit. Interview revealed the flag was used as a visual reminder for the providers and LIPs to sign the verbal order. Interview confirmed the telephone order should be signed by the ordering provider or LIP.

Interview on 07/07/2021 at 1108 with the Director of Quality and Risk Management revealed she audited all the restraint packets within the first twenty-four hours following the restraint episode. Interview revealed it was the nurse's responsibility to ensure the verbal telephone orders got signed by the ordering provider or LIP. Interview revealed ordering providers and LIPs not signing the telephone orders was a "systemic problem and closing the loop was missing."

Interview on 07/07/2021 at 1122 with Nurse Practitioner #1 (NP) revealed she was under the impression if she was not the LIP on call that gave the telephone order for a restrictive intervention, she still could sign the telephone order form is she was on the unit performing her rounds. Interview revealed traditionally verbal telephone orders needed to be signed within 24 hours. Interview revealed several of the nurses flagged the verbal telephone orders, but that process was something "that we could be more consistent with, that is definitely an area we can work on."



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4. Closed medical record review for Patient #10 revealed he was a 16-year-old male admitted under Involuntarily Commitment Petition on 03/16/2021 for "aggression and suicidal and homicidal thoughts." Review of the "Behavioral Health MD (medical doctor) Order Form" dated 04/01/2021 at 1212, 04/02/2021 at 1835, 04/03/2021 at 1310 and 04/10/2021 at 1836 revealed a nurse obtained a telephone order for a restrictive intervention. Further review failed to reveal the ordering provider or LIP signed the order form verifying the telephone order.

Interview on 07/07/2021 at 1008 with RN #2 (registered nurse) revealed that she had obtained multiple telephone orders for Patient #1, #3 and #10 for a restrictive intervention. Interview revealed RN #2's process was to flag the order form so the provider or LIP would sign it upon coming to the unit. Interview revealed the flag was used as a visual reminder for the providers and LIPs to sign the verbal order. Interview confirmed the telephone order should be signed by the ordering provider or LIP.

Interview on 07/07/2021 at 1108 with the Director of Quality and Risk Management revealed she audited all the restraint packets within the first twenty-four hours following the restraint episode. Interview revealed it was the nurse's responsibility to ensure the verbal telephone orders got signed by the ordering provider or LIP. Interview revealed ordering providers and LIPs not signing the telephone orders was a "systemic problem and closing the loop was missing."

Interview on 07/07/2021 at 1122 with Nurse Practitioner #1 (NP) revealed she was under the impression if she was not the LIP on call that gave the telephone order for a restrictive intervention, she still could sign the telephone order form is she was on the unit performing her rounds. Interview revealed traditionally verbal telephone orders needed to be signed within 24 hours. Interview revealed several of the nurses flagged the verbal telephone orders, but that process was something "that we could be more consistent with, that is definitely an area we can work on."

Based on review of policy and procedures, medical records review and staff and physician interviews, the facility staff failed to coordinate a discharge plan for 2 of 11 patients records reviewed. (Patient #5; #8)

Findings included:

Review of the facility policy titled, "Discharge and Continuing Plan of Care," revised 06/01/2019, revealed "Policy: Discharge planning is an organized coordinated process with multidisciplinary team patient and family input identifies the patient's needs after discharge, delineates plans to meet these needs and teaches the patient and family how to implement the plans ..."

1. Closed medical record review on 07/07/2021 revealed a 12-year-old female patien,t (Patient #5), admitted on 04/05/2021 involuntarily for an altercation with her guardian, behavioral concerns, and visual hallucinations. Review of a "Daily Therapist Contact Note" dated 04/20/2021, no time, revealed the facility Therapist, DSS (Department of Social Services) worker, the North Carolina Disability Team and the guardian had a telephone discussion that concluded that the patient would be discharged to live with her guardian with outpatient mental health services. Review of a "Therapy Discharge Note" dated 04/26/2021 at 1113 revealed that the guardian expressed concern of Patient #5 returning home. "Resident (Patient #5`s name) is being discharged via sheriff. Sister [guardian] has requested emergency respite [short-term relief for a primary caregiver] and is refusing for the resident to come back home but resident must leave due to not meeting acute criteria ..." Review of a "Daily Therapy Contact Note" dated 04/27/2021 at 1400 revealed a therapist from the facility, a community mental health outpatient provider, DSS worker, an outpatient provider for children with mental health needs, and Disability Rights representative had a telephone discussion regarding Patient #5's discharge. Review revealed "that patient no longer met the requirements to remain at the hospital on the acute unit and she was no longer a danger to self or others. The sister indicated that [Patient #5`s name] would not return home until she was properly trained on restraining. Several referrals were completed for a 30-day respite bed and the team was waiting approval. It was reported that patient would be discharged and transported via sheriff to sister`s home and she indicated that she would not accept [Patient #5`s name] ... Consequences of her actions were reiterated to sister." Review of the "Discharge Continuing Care Plan" dated 04/27/2021, no time, revealed the names of an outpatient psychiatrist, a therapist and an outpatient in-home services with phone numbers and appointment dates. Review revealed in the place where the guardian would sign, the signature line, "DSS signed with therapist" was written. Review of the "Discharge Follow Up Authorization" dated 04/27/2021, no time, revealed the home address of the guardian, and the sheriff `s office was listed as the transportation for the patient upon discharge. Review revealed an employee's signature and "patient goes home ...social worker signed with therapist" located where the guardian would sign. Review of the "Discharge Notification" dated 04/28/2021 at 1806 revealed " ...Disposition: Home/ DSS Custody." Review of the "Discharge Summary" dated 04/28/2021, no time, revealed "[Patient #5`s name] will be going to the care of DSS custody." Review revealed no documentation of the guardian`s involvement with the discharge instructions and process. Review revealed discrepancies of Patient #5`s disposition: home versus DSS.

Interview request on 07/07/2021 with the employee, whom completed the Discharge Follow Up Authorization; with the primary counselor, whom coordinated the Daily Therapy Contact Notes from 04/21/2021 through 04/27/2021; with a Social Worker; a family therapist; and with the Director of Clinical Services; during Patient #5`s stay, was no longer employed at the facility.

Telephone Interview on 07/07/2021 at 1400 with Registered Nurse #3, whom discharged the patient, revealed she vaguely remembered Patient #5 and did not have access to the medical record during interview. Interview revealed she thought Patient #5 was to be discharged to the department of social services to get emergency respite before returning to home with the sister. She recalled the sister wanted to get some type of training. Interview revealed the therapists handled the actual discharge disposition and follow-ups for all patients at the facility.

Interview on 07/07/2021 at 1735 with the Chief Executive Officer revealed there is a reason why many staff are no longer here. Interview revealed "Clearly there are some deficiencies with discharge." Interview confirmed discrepancies with the discharge disposition, regarding discharge to home or DSS custody. Interview revealed, based on brief review of the medical record of Patient #5, "It appears that the patient was discharged to home."

2. Closed medical record review on 07/07/2021 revealed a 17-year-old male patient, Patient #8, admitted on 05/24/2021 involuntarily for destruction of property, altercations with family, and homicidal threats to family. Review revealed the patient was involuntarily committed from County A. Review of the "Admission Information" on 05/24/2021 at 1133 revealed an address in County B. Review of a Discharge Follow Up Authorization dated 06/16/2021 listed an outpatient psychiatrist and therapist closer to County A as referrals upon discharge. Review revealed the signature line for the guardian was blank. Review of a Therapy Discharge Note dated 06/16/2021 at 1818, revealed "After care plan reviewed with family [mothers name]. Family understands the importance of following up with aftercare services and assisting with patient safety plan. Review of the Discharge Continuing Care Plan dated 06/16/2021 at 1909 revealed patient's home address was listed in County B and transportation to home was the Sheriff from County B. Review of the Discharge Continuing Care Plan dated 06/16/2021 at 1907 by a Social Worker, revealed two follow up appointments: one dated 06/21/2021 (three days prior to actual discharge) with an outpatient provider for children with mental health needs and one dated 06/22/2021 (two days prior to actual discharge date) for outpatient progressive care services. Review of the same Discharge Continuing Care Plan revealed the lower portion was completed by a nurse on 06/24/2021 (8 days after the social worker completed the top portion) at 1205, which included vital signs, and a brief summary of the patient`s treatment and condition at discharge. Review of a "Progress Note" dated 06/18/2021 at 1033 revealed "Spoke with DSS worker about [named facility] keeping patient longer until placement is found ..." Review of a Daily Nursing Note dated 06/19/2021 at 1130 revealed "Discharge has been postponed due to placement issues ..." Review of a Daily Nursing Note dated 06/21/2021 at 1000, revealed " ... Waiting on CPS [Child Protective Services] placement and he wouldn't be going to his mother's home ..." Review of a Therapy Discharge Note dated 06/24/2021 at 1144 revealed " [Patient #5`s name] is aware of discharge plan to do PRTF [Psychiatric Residential Treatment Facility]." Review of a "Daily Nursing Note," dated 06/24/2021, no time, revealed " ...Resident discharge from unit ..." Review of the "Discharge Notification" dated 06/24/2021 at 1225 revealed "Disposition: Home." Review revealed no available documentation of the change from the need for long term residential treatment to the patient going home. Review revealed discharge appointments were not updated when the actual discharge was delayed. Review revealed no notification or correspondence with DSS Social Worker. Review revealed no available documentation of the guardian's involvement at time of discharge.

Interview on 07/07/2021 at1710 with Therapist #8, whom cared for the patient earlier in his stay, revealed she was made aware that the patient was transported to a wrong address. Interview revealed she was told that the sheriff called the facility and the sister was contacted and ultimately the sister met the sheriff to pick up the patient. Interview revealed she was told that the patient remained in the sheriff's care until the sister met him. Interview revealed that she recalled that the family was unstable and moved a lot. Interview revealed that the practice was for the address to be verified prior to discharge and that the parent's involvement in the discharge process was to be documented. Interview revealed that she understood that if DSS had an investigative case open the patient could still return to the previous home if it was deemed safe. Interview revealed Therapist #8 was not involved in the patient`s care from 06/16/2021 through 06/24/2021. Interview confirmed the discharge forms were not completed by the therapist or social worker, and the therapist should have made a note on the date of discharge and that the review of discharge with the guardian was not documented.

Interview request on 07/07/2021 with Nurse #5 whom was present the day of discharge, Social Worker #6 whom prepared the Therapy Discharge note dated 06/16/2021 and the Discharge Follow Up Authorization dated 06/16/2021, the therapist whom prepared the progress note on 06/18/2021, and the Director of Clinical Services, during Patient #8`s stay was no longer employed at the facility.

Interview on 07/07/2021 at 1000 with Social Worker #4, revealed for discharges she went by the "Admission Information" to verify addresses. Interview revealed that she documents the patients name and uses a second employee to verify any telephone review of discharge forms with guardians. Interview revealed it was the practice that if a guardian does not answer upon a sheriff`s arrival with a patient the sheriff brought the patient back to the facility.

Interview on a 07/07/2021 at 1520 with Nurse #7, whom cared for the patient, revealed the therapist and social workers arranged discharge dispositions, that included address verification and transportation. Interview revealed patients could have been discharged while a DSS case was opened if DSS declared that it was safe for the patient to return home.

Interview on 07/07/2021 at 1110 with the current Director of Clinical Services revealed it is the expectation that all forms were to be filled out completely and if forms were reviewed with a person over the telephone, that person's name and that the conversation occurred over telephone should have been documented. Interview revealed that the county that the patient came from dictated which Sheriff's office was contacted upon discharge. Interview revealed the patient's return address should have been confirmed and verified before the patient left the facility.

Interview on 07/07/2021 at 1450 with the Director of Nursing revealed when Patient #8`s discharge was delayed on 06/19/2021 the discharge continuing care plan should have been started over and new appointments arranged. Interview revealed documentation should have reflected changes to the discharge plan ongoing. Interview revealed all forms should have been completed to include the guardian's signature or that a telephone conversation occurred.

Interview on 07/07/2021 at 1600 with the DSS Social Worker in County A revealed an investigation was opened during Patient #8`s admission and was in progress on the actual day of discharge, 06/24/2021. Interview revealed that it was unsafe for Patient #8 to return home and the Social Worker was not notified of the patients discharge.

NC00176109, NC00176431, NC00176897, NC00176910, NC00177472, NC00178761, NC00178856