HospitalInspections.org

Based on observation, interview, and record review, the GB failed to ensure the safe and effective operation of the hospital as evidenced by:

1. The GB did not ensure the RN conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25. Cross reference to A175, example # 1.

2.The GB did not ensure Patient 2 received care in a safe, sanitary, and therapeutic environment when the patient was placed in seclusion. Cross-reference to 144.

3. The GB did not ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital's P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3's readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration. Cross reference to A175, example # 2.

4. The GB did not ensure a P&P developed specifying what personnel should be present when a full skin assessment was performed on an adolescent patient and failed to protect the dignity, privacy, and patient rights for one of seven sampled patients (Patient 1) when it conducted an invasive intake skin assessment using two male staff members of the opposite sex, without offering a same-sex alternative or obtaining informed consent. Cross reference to A142.

5. The GB did not ensure the Order for seclusion to manage violent behavior was renewed when the order exceeded four hours for Patient 3 as required by the hospital's P&P. Cross reference to A171.

6. The GB did not ensure the development, implementation, and maintenance of an effective, ongoing, hospital-wide, data driven QAPI program. Cross reference to A263.

The cumulative effect of these systemic failures resulted in the GB's inability to ensure provision of quality healthcare in a safe environment.

Based on observation, interview, and record review, the hospital failed to protect and promote the rights of each patient as evidenced by:

1. The hospital failed to ensure the RN conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25. Cross reference to A175, example # 1.

2. The hospital failed to ensure Patient 2 received care in a safe, sanitary, and therapeutic environment when the patient placed in seclusion. Cross-reference to 144.

3. The hospital failed to ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital's P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3's readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration. Cross reference to A175, example # 2.

4. The hospital failed to develop a P&P specifying what personnel should be present when a full skin assessment was performed on an adolescent patient and failed to protect the dignity, privacy, and patient rights for one of seven sampled patients (Patient 1) when it conducted an invasive intake skin assessment using two male staff members of the opposite sex, without offering a same-sex alternative or obtaining informed consent. Cross reference to A142.

5. The hospital failed to ensure the Order for seclusion to manage violent behavior was renewed when the order exceeded four hours for Patient 3 as required by the hospital's P&P. Cross reference to A171.

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision and protection of patient rights.

Based on observation, interview, and record review, the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven QAPI program as evidenced by:

The hospital failed to collect and analyze detailed, patient-specific restraint/seclusion data limits, the hospital's ability to identify patterns or high-risk patients, prevented accurate evaluation of the appropriateness and safety of interventions. Cross reference to A273.

The cumulative effects of these systemic problems resulted in failure to ensure hospital services were delivering care in the safest and most effective manner.

Based on interview and record review, the hospital failed to protect the dignity, privacy, and patient rights for one of seven sampled patients (Patient 1) when it conducted an invasive intake skin assessment using two male staff members of the opposite sex, without offering a same-sex alternative or obtaining informed consent. The procedure included genital exposure and a cough-and-squat maneuver, actions that were not part of a standard clinical skin assessment and lacking clinical justification. In addition, the leadership and clinical staff also failed to ensure that appropriate protocols and P&Ps were available and failed to protect Patient 1's rights and emotional well-being. This failure had the potential to affect Patient 1's psychosocial well-being and could lead to allegations of child abuse against the staff.

Findings:

During a review of the hospital's document titled "ARBH Skin Assessment Method (SAM) "(undated), indicated the outlined procedure included steps that exceed the scope of a standard clinical skin assessment. The guidelines directed staff to:

1. Have the patient remove their clothing while providing a paper gown for them to change into.
2. Once gowned, inspect every area of the body (including hair, nape of neck, mouth, palms, and soles of feet), keeping accurate notes of any abnormalities of the skin for documentation.
3. Have the patient reveal their back and buttocks for assessment.
4. Have the patient face you and reveal their upper body above the waist. Patients with pendulous breasts and heavier patients with skin folds will lift them so staff can assess for injuries or contraband.
5. Have patient reveal their lower body from waist down. All skin folds and genitals must be viewed to ensure no injuries or objects are present.
a. Males must life their scrotum and penis individually to ensure no contraband has been hidden, then have them squat and cough forcefully three times.
b. Females must squat and cough and cough forcefully three times to ensure no contraband has been hidden.

