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East End Behavioral Health (EEBH) respects the rights of individuals seeking services within the hospital. Due to ongoing concerns and staff non-compliance regarding restraint/seclusion protocols and Abuse and neglect EEBH has implemented ongoing corrective actions and strives to provide a safe environment and quality of care. Each patient has the right to a human physical and psychological environment. An ongoing assessment of the environment, staff, and each individual patients needs and rights has been implemented.
Due to concerns by the administrators of EEBH regarding patient safety and ongoing concerns for front line staff not implementing and following policies and process correctly to ensure patient safety the education curriculum and agenda were reviewed by the administrator, educator, Comprehensive Crisis Management (CCM) instructors, and the Corporate Vice President of Quality and Risk virtually on 11/28. Although ongoing education had occurred it was assessed that the current education on restraint/seclusion and CCM training required further revisions. A full assessment of the policies "Abuse, Neglect, Assault Alleged or Suspected" Restraint and Seclusion, and "Progressive Discipline" was also reviewed at that time.
The revised education includes a step-by-step review of all 3 policies (Restraint/Seclusion, Abuse and Neglect, and the Progressive Discipline) and allows staff to ask and answer question. The Abuse abuse/Neglect and Progressive Discipline polices were revised and approved by MEC and Governing Board on 12/5/2023. During the class, reporting concerns of potential and actual abuse/neglect is stressed with the understanding if concerns were identified a investigation would occur and all staff involved may be held accountable per the progressive discipline policy.
The restraint/seclusion policy had been revised but it is believed the education was deficient and staff did not understand the policies and the goal of the facility to promote a "restraint free environment". The education was revised to include in person participation and active engagement of staff. The program stresses the importance of patient's rights, and how an individual's behavior may be related to his/her diagnosis. A full review of the polices restraint/seclusion, Abuse and neglect, and progressive discipline is done during each class, so staff are aware of all requirements and regulations. Restraints/seclusion is discussed in length, so staff understand their responsibilities and that restraints/seclusion including during physical holds and escorts is only implemented when there is "imminent danger to self and others". Restraint education includes Physician notifications including notifying the attending psychiatrist as soon as possible if at the time of the event the on-call psychiatrist is notified, obtaining orders timely, 1 hour face to face reassessments and notifications to the physician post assessment. Restraint documentation and order form has been updated and approved by MEC and Governing Board on 12/4 and prompts the staff to check all the restraint/seclusion requirements and document all procedures i.e., 1 hour face to face by appropriate discipline, timely notifications, and orders to be obtained. The education includes viewing of restraint/seclusion episodes and active participation of the learners to identify both compliant and inappropriate non-compliant actions performed during the video review. All restraint/seclusion episodes continue to be reviewed by the hospital administrator or designee and any concerning episodes are communicated too and reviewed by the corporate Vice President of Quality and Risk as this process has been successful in identifying non-compliance and the need for self-reporting to the appropriate regulatory entities.
The Comprehensive Crisis Management (CCM) training which promotes safe interventions during restraint/seclusion episodes including during escorts and physical holds has been reviewed and additional information added to the curriculum to emphasize alternatives to restraint/seclusion through de-escalation training that includes verbal de-escalation, time-out quiet room to decrease stimulation, role playing, and reenactments of what staff should and should not do during behavioral risk concerns. The need to "tap out" individuals who may be utilizing incorrect procedures or having difficulty holding patients during restraint/seclusion episodes and to "speak up" when witness to concerns or inappropriate conduct and report any concerning events. A discussion regarding "Passive Neglect" and observers failing to speak up when identified inappropriate conduct is witnessed is included in the curriculum. The need for Staff and patient debriefings after each restraint/seclusion episodes and documentation is also stressed. This gives the staff a chance to review the event and identify any concerns.
The importance and process for reporting any potential or actual abuse/neglect is also discussed in length and how failure to report timely may impact each induvial employee through the disciplinary process. The education is the responsibility of the hospital educator, interim DON, and CCM instructors and implemented on 12/4/23 and completed on 12/16/23.
The procedure for implementing and completing a full investigation when actual or potential non-compliance has been identified and places patients at risk for harm has been reviewed and is the responsibility of the Human Resources Manager, Quality manager, and department leader the interim Director of Nursing. Education was performed on 11/28/23 with the HR Manager and interim Director of Nursing (DON). The education addressed the steps to the investigation when a concern arises i.e., immediate suspension pending the results of the investigation, video review, timely interviews and statements from all staff involved and the patient by the assigned psychiatrist, and termination and regulatory entity reporting as needed. Policy HR029.01 Progressive Discipline has been revised to identify additional grounds for disciplinary actions up to and including termination i.e., Failure to document and enact non-physical interventions prior to restraint, speaking in a hallway or other patient care areas about a patient in an unprofessional manner, failure to report potential or actual abuse and neglect, and acting outside scope of license (MHT's or LVN's initiating a physical restraint without an RN or MD order) . The Abuse and Neglect policy had been revised to include staff accountability for inappropriate and non-compliant conduct during restraint/seclusion episodes and failure to report any potential or actual abuse. The revised policies were approved by MEC/GB on 12/4/2023.

During the 11/28 review of the educational curriculum for CCM training and restraint and seclusion, ongoing and revised education was required. The education was revised to include additional information on restraint and seclusion, abuse and neglect, progressive discipline, and de-escalation techniques to prevent the need of restraints/seclusion including physical holds and escorts. A full policy review and discussion is presented during the class.
In addition to the CCM curriculum additional information is discussed including inappropriate measures during physical holds and the role of each Code Support team member, i.e., not holding patients in the prone position and either releasing the patient or turning them to a side lying or supine position, total amount of time a patient can be placed in a physical hold and when a new order is required, roles and responsibilities of each assigned team member including the importance of a dedicated observer who keeps track of the time a patient is held and taps staff out when tiring or not following appropriate procedure, and that only a psychiatrist or registered nurse can order a physical hold or escort. Additional information added to the curriculum to emphasize alternatives to restraint/seclusion through de-escalation training that includes verbal de-escalation, time-out quiet room to decrease stimulation, role playing, and reenactments of what staff should and should not do during behavioral risk concerns. Staff are informed that the charge nurse may reassign some staff involved in the event regardless of the intent to promote patients to feel safe and protect staff from any concerning perceptions the patient may have of them after the event. The importance of and the process for reporting any potential or actual abuse/neglect is also discussed in length and how failure to report timely may impact each induvial employee through the disciplinary process.

During the policy review of Restraint/Seclusion staff are educated on the importance of timely physician notifications and orders obtained prior to any restraint/seclusion incident and timely notification post event if a physical hold/escort is ordered by an RN. The importance of notifying the physician of any concerning behavior and current deescalating techniques being performed as needed and obtaining orders prior to the need for restraint/seclusion and if notifying the on-call psychiatrist, the need to notify the attending psychiatrist as soon as possible per the policy. Ensuring the one-hour face to face is performed by the appropriate discipline is also addressed in the policy and notifying the physician post assessment when performed by a qualified RN is discussed in length. Dating and timing all medical record entries is also discussed in length. Charge nurses are taught to re-assign staff who have been involved with the incident and who may have been the alleged perpetrator, regardless of the intent. The physician is notified of all events/incidents, to ensure he/she thoroughly assess the patient and document any findings of injury. Restraint documentation has been updated and approved by MEC and Governing Board on 12/4 that allows the staff to identify all procedures i.e., 1 hour face to face by appropriate discipline, timely notification, and orders to be obtained.
The Abuse/Neglect policy review includes a discussion of patients' rights, staff responsibilities and reporting of actual or potential abuse and neglect. During the review of the Abuse/Neglect and Progressive Discipline policy staff are made aware of the investigative process if any concerns are identified and failure to report concerns for inappropriate conduct may result in progressive discipline. Staff may report concerns directly to their supervisors or directors and/or the internal compliance line developed on 7/20/23 which remains in place for patients and/or staff to report anonymously any clinical and non-clinical concerns including potential or actual abuse/neglect or complaints and grievances. Callers may call 412-247-2659 and report concerns. All concerns are routed to the administrator's office or leader designee and the patient Advocate. Patients/families/legal representatives are educated on admission when they receive the patient Handbook. The handbook had been revised on 7/19 and 9/21. All admissions Medical Records are reviewed/audited within 24 hrs. of admission or the next business day for compliance of the patient/family education by the DON or designee. Leadership rounding remains in place and is performed 5 times a week including rounding on 1 night shift and 1 weekend shift. Leaders are assigned weekly timeframes and complete a report on any identified patient concerns, events, and complaints and are approachable to staff. All reports are forwarded to the administrator/designee within 24hrs or the next business day and monitored for compliance and discussed during administrative Flash meetings Monday through Friday.
Open communication is encouraged during the education sessions. Learners can ask and answer questions and actively participate throughout the sessions. Role playing and the game Jeopardy with specific questions regarding Abuse/Neglect, and Restraint/Seclusion have been added to the curriculum to promote understanding of the policies and procedures. The education is the responsibility of the hospital educator, interim DON, and CCM instructors and implemented on 12/4/23 and completed on 12/16/23.
Staff evaluations are collected after each session and reviewed by the DON and educator within one week of the session to identify any deficits or misunderstandings. All current clinical staff were scheduled to attend the full educational session including CCM training and the program set to be repeated during new hire orientation and annually during skills fair. The education is the responsibility of the Interim Director of Nursing (DON), educator, and CCM instructors. The education for the current clinical employees began on 12/4/23 and completed on 12/16. Additional education on specific information and policy changes has been shared during shift huddles via a "Did You Know" format by the new interim DON and charge nurses at the beginning of each shift during the weeks of 12/4 and 12/11/23 and will remain ongoing as needed. Any current clinical employees who did not attend the educational session have been suspended and required to attend the next scheduled new hire orientation class. If the employee does not attend the mandatory scheduled class of new hire orientation the employee is terminated. This information would be documented per the Progressive Discipline Policy.
All restraint/seclusion episodes are audited for documentation to include, description of the event, de- escalation techniques utilized prior to the restraint/seclusion, type of restraint, potential or actual injuries, timely physician notification and orders, staff and patient debriefings, Mass scores, 1 hour Face to Face assessments and notifications, and completing and submitting an incident report at the time of the event. The new audit tool has been developed and was implemented on 11/30/23 and is the responsibility of the DON or designee and/or the HIM director.
The procedure for implementing and completing a full investigation when actual or potential non-compliance has been identified and places patients at risk for harm has been reviewed and is the responsibility of the Human Resources Manager, Quality manager, and department leader the interim Director of Nursing. Education was performed on 11/28/23 with the HR Manager and interim Director of Nursing (DON). The education addressed the steps to the investigation when a concern arises i.e., immediate suspension pending the results of the investigation, video review, timely interviews and statements from all staff involved and the patient by the assigned psychiatrist, and termination and regulatory entity reporting as needed. Policy HR029.01 Progressive Discipline has been revised to identify additional grounds for disciplinary actions up to and including termination i.e., Failure to document and enact non-physical interventions prior to restraint, speaking in a hallway or other patient care areas about a patient in an unprofessional manner, failure to report potential or actual abuse and neglect, and acting outside scope of license (MHT's or LVN's initiating a physical restraint without an RN or MD order) . The Abuse and Neglect policy had been revised to include staff accountability for inappropriate and non-compliant conduct during restraint/seclusion episodes and failure to report any potential or actual abuse. The revised policies were approved by MEC/GB on 12/4/2023.

During the 11/28 review of the educational curriculum for CCM training and restraint and seclusion, ongoing and revised education was required. The education was revised to include additional information on restraint and seclusion, abuse and neglect, progressive discipline, and de-escalation techniques to prevent the need of restraints/seclusion including physical holds and escorts. A full policy review and discussion is presented during the class.

In addition to the CCM curriculum additional information is discussed including inappropriate measures during physical holds and the role of each Code Support team member, i.e., not holding patients in the prone position, roles, and responsibilities of each assigned team member. Additional information added to the curriculum to emphasize alternatives to restraint/seclusion through de-escalation training that includes verbal de-escalation, time-out quiet room to decrease stimulation, role playing, and reenactments of what staff should and should not do during behavioral risk concerns. Staff primarly in the Observer role are educated on the need to "tap out" individuals who may be utilizing incorrect procedures or having difficulty holding patients during restraint/seclusion episodes and to "speak up" when witness to concerns or inappropriate conduct and report any concerning events. A discussion regarding "Passive Neglect" and observers failing to speak up when identified inappropriate conduct is witnessed is included in the curriculum. The need for Staff and patient debriefings after each restraint/seclusion episodes and documentation is also stressed. This gives the staff a chance to review the event and identify any concerns. The importance and process for reporting any potential or actual abuse/neglect is also discussed in length and how failure to report timely may impact each induvial employee through the disciplinary process.


During the policy review of Restraint/Seclusion staff are educated on the importance of timely physician notifications and orders obtained prior to any restraint/seclusion incident and timely notification post event if ordered by a qualified RN. The importance of notifying the physician of any concerning behavior and current deescalating techniques being performