West Valley Medical Center

Based on a review of medical records, facility policies, grievances, staff education transcripts, QAPI documents, Governing Board meeting minutes, and staff interview, it was determined the facility's Governing Board failed to ensure patients' rights were protected and promoted, patients received care in a safe setting, and restraints were used safely and appropriately. Additionally, the Governing Board failed to monitor and oversee the facility's QAPI program related to restraint/seclusion use in the facility. This resulted in deficient practices that placed the health and safety of Patient #6 in immediate jeopardy of serious harm, impairment, or death, and had the potential to impact all patients receiving services at the facility. Findings include:

1. Refer to A-0115 as it related to facility's failure to ensure patients' rights were protected and promoted, and patients received care in a safe setting.

2. Refer to A-0263 as it related to an ineffective Quality Assessment and Performance Improvement Program that ensured monitoring and evaluation of the use of restraints and seclusion.

The cumulative effects of these negative systemic practices seriously impeded the ability of the Governing Board to ensure the facility to protected patient rights and provided services in a safe setting.

Based on record review, review of patient rights information, grievance information, restraint documentation, policy review, review of video, and staff interview, it was determined the facility failed to ensure patients' rights were protected and promoted, patients received care in a safe setting, and restraints were used safely, appropriately and only in accordance with a physician's order. Findings include:

1. Refer to A-0117 as it relates to the facility's failure to ensure patients were informed of their rights.

2. Refer to A-0123 as it relates to the facility's failure to ensure the written notice provided to patients or their legal representatives included the steps taken to investigate the grievance, results of the grievance process and the date of completion.

3. Refer to A-0132 as it relates to the facility's failure to ensure patients, or their representatives, were given an opportunity to formulate advance directives.

4. Refer to A-0143 as it relates to the facility's failure to ensure patients' privacy was safeguarded while under video and/or audio surveillance.

5. Refer to A-0144 as it relates to the facility's failure to ensure care was provided in a safe manner and setting. This resulted in the identification of immediate jeopardy on 3/06/17 at 4:30 PM. Lack of education and training of staff, lack of appropriate policies and implementation of policies, and lack of initial and ongoing assessment resulted in patients being placed at risk for serious harm, injury, or death.

6. Refer to A-0145 as it relates to the facility's failure to ensure psychiatric treatment and interventions for violence and aggression were appropriately provided by staff.

7. Refer to A-0154 as it relates to the facility's failure to ensure restraints and/or seclusion were only imposed to ensure the immediate physical safety of the patient or others and were discontinued at the earliest possible time.

8. Refer to A-0160 as it relates to the facility's failure to ensure a policy was developed which clearly identified the use of a drug or medication used as a chemical restraint, criteria for the use of a chemical restraint, and how patients who received a chemical restraint(s) should have been monitored.

9. Refer to A-0165 as it relates to the facility's failure to ensure the type of restraint used was the least restrictive intervention.

10. Refer to A-0168 as it relates to the facility's failure to ensure the use of restraints was in accordance with the order of a physician and facility policy.

11. Refer to A-0171 as it relates to the facility's failure to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours.

12. Refer to A-0172 as it relates to the facility's failure to ensure patients restrained and/or secluded for more than 24 hours consecutively were seen and assessed by a physician or LIP prior to renewal of orders for continued restraint.

13. Refer to A-0174 as it relates to the facility's failure to ensure restraints were discontinued at the earliest possible time.

14. Refer to A-0175 as it relates to the facility's failure to ensure patients in restraints were monitored based on the individual needs of the patient and in accordance with facility policy.

15. Refer to A-0178 as it relates to the facility's failure to ensure a face-to-face meeting by an appropriate staff member was conducted within 1 hour of the application of behavioral restraints.

16. Refer to A-0179 as it relates to the facility's failure to ensure face-to-face assessments were comprehensive and included all necessary information.

17. Refer to A-0182 as it relates to the facility's failure to ensure a psychiatrist, or LIP, was consulted after the face-to-face assessments were completed.

18. Refer to A-0183 as it relates to the facility's failure to ensure patients were continuously monitored when there was simultaneous use of restraint and seclusion.

19. Refer to A-0188 as it relates to the facility's failure to ensure documentation of patient's responses to physical restraint and the rationale for the continued use of restraint.

20. Refer to A-0194 as it relates to the facility's failure to ensure staff caring for patients restrained for violent behavior had education, training, and demonstrated competency to manage patients exhibiting out-of-control and/or aggressive behavior.

21. Refer to A-0196 as it relates to the facility's failure to ensure all staff required competencies for the application of restraints, implementation of seclusion, and in providing care for a patient in restraint or seclusion were up to date.

22. Refer to A-0199 as it relates to the facility's failure to ensure RNs, who worked with potentially violent patients, received required training in factors that could trigger the need for restraints.

23. Refer to A-0201 as it relates to the facility's failure to ensure all staff caring for patients in violent restraints received training in choosing the least restrictive interventions based on individualized assessment of the patient's condition.

24. Refer to A-0204 as it relates to the facility's failure to ensure all staff caring for restrained patients were trained in recognizing when restraints were no longer necessary.

25. Refer to A-0205 as it relates to the facility's failure to ensure BHU staff were trained in assessing a patients physical and emotional response to restraint and seclusion.

The cumulative effects of these negative systemic practices seriously impeded the ability of the facility to protect patient rights and provide services in a safe setting. This resulted in the identification of immediate jeopardy on 3/06/17 at 4:30 PM. Lack of education and training of staff, lack of appropriate policies and implementation of policies, and lack of initial and ongoing assessment, resulted in patients being placed at risk for serious harm, injury, or death.

Based on staff interview, review of facility policies, restraint/seclusion documentation, and QAPI documents, it was determined the facility failed to ensure quality indicators were developed to assess processes of care, facility services, and operations related to the use of restraint/seclusion in the facility. Additionally, the facility failed to use restraint/seclusion data to monitor effectiveness and safety of patient care provided in the facility. This resulted in the inability of the facility to evaluate programs and systems, and prevented the facility from identifying measurable improvement methods. Findings include:

A facility policy Patient Safety Quality Assessment Performance Improvement Plan 2016, next review date 4/19/17, documented:

- The purpose of the Patient and Employee Safety/Quality Assessment/Performance Improvement Plan for [Name of the facility] is to ensure that the Board of Trustees, medical staff, and professional staff consistently endeavor to deliver safe, effective, optimal patient care and services in a safe environment for our patients and employees. The Board of Trustees is ultimately accountable for the quality of care provided by the facility. This plan allows for a systematic, coordinated, continuous data-driven approach to improving performance, focusing upon the processes and mechanisms that address our values. In carrying out the plan, our ultimate focus is a desire for an excellent patient experience and safe work conditions.

- The plan identified an interdisciplinary, Quality Leadership Council (QLC.) The plan stated the Council established the 2016 Patient Safety Quality Assessment Performance Improvement Plan, with support and approval from the facility's Governing Body (GB.) The plan documented the council ...has the responsibility for monitoring all aspects of patient care and services (including contracted services), from the time of patient's initial participation with any of the services provided, including diagnosis, treatment recovery, and discharge activities. These activities are monitored in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate the best patient outcomes.

Also included in the policy was the following:

- ...Provide a systematic mechanism for the organization's appropriate individuals, departments and professions to function collaboratively in their efforts toward performance improvement, providing feedback and learning throughout the organization;

- ...Incorporate available information from internal sources and other organizations about the occurrence of medical errors and sentinel events to reduce the risk of similar events;

- ...Assures that the improvement process is organization-wide, monitoring, assessing and evaluating the quality and appropriateness of patient care, patient safety practices and clinical performance, to resolve identified problems and improve performance.

- ...Appropriately report information to the Governing Board, providing leaders with the information needed to ensure quality patient care and safety.

- ...Track identified problems and action plans to ensure improvement or problem resolution.

- ...Use information from departments/services and the findings of discrete performance improvement activities and adverse patient events to detect trends, patterns of performance or potential problems that affect multiple departments/services ...

- Membership on the Quality Leadership Council is composed of leaders of the organization ...Directors from the following departments: Quality and Risk Management, Case Management, Medical Staff Services, Human Resources, Education & Training, ...Emergency Department/Cardiopulmonary, ICU, Telemetry, etc.

The facility did not adhere to this policy as follows:

1. Refer to A-0144 as it relates to the facility's failure to ensure care was provided in a safe manner and setting for 2 of 4 patients (#6 and #9) who were secluded and/or restrained, resulting in Patient #6 having been at risk for harm or death and the identification of an immediate jeopardy on 3/06/17 at 4:30 PM.

2. An untitled electronic report, listing each incident of restraint and/or seclusion, and physical hold, included incidents from 12/03/16 to 3/01/17 and was provided during the survey. The report involved 13 different patients and included 13 separate incidents of restraint, 1 incident of seclusion, 2 incidents of physical hold.

According to an interview with the DQRM, on 3/06/17 at 9:15 AM, the report was used for auditing restraint and/or seclusion documentation in patient records.

A copy of a page from the Restraint/Seclusion Log, listing each incident of restraint and/or seclusion from, 12/03/16 to 3/01/17, was provided during the survey. The document included 7 separate incidents of restraint involving 6 different patients. The document did not include incidents of seclusion or hands-on physical holds.

When compared to the electronic audit report for the same time period, 12/03/16 to 3/01/17, the Restraint/Seclusion Log was missing the names and correlating events of 4 patients.

The DQRM, and the Director of BHU were interviewed together on 3/03/17, beginning at 8:00 AM. When asked how incidents of restraint/seclusion were tracked in the facility, the DQRM stated each incident of restraint and/or seclusion was recorded in a log book that was maintained by the facility's nursing supervisors. The DQRM stated he was uncertain how the restraint/seclusion data was tracked and analyzed to improve patient care in the facility. The DQRM said he was uncertain whether the data was included in the facility's quality program and presented to the Governing Board.

The DQRM was interviewed on 4/03/17, beginning at 10:45 AM. He confirmed the information contained on the Restraint/Seclusion log and the audit tool were different. When asked which was accurate, he stated the audit tool was probably more accurate than the Restraint/Seclusion log. He stated it was the responsibility of the nursing supervisors to complete the Restraint/Seclusion log. The DQRM stated they become busy at times and may forget to make an entry.

The facility failed to accurately collect data related to the use of restraint and/or seclusion in the facility. Additionally, data was not used to adequately monitor the effectiveness and safety of patient care provided in the facility regarding those patients on whom restraints and/or seclusion were used.

3. A facility policy Patient Safety Quality Assessment Performance Improvement Plan 2016, next review date 4/19/17, identified an interdisciplinary Quality Leadership Council (QLC.) The plan stated the Council established the 2016 Patient Safety Quality Assessment Performance Improvement Plan, with support and approval from the facility's Governing Board. The plan documented the council ...has the responsibility for monitoring all aspects of patient care and services (including contracted services), from the time of patient's initial participation with any of the services provided, including diagnosis, treatment recovery, and discharge activities. These activities are monitored in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate the best patient outcomes.

The policy documented ...Membership on the Quality Leadership Council was composed of leaders of the organization ... Directors from the following departments: Quality and Risk Management, Case Management, Medical Staff Services, Human Resources, Education & Training, ... Emergency Department/Cardiopulmonary, ICU, Telemetry ... Twenty six departments in the facility were represented on the QLC. However, the Director of BHU was not included on the QLC.

An untitled electronic report, listing each incident of restraint and/or seclusion, and physical hold, included incidents from 12/03/16 to 3/01/17 and was provided during the survey. The report documented 8 of 13 restraint incidents and 1 incident of seclusion occurred on the Behavioral Health Unit of the facility.

A copy of a page from the Restraint/Seclusion Log, listing each incident of restraint and/or seclusion from, 12/03/16 to 3/01/17, was provided during the survey. The log documented 4 of the 7 recorded restraint incidents occurred on the Behavioral Health Unit of the facility.

The Director of BHU was not included on the QLC, preventing involvement in the committees' responsibility for monitoring all aspects of patient care and services provided by the facility.

The facility did not develop a specific QAPI program that was sufficient to show measurable improvement in indicators that would improve health outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, review of video recording, and staff interview, it was determined the facility failed to ensure care was provided in a safe manner and setting for 2 of 4 patients (#6 and #9) who were secluded and/or restrained and whose records were reviewed. Lack of education and training of staff, lack of appropriate policies and implementation of policies, and lack of initial and ongoing assessment resulted in patients being placed at risk for serious harm, injury, or death. This resulted in Patient #6 being at risk for immediate harm or death and the identification of an immediate jeopardy on 3/06/17 at 4:30 PM. Additionally, this had the potential for all patients being treated for Behavioral Health at risk for serious harm, injury, or death. Findings include:

The facility policy Patient Restraint/Seclusion policy, effective 6/03/14, included:

PURPOSE: ...To protect the dignity and safety of inpatients, outpatients, staff and visitors through safe restraint process ...To provide guidelines for use of least restrictive interventions to avoid restraint or seclusion use. To define the procedure to be followed when all alternatives have been exhausted and proven ineffective, and restraints are necessary to maintain patient safety ...To define staff training requirements related to safe restraint or seclusion processes ...

POLICY: ...Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints or seclusion.

- An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.

- If a telephone order is required, the RN must write down the order while the physician is on the phone and read-back the order to verify accuracy. The order must specify clinical justification for restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

- When a LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.

- Duration of order for restraint must not exceed twenty-four (24) hours for the initial order ...

Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met.

- To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of the restraint is necessary.

If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/physician.

- Orders for restraint or seclusion must not exceed: ...4 hours for adults, aged 18 years and older. Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint or seclusion when criteria for release are met.

- Orders may be renewed according to time limits ...for a maximum of 24 consecutive hours.

- Restraints are applied by staff with demonstrated competence in restraint application.

Patients are assessed by an RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion.

- An RN will assess the patient at least every 2 hours. The assessment will include ...circulation of affected extremities, respiratory and cardiac status, psychological status including level of distress or agitation, mental status and cognitive functioning ..., Hygiene, toileting /elimination needs are being met, The patient's rights, dignity, and safety are maintained, consideration of less restrictive alternatives to restraint.

- A trained staff member monitors each patient in restraint or seclusion at least 3 times an hour for safety, and to confirm that the patient's rights and dignity are maintained.

- A patient in restraint and seclusion simultaneously requires a higher level of monitoring: Continuous, uninterrupted monitoring, face-to-face by a specifically assigned staff member with demonstrated competence in close proximity to the patient for at least the first hour.

- A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation ...

The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time.

- The medical record contains documentation of: Determination of effectiveness/ineffectiveness of restraint or seclusion ..., Order for restraint or seclusion and any renewal orders ..., Assessment of the patient in restraint or seclusion ..., Monitoring of patient in restraint or seclusion, Medical and behavioral evaluation for restraint or seclusion management of violent or self destructive behavior.

DEFINITIONS Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement ... Psychotherapeutic medications are to enable, not disable.

A separate policy was requested related to the identification and use of chemical restraints, criteria for use of chemical restraints, and appropriate monitoring of patients who receive chemical restraints. It was reported the facility did not have a chemical restraint policy.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. The practice of using chemical restraints in the facility was discussed. She stated We talk about that we do not use chemical restraints. The order has to reflect the reason for the medication. However, she agreed chemical restraints are being used in the emergency room .

The facility failed to adhere to the Patient Restraint/Seclusion policy as follows:

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a Psychiatric Evaluation, dated 2/01/17, and signed by Psychiatrist B. Psychiatrist B documented Patient #6 was admitted to the BHU on a mental health hold and had a long history of psychiatric illness and multiple inpatient psychiatric admissions. The evaluation documented Patient #6 appeared anxious and had a blunt affect, with obvious facial tics. Patient #6 denied suicidal or homicidal thought, but stated he had auditory hallucinations and heard God's voice. Psychiatrist B documented Patient #6's thought processes were ...illogical, with grandiose and religious delusions ... The evaluation further documented Patient #6 had poor impulse control and judgment.

An RN clinical note, dated 2/27/17 at 2:15 AM, documented Patient #6 physically assaulted a BHU staff member. The note stated Patient lay in wait for staff member to do 15 minute rounds. When staff member entered room she was immediately set upon by patient who used pens to stab staff member repeatedly with both hands and with extreme force. And attempted to force staff member into corner [sic]. Patient tripped on his bed in the process and staff member was able to move past patient. fell ow staff members were able to come and close the door to patients [sic] room as he fought against them. Staff from hospital responded to Code Gray (A facility wide call for assistance). And Caldwell police called [sic]. Police arrived and patient resisted and barricaded in shower. Turned water on and soaked himself. He was talked to hallway and and [sic] moved past the obs (observation) room that was the destination. And was moving toward end of hallway and emergency exit where staff were standing in a line [sic]. Police determined it best to handcuff him in the interest of protecting staff and patients. As patients were in rooms nearby [sic]. Patient handcuffed and medication provided IM. Patient lifted to feet. And patient guided by police to room [sic]. Patient placed in restraints. Patient was yelling in confused fashion and fighting against police. Placed in restraints. Restraints checked for adequacy and patient safety. Patient scrubs were removed due to being soaked with water. Sheft [sic] placed on patients [sic] body. Patient tolerating well. Was provided additional medication by physician order. Currently resting with 2 arms and 1 leg in restraint. Staff debriefed.

a. Patient #6's orders restraints and/or seclusion exceeded the policy time frames.

i. An initial restraint order was documented in Patient #6's medical record on 2/27/17 at 1:09 AM. The order was documented as a telephone order from Psychiatrist C. The order was for seclusion/restraint and locking synthetic leather restraints to all extremities. The order documented the restraint order expired on [DATE] at 5:09 AM. The order was signed by Psychiatrist C on 2/27/17 at 2:04 PM.

Subsequent restraint renewal orders for Patient #6 did not meet regulatory time frames for behavioral/ violent restraint and seclusion orders as follows:

- Renewal order for seclusion/restraint ordered on [DATE] at 8:40 AM. This was documented as a telephone order from Psychiatrist C. The order did not include locking synthetic leather restraints to all extremities. The order expired on [DATE] at 12:40 PM. The order was signed by Psychiatrist C on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 7 hours and 31 minutes later.

- Renewal order for seclusion/restraint and locking synthetic leather restraints to all extremities on 2/27/17 at 9:27 AM. This was documented as a telephone order from the Psychiatrist B. The order expired on [DATE] at 1:27 PM. Psychiatrist B signed the order on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 8 hours and 18 minutes later.

ii. A nursing note, dated 2/28/17 at 3:16 AM, signed by RN B documented Patient #6 began kicking at the door of his room around 2:30 AM. Local law enforcement were called by staff and assisted staff with placing Patient #6 back into restraints to all of his extremities.

An initial order for locking synthetic leather restraints to all extremities was entered on 2/28/17 at 2:50 AM. The order expired on [DATE] at 6:50 AM. The renewal order was entered on 2/28/17 at 7:18 AM, for locking synthetic leather restraints to all extremities. The order was greater than 4 hours after the initial order. It was entered 28 minutes later.

During an interview at 4:20 PM on 3/02/17, RN A reviewed the record and confirmed the orders were not written every 4 hours for restraint and/or seclusion.

During an interview at 11:50 AM on 4/04/17, Psychiatrist C stated patients in restraint and/or seclusion should be seen by a physician or LIP every 4 hours and again at 24 hours. He confirmed he signed the orders but stated Psychiatrist B should have seen Patient #6 after 24 hours because he had returned at that point.

During an interview at 12:40 PM on 4/04/17, Psychiatrist B stated all the physicians discussed Patient #6 and his safety, and the decision was to keep him isolated but was not aware of the continued use of restraints.

Patient #6 was restrained and secluded without orders and he was in locking synthetic leather restraints and/or seclusion for 39 hours.

b. Patient #6's record included a Restraint/Seclusion Observation Form. The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document Y or N, for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraint on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM on 2/28/17 to 4:15 PM. The observation form documented Patient #6 was in seclusion the entire time. There was no documentation of continuous uninterrupted 1:1 monitoring for Patient #6.

While Patient #6 was in 4 point restraints there was no documentation on the observation form his upper extremities were released. There was documentation by staff, during the first time period he was restrained, Patient #6's left leg was released for a total period of 2 hours and 15 minutes. His right leg was released for a total period of 1 hour and 30 minutes. During the second time period Patient #6 was restrained, his left leg was released for 3 hours. His right leg was released for 2 hours and 15 minutes.

The observation form documented Patient #6 was cooperative for significant periods of time. On 2/27/17 from 5:15 AM to 7:00 AM, the form documented he was cooperative. During that time the only restraint released was on Patient #6's left leg. The observation form included documentation Patient #6 was cooperative from 2/27/17 at 4:00 PM to 2/28/17 at 2:15 AM. There was no documentation staff attempted to discontinue seclusion during that time.

During an interview on 3/06/17 at 3:00 PM, the Director of BHU stated monitoring of Patient #6 was documented every 15 minutes. She confirmed the documentation did not include continuous monitoring of Patient #6 while he was in seclusion and restrained. She confirmed the video showed staff intermittently looking through the window in the door of the seclusion room. The Director of BHU confirmed Patient #6's restraints were not routinely released to allow for range of motion.

The facility failed to ensure Patient #6 was appropriately monitored while in seclusion/restraint and his restraints were released to allow for range of motion.

c. Medications were ordered, by Psychiatrist A, Psychiatrist B, and Psychiatrist C, for Patient #6 on a PRN basis to help with agitation and psychosis. During his admission, Patient #6 received the combination of medications 19 out of 28 days. On 2/19/17, 2/21/17, 2/22/17, 2/24/17, and 2/26/17, Patient #6 received the combination of medications 2 times a day. On 2/20/17, he received the combination of medications 3 times. On 2/27/17, he received the combination 4 times.

It was unclear whether the use of the combination of medications was being used to restrict or control Patient #6's behavior.

During an interview at 9:35 AM on 4/04/17, RN A confirmed medications were being given to Patient #6 at his request. He also confirmed they were not given as ordered.

During a telephone conversation at 11:30 AM on 3/23/17, the CNO confirmed administering Haldol, Ativan, and Benadryl at the same time was considered a chemical restraint and should have been treated as one for Patient #6.

d. Patient #6's record included documentation of police involvement 4 times during his admission and commitment.

- Local police were called to assist staff with Patient #6 on 2/06/17 at 12:26 PM. RN C documented Patient #6 was at a door and used his shoulder to charge at the door 3 to 4 times. He then walked down the hall and hit another set of doors which divided the unit. The local police were contacted by staff and a Code Gray was called using the facility overhead paging system after he hit the second set of doors. Patient #6 was medicated per order and RN C documented he became cooperative and ... we did not need to go hands on.

- A nurse's note, dated 2/27/17 at 2:15 AM, signed by RN N documented Patient #6 had physically attacked a staff member. Staff called a Code Grey and also called the local police. Patient #6 had barricaded himself in the bathroom of his room and police talked him out. They then attempted to escort him to the seclusion room and Patient #6 walked past the room toward the exit. Police then handcuff Patient #6 and lifted him off his feet and into the seclusion room to be restrained by staff.

- A Social Service note, dated 2/27/17 at 2:51 PM, documented police came to the BHU so Patient #6 could be taken off restraints. When asked about this on 3/03/17 at 8:00 AM, the Director of BHU stated police were already in the facility in the ED. They were asked to come up to the BHU as a stand-by in case Patient #6 became violent.

- A nurse's note, dated 2/28/17 at 3:16 AM, documented at 2:30 AM Patient #6 kicked at the door to his room. Patient #6 continued to kick at the door and the security guard, who was stationed outside the door, had to hold it to keep the lock from breaking. RN B documented local police were called. The note documented 5 police officers went into the room with RN M. RN M placed Patient #6 in 4 point restraints while law enforcement stood by.

The Director of BHU was interviewed on 3/03/17, beginning at 8:00 AM. She stated law enforcement was called to assist staff with restraining Patient #6 on 2 occasions. When asked why staff was unable to restrain Patient #6 and required the assistance of law enforcement, she said because facility staff was unable to deal with Patient #6.

The Director of BHU was again interviewed on 3/03/17 at approximately 11:03 AM. She stated When police are called and come to assist, they run the show. They do not listen to directions. They do their own thing.

The DQRM was interviewed on 3/02/17 at approximately 3:10 PM. He stated the second time assistance was requested from law enforcement was when staff was preparing to remove Patient #6 from restraints. He stated there were 2 law enforcement officers in the ER, and we asked if they would help us release Patient #6 because they were worried about staff safety.

The facility failed to identify a process regarding the use of law enforcement in the facility.

e. During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM and quality staff.

A BHU document, ...PATIENT AND FAMILY HANDBOOK, documented Every [name of faciliy] patient has the right: ... To security, personal privacy and confidentiality of information ...

While observing the video recording it was noted Patient #6 was restrained in a prone position for 12 + hours. Additionally, his scrubs were removed at the initiation of the restraints and were not replaced for almost 5 hours. Patient #6 was only covered with a blanket.

On 2/27/17, beginning at 10:38 PM, Patient #6 was no longer restrained but remained in seclusion. He was observed shaking feces from the left leg of his scrubs, while talking with a staff member through the locked door. Patient #6 was observed removing his scrub pants, dragging them on the floor, then picking the pants up with his hands and dropping them in a corner of the seclusion room.

Patient #6 became increasingly agitated, pacing around the restraint bed, while dragging his soiled scrub pants on the floor. He appeared to have feces on his buttocks, hands, legs and feet. Patient #6 was observed shaking his fists while speaking with a staff member through the seclusion room door. He then dragged his buttocks along one of the seclusion room walls, smearing feces. Staff entered the seclusion room and provided Patient #6 with a bed pan, disposable wipes, a towel, a small white medicine cup and a cup of water. The staff member then left the room.

Patient #6 began to clean between his buttocks with one of the wipes, and attempted to clean other parts of his body with the same, soiled wipe. He was observed repeating this process with another 1-2 wipes, cleaning himself with the wipes that were soiled with feces. Patient #6 was also observed putting the small white medication cup to his mouth, followed by a drink of water. Next he began to clean the bed, floor, and walls with the towel that was provided, and used the same, contaminated towel on his body.

Throughout the time of these events, staff was observed intermittently watching Patient #6 through the window in the seclusion room door. Staff was not observed offering hand sanitizer or assisting Patient #6 with cleaning himself. Staff was not observed cleaning the floors, walls, or bed during this time. At approximately 11:27 PM, staff brought some popcorn, 2 granola bars and cup of water to Patient #6. He began to eat the food with his hands that were still contaminated with feces.

Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and/or 4 point restraints. Additionally, the restraint monitoring which was documented was inconsistent and incomplete. Documentation did not clearly include consistent assessment of respiratory and cardiac status during the time Patient #6 was in restraints and in a prone position.

The DQRM and the Director of BHU confirmed Patient #6 was not provided personal privacy during the time he was without clothing and in restraints. He was in restraints and without clothing for 5 hours before he was assisted with donning scrubs.

The DQRM was interviewed on 4/03/17 at 10:45 AM. He confirmed the Patient Rights and Responsibilities policy and the policy related to Photographing, Video recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM), did not reflect the current facility practice. When asked the reason for video monitoring and/or video recording of patients, he stated patient monitoring occurred to ensure patient safety. However, he said video recordings of patients were reviewed and used to improve quality of patient care.

The Director of HIM was interviewed on 4/03/17, beginning at 1:45 PM. When asked if video recordings of patients were retained as a part of the permanent patient record, she confirmed video recordings were not retained and were not considered a part of the permanent record.

The Director of Facility Operations was interviewed on 4/03/17, beginning at 3:30 PM. He stated the IT department now maintains the video monitoring system in the facility. He stated the system is now digital in nature, and information is stored on a corporate server for a maximum of 30 days, when a system override occurs. He stated if a copy of a video is required, his department is responsible for flagging the video, making copies, and if the recording is related to a patient, he discusses with the DQRM for direction. He stated most of the time, recordings are used for investigation and quality of care. The Director of Facility Operations stated if copies are created on CDs, he keeps them in his locked desk drawer. He stated some CDs are years old, and he does not really know what to do with them other than keep them locked in his desk. He was uncertain whether patient related video recordings were considered a part of the permanent patient record.

The facility failed to follow their policies and provide a safe patient care environment.

2. Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE] at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's emergency room record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physical aggression and combative. The restraint device was described, locking synthetic leather all. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release. There was no documentation of uninterrupted 1:1 monitoring.

An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, included ...2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints. The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She reviewed Patient #9's record and confirmed he was not assigned a sitter or 1:1. She stated sitters are routinely requested when a patient is in restraints, but often no one is available. If a sitter is unavailable, she stated patients are moved to 1 of 2 rooms closest to the nurses' station, where staff can more easily observe them. The Director of ER also confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

Restraint documentation did not support Patient #9 was under constant observation during the time he was in restraints. Additionally, documentation did not clearly indicate Patient #9 was released from restraints at the earliest possible time.

Based on medical record review, review of serious reportable events, facility policy review, and staff interview, it was determined the facility failed to ensure adverse patient events were reported, analyzed, and actions were taken to prevent further incidents for patients on whom restraints were used. This affected the care of 2 of 4 patients (#6 and #9) who were in restraints and/or seclusion during their stay in the facility and whose records were reviewed. Additionally, this negative practice affected the safety of employees. The failure to report, analyze, and take actions to prevent future incidents interfered with the facility's ability to keep patients and employees safe. Findings include:

A facility policy, Patient Safety Quality Assessment Performance Improvement Plan 2016, next review date, 4/19/17, was reviewed. It stated:

- Patient and Employee Safety is focused on reducing harm, mitigating risk, and seeking to assure a safe environment...Our plan relates specifically to a systemic hospital-wide program to minimize physical injury, accidents and undue psychological stress of our employees and patients during hospitalization ...

- Leadership assumes a role in establishing a culture of safety that minimizes hazards for employee harm and patient harm by focusing on processes. The leaders of the organization are responsible for...emphasizing employee and patient safety as a priority, providing education to medical and hospital staff regarding the commitment to reduction of unsafe practices...

- The Objectives of Employees and Patient Safety are to...Collect and analyze data, evaluate care processes for opportunities to reduce risk and initiate actions

- The severity categories of medical errors/health care errors include: ...Mild to Moderate Adverse Outcome - any set of circumstances that do not achieve the desired outcomes and result in an mild to moderate physical or psychological adverse patient outcome...Hazardous Condition - any set of circumstances, exclusive of disease or condition for which the patient is being treated, which significantly increases the likelihood of a serious adverse outcome

- Components of the organization are integrated through a collaborative effort of multiple disciplines. This is accomplished by: ...Reporting patient safety and operational safety measurements/activity to the performance improvement oversight group, Quality Leadership Council...Reporting of employee safety and operational safety measurements/activity to the performance improvement oversight group; Environment of Care (EOC).

- The procedures for immediate response to employee and patient medical/heath care error are as follows: Staff should immediately report the event to the supervisor (either the Clinical Director or the House Supervisor, if the event occurs during off-hours)...Staff must complete an incident report in the software program for all patient related issues. Incident/Occurrence Report or other documents are needed to preserve information.

- Sources of Data...Incident reports...Employee injuries

The policy was not adhered to as follows:

1. Facility adverse event reports from 12/03/16 to 4/04/17 were requested from the DQRM and reviewed. Some examples of adverse events were as follows:

- 12/6/2016 Extended stay in PACU d/t [due to] sedation level after 8 hour surgery.

- 12/9/2016 Pt called to complain that wounds from her MVC [motor vehicle collision] were not cleaned

- 12/14/2016 Pt required additional time in PACU [post anesthesia care unit] for anesthesia recovery after extensive cervical surgery. No cause for concern

- 1/5/2017 Blood cultures were not drawn at time of order.

- 1/6/2017 No hx of CT(computerized tomography/commonly known as cat scan). Pt very severe reaction to IV [intravenous] contrast. Taken back to ED where he was treated for anaphylaxis

- 2/21/2017 Child climbed on stool in ED with parents nearby and fell off of stool

- 2/28/2017 Pt discharged earlier than wanted by admitting orthopedist

- 3/1/2017 Hypotensive during recovery period

- 3/23/2017 Broken gurney in ED not taken our of commission before pt use.

- 3/28/2017 Pt eloped from ED with Sitter. Returned to ED in handcuffs

Events related to restraint and/or seclusion, and employee injuries, were not included.

The DQRM and Director of BHU were interviewed on 3/03/17, beginning at 8:00 AM. The DQRM stated the facility did not track incidents of restraint and/or seclusion, or employee injuries, through the Serious Event Analysis (SEA) system. He agreed the events surrounding the seclusion and/or restraint of Patient #6, including the related employee injury and extended time Patient #6 was in restraints and/or seclusion, should have been considered a a reportable serious event appropriate for investigation.

2. Refer to A-0144 as it relates to the facility's failure to ensure care was provided in a safe manner and setting for 2 of 4 patients (#6 and #9) who were secluded and/or restrained, resulting in Patient #6 having been at risk for harm or death and the identification of an immediate jeopardy on 3/06/17 at 4:30 PM.

The facility failed to ensure adverse events were tracked, analyzed and actions were taken to prevent further incidents.

Based on staff interview, review of policies, incident reports, and review of QAPI documents, it was determined the hospital failed to ensure an effective, ongoing, hospital-wide, data-driven QAPI program was developed and implemented regarding restraints. It was also determined the hospital's Governing Body failed to provide leadership and oversight of the QAPI program. This resulted in the inability of the hospital to monitor the quality of services it provided. Findings include:

Refer to A-0273 as it relates to the facility's failure to collect and analyze data related to the use of restraint and seclusion.

Refer to A-0283 as it relates to the facilities failure to ensure the QAPI program used restraint and seclusion data to identify opportunities for improvement, and the facility's failure to identify high-risk, high-volume, or problem prone areas in order to focus its QAPI program.

Refer to A-0286 as it relates to the facilities failure to ensure adverse patient events were reported, analyzed, and actions were taken to prevent further incidents for patients on whom restraints were used.

These failures seriously impeded the facilities ability to safely care for patients requiring restraints and/or seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient video, record review, policy review, and staff interview, it was determined the facility failed to ensure psychiatric treatment and interventions for violence and aggression were appropriately provided for 1 of 4 patients (Patient #6) who was placed in seclusion and/or restraints and whose records were reviewed. This resulted in potentially unnecessary mental anguish and neglect. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period. Additionally, the policy stated monitoring of the patient in restraints and/or seclusion should include The patient's rights, dignity, and safety are maintained, as well as Patient's understanding of reasons for restraint and criteria for release from restraint. This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Beginning on 2/27/17 at 12:47 AM, Patient #6 was placed in 4 point restraints and/or seclusion. Patient #6 was in either 4 point restraints and/or seclusion for 39 hours until his discharge. During that time he did not have access to a bathroom, privacy, or was he released from restraint/seclusion at the earliest time.

1. Patient #6's record included documentation he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

a. An initial restraint order for locking synthetic leather restraints and seclusion, dated 2/27/17 at 1:09 AM, stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/27/17. The observation form documented between 1:45 AM and 2:45 AM Patient #6 was sleeping or resting after the initiation of the restraints and seclusion. There was no documentation of the above described criteria.

On 2/27/17, between 3:00 AM and 7:00 AM, Patient #6 was documented as calling out 2 times and pulling and messing with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation of the above described criteria.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what criteria Patient #6 met to keep him in restraints.

Patient #6 remained in 4 point restraints and seclusion until 1:30 PM on 2/27/17, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back in 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine (a medication for schizophrenia, and to reduce anxiety, it can cause drowsiness) 100 mg IM, Benadryl (a medication to reduce allergic reactions and side effects of some medications, it can cuae drowsiness), 50 mg IM, and Ativan (a medication to reduce anxiety, it can cause drowsiness), 2 mg IM.

An initial restraint order, for locking synthetic leather restraints, was documented on 2/28/17 at 2:40 AM. The order stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM and 8:45 AM to 10:00 AM Patient #6 was sleeping. There was no documentation of the above described criteria.

A nurse's note, at 11:00 AM on 2/28/17, signed by RN A, documented Patient #6 was to remain in restraints until he was discharged per the CNO and the Director of BHU. Patient #6 requested to use the bathroom and RN A documented I was told per the above named supervisors [CNO and BHU Director] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by.

During an interview at 9:35 AM on 4/04/17, RN A stated he felt Patient #6 should have had a period where restraints were removed to assess his reaction and response. He stated he was directed not to remove the restraints, after the second application, by the Director of BHU.

Patient #6 was not released from restraints or seclusion at the earliest possible time, or when the ordered criteria were met.

2. Renewal orders for continued use of seclusion/restraint and locking synthetic leather to all extremities did not include documentation of Patient #6's behaviors or if he continued to pose a threat to staff, himself, or other patients on the unit.

Patient #6's record included a Restraint/Seclusion Observation Form. The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document Y or N, for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was cooperative for significant periods of time. On 2/27/17 from 5:15 AM to 7:00 AM, the form documented he was cooperative. The observation form also documented Patient #6 was cooperative from 4:00 PM on 2/27/17 to 2:15 AM on 2/28/17. There was no documentation staff attempted to discontinue seclusion during that time.

3. During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and quality staff.

While observing the video recording it was noted Patient #6 had all 4 of his extremities restrained and he was in a prone position for 12 + hours. Additionally, his scrubs were removed at the initiation of the restraints and Patient #6 was covered only with a blanket for almost 5 hours.

Throughout the time of these events, staff was observed intermittently offering the use of a bedpan for Patient #6. He was not offered privacy when toileting. Additionally, at one point Patient #6 was not released from his restraints or assisted with changing his position in order to use a bedpan.

Physician B, who discharged Patient #6, was interviewed by phone on 4/04/17 at 12:40 PM. When asked if he was aware of the decision to keep Patient #6 in restraints until he was discharged to jail, he stated he remembered having a conversation with the Medical Director of BHU and Physician C. He stated to keep the other patients and staff safe, the decision was made to keep Patient #6 in the isolation room until he was discharged to jail. He stated he was not aware of the restraint part.

RN A, who was a Charge Nurse on BHU, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17 during the day shift. RN A stated he was approached by the Director of BHU on 2/28/17, when Patient #6 was in 4 point restraints for the second time. RN A stated the Director of BHU informed him a decision had been made to keep Patient #6 in restraints until he was discharged .

The facility failed to ensure Patient #6 was free from the potential of possible neglect and mental anguish related to his treatment and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours for 1 of 1 patients (Patient #6) who was restrained for more than 4 hours to manage violent or self-destructive behavior and whose record was reviewed. This resulted in lack of oversight by a physician or qualified LIP and had the potential to interfere with patient safety. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated Physician orders for restraint or seclusion must be time limited, and must specify clinical justification for the restraint or seclusion, the date and time ordered, duration of restraint or seclusion use, the type of restraint, and behavior-based criteria for release. The policy stated orders for restraint or seclusion must not exceed 4 hours for adults, and for a maximum of 24 consecutive hours. Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion. This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

An initial restraint order was documented in Patient #6's medical record on 2/27/17 at 1:09 AM. The order was documented as a telephone order from Psychiatrist C. The order was for seclusion/restraint and locking synthetic leather restraints to all extremities. The order documented the restraint order expired on [DATE] at 5:09 AM. The order was signed by Psychiatrist C on 2/27/17 at 2:04 PM.

Subsequent restraint renewal orders for Patient #6 did not meet regulatory time frames for behavioral/ violent restraint and seclusion orders as follows:

- Renewal order for seclusion/restraint ordered on [DATE] at 8:40 AM. This was documented as a telephone order from Psychiatrist C. The order did not include locking synthetic leather restraints to all extremities. The order expired on [DATE] at 12:40 PM. The order was signed by Psychiatrist C on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 7 hours and 31 minutes later.

- Renewal order for seclusion/restraint and locking synthetic leather restraints to all extremities on 2/27/17 at 9:27 AM. This was documented as a telephone order from the Psychiatrist B. The order expired on [DATE] at 1:27 PM. Psychiatrist B signed the order on 3/01/17. The renewal order was greater than 4 hours from the initial order. It was entered 8 hours and 18 minutes later.

b. A nursing note, dated 2/28/17 at 3:16 AM, signed by RN B documented Patient #6 began kicking at the door of his room around 2:30 AM. Local law enforcement were called by staff and assisted staff with placing Patient #6 back into restraints to all of his extremities.

An initial order for locking synthetic leather restraints to all extremities was entered on 2/28/17 at 2:50 AM. The order expired on [DATE] at 6:50 AM. The renewal order was entered on 2/28/17 at 7:18 AM, for locking synthetic leather restraints to all extremities. The order was greater than 4 hours after the initial order. It was entered 28 minutes later.

During an interview at 4:20 PM on 3/02/17, RN A reviewed the record and confirmed the orders were not written every 4 hours for restraint and/or seclusion.

During an interview at 12:40 PM on 4/04/17, Psychiatrist B stated all the physicians discussed Patient #6 and his safety, and the decision was to keep him isolated but was not aware of the continued use of restraints until after his discharge.

Patient #6 was restrained and secluded without an order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure patients restrained and/or secluded for more than 24 hours consecutively were seen and assessed by a physician or LIP for 1 of 1 patients (Patient #6) who were restrained and/or secluded for more than 24 consecutive hours and whose records were reviewed. This had the potential for patients to be harmed physically and mentally, and endanger their safety. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion. This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included orders for locking synthetic leather restraints to all extremities and/or seclusion. Patient #6 was placed in seclusion and 4 point restraints on 2/27/17 at 12:47 AM. The initial order for locking synthetic leather restraints to all extremities and seclusion was documented in his record on 2/27/17 at 1:09 AM.

An Interdisciplinary Education note, dated 2/27/17 at 1:56 PM, documented Patient #6 was released from the locking synthetic leather restraints at 1:40 PM, 12 hours and 53 minutes after they were initiated, but remained in seclusion. The order for Patient #6 to remain in seclusion was renewed by telephone orders 3 additional times on 2/27/17, at 1:51 PM, 6:04 PM, and 9:54 PM.

On 2/28/17 at 12:47 AM, Patient #6 had been in seclusion for 24 hours. Another renewal order was documented on 2/28/17 at 1:48 AM. There was no documentation Patient #6 was seen, assessed, and evaluated by a psychiatrist prior to the order. Additionally, Patient #6 was placed back into 4 point restraints on 2/28/17 around 2:40 AM.

During an interview at 8:00 AM on 3/03/17, the Director of BHU confirmed Patient #6 was not evaluated by a physician after 24 hours of continuous restraint/seclusion orders.

During an interview at 11:50 AM on 4/04/17, Psychiatrist C stated patients in restraint and/or seclusion should be seen by a physician or LIP every 4 hours, and again at 24 hours. He confirmed he signed the orders, but stated Psychiatrist B should have seen and evaluated Patient #6 after 24 hours because he had returned from vacation at that point.

Patient #6 was in 4 point restraints and/or seclusion beyond 24 hours and was not evaluated in person by a physician or psychiatrist prior to renewal of orders for continued seclusion and/or restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure face-to-face assessments were comprehensive and included all necessary information for 1 of 4 patients (Patient #6) for whom face-to-face assessments were conducted and whose records were reviewed. This resulted in a lack of information on which to base additional intervention and treatment decisions and had the potential for an adverse outcome. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior... The policy also stated at the time of the 1 hour face-to-face the physician/LIP/RN will evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, the need for continued restraint or seclusion, and revise the plan of care as needed. This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

a. Patient #6's record included a Restraints Monitor note, on 2/27/17 at 1:02 AM, which documented restraints were applied at 12:30 AM for physical aggression and he was a danger to himself and others. The note documented the type of restraints used were seclusion and locking synthetic leather restraints. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine 100 mg IM, another medication used for psychosis and sedation.

A nurse's note, dated 2/28/17 at 3:31 AM, signed by RN F documented the face-to-face assessment was completed, 3 hours after he was placed into restraints/seclusion. The note stated Face to face assessment completed. Pt [Patient #6] remains at risk for violent behavior. Pt verbalizing his need to stab staff as he is being told to and he could not Rat out. Pt was explained [sic] why restraints were on and criteria for release. CMS [circulation, motion, sensation] good in extremities. Currently rt [right] leg released from restraint.

The face-to-face did not include documentation of Patient #6's reaction to the intervention and medical condition. There was no documentation of vital signs, cardiac status or assessment, respiratory status or assessment, bowel or gastrointestinal assessment, or urologic assessment. There was also no documentation of Patient #6's reaction or response to the medications which were administered.

b. Patient #6's record included a nurse's note, on 2/28/17 at 3:02 AM. The note documented while Patient #6 was in seclusion, he kicked at the seclusion room door around 2:30 AM. RN K documented local law enforcement were called and when they arrived Patient #6 was restrained in 4 point restraints, all 4 extremities, in the face down position on his bed. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

A nurse's note, dated 2/28/17 at 4:54 AM, RN K documented Face to face nurses [sic] note at about 0300 [3:00 AM] this was done. Pt's [Patient #6] reaction to intervention of being in leather restraints is calm and answering questions [sic] Pt has good circulation to all extremities. CRT [capillary refill time] < 2 sec [seconds] all ext [extremities]. Pulses strong. Pt is breathing non labored. He is calm now.

The face-to-face did not include documentation of Patient #6's vital signs, bowel or gastrointestinal assessment, or urological assessment. There was no documentation of his reaction or response to the medications which were administered.

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed the face-to-face 1 hour assessments were not comprehensive for Patient #6 and did not include the required elements stated in the policy.

The 1 hour face-to-face evaluation for Patient #6 was not comprehensive and did not include the information necessary on which to base future interventions and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a psychiatrist, or LIP, was consulted after the face-to-face assessments were completed for 1 of 4 patients (Patient #6) for whom face-to-face assessments were completed and whose records were reviewed. This resulted in the potential for patients to not receive additional interventions or treatments. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated The RN or physician assistant with demonstrated competence must consult the attending physician or LIP who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. (As soon as possible is to be as soon as the attending physician is able to be reached by phone or in-person.) This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6 was placed in 4 point restraints, all extremities, 2 times from 2/27/17 until his discharge on 2/28/17. The face-to-face assessment was not completed within 1 hour of placing Patient #6 into restraints and seclusion for both occurrences.

a. Patient #6's record included a Restraints Monitor note, on 2/27/17 at 1:02 AM, which documented restraints were applied at 12:30 AM for physical aggression and he was a danger to himself and others. The note documented the type of restraints used were seclusion and locking synthetic leather restraints.

A nurse's note, dated 2/27/17 at 3:31 AM, RN F documented the face-to-face assessment was completed. There was no documentation a psychiatrist was consulted after completion of the face-to-face.

b. Patient #6's record included a nurse's note, on 2/28/17 at 3:02 AM, which documented while he continued to be in seclusion he started kicking at the seclusion room door at around 2:30 AM. RN K documented local law enforcement were called and when they arrived Patient #6 was restrained, all 4 extremities, in the face down position on his bed.

A nurse's note, dated 2/28/17 at 4:54 AM, RN K documented Face to face nurses [sic] note at about 0300 [3:00 AM] this was done. There was no documentation a psychiatrist was consulted after completion of the face-to-face.

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed there was no documentation in Patient #6's record a psychiatrist was consulted after the face-to-face assessments.

During an interview at 12:40 PM on 4/04/17, Psychiatrist B stated all the physicians discussed Patient #6 and his safety, and the decision was to keep him isolated but was not aware of the continued use of restraints.

Patient #6's psychiatrist was not consulted after the completion of the face-to-face by an RN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, facility policy review, review of video recording, and staff interview, it was determined the facility failed to ensure patients were continuously monitored when there was simultaneous use of restraint and seclusion for 1 of 1 patients (Patient #6) who was simultaneously restrained and secluded and whose record was reviewed. This had the potential for patients to experience serious harm and/or injury. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated A patient in restraint and seclusion simultaneously requires a higher level of monitoring. The policy further stated Continuous, uninterrupted monitoring, face-to-face by a specifically assigned staff member with demonstrated competence in close proximity to the patient for at least the first hour. After the first hour, the policy stated continuous uninterrupted monitoring by a specifically assigned staff member must be done in close proximity to the patient to allow emergency intervention if a problem arises. This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a Restraint/Seclusion Observation form which documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form.

The observation form included documentation by staff in 15 minute increments. The observation form did not include documentation he was continuously monitored while in simultaneous seclusion and restraints. Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and 4 point restraints.

During the time Patient #6 was in restraints and seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and Quality staff.

While observing the video recording it was noted there was no audio recorded. Staff was observed intermittently watching Patient #6 through the window of the seclusion room door.

During an interview at 4:00 PM on 3/07/17, the Director of the BHU confirmed the record did not include documentation Patient #6 was continuously monitored. She also confirmed that during observation of the video recording staff was visible at times behind the seclusion room door, however they were not continuously watching Patient #6.

Patient #6 was not continuously monitored while simultaneously in restraints and seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and staff interview, it was determined the facility failed to ensure 1 of 4 restrained patients' medical records (Patient #6) included documentation of his response to physical restraint and the rationale for the continued use of restraint. This resulted in the inability of the facility to evaluate the efficacy of restraint use. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included an observation form, dated 2/27/17. The observation form documented between 1:45 AM and 2:45 AM Patient #6 was sleeping or resting after the initiation of the restraints and seclusion. There was no documentation of Patient #6's response to the restraints and seclusion.

On 2/27/17, between 3:00 AM and 7:00 AM, Patient #6 was documented as calling out 2 times and pulling and messing with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he reacted adversely with them.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what criteria Patient #6 met to keep him in restraints and seclusion.

Patient #6 remained in 4 point restraints and seclusion until 1:30 PM on 2/27/17. There was no further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

Patient #6's record included a Restraint/Seclusion Observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM and 8:45 AM to 10:00 AM Patient #6 was sleeping. There was no documentation of Patient #6's response to the restraints, seclusion, and medications.

A nurse's note, at 11:00 AM on 2/28/17, signed by RN A documented the plan was for Patient #6 to remain in restraints until he was discharged per the CNO and the Director of BHU.

Physician B, who discharged Patient #6, was interviewed by phone on 4/04/17 at 12:40 PM. When asked if he was aware of the decision to keep Patient #6 in restraints until he was discharged to jail, he stated he remembered having a conversation with the Medical Director of BHU and Physician C. He stated to keep the other patients and staff safe, the decision was made to keep Patient #6 in the isolation room until he was discharged to jail. He stated he was not aware of the restraint part.

RN A, who was a Charge Nurse on BHU, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17 during the day shift. RN A stated he was approached by the Director of BHU on 2/28/17, when Patient #6 was in 4 point restraints for the second time. RN A stated the Director of BHU informed him a decision had been made to keep Patient #6 in restraints until he was discharged .

The facility failed to document an assessment of Patient #6's reaction to the use of restraints, seclusion, and medications. Additionally, the facility failed to document a rationale for the continued use of restraints and seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, video review, and staff interview, it was determined the facility failed to ensure the RN evaluated and appropriately provided the nursing care for 1 of 4 patients (Patient #6) who was in restraints and/or seclusion and whose records were reviewed. This resulted in directly impacting the nursing care received by Patient #6 and compromised his dignity, safety, and treatment. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

A facility policy Patient Restraint/Seclusion, dated 4/22/16, stated monitoring of patients in restraints or seclusion included assessment by an RN immediately after they are initiated. The policy further stated an RN will assess the patient at least every 2 hours and the assessment will include the following when appropriate:

- Signs of injury associated with restraint, including circulation of extremities

- Respiratory and cardiac status

- Psychological status

- Needs for range of motion

- Hydration/nutritional needs are being met

- Hygiene, toileting/elimination needs are being met

- The patient's rights, dignity, and safety are maintained

The policy also stated patients in simultaneous restraints and seclusion must be continuously monitored by competent staff. This policy was not followed.

During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and Quality staff.

While observing the video recording it was noted Patient #6 was restrained in a prone position for 12 + hours. Additionally, his scrubs were removed at the initiation of the restraints and were not replaced for almost 5 hours. Patient #6 was only covered with a blanket.

On 2/27/17, beginning at 10:38 PM, Patient #6 was no longer restrained but remained in seclusion. He was observed shaking feces from the left leg of his scrubs, while talking with a staff member through the locked door. Patient #6 was observed removing his scrub pants, dragging them on the floor, then picking the pants up with his hands and dropping them in a corner of the seclusion room.

Patient #6 became increasingly agitated, pacing around the restraint bed, while dragging his soiled scrub pants on the floor. He appeared to have feces on his buttocks, hands, legs and feet. Patient #6 was observed shaking his fists while speaking with a staff member through the seclusion room door. He then dragged his buttocks along one of the seclusion room walls, smearing feces. Staff entered the seclusion room and provided Patient #6 with a bed pan, disposable wipes, a towel, a small white medicine cup and a cup of water. The staff member then left the room.

Patient #6 began to clean between his buttocks with one of the wipes, and attempted to clean other parts of his body with the same, soiled wipe. He was observed repeating this process with another 1-2 wipes, cleaning himself with the wipes that were clearly soiled with feces. Patient #6 was also observed putting the small white medication cup to his mouth, followed by a drink of water. Next he began to clean the bed, floor, and walls with the towel that was provided, and used the same, contaminated towel on his body.

Throughout the time of these events, staff was observed intermittently watching Patient #6 through the window in the seclusion room door. Staff was not observed offering hand sanitizer or assisting Patient #6 with cleaning himself. Staff was not observed cleaning the floors, walls, or bed during this time. At approximately 11:27 PM, staff brought some popcorn, 2 granola bars and a cup of water to Patient #6. He began to eat the food with his hands that were still contaminated with feces.

Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and 4 point restraints. Additionally, the restraint monitoring which was documented was inconsistent and incomplete. Documentation did not clearly include consistent assessment of respiratory and cardiac status during the time Patient #6 was in restraints and in a prone position. Examples include:

1. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6 was not monitored or assessed by the RN, as required according to the facility policy, while he was in seclusion and/or restraints. Additionally, the RN did not ensure all of Patient #6's needs were being met while in restraints and/or seclusion.

- A Restraints Monitor note, dated 2/27/17 at 12:47 AM, did not include documentation of his respiratory or cardiac status, hygiene or toileting needs, or range of motion needs. Additionally, there was no documentation Patient #6's dignity and safety was maintained during initial application of the restraints and seclusion.

- A Restraints Monitor note, dated 2/27/17 at 1:06 AM, did not include documentation of Patient #6's respiratory or cardiac status, hygiene or toileting needs, or if he was offered food or water.

- A Restraints Monitor note, dated 2/27/17 at 2:55 AM, did not include documentation of Patient #6's respiratory or cardiac status, hygiene or toileting needs, or range of motion needs. Additionally, there was no documentation his dignity and safety was maintained.

- A Restraints Monitor note, dated 2/27/17 at 4:17 AM, did not include documentation of Patient#6's respiratory or cardiac status, hygiene or toileting needs, or range of motion needs. The note stated his Safety/Rights/Dignity maintained verified: Done now, however, the note did not state how that was accomplished.

During an interview at 4:20 PM on 3/02/17, RN A stated every 2 hours the RN responsible for the direct care of the patient was required to perform an assessment. He confirmed the documentation of assessments was not comprehensive.

The RN failed to comprehensively assess Patient #6 and his needs while in restraints/seclusion.

2. Patient #6 was in restraints/seclusion for 39 hours until he was discharged from the facility. During that time his vital signs were documented twice in his record.

Patient #6's vital signs were documented at 4:40 AM on 2/27/17. His oxygen saturation was documented at 86%. At 4:44 AM, the RN documented his oxygen saturation was rechecked with a hand monitor and it was 98%. The RN documented Patient #6's CMS (Circulation, Movement, and Sensation) remain good. There was no documentation of the RN performed a cardiopulmonary or respiratory assessment.

Vital signs were next documented in Patient #6's record at 6:33 AM on 2/28/17.

During an interview at 4:20 PM on 3/02/17, RN A confirmed Patient #6's vital signs were only documented twice in his record after application of restraints.

During an interview at 12:40 PM on 3/06/17, RN K stated he checked Patient #6's vital signs once during his 12 hour night shift.

Patient #6's vital signs were not checked frequently according to his status and needs.

3. Patient #6's record included a Restraint/Seclusion Observation Form. The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document Y or N, for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

The observation form included documentation by staff in 15 minute increments. The observation form did not include documentation Patient #6 was continuously monitored while in simultaneous seclusion and restraints.

During an interview at 4:20 PM on 3/02/17, RN A stated every 2 hours the RN responsible for the direct care of the patient was required to perform an assessment. He confirmed the documentation of assessments was not comprehensive. RN A confirmed Patient #6's vital signs were only documented once in his record after application of restraints.

The RN failed to comprehensively assess Patient #6 and his needs while in restraints/seclusion.

During an interview on 3/06/17 at 3:00 PM, the Director of BHU stated monitoring of Patient #6 was documented every 15 minutes. She confirmed the documentation did not include continuous monitoring of Patient #6 while he was in seclusion and restrained. She confirmed the video showed staff intermittently looking through the window in the door of the seclusion room. The Director of BHU confirmed Patient #6's restraints were not routinely released to allow for range of motion.

The facility failed to ensure Patient #6 was appropriately monitored, assessed, and his needs were met while in restraint/seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, staff education transcript review, and staff interview, it was determined the facility failed to ensure nursing assignments were based on staff competency and patients' needs for 1 of 4 patients (Patient #6) who were in s restraints and whose records were reviewed. This failure resulted inadequate assessments and resulted in poor quality of care. Findings include:

The facility policy titled Assignments (PCS), approved 12/08/16, stated Patient Care Assignments are based upon specific patient needs and nursing care competency of available personnel. Assignments include the following:

a. Patients rooms and bed numbers

b. Times for meetings, inservices and education programs.

c. Code Team assignment, if applicable.

d. Notation of students assigned to specific patients. ...

e. Special duty area assignments.

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

An observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. The BHU staff assignment sheet for the night of 2/27/17 was reviewed. RN K was listed as caring for 5 patients, including Patient #6. There was no documented charge RN or preceptor on the staff sheet.

RN K was interviewed at 12:40 PM, on 3/06/17. His orientation was discussed. He stated he had not yet received restraint training or attended the Non-Violent Intervention Training.

The Director of BHU was interviewed on 3/06/17, at 3:05 PM. She stated RN K had worked 4 nights of orientation and was being precepted by the charge nurse, RN M, when RN K cared for Patient #6 in seclusion. She confirmed RN K had not received his NVCI or restraint training.

It was unclear why he was assigned a patient in restraints and seclusion.

b. A Labor and Delivery CNA monitored Patient #6 on 2/28/17, from 7:00 AM until 11:28 PM.

The CNA's education transcript was reviewed. She completed a basic Healthstream (the facility's online education program), however, she had not participated in the NVIT or demonstrated restraint competency since 2014.

The CNA was interviewed on 3/02/17 at 3:15 PM. She stated she had worked in the ER where there were restrained patients, however, because she now worked in Labor and Delivery, she no longer took the restraint courses. She stated she was told to sit outside the room and observe the patient every 15 minutes, so she looked through the window of the door to the seclusion room every 15 minutes, and filled out their form.

The Director of the BHU was interviewed on 4/03/17, starting at 2:15 PM. She stated the Healthstream modules were a adjunct to the staff restraint training, which they had previously done in a skills fair format. In 2016, some of the staff were assigned a module on restraint documentation by the Clinical Educator, rather than the standard restraint module. Additionally, she stated in 2016 the facility had incorporated restraint training into the NVIC. She stated the NVIC course allowed for facilities to put in training according to their own restraint policies. She stated during this part of the course, staff was required to do a return demonstration of restraint use.

It was unclear why a CNA without updated restraint training was assigned to a restrained and secluded patient.

The facility failed to assign staff who was adequately trained, educated and competent to care for Patient #6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to define and educate RNs on chemical restraints and their use which directly impacted 1 of 2 patients (Patient #6) who received chemical restraints and whose records were reviewed. This had the potential to result in serious harm and/or adverse reactions for patients receiving care in the facility related to behavioral problems and diagnosis. Findings include:

A facility policy was requested regarding the use of chemical restraints on 3/01/17, the Clinical Quality Coordinator stated there was not a policy for chemical restraints.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Medications were ordered by Psychiatrist A, Psychiatrist B, and Psychiatrist C, for Patient #6 on a PRN basis to help with anxiety, agitation, and psychosis. The medication orders were written as follows:

- 2/06/17 at 9:00 AM: Haldol 10 mg PO every 6 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Ativan 2 mg PO every 6 hours PRN, PRN Reason: Agitation, Special Instructions: Give with Haldol and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Benadryl 50 mg PO every 6 hours PRN, PRN Reason: Agitation/Extrapyramidal Symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Haldol 10 mg PO every 4 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Ativan 2 mg PO every 4 hours PRN, PRN Reason: Agitation, Special Instructions: Give Haldol and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Benadryl 50 mg PO every 4 hours PRN, PRN Reason: Agitation/Extrapyramidal symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/24/17 at 4:15 PM: Ativan 2 mg PO every 3 hours PRN, PRN Reason: Agitation, Special Instructions: If possible, try to give first before antipsychotic. However, may give with Haldol and Benadryl if needed or give IM if patient unable to take oral or violent.

Medications were not given as ordered. Examples include:

- On 2/09/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 7:55 AM and 12:44 PM. However, the order was for the medications to be given as needed every 6 hours. The orders for these medications to be given every 4 hours had not been received until after the second dose. Additionally, at 7:55 AM RN L documented the combination of medications were given per Patient #6's request due to anxiety, not for agitation/psychosis.

- On 2/10/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 10:09 AM per Patient #6's request. On 2/12/17, 2/13/17, 2/19/17, and 2/21/17 Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO twice per Patient #6's request. However, the order for the combination of medications was for agitation/psychosis.

During his admission, Patient #6 received the combination of medications 19 out of 28 days. On 2/09/17 to 2/13/17, 2/19/17, 2/21/17, 2/22/17, 2/24/17, and 2/26/17, Patient #6 received the combination of medications 2 times a day. On 2/20/17, he received the combination of medications 3 times. On 2/27/17, he received the combination 4 times.

It was unclear whether the use of the combination of medications was being used to restrict or control Patient #6's behavior.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. The practice of using chemical restraints in the facility was discussed. She stated We talk about that we do not use chemical restraints. The order has to reflect the reason for the medication. However, she agreed chemical restraints are being used in the emergency room .

During a telephone interview at 11:30 AM on 3/23/17, the CNO confirmed administering Haldol, Ativan, and Benadryl at the same time was considered a chemical restraint and should have been treated as one for Patient #6.

During an interview at 9:35 AM on 4/04/17, RN A confirmed medications were being given to Patient #6 at his request. He also confirmed they were not given as ordered.

Patient #6 was did not receive his medications as ordered and the RNs failed to recognize the use of chemical restraints.

Based on staff interview, facility policy review, and review of QAPI documents, it was determined the facility failed to ensure the QAPI program used restraint and seclusion data to identify opportunities for improvement. Additionally, the facility failed to identify high-risk, high-volume, or problem prone areas in order to focus its QAPI program. This prevented the facility from analyzing its processes in order to improve them. Findings include:

1. A facility policy, Patient Safety Quality Assessment Performance Improvement Plan 2016, next review date 4/19/17, documented some of the QAPI goals for 2016 as follows:

- Behavioral Health - Fall Risk Reduction

- Cardiac/Cardiopulmonary Services - EKG Process

- Case Management - Transitions of Care

- Cath Lab/EP Lab - Radiation Dose/Notification Process

- Education - Meditech Education

- Employee Health - Lift Related Injury Reduction

- Emergency Department - Medication Labeling/Outdate Management

- Medical Staff - Committee/Board Reporting

- Quality - Board/Medical Staff Reporting Process

The DQRM, and the Director of BHU were interviewed together on 3/03/17, beginning at 8:00 AM. When asked how incidents of restraint and/or seclusion were tracked in the facility, the DQRM stated each incident of restraint and/or seclusion was recorded in a log book that was maintained by the facility's nursing supervisors. The DQRM stated he was uncertain how the restraint/seclusion data was tracked through the QAPI program and analyzed to improve patient care in the facility. The DQRM stated he was uncertain whether the data was included in the facility's quality program and presented to the Governing Board.

There was no QAPI documentation about how restraint and seclusion data was tracked, gathered and used to decrease the use of restraint and/or seclusion in the facility. The facility failed to use data to assess care of patients for whom restraint and/or seclusion was used. The lack of data prevented the facility from identifying opportunities for improvement.

The facility did not identify high-risk, high-volume, or problem-prone areas for evaluation.

Based on review of facility policy review, and staff interview, it was determined the facility failed to develop a policy that clearly identified the use of a drug or medication used as a chemical restraint, criteria for the use of a chemical restraint, and how patients who received a chemical restraint(s) should have been monitored. The lack of a fully developed policy, that included clear guidance, prevented staff from recognizing the use of chemical restraints and impeded adequate patient monitoring of those patients who received medication(s) as a chemical restraint. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated:

- APPENDIX D: DEFINITIONS ...Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint. When medications are used as restraints, it is important to note that the decision as to whether they constitute restraint is not specific to the treatment setting, but to the situation the restraint is being used to address. A medication that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint.

- ...standard use of a psychotherapeutic medication to treat the patient's condition enables the patient to more effectively or appropriately function in the world around him/her than would be possible without the use of the medication. Psychotherapeutic medications are to enable, not disable.

The policy did not include criteria to identify and determine the need for a chemical restraint, or staff guidance related to monitoring patients who received a chemical restraint. A separate policy that specifically addressed chemical restraints was requested, but was not provided.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. The practice of using chemical restraints in the facility was discussed. She stated We talk about that we do not use chemical restraints. The order has to reflect the reason for the medication. She however agreed chemical restraints were being used in the facility.

The policy did not include criteria to identify and determine the need for chemical restraint or staff guidance related to monitoring patients who received a chemical restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of facility policies, and staff interview, it was determined the facility failed to ensure the type of restraint used was the least restrictive intervention for 2 of 4 patients (#6 and #8) who were restrained and whose records were reviewed. This resulted in unnecessary use of restraint. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated POLICY: Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints or seclusion. This policy was not followed.

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a Restraint/Seclusion Observation Form. The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document Y or N, for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and from 2:35 AM on 2/28/17 to 4:15 PM on 2/28/17. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a MAR. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine 100 mg IM, another medication used for psychosis and sedation.

The observation form documented the following:

- 1:45 AM, sleeping

- 2:00 AM, sleeping

- 2:15 AM, sleeping

- 2:30 AM, resting with eyes closed

- 2:45 AM, awake

Between 3:00 AM and 7:00 AM, Patient #6 was documented as calling out 2 times and pulling and messing with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he was threatening or inappropriate.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what the conversation entailed.

Patient #6 remained in 4 point restraints and seclusion until 2/27/17 at 1:30 PM, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was then medicated with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg.

A nurse's note, on 2/28/17 at 11:00 AM , signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the BHU Director. Patient #6 requested to use the bathroom and RN A documented I was told per the above named supervisors [CNO and BHU Director] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by.

The observation form documented from 3:00 AM to 1:00 PM, Patient #6 was sleeping and cooperative. There was no documentation he was aggressive, threatening, or a risk for harming himself or others.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. RN A stated he planned to remove the restraints and observe Patient #6 during his time out of restraints, and if appropriate behavior was observed, leave the restraints off. However, RN A stated he was approached by the Director of BHU, who informed him a decision was made to keep Patient #6 in restraints until he was discharged . RN A stated, without removing Patient #6's restraints, he assessed him and assisted him with personal care and toileting needs, but felt he had a good rapport with Patient #6 and would have preferred to remove his restraints.

The facility failed to ensure the least restrictive intervention was used for Patient #6.

2. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- On 12/08/16 at 1:57 PM, an RN assessment was documented in Patient #8's record. It included the question What are some things that make you angry ... Patient #8's response was documented Being isolated, Being restrained ... The question Have you ever been restrained ... was also asked, to which Patient #8 responded No.

- The Psychiatric Evaluation dated 12/09/16, completed by a physician, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included the patient was ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation. The report included ...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room. The evaluation did not document Patient #8 was violent or aggressive.

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she, the RN, was making rounds when she found Patient #8 ...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ... No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ... Patient #8's behavior was not described as aggressive or violent toward others.

- On 12/09/16 at 9:25 AM, an order for restraints was received by an RN, but not entered until 12/09/17 at 11:20 AM. The record did not include an explanation of late order entry. The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described, locking synthetic leather all. The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert. Although Patient #8 was held in 4 point, locking restraints, an RN documented the least restrictive restraint application was used.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM. At 11:45 AM, the observation form included Pt stated she's calm and wants out. At 12:00 PM, documentation included Pt laying quietly. At 12:15 PM, it was documented Pt stating she want restraints off. At 1:15 PM, it was documented Patient #8 was released from restraints on 12/09/16. Patient #8 remained in 4-point, locking restraints.

Patient #8's behavior did not justify the use of 4 point, locking restraints.

The Director of BHU was interviewed on 3/07/17, beginning at 2:00 PM. She stated she was unable to find documentation in Patient #8's record supporting the use of 4 point restraints, as opposed to bilateral wrist restraints only.

The facility failed to ensure the least restrictive restraint application was used on Patient #8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, facility policy review, and medical record review, it was determined the facility failed to ensure patients or their representative were informed of their rights for 1 of 2 ER patients (Patient #9) whose records were reviewed. This had the potential to prevent patients from exercising their rights while receiving services from the hospital. Findings include:

A facility policy Patient's Rights and Responsibilities (QUAL), approved 3/02/15, was reviewed. The policy included:

[Name of facility] provides each patient with a written statement of patient rights at the time of registration, and again at the time any patient or patient's representative has questions regarding their rights.

The facility failed to follow their policy and notify Patient #9 of his rights.

Patient #9 was a [AGE] year old male admitted on [DATE], at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE], at 1:30 AM to home and his own care.

Patient #9's record included an Emergency Provider Report. The report documented Patient #9 was seen initially in the ER on 1/15/17, at 6:39 PM. The report stated Pt is a 58 y/o male who presents to ER via EMS status post being found by neighbor approximately + hour ago. Pt's neighbor heard a dog barking for 30 minutes before he went outside where he found the pt laying on the ground. As per EMS, pt has been seen here for psych eval [evaluation] and alcoholism, self medicates with alcohol, and has chronic back pain. He frequently visits the firestation while intoxicated. Tonight pt answers some questions appropriately and others not so ...

Patient #9's record included a copy of Conditions of Admission and Consent for Outpatient Care. The form included a section related to acknowledgement of notice of patient rights and responsibilities. The form instructed Patient #9 to enter his initials, date, and time, which would indicate he was furnished with a copy of patient rights and responsibilities. Hand written on the form in Patient #9's record was Pt medically unable to sign. Two unidentified individuals signed the form as witnesses, and entered the date and time, 1/15/17 at 7:41 PM.

The facility did not document attempts to contact a family member, friend, or guardian, who could speak on behalf of Patient #9. Patient #9's competency was later reassessed during his ER visit, and he was prepared for discharge.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She reviewed Patient #9's record and confirmed staff should have attempted to contact a family member, friend, or guardian. Additionally she confirmed staff should have discussed Patient #9's rights and responsibilities with him once he became coherent and before he was discharged from the ER.

The facility failed to follow their policy and provide Patient #9 a copy of his patient rights and responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, review of a patient video recording, and review of facility policies, and BHU documents, it was determined the facility failed to ensure the personal privacy of 1 of 2 BHU patients (Patient #6) who was video recorded and whose records were reviewed. This resulted in the violation of Patient #6's personal privacy and had the potential for interfering with the personal privacy of all facility patients being monitored and/or recorded by video and/or audio surveillance. Findings include:

The following facility policies, consent form and BHU documents, were reviewed during the survey and found to have been unclear and inconsistent, negatively impacting the facility's practices and preventing the facility from protecting the privacy rights of patients as follows:

1. A facility policy, Patient's Rights and Responsibilities (QUAL), approved 3/02/15, included an attached document, Statement of Patient Rights and Responsibilities. It stated:

- Considerate and Respectful Care...To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment.

- ...and the right not to remain undressed any longer than is required for accomplishing the medical purpose...

2. A BHU document, ...PATIENT AND FAMILY HANDBOOK, documented Every [name of faciliy] patient has the right: ...To security, personal privacy and confidentiality of information ...

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Surveyors reviewed a video recording of Patient #6 on 3/06/17, beginning at 9:50 AM. The video recording included the time when Patient #6 was in restraints and/or seclusion. Others in attendance included the facility's COO, the DQRM, and the Director of BHU.

Patient #6 was in restraints and without clothing for 5 hours before he was assisted with donning scrubs. The DQRM and the Director of BHU confirmed Patient #6 was not provided personal privacy during the time he was without clothing and in restraints.

Additionally they confirmed Patient #6 was not offered privacy during times of personal care and toileting.

The camera was never turned off during the 39 hours Patient #6 was in restraints and/or seclusion to allow for privacy.

The facility did not protect the privacy of Patient #6.

3. A facility policy, Photographing, Video Recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM), approved 7/29/16, was reviewed. It stated:

- ...Photographing Patients by Workforce Members,...for Security of Health Care Operations Purposes: The Conditions of Admission or Consent for Outpatient Care form (or the equivalent form in non-hospital settings) should advise patients that photographs and/or video monitoring may be taken for security or health care operations purposes (e.g., quality assurance)...

- Storage: Facilities must refer to the facility model Designated Record Set Policy to determine which photographs and/or audio recordings must be stored in the medical record. Facilities must designate a secure area(s) to store photographs and recordings that contain protected health information and will not be housed in the patient's record. Photographs and recordings must be clearly identified, securely stored and transmitted, and readily accessible for retrieval...

The DQRM was interviewed on 4/03/17 at 10:45 AM. He confirmed the Patient Rights and Responsibilities policy and the policy related to Photographing, Video recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM), did not reflect the current facility practice. When asked the reason for video monitoring and/or video recording of patients, he stated patient monitoring occurred to ensure patient safety. However, he said video recordings of patients were reviewed and used to improve quality of patient care.

The Director of HIM was interviewed on 4/03/17, beginning at 1:45 PM. When asked if video recordings of patients were retained as a part of the permanent patient record, she confirmed video recordings were not retained and were not considered a part of the permanent record.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:05 AM. He stated video recordings of patients on BHU are made as a part of patients' plans of care.

The Patient Rights and Responsibilities policy and the policy related to Photographing, Video recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM) were inconsistent and unclear to staff. The policies did not reflect the facility's current practices.

4. A facility form, Conditions of Admission and Consent for Outpatient Care, included ...Consent to Photographs, Videotapes and Audio recordings. I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the hospital's quality improvement and/or risk management activities. I understand that the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law ...

The Director of Facility Operations was interviewed on 4/03/17, beginning at 3:30 PM. He stated the IT department now maintains the video monitoring system in the facility. He stated the system is now digital in nature, and information is stored on a corporate server for a maximum of 30 days, when a system override occurs. He stated if a copy of a video is required, his department is responsible for flagging the video, making copies, and if the recording is related to a patient, he discusses with the DQRM for direction. He stated most of the time, recordings are used for investigation and quality of care. The Director of Facility Operations stated if copies are created on CDs, he keeps them in his locked desk drawer. He stated some CDs are several years old, and he does not really know what to do with them other than keep them locked in his desk. He was uncertain whether patient related video recordings were considered a part of the permanent patient record.

The Systems Administrator was interviewed on 4/04/17, beginning at 1:00 PM. He stated the video surveillance system that is currently in place is approximately 1.5 years old. He stated the staff on the units are unable to change camera views and cannot turn the cameras off/on. He stated if staff needs to disable a camera, they must contact the Systems Department, which has the ability to turn the cameras off and on. He stated the only cameras in the patient care areas that have the capacity to record are on BHU, rooms 306 and 312. He said all other cameras in the patient care areas have only monitoring capabilities. The Systems Administrator confirmed the video surveillance system retained information for 30 days, when the system begins to override, then 30 day old information is no longer available.

If BHU patients were assigned to room 306 or room 312, and the subject of video recording, the facility was unable to provide copies of the recordings if they were 30 days or older.

BHU patients assigned to room 306 or 312 were not afforded personal privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure the use of restraint was in accordance with the order of a physician and facility policy for 2 of 4 patients (#8 and #10) who were restrained and whose medical records were reviewed. This had the potential for restraint use without a physician order. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated ...Order for Restraint or Seclusion ... If a telephone order is required, the RN must write down the order while the physician is on the phone and read-back the order to verify accuracy. It also stated Physically holding a patient during a forced psychotropic medication procedure is considered a restraint ...The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint ...The use of force in order to medicate a patient, as with other restraint, must have a physician's order prior to the application of restraint (use of force)...A drug or medication when it is used as a resriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint.

The policy was not adhered to as follows:

1. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- The Psychiatric Evaluation, dated 12/09/16, dictated by a physician at 11:06 AM, stated Patient #8 began to harm herself when she arrived on the unit. The evaluation included the patient was ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation. The report included ...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room.

- On 12/09/16 at 9:15 AM, an RN documented she, the RN, was making rounds when she found Patient #8 ...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ... No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ...

- A Clinical Documentation Record included an initial order for restraints, entered at 12/09/16 at 11:20 AM. The restraint device was described, locking synthetic leather all.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM, and released from restraints at 1:15 PM the same day.

The Director of BHU and the DQRM were interviewed together on 3/07/17, beginning at 2:00 PM. They reviewed Patient #8's record. When asked about the 11:20 AM restraint order for Patient #8, the Director of Quality stated the initial verbal order was received on 12/09/16 at 9:25 AM, but the order was not entered into the EMR until 11:20 AM on the same day. He confirmed the restraint orders were unclear and said it was a problem with the EMR for which the facility is currently seeking resolution.

Patient #8's record documented he was restrained from 9:25 AM to 11:20 AM without an order from a physician or LIP.

2. Patient #10 was a [AGE] year old female admitted on [DATE] at 12:54 PM for care related to a suicide attempt and depression. She was medicated and kept for 2 nights in the ER until her discharge home with her mother on 12/21/16.

The orders and record indicated Patient #10 was placed locked synthetic restraints at 6:32 PM. However, prior to this, Patient #10 received Haldol 5 mg and Ativan 2 mg given at 6:12 PM via IM injection.

Patient #10's assigned RN was interviewed on 3/06/17 at 12:04 PM. She stated prior to Patient #10 being placed in the synthetic locking restraints, she was asked to grab medications and staff held Patient #10 down to medicate her. She stated security was called to assist in giving another medication. There was no order written prior to or just after the medications were given forcefully during a physical hold.

The Director of ER was interviewed on 4/03/17 at 11:25 AM. Patient #10's chart was reviewed electronically. She confirmed there was not a restraint order for a physical hold or chemical restraint for Patient #10.

The facility failed to ensure a restraint order was written for Patient #10's physical hold and forced medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of facility policies and medical records, it was determined the facility failed to ensure patients in restraints were monitored based on the individual needs of the patient and in accordance with facility policy for 1 of 4 patients (Patient #9) who were restrained and whose records were reviewed. This failed practice negatively impacted the safety of Patient #9, and had the potential to compromise patient safety and interfere with quality of patient care for all patients requiring restraints in the facility. Findings include:

A facility policy, Patient Restraint/Seclusion, effective 6/03/14, included ...Monitoring the Patient in Restraints or Seclusion ... Monitoring is based on the individual needs of the patient. Variables of the patient's condition, cognitive status, risks associated with the chosen intervention may require more frequent evaluations.

The facility failed to adhere to the policy as follows:

Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE] at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's emergency room record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physical aggression and combative. The restraint device was described, locking synthetic leather all. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused. There was no documentation of uninterrupted 1:1 monitoring.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release. There was no documentation of uninterrupted 1:1 monitoring.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She reviewed Patient #9's record and confirmed he was not assigned a sitter or 1:1. She stated sitters are routinely requested when a patient is in restraints, but often no one is available. If a sitter is unavailable, she stated patients are moved to 1 of 2 rooms closest to the nurses' station, where staff can more easily observe them.

The facility failed to ensure a restrained patient in the ER was monitored based on his individual needs and in accordance with facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure a face-to-face meeting by a competent staff member was conducted within 1 hour of the application of behavioral restraints for 1 of 4 patients (Patient #6) who were restrained to manage violent or self-destructive behavior and whose records were reviewed. This failure prevented the facility from evaluating the causes and appropriateness of the need for restraint. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior... This policy was not followed.

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6 was placed in 4 point restraints, all extremities, twice from 2/27/17 until his discharge on 2/28/17. The face-to-face assessment was not completed within 1 hour of placing Patient #6 into restraints and seclusion for both occurrences.

Patient #6's record included a Restraints Monitor note, on 2/27/17 at 1:02 AM, which documented restraints were applied at 12:30 AM for physical aggression and he was a danger to himself and others. The note documented the type of restraints used were seclusion and locking synthetic leather restraints.

A nurse's note, dated 2/28/17 at 3:31 AM, signed by RN F documented the face-to-face assessment was completed 3 hours after he was placed into restraints and seclusion.

During an interview at 9:35 AM on 4/04/17, RN A confirmed there was no documentation of a face-to-face assessment within 1 hour of the application of restraints and seclusion.

Patient #6 did not have a face-to-face assessment completed within 1 hour of the application of restraints and seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff education transcript review, policy review, and staff interview, it was determined the facility failed to ensure all staff caring for patients restrained for violent behavior had education, training, and demonstrated competency to manage patients exhibiting out-of-control, aggressive behavior or in restraints. This failure placed all patients experiencing behavioral and psychiatric challenges at risk of physical and/or mental harm. Findings include:

The American Psychiatric Nurses Association website was accessed on 3/08/17. Under their Seclusion and Restraint Standards of Care, revised April 2014, stated the following regarding staff education:

- Any staff providing care to persons at risk for harming themselves or others and who participate in seclusion and restraint shall have received training and demonstrate current competency in all aspects of dealing with behavioral emergencies.

- Be approved by the organization assuring that program components include adequate attention to the clinical contributors to behavioral emergencies, the actual management of those emergencies, and the assessments and interventions necessary to maintain physical well-being.

- Be provided during a staff member's orientation period and at least annually thereafter.

The facility policy Patient Restraint/Seclusion, dated 6/03/14, contained Appendix A: Training Requirements. Appendix A stated direct care staff, security personnel and non-healthcare staff, as defined and listed by the facility, will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion...Training will occur:

1. Before performing restraint application, implementation of seclusion, monitoring and assessment and providing care for a patient in restraint and seclusion,

2. As part of orientation, and

3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients.

Additionally, it stated the training for RNs who conducted one-hour face-to-face evaluations should include Monitoring, assessment and providing care for a patient in restraint or seclusion, including:

The patient's immediate situation

The patient's reaction to the situation

The patients' medical and behavioral condition

The need to continue or terminate the restraint or seclusion.

1. Employee education records documenting restraint training were requested and received 3/07/17. Twenty-eight of the facility's behavioral health employee Student and Group Transcript Reports were reviewed. Several BHU training files contained no documentation of restraint training in the last 12 months. Additionally, there was no evidence of competency assessments in managing behavioral emergencies and restraint use in the last 12 months. There was no documentation of evidence of RN training for the one-hour face-to-face evaluation of the restrained or secluded patient.

The Director of BHU was interviewed at starting at 2:00 PM, on 3/07/17. She stated the Non-Violent Crisis Intervention class and the restraint module in Healthstream (the facility's online training program) were to be completed annually by staff involved in restraint and seclusion.

The Director of BHU was interviewed again on 4/03/17, starting at 2:15 PM. She stated the Healthstream modules were an adjunct to the staff restraint training, which they had in a skills fair format prior to 2016. She stated starting in 2016, some of the staff were assigned a module on restraint documentation by the Clinical Educator, rather than the standard restraint module. Additionally, she stated in 2016, the facility had incorporated restraint training into the NVIT. She stated the NVIT course allowed for facilities to put in training according to their own restraint policies. She stated during this part of the course, staff was required to do a return demonstration of restraint use. The Director of BHU stated it was a BHU requirement for the staff to complete the course by the end of June, or they would be suspended. She stated she attested to the fact that all of her employees took the class in 2016.

The BHU failed to provide evidence of training for all staff performing restraint and seclusion.

2. The American Psychiatric Nurses Association Seclusion and Restraint Standards of Care stated Differentiate chemical restraint from medication that may support and assist the person to successfully manage circumstances...

The facility's policy Patient Restraint/Seclusion defined a chemical restraint as A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint.

Patient #10 was a [AGE] year old female admitted on [DATE] at 12:54 PM for care related to a suicide attempt and depression. She was medicated in the ER, kept for 2 nights in the ER until her discharge home on 12/21/16.

The Director of the ER was interviewed at 2:25 PM, on 3/7/17. She was asked if the staff was trained in chemical restraint use. She stated Employees are taught that we do not use chemical restraints. However, she confirmed they were using chemical restraints in the emergency room .

The facility failed to ensure staff were trained regarding chemical restraints.

Based on review of facility policies, staff education transcript review, and staff interview, it was determined the facility failed to ensure all staff were kept up to date in required competencies for the application of restraints, implementation of seclusion, and in providing care for a patient in restraint or seclusion. This resulted in an unsafe environment for all patients. Findings include:

The facility policy Patient Restraint/Seclusion, approved 4/22/16, included an APPENDIX A: TRAINING REQUIREMENTS. It stated training will occur:

1. Before performing restraint application, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion,

2. As part of orientation, and

3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients.

4. The results of skills and knowledge assessment, new equipment, or QAPI data may indicate a need for targeted training or more frequent or revised training.

The Director of BHU was interviewed on 4/03/17, starting at 2:15 PM. She stated restraint education was required annually. In 2016, some of the staff were assigned a module on restraint documentation by the Clinical Educator, rather than the standard restraint module. Additionally, she stated in 2016 the facility had incorporated restraint training into the NVIC. She stated the NVIC course allowed for facilities to put in training according to their own restraint policies. She stated during this part of the course, staff was required to do a return demonstration of restraint use. The Director of BHU stated it was a requirement of the unit for the staff completed the course by the end of June, or they would be suspended. She stated she attested to the fact that all of her employees took the class in 2016.

Documentation of BHU staff demonstrated competencies for 2016 was requested on 4/03/17 during the interview. The Director of BHU was unable to produce documentation for all employees. She stated the education department received the paperwork and placed them in the staff education transcripts, and was unsure what had happened to some of them. She was unable to produce documentation of demonstrated competency for the following staff for the 2016: RN B, RN E, RN G, RN I, RN K, RN L, RN M, RN N, RN Q, BHT A, BHT B, BHT K, BHT L, BHT M, BHT N, BHT O, MSW B, and MSW C.

The facility failed provide evidence all staff was trained in restraint use at adequate intervals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on video review, record review, staff interview, it was determined the facility failed to ensure RNs, who worked with potentially violent patients, received required training in factors that could trigger the need for restraints. This directly effected 1 of 3 patients (Patient #6) who were restrained for violent behavior and had the potential to result in injury to other patients and staff dealing with application of restraints. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

It was documented in Patient #6's record he attacked an employee on 7/27/10 at 12:00 AM, and was placed in seclusion and restraints after the attack. He was removed from restraints at 1:30 PM, but remained in seclusion. On the staffing assignments sheet it was documented RN K was the nurse caring for Patient #6 during the shift starting at 7:00 PM, on 7/27/16.

On 3/06/17 segments of the video of Patient #6 taped on 2/27/2 17 and 2/28/17 were viewed by surveyors with the Director of BHU, The DQRM, and the Facility COO. Patient #6 was seen going to the door and talking to someone through the window at 10:18 PM. It was documented in his record Patient #6 had requested a bedpan at that time. He waited, until 10:28 PM, and went to the door again.

Patient #6 then became increasingly agitated, and proceeded to defecate in his scrub pants. The feces fell out of his scrub pants on to the floor. He appeared to be agitated and shook his arms in frustration. Patient #6 removed his scrub pants and proceeded to smear feces around the room with his feet using the scrub pants at 10:41 PM. At 10:45 PM he is at the door talking to staff, gesturing to the feces with his right palm up. He then sat on the bed, and feces was left on the uncovered mattress.

At the 10:48 PM marking on the recording, RN K was identified at the door by the Director of BHU. She stated RN M was at the monitor during that time. She stated they were watching Patient #6 as he smeared his feces against the wall with his buttocks.

At 10:51 it appeared Patient #6 was told to sit in the corner, which he did. Staff placed a bedpan, saniwipes, a white towel, clean scrubs, a medicine cup, and a styrofoam cup full of water on the feces contaminated bed. Patient #6 proceeded to attempt to clean himself, using wipes soiled with feces to wipe his arms, chest and legs. He took some time to place what was in the medicine cup in his mouth. At 10:56, Patient #6 continued to attempt to clean the floor with feces covered wipes.

During Patient #6's attempts at cleaning, RN K was watching through the window. Patient #6 continued to clean himself and the room, spending time on his hands and knees to wipe the floor. He had new scrub pants on by 11:10 PM. At 11:15 PM, he wiped his head with a contaminated saniwipe.

At 11:24, staff comes in and sprays air freshener. At 11:28 PM, staff places some popcorn contained in a coffee filter and some granola bars on the contaminated bed. Patient #6 ate some food despite not being properly cleaned or washing his hands.

At 2:19 AM Patient #6 is seen talking at the door, and then starts kicking hard at the door at 2:20 AM. The door appeared to loosen, and the DQRM stated the door lock was broken from Patient #6's kicking.

It was unclear how the staff during this shift were identifying and reducing behaviors that could trigger agitation and aggression in Patient #6. He was placed back in 4 point hard restraints facedown on the contaminated bed at 2:38 AM.

The security guard that was the sitter for Patient #6 was interviewed on 3/02/17 at 2:40 PM. He stated Patient #6 requested to go to the bathroom, and he let the nurse know right away. He stated it was a long time before the nurse came.

RN K was interviewed at 12:40 PM, on 3/06/17. He stated he had previously offered Patient #6 the bedpan and he had declined. RN K stated he was assessing another patient when Patient #6 requested the bedpan and finished with the other patient first, before returning to Patient #6. RN K's orientation was discussed. He stated he had not yet received restraint training or attended the Non-Violent Intervention Class.

The Director of BHU was interviewed on 3/06/17, at 3:05 PM. She stated RN K had worked 5 nights of orientation and was being precepted by the charge nurse, RN M, when RN K cared for Patient #6 in seclusion. She confirmed RN K had not received NVIT or restraint training.

The facility failed to ensure staff caring for patients were educated in techniques for identifying situations that could trigger circumstances requiring restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff education transcripts, record review, staff interview, and review of facility policy, the facility failed to ensure all BHU staff caring for patients in violent restraints received training in choosing the least restrictive interventions based on individualized assessment of the patient's condition. This resulted in the lack of assessments for choosing the least restrictive restraint for 2 of 2 patients (#6 and #8) and the potential to result in the lack of assessment for other patients upon which to base restraint decisions. Findings include:

The facility's policy Patient restraint/Seclusion stated Staff will be trained on choosing the least restrictive intervention based on the individualized assessment of the patient's medical or behavioral status or condition. Safe patient care requires looking at the patient as an individual and assessing the patients's condition, needs, strengths, weaknesses, and preferences, and tailoring interventions to individual patient's needs after weighing factors such as the patient's condition, behaviors, history and environmental factors.

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

Patient #6's record included a Restraint/Seclusion Observation Form. The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document Y or N, for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and from 2:35 AM on 2/28/17 to 4:15 PM on 2/28/17.

Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a MAR. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine 100 mg IM, another medication used for psychosis and sedation.

The observation form documented the following:

- 1:45 AM, sleeping

- 2:00 AM, sleeping

- 2:15 AM, sleeping

- 2:30 AM, resting with eyes closed

- 2:45 AM, awake

Between 3:00 AM and 7:00 AM, Patient #6 was documented as calling out 2 times and pulling and messing with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he was threatening or inappropriate.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what the conversation entailed.

Patient #6 remained in 4 point restraints and seclusion until 2/27/17 at 1:30 PM, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was then medicated with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg.

A nurse's note, on 2/28/17 at 11:00 AM , signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the BHU Director. Patient #6 requested to use the bathroom and RN A documented I was told per the above named supervisors [CNO and BHU Director] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by.

The observation form documented from 3:00 AM to 1:00 PM, Patient #6 was sleeping and cooperative. There was no documentation he was aggressive, threatening, or a risk for harming himself or others.

2. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- On 12/08/16 at 1:57 PM, an RN assessment was documented in Patient #8's record. It included the question What are some things that make you angry ... Patient #8's response was documented Being isolated, Being restrained ... The question Have you ever been restrained ... was also asked, to which Patient #8 responded No.

- The Psychiatric Evaluation dated 12/09/16, completed by a physician, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included Patient #8 was ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation. The report included ...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room. The evaluation did not document Patient #8 was violent or aggressive.

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she, the RN, was making rounds when she found Patient #8 ...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ...No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self-harm or release tension. After assessment the patient said that she wanted another shot. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ... Patient #8's behavior was not described as aggressive or violent toward others.

- The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described, locking synthetic leather all. The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM. At 11:45 AM, the observation form included Pt stated she's calm and wants out. At 12:00 PM, documentation included Pt laying quietly. At 12:15 PM, it was documented Pt stating she want restraints off. At 1:15 PM, it was documented Patient #8 was released from restraints on 12/09/16. Patient #8 remained in 4-point, locking restraints. Although Patient #8 was held in 4 point, locking restraints, an RN documented the least restrictive restraint application was used.

Patient #8's behavior did not justify the use of 4 point, locking restraints.

The Director of BHU was interviewed on 3/07/17, at 4:20 PM. She stated she was unable to find documentation in Patient #8's record supporting the use of 4 point restraints, as opposed to bilateral wrist restraints only.

Documentation of restraint training content was requested during the interview. She stated there was no other training agenda besides the Restraint Application Competency form to show evidence of class content. Twenty Restraint Application Competency forms were presented. The form had 4 columns. The title of the second column was Points of Measure, which named the skill being demonstrated for competency. The column did not contain any skill related to using the least restrictive restraint.

The facility failed to ensure staff were trained in assessing patients for the least restrictive restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, staff interview and policy review, the facility failed to ensure all staff caring for restrained patients were trained in recognizing when restraints were no longer necessary. This impacted 3 of 4 patients (#6, #8, and #9) that were restrained and whose records were reviewed, and had the potential to result in the continuation of patient restraints without justification on other restrained patients in the facility. Findings include:

The facility policy Restraint and Seclusion, approved 4/22/16, stated The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period... additionally, it stated:

Staff will be trained and able to demonstrate competency in identification of specific behavioral changes that may indicate that restraint or seclusion is no longer necessary and can safely be discontinued.

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ED, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

The observation form documented Patient #6 was cooperative for significant periods of time. On 2/27/17 from 5:15 AM to 7:00 AM, the form documented he was cooperative. During that time the only restraint released was on Patient #6's left leg. The observation form included documentation Patient #6 was cooperative from 2/27/17 at 4:00 PM to 2/28/17 at 2:15 AM. There was no documentation staff attempted to discontinue seclusion during that time.

According to the record, Patient # 6 was cared for by RN K on 3/27 night shift. RN K was interviewed at 12:40 PM, on 3/06/17. His orientation was discussed. He stated he had not yet received restraint training or attended the Non-Violent Intervention Class.

RN A, who acted as a charge nurse on the BHU, was interviewed on 4/04/17 at 9:15 AM. He stated it appeared from the documentation the patient was not given the opportunity to be kept in the least restrictive restraint.

2. Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharge on 1/16/17 at 1:30 AM to home and his own care.

An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, was reviewed. The provider report included ...2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints. The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

3. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/17, beginning at 9:30 AM, and released from restraints at 1:15 PM the same day. At 11:45 AM, the observation form included Pt stated she's calm and wants out. At 12:00 PM, documentation included Pt laying quietly. At 12:15 PM, it was documented Pt stating she want restraints off.

Patient #8 was not released from restraints at the earliest possible time.

The Director of BHU was interviewed on 3/07/17, at 4:20 PM. Documentation of BHU staff demonstrated competencies for 2016 was requested on 4/03/17 during the interview. Twenty Restraint Application Competency forms were presented. The form had 4 columns. The title of the second column was Points of Measure, which named the skill being demonstrated for competency. The column did not contain any skill related to recognizing behaviors indicating a patient might be safe to release from seclusion or restraint.

The facility failed to ensure employees were trained in recognizing behaviors indicating when a patient could be safely removed from restraint or seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, it was determined the facility failed to ensure BHU staff was trained in assessing a patients' physical and emotional response to restraint and seclusion. This directly impacted the care of 1 of 2 patients (Patient #6) who were placed in restraints in the BHU and whose records were reviewed, and had the potential to impact other BHU patients placed in restraints. Findings include:

Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

Patient #6's record included a Restraint/Seclusion Observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM Patient #6 was sleeping. There was no documentation of Patient #6's response to the restraints, seclusion, and medications. According to the 2/27/17 the staff assignment sheet, RN K was caring for Patient #6.

The Director of the BHU was interviewed on 3/06/17, at 3:05 PM. RN K had worked 5 nights of orientation and was being precepted by the charge nurse, RN M, when RN K cared for Patient #6 in seclusion. She confirmed RN K had not received his NVIC or restraint training.

The facility failed to ensure RN K was appropriately trained to monitor Patient #6 while in seclusion/restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility policy, and staff interview, it was determined the facility failed to ensure patients, or their representatives, were given an opportunity to formulate advance directives for 1 of 2 ER patients (Patient #9) whose records were reviewed. This had the potential to result in patients' wishes not being addressed. Findings include:

A facility policy Advance Directives, approved 2/27/15, included PURPOSE: To protect and assure the patient's right to complete and/or execute advance directives and make known their desires regarding healthcare choices ...POLICY: [Name of facility] will offer the adult patient (inpatient and outpatient [AGE] years or older)/legal guardian /family/primary caregiver information concerning advance directives. Upon admission to the facility, the existence, change, or revocation of the patient's advance directives is determined, documented and communicated to all appropriate staff. This policy was not adhered to as follows:

Patient #9 was a [AGE] year old male admitted on [DATE], at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE], at 1:30 AM to home and his own care.

Patient #9's record included an Emergency Provider Report. The report documented Patient #9 was seen initially in the ER on 1/15/17, at 6:39 PM. The report stated Pt is a 58 y/o male who presents to ER via EMS status post being found by neighbor approximately + hour ago. Pt's neighbor heard a dog barking for 30 minutes before he went outside where he found the pt laying on the ground. As per EMS, pt has been seen here for psych eval and alcoholism, self medicates with alcohol, and has chronic back pain. He frequently visits the firestation while intoxicated. Tonight pt answers some questions appropriately and others not so ...

Patient #9's record included a Conditions of Admission and Consent for Outpatient Care. The form included a section related to advance directives. Contained within this section were instructions to initial the box beside the description that best described the patient's advance directive status. The choices allowed patients to use an existing advance directive and provide the facility with a copy of the information, to receive information and execute an advance directive while a patient in the facility, and to refuse information and refuse to execute an advance directive. The boxes beside all options were blank.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed staff should have followed up with Patient #9 once he was coherent, and prior to discharge, to allow him the opportunity to formulate advance directives.

Patient #9 was not informed about advance directives or allowed to request/refuse information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient video, record review, policy review, and staff interview, it was determined the facility failed to ensure restraints and/or seclusion were only imposed to ensure the immediate physical safety of the patient or others and were discontinued at the earliest possible time for 3 of 4 patients (#6, #8, and #9) who were restrained and/or secluded, and whose records were reviewed. This resulted in unnecessary use of restraint and/or seclusion. Findings include:

A facility policy, Patient Restraint/Seclusion, effective 6/03/14, included:

- PURPOSE: To protect the dignity and safety of inpatients, outpatients, staff and visitors through safe restraint process...

- ...Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restraint will be used...

- ...Duration of order for restraint must not exceed twenty-four (24) hours for the initial order...Twenty-four (24) hours is the maximum duration...

- ...Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met...

- ...The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time.

- APPENDIX D: DEFINITIONS ...Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient ' s behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient ' s condition is considered a restraint. When medications are used as restraints, it is important to note that the decision as to whether they constitute restraint is not specific to the treatment setting, but to the situation the restraint is being used to address. A medication that is not being used as a standard treatment or in a dosage for the patient ' s medical or psychiatric condition and that results in controlling the patient ' s behavior and/or in restricting his or her freedom would be a drug used as a restraint.

- ...standard use of a psychotherapeutic medication to treat the patient's condition enables the patient to more effectively or appropriately function in the world around him/her than would be possible without the use of the medication. Psychotherapeutic medications are to enable, not disable.

The policy was not adhered to as follows:

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

a. Patient #6's record included documentation he was initially placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a Restraint/Seclusion Observation Form. The form included documentation in 15 minute intervals beginning with the first entry on 2/27/17 at 12:45 AM and ending with the last entry on 2/28/17 at 4:00 PM. The form included a section for staff to document Y or N, for yes or no, in 17 categories. The categories listed were for seclusion, restraint, which extremities were restrained, the mental condition of the patient, a circulation check, fluids, food, bathroom, release and range-of-motion, vital signs, and medications. The form also included a section for staff initials, and a narrative section for observations or comments.

The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

A nurses note, dated 2/28/17 at 11:00 AM, documented Restraint Face to Face...Per Nursing Director [Directorof BHU's Name] and CNO [CNO's Name] patient is to remain in restraints until transferred to jail.

Physician B, who discharged Patient #6, was interviewed by phone on 4/04/17 at 12:40 PM. When asked if he was aware of the decision to keep Patient #6 in restraints until he was discharged to jail, he stated he remembered having a conversation with the Medical Director of BHU and Physician C. He stated to keep the other patients and staff safe, the decision was made to keep Patient #6 in the isolation room until he was discharged to jail. He stated he was not aware of the restraint part.

RN A, who was a Charge Nurse on BHU, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17 during the day shift. RN A stated he was approached by the Director of BHU on 2/28/17, when Patient #6 was in 4 point restraints for the second time. RN A stated the Director of BHU informed him a decision had been made to keep Patient #6 in restraints until he was discharged .

Patient #6 was in locking synthetic leather restraints and/or seclusion for 39 hours.

b. During the time Patient #6 was in restraints and/or seclusion, he was under constant video observation. Segments of the video recording were reviewed on 3/06/17, beginning at 9:50 AM, by surveyors, the COO, the Director of BHU, the DQRM, and Quality staff.

While observing the video recording it was noted Patient #6 was restrained in a prone position for 12 + hours. Additionally, his scrubs were removed at the initiation of the restraints and were not replaced for almost 5 hours. Patient #6 was covered only with a blanket.

On 2/27/17, beginning at 10:38 PM, Patient #6 was no longer restrained but remained in seclusion. He was observed shaking feces from the left leg of his scrubs, while talking with a staff member through the locked door. Patient #6 was observed removing his scrub pants, dragging them on the floor, then picking the pants up with his hands and dropping them in a corner of the seclusion room.

Patient #6 became increasingly agitated, pacing around the restraint bed, while dragging his soiled scrub pants on the floor. He appeared to have feces on his buttocks, hands, legs and feet. Patient #6 was observed shaking his fists while speaking with a staff member through the seclusion room door. He then dragged his buttocks along one of the seclusion room walls, smearing feces. Staff entered the seclusion room and provided Patient #6 with a bed pan, disposable wipes, a towel, a small white medicine cup and a cup of water. The staff member then left the room.

Patient #6 began to clean between his buttocks with one of the wipes, and attempted to clean other parts of his body with the same, soiled wipe. He was observed repeating this process with another 1-2 wipes, cleaning himself with the wipes that were clearly soiled with feces. Patient #6 was also observed putting the small white medication cup to his mouth, followed by a drink of water. Next he began to clean the bed, floor, and walls with the towel that was provided, and used the same, contaminated towel on his body.

Throughout the time of these events, staff was observed intermittently watching Patient #6 through the window in the seclusion room door. Staff was not observed offering hand sanitizer or assisting Patient #6 with cleaning himself. Staff was not observed cleaning the floors, walls, or bed during this time. At approximately 11:27 PM, staff brought some popcorn, 2 granola bars and cup of water to Patient #6. He began to eat the food with his hands that were still contaminated with feces.

Patient #6's record did not include documentation of consistent and continuous observation and monitoring while he was in seclusion and 4 point restraints. Additionally, the restraint monitoring which was documented was inconsistent and incomplete. Documentation did not clearly include consistent assessment of respiratory and cardiac status during the time Patient #6 was in restraints and in a prone position.

The facility failed to ensure Patient #6's safety and dignity were maintained and protected while he was admitted to the BHU and in restraints and/or seclusion.

c. The observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:47 AM to 2/27/17 at 1:30 PM, and on 2/28/17 from 2:35 AM to 4:15 PM. Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

i. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

Patient #6's record included a MAR. The MAR documented on 2/27/17 at 12:17 AM, Patient #6 received Haldol a medication to reduce pshychosis and anxiety)10 mg IM, Benadryl (a medication to reduce allergies and side effects, it can cause drowiness), 50 mg IM, and Ativan (a medication to reduce anxiety, it can cause drowsiness), 2 mg IM. Additionally, on 2/27/17 at 1:20 AM, he received Thorazine ( amedication for schizophrenia and reduces anxiety, it can cuase drowsiness) 100 mg IM, another medication used for psychosis and sedation.

The observation form documented the following:

- 1:45 AM, sleeping

- 2:00 AM, sleeping

- 2:15 AM, sleeping

- 2:30 AM, resting with eyes closed

- 2:45 AM, awake

Between 3:00 AM and 7:00 AM, Patient #6 was documented as calling out 2 times and pulling and messing with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation he was threatening or inappropriate.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what criteria Patient #6 met to keep him in restraints.

Patient #6 remained in 4 point restraints and seclusion until 2/27/17 at 1:30 PM, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and confirmed Patient #6 was not released from restraints and seclusion at the earliest possible time.

Staff failed to remove or discontinue restraints and seclusion as early as possible.

ii. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was then medicated with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

A nurse's note, on 2/28/17 at 11:00 AM , signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the Director of BHU. Patient #6 requested to use the bathroom and RN A documented I was told per the above named supervisors [CNO and Director of BHU] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by.

The observation form documented from 3:00 AM to 1:00 PM, Patient #6 was sleeping and cooperative. There was no documentation he was aggressive, threatening, or at risk for harming himself or others.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and explained he was the Charge Nurse scheduled on 2/28/17, and he assigned the care of Patient #6 to himself during that shift. RN A stated he was in the ante-room (a room immediately outside the locked door of the restraint and seclusion room,) preparing to enter the seclusion room, and based on behavior, remove Patient #6 from his restraints, assess him, and assist him with toileting needs. RN A stated he planned to observe Patient #6 during this time out of restraints, and if appropriate behavior was observed, leave the restraints off. However, RN A stated he was approached by the Director of BHU, who informed him a decision was made to keep Patient #6 in restraints until he was discharged . RN A stated, without removing Patient #6's restraints, he assessed him and assisted him with personal care and toileting needs, but felt he had a good rapport with Patient #6 and would have preferred to remove his restraints.

Though Patient #6's behavior was documented cooperative, the facility failed to begin removing his restraints to ensure the least restrictive intervention was used for Patient #6 during the time he was in restraints and/or seclusion.

d. Medications were ordered by Psychiatrist A, Psychiatrist B, and Psychiatrist C, for Patient #6 on a PRN basis to help with anxiety, agitation, and psychosis. The medication orders were written as follows:

- 2/06/17 at 9:00 AM: Haldol 10 mg PO every 6 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Ativan 2 mg PO every 6 hours PRN, PRN Reason: Agitation, Special Instructions: Give with Haldol and Benadryl or give IM if patient unable to take oral.

- 2/06/17 at 9:00 AM: Benadryl 50 mg PO every 6 hours PRN, PRN Reason: Agitation/Extrapyramidal Symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Haldol 10 mg PO every 4 hours PRN, PRN Reason: Agitation/Psychosis, Special Instructions: Give with Ativan and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Ativan 2 mg PO every 4 hours PRN, PRN Reason: Agitation, Special Instructions: Give Haldol and Benadryl or give IM if patient unable to take oral.

- 2/09/17 at 1:30 PM: Benadryl 50 mg PO every 4 hours PRN, PRN Reason: Agitation/Extrapyramidal symptoms, Special Instructions: Give with Haldol and Ativan or give IM if patient unable to take oral.

- 2/24/17 at 4:15 PM: Ativan 2 mg PO every 3 hours PRN, PRN Reason: Agitation, Special Instructions: If possible, try to give first before antipsychotic. However, may give with Haldol and Benadryl if needed or give IM if patient unable to take oral or violent.

Medications were not given as ordered. Examples include:

- On 2/09/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 7:55 AM and 12:44 PM. However, the order was for the medications to be given as needed every 6 hours. The orders for these medications to be given every 4 hours had not been received until after the second dose. Additionally, at 7:55 AM RN L documented the combination of medications were given per Patient #6's request due to anxiety, not for agitation/psychosis.

- On 2/10/17, Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO at 10:09 AM per Patient #6's request. On 2/12/17, 2/13/17, 2/19/17, and 2/21/17 Patient #6's MAR documented he received 10 mg of Haldol PO, 2 mg of Ativan PO, and 50 mg of Benadryl PO twice per Patient #6's request. However, the order for the combination of medications was for agitation/psychosis.

During his admission, Patient #6 received the combination of medications 19 out of 28 days. On 2/09/17 to 2/13/17, 2/19/17, 2/21/17, 2/22/17, 2/24/17, and 2/26/17, Patient #6 received the combination of medications 2 times a day. On 2/20/17, he received the combination of medications 3 times. On 2/27/17, he received the combination 4 times.

It was unclear whether the use of the combination of medications was being used to restrict or control Patient #6's behavior.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. He reviewed Patient #6's record and confirmed medication orders were not consistently followed, and chemical restraints were administered to Patient #6 to control his behavior.

Staff failed to follow orders for administration of medication to Patient #6 and did not recognize the use of chemical restraints.

e. A facility policy Use of Force Policy (Safety), approved 10/24/12, stated Law enforcement agencies will be called when needed.

The policy did not provide staff guidance regarding criteria for use of law enforcement in the facility. Additionally, the policy did not clearly define the role of law enforcement versus the role of facility staff, when law enforcement was called to the facility.

Patient #6's record included documentation of police involvement 4 times during his admission and commitment.

The following entry in Patient #6's record described an example of potentially unnecessary police involvement.

A nurse's note, dated 2/27/17 at 2:15 AM, signed by RN N documented Patient #6 had physically attacked a staff member. Staff called a Code Grey and also called the local police. Patient #6 had barricaded himself in the bathroom of his room, and police talked him out. They then attempted to escort him to the seclusion room and Patient #6 walked past the room toward the exit. Police then handcuffed Patient #6 and lifted him off his feet and into the seclusion room to be restrained by staff.

The Director of BHU was interviewed on 3/03/17, beginning at 8:00 AM. She stated law enforcement was called to assist staff with restraining Patient #6 on 2 occasions. When asked why staff was unable to restrain Patient #6 and required the assistance of law enforcement, she said because facility staff was unable to deal with Patient #6.

The Director of BHU was again interviewed on 3/03/17 at approximately 11:03 AM. She stated When police are called and come to assist, they run the show. They do not listen to directions. They do their own thing.

The DQRM was interviewed on 3/02/17 at approximately 3:10 PM. He stated the second time assistance was requested from law enforcement was when staff was preparing to remove Patient #6 from restraints. He stated there were 2 law enforcement officers in the ER, and we asked if they would help us release Patient #6 because we were worried about staff safety.

The facility failed to provide adequate guidance to staff regarding the use of law enforcement in the facility.

2. Patient #8 was a [AGE] year old female who was admitted on [DATE], at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- The Psychiatric Evaluation, dated 12/09/16, dictated by a physician at 11:06 AM, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included the patient was ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation. The report included ...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room.

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she was making rounds when she found Patient #8 ...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ...No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ...

- On 12/09/16 at 9:25 AM, an order for restraints was received by an RN, but not entered until 12/09/16 at 11:20 AM. The record did not include an explanation of the late entry. The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described as locking synthetic leather all. The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert. Additionally, the RN verified the least restrictive restraint application was used.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM. At 11:45 AM, the observation form included Pt stated she's calm and wants out. At 12:00 PM, documentation included Pt laying quietly. At 12:15 PM, it was documented Pt stating she want restraints off. At 1:15 PM, it was documented Patient #8 was released from restraints on 12/09/16. Patient #8 was not released from restraints at the earliest possible time.

The Director of BHU was interviewed on 3/07/17 at approximately 4:20 PM. She confirmed Patient #8's record did not include documentation that clearly supported she was released from restraints at the earliest possible time.

The facility failed to ensure Patient #8 was released from restraints at the earliest possible time.

3. Patient #9 was a [AGE] year old male admitted on [DATE],7 at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharged on [DATE], at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's ER record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physically aggression and combative. The restraint device was described as locking synthetic leather all.

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release.

- An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, was reviewed. The provider report included ...2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints. The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

Patient #9's record did not clearly document he was released from restraints at the earliest possible time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records, facility policy, and staff interview, it was determined the facility failed to ensure restraints were discontinued at the earliest possible time for 3 of 4 patients who were restrained (#6, #8, and #9) and whose records were reviewed. This resulted in patients being restrained longer than was necessary to ensure safety. Findings include:

A facility policy Patient Restraint/Seclusion, effective 6/03/14, stated ...The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time.

1. Patient #6 was a [AGE] year old male admitted on [DATE], for depression, bipolar disorder, mania, and suicidal ideation. Patient #6 was placed on a physician hold in the ER, and subsequently, after appropriate examination and a court hearing, committed to the State of Idaho on 2/06/17, due to grave disability related to his psychiatric diagnoses.

An observation form documented Patient #6 was in seclusion and 4 point restraints on 2/27/17 from 12:45 AM to 2/27/17 at 1:30 PM, and from 2:35 AM on 2/28/17 to 4:15 PM on 2/28/17.

Patient #6 was in seclusion the entire time documented on the observation form. Patient #6 was in seclusion from 2/27/17 at 12:45 AM to 2/28/17 at 4:15 PM, when he was discharged from the facility.

a. Patient #6's record documented he was placed in 4 point restraints and seclusion on 2/27/17 at 12:47 AM. The documentation stated he was placed in restraints and seclusion for violent and aggressive behavior toward a staff member.

An initial restraint order for locking synthetic leather restraints and seclusion, dated 2/27/17 at 1:09 AM, stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/27/17. The observation form documented between 1:45 AM and 2:45 AM Patient #6 was sleeping or resting after the initiation of the restraints and seclusion. There was no documentation of the above described criteria.

On 2/27/17, between 3:00 AM and 7:00 AM, Patient #6 was documented as calling out 2 times and pulling and messing with his restraints twice. BHT I documented Patient #6 interacted with staff, but there was no documentation of the above described criteria.

A nurse's note, dated 2/27/17 at 5:39 AM, signed by RN N documented a decision was made to keep Patient #6 in restraints by the physician when he was called. There was no documentation what time the physician was called, which physician was called, or what criteria Patient #6 met to keep him in restraints.

Patient #6 remained in 4 point restraints and seclusion until 1:30 PM on 2/27/17, without further documentation in his records he was aggressive or threatening, or he was a risk for harming himself or others.

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed there was no documentation in the record for the continuation of restraints and/or seclusion.

b. Patient #6's record documented he was placed back into 4 point restraints on 2/28/17 at 2:45 AM. RN K documented Patient #6 was kicking at the door of the seclusion room and was delusional. RN K documented local law enforcement was called and they assisted staff in placing Patient #6 back into 4 point restraints. Patient #6 was medicated at 3:00 AM with Thorazine 100 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM.

An initial restraint order, for locking synthetic leather restraints, was documented on 2/28/17 at 2:40 AM. The order stated the criteria for release of restraints was met when Patient #6 stopped exhibiting the following behaviors:

- Physical aggression

- Combative behavior

- A danger to self or others

- Destructive behavior

- Violence

Patient #6's record included an observation form, dated 2/28/17. The observation form documented between 3:00 AM and 6:15 AM Patient #6 was sleeping after the initiation of the restraints. Additionally, the observation form documented from 7:15 AM to 8:15 AM and 8:45 AM to 10:00 AM Patient #6 was sleeping. There was no documentation of the above described criteria.

A nurse's note, at 11:00 AM on 2/28/17, signed by RN A documented Patient #6 was to remain in restraints until he was discharged per the CNO and the Director of BHU. Patient #6 requested to use the bathroom and RN A documented I was told per the above named supervisors [CNO and Director of BHU] that the patient [Patient #6] was not to transfer to the ante room or bathroom unless police were at stand by.

During an interview at 4:00 PM on 3/07/17, the Director of BHU confirmed there was no documentation in the record for the continuation of restraints and/or seclusion. She confirmed a decision was made by herself and the CNO for Patient #6 to remain in seclusion unless police were on stand by, in order to keep staff safe.

RN A, who was a Charge Nurse on BHU during the day shift, was interviewed on 4/04/17, beginning at 9:35 AM. RN A stated he planned to remove the restraints and observe Patient #6 during his time out of restraints, and if appropriate behavior was observed, leave the restraints off. However, RN A stated he was approached by the Director of BHU, who informed him a decision was made to keep Patient #6 in restraints until he was discharged . RN A stated, without removing Patient #6's restraints, he assessed him and assisted him with personal care and toileting needs, but felt he had a good rapport with Patient #6 and would have preferred to remove his restraints.

Patient #6 was not released from restraints or seclusion at the earliest possible time.

2. Patient #8 was a [AGE] year old female who was admitted on [DATE] at 11:43 AM for care related to depression and worsening suicidal ideations. She was transferred to the Behavioral Health Unit for on-going care. She was discharged to her care taker and returned to her group home on 12/14/16.

The following documentation was included in Patient #8's record:

- The Psychiatric Evaluation, dated 12/09/16, dictated by a physician on 11:06 AM, stated Patient #8 began to try to harm herself when she arrived on the unit. The evaluation included the patient was ...provided several different medications to try to bring her under control, but she ended up ultimately this morning in restraints, where she was seen for her evaluation. The report included ...She was seen in the observation room in 4-point restraints. Her right arm was removed during the course of our discussion to see if she would be able to maintain calmness. She started scratching on herself once I left the room.

- On 12/09/16 at 8:39 AM, an RN documented Patient #8 was scratching herself. The record included patient had staff for 1:1 monitoring assigned to her.

- On 12/09/16 at 9:15 AM, an RN documented she was making rounds when she found Patient #8 ...persistently scratching herself even with a sitter (staff for 1:1 monitoring) present ... No newly opened wounds were seen. Patient appeared to be scratching for attention instead of actual intention to self harm or release tension. After assessment the patient said that she wanted another 'shot'. I told her we could get her a shot to help her symptoms but that she need to allow us to see her arms at all times and that she is not to scratch because we will help her with medications ...

- Patient #8's record documented a restraint order on 12/09/16 at 11:20 AM. The RN described the factors affecting Patient #8's behavior as restlessness. The circumstances leading to restraints included continued scratching and reopening old wounds. The restraint device was described, locking synthetic leather all. The record also documented Patient #8 continued to have a sitter with her. An RN described Patient #8's behavior as a danger to self and others. Patient #8's response to restraint was tolerant. Her level of consciousness was described as awake and alert.

- A Restraint/Seclusion Observation Form documented Patient #8 was placed in restraints on 12/09/16, beginning at 9:30 AM, and released from restraints at 1:15 PM the same day. At 11:45 AM, the observation form included Pt stated she's calm and wants out. At 12:00 PM, documentation included Pt laying quietly. At 12:15 PM, it was documented Pt stating she want restraints off.

The Director of BHU was interviewed on 3/07/17 at approximately 4:20 PM. She confirmed Patient #8's record did not include documentation that clearly supported she was released from restraints at the earliest possible time.

Patient #8 was not released from restraints at the earliest possible time.

3. Patient #9 was a [AGE] year old male admitted on [DATE] at 6:27 PM for care related to alcohol intoxication and dehydration. He was discharge on 1/16/17 at 1:30 AM to home and his own care.

The following documentation was included in Patient #9's ER record:

- On 1/15/17 at 6:55 PM, an order for restraints was entered in Patient #9's record, by an RN. The record described the factors affecting Patient #9's behavior as agitated, altered consciousness, and alcohol intoxication. The circumstances leading to restraints were described as physical aggression and combative. The restraint device was described, locking synthetic leather all.

- On 1/15/17 at 7:10 PM, an RN described Patient #9's behavior as aggressive, combative, violent, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:25 PM, an RN described Patient #9's behavior as aggressive, combative, and a danger to self and others. Patient #9's response to restraint was combative. His level of consciousness was described as disoriented and unable to follow commands.

- On 1/15/17 at 7:30 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 7:45 PM, an RN described Patient #9's behavior as a danger to self and others. Patient #9's response to restraint was tolerant. His level of consciousness was described as confused.

- On 1/15/17 at 8:10 PM, an RN documented Patient #9 met the criteria, and he was released from restraints. Patient #9's behavior or level of consciousness was not described at the time of release.

- An emergency provider report, dated 1/15/17 at 6:35 PM, completed by a physician, was reviewed. The provider report included ... 2000: Rechecked patient. He has improved and is no longer saying violent things. If he maintains improvement for 45 minutes I will remove restraints. The time the patient was assessed by the physician and the time the entry was made in the record was unclear.

The Director of ER was interviewed on 3/07/17, beginning at 2:45 PM. She confirmed Patient #9's record did not include documentation that clearly supported he was released from restraints at the earliest possible time.

Patient #9's record did not clearly document he was released from restraints at the earliest possible time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, hospital policy review, staff interview, and patient interview, it was determined the hospital failed to ensure 1 of 5 patients (Patient #53), whose procedures were observed, were informed of and retained a copy of their patient's rights. This had the potential to prevent patients from exercising their rights. Findings include:

A hospital policy Patient's Rights and Responsibilities (QUAL), approved 3/02/16, was reviewed. The policy included:

- West Valley Medical Center provides each patient with a written statement of patient rights at the time of registration, and again at the time any patient or patient's representative has questions regarding their rights.

The hospital failed to follow their policy and provide Patient #53 a copy of his patient's rights. Examples include:

Patient #53 was an alert and oriented [AGE] year old male who was admitted for outpatient surgery on 12/01/16, for a laparoscopic right inguinal hernia repair and whose pre, intra, and post-operative care was observed. The OR Manager and Risk Management Clinical Quality Coordinator (RMCQC) were also present during the observation.

Patient #53 and his spouse were interviewed on 12/01/16, beginning at 8:35 AM. When asked if he had received a copy of his patient's rights, Patient #53 stated no. Patient #53's spouse was asked if she had a copy of Patient #53's patient's rights and she also stated no. Patient #53's spouse stated someone had informed them they would receive a copy of all of their paperwork upon discharge from the hospital. Patient #53's spouse presented what appeared to be a hospital receipt and stated it was the only paper she was provided.

Patient #53's record included a signed copy of patient's rights and responsibilities, dated 12/01/16 at 8:00 AM; however, a copy of the written statement of patient rights, at the time of registration, was not provided to Patient #53 or his spouse.

The Infection Preventionist (IP), OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed all patients should receive a copy of their patient's rights upon admission and stated hospital policy was not followed for Patient #53.

The hospital failed to follow their policy and provide Patient #53 a copy of his patient's rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of Idaho state laws and medical records, it was determined the hospital failed to ensure the rights of 1 of 3 patients, who were placed on involuntary holds (Patient #8) and whose records were reviewed, were protected. The hospital failed to allow the patient to refuse treatment and failed to follow state statutes. This resulted in the unlawful detainment of the patient and the failure to protect his right to due process. Findings include:

Idaho state law at Title 66 Chapter 3, 66-320 states a ...person may be detained at a hospital...[if a] peace officer or a physician...has reason to believe that the person is gravely disabled due to mental illness or the person's continued liberty poses an imminent danger to that person or others, as evidenced by a threat of substantial physical harm...Whenever a person is taken into custody or detained under this section without court order, the evidence supporting the claim of grave disability due to mental illness or imminent danger must be presented to a duly authorized court within twenty-four (24) hours from the time the individual was placed in custody or detained. The law then states a court will assign a designated examiner to review the case.

Idaho state law at Title 66 Chapter 3, 66-320 further states (3) if the director of the facility [hospital] determines that the patient should be hospitalized under the provisions of this chapter, the patient may be detained up to three (3) days, excluding Saturdays, Sundays and legal holidays, for the purpose of examination by a designated examiner and the filing of an application for continued care and treatment...(d) A patient admitted for examination pursuant to section 20-520 or 18-211, Idaho Code, may not be released except for purposes of transportation back to the court ordering, or party authorizing, the examination.

State law was not followed by the hospital in relation to 1 of 3 patients (Patient #1) who were placed on involuntary holds by the hospital and were not allowed to leave the hospital. Examples inlcude:

Patient #8 was a [AGE] year old male who was admitted on [DATE], and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

A nursing progress note, dated 8/06/16 at 5:38 PM, stated Patient #8 attempted to leave and was walking to the elevator doors. The note stated he was physically restrained and was given an IM injection of haldol, benadryl, and ativan.

A nursing note, dated 8/06/16 at 9:45 PM, stated Patient #8 wanted to leave the hospital. Again, the note stated he was given an IM injection of haldol, benadryl, and ativan.

A physician progress note, dated 8/06/16 at 3:45 PM, stated Patient #8's chief complaint was altered mental status. The note stated Neuro: Reports confusion (easily agitated). Psych: Reports: agitation (tangential thinking, slow ment). The note stated Patient #8 was ...alert, (oriented times 2), is disoriented to time. No focal neurological or motor deficit. [Patient #8] became very angry and agitated. He refuses to do further testing and now is not mentally capable to make decisions for himself. He meets criteria at this point to be placed on a mental hold. IM haldol, benadryl, and ativan will be given now. Psychiatric consultation will be placed. An addendum to the note, dated 8/06/16 at 5:03 PM, stated Patient #8 ...required physical escort to his room, he was given IM haldol, IM benadryl, IM ativan. Physical restraints for 3 minutes. Sitting in room, lights are dark. Mental hold and psychiatric consultation placed.

The next physician progress note was dated 8/07/16, at 2:38 PM. It stated Patient 8 ...is on a mental hold, not complaining of anything today...The patient will continue on mental hold until full medical evaluation is completed.

The final physician progress note was the discharge summary dated 8/08/16, at 12:09 PM. It stated Patient #8 had a lumbar puncture and he was diagnosed with [DIAGNOSES REDACTED]Psychiatry: normal affect, normal mood. It stated Evaluated by psych and at the time of the operation mental status returned to normal and he felt there was no reason to maintain him on a hold or admit him to the psych unit. -Mental status appears to have resolved.

Patient #8 was discharged to home with his wife on 8/08/16.

There was no evidence the hospital followed a process to place Patient #8 on a mental hold even though he was prevented from leaving. There was no documentation that the legal process was initiated or that the court was notified of the hold. There was no documentation that Patient #8 was provided an evaluation by a Designated Examiner or given the opportunity to argue in court that he should be allowed to leave the hospital. There was no documentation Patient #8's hold was formally dropped before allowing him to leave the hospital.

Patient #8's physician was interviewed on 11/30/16, beginning at 11:25 AM. He stated he was not sure of the hold procedure. He stated a psychiatric nurse assisted him to complete the paperwork to file a mental hold for Patient #8. He stated he was not sure if the paperwork was filed with the legal authorities. He stated Patient #8 wanted to leave the hospital and was prevented from doing so.

Patient #8's medical record was reviewed with the Director of Advanced Clinicals, an RN, on 11/28/16, beginning at 3:15 PM. She confirmed the documentation and stated Patient #8 was prevented from leaving. She stated it was documented that Patient #8 was placed on a hold. She stated there was no documentation that the process was followed to place Patient #8 on a hold. She also confirmed there was no documentation the hold was discontinued by a court before the patient was discharged .

The hospital did not allow Patient #8 to refuse treatment. The hospital deprived Patient #8 of his physical freedom and his ability to participate in his care. When he requested to leave, the hospital detained him and then failed to notify the court which prevented him from receiving due process. The hospital discharged Patient #8 before a judgement was rendered that he was not a danger to himself or others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, hospital policy review, hospital document review, patient interview, and staff interview, it was determined the hospital failed to ensure the personal privacy of 1 of 1 ICU patients (Patient #54) who were interviewed about their patient's rights. This had the potential for inadequate patient privacy for all hospital patients being monitored by video surveillance. Findings include:

A hospital pamphlet given to patients upon admission, Patient Rights and Responsibilities, revised 1/2016, was reviewed. The pamphlet included:

- To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment.

A hospital document Consent for Photographing or Other Recording for Security and/or Health Care Operations, undated, was reviewed. The document included:

- (Patient Initials [sic]) I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice's health care operations purposes (e.g. quality improvement activities).

- I understand that these images and/or recordings will be securely stored and protected.

A hospital policy Photographing, Video Recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM), approved 7/29/16, was reviewed. The policy included 12 scenarios where photographs, audio/video recording, and/or video monitoring would be utilized. However, the policy did not include a scenario where video monitoring would take place via a stationary monitoring camera in a patient's room 24 hours per day, 7 days per week for the purpose of quality improvement activities, and did not include safeguards for patient privacy.

The hospital failed to protect patients' privacy. Examples include:

1. A tour of the ICU was conducted on 11/28/16, beginning at 10:35 AM, in the presence of the ICU Director and Risk Management Clinical Quality Coordinator (RMCQC). During the tour, stationary video monitoring cameras were observed in all ICU patient rooms. Each monitoring camera was mounted on the ceiling, oriented to face the patients' bed, and gave a full, detailed display of the room. The ICU Director stated the monitoring cameras did not record and were used for surveillance only.

When asked about the purpose of the monitoring cameras, the ICU Director stated they were used for patient safety and to reduce falls. When asked how the monitoring cameras were being utilized for quality improvement purposes, either unit-based or through the hospital QAPI program, the ICU Director stated she did not know and did not think the monitoring cameras were being used for that reason.

The display screen for the video feeds was located at the front ICU nurses station and was monitored by the telemetry tech. Each individual ICU room was displayed as one of 13 tiles on the nurses station monitor. The telemetry tech working at the time of the tour demonstrated how each room was displayed and how an individual room could be selected to fill the entire screen for increased detail and observation. When asked if the monitoring cameras could be turned off, both the telemetry tech and ICU Director first stated they were unsure, but later stated they could not. When asked how patient privacy was enforced during intimate personal care periods, the telemetry tech demonstrated how a Post-It note would be used to cover a patient's room tile on the display screen. When asked if the practice of covering the patient's room display with a sticky note was approved in a hospital policy, the telemetry tech stated she did not know.

During the tour, an ICU bedside RN and ICU Charge Nurse were interviewed together at approximately 11:25 AM. When asked if they were educated on the monitoring cameras purpose, they both replied no. When asked if they knew if the monitoring cameras could be turned off, they both replied no. When asked how they would protect patient's privacy if the monitoring cameras could not be turned off, they replied they would cover the patient's room display with a sticky note. Both RNs and the ICU Director were asked if the practice of covering the patient's room display with a sticky note was approved in a hospital policy, to which they stated no.

The display screen, with all 13 individual monitoring camera tiles, was easily viewable from either side of the nurses' station from both main hallways by other patients, employees, and the public. The ICU Director confirmed the display screen with private patient images could be viewed by anyone walking by the nurses station on either side in the main hallways. She confirmed the display screen would need to be covered, turned, or placed in a new location to protect patients' privacy.

Patient #54 was an alert and oriented [AGE] year old male who was admitted on [DATE], for chest pain, and was an inpatient during the unit tour on 11/28/16. Patient #54 was interviewed in the ICU on 11/28/16, beginning at 1:30 PM. Patient #54 was asked if he understood why a monitoring camera was being used in his room, to which he replied he did not. He stated a RN told him the monitoring camera had to be used because I was in the ICU, but remarked the RN did not elaborate further. Patient #54 stated he did not know if the camera could be turned off and stated it made him feel uncomfortable. When asked if anyone had explained the consent for video surveillance he had signed, Patient #54 stated he was unsure as he had signed a lot of stuff.

The ICU Director was interviewed on 11/28/16, beginning at 1:57 PM, and Patient #54's interview comments were discussed. The ICU Director stated the monitoring cameras, video surveillance consent, and patient privacy concerns should have been fully explained to the patient.

2. A tour of the ED was conducted with the ED Director, ED Charge Nurse, Director of Quality and Risk Management, and the Clinical Quality Coordinator, on 11/29/16, beginning at 1:00 PM.

a. During the tour, a monitoring camera was noted in ED Room #6, which was used specifically for psychiatric patients. The display screen for the monitoring camera was located at the rear ED nurses station and was easily viewable from the left side hallway by patients, employees, and the public.

The CNO and Director of Quality and Risk Management were interviewed together on 11/29/16, beginning at 2:15 PM. They confirmed the ED display screen could be viewed by anyone on the left side hallway of the nurses station and stated it should be covered, turned, or placed in a new location to protect patients' privacy.

b. During the tour, 6 ED patient tracking boards were observed throughout the department. The tracking boards were large screen TV monitors which displayed information to track patients in the ED. These tracking boards were visible to patients, family members, and the public walking through the department. The monitors displayed the following information:

- The first 3 letters of the ED patient's first and last name

- Patient age

- Primary symptoms/diagnosis

- ED room number

- ED nurse assigned to the patient

- ED physician caring for the patient

One ED patient listed on the tracking board had Psych, psychiatric, listed as his primary symptom/diagnosis.

When asked during the tour, the ED Director and Director of Quality and Risk Management confirmed the tracking boards displayed this information since they began using them several years ago. The ED Director stated the tracking boards were utilized to assist staff in monitoring patients in the ED for orders or pending orders, and which physician was in charge of the ED patient's care, and to aid in the flow of the department. They confirmed the boards were visible to staff, patients, and public walking through the ED. When asked about the patient information displayed on the tracking board they confirmed some of the information may be considered sensitive or private.

The hospital failed to protect patients' privacy.

3. A tour of the Behavioral Health Unit was conducted with the Director of the unit on 11/29/16, beginning at 9:55 AM. During the tour, a patient was noted to be sleeping in room 306. In the nursing station, it was observed that a video feed displayed the patient while he slept. The Director of the unit stated there was continuous video monitoring of room 306. She stated staff were not able to turn off the video camera, even while the patient may be undergoing personal cares or dressing. She stated the patient had chosen to sleep in room 306 because it was quiet. She stated there was no clinical need for video surveillance of the patient.

Patients in room 306 were not afforded personal privacy.

The hospital failed to protect patients' privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, observation, hospital policy review, and staff interview, it was determined the facility failed to ensure thorough nursing care plans were developed, and/or followed, for 5 of 55 patients (#7, #8, #21, #22, and #41) whose care plans were reviewed. Lack of a complete care plan and failure to follow care plan interventions had the potential to result in patient care needs that were not addressed and interfered with coordination of patient care among disciplines. Findings include:

A hospital policy Care Planning, approved 11/28/16, was reviewed. The policy included:

- Priorities for care will be identified by reviewing the following and placed on the patient's care plan

- ...Identification of the priority (need)

- ...Plans/steps to meet the needs, based on the patient's individual needs.

The hospital failed to follow their policy and ensure thorough care plans were developed for patients. Examples include:

1. Patient #7 was a [AGE] year old female who was admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]

An ICU interdisciplinary meeting was observed on 11/28/16, beginning at 11:10 AM. Patient #7's hospitalist, assigned RN, and the ICU Charge Nurse were present for the meeting. Patient #7's assigned RN stated Patient #7 had been experiencing increased chronic and acute pain. Patient #7's hospitalist stated he was previously aware of her pain, but did not want to order anything new at that time.

Patient #7's electronic medical record was reviewed with the ICU Charge Nurse on 11/28/16, beginning at 12:55 PM. Patient #7's electronic medical record included a form Health plan of care, dated 11/28/16, and completed by the assigned RN for the current shift. The following problems were identified on Patient #7's care plan:

- Fluid volume

- Activity

- Gastrointestinal

- Injury risk

Pain was not documented in Patient #7's care plan. The ICU Charge RN was asked if pain should be addressed in her care plan, to which she stated yes.

The hospital failed to follow their policy and ensure a thorough care plan was developed for Patient #7.

2. Patient #41 was a [AGE] year old female who was admitted on [DATE], for suicidal ideation and bipolar disorder. She was currently a patient as of 12/01/16.

The Inpatient Admission History and Assessment, dated 11/18/16, at 5:17 PM, stated Patient #41 had a plan to harm herself by overdosing. The document stated she had a history of at least 5 prior psychiatric hospitalization s.

A physician progress note, dated 11/25/16, at 1:13 PM, stated Patient #41 was receiving electroconvulsive therapy for severe depression. The note stated she would have a PICC line placed to facilitate the procedures. The note stated Patient #41 was ...still having suicidal ideation with plans.

The PICC line was placed on 11/26/16. PICC lines provide direct access to the patient's heart via an intravenous tube. A PICC line provides several options for a suicidal patient who wishes to harm herself, such as blood loss from PICC line self-removal or injecting foreign substances directly into the line.

Patient #41's current POC, dated 11/29/16, included problems of self harm potential and PICC line. Interventions for self harm included 15 minute general checks and environmental rounding. Interventions for the PICC line included flushing the line periodically and assessing the insertion site. The POC did not include interventions to prevent Patient #41 from using the PICC line to harm herself.

The Director of the Behavioral Health Unit was interviewed on 12/01/16 beginning at 11:00 AM. She reviewed Patient #41's POC and stated it did not address the how staff would monitor the PICC line to prevent the patient from using it to harm herself.

Patient #41's POC was not complete.

3. Patient #8 was a [AGE] year old male who was admitted on [DATE], and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

Patient #8's H&P, dated 8/05/16 at 9:52 PM, stated he took morphine, norco (hydrocodone, a narcotic), and Advil for pain. The H&P stated Patient #8's wife reported he had chronic pain and chronic narcotic dependence.

Due to Patient #8's mental status, no narcotic medications were ordered while he was hospitalized .

Patient #8's POC was updated on 8/05/16 at 10:22 PM, and again on 8/08/16 at 5:17 PM. Pain was not included in the POC.

Patient #8's medical record was reviewed with the Director of Advanced Clinicals, an RN, on 11/28/16, beginning at 3:15 PM. She stated pain was not included in his POC.

Patient #8's POC was not complete.

4. Patient #21 was a [AGE] year old female who was admitted on [DATE], for pre-term vaginal delivery in the ED of Patient #22. The nursing care plans for Patient #21 and Patient #22 were not individualized to meet their current needs as follows:

Patient #21 was at 37 and 2/7 weeks gestation and delivered Patient #22 at 8:45 AM on 11/28/16. Her record documented she came to the ED by car and the L&D staff was called to the ED for a precipitous delivery. A precipitous delivery is when the mother experiences an unusually rapid labor and the infant is spontaneously delivered, often unexpectedly outside of a hospital or Labor and Delivery area (e.g. ED, car, parking lot).

Patient #21's record documented she received no prenatal care during her pregnancy and her urine tested positive for methamphetamines and amphetamines. Patient #22 was tested for illegal substances and tested positive as well. Child Protective Services (CPS) was notified by nursery staff of the positive urine drug test for Patient #21 and Patient #22. Patient #22 was placed on a hold by CPS.

- Patient #21's nursing care plan included discharge planning, safety, falls, infection, pain, age-related care, knowledge deficit, and postpartum anxiety. The nursing care plan did not address Patient #21's illegal drug use or involvement of CPS and social services.

- Patient #22's nursing care plan included discharge planning, safety, infection, age related care, hypothermia, and [DIAGNOSES REDACTED]. The nursing care plan did not address Patient #22's hold by CPS, exposure to illegal drugs, or involvement of social services.

During an interview on 11/29/16 at 9:45 AM, the Director of L&D confirmed the nursing care plan did not address the significant issues identified above for Patient #21 and Patient #22.

Patient #21's and Patient #22's nursing care plans were not individualized or updated to meet their current needs or circumstances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, observation, hospital policy review, and staff interview, it was determined the hospital failed to ensure patient medical record entries were complete and accurate for 1 of 5 surgical patients (Patient #53) whose records were reviewed. This resulted in inconsistent documentation of patients' allergies and had the potential for unsafe medication administration for all hospital patients. Findings include:

A hospital policy Organizational Plan for Assessment and Reassessment, approved 8/17/16, was reviewed. The policy included:

- Admission Assessment/Reassessment Criteria: ...Allergies.

The hospital failed to follow their policy and ensure complete and accurate patient allergy documentation. Examples include:

Patient #53 was an alert and oriented [AGE] year old male who was admitted for outpatient surgery on 12/01/16, for a laparoscopic right inguinal hernia repair and whose pre, intra, and post-operative care was observed.

Patient #53 was observed in pre-op holding on 12/01/16, beginning at 8:35 AM. He was noted to have an allergy band on his right wrist which stated ALLERGY. Patient #53's pre-op RN was observed asking him to confirm his allergies as part of the pre-operative assessment. When asked what allergy he had, Patient #53 stated he was allergic to hydrocodone (a medication for pain) and penicillin (an antibiotic medication).

Patient #53's surgeon pre-op evaluation was observed on 12/01/16, at approximately 8:50 AM. The surgeon asked Patient #53 if he was allergic to any medication to which Patient #53 stated hydrocodone and penicillin.

Patient #53's medical record included a document ADULT PRE-OP GENERAL SURGERY ORDERS, revised 6/2015, and signed by Patient #53's surgeon. The order did not document a date or time they surgeon signed it; however, the order was noted by an RN on 12/01/16, at 7:30 AM. The document included a section titled Allergies & Sensitivities which allowed space to list Patient #53's medication and/or environmental allergies. This section did not document he was allergic to hydrocodone and penicillin.

Patient #53's medical record included a document ADULT POST-OP GENERAL SURGERY ORDERS DAY SURGERY, revised 4/2013, and signed by his surgeon. The order was signed by the surgeon on 12/01/16, at 10:45 AM and noted by a different RN on 12/01/16, at 11:50 AM. The document included a section titled Allergies & Sensitivities which allowed space to list Patient #53's medication and/or environmental allergies. This section did not document he was allergic to hydrocodone and penicillin. Additionally, the document included a section titled Analgesia which had pre-printed pain medications orders for moderate and severe pain. One medication ordered in this section for moderate pain, as denoted by a filled-in checkbox next to the medication name, was HYDROcodone [sic]/APAP 10/325 mg 1 - 2 Tabs PO Q 4 hrs PRN moderate pain.

The OR Manager was interviewed on 12/01/16, beginning at 2:42 PM, and Patient #53's medical record was reviewed in her presence. She confirmed the pre and post-operative orders should have listed Patient #53's allergies. Additionally, the OR Manager confirmed hydrocodone was ordered for him despite his verified allergy. She stated the error should have been identified by the surgeon and the PACU RN.

The hospital failed to follow their policy and ensure complete and accurate patient allergy documentation for Patient #53.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, it was determined the hospital failed to ensure patient records included all reports of treatment and interventions for 1 of 11 patients (Patient #21) whose ED records were reviewed. This failure had the potential to negatively affect the care provided for the patient and the ability to appropriately monitor the patient's condition. Findings include:

Patient #21 was a [AGE] year old female who was admitted on [DATE], for pre-term vaginal delivery in the ED.

Patient #21's record included a form Deliveries Unattended by a Physician or CNM. The form documented Patient #21 was 37 and 2/7 weeks pregnant and delivered the baby at 8:45 AM on 11/28/16, in the ED. The form stated she came to the ED by car and the L&D staff was called to the ED for a precipitous delivery (A precipitous delivery is when the mother experiences an unusually rapid labor and the infant is spontaneously delivered, often unexpectedly outside of a hospital or Labor and Delivery area (e.g. ED, car, parking lot).

The form additionally documented she was taken from the ambulance bay in the ED to ED room 12 and the newborn was delivered while wheeling her into the room. After delivery of the baby, Patient #21 and her baby were transported to the Family Maternity Center by L&D staff. Patient #21's L&D assessment was timed 9:49 AM on 11/28/16.

Patient #21's record did not include documentation from the ED regarding her presentation, triage, or delivery.

During an interview on 11/29/16 at 9:45, the Director of L&D confirmed there was no ED record for Patient #21.

During an interview on 11/30/16 at 2:50 PM, the Director of the ED confirmed there was no ED record for Patient #21.

The hospital failed to ensure Patient #21's record included all reports of treatment and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, observation, and staff interview, it was determined the hospital failed to ensure physicians and nursing staff followed effective infection control practices, including hand hygiene. This directly affected 1 of 5 patients (Patient #53) whose procedures were observed, and had the potential to affect all patients. This had the potential to result in patients acquiring healthcare associated infections. Findings include:

A hospital policy Hand Hygiene Policy (IC), approved 11/24/15, was reviewed. The policy included:

- Use soap and water OR [sic] an alcohol-based hand sanitizer for the following:...before and after use of gloves, standard or sterile.

A second hospital policy Aseptic Technique (OR), approved 8/19/16, was reviewed. The policy included:

- All personnel working within the Perioperative Services must have a basic knowledge and appreciation of aseptic technique and contamination control.

- The Perioperative Services Department will adhere to the Infection Control Committee and Infection Control Practitioner guidelines for infection control.

The hospital failed to follow their policies and guidelines. Examples include:

1. Patient #53 was an alert and oriented [AGE] year old male who was admitted for outpatient surgery on 12/01/16, for a laparoscopic right inguinal hernia repair and whose pre, intra, and post-operative care was observed. The OR Manager and Risk Management Clinical Quality Coordinator (RMCQC) were also present during the observation.

a. Patient #53's pre-surgical surgeon evaluation was observed on 12/01/16, beginning at 8:50 AM. During the pre-surgical evaluation, the surgeon asked Patient #53 if his surgical site had been previously marked; to which he responded no. Patient #53's surgeon removed a commercial dry-erase marker from the wall, used it to mark his groin surgical site, and then placed the marker back on the wall. A surgical pen was not used to mark his groin surgical site and the commercial marker was not cleaned before or after use.

The Infection Preventionist (IP), OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the commercial dry-erase markers should never be used for marking surgical sites and stated after the marker had been used it should have been discarded. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

b. Patient #53 was observed being transported via gurney to the OR suite at 9:50 AM. Prior to intubation, the Anesthesiologist delivered oxygen via an amboo bag and mask. When removing the mask from Patient #53, the mask was observed to fall to the floor. The contaminated mask was then picked up by the Anesthesiologist and placed on the anesthesia cart in the same area medications were prepared. The mask was not cleaned before it was returned to the anesthesia cart. Multiple medications were observed being prepared in this area during the surgical procedure. At the end of the procedure, at approximately 10:50 AM, the Anesthesiologist was observed placing the same, contaminated mask back on Patient #53's mouth after he was extubated.

The IP, OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the oxygen delivery mask should have either been cleaned or replaced once it fell to the ground. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

c. Patient #53 was observed being transported via gurney to the OR suite at 9:50 AM. Prior to the pre-surgical hair clipping of his groin area, the circulating RN was observed placing two long pieces of abdominal tape on the side of the gurney. During the hair clipping, one of the pieces of tape fell to the floor. The surgeon entered the OR suite at approximately 9:55 AM where he was observed to pick up the fallen piece of tape with gloved hands and immediately use it to remove Patient #53's clipped groin hair.

The IP, OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the tape should have been discarded immediately after it fell to the ground and should have never been used to remove Patient #53's hair clippings. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

d. At approximately 10:00 AM, once Patient #53 was in the OR suite, the circulating RN was observed to not wash his hands or use alcohol-based hand sanitizer prior to donning sterile gloves.

The IP, OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the circulating RN should have used an approved method of hand hygeine prior to donning sterile gloves. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

Based on staff interview, it was determined the hospital failed to ensure discharge plans were reviewed to ensure that they were responsive to discharge needs. This prevented the hospital from monitoring its discharge planning process. Findings include:

The Director of Case Management was interviewed on 11/30/16, beginning at 10:20 AM. She was asked for documentation to show discharge plans were reviewed to determine if they were responsive to discharge needs, she stated discharge plans were reviewed by the Utilization Review Committee as part of a larger review of patients who were readmitted to the hospital. She stated there was no specific documentation that a review of discharge plans had been conducted to determine if they were responsive to discharge needs.

The Director of Quality and Risk Management was interviewed on 12/02/16, beginning at 9:30 AM. He stated a program had been developed to review discharge plans but said it had not been implemented yet.

The hospital failed to review discharge plans to ensure that they were responsive to discharge needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, policy, and interview it was determined the hospital failed to ensure a timeout was performed for 1 of 5 patients observed (Patient #6) during a procedure. This deficient practice had the potential to cause harm to the patients. Findings include:

The hospital's policy SAFE PROCEDURAL AND SURGICAL VERIFICATION, last approved 8/19/16, stated the following:

Time-Out (Immediately prior to the incision/or start of procedure):

Physician/proceduralist performing the procedure initiates Time-out. At a minimum this includes:

Surgeon/ proceduralist calls the time out.

Surgeon/ proceduralist ensures all activities [sic] ceases.

Surgeon/ proceduralist ensures active engagement of all team members.

Surgeon/ proceduralist ensures all questions and/or concerns are answered ...

Time-Out is a period of time after induction and before puncture or incision during which all activity and conversation in the procedure area ceases. All members of the surgical/procedural team participates in the positive verification of the patient, the intended procedure, and the visualization of the marked site of the procedure.

Patient #6 was a [AGE] year old male admitted on [DATE], for supra[DIAGNOSES REDACTED] (a rapid heart rate that causes poor heart function, and often causing a fluttering sensation in the chest and/or lightheadedness). He had a planned electrophysiology study (also called EPS - a study of how electricity moves through the heart to cause it to pump).

An observation of the start of Patient #6's EPS study occurred on 11/28/16, beginning at 2:28 PM. Patient #6 was brought into the CCL suite at 2:29 PM and he was prepped for the procedure. At 2:48 PM the Cardiologist entered the room and spoke with the circulating RN regarding the procedure. Three other team members were in the CCL room; the CV Technician, an RN doing the monitoring, and an RN training on the monitor. The three team members were involved in other activities and did not appear to participate in the discussion with the Circulating RN and the Cardiologist. There was no team consensus on Patient #6's identification, procedure, allergies, or other potential concerns.

The RN training on the monitor was questioned, and she stated the conversation between the Circulating RN and the Cardiologist was the Time-Out. She stated Yes, this is what this cardiologist does for the Time-Out.

The Director of Quality and Risk Management was present during the observation. He agreed no Time-Out was performed for Patient #6's procedure.

The hospital failed to ensure a Time-Out was performed prior to the start of the procedure on Patient #6.

Based on observation, the facility failed to ensure that fire and smoke resistive properties of the structure were maintained. Failure to maintain fire protective coatings and seal penetrations between floors, could allow fires, smoke and dangerous gases to spread and also reduce structural integrity during a fire. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the facility tour conducted on November 28, 2016 from approximately 11:00 AM to 2:00 PM, observation of the ceiling and floor fire rated assemblies in the second floor Post-partum mechanical room, revealed conduit installations ranging in size from approximately 1-1/2 inches to four (4) inches housing data cabling, which were absent of sealant in the annular space, or were not fully sealed to 360 degrees of the conduit and installed cabling.

2.) During the facility tour conducted on November 28 and 29, 2016 from approximately 11:00 AM to 3:30 PM, observation of the steel beams supporting floors in the structure, revealed missing fire protective coatings due to bracing and conduit installations, ranging in size from approximately three inches by five inches to eight inches by four feet. This observation was determined to be systemic in nature on all three floors and further documentation was deemed to be unnecessary.

Actual NFPA standard:

19.1.6 Minimum Construction Requirements.

19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)

8.3.4 Opening Protective's.

8.3.4.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke

from one side of the fire barrier to the other.

8.3.4.2* The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4.

Based on record review, observation, operational testing and interview, the facility failed to ensure that fire rated assemblies were in accordance with NFPA 80. Failure to maintain self-closing devices on fire rated doors could result in a lack of system performance as designed. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During review of provided facility annual inspection records conducted on November 28, 2016 from approximately 9:00 AM to 11:00 AM and on November 29, 2016 from approximately 2:30 PM to 3:30 PM, records provided from the annual inspection conducted by facility staff in August, 2016 did not reveal any deficiencies found for the two-hour rated assembly entering Medical Records from the adjacent patient lobby office.

2.) During the facility tour conducted on November 28 and 29, 2016 from 9:00 AM to 3:30 PM on both days, observation of installed doors revealed doors installed in the facility were tagged with fire labels indicating fire protective ratings of doors ranging between twenty minutes (20 minutes) to an hour and a half (90 minutes) duration.

3.) During the facility tour conducted on November 29, 2016 from approximately 10:00 AM to 10:30 AM, observation of the door entering Medical Records from the adjacent office/lobby, revealed the door was rated as part of a two-hour fire rated assembly with a fire-resistive rating of ninety (90) minutes. Further observation revealed this door was equipped with a self-closing device which was inoperable.

4.) During the facility tour conducted on November 29, 2016 from approximately 10:00 AM to 10:30 AM, observation and operational testing of the fire rated door assembly from the corridor into CT revealed the self-closing device was not functional.

Actual NFPA standard:

NFPA 101

19.2 Means of Egress Requirements

19.2.2.2 Doors.

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1 Door Openings.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:

(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7

(2) Door assemblies in exit enclosures

(3) Electrically controlled egress doors

(4) Door assemblies with special locking arrangements subject to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 80

5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.14 Maintenance of Closing Mechanisms.

5.2.14.1 Self-closing devices shall be kept in working condition at all times.

Based on record review, observation, operational testing and interview, the facility failed to ensure automatically operated Alcohol Based Hand Rub Dispensers (ABHR) were maintained in accordance with NFPA 101. Failure to test and document operation of automatic dispensing ABHR dispensers during refilling procedures could result in inadvertently spilling flammable liquids increasing the risk of fires. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the review of facility inspection records conducted on November 28, 2016 from approximately 9:00 AM to 11:00 AM, no records were available indicating inspection and testing of ABHR dispensers was performed when refilling dispensers in accordance with manufacturer's care and use instructions.

2.) During the facility tour conducted on November 28 and 29, 2016 from approximately 10:00 AM to 3:30 PM each day, observation of all installed ABHR dispensers revealed installed dispensers were automatically activated with motion sensing. Random operational testing confirmed these dispensers activated with motion.

3.) During the facility tour conducted on November 28, 2016 from approximately 11:00 AM to 1:00 PM, observation of the ABHR dispenser installed in the MHU nurse's station revealed the dispenser was installed approximately 1/2 inch from the light switch.

4.) During the facility tour conducted on November 29, 2016 from approximately 10:00 AM to 12:00 PM, observation and operational testing of the ABHR dispenser installed in Decon Soiled Utility holding area, revealed the dispenser would not activate and held a full refill.

When asked about refill testing and documentation, the Housekeeping Supervisor stated staff did not test dispensers each time a new refill was installed.

Actual NFPA standard:

NFPA 101

19.3.2.6* Alcohol-Based Hand-Rub Dispensers.

Alcohol-based hand-rub dispensers shall be protected in accordance with

8.7.3.1, unless all of the following conditions are met:

(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).

(2) The maximum individual dispenser fluid capacity shall be as follows:

(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors

(b) 0.53 gal (2.0 L) for dispensers in suites of rooms

(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA30B, Code for the Manufacture and Storage of Aerosol Products.

(4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm).

(5) Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution or 1135 oz (32.2 kg) of Level 1 aerosols, or a combination of liquids and Level 1 aerosols not to exceed, in total, the equivalent of 10 gal

(37.8 L) or 1135 oz (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 19.3.2.6(6).

(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 19.3.2.6(5).

(7) Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.

(8) Dispensers shall not be installed in the following locations:

(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source

(b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source

(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source

(9) Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.

(10) The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume.

(11) Operation of the dispenser shall comply with the following criteria:

(a) The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.

(b) Any activation of the dispenser shall occur only when an object is placed within 4 in. (100 mm) of the sensing device.

(c) An object placed within the activation zone and left in place shall not cause more than one activation.

(d) The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.

(e) The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.

(f) The dispenser shall be tested in accordance with the manufacturer's care and use instructions each time a new refill is installed.

Based on observation the facility failed to ensure the fire alarm system initiating devices were installed in accordance with NFPA 72. Failure to ensure initiating devices were installed correctly would inhibit early occupant notification and delay emergency response. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings Include:

During the facility tour on November 28 and November 29, 2016, observation revealed the manual alarm-initiating devices were installed above the maximum height of 48 inches throughout the facility in the following areas:

+ First Floor Kitchen corridor near Director of Nutrition office

+ First floor Maintenance Hallway near exit

+ Second floor Nurse Station in Medical/Surgical Suite

+ Second Floor Nurse Station in Post Partum Suite

This deficiency was acknowledged during the exit interview.

Actual NFPA Standard:

NFPA 72

17.14.4 The operable part of each manual fire alarm box

shall be not less than 42 in. (1.07 m) and not more than 48 in.

(1.22 m) above floor level.

17.14.5 Manual fire alarm boxes shall be installed so that they

are conspicuous, unobstructed, and accessible.

Based on observation, the facility failed to ensure fire suppression system pendants were maintained free of obstructions such as paint, corrosion or storage. Failure to maintain fire sprinkler pendants free of obstructions could hinder system performance during a fire event. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of the survey.

Findings include:

During the facility tour conducted on November 29, 2016 from approximately 11:00 AM to 11:30 AM, observation of the installed fire sprinkler pendants revealed the following:

Existing Laundry room first floor: three (3) corroded heads

Kitchen: One (1) corroded head above the dishwashing station

First floor Com closet off Admin. Reception: sprinkler head blocked by

equipment rack with approximately twelve inches clearance from the

bottom of the pendant to the top of the racked equipment.

Actual NFPA standard:

NFPA 25

5.2.1 Sprinklers.

5.2.1.1* Sprinklers shall be inspected from the floor level

annually.

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following

shall be replaced:

(1) Leakage

(2) Corrosion

(3) Physical damage

(4) Loss of fluid in the glass bulb heat responsive element

(5)*Loading

(6) Painting unless painted by the sprinkler manufacturer

5.2.1.2* The minimum clearance required by the installation standard shall

be maintained below all sprinkler deflectors.

NFPA 13

8.5.6* Clearance to Storage.

8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Based on observation the facility failed to ensure fire extinguishers were installed in accordance with NFPA 10. Failure to install fire extinguishers at the correct height could hinder access during a fire. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

During the facility tour conducted on November 28 and November 29, 2016 from approximately 9:00 AM to 12:00 PM, observation of the installed portable fire extinguishers revealed the following extinguishers were installed over the maximum height of 60 inches to the top of the extinguisher when measured from the finished floor:

+ Mental Health Unit Nurse Station: 63 1/2 inches above floor

+ Generator Room: 67 inches above floor

+ Lab Room: 63 inches above floor

Upon further evaluation of the installed fire extinguisher on the 2nd floor mechanical room revealed an improper orientated arrow/sign directed towards an HVAC unit

When asked, the Maintenance Supervisor stated the facility was unaware of the height and orientation of the extinguishers

Actual NFPA standard:

NFPA 10

6.1.3.8 Installation Height.

6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 l (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

6.1.3.3 Visual Obstructions.

6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured

from view.

6.1.3.3.2* In large rooms and in certain locations where visual

obstructions cannot be completely avoided, means shall be

provided to indicate the extinguisher location.

Based on observation, operational testing, and interview the facility failed to maintain doors that protect corridor openings. Failure to maintain corridor doors could allow smoke and dangerous gases to pass freely between smoke compartments. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the facility tour on November 28, 2016 at approximately 1:00 PM observation and operational testing of the corridor door to room 328 on the third floor revealed the door would not latch when closed.

2.) During the facility tour on November 28, 2016 at approximately 1:00 PM observation and operational testing of the corridor door to room 331 on the third floor revealed the door would not latch when closed.

3.) During the facility tour on November 28, 2016 at approximately 2:30 PM observation and operational testing of the corridor door to room 234 on the second floor revealed the door would close due to a screw impeding the progress of the door.

When asked, the Maintenance Supervisor stated the facility was unaware the two room doors would not latch and a screw was impeding the door from closing.

*This deficiency was corrected by the end of survey

Actual NFPA Standards:

19.3.6.3* Corridor Doors.

19.3.6.3.1* Doors protecting corridor openings in other than

required enclosures of vertical openings, exits, or hazardous

areas shall be doors constructed to resist the passage of smoke

and shall be constructed of materials such as the following:

(1) 13/4 in. (44 mm) thick, solid-bonded core wood

(2) Material that resists fire for a minimum of 20 minutes

Based on observation, operational testing and interview, the facility failed to ensure smoke barrier doors would close properly when activated by the smoke detection system. Failure to ensure that smoke compartment doors closed completely could allow the spread of fire and allow the movement of smoke from one side of the barrier to the other. This deficient practice affected patients, staff and visitors on the date of the survey. The facility is licensed for 150 hospital beds and had a census of 66 on the day of exit.

Findings include:

1.) During the facility tour on November 28, 2016, at approximately 11:30 AM, operational testing of the cross corridor doors on the third floor entering Critical Care Unit revealed the doors would not close and seal properly.

2.) During the facility tour on November 28, 2016, at approximately 11:30 AM, operational testing of the cross corridor doors on the third floor in the Critical Care Unit on the North West side of Nursing station revealed would not close and seal properly.

3.) During the facility tour on November 29, 2016, at approximately 10:00 AM, operational testing of the 45 minute fire rated doors on the first floor entering the Emergency Department from the Imaging revealed a 3/4 inch gap between the doors when closed.

When asked, the Maintenance Supervisor stated the facility was unaware of the doors not closing properly and the gap between the two doors.

Actual NFPA standard:

NFPA 101

19.3.7.6 Openings in smoke barriers shall be protected using

one of the following methods:

(1) Fire-rated glazing

(2) Wired glass panels in steel frames

(3) Doors, such as 13/4 in. (44 mm) thick, solid-bonded woodcore

doors

(4) Construction that resists fire for a minimum of 20 minutes.

19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and

all of the following:

(1) The doors shall be self-closing or automatic-closing in accordance

with 19.2.2.2.7.

(2) Latching hardware shall not be required

(3) The doors shall not be required to swing in the direction

of egress travel.

19.3.7.6*

Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

Based on review of hospital policy and grievance documentation, it was determined the hospital failed to ensure written notice was provided to patients or their legal representatives that included the steps taken to investigate the grievance and the results of the grievance process for 1 of 2 patients (#4) whose grievances were reviewed. This resulted in an incomplete resolution to the grievance process. Findings include:

The hospital policy Patient/Family Complaint and Grievance Policy, dated 8/06/15, was reviewed. It stated In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion.

Two grievances were reviewed. Complaint documentation indicated a complaint was received on 9/15/15 by a legal guardian of Patient #4. The complainant alleged he was not included in treatment team meetings, that Patient #4's medications were being changed without his approval, and that he was not notified of Patient #4's impending transfer to another facility.

The written notice of response, dated 10/09/15, did not include the steps taken to investigate the grievance and the results of the grievance process. This was confirmed by the Patient Advocate on 11/18/15 at 2:28 PM. She stated the complaint had been investigated and the complainant had not responded to telephone calls and she expected him to contact her after receipt of the letter.

In its resolution of a grievance, the hospital did not provide Patient #4 or her legal representative with written notice that included the steps taken to investigate the grievance and the results of the grievance process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the use of restraints was not implemented in accordance with current, clear, and complete orders of physicians or other LIPs for 1 of 5 patients (#12) who were physically restrained and whose medical records were reviewed. This resulted in missing or incomplete orders and restraint use that was not consistent with the orders of a physician or other LIP. This had the potential to result in unsafe care of restrained patients. Findings include:

A hospital policy titled Patient Restraint/Seclusion, approved 7/08/14, stated An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. The facility failed to ensure the staff followed the policy in the following examples:

1. Patient #12 was a [AGE] year old male who was admitted on [DATE], for psychiatric services related to depression. He was discharged on [DATE]. His record included documentation he was placed in restraints on two occasions.

a. Patient #12's record included a verbal order for Seclusion/Restraint on 10/29/15 at 1:02 PM. However, the order was not clear and specific as follows:

The order did not specify the type of restraints, such as leather restraints or the limbs to be restrained, such as all 4 extremities. Patient #12's record documented he was placed in leather restraints on all four extremities. A note entered by the RN caring for Patient #12 at that time read Patient stated he was hearing voices but would not reveal what they were saying. Stated he could not remain safe. Staff offered 1:1 to help him stay safe and he began to strike himself in the head. Patient agreed to lie down for restraints. Restraints safely applied while pt was very cooperative. Patient #12's record did not include documentation he was placed in seclusion in accordance with the order.

b. Patient #12's record included a verbal order for Seclusion/Restraint on 10/30/15 at 7:12 PM. However, the order was not clear and specific as follows:

The order did not specify the type of restraints, such as leather restraints or the limbs to be restrained, such as all 4 extremities. Patient #12's record documented he was placed in leather restraints on all four extremities. A note entered by the RN caring for Patient #12 at 7:20 PM read Due to prior amount of prn's no additional meds were ordered and order received for seclusion and restraints now. BERT team called and restraints were placed [4 points]. 1:1 sitter placed outside door.

During an interview on 11/20/15 beginning at 11:00 AM, an RN from the Behavioral Health Unit reviewed Patient #12's record and stated A restraint order means 4 point hard restraints. He further demonstrated how restraint orders were entered in the EMR. The RN stated the drop down screen did not allow the user to select the type of restraint or the limbs to be restrained. The RN stated they did not seclude patients on the Behavioral Health Unit, and the room Patient #12 was placed in was used as a quiet room, it had video monitoring, and the patient had a one-to-one sitter. The RN confirmed the nursing note entered on 10/30/15 at 7:20 PM documented Patient #12 was placed in seclusion. Additionally, he confirmed the EMR orders for Patient #12 did not specify the type and amount of restraints to be used.

The hospital failed to ensure physician orders for restraint and seclusion were complete and clear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours for 1 of 1 patients (#12) who was restrained for more than 4 hours to manage violent or self-destructive behavior and whose record was reviewed. This resulted in lack of oversight by a physician or qualified LIP and had the potential to interfere with patient safety. Findings include:

The hospital's policy titled Patient Restraint/Seclusion, approved 7/08/14, stated Physician orders for restraint or seclusion must be time limited, and must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of restraint or seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed 4 hours for adults. Additionally, the policy stated To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order.

1. Patient #12 was a [AGE] year old male who was admitted on [DATE], for psychiatric services related to depression. He was discharged on [DATE].

Patient #12's record included a verbal order on 10/30/15 at 7:12 PM, for Seclusion/Restraint for Violent/Self Destructive behavior. The order was written for 4 hours, which would have expired at 11:12 PM. However, he was released from seclusion and restraint on 10/31/15 at 1:10 AM, which was a total of 5 hours and 58 minutes. Patient #12's record did not include additional orders for further restraint and seclusion beyond 11:12 PM.

During an interview on 11/20/15 beginning at 11:00 AM, an RN from the Behavioral Health Unit reviewed Patient #12's record and confirmed he was in 4 point leather restraints and seclusion for greater than four hours.

The hospital failed to ensure orders for restraint and seclusion were renewed after four hours.

Based on staff interview, observation of patient rights posters, and review of hospital policy and patient rights information provided to patients upon admission, it was determined the hospital failed to establish a clearly explained procedure for the submission of a patients' written or verbal grievance to the hospital. This had the potential to interfere with the ability of patients to exercise their right to submit a grievance and have it promptly addressed. Findings include:

1. The hospital's policy Patient/Family Complaint and Grievance, dated 10/12/10, was reviewed. It included, but was not limited to, the following information:

- Each patient and/or the patient's representative will be informed of the grievance process, including whom to contact to file a grievance or complaint. The patient will be informed that a grievance maybe directly lodged with the Idaho Bureau of Facility Standards or the Joint Commission, regardless of whether he/she has first used the organization's grievance process.

- Each patient and/or patient representative is informed of the rights and responsibilities afforded patients upon entry into the facility, and the process by which they may lodge a complaint. This information includes the name of the designee of the organization, such as the Risk Manager, and the method of access to the designee to provide immediate assistance as needed.

The policy did not state how patients would be informed of the hospital's grievance process including how to file a written and verbal grievance with the hospital. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

2. An undated patient handout, Your Patient Rights and Responsibilities, was reviewed. Although the handout included information on how to file a written or verbal grievance with the Joint Commission and Bureau of Facility standards, it did not inform the patient how to file a verbal or written grievance with the hospital or a phone number to call. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

3. A patient rights poster, was observed in the hospital's lobby area on 7/07/15 at 11:12 AM. The poster did not include information on how to file a written and verbal grievance with the hospital. Although the handout included information on how to file a written or verbal complaint with the Joint Commission, Bureau of Facility Standards, and HCA, it did not inform the patient how to file a verbal or written grievance with the hospital or a phone number to call. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

The hospital did not establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital.

Based on review of grievance information and hospital policy and staff interview, it was determined the hospital failed to ensure grievances were responded to within the time frame specified in policy, or notified when a delay was anticipated to occur in accordance with policy, for 2 of 6 patients (#8 and #9) whose grievances were reviewed. This resulted in unexplained delays in communicating results of the grievance investigation. Findings include:

1. The hospital's policy Patient/Family Complaint and Grievance, dated 10/12/10, was reviewed. The policy included, but was not limited to the following information:

- Upon receipt of a grievance, the Risk Manager, House Supervisor, or other designee of the organization, will confer with the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. A representative of the administrative staff will oversee and assist with the resolution process as needed. medical staff leadership may be involved as needed to resolve physician delivery of care issues.

- Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days.

The hospital's letter of response to patients/complainants was not within the time frame specified in policy. Examples include:

a. A complaint was received 4/12/15, on behalf of Patient #8 regarding physician care and behavior for an ED visit in December, 2014. Two letters of response were provided, dated 4/24/15 and 4/28/15. There was no documentation to indicate the complainant was informed of the delay beyond the seven days specified in hospital policy. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:15 AM.

b. A complaint was received on 4/18/15, on behalf of Patient #9 related to physician care in the ED the prior week. Letters of response were dated 5/21/15 and 6/02/15. There was no documentation to indicate the complainant was informed of the delay beyond the seven days specified in hospital policy. This was confirmed by the Interim Patient Advocate during an interview on 7/07/15 at 11:24 PM.

Patient #8 and Patient #9 were not sent responses to their grievances within the time frame specified in policy, nor were they notified the response would be delayed.

Based on review of letters of response to grievances, hospital policy, and staff interview, it was determined the hospital failed to ensure written notice of response included the date of completion of the investigation of complaints for 4 of 6 patients (#5, #7, #8 and #9) whose grievances were reviewed. This resulted in a lack of clarity as to whether the investigation was complete. Findings include:

1. The hospital's policy Patient/Family Complaint and Grievance, dated 10/12/10, was reviewed. The policy stated In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion.

The following are examples of letters of response to grievances that did not include the date the investigation was considered complete:

a. A complaint was received on 4/02/15, on behalf of Patient #5 regarding physician care during an ED visit on 4/01/15. The letter of response, dated 4/10/15 did not include the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

b. A complaint was received 4/12/15, on behalf of Patient #8 regarding physician care and behavior for an ED visit in December, 2014. Two letters of response were provided, dated 4/24/15 and 4/28/15. Neither letter indicated the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:15 AM.

c. A complaint was received on 4/10/15, by Patient #7 related to nursing care in the ED during a visit on 4/10/15. Letters of response, dated 4/15/15 and 6/10/15, did not include the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:15 AM.

d.. A complaint was received on 4/18/15, by Patient #9 related to physician care in the ED the prior week. Letters of response, dated 5/21/15 and 6/02/15, did not include the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during an interview on 7/07/15 at 11:24 PM.

Letters of response to grievances for Patients #5, #7, #8 and #9 were incomplete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, policy review, and medical record review, it was determined the hospital failed to ensure a process was established to ask patients if they wanted a family member/representative and/or personal physician notified of their admission to the hospital. This directly impacted 3 of 11 patients (#1, #3 and #4) whose admission documents were reviewed for this purpose. This had the potential to interfere with the ability of patients to coordinate their personal and healthcare needs. Findings include:

1. An undated patient handout, Your Patient Rights and Responsibilities, was reviewed. The policy stated the patient could expect prompt notification to your physician and a family member, per your request, if you are admitted to the hospital.

Documentation was not found in the following records indicating the facility had asked patients whether they wanted the hospital to notify a family member/representative and/or a personal physician of admission to the facility as follows:

- Patient #1 was a [AGE] year old female admitted to the Mental Health Unit of the facility on 4/01/15. Her diagnoses included bipolar 1 disorder with manic with psychotic features. There was no documentation in Patient #1's medical record indicating she had been asked if she wanted the facility to notify a personal physician of her admission.

- Patient #3 was a [AGE] year old female admitted to the facility on [DATE], for care related to a hernia repair. Documentation was not found in her medical record indicating she had been asked if she wanted the facility to notify a family member/representative or personal physician of her admission.

- Patient #4 was a [AGE] year old female admitted to the facility on [DATE], for delivery of a male infant. Documentation was not found in her medical record indicating she had been asked if she wanted the facility to notify a family member/representative or personal physician of her admission.

The Director of Advanced Clinical & Meaningful Use Coordinator was interviewed on 7/07/15, beginning at 1:05 PM. She reviewed the inpatient admission records of Patients #1, #3 and #4 and confirmed she did not see documentation of family members/patient representative notification of admission for Patients #3 and #4. She also said she did not see documentation of notification of personal physicians for Patients #1, #3 or #4.

The Director of the Mental Health Unit was interviewed on 7/07/15, beginning at 1:51 PM. She stated patients were asked if they wanted a family member or representative notified of their admission during the initial, psychiatric-social assessment. The Director of the Mental Health Unit also said she was not aware of a hospital process or document instructing staff to ask patients if they wanted their family/personal physicians notified of their admission.

The hospital did not have a uniform process in place to ensure patients were asked if they wanted family members or representatives and/or a personal physician notified of their admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of hospital policy and medical records, it was determined the hospital failed to ensure restraint use was in accordance with the order of a physician or other LIP for 2 of 2 patients placed in behavioral restraints in the ED (#12 and #17) whose medical records were reviewed. This resulted in unauthorized restraint use. Findings include:

1. The Restraint/Seclusion policy, dated 6/03/14, was reviewed. The policy included, but was not limited to the following information:

- An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion.

This policy was not followed. Examples include:

a. Patient #12 was a [AGE] year old male seen in the ED on 4/01/14, after being brought into the ED by police and placed on an involuntary hold due to suicidal and homicidal ideation. Nursing documentation indicated physical restraints were initiated on 4/01/15 at 5:40 PM. The time of discontinuation of restraints was not indicated in Patient #12's record. There was no order documented in the record, by a physician or other LIP, for restraints for Patient #12. This was confirmed by the Director of Advanced Clinicals and Meaningful Use Coordinator during interview on 7/08/15 at 1:20 PM.

b. Patient #17 was a [AGE] year old female seen in the ED on 4/15/15 and 4/16/15, for care related to a drug overdose. Nursing documentation indicated Patient #17 was placed in locking synthetic leather restraints (number or limbs not documented) at 4/15/15 at 9:50 PM, related to violent behavior. The physician's order for restraints was dated 4/16/15 at 2:38 AM, more than 4 hours after initiation of restraints.

An ED RN and the Director of Advanced Clinicals and Meaningful Use Coordinator were interviewed together at 7/08/15 at 12:45 PM. The ED RN stated there should have been a hard copy of an order written at the time of restraint initiation and scanned into Patient #17's medical record by the Medical Records Department. She confirmed the hard copy of the order was not in the record and she did not know why.

The use of restraint was not in accordance with the order of a physician or other licensed independent practitioner for Patient #12 and Patient #17 in accordance with hospital policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of hospital policy and medical records, it was determined the that the hospital failed to ensure restraints used to ensure the physical safety of the non-violent or non-self-destructive patients, were renewed in accordance with hospital policy. This directly impacted 2 of 2 patients (#13 and #14) who were restrained for medical reasons. This resulted in unauthorized restraint use. Findings include:

1. The Restraint/Seclusion policy, dated 6/03/14, was reviewed. The policy stated an order for restraint for non-violent or non-self destructive behavior must not exceed twenty-four hours for the initial order and a new order must be written each calendar day. The hospital's policy was not followed in the following examples:

a. Patient #13 was a [AGE] year old male admitted to the critical care unit of the hospital on [DATE]. Nursing notes documented continuous upper extremity soft wrist restraints from 6/26/15 at 9:15 PM until 7/05/15 at 11:00 AM.

Physician orders for upper extremity bilateral wrist restraints were documented at the following dates and times for 24 hours each time:

- 6/26/15 11:16 PM

- 6/28/15 6:27 PM

- 6/29/15 4:56 PM

- 7/01/15 4:00 PM

- 7/02/15 9:34 AM

- 7/02/15 4:00 PM

- 7/03/15 4:00 PM

- 7/04/15 9:11 AM

There were no orders present for the following times when Patient #13 was in bilateral wrist restraints:

- 6/27/15 at 11:16 PM until 6/28/15 at 6:27 PM

- 6/30/15 at 4:56 PM until 7/01/15 at 4:00 PM

- 7/05/15 at 9:11 AM until 7/15/15 at 11:00 AM

Orders per calendar day, were missing on 6/27/15, 6/30/15, and 7/05/15.

The Director of Advanced Clinical & Meaningful Use Coordinator reviewed Patient #13's record on 7/07/15 at 1:35 PM with the surveyor and confirmed there were missing orders for restraints.

b. Patient #14 was a [AGE] year old female, admitted on [DATE], for surgery related to lumbar stenosis. The hospital's restraint log indicated Patient #14 was restrained from 6/12/15 at 12:00 PM until 6/16/15 at 11:45 AM.

Physician orders for bilateral upper extremity restraints were documented at the following dates and times for 24 hours each time:

- 6/11/15 at 12:04 PM

- 6/12/15 at 5:30 PM

- 6/13/15 at 9:00 PM

- 6/15/15 at 6:44 PM

There were no orders present for the following times when Patient #14 was restrained:

- 6/13/15 at 5:30 PM until 6/13/15 at 9:00 PM

- 6/14/15 at 9:00 PM until 6/15/15 at 6:44 PM.

An order per calendar day, was missing on 6/14/15.

The Director of Advanced Clinical & Meaningful Use Coordinator reviewed Patient #14's record on 7/07/15 at 1:35 PM, with the surveyor and confirmed there were missing orders for restraints.

Restraints used to ensure the physical safety of the non-violent or non-self-destructive patients, were not renewed every 24 hours as authorized by hospital policy.

Based on staff interview and review of hospital policy and staff orientation documents, it was determined the hospital failed to ensure physicians and other LIPs had a working knowledge of hospital policy regarding the use of restraint or seclusion. This had the potential to interfere with patient safety and lead to inappropriate continued restraint use. Findings include:

1. The Restraint/Seclusion policy, dated 6/03/14, was reviewed. The policy stated Physicians and other LIPs authorized to order restraint will have a working knowledge of this policy on the use of restraint and seclusion.

A page of physician orientation was provided for review that included information provided to physicians at orientation. There was a half a page of information related to Restraint and seclusion and a referral to the hospital's restraint and seclusion policy for more information.

The Medical Staff Coordinator was interviewed on 7/08/15, beginning at 9:14 AM. She said reminders of necessary education were emailed at various times throughout the year, including reminders concerning restraint training. She indicated physicians were prompted to review the restraint policy and the 1 page document previously discussed. She stated physicians were not required to provide proof of competency or attest that they have reviewed the restraint policy.

An ED physician was interviewed by telephone on 7/08/15 at 10:06 AM. When asked about his understanding of the face-to-face requirement for restraints used to manage violent or self-destructive behavior, he stated he was not sure of the specific requirements and he was not sure they applied to the ED setting since providers were in and out of the room and would likely see a patient within one hour of initiation of restraints. He stated nurses usually document doctor in room which would be evidence a face-to-face was conducted.

The hospital failed to ensure physicians had a working knowledge of restraint policy.

2. Refer to A184 as it relates to the failure of the hospital to ensure patients were assessed within one hour of the application of behavioral restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of hospital policies and medical records, it was determined the hospital failed to ensure a face-to-face evaluation was conducted within one hour of application of behavioral restraints to assess the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion, for 2 of 2 ED patients (#12 and #17) whose medical records were reviewed. Findings include:

The hospital's Restraint/Seclusion policy, dated 6/03/14, was reviewed. The policy included, but was not limited to, the following information:

a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manager violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will:

1) Work with staff and patient to identify ways to help the patient regain control

2) Evaluate the patient's immediate situation

3) Evaluate the patient's reaction to the intervention

4) Evaluate the patient's medical and behavioral condition

5) Evaluate the need to continue or terminate the restraint or seclusion

6) Revise the plan of care, treatment, and services as needed

Note: A telephone call or telemedicine methodology does not constitute face-to-face assessment.

b. When the 1 hour face-to-face is performed by a RN or physician assistant with demonstrated competence, the following must occur:

1) The RN or physician assistant with demonstrated competence must consult the attending physician or LIP who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. ('As soon as possible' is to be as soon as the attending physician is able to be reached by phone or in-person.) A consultation that is not conducted prior to renewal of the order would not be consistent with the requirement as soon as possible.

2) The consultation should include, at a minimum, a discussion of the findings of the 1 hour face-to-face evaluation, the need for other treatments, and the need to continue of discontinue the use of restraint or seclusion.

3) If a patient who is restrained or secluded for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the face-to-face assessment, the physician must still see the patient face-to-face to perform the assessment within 24 hours after the initiation of restraint or seclusion.

The records of 2 ED patients who were restrained in the ED for violent or self-destructive behavior were reviewed. There was no documentation to confirm a qualified individual conducted a face-to-face evaluation within one hour of initiation of restraints to manage violent or self-destructive behavior. Examples include:

a. Patient #12 was a [AGE] year old male who was seen in the ED on 4/01/14 after being brought to the ED by police, and placed on an involuntary hold, due to suicidal and homicidal ideation. Nursing documentation indicated physical restraints were initiated on 4/01/15 at 5:40 PM. The time of discontinuation of restraints was not indicated in Patient #12's record. There was no documentation that Patient #12 was evaluated face-to-face for Patient his reaction to the restraints, behavioral condition, and the need to continue or terminate restraints. This was confirmed by the Director of Advanced Clinicals and Meaningful Use Coordinator and an ED RN during an interview on 7/08/15 at 12:45 PM.

b. Patient #17 was a [AGE] year old female who was seen in the ED on 4/15/15 and 4/16/15 for care related to a drug overdose. Nursing documentation indicated Patient #17 was placed in locking synthetic leather restraints (number or limbs not documented) at 4/15/15 at 9:50 PM related to violent behavior. There was no documentation that Patient #17 was evaluated face-to-face for her reaction to the restraints, behavioral condition, and the need to continue or terminate restraints.

An ED physician was interviewed by telephone on 7/08/15 at 10:06 AM. When asked about his understanding of the face-to-face requirement for restraints used to manage violent or self-destructive behavior, he stated he was not sure of the specific requirements and he was not sure they applied to the ED setting since providers were in and out of the room and would likely see a patient within one hour of initiation of restraints. He stated nurses usually document doctor in room which would be evidence a face-to-face was conducted.

The hospital failed to ensure patients restrained in the ED for behavioral reasons received a one hour face-to-face assessment related to the use of the restraints.

Based on review of grievance information, hospital policies, and staff interview, it was determined the facility failed to notify patients/representatives of whom to contact, within the hospital, to file a grievance. This had the potential to impact all patients/representatives who wished to file a grievance. It also had the potential to interfere with, or prevent, patients/representatives from filing a grievance. Findings include:

1. The hospital's policy Patient/Family Complaint and Grievance, dated 10/12/10, was reviewed. It included, but was not limited to, the following information:

Each patient and/or the patient's representative will be informed of the grievance process, including whom to contact to file a grievance or complaint. The patient will be informed that a grievance maybe directly lodged with the Idaho Bureau of Facility Standards or the Joint Commission, regardless of whether he/she has first used the organization's grievance process. The policy did not inform each patient whom to contact, within the facility, to file a grievance. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

2. A framed document containing patients' rights information was observed in the lobby area of the facility on 7/07/15 at approximately 11:12 AM. The poster included information on how to file a written or verbal complaint with the Joint Commission, Bureau of Facility Standards and the facility's parent company, HCA. The poster did not provide the name or contact information for the individual(s), in the facility, patients or representatives could contact to file a grievance. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

3. An undated patient handout, Your Patient Rights and Responsibilities, was reviewed. Although the handout included information about how to file a written or verbal complaint with the Joint Commission and Bureau of Facility standards, it did not provide the name or phone number of an individual(s), within the facility, patients' could contact to file a grievance. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

Patients and representatives were not informed of who to contact, within the facility, to file a grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and hospital policies, and interview, it was determined the hospital failed to establish policies and procedures that ensured patients' representatives received patients' rights information. This impacted 1 of 1 patient (#1) who was incapacitated and had a legal guardian who was not present during the admission process. This resulted in a representative not having the required information necessary to exercise rights on behalf of the patient. Findings include:

Patient #1 was an [AGE] year old female admitted on [DATE] for treatment of a small bowel obstruction (which required surgery to correct) and sepsis (an infection in the blood stream). Prior to hospitalization , she resided in a SNF and was discharged back to the SNF on 11/30/11.

Patient #1's medical record indicated she was admitted to the hospital after an evaluation in the ED. Her medical record contained documentation transferred with her from the SNF, including legal documents of appointment of guardianship. The ED physician documented attempting to contact the guardian to discuss Patient #1's care and treatment, but noted the guardian was not available when Patient #1 was admitted .

Patient #1's medical record contained a Conditions of Admission document which was signed by a registrar and a second witness. The registrar wrote Pt [patient] unable to sign at all.

On 4/18/12 at 11:00 AM, a Registrar who worked with admissions from the ED was interviewed. She explained her role in the admission process, obtaining signatures for the Condition of Admission document, and dispersing patient rights information when the patient was not able to participate in this process. She stated if the patient's representative was available they would be given the patient rights information and asked to sign the Condition of Admission form.

She stated if the patient was not able to participate in the admission process due to their mental status, and there was no representative present at the time, she relied on the ED nurse caring for the patient to know if the guardian or DPOA would be in the see the patient at some point during the stay. If someone was going to be available at a later date, the admission paperwork would be placed in a need more info [information] basket to be completed later. She explained that whichever registrar had time would follow up on obtaining the appropriate signature and providing the patient rights information. If the patient was incapacitated and did not have a representative that the facility was aware of, she documented on the Condition of Admission form the patient was unable to sign, and had an RN cosign.

She stated if the admission paperwork was not given to the patient or representative, and the registration office was not planning to follow up on the documentation, the information, including patient rights, was transferred with the patient from the ED to their assigned room. She stated she was not sure if this information was passed on to a representative/guardian, or even to the patient if their mental status cleared enough to enable them to understand their patient rights. She confirmed that the only time a registrar contacted a legal guardian, was if the patient was a minor.

A Registrar who worked with outpatient services and patients who were directly admitted on [DATE] at 11:30 AM. She stated she always reviewed the Condition of Admission form with the patient, explained the patient rights and responsibilities, and offered them the patient handbook with this information. She stated if a patient required a representative to sign on their behalf and receive information, and the representative was not present upon admit, she would ask the patient if the representative would be coming in at a later time and then place the documentation in a need sigs [signature] basket in the admissions area. She stated if a representative was not coming in at all, the paperwork would be signed by two registrars and the information would be sent with the patient. She was not certain that nursing staff on the floor passed on patient rights information to either the patient and/or the appropriate representative if the information had not already been disseminated.

RN B was interviewed on 4/18/12 at 3:15 PM. She stated if a patient was admitted to her care and she was aware the patient had a guardian or representative, she passed this information on to the physician in order for the physician to discuss care and treatment plans with the appropriate individual. She stated she did not contact patients' guardians or representatives. She explained if admission documentation needed to be signed by a patient representative, this was completed by the registrars. She confirmed she did not disperse patient rights information to guardians/representatives if they were not present during the admission process with the registrar, and that this was typically handled by the registrar or a case manager.

A Service Line Coordinator, RN Case Manager, was interviewed on 4/19/12 at 9:00 AM. She stated she did not have a role in ensuring patient rights information was provided to a patient's guardian/representative if that individual was not present to sign the documentation and speak with a registrar.

A Social Worker was interviewed on 4/19/12 at 9:10 AM. When asked how the hospital ensured guardians who were not present upon patient admission were given patient rights information, she replied whatever registration does related to patient rights is what is done. She explained dispensing patient rights information was not the role of the social worker. When asked who communicated with the guardian, she stated the physician or charge nurse or case managers might call a guardian or DPOA if they felt it was needed.

Patient #1's legal guardian was interviewed on 4/18/12 at 2:50 PM. She confirmed that she was not able to be present at the time Patient #1 was admitted through the ED, but was in contact with hospital staff soon after the admission to discuss the plan of care. She stated she was not given information related to patients' rights and responsibilities even though she was involved in Patient #1's care and treatment throughout her hospitalization .

The Patient's Rights and Responsibilities policy, dated 10/12/10, was reviewed. The policy indicated all patients admitted for care and service or their legal guardian, family or caregiver will receive verbal instructions and a written copy of patient rights information. The policy did not contain instructions to effectively ensure a patient's representative received the required patient rights information if the representative was not present at the time of the admission or did not have the opportunity to speak with a registrar to complete admission paperwork on behalf of the patient.

The Supervisor of Quality and Risk Management was interviewed on 4/18/12 at 1:15 PM. She reviewed the hospital's policies related to patient rights and acknowledged they did not include a process of how patients and/or caregivers/representatives would receive patient rights information if this did not occur with contact through a registrar. She stated she wanted to double check to confirm this, but had not produced additional information as of 4/19/12.

The hospital failed to establish and implement procedures to effectively ensure that patients' representatives had information necessary to exercise rights on behalf of the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, hospital policies, and interview, it was determined the hospital failed to ensure personal information was not released to unauthorized individuals for 1 of 2 patients (#1) who had a legal guardian and whose records were reviewed. This resulted in personal health information being shared with individuals who had not been authorized by the legal guardian to receive information. Findings include:

Patient #1 was an [AGE] year old female admitted on [DATE] for treatment of a small bowel obstruction (which required surgery to correct) and sepsis (an infection in the blood stream). Prior to hospitalization she resided in a SNF and was discharged back to the SNF on 11/30/11.

Patient #1's medical record indicated she was admitted to the hospital after an evaluation in the ED. Her medical record contained documentation transferred with her from the SNF including legal documents of appointment of guardianship and an Admission Face Sheet from the SNF. At the bottom of face sheet, the name and phone number of an individual had been written in. A hand written message next to this information referenced the individual and read, Friend - Do not contact [with] [change] of status. [Name of guardian] is guardian.

Patient #1's medical record contained a Conditions of Admission document. The registrar signed this document, on 11/16/11at 1:04 PM, along with a second witness, and wrote Pt [patient] unable to sign at all. There was no documentation to indicate the legal guardian was aware of the patient rights and responsibilities, including the right to limit the release of PHI on behalf of Patient #1.

PHI was disclosed to individuals without authorization of the legal guardian in the following examples:

- The RN documented on 11/25/11 at 4:28 PM that the family was educated on Patient #1's medications, pain, and the intravenous nutrition she received.

- The Speech Therapist documented on 11/26/11 at 3:04 PM that Patient #1's son, family friend, and nursing staff were educated on Patient #1's swallowing progress.

The legal guardian for Patient #1 was interviewed on 4/18/12 at 2:50 PM. She stated she was involved in the care plan and treatment for Patient #1 and had spoken freely with staff the first few days of Patient #1's admission. She stated she was not asked about who may or may not have authorization to receive PHI for Patient #1. She stated that during a conversation with nursing staff she became aware that a friend of Patient #1's had been receiving information about Patient #1's health status and the friend had notified Patient #1's son of the admission. According to the legal guardian, not only had the son been notified of the admission, but had come from out of state to become involved in Patient #1's care. The legal guardian stated she had not authorized these individuals to receive information and confirmed that staff had been disclosing information to the friend and the son until she requested this be discontinued.

RNs A, B, C, and D and LPNs A, B, and C were interviewed on 4/19/12 between 11:15 AM and 11:45 AM. They were each asked how they obtained authorization to discuss PHI with individuals other than the patient. Each stated, even if the patient had a legal guardian, they would ask the patient, provided they were able to respond, for verbal consent to share PHI. There was varying levels of interpretation of the role of a legal guardian but no one stated that they were aware that the legal guardian was responsible for making decisions for the patient, including the decision of who was authorized to receive PHI.

RNs E, F, and G were interviewed on 4/19/12 at 11:30 AM. Each RN confirmed they were not authorized to release PHI without consent from the patient. RN E explained that if the patient, who was unable to give consent, had a legal guardian, she would require proof of the legal guardianship and then allow the guardian to determine who was authorized to obtain patient PHI. RN F explained that if a patient was not confused and gave staff permission to share PHI with an individual, that consent was considered sufficient regardless of whether or not a patient had a legal guardian. She stated that she understood a legal guardian to make decisions on behalf of the patient when the patient was incapacitated.

The VERIFICATION OF EXTERNAL REQUESTORS policy, last reviewed 7/2006, indicated Every member of the facility workforce must verity the identity of any person or entity when the person or entity is unknown to the workforce member and is requesting protected health information (PHI) either in person, verbally or via written request. The policy then outlined mechanisms to verify the identity of individuals, one of which was requiring a requestor to provide a minimum of three information items from a specific list.

The USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO FAMILY MEMBERS OR FRIENDS FOR PATIENT CARE PURPOSES policy, last reviewed 7/2006, was reviewed. According to the policy, If the patient is present for or otherwise available prior to the use or disclosure and has the capacity to make health care decisions, workforce members with access to PHI may use or disclose the PHI if one of the following has occurred... Except in emergent situations, the policy did not include direction to staff regarding who may determine and provide authorization for release of PHI when the patient did not have the capacity to make healthcare decisions and required a representative such as a legal guardian.

The facility failed to ensure that a legal guardian had authorized the disclosure of personal health information to specific individuals.