The ARBH Skin Assessment Method (SAM) did not distinguish between a clinical skin assessment and a contraband search and did not provide clinical justification for these invasive steps.

There was no mention of obtaining informed consent or offering patients the option to have the assessment conducted by staff of the same sex.

During an interview on 8/19/25 at 1125 hours with RN 1, RN 1 stated that during admission skin assessments, the goal was to have two staff members of the same sex as the patient. RN 1 stated if having two staff members of the same sex was not possible, at least one same-sex staff member performed the assessment while an opposite-sex staff member remained in the room with their back turned to the patient for privacy.

During an interview on 8/19/25 at 1120 hours with RN 2, RN 2 stated he was an intake nurse, and it was his job to assess the new arrivals and complete a full body, head-to-toe skin check on all newly admitted patients. RN 2 stated the staff assigned to perform the assessments depended on the sex/gender of the patient. RN 2 stated if the patient was a female adolescent, they had a female staff member completing the assessment and if possible, another female staff in the room. RN 2 also stated for an adolescent female, they did not assign two male RNs to perform the head-to-toe skin assessment. RN 2 confirmed that during the full body, head-to-toe assessment, the cough-and-squat evaluation was conducted for safety. RN 2 stated the purpose was to ensure there was no contraband hidden inside a body cavity. RN 2 did not recall the skin assessment performed on Patient 1 on 2/14/25.

During a review of Patient 1's medical record, conducted on 8/19/25 at 1405 hours, indicated Patient 1 was an adolescent female who was admitted to the hospital on 2/14/25 and discharged on 2/20/25.

During a review of Patient 1's "Nursing Admission Assessments" dated 2/14/25, the Nursing Admission Assessments indicated Patient 1's admission skin assessment was completed by RN 2 and MHW 1 (both males).

During a review of Patient 1's "Intake Assessment" dated 2/14/25 at 1145 hours, did not indicate that Patient 1 was offered a female staff member to perform the admission skin assessment. The document also did not reflect that Patient 1 or Patient 1's parent or legal guardian provided explicit consent for the skin assessment to be conducted by two staff members of the opposite sex.

During an interview on 8/20/25 at 1120 hours with the CNO, the CNO acknowledged the hospital did not have a P&P showing what staff would be present when a skin assessment was performed. The CNO was also notified of and acknowledged the above findings.

During an interview on 8/21/25 with Family Member 1, Family Member 1 stated Patient 1 had recently begun experiencing nightmares related to an event that occurred during Patient 1's admission skin assessment. Family Member 1 stated Patient 1 alleged being touched inappropriately by a male staff member during the skin assessment.

Based on observation, interview, and record review, the hospital failed to ensure the patient received care in a safe, sanitary, and therapeutic environment when the patient placed in seclusion. This deficient practice was identified for one of seven sampled patients (Patient 2) and resulted in prolonged seclusion under inhumane conditions, including lack of access to restroom facilities and evidence of physical injury. These unsafe seclusion conditions placed Patient 2 at risk for both physical harm and psychological harm.

Findings:

During a review of the hospital's P&P titled, "Seclusion/Restraint," dated June 2025, the hospital's P&P indicated, "Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified ... Discontinuation of restraint and seclusion occurs as soon as possible, based on an individualized patient assessment and reevaluation, regardless of the scheduled expiration of the order ... A provider or registered nurse will assess the need for Seclusion and/or Restraints only after less restrictive measures have failed... B. Applying Restraint or Initiating Seclusion....Maintain a clean, safe and comfortable environment ... C. Monitoring ... Qualified staff members do the following: ... Evaluate the patient for safety and comfort at the initiation of the restraint or seclusion and minimally every 15 minutes unless otherwise noted ... The evaluation includes any of the following, as appropriate to the patient and the type of restraint or seclusion... Nutrition and hydration are offered at least hourly, offer meals and snacks per hospital schedule. ... Vital signs... Hygiene and elimination are offered toileting at least hourly or as needed...Readiness for discontinuation of restraint or seclusion."

On 8/19/25, a review of Patient 2's medical record was initiated. Patient 2's medical record indicated the patient was admitted to the hospital on 8/3/25.

During a review of Patient 2's "Psychiatric Evaluation," dated 8/3/25, the Psychiatric Evaluation indicated Patient 2 was admitted to the hospital with history pf psychosis. On exam, the patient reported not taking his psychiatric medications in two weeks because the patient felt the patient did not need to. The patient reported difficulty with auditory hallucinations. The patient reported ongoing paranoia and reported that people were after him and trying to harm him. The patient reported difficulty with voices telling him not to take medications. The patient was admitted on a 5150-hold.

Review of the "Seclusion/Restraint Flowsheet" indicated Patient 2 was placed in seclusion on multiple occasions (approximately 17 occasions) from 8/4/25 to 8/19/25. The total cumulative duration of the seclusion was approximately 125 hours and 21 minutes between 8/4/25 and 8/19/25. The individual seclusion episode ranged from 2 hours and 5 minutes to 18 hours and 21 minutes. For each seclusion episode, the "Seclusion/Restraint Flowsheet" documented behavioral observations every 15 minutes. Cross reference to A175, example # 1.

During an observation of the seclusion room on 8/19/25 at 0900 hours, the following was observed:

- The seclusion room had multiple disposable paper cups on the floor, one of which contained a yellow liquid with a strong odor of urine.

- Food and snack wrappers were scattered across the floor.

- The mattress was observed with dark reddish-brown, blood-like stains and was dirty, with a strong odor of urine.

- The seclusion room had no bathroom, toilet, or running water. The only patient bathroom available was located outside, across the seclusion area.

- The floor of the seclusion room contained urine puddles, and the walls were marked with graffiti drawings.

During a review of the "Seclusion/Restraint Flowsheet," dated 8/19/25, the "Seclusion/Restraint Flowsheet" indicated Patient 2 was placed in seclusion from 8/18/25 at 1258 hours, and out of Seclusion on 8/19/25 at 0058 hours (a total duration of 12 hours).

During a review of the "Face to Face Evaluation" dated 8/18/25 at 2058 hours, the "Face to Face Evaluation" indicated under Patient Injuries: "Bruised and scabbed knuckles on bilateral knuckles from punching walls, the door, attacking staff."

During an interview on 8/19/25 at 0900 hours with the CNO, the CNO stated Patient 2 was aggressive, and there had been situations where they attempted to let him out of seclusion to use the bathroom, and Patient 2 attacked staff. The CNO stated Patient 2 was a danger to others, he was bleeding because he punched the walls out of frustration and threatened to hurt staff. The CNO stated they had a few staff members out due to being hit a few times in their face and head all unprovoked. The CNO stated Patient 2 was the last patient that had used the seclusion room.

During a concurrent observation and interview on 8/19/25 at 0930 hours with Patient 2, Patient 2 was observed wearing a T-shirt with visible blood stains on the collar. Patient 2 had dry scabbed wounds on the knuckles of both hands. Patient 2 stated if remaining compliant while in seclusion, he would be discharged, and that all he needed was snacks and a paper cup to urinate.

During a concurrent video surveillance review, from the inside seclusion room, and interview on 8/20/25 at 1100 hours with the CNO, the CNO reviewed the video surveillance recording dated 8/18/25 at 2033 hours, which captured Patient 2 urinating into a paper cup, without privacy, while in seclusion. On 8/20/25 at 2149 hours, the nursing staff allowed Patient 2 to go out to the bathroom, located across the restraint rooms. The CNO stated the hospital's policy only allowed physical holds and did not permit the use of mechanical restraints. The CNO stated the hospital was trying to protect other patients and staff from Patient 2. The CNO verified and acknowledged the above findings.

During an interview on 8/21/25 at 1100 hours with the hospital's Medical Director, the Medical Director stated aside from administering medication and initiating seclusion, there were no additional interventions available when Patient 2 began hitting the door and sustained bleeding, behavior that constituted a danger to self. The Medical Director acknowledged that the appropriate clinical response would have been to initiate mechanical restraints, but this intervention was not implemented due to the hospital's policy, which permits only physical holds and seclusion.

Based on interview and record review, the hospital failed to ensure the physician's order for seclusion to manage violent behavior was renewed when the order exceeded four hours for one of seven sampled patients (Patient 3) as required by the hospital's P&P. This failure could lead to the unnecessary use of restraint for the patient.

Findings:

During a review of the hospital's P&P titled, "Seclusion and Restraints," dated June 2025, the hospital's P&P indicated, "Authorizing/Ordering Restraint or Seclusion...Order the use of restraint or seclusion when determined to be clinically necessary ... Duration or anticipated ending time (as soon as possible, based on an individualized patient assessment and reevaluation) .... Adults - maximum of 4-hour duration...Seclusion or restraint must be discontinued at the earliest possible time once the patient has met criteria for release and no longer poses an imminent threat to him/ herself or others ... If the patient has not met release criteria and cannot safely be released from seclusion or restraint by the end of the initial order, a new order must be obtained from the psychiatrist or LIP to continue the restrictive measure. ... The clinical justification for continued use of restraint or seclusion at the time of the order's expiration."

During a review of Patient 3's medical record on 8/19/25, Patient 3's medical record indicated Patient 3 was admitted to the hospital on 7/25/25 and discharged on 8/1/25.

During the review of the "Seclusion/Restraint" dated 7/26/25 at 0448 hours, the Seclusion/Restraint indicated on 7/25/25 at 2057 hours, Patient 3 told RN that he "wanted to wind down" because the dayroom was getting loud. The RN asked other patients to quiet down. Patient 3 went up to nursing station and started banging on the window and asking the staff to put on "god or religious movies on the TV", but the staff told Patient 3 that other patients were still watching the movie. Patient 3 stated he was feeling "anxious" and the RN offered patient a Vistaril (a medication used as a sedative to treat anxiety and tension). The patient stated, "I do not have anxiety" and refused Vistaril. Patient 3 was sitting next to another patient and started washing their feet. MHW 2 asked Patient 3 to stop and Patient 3 became agitated and started swinging and attacking MHW 2. MHW 2 attempted to use MAB technique, but Patient 3 continued to attack MHW 2. Patient 3 pulled MHW 2 over dayroom tables and a few tables were knocked over. Patient 3 then grabbed MHW 2's hair and would not let go. An RN attempted to intervene and help MHW 2, but Patient 3 was too strong and continued to attack MHW 2. Patient 3 then "dislocated MHW's right shoulder." Code Grey was called and several RNs and MHWs responded to the code, holding Patient 3 down using four-point restraint at 2101 hours.

Review of the RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated seclusion started on 7/25/25 at 2109 hours and ended at 0416 hours and the restraint was started at 2100 hours and ended at 2107 hours. The Type of Restrictive Intervention Implemented section indicated the boxes of "Seclusion" and "Physical Hold (restraint)" were checked. The Type of Behavior Warranting Restraint/Seclusion section indicated the box of "Imminent danger to others" was checked and the patient attacked the MHW and dislocated the MHW's shoulder. The Event Description section indicated the NP approved renewal for seclusion in advance because Patient 3 was extremely violent and unpredictable. At that time, staff did not feel comfortable releasing the patient from seclusion due to his violent behavior.

Review of the Order for Restrain/Seclusion indicated a telephone order dated 7/25/25 at 2121 hours, for seclusion and physical restraint of the upper right limb, upper left limb, lower right limb and lower left limb. The duration of seclusion was four hours for patients over 18-year-old. The specific measures for ensuring patient's health and wellbeing included to continuous visual observation of patient, obtain vital signs every hour, assess skin integrity, RN reassess patient hourly, offer fluids hourly, offer toilet hourly, offer food per unit routine. The Criteria for Discontinuation section indicated the boxes of "No longer presents an imminent danger to self" and "No longer presents as an imminent danger to others" were left blank.

There was no clinical justification documented for the continued use of seclusion, and the seclusion order was not renewed after Patient 3 remained in seclusion for more than four hours.

During a concurrent interview and review of Patient 3's medical record on 8/20/25 at 1333 hours with the CNO, the CNO reviewed the medical record and acknowledged the above findings.

Based on observation, interview, and record review, the hospital failed to ensure two of seven sampled patients (Patients 2 and 3) were monitored when were placed in seclusion as per the hospital's P&P as evidenced by:

1. The hospital failed to ensure the RN conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25.

2. The hospital failed to ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital's P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3's readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration.

These failures posed a risk to patient safety due to the lack of timely monitoring and clinical evaluation during seclusion.

Findings:

During a review of the hospital's P&P titled, "Seclusion/Restraint," dated June 2025, the hospital's P&P indicated, "Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified ... Discontinuation of restraint and seclusion occurs as soon as possible, based on an individualized patient assessment and reevaluation, regardless of the scheduled expiration of the order ... A provider or registered nurse will assess the need for Seclusion and/or Restraints only after less restrictive measures have failed..." "Monitoring ...Qualified staff members do the following: ... Evaluate the patient for safety and comfort at the initiation of the restraint or seclusion and minimally every 15 minutes unless otherwise noted...The evaluation includes any of the following, as appropriate to the patient and the type of restraint or seclusion: ... Nutrition and hydration are offered at least hourly; offer meals and snacks per hospital schedule. ... Vital signs... Hygiene and elimination are offered toileting at least hourly or as needed...Readiness for discontinuation of restraint or seclusion." "Release from Restraint or Seclusion...The Psychiatrist/Provider or Registered Nurse will:...Assess the patient's vital signs at regular intervals that ensure the patient's safety ... Assess the patient for readiness to discontinue restraint or seclusion at regular intervals that ensure the patient's safety and meet the hospital's requirements ... Document the assessments in the patient's medical records... Documentation...The attending/on call psychiatrist, provider or RN will document:...each in-person evaluation and reevaluation of the patient."

1. On 8/19/25, a review of Patient 2's medical record was initiated. Patient 2's medical record indicated the patient was admitted to the hospital on 8/3/25.

During a review of Patient 2's "Psychiatric Evaluation," dated 8/3/25, the Psychiatric Evaluation indicated Patient 2 was admitted to the hospital with history pf psychosis. On exam, the patient reported not taking his psychiatric medications in two weeks because the patient felt the patient did not need to. The patient reported difficulty with auditory hallucinations. The patient reported ongoing paranoia and reported that people were after him and trying to harm him. The patient reported difficulty with voices telling him not to take medications. The patient was admitted on a 5150-hold.

During an observation of the Seclusion Room on 8/19/25 at 0900 hours, the seclusion room mattress was observed stained and dirty, with a strong odor of urine. The floor of the seclusion room contained urine puddles, and the walls were marked with graffiti. Inside the room, the floor was observed with bags of snacks, a paper cup full of yellow liquid with smelling-like urine. The seclusion room had no bathroom, toilet, or running water. The only patient bathroom was located outside across the seclusion area.

During an interview with Patient 2 on 8/19/25 at 1115 hours, Patient 2 stated he wanted to be discharged from the hospital. Patient 2 stated...as long he had snacks and a paper cup, he could stay in seclusion. Patient 2 stated the paper cup was to pee because staff did not let him go to the bathroom.

A concurrent video surveillance review, from the inside seclusion room, and interview with the CNO was conducted on 8/20/25 at 1100 hours. Review of the video surveillance recording dated 8/18/25 at 2033 hours, captured Patient 2 was urinating into a paper cup, without privacy, while in seclusion. On 8/20/25 at 2149 hours, the nursing staff allowed Patient 2 to go out to the bathroom, located across the seclusion rooms.

During a review of the Seclusion/Restraint and the Seclusion/Restraint Flowsheets for Patient 2 from 8/4/25 to 8/19/25, the Seclusion/Restraint and the Seclusion/Restraint Flowsheets indicated Patient 2 was placed in seclusion for approximately 17 episodes between 8/4/25 to 8/19/25. Each episode of the seclusion was initiated under the pre-printed Order for Restraint/Seclusion that contained identical directives, including:
* Order Type: Seclusion
* Specific Measures for Ensuring Patient Safety
- Continuous visual observation
- Obtain vital signs every hour
- Assess skin integrity
- RN reassess the patient hourly
- Offer fluids hourly
- Offer toilet hourly
- Offer food per unit routine
- Criteria for Discontinuation: "No longer presents an imminent danger to others"

The hospital's Seclusion/Restraint Flowsheets included the printed instructions requiring that "Staff observed patient continuously with documentation minimally every 15 minutes...registered nurse must perform assessment at least once every hour during the course of restraint or seclusion." Documentation on the Seclusion/Restraint Flowsheet included vital signs every hour; fluid, food, elimination every hour; and describe patient behavior every 15 minutes.

Review of the Seclusion/Restraint and the Seclusion/Restraint Flowsheets for Patient 2 from 8/4/25 to 8/19/25, indicated the following:

* On 8/4/25, Patient 2 was placed in seclusion from 1312 hours to 1517 hours (2 hours and 5 minutes). No RN assessment was documented at least once every hour during the course of seclusion. The only RN entry was at the time of the release of the patient from seclusion.

* On 8/5/25, seclusion occurred from 1527 hours to 1948 hours (4 hours and 21 minutes). The Seclusion/Restraint Flowsheet noted the repeated entries of "laying on bed" or "lying on floor," with no escalation in behavior. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/6/25, seclusion was initiated at 0735 hours and ended at 1537 hours (8 hours and 2 minutes). No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/6/25, the second episode of seclusion occurred from 1548 hours to 1952 hours (4 hours and 4 minutes). The Restraint/Seclusion Flowsheet did not indicate any behavioral escalation from 1815 to 1930 hours. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/7/25, seclusion occurred from 1221 hours to 2021 hours (8 hours). On 8/7/25 at 1621 hours, the RN came to the patient's room to reassess the patient; the seclusion order was renewed; and the patient was currently in locked seclusion room. The patient was sitting on the floor, lying on the floor, or lying on the bed from 1715 to 2015 hours. No RN assessment was documented at least once every hour during the course of seclusion. No evaluation for readiness to discontinue was noted.

* On 8/9/25, seclusion was documented from 1138 hours to 2119 hours (9 hours and 41 minutes). No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/9/25 at 2219 hours to 8/10/25 at 0258 hours (4 hours and 39 minutes), the patient was placed in seclusion. The patient was asleep from 0000 to 0300 hours. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/11/25, seclusion lasted from 0921 hours to 2110 hours (11 hours and 49 minutes). The patient's behavior was alternated between sleeping and verbal threats. No RN assessment was documented at least once every hour during the course of seclusion.

The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/11/25 at 1321 and 1720 hours. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/12/25, seclusion occurred from 1130 hours to 2155 hours (10 hours and 25 minutes). The patient's behavior alternated between aggression and sleep.

The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/12/25 at 1530 and 1935 hours. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/13/25, the patient was placed in seclusion at 0934 hours. The patient was sleeping, lying in bed, pacing, or resting from 0945 to 1300 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section dated 8/13/25 at 1457 hours, indicated the patient was assessed in the seclusion room; the provider was notified about the patient's current status and provided an order for lock seclusion at this time; the seclusion was started at 1334 hours and ended at 1705 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint dated 8/13/25 at 1705 hours, indicated the EMT transport arrived to transport the patient to an acute care hospital. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/14/25, a seclusion episode initiated at 1256 hours as per physician's order. The duration of the seclusion episode was not specified in the documentation. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/15/25, a seclusion episode started at 1022 hours and ended on 8/16/25 at 0443 hours (18 hours and 21 minutes). The patient was documented as asleep or lying quietly from 1245 hours to 1345 hours, 1430 hours to 1500 hours, and from 2000 hours to 0200 hours. On 8/16/25 at 0215 hours, the RN attempted to give the patient a gown; the patient refused, remaining withdrawn in the corner of the room. At 0440 hours, staff unlocked the seclusion room. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/15/25 at 1123, 1544, and 1835 hours; and on 8/16/25 at 0220 hours. Despite extended periods of inactivity, no reassessment or consideration for release was documented. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/16/25, the patient was placed in seclusion at 1201 hours. At 2001 hours, the patient was escorted back to the patient's room from the seclusion room. At 2018 hours, the patient punched a mental health worker. The patient was restrained from 2018 to 2022 hours. At 2023 hours, the patient was in locked seclusion room. On 8/17/25 at 0023 hours, the door of the seclusion room was open, and the patient was escorted back to the patient room. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section of the Seclusion/Restraint indicated the RN signed and dated this section on 8/16/25 at 2354 hours. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/17/25, a seclusion episode was started at 1624 hours and ended on 8/18/25 at 0022 hours (7 hours and 58 minutes). The flowsheet indicated the patient was restless. The flowsheet did not indicate any escalation in behavior. No RN assessment was documented at least once every hour during the course of seclusion.

* On 8/18/25, Patient 2 was placed in seclusion from 0828 to 1248 hours (4 hours and 24 minutes). The patient was lying in bed, eating, sitting in bed, or sleeping from 0830 to 1245 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section indicated the RN signed and dated this section on 8/18/25 at 1022 hours. No RN assessment was documented at least once every hour during the course of seclusion.

* The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section dated 8/18/25 at 1505 hours, indicated at 1248 hours, staff unlocked the seclusion room door and attempted to let the patient out into the unit after the patient contracted for safety; the patient came to the seclusion doorway and attacked staff member unprovoked, striking staff member in the jaw with a closed fist. Code Grey was called, and staff members intervened, escorting the patient to seclusion room bed. The door of the seclusion room was locked at 1258 hours.

The Seclusion/Restraint Flowsheet dated 8/18 and 8/19/25, indicated Patient 2 was placed in seclusion from 8/18/25 at 1258 hours to 8/19/25 at 0058 hours (12 hours). The patient was sleeping from 1325 to 1545 hours. The RN Assessment of Patient Behavior Requiring Seclusion/Restraint section indicated the RN signed and dated this section on 8/18/25 at 1433, 1505, 1800, 2210 hours. No RN assessment was documented at least once every hour during the course of seclusion.

During a review of the "Seclusion/Restraint Flowsheets," the "Seclusion/Restraint Flowsheets" indicated Patient 2 was placed in seclusion on approximately 17 occasions or approximately a total of 125 hours and 21 minutes between 8/4/25 to 8/19/25. The shortest episode occurred on 8/4/25, lasting 2 hours and 5 minutes, while the longest episode was from 8/15/25 to 8/16/25, lasting 18 hours and 21 minutes.

During a review of the "Seclusion/Restraint Flowsheets," the "Seclusion/Restraint Flowsheets" documented the behavioral observations at 15-minute intervals.

A review of Patient 2's medical record failed to show documented evidence the RN assessments conducted at least once every hour during any of the seclusion periods as required by the orders and hospital's P&P.

A review of Patient 2's medical record failed to show documented evidence of evaluations regarding Patient 2's readiness for release from seclusion, even when the Flowsheets indicated the patient had calm behavior, was sleeping, or lack of aggression.

During an interview on 8/21/25 at 0835 hours with RN 5, RN 5 stated the RN assessments were conducted after an emergency situation, where the patients were placed in restraint/seclusion. RN 5 stated there was no specific hourly RN assessment requirement.

During an interview on 8/21/25 at 1000 hours with the CNO, the CNO stated the restraint P&P needed to be reviewed, the hospital's P&P indicated to assess the patients in restraints/seclusion at regular intervals. The CNO acknowledged the above findings.


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2. During a review of Patient 3's closed medical record on 8/19/25, Patient 3's medical record indicated Patient 3 was admitted to the hospital on 7/25/25 and discharged on 8/1/25.

During the review of the "Order for Restrain/Seclusion," the "Order for Restrain/Seclusion" indicated, a telephone order dated 7/25/25 at 2121 hours, was received for a physical restraint on upper right limb, upper left limb, lower right limb, and lower left limb and for seclusion with the duration of seclusion was four hours for patient over 18-year-old. Specific measures for ensuring patient's health and wellbeing included to continuous visual observation of patient, obtain vital signs every hour, assess skin integrity, RN reassess patient hourly, offer fluids hourly, offer toilet hourly, offer food per unit routine.

a. During the review of the "Seclusion/Restraint Flowsheet" dated 7/25/25, indicated the form instructions indicated staff observed patient continuously with documentation minimally every 15 minutes, registered nurse must perform assessment at least once every hour during the course of restraint or seclusion. Documentation on the Seclusion/Restraint Flowsheet included vital signs every hour; fluid, food, elimination every hour; and describe patient behavior every 15 minutes. Further review of the Seclusion/Restraint Flowsheet indicated the following:

* Patient 3 was placed in Physical Hold from 2100 hours, and out of Physical Hold at 2107 hours (seven minutes).

* Patient 3 was placed in seclusion from 2109 hours, and out of Seclusion at 0416 hours.

* Patient 3 refused vital sign measurements from 2100 to 2300 hours. There was no documented evidence showing attempts to obtain the patient's vital signs every hour from 0000 to 0416 hours. There was no documented evidence showing the patient's needs were assessed and recorded as per the hospital's P&P, specifically for nutrition, hydration, hygiene, and elimination needs, from 0000 to 0416 hours.

b. Review of the Seclusion/Restraint for Patient 3 indicated the seclusion was started on 7/25/25 at 2109 hours and ended at 0416 hours. The Order for Restraint/Seclusion section of the Seclusion/Restraint indicated the Criteria for Discontinuation section showing the boxes of "No longer present as an imminent danger to self" and "No longer presents as an imminent danger to others" were left blank. There was no RN assessment or evaluation Patient 3 for readiness to discontinue seclusion.

During an interview and concurrent review of Patient 3's medical record on 8/21/25 at 0907 hours, with the CNO, the CNO verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure its QAPI program collected and analyzed data related to the use of restraints/seclusion. The hospital was unable to demonstrate that restraint and seclusion use was being monitored and evaluated, and could not produce any restraint data for July and August 2025. This lack of documentation and analysis impaired the hospital's ability to identify patterns, recognize high-risk patients, and evaluate the appropriateness and safety of interventions.

Findings:

During a review of the hospital's "Performance Improvement Plan 2025," indicated, ... "The Performance Improvement Plan for the Hospital has the following objectives: ... To support and review, on an ongoing basis, processes that objectively and systematically monitor and evaluate the quality and appropriateness of the aspects of patient care that directly or indirectly affect patient outcomes and that improve efficiency of patient care...Through the Performance Improvement Program, information on important aspects of patient care is collected routinely though the following mechanisms: ... medical records review and patient satisfaction, complaints and clinical outcomes used ... safety/risk management program (high risk procedures, incident reporting, untoward occurrences)..."

During an observation, interview, and record review on 8/19, 8/20, and 8/21/25, the following deficient practices related to the use of seclusion were identified:

* The hospital failed to ensure the RNs conducted ongoing hourly assessments during approximately 17 episodes of seclusion for Patient 2, who remained in seclusion for a cumulative total of 125 hours and 21 minutes between 8/4/25 and 8/19/25. Cross reference to A175, example # 1.

* The hospital failed to ensure Patient 2 received care in a safe, sanitary, and therapeutic environment while in seclusion. Cross reference to 144.

* The hospital failed to ensure Patient 3 was assessed for vital signs, nutrition need, hydration need, hygiene need, and elimination need as per the Order and the hospital's P&P. In addition, the hospital failed to ensure the nursing staff completed a timely assessment and evaluation of Patient 3's readiness to discontinue seclusion despite the patient remaining in seclusion beyond the initial order duration. Cross reference to A175, example # 2.

* The hospital failed to ensure the Order for seclusion to manage violent behavior was renewed when the order exceeded four hours for Patient 3, as required by the hospital's P&P. Cross reference to A171.

During a review of the "2025 Clinical Benchmarking Report" from January to June 2025, indicated the hospital only tracked aggregate monthly totals for mechanical restraint, physical restraint, and seclusion. The report lacked the following:

1. Identification of the individual patients restrained/secluded.
Duration of each episode (number of hours).
Type of intervention used (emergency vs. planned).
Unit or location of each episode.
Documentation of whether release occurred at the earliest possible time.

2. Lack of Rate Calculations:
The data was presented as raw counts. There were no rates per 1,000 patient days or percentage of patients restrained/secluded, preventing valid comparisons over time or against benchmarks.

3. No Trend or Root Cause Analysis:
Large month-to-month fluctuations (e.g., Physical Restraint - Adult: March = 56; April = 11) had no documented explanation or analysis to determine causative factors.

During an interview on 8/21/25 at 1100 hours, with the Director of Quality, the Director of Quality was not able to produce documentation to show a system to collect or analyze patient-level data related to restraint or seclusion use. There were no logs, rate-based metrics, or trend analyses available for review. The Director of Quality stated the QAPI only received aggregate totals.