HospitalInspections.org

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Based on observation, interview, video review and record review the facility failed to ensure the hospital protected and promoted each patient's rights, according to the Condition of Participation: CFR 482.13 Patient Rights. Findings:

The facility failed to ensure:

1. Patients recieved care in a safe setting. Reference at A tag 0144:

This failed practice caused physical and/or psychosocial harm from assaults for two patients (#5 and #20) attempting to receive care at the facility, which constituted an immediate jeopardy, at CFR 482.13(c)(2) The patient has the right to receive care in a safe setting. And further, placed all patients at risk for continued patient-to-patient assaults, based on a census of 33.

This situation was brought to the attention of the facility's administration on, 4/7/22 at 3:53 PM, at which time the facility was notified of identified physical and psychosocial harm and immediate jeopardy.

The facility submitted an acceptable removal plan on 4/11/22 at 11:49 am.

The State Agency verified onsite that the immediacy was removed on 4/10/22 at 7:00 PM.
Following the removal of the immediacy, noncompliance remained at the condition level for Patient Rights;

2. Patients were able to participate in their plan of care. Reference at A tag 130;

3. Patients were free from abuse. Reference at A tag 145;

4. Patients were free from restraint and seclusion. Reference at A tag 154;

5. Written modification completed to the care plans. Reference at A tag 166;

6. A physician order was obtained for seclusion and restraint. Reference at A tag 168;

7. Time limits for seclusion for specific age groups were met. Reference at A tag 171;

8. Patients in seclusion were monitored in intervals developed by hospital policy. Reference at A tag 175;

9. Patients were seen face to face within one hour of a seclusion intervention. Reference at A tag 179;

10. Documentation of the patient's behavior and the intervention used during a seclusion or restraint. Reference at A tag 185;

11. Documentation of alternatives to seclusion. Reference at A tag 186;

12. Documentation of the condition that warrented use of restraint or seclusion. Reference at A tag 187;

13. Documentation of the patients' response to the seclusion intervention. Reference at A tag 188;

14. Staff demonstrated competency in the implementation of seclusion. Reference at A tag 196.
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Based on record review, interview, video review and observation, the facility failed to ensure the patients' treatment plan was implemented, for 3 patients (#'s 4; 15; and 17) out of 13 sampled patients. This failed practice denied the patients' treatment options that were developed in their treatment plans and had the potential to affect the overall outcome and sustainability of treatment goals for all patients, based on a census of 33. Findings:

Patient #4

Record review on 4/4/22 at 11:00 AM revealed Patient #4 was admitted to the facility for 40 days in August and September 2021 and readmitted 6 days later with diagnoses that included autism, post traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and intermittent explosive disorder (mental disorder marked by episodes of unwarranted anger).

Review of Patient #4's "Acute Interdisciplinary Treatment Plan," dated 9/8/21, revealed: "Modalities[-] Weekly Individual Psychotherapy and mental health status assessment [;] Weekly Family Psychotherapy ..."

Further review revealed "Staff Interventions in order to increase behavioral and emotional self-regulation skills, the following interventions are in place: [Clinical Therapist] will provide psychoeducation (i.e., frustration management, noticing triggers and warning signs) and teach skills (i.e., distracting coping skills, taking a time out) weekly during [Individual Therapy, Family Therapy and daily Group Therapy]."

Record review of Patient #4's "North Star Behavioral Health Acute Clinical Therapy Progress Note," dated 8/9/21 from 1:00 PM to 1:45 PM, revealed the type of session as family therapy session. Further review revealed "[Clinical Therapist] met [with patient's] father telephonically to gather information to complete psychosocial assessment."

Record review of Patient #4's "North Star Behavioral Health Acute Clinical Therapy Progress Note," dated 8/9/21 from 2:00 PM to 2:45 PM, revealed the type of session as individual therapy session. Further review revealed "[Clinical Therapist] met [with patient] to gather information to complete psychosocial assessment."

Further review revealed no documentation of any other family or individual clinical therapy sessions for the 40-day length of stay.

During an interview on 4/6/22 at 12:00 PM, the Clinical Therapist (CT) #1 stated individual therapy sessions were provided once per week, sometimes twice, but at a minimum once a week. When asked about family therapy sessions, the CT stated family therapy is also provided once per week. When asked if the psychosocial assessment counted as a family therapy session, CT #1 stated it would not, because the patient would not have been involved with the psychosocial assessment, so it would not have counted as a family therapy session.

During an interview on 4/7/22 at 9:56 AM, when asked about the process for clinical therapy, the Social Services Director (SSD) stated the facility should have provided one individual therapy session per week and one family therapy session per week. When asked to review Patient #4's medical record for the clinical therapy sessions, the SSD stated there were no weekly notes in the patient's medical record.

During an interview on 4/7/22 at 1:21 PM, Physician #1 stated individual and family therapy sessions were a pivotal part of the patients' treatment plan.

Review of the facility's policy "Medical Record Documentation," dated 1/2022, revealed "It is the policy of North Star Behavioral Health system to ensure that documentation of patient care is recorded to communicate the treatment provided and its results."

Patient #15:

Record review on 4/9/22 at 4:00 PM revealed Patient #15 was admitted to the facility in March 2022 with diagnoses that included Bipolar disorder (A serious mental illness characterized by extreme mood swings), depressed, severe with psychosis (break from reality) and PTSD.

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM.

On 4/4/22 at 4:36 PM to 4:42 PM, Patient #15 was observed kicking the outside door of the anteroom from the unit hallway. Further observation revealed the Patient kicked the wall eight times.

The Clinical Therapist (CT) #2 was observed to walk past the agitated patient without speaking to the patient.

At 4:42 PM, two unidentified staff members were observed walking past Patient #15, while the patient was visibly agitated and hitting the walls with his/her hands.

When asked if the CT should have attempted to de-escalate the Patient, the QD stated she would have thought so. The QD further stated it appeared no staff member attempted to de-escalate the Patient. When asked if staff should have attempted de-escalation, the QD stated staff may have let the Patient "blow off steam." When asked if staff should have followed the patient's care plan, the QD stated that yes, the patient's care plan should have been followed.

Review of the Patient #15's care plan on 4/8/22 at 3:30 PM revealed:

"Each time I have the urge/thought to be aggressive, make homicidal threats or gestures towards others I will my fidget as my preferred coping skill and squeeze my calming sensory rock, 50 times without acting upon the urge/thought and share with staff each shift and CT weekly ..." Further review revealed [Mental Health Services} will closely monitor for signs of aggressive and homicidal behavior and encourage youth to use coping skills (i.e., take a break as well as notify the nurse of any concerns)."

Patient #17:

Record review on 4/6/22 at 3:45 PM revealed Patient #17 was admitted to the facility in March 2022 with diagnoses that included Generalized Anxiety disorder and Oppositional Defiance Disorder (A condition in which a child displays argumentative behavior towards people in authority).

An observation on 4/6/22 at 2:56 PM revealed Patient #17 in the hallway of the unit, punching the window of the door leading to the main nurses' station. Patient #17 was crying and yelling "no one cares about me." An unidentified staff member came out of an office to speak with the patient.

From 3:05 PM to 3:12 PM, Patient #17 was observed alone in the hallway, banging on the same window to the nurses' station. LN #3 was observed to be sitting inside the nurses' station typing at the computer. Patient #17 was yelling "I want to talk to my Mom," and "I want to die."

At 3:14 PM, LN #3 handed the phone receiver through the door to the Patient. The Patient was screaming and red in the face. Patient #17 was unable to speak on the phone and the phone receiver was returned to the nurses' station.

At 3:20 PM, Patient #17 was observed to continue to bang on the window and yell. The LN stated Patient #17 had slammed down the phone on the other side of the door.

During an interview on 4/6/22 at 3:22 PM, LN #1, in regard to Patient #17's behavior, stated he/she was not working on that side, but stated he/she had used interventions in the past to help de-escalate that age group.

At 3:24 PM, LN #3 was observed to enter the unit to make rounds. Patient #17 was laying on the floor of the hallway yelling and crying.

At 3:30 PM, Patient #17 was observed banging on the nurses' station window. An unidentified MHS arrived to the unit and began speaking to the patient.

At 3:33 PM, the other patients were lined up single file and entered the unit. The MHS stated he/she was on the unit by him/herself, because the other MHS staff were attending to patients who required one on one staffing.

At 3:36 PM, Patient #17 continued to bang on the window, yelling to the LN to call his/her mother. LN #3 opened the door and spoke briefly to the patient before continuing to chart on the computer. Patient #17 was yelling the LN's name and stated "You are ignoring me."

At 3:38 PM, an unidentified MHS staff began speaking to the patient and walked the patient down the hall, where with an unidentified LN, were able to de-escalate the patient.

Review of "Acute Interdisciplinary Treatment Plan," dated 4/4/22, revealed "Distractions I'm willing to use to prevent the use of unsafe (high risk) behaviors[:] 5-min[ute] self time -out[;] Journaling [;] Stress ball [;] Prayer [;] Think positive [;] Color/draw [;] Deep breathing [;] Process with staff."
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Based on observation, interview, record review and video review, the facility failed to ensure 2 patients (Patient #'s 5 and 20) , out of 13 sampled patients, received care in a safe setting. Specifically, the facility:

1) failed to properly supervise the anteroom (which staff referred to as the quiet room) while used to deescalated more than 1 patient at a time, resulting in a patient to patient (#'s 13 and 20) assault:

2) failed to investigate the assault and put measures into place to prevent future occurrences:

3) continued to use the anteroom for agitated patients, and escorted other agitated patients through the anteroom, passing by another patient, to utilize a seclusion room;

4) allowed patients to sleep in the anteroom for extended periods of time, increasing the risk of injury to the sleeping patient when an escalated patient was required to enter the anteroom on way to use a seclusion room; and

5) failed to report an assault/injury to Patient #5's guardian (mother) after an assault from peers occurred.

These failed practices caused physical and/or psychosocial harm from assaults for two patients (#5 and #20) attempting to receive care at the facility, which constituted an immediate jeopardy, at CFR 482.13(c)(2) The patient has the right to receive care in a safe setting. And further, placed all patients at risk for continued patient-to-patient assaults, based on a census of 33.

This situation was brought to the attention of the facility's administration on, 4/7/22 at 3:53 PM, at which time the facility was notified of identified physical and psychosocial harm and immediate jeopardy.

The facility submitted an acceptable removal plan on 4/11/22 at 11:49 AM.

The State Agency verified onsite that the immediacy was removed on 4/10/22 at 7:00 PM.
Following the removal of the immediacy, noncompliance remained at the condition level for Patient Rights.

Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom. On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 individual locked doors for the seclusion rooms. All doors were locked when closed and required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked the purpose of the 4 rooms, connected by the anteroom, the LN replied the 4 rooms were utilized for seclusion. When asked if LN could see the doors and the bathroom from the medication room window, the LN confirmed that there was a "blind spot" from viewing through the window or the camera monitor at the nurse's station, adding the "monitor was not working since yesterday." The LN also stated as a rule the staff should have checked the bathroom and closed the bathroom door but sometimes staff had not checked.

Altercation between Patient #13 and Patient #20:

Review on 4/5/22 at 3:00 PM of the "Nurses Daily Assessment/ Progress Notes," dated 11/11/21 night shift (7:00 PM to 7:00 AM), revealed " ... [Patient #13] ... had assaulted a peer [Patient #20] in the quiet room [the anteroom] because [the] staff did not know this patient [Patient #13] was still in the quiet room [the anteroom] when they put the peer [Patient #20] in the quiet room. [Patient #13] was reportedly in the bathroom. [Patient #13] attacked the peer because the peer was instigating [him/her]. [Patient] was assaultive to other peers as well ..."

Review on 4/5/22 at 3:00 PM of the Mental Health Specialist (MHS) Evening Progress Notes, dated 11/11/21, revealed [Patient #13] was very angry. Poor self-control. [He/She] was very frustrated and assaultive. [He/She] was attacking some of [his/her] peers. [He/She] was very out of control. Poor attitude. [He/She] was fighting and was very agitated ...Staff talked to [him/her] about [his/her] aggressive behavior."

Review on 4/6/22 at 8:47 AM of an Incident Report #132 dated 11/12/21, revealed Patient #13 had an incident of "aggression/assault patient towards patient [Pt. #20]" on 11/11/21 at 7:05 PM. The document further revealed [Pt. #13 was] placed in quiet room [the anteroom] due to aggression. Pt. was using bathroom when another peer was placed in the quiet room [the anteroom]. This patient then came out of the bathroom and began attacking peer by punching [him/her] on the left cheek giving a bloody nose. Staff separated patients."

Review on 4/7/22 at 2:30 PM of an Incident Report #135 dated 11/12/21, revealed Pt. #20 had an incident of "aggression/assault by another patient" on 11/11/21 at 7:05 PM. The document further revealed "[Patient #20] was placed in the quiet room [the anteroom] due to [his/her] peers. [Patient] was posturing peer and ... [refusing staff redirection]. A peer who was exhibiting similar behaviors was in the quiet room [the anteroom] bathroom, but the staff did not know this. Peer then came out of the bathroom and began attacking the peer."

Investigation:

During an interview with the Quality Director (QD) on 4/6/22 at 8:15 AM, when asked if there was an investigation conducted on a peer-to-peer altercation, the QD stated the facility had not investigated the peer-to-peer altercation, but she would have followed-up on the medical component if the patient suffered an injury. The QD explained that the facility classified an incident according to the degree of injury such as 1- for bruise or scratch, 2- bleeding, black-eye, 3- fracture, death within 30 days of discharge, and 4- permanent disability or death.

In the same interview, when asked if there was in investigation on the Patient-to-Patient assault in the anteroom on 11/11/21, the QD stated an incident report was completed but no investigation was conducted. The facility reported the incident to the guardian at the Office of Children's Services by a voicemail.

Continued Anteroom Usage after Incident:

A video review of the anteroom and joint interview was conducted with the QD on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on the same day.

At 8:02 AM, Patient #17 was observed to be agitated in the anteroom of the seclusion rooms . A staff member and Patient #18 were observed to pass through the anteroom with Patient #17 visibly agitated in the room. Patient #18 had to pass by Patient #17 and was escorted into the seclusion room with a staff member.

At 2:22 PM, a staff member dragged a mattress into the seclusion room and Patient #18 was observed to lay down on the mattress with the door of the seclusion room door opened, and the anteroom door was closed and locked .

At 3:00 PM, the door to the anteroom was observed to be opened, while Patient #18 remained laying down in the unlocked seclusion room.

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

At 3:05 PM, MHS #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing in the anteroom.

At 3:26 PM, Staff exited the area and left the door to the anteroom unlocked and open. Patient #18 remained inside the unlocked seclusion room without staff present.

At 4:24 PM, Patient #18 exited the anteroom with a staff member. Patient #18 had been left to sleep in the seclusion room for 58 minutes unattended.

Review on 4/7/22 at 5:30 PM of Patient #18's "North Star Hospital Monitoring Precautions Record and Sleep Log," dated 4/4/22 from 2:15 PM through 4:30 PM, revealed the Patient was coded as sleeping in his/her bedroom during the time the patient was observed to be laying on a mattress in the seclusion room.

During an interview on 4/6/22 at 1:25 PM, when asked about using the anteroom to deescalate the patients, LN #2 stated the doors were closed because staff did not want the patients to go to the other side of the unit. The LN further stated there was lack of communication between the 2 sides (units). The LN stated there was a potential for an agitated patient to use the anteroom when a different patient was utilizing the same room. The LN clarified this situation had happened in the past.

During an interview on 4/7/22 at 1:21 PM with Physician #1, when asked how the facility kept the patients safe, the physician stated there should have been enough staff, the staff should have been close by to monitor one on one for a patient who displayed aggressive behavior. The Physician also explained that staff were expected to monitor a patient in the quiet room [the anteroom] on a 1 staff to 1 patient [1:1] ratio. When asked if it was safe to bring another patient into the quiet room [the anteroom], the physician answered "no," adding it is not safe for one kid to come in. The physician recalled that in the past there was a patient who was punched by another patient in the quiet room [the anteroom] because the staff was not aware that another patient was in the room. When asked if the staff should have checked the quiet room [the anteroom] for safety as a standard operating procedure before placing a patient in the room, the physician replied "yes."

Sleeping in the anteroom:

Review on 4/4/22 at 11:00 AM of "North Star Hospital Monitoring Precautions Record and Sleep Log," dated 9/1/21 revealed from 11:30 PM to 7:15 AM, Patient #4 was coded as sleeping in the quiet room [the anteroom]. Further review revealed Patient #4 was in the quiet room [the anteroom] lying or sitting/quiet or resting from 8:45 PM to 9:15 PM, then coded as sleeping from 9:30 PM to 11:15 PM.

Review on 4/4/22 at 11:00 AM of "North Star Hospital Monitoring Precautions Record and Sleep Log," dated 9/2/21 revealed from 11:30 PM to 7:00 AM, Patient #4 was coded as sleeping in the quiet room [the anteroom]. From 7:15 AM to 7:45 AM, Patient #4 remained quiet or resting/lying or sitting in the quiet room [the anteroom]. Further review revealed Patient #4 was walking or pacing/lying or sitting in the quiet room [the anteroom] from 7:15 PM to 9:00 PM. Then from 9:15 PM to 11:15 PM, the Patient was coded as sleeping in the quiet room [the anteroom].

Review on 4/4/22 at 11:00 AM of "North Star Hospital Monitoring Precautions Record and Sleep Log," dated 9/3/21 revealed from 11:30 PM to 6:30 AM, Patient #4 was coded as sleeping in the quiet room [the anteroom]. Then from 6:45 AM to 7:15 AM, the Patient was coded as lying or sitting in the quiet room [the anteroom]. Further review revealed from 7:30 PM to 8:30 PM and at 9:00 PM, the Patient was coded as lying or sitting in the quiet room [the anteroom]. Further review revealed from 9:15 PM to 11:15 PM, the Patient was coded as sleeping in the quiet room [the anteroom].

Review on 4/4/22 at 11:00 AM of "North Star Hospital Monitoring Precautions Record and Sleep Log," dated 9/4/21, revealed from 11:30 PM to 5:30 AM, Patient #4 was coded as sleeping in the quiet room [the anteroom]. Then from 5:45 AM to 7:15 AM, the Patient was coded as quiet or resting/walking or pacing/lying or sitting in the quiet room [the anteroom]. Further review revealed from 6:30 PM to 9:45 PM, no monitoring of the Patient's location was documented on the form.

During an interview on 4/6/22 at 8:15 AM, when asked if a patient was allowed to sleep in the seclusion rooms, the QD stated if a patient had received medications and he/she was groggy, the staff would have allowed the patient to stay in the room, but the patient should not have spent the night in the seclusion rooms.

Patient #5:

Review on 4/5/22 at 9:55 AM of "MHS Intervention/Progress Sheet," dated 7/25/21 revealed "Day Progress Notes: Behavior: Punched [and] slapped in eye by peer [and] kicked by another [patient] for instigation ..." Further review revealed "Evening Progress Notes: Behavior: ...[He/She] was also getting bullied and had kids gang up on [him/her]."

Review on 4/5/22 at 10:10 AM of "Nurses Daily Assessment/Progress Note," dated 7/25/21 at 7:00 AM to 7:00 PM, revealed " ...Continues to be instigated intermittently but does redirect quickly. [Patient] denied any pain or injury." Further review revealed no documentation by the LN regarding Patient #5 being punched and kicked by peers.

Review on 4/5/22 at 10:40 AM of "North Star Behavioral Health Acute Clinical Therapy Progress Note," dated 7/25/21 at 3:00 PM to 4:30 PM of family therapy session revealed "The mother was upset over patient being injured, slapped in the face, and then having [his/her] door held closed with another patient's foot to prevent [him/her] from getting out ...The mother stated she is really upset for not being notified when her child was attacked by another patient. The mother has safety issues for patient being here at North Star Hospital ...The mother wanted to do a discharge immediately, but after talking with a nurse and [Clinical Therapist] she agreed to wait until tomorrow ...Mother did ask if patient could have a one on one until [he/she] was released tomorrow."

During an interview on 4/6/22 at 11:30 AM, when asked what he/she would have reported to the LN's, MHS #2 stated he/she would have reported contraband, negative behaviors, or assaultive behaviors. When asked the process for reporting patient abuse from a peer, the MHS stated if a patient came to him/her and reported an issue with a peer, he/she would have separated the two and would have spoken to the other peer to find out what happened.

During an interview on 4/6/22 at 1:25 PM, when asked how information was relayed to him/her from the MHS staff, LN # 2 stated he/she spoke to the staff members directly. The LN further stated the facility had a "shift to shift" report that he/she had not attended because he/she spoke to the staff "upstairs." When asked if he/she read the MHS's shift notes, the LN stated he/she had not read the shift notes but would have read the shift-to-shift binder when he/she had time. When asked if he/she would have informed a patient's parent of an injury after a peer-to-peer assault, LN #2 stated that the parent would have been notified, as well as the supervisor, physician and therapist.

During a phone interview on 4/5/22 at 11:56 AM, Patient #5's Mother stated the patient was discharged because it was not safe for him/her in the facility. When asked what made the facility unsafe for her child, the Mother stated there was lack of supervision and his/her child was getting "beat up on a daily basis," by peers. The Mother further stated the patient told the LN, but nothing was getting done. The Mother stated the patient could not even finish his/her neurological testing because he/she was unsafe. The Mother clarified that the patient had physical marks on his/her face from being assaulted by his/her peers. The Mother also stated she came to the facility for a family meeting and the patient had scabbed up scratches on his/her face and forehead. The Mother stated the facility had never contacted her about the patient's injuries after being assaulted by his/her peers.

During an interview on 4/7/22 at 1:21 PM, when asked how the facility kept the patients safe, Physician #1 stated staffing the facility properly to enhance supervision has kept the patients safe, but the facility had suffered a staffing shortage recently.

Review on 4/8/22 at 9:01 AM of "North Star Behavioral Health PATIENT RIGHTS & RESPONSIBILITIES," not dated, revealed "Each person in the hospital has rights (or privileges), which include, but are not limited to ...The right to a clean and safe unit and hospital."
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Based on interview, staff education and policy review the facility failed to ensure: 1) abuse and neglect policies included a procedure to notify the State Agency (SA) of suspected abuse and neglect towards vulnerable adult patients by facility staff, volunteers, and/or contractors, 2) a process to protect these patients during potential abuse investigations and timely response for corrective, remedial, or disciplinary actions; and 3) staff training included a mechanism for reporting any potential abuse, neglect, and misconduct towards vulnerable adults in a hospital setting. This failed practice had a potential to effect adults receiving trauma-based care, detoxification, and rehab at the adult Chris Kyle Patriots Hospital & Arctic Recovery Program. Findings:

During an interview on 4/06/22 at 11:10 AM the Director of Human Resources and Senior HR Generalist stated the abuse training was for the reporting of abuse and neglect of children to OCS.

Review of staff education on 4/06/22 AM revealed clinical staff received education on reporting abuse and neglect against children to the State Department Office of Children's Services (OCS) upon hire. There was no education about the reporting requirements for potential abuse and neglect of vulnerable adults by staff.

Review of a sampled list, provided by the facility revealed Licensed Nurse #5 had received abuse and neglect training on 9/17/17, the Chief Nursing Officer had received abuse and neglect training on 12/05/05, Clinical Therapist #1 had received abuse and neglect education on 12/03/12, Hospital Administrative Manager #1 had received abuse and neglect education on 11/10/14, and Milieu Manager #1 had received abuse and neglect education on 6/05/17.

Review of the facility policy "Patient Rights Abuse Reporting," reviewed 1/2021, revealed "It is the policy of NorthStar Behavioral Health System (NSBHS) to fully comply with and support investigations as suspected child abuse or neglect by reporting such to the proper authorities in a timely manner regardless of whether or not the person suspected of victimization of an NSBHS patient/ resident. NSBHS also supports the efforts of victims of domestic violence to obtain safe shelter. All employees will receive training in recognizing and reporting abuse. Training with handouts will occur during orientation regarding abuse/ neglect reporting and annual updates will be provided."

"Reports of abuse committed during the course of treatment"

"Every patient or resident has the right to be free from all forms of mental, physical, sexual and physical verbal abuse, neglect and exploitation. If staff witness and abuse/ neglect event, or if abuse is alleged to have occurred by a staff member to a patient/ resident then the following protocol is to be followed. Abuse and neglect are defined for purposes of this policy as followed:

Abuse: any act or failure to act by an employee of a facility rendering care or treatment which was performed, or which was failed to be performed, knowingly, recklessly, or intentionally, and which caused, or may have caused, injury or death to an individual with mental illness. Includes rape or sexual assault striking, use of excessive force when placing the individual in bodily restraints, and the use of bodily or chemical restraints on the individual that is not in compliance with federal or state laws and regulations.

Neglect: negligent act or admission by any individual responsible for providing service in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness, or which placed an individual with mental illness at risk of injury or death. Includes an act or omission such failure to establish or carry out appropriate individual program plan or treatment plan for the individual, failure to provide adequate nutrition, clothing, or health care, or failure to provide safe environment the individual.

1. At the time of the allegation, the following protocol will be followed... A report is promptly made to the Office of Children's Services Intake Department and (APD [Anchorage Police Department] if sexual abuse). This is done by the patient advocate during business hours or by the nursing supervisor after hours and weekends..."

"Abuse of Vulnerable Adult and Domestic Violence"

"In the case of abuse/ next of neglect of honorable adult the adult should be encouraged to make their own report to adult Protective Services within 24 hours. Reports can be made to local law enforcement agencies if the division cannot be reached. The Clinical Therapist and/or a Nursing staff member should be present for such reports. If the adult is unwilling to self-report, inform the patient the staff are obligated by law to report and will make the report on their behalf."

The policy did not have a process for reporting the potential abuse or neglect of vulnerable adults by facility staff, contractors, or volunteers.

During an interview on 4/05/22 at 8:17 AM the Quality Manager stated allegations of abuse and neglect by peer to peer or by facility staff are reported to OCS. The Quality Manger stated there was no process for reporting allegations of abuse and/or neglect towards vulnerable adults by facility staff. The Quality Manager stated adult patients going through treatment could be vulnerable to exploitation and abuse.
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Based on observation, interview, video review and record review, the facility failed to ensure 5 non sampled patients (#'s 14;16;17;18; and 19) out of 13 sampled patients, were free from seclusion, and 1 patient (#17) was free from restraint, out of a census of 33 patients. Specifically, 1) the patients were locked in the anteroom (which staff referred to as the quiet room) and were unable to leave and 2) a restraint episode was not documented. This failed practice had the potential compromise the safety of the patients in seclusion and restraint, by not monitoring the patients continuously, not notifying the physician of the seclusion/restraint, thereby not updating the treatment plan to ensure the patients received appropriate care and services . Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom. On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #19:

During an observation on 4/7/22 at 9:50 AM, Patient #19 was observed to be locked in the anteroom, banging on the door between the anteroom and the medication room. LN #2 went inside the anteroom through the medication room to deescalate the patient. The doors on both sides of the anteroom that lead to Unit A and B were locked. At 10:05 AM, the patient was observed to be out of seclusion in the unit hallway. The patient was observed locked in the anteroom for 15 minutes.

During an interview on 4/7/22 at 10:25 AM, LN #2, when asked what happened with Patient #19, stated Patient #19 came up from school to take a break because he/she was aggressive. The patient was offered to take a PRN (as needed) medication, but the patient refused. The LN stated the patient went inside the anteroom and closed the metal door [on the Unit A side] by banging shut the door. Then, the patient was banging on the medication room door. The LN stated he/she went inside the quiet room [the anteroom] to deescalate the patient. The LN offered the patient to go out in hallway, the patient agreed and so the LN unlocked the door [on the Unit A side].

During an interview on 4/7/22 at 10:25 AM with LN #2, when asked if he/she documented the event, the LN stated "[I do] not usually write in the notes." The LN further stated he/she would have written a note only when something serious happened.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient # 17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 am, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this seclusion event, or updates of the seclusion event added to Patient #17's treatment plan.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #18:

During the same video review and joint interview, on 4/4/22 at 1:37 PM, Patient #18 was observed to be held in a manual restraint by a staff member and escorted into a seclusion room.

At 1:45 PM, Patient #18 was observed to exit the seclusion room into the locked anteroom.

At 1:53 PM, staff exited the anteroom and Patient #18 remained behind locked doors in the anteroom.

When asked if the patient was still in seclusion, the QD stated Patient #18 was still in seclusion because the doors to the anteroom were locked.

At 2:22 PM, a staff member was observed speaking to Patient #18. The staff member left and returned with a cup of water. Patient #18 was observed to by laying on the floor of the anteroom. A staff member dragged a mattress into a seclusion room and Patient #18 was observed to lay down on the mattress with the door of the seclusion room opened, and the anteroom door locked.

At 3:00 PM, the door to the anteroom was observed to be opened, while Patient #18 remained in the unlocked seclusion room. The total time the patient remained in seclusion was 1 hour and 23 minutes.

Documentation for Patient #18:

Review on 4/8/22 at 8:33 AM of Patient #18's seclusion documentation, "North Star Behavioral Health Post Intervention Face to Face Evaluation," dated 4/4/22 at 2:00 PM revealed "Assessment of Immediate Situation ...Pt [Patient] agitated, still in Quiet room area [the anteroom], out of seclusion."

Further review of the seclusion documentation, "North Star Behavioral Health Termination/Post Intervention Nursing Summary and Notifications," dated 4/4/22 at 2:00 PM, revealed Patient #18's seclusion time was only documented from 1:29 PM to 1:36 PM (a total of 7 minutes).

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by NM #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, or updates of the seclusion event added to Patient #16's treatment plan.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, or updates of the seclusion event added to Patient #14's treatment plan.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (the anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (the anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Seclusion training:

During an interview at 4/06/22 at 11:10 AM, the Director of Human Resource (HR) and Senior HR Generalist stated clinical staff received the education for restraints and seclusion during their initial job orientation.

During an interview on 4/06/22 at 2:45 PM, when asked about the training for restraint and seclusion, NM # 1 stated staff received the restraint and seclusion training during initial orientation and the "Handle with Care" training, used for manual restraints and de-escalation techniques, once a year.

Review of staff education on 4/06/22, revealed the LNs, MHS, clinical therapists, and Milieu Managers (a mental health specialist responsible to ensure the treatment spaces are safe, secure, and therapeutic) had received training on restraints and seclusion (R & S) during job orientation and the "Handle with Care" training annually.

During an interview on 4/7/22 at 2:21 PM, when asked if seclusion was covered in the Handle with Care training, the Handle with Care trainer #1 stated no, seclusion was not covered, that he/she only "touched on in" when covering de-escalation techniques. The Trainer further stated he/she was not fully qualified to train on the topic of seclusion. When asked when he/she was last trained on seclusion, Trainer #1 stated he/she was trained 5 years ago upon hire. The trainer further stated he/she was unsure if the training was provided yearly.

Review of a sample of staff education revealed Milieu Manager #1 had completed the education for R & S on 3/24/18, Clinical Therapist #1 had completed the R & S education on 12/06/12, and Mental Health Specialist (MHS) #5 had completed the R & S education on 3/24/18.

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not."

Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff."

Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."
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Based on observation, interview and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint had written modification to their treatment plans. Specifically, the restraint and seclusion episodes were not documented and no documentation updates to the patients' treatment plans were found. This failed practice had the potential to prevent the patients from receiving appropriate care and services. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred to as the quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient # 17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom of the seclusion room area. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this restraint and seclusion event, and no written modification to the patient's treatment plan for this restraint and seclusion event.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review of the Patient's medical record revealed no Physician order for the seclusion event and no written modification to the Patient's treatment plan for this seclusion event.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, and no written modification to the Patient #16's treatment plan for this seclusion event.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion were indicated, a review and modification for the treatment plan is indicated. Based upon the consultation with the attending physician or LIP [Licensed Independent Practitioner], information gathered from the debriefing with the patient, and the face- to face evaluation, the [LN] shall review and updated the treatment plan within 8 hours."
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Based on observation, interview and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint, was performed in accordance with the order of the physician responsible for the care of the patient. Specifically, the restraint and seclusion episodes were not documented and no documentation of a physician's order was found. This failed practice had the potential to prevent the all patients, based on a census of 33, from receiving the appropriate care and services. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred to as the quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient #17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this restraint and seclusion event, and no written modification to the patient's treatment plan for this restraint and seclusion event.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review of the Patient's medical record revealed no Physician order for the seclusion event and no written modification to the Patient's treatment plan for this seclusion event.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, and no written modification to the Patient #16's treatment plan for this seclusion event.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Physician Orders ...Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ...The physician/LIP [Licensed Independent Practitioner] must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated ...The physician's order for use of restraint or seclusion will be recorded in the medical record ..."
.

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Based on observation, interview, video review and record review, the facility failed to ensure 1 non sampled patient (#17) out of 13 sampled patients, who was observed to be in seclusion, had an order renewed in accordance with the time limits. Specifically, the seclusion episode lasted longer than 1 hour for a child under 9 years of age. This failed practice had the potential to cause psychological harm to the patient by secluding the patient longer than necessary and by not providing the physician the opportunity to assess the patient for continued need for seclusion. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred to as the quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient # 17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom.

At 8:05 AM, Patient #17 was observed banging on the door of the nurses' medication room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:43 AM, Patient #17 exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed the patient to be 8 years of age. Further review revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this restraint and seclusion event, and no written modification to the patient's treatment plan for this restraint and seclusion event. Further review revealed no renewal order after 1 hour of seclusion.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Physician Orders ...Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ...The physician/LIP [Licensed Independent Practitioner] must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated ...The physician's order for use of restraint or seclusion will be recorded in the medical record and include the following: ...time limits not to exceed ...1 hour for children under age 9 ..."
.

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Based on observation, interview, video review and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint, were monitored at an interval determined by hospital policy. Specifically, the restraint and seclusion episodes were not documented, and no documentation of continuous monitoring was found. This failed practice had the potential to prevent the patients from exiting seclusion at the earliest possible time. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred to as the quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient #17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this restraint and seclusion event, and no written modification to the patient's treatment plan for this restraint and seclusion event.

Further review revealed no continuous documentation of the patient's condition while in seclusion.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review of the Patient's medical record revealed no Physician order for the seclusion event and no written modification to the Patient's treatment plan for this seclusion event.

Further review revealed no continuous documentation of the patient's condition while in seclusion.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, and no written modification to the Patient #16's treatment plan for this seclusion event.

Further review revealed no continuous documentation of the patient's condition while in seclusion.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Physician Orders ...Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ...The physician/LIP [Licensed Independent Practitioner] must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated ...The physician's order for use of restraint or seclusion will be recorded in the medical record ..."
.

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Based on observation, interview, video review and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint, was seen face to face within 1 hour after the initiation of the intervention. Specifically, the restraint and seclusion episodes were not documented and no documentation of a face to face evaluation was found. This failed practice had the potential to prevent a comprehensive review of the all patient's condition, based on a census of 33, to determine if other factors contributed to the patient's behavior. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred to as the quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient # 17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.
When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this restraint and seclusion event, no 1 hour face to face evaluation after the event, and no written modification to the patient's treatment plan for this restraint and seclusion event.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, no 1 hour face to face evaluation after the event, and no written modification to the Patient's treatment plan for this seclusion event.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, no 1 hour face to face evaluation after the event, and no written modification to the Patient #16's treatment plan for this seclusion event.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Physician Orders ...Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ...The physician/LIP [Licensed Independent Practitioner] must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated ...The physician's order for use of restraint or seclusion will be recorded in the medical record ..."

Further review revealed "Face to Face Evaluation by the Physician, LIP [Licensed Independent Practitioner], or trained [LN/Physician Assistant]: Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP, or trained {LN}/PA. A telephone call or telemedicine methodology is not allowed for these evaluations. The evaluation will be documented in the medical record ..."
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Based on observation, interview, video review and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint, had a clear description of the behavior that warranted the use of the seclusion or restraint documented in the medical record. Specifically, the restraint and seclusion episodes were not documented, and no descriptive documentation of patient's behavior and intervention used prior to the seclusion or restraint episode were found. This failed practice had the potential to deny the patients alternative interventions for de-escalation prior to the usage of seclusion or restraint. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred as quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient #17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into a seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in a seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the doorjam.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review revealed no descriptive documentation of the patient's behavior and intervention used before patient was placed in seclusion.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review revealed no descriptive documentation of the patient's behavior and intervention used before patient was placed in seclusion.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review revealed no descriptive documentation of the patient's behavior and intervention used before patient was placed in seclusion.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some "blurriness". If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Physician Orders ...Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ...The physician/LIP [Licensed Independent Practitioner] must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated ...The physician's order for use of restraint or seclusion will be recorded in the medical record ..."
Further review revealed " ...Restraint and seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm ...the patient has the right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline or retaliation by staff ... the RN [registered nurse] and unit staff implement the least restrictive non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to seclusion/ restraint ..."
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Based on observation, interview, video review and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint, were given alternatives or less restricted interventions before seclusion and document in the medical record as determined by hospital policy. Specifically, the restraint and seclusion episodes were not documented, and no documentation of alternatives or less restricted interventions used was found. This failed practice had the potential to use inappropriate interventions and seclusion of the patient. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred as the quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient #17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.
When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review revealed no documentation of alternatives or less restricted interventions prior to seclusion or restraint were found.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review revealed no documentation of alternatives or less restricted interventions used prior to seclusion were found.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record. The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review revealed no documentation of alternatives or less restricted interventions used prior to seclusion were found.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed " ...Restraint and seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm ...the patient has the right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline or retaliation by staff ... the RN [registered nurse] and unit staff implement the least restrictive non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to seclusion/ restraint ..."
.

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Based on observation, interview, video review and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint, had patient's condition or symptom(s) identified that warranted the use of the restraint or seclusion and document in the medical record as determined by hospital policy. Specifically, the restraint and seclusion episodes were not documented, and no documentation of patient's condition or symptom(s) identified that warranted the use of the restraint or seclusion were found. This failed practice had the potential to use inappropriate interventions and seclusion of the patient. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred as quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient #17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom of the seclusion room area. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review revealed no documentation of patient's condition or symptom(s) identified that warranted the use of the restraint or seclusion.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review revealed no documentation of patient's condition or symptom(s) identified that warranted the use of the restraint or seclusion.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review revealed no documentation of patient's condition or symptom(s) identified that warranted the use of the restraint or seclusion.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed " ...Restraint and seclusion may only be used ... utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to seclusion/ restraint ...
.

.
Based on observation, interview, video review and record review, the facility failed to ensure 3 non sampled patients (#'s 14; 16; and 17) out of 13 sampled patients, who were observed to be in seclusion or restraint, had documentation in the medical record of their response to the intervention. Specifically, the restraint and seclusion episodes were not documented and no documentation of the patients' response to the intervention was found. This failed practice had the potential to prevent the patients from receiving appropriate care and services by not including the descriptions of the impact of the intervention on the patient's behavior. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom (which staff referred to as the quiet room). On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient # 17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this restraint and seclusion event, no written modification to the patient's treatment plan for this restraint and seclusion event, and no documentation of the patient's response to the intervention.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, no written modification to the Patient's treatment plan for this seclusion event, and no documentation of the patient's response to the intervention.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, no written modification to the Patient #16's treatment plan for this seclusion event, and no documentation of the patient's response to the intervention.
Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Physician Orders ...Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ...The physician/LIP [Licensed Independent Practitioner] must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated ...The physician's order for use of restraint or seclusion will be recorded in the medical record ..."
Further review revealed "Post- Restraint/Seclusion Debriefing: Debriefing following the use of restraint/seclusion is important in reducing the use of recurrent restraint/seclusion ...The debriefing is used to ...Identify what led to the incident and what could have been handled differently ...Ascertain that the individual's physical well-being, psychological comfort, and right to privacy were addressed ...Counsel the individual involved for any trauma that may have resulted from the incident, and ...When indicated, modify the treatment plan ...Information obtained from debriefing is used in performance improvement activities."
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Based on observation, interview and record review, the facility failed to ensure 5 non sampled patients (#'s 14;16;17;18; and 19) out of 13 sampled patients, were free from seclusion, out of a census of 33 patients. Specifically, 1) the patients were locked in the anteroom (which staff referred to as the quiet room) and were unable to leave and 2) Staff were unable to demonstrate competency in the implementation of seclusion. These failed practices had the potential to inappropriately seclude the patients, keep the patients in seclusion for longer than necessary, and not properly monitor the patients while in seclusion. Findings:

Anteroom/Seclusion Room Layout:

An observation on 4/6/22 at 9:37 AM of the room behind the nurses' station, revealed two locked metal doors on each side of units A and B, that led to an anteroom. On the right side, when entering from unit A door, there was a bathroom and a door that led to the medication room behind the nurses' station. The door had a clear window. On the left side of the anteroom, there were 4 locked doors. All doors were locked when closed and would have required a key to exit.

During an interview on 4/6/22 at 9:37 AM with Licensed Nurse (LN) #3, when asked what the purpose of the 4 rooms inside the anteroom, the LN replied the 4 rooms were utilized for seclusion.

Patient #19:

During an observation on 4/7/22 at 9:50 AM, Patient #19 was observed to be locked in the anteroom, banging on the door between the anteroom and the medication room. LN #2 went inside the anteroom through the medication room to deescalate the patient. The doors on both sides of the anteroom that lead to Unit A and B were locked. At 10:05 AM, the patient was observed to be out of seclusion in the unit hallway. The patient was observed locked in the anteroom for 15 minutes.

During an interview on 4/7/22 at 10:25 AM, LN #2, when asked what happened with Patient #19, stated Patient #19 came up from school to take a break because he/she was aggressive. The patient was offered to take a PRN (as needed) medication, but the patient refused. The LN stated the patient went inside the anteroom and closed the metal door [on the Unit A side] by banging shut the door. Then, the patient was banging on the medication room door. The LN stated he/she went inside the quiet room [anteroom] to deescalate the patient. The LN offered the patient to go out in hallway, the patient agreed and so the LN unlocked the door [on the Unit A side].

During an interview on 4/7/22 at 10:25 AM with LN #2, when asked if he/she documented the event, the LN stated "[I do] not usually write in the notes." The LN further stated he/she would have written a note only when something serious happened.

Patient #17:

A video review and joint interview was conducted with the Quality Director (QD) on 4/7/22 at 10:45 AM. The video review start was dated 4/4/22 at 7:30 AM and ended at 4:55 PM on 4/4/22.

At 7:37 AM, Patient # 17 was observed to be restrained by an unidentified staff member and forced to walk into the anteroom. The door to the anteroom was closed behind the patient and 2 staff members.

When asked if the hold observed on the video would have been considered a restraint, the QD stated the hold was considered a restraint. When asked if paperwork to document the event would have been found in the Patient's medical record, the QD stated the restraint would have been documented.

At 7:38 AM, the first staff member exited the anteroom with the door locked behind them. Patient #17 was observed attempting to exit the room by following the staff member out .

When asked if Patient #17 was in seclusion, the QD stated the patient was in seclusion.

At 7:44 AM, Patient #17 began to attack the second staff member by pulling his/her hair. The staff member was observed to open the door of the seclusion room and entered the seclusion room. The patient was observed to be pushing the door of the seclusion room closed with the staff member on the other side of the door.

When asked what she was observing on the video, the QD stated the staff member may be trying to put the Patient into the seclusion room. When asked if the Patient was already secluded, the QD stated the patient was already secluded because the outer door to the anteroom was locked and the patient could not leave the room.

At 7:47 AM, the staff member was observed pushing Patient #17 into the seclusion room. Patient #17 resisted and was kicking his/her legs out of the room, preventing the door from being closed.

At 7:48 AM, Patient #17 was observed inside the seclusion room, pushing at the door with the staff member holding the door from the other side. Patient #17 attempted to exit the room, while the staff member was attempting to secure the patient into the seclusion room.

At 7:50 AM, Patient #17 was able to exit the seclusion room, but remained in the anteroom behind locked doors.

At 7:53 AM, the patient was observed sitting on the floor, putting his/her socks on.

At 7:56 AM, the staff member exited the anteroom. Patient #17 remained in the anteroom secluded behind locked doors.

When asked the process of monitoring the patient, the QD stated staff would have checked on the patient every 15 minutes.

At 7:57 AM, Patient #17 was observed banging on the window of the door facing the nurses' medication room. The patient was observed to punch the window and began rubbing his/her hand and wrist afterward.

At 8:00 AM, a staff member was observed to enter the anteroom and offered the Patient a medication in a small cup.

At 8:02 AM, another staff member and Patient #18 were observed to pass through the anteroom with Patient #17 still agitated in the room. Patient #18 was escorted into the seclusion room with a staff member.

At 8:04 AM, Nurse Manager (NM) #1 was observed speaking with the staff member and Patient #17 and left the room at 8:05 AM, leaving Patient #17 secluded in the anteroom and Patient #18 secluded in the seclusion room. The Staff member stood outside the seclusion room door to monitor Patient #18.

At 8:05 AM, Patient #17 was observed banging on the door, distracting the staff member from continuously observing Patient #18 in the seclusion room.

At 8:20 AM, Patient #17 was observed pacing in the locked anteroom and banging on the doors.

At 8:42 AM, Patient #18 exited the seclusion room.

At 8:43 AM, Patient #17 and Patient #18 both exited the anteroom. The total time Patient #17 remained in seclusion was 1 hour and 6 minutes.

Lack of Seclusion documentation Patient #17:

On 4/7/22 at 11:30 AM, when asked to provide documentation of Patient #17's restraint at 7:37 AM and seclusion from 7:38 AM to 8:43 AM, The Social Services Director (SSD) stated no paperwork for the restraint and seclusion for that time frame was located in the chart.

On 4/7/22 at 11:50 AM, the SSD further stated she spoke to the Licensed Nurse (LN) who stated there was no seclusion paperwork because staff were unable to lock the door of the seclusion room, as Patient #17 prevented the door closure by keeping his/her legs in the door jam area.

Review on 4/7/22 at 4:20 PM of Patient #17's medical record revealed no documentation of the Patient's restraint at 7:37 AM, nor the Patient's seclusion from 7:38 AM to 8:43 AM.

Further review of "NHS Intervention/Progress Sheet," dated 4/4/22, revealed "Day Progress Notes: Behavior: Poor attitude. [He/She] was having a temper tantrum. Poor self-control. [He/She] was yelling and cussing at staff. Refused to come to school in the evening. Poor self-control." Further review revealed no documentation of restraint or seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 from 7:00 AM to 7:00 PM, revealed "[Patient] was ignoring de-escalation attempts, and was repeating "I wanna die", "I will die if I stay in here" and was screaming and yelling to staff to let [him/her] out of the quiet area." Further review revealed no documentation of the restraint episode at 7:37 AM or seclusion episode from 7:38 AM to 8:43 AM.

Further review of the Patient's medical record revealed no Physician order for this seclusion event, or updates of the seclusion event added to Patient #17's treatment plan.

During an interview on 4/7/22 at 1:21 PM, when asked if he/she was aware that Patient #17 was in seclusion during this timeframe, Physician #1 stated he/she was not aware of this seclusion. The Physician further stated the issue of what constituted a seclusion had come up in the past. Physician #1 stated the staff had closed the doors of the anteroom and had not considered this to be a seclusion.

Patient #18:

During the same video review and joint interview, on 4/4/22 at 1:37 PM, Patient #18 was observed to be held in a manual restraint by a staff member and escorted into a seclusion room.

At 1:45 PM, Patient #18 was observed to exit the seclusion room into the locked anteroom.

At 1:53 PM, staff exited the anteroom and Patient #18 remained behind locked doors in the anteroom.

When asked if the patient was still in seclusion, the QD stated Patient #18 was still in seclusion because the doors to the anteroom were locked.

At 2:22 PM, a staff member was observed speaking to Patient #18. The staff member left and returned with a cup of water. Patient #18 was observed to by laying on the floor of the anteroom. A staff member dragged a mattress into a seclusion room and Patient #18 was observed to lay down on the mattress with the door of the seclusion room opened, and the anteroom door locked.

At 3:00 PM, the door to the anteroom was observed to be opened, while Patient #18 remained in the unlocked seclusion room. The total time the patient remained in seclusion was 1 hour and 23 minutes.

Documentation for Patient #18:

Review on 4/8/22 at 8:33 AM of Patient #18's seclusion documentation, "North Star Behavioral Health Post Intervention Face to Face Evaluation," dated 4/4/22 at 2:00 PM revealed "Assessment of Immediate Situation ...Pt [Patient] agitated, still in Quiet room area [anteroom], out of seclusion."

Further review of the seclusion documentation, "North Star Behavioral Health Termination/Post Intervention Nursing Summary and Notifications," dated 4/4/22 at 2:00 PM, revealed Patient #18's seclusion time was only documented from 1:29 pm to 1:36 pm (a total of 7 minutes).

Patient #16:

At 3:01 PM, Patient #16 was observed to be escorted into the locked anteroom by Nurse Manager (NM) #1.

When asked if Patient #16 was in seclusion, the QD stated Patient #16 was in seclusion because the anteroom door was locked.

At 3:05 PM, Mental Health Specialist (MHS) #2 was observed sitting in front of the opened seclusion room door with Patient #18 inside, while Patient #16 was attempting to climb upon yellow plastic blocks secured to the wall and pacing the room. Shortly thereafter the patient sat down and ate a meal.

At 3:26 PM, the door to the anteroom area was unlocked and left open, releasing both Patients from seclusion. The total time Patient #16 was in seclusion was 25 minutes.

At 4:24 PM, Patient #18 exited the anteroom with a staff member.

Lack of Seclusion documentation Patient #16:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 3:01 PM to 3:26 PM.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, or updates of the seclusion event added to Patient #16's treatment plan.

Further review of "MHS Intervention/Progress Sheet," dated 4/4/22, revealed "Evening Progress Notes: Behavior: posturing peers, assaultive to peers [and] staff, demanding [behaviors] yelling screaming about not getting what they want." Further review revealed no documentation of the seclusion event.

Patient #14:

At 4:36 PM, Patient #14 walked into the anteroom with the door closed behind him/her. The patient was observed to be visibly agitated, pacing in the room with closed fists.

When asked if this was considered a seclusion and should have been documented, the QD stated Patient #14 was being secluded and seclusion paperwork should have been documented. This documentation should have been located in the Patient's medical record.

The QD further stated that staff did not know what constituted a seclusion.

At 4:43 PM, the patient was observed to accept Intermuscular medications from the Licensed Nurse (LN). The LN exited the room at 4:45 PM and the outer door of the anteroom remained closed and locked. The Patient continued to pace in the room with closed fists.

At 4:55 PM, the anteroom door was opened, and the Patient exited the room.

Lack of Seclusion documentation Patient #14:

Review on 4/7/22 at 4:00 PM of Patient #16's medical record revealed no documentation of the Patient's seclusion from 4:36 PM to 4:55 PM, a total of 19 minutes.

Further review of the Patient's medical record revealed no Physician order for the seclusion event, or updates of the seclusion event added to Patient #14's treatment plan.

Further review of "MHS Intervention/Progress Sheet," revealed "Evening Progress Notes: Behavior: Pt [Patient] became agitated during activity therapy [because] a peer was instigating. [Patient] then shoved peer's head before leaving room to take break in hallway. [Patient] continued to threaten peers, but eventually was able to calm down [and] join milieu [common area]." Further review revealed no documentation of the patient's seclusion episode.

Further review of "Nurses Daily Assessment/Progress Note," dated 4/4/22 at 7:00 AM to 7:00 PM, revealed "Patient agitated due to select peers instigative and bullying behavior on and off the unit. Patient requested medication to help with severe agitation with comment "before I beat up someone." Thorazine [antipsychotic medication] 50 mg with Benadryl [antihistamine] 50 mg IM [intermuscular] per Doctor's order administered." Further review revealed no documentation of the patient's seclusion episode.

During an interview on 4/6/22 at 11:30 AM, when asked the difference between a time out and a seclusion, MHS #2 stated a time out would include going for a walk, talking to a staff member, or sitting by themselves in staff's view. When asked if the patients utilized the quiet room (anteroom) for a time out area, MHS #2 stated that patients do use the quiet room (anteroom) to take a break, and if the patients go into the room willingly, the doors were left open. The MHS further stated if the door is open and the patient is sitting down, staff would have monitored them every 15 minutes. When asked who determined if the patient required a time out versus a seclusion, MHS #2 stated he/she would look toward the LN or NM to decide.

When asked about training for seclusion, MHS #2 stated he/she received training on the documentation by a Nurse Manager.

During an interview on 4/6/22 at 1:25 PM, when asked if he/she was informed when a patient was put into the anteroom by MHS staff, LN #2 stated he/she was not always informed. When asked about the anteroom doors being locked, LN #2 stated if a patient started to hit a staff member, the door to the unit [anteroom] was locked. LN #2 further stated it was best practice for staff not to enter the anteroom when the patient was aggressive. When asked about supervision, LN #2 stated he/she would have watched the patient from the nurses' station window to make sure the patient wasn't hurting themselves.

When asked about the difference between a time out and a seclusion, LN #2 stated there was some blurriness. If a patient was assaultive, he/she would go into the quiet room [anteroom]. LN #2 stated he/she had not seen a patient in the quiet room [anteroom] with the door open. The LN further stated a patient could have knocked to be let out of the quiet room [anteroom]. LN #2 stated staff don't want the patients to come out of the room if they were assaultive, that the patient would have needed to voice that they were calm before being let out of the quiet room [anteroom].

Seclusion training:

During an interview at 4/06/22 at 11:10 AM, the Director of Human Resource (HR) and Senior HR Generalist stated clinical staff received the education for restraints and seclusion during their initial job orientation.

During an interview on 4/06/22 at 2:45 PM, when asked about the training for restraint and seclusion, NM # 1 stated staff received the restraint and seclusion training during initial orientation and the "Handle with Care" training, used for manual restraints and de-escalation techniques, once a year.

Review of staff education on 4/06/22, revealed the LNs, MHS, clinical therapists, and Milieu Managers (a mental health specialist responsible to ensure the treatment spaces are safe, secure, and therapeutic) had received training on restraints and seclusion (R & S) during job orientation and the "Handle with Care" training annually.

During an interview on 4/7/22 at 2:21 PM, when asked if seclusion was covered in the Handle with Care training, the Handle with Care trainer #1 stated no, seclusion was not covered, that he/she only "touched on in" when covering de-escalation techniques. The Trainer further stated he/she was not fully qualified to train on the topic of seclusion. When asked when he/she was last trained on seclusion, Trainer #1 stated he/she was trained 5 years ago upon hire. The trainer further stated he/she was unsure if the training was provided yearly.

Review of a sample of staff education revealed Milieu Manager #1 had completed the education for R & S on 3/24/18, Clinical Therapist #1 had completed the R & S education on 12/06/12, and Mental Health Specialist (MHS) #5 had completed the R & S education on 3/24/18.

Review on 4/5/22 at 12:00 PM of the facility policy "Proper use and monitoring of Physical/Chemical Restraints and Seclusion-Acute," dated 2/2022, revealed "Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not." Further review revealed "In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff." Further review revealed "The [LN] immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode ...The use of restraint/seclusion will be thoroughly documented in the patient's medical record."

Further review revealed "Staff Training and Competence Assessment ...As part of orientation ...and at least annually ...In order to minimize the use of restraint/seclusion, all direct care staff, as well as any other staff involved in the use of restraint/seclusion receive on-going training ..."
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Based on record review and interview the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Program was effectively functioning to ensure improved outcomes and improve patient care services through systemic collection of hospital wide performance data according to the Condition of Participation: CFR 482.21 Quality Assessment and Performance Improvement Program. Findings:

The hospital failed to:

1) Analyze data from patient aggression to reduce manual (physical) holds and reduce staff injury. Reference at A tag 283;

2) Analyze the use of "time outs" and ensure they were not resulting in seclusions. Reference at a A tag 283;

3) Accurately Analyze clinical therapy staff performance and ensure they were performing therapy and interventions as per care plan. Reference at A tag 283;

4) Ensure all data identified in the QAPI 2022 plan is presented to the QAPI team and Governing Body. Reference at A tag 286; and

5) Analyze unusual occurrences and incidents that potentially effect patient safety and quality of care. Reference at A tag 286.
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Based on quality review, interview, and observation, the facility failed to: 1) identify opportunities and institute improvement in the area of seclusion; 2) ensure collected data was accurate in the area of seclusion and B-Tag audits (a detailed set of standards for patient evaluations, medical records, and staffing in inpatient psychiatric facilities); and 3) provide evidence that measured the success and tracked the performance of identified performance improvement projects. This failed practice placed all the patients receiving care in the hospital at risk for injury or substandard quality of care. Findings:

The "Annual Review of Performance Improvement Program", for 2021, was reviewed with the Quality Director (QD) and the following targets were selected for review:
4. Patient Aggression Reduction,
5. Restrictive Interventions (restraints-any manual of physical, material, or equipment that reduces the ability of the patient to move his/her arms, legs, body, or head freely and/or seclusion-the act of leaving a patient alone confined in an area they cannot physically leave), and
6. B-Tag Audits

4. Patient Aggression reduction

Review of the 2021 PI Data for Patient Aggression revealed:

"Included in this count: Damage by patient, Hospital property damage, Patient out of control, Physical confrontation with other patients, Aggression/ Assault by another patient. Aggression/Assault by Other towards patient, Aggression/ Assault patient towards patient, Aggression/ Assault patient towards staff, Aggression/ Assault by patient towards other."

"Total in 2021 433 40% reduction from 2020 (1092) =60.3 % reduction."

Review of the QOC [quality of care] dashboard for 2021 revealed "Physical Hold Rate Benchmark 5.34 %."

Review of the Performance Improvement [PI] Plan for 2022 revealed "1. Reduce the incidence of physical holds a. Acute: 0.6% from a baseline of 5.41 rate to a 4.41 goal rate by 2/28/22."

Review of the "2022 Goal" revealed "Department Program ...Milieu Management."

"Goal ...Reduce the overall rate of a) staff injuries due to patient aggression and b) use of restriction interventions through targeted trainings and competencies specific to advance verbal De-escalation skills."

"Measurement ...Milieu management department (Director of MM, Milieu Management Director) will 1) ensure all staff are trained and have demonstrated competencies in the Advanced Verbal De-escalation Skills curriculum 2) Assess staff for competencies through interactive Engagement, Observations. Assessments at hire and annually. 3) Engage staff monthly for individualized supervision and 3) Review/analyze staff injury and restrictive intervention use data. Director of Milieu Management will report findings to QC [quality committee monthly and annually].

During an interview on 4/7/22 at 4:30 PM, when asked to see implementation of the performance improvement (PI), the QD stated the facility will individually identify staff and provide training at the time of the event. The supervisors are then asked so to see if the education was effective. The QD stated feedback was not returned to the QAPI [Quality Assurance Performance Improvement] department.

5. Restrictive Interventions

Review of the 2021 PI Data for Restrictive Interventions revealed:

"Includes seclusions, restrains, patient injury from r/s and metrics included comparison with UHS [Universal Health Service] overall benchmark rates."

For 2021 Acute Rate UHS Rate Diff
"Seclusions" 1.86 2.10 11.4 %
"Restraints" 5.34 6.24 14.4%
"Pt injury from S/R 0.04

Observations during the survey via video review on 4/07/21 with the QD revealed Patient #s 16, 17, and 18 were at various times locked in the anteroom to the facility's seclusions rooms. Facility staff documented the interventions as a "Time Out."

During an interview on 4/06/22 at 3:19 PM, Licensed Nurse (LN) #5 stated that sometimes kids will play in the seclusion anteroom, he/she stated if the door is closed a staff will watch the room to ensure they are safe. The LN stated the facility used to have a "comfort room" room (where patients could go to cool off) in the facility.

During the interview the LN stated the room had been destroyed by one of the patients.

6. B-Tag Audits Goal: 90% or above compliance in all items in audit by all programs

Review of the "2021 Score" revealed:

Psyc [psychiatric] evaluation 99.7 %
Other Assessments 97.2 %
History & physical 90.6 %
Physician orders 78.8 %
Initial treatment plan 95.1 %
Master treatment plan 97.7 %
Progress notes 95.6 %
Group notes 95.6 %
Physician progress notes 99.7 %
Discharge summary 100%

The "B Tag audits" for December 2021 revealed:

Psychiatric evaluation 100%
History and physical 100%
Psychosocial and RT 100%
Physician orders 100%
Initial treatment plan 83.3%
Master treatment plan 86.5%
Progress notes 83.3%
Group notes 100%
Physician progress notes 100%
Discharge summary 100%

Review of a comment below the data revealed:

"December data showed a decrease in compliance for treatment plan and progress notes for the B-tag chart areas. Members of leadership to attend treatment plan meeting weekly. Specific group note deficiencies to be reviewed with clinical staff." Record review on 4/06/22 revealed Patient #4, who resided at the facility from 8/4/21-9/12/21, a period of almost 6 weeks, did not have evidence of weekly family therapy notes in his/her record. The Patient had 1 psychosocial assessment and no further weekly individual theory notes.

The Patient was readmitted to the facility 7 days after discharge.

During an interview on 4/07/22 at 10:13 AM, the Director of Clinical Services stated Patient #4 did not have any family meeting notes and only had one assessment and no other weekly individual therapy notes in his/her record. She stated the care plan identified the clinical therapist was supposed to meet with the Patient and family weekly.

The Director of Clinical Services, a Licensed Clinical Social Worker, further stated she had recently been assigned supervision of the unlicensed clinical therapists in the acute hospital.

During an interview on 4/07/22 at 4:30 PM, when asked what was put in place to ensure the processes for treatment was improved, the QD stated the prior clinical manager would have the clinical therapists fix their notes and report that data. As a result, the B-tag data for 2021 was not an accurate representation. The QD could not explain how fixing the error would improve the processes for patients that did not have their charts audited.
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Based on Quality Assurance Performance Improvement (QAPI) review and interviews the facility failed to: 1) ensure the infection control committee was integrated into their Performance Improvement (PI) process and 2) failed to identify an injury caused by incorrect use of the anteroom to the seclusion rooms. This failed practice denied the facility the opportunity to identify and implement measures for improvement and placed all patients residing on the facility at risk for injury and/or inadequate quality of care. Findings:

Infection Control and QAPI

Review of the "Annual Review of Performance Improvement Program", for 2021 revealed no data for infection control.

Review of the QAPI Plan for 2022 revealed "Data collected ... At a minimum the organization collects data on quality assurance outlined by the Joint Commission, CMS [Centers for Medicare and Medicaid Services]. And state regulations including ...Infection Prevention and Surveillance."

During an interview on 4/7/22 at 4:30 PM, the Quality Director (QD) stated that Infection Control (IC) was not a part of QAPI. The QD stated IC has a different committee. The QD stated the DON was on the QAPI committee but was only there to respond to questions. The QD stated the infection control committee does report any data to her.

During an interview on 4/08/22 at 2:45 PM, the contracted Infection Preventionist stated she was hired to assist with the facility's policies and procedures. The IP stated she was not involved with QAPI and did not perform any data collection or hand hygiene audits for the facility.

During an interview on 4/12/22 at 9:00 AM, the Interim Director of Nursing (DON), who functioned as the onsite Infection Preventionist, stated his part was small and he was still learning his role and stated it was a team effort. The DON stated he talked about IP to new hires and also ensured reportable infections were submitted to State Department of Epidemiology.

Use of Anteroom for Time-Outs

Review on 4/6/22 at 8:47 AM, of an Incident Report dated 11/12/21, revealed Patient #13 had an incident of "aggression/assault patient towards patient [other]" on 11/11/21 at 7:05 PM. The document further revealed [Pt. #13 was] placed in quiet room [anteroom] due to aggression. Pt. was using bathroom when another peer was placed in the quiet room [anteroom]. This patient then came out of the bathroom and began attacking peer by punching him on the left cheek giving a bloody nose. Staff separated patients."

Review on 4/7/22 at 2:30 PM of an Incident Report dated 11/12/21, revealed Pt. #20 had an incident of "aggression/assault by another patient" on 11/11/21 at 7:05 PM. The document further revealed "[Patient #20] was placed in the quiet room [anteroom] due to his peers. [Patient] was posturing peer and staff refusing redirection. A peer who was exhibiting similar behaviors was in the quiet room [anteroom] bathroom, but the staff did not know this. Peer then came out of the bathroom and began attacking the peer."

During an interview on 4/6/22 at 8:15 AM, when asked if there was an investigation conducted on a peer-to-peer altercation, the QD stated the facility had not investigated the peer-to-peer altercation, but she would have followed-up on the medical component if the patient suffered an injury. The QD explained that the facility classified an incident according to the degree of injury such as 1- for bruise or scratch, 2- bleeding, black-eye, 3- fracture, death within 30 days of discharge, and 4- permanent disability or death.

In the same interview, when asked if there was an investigation on the Patient-to-Patient assault in the anteroom on 11/11/21, the QD stated an incident report was completed but no investigation was conducted.

On 4/07/22, a video review conducted with the QD, of the seclusion and anterooms revealed facility staff directed patients in the anteroom to the seclusion rooms for "time outs". As the doors to the anteroom locked when closed, the patients were unable to leave, which placed them in a seclusion (involuntary confinement of a patient in a room or area and physically prevented from leaving) without orders, assessments, or monitoring.

Use of the anteroom to the seclusion rooms for time outs, or as a play area, created a potential barrier to staff when needing to transport a patient safely to a seclusion room for a psychiatric emergency.

The failure to investigate the misuse of facility interventions, created a patient injury, and created risk for further harm to patients and/or staff.
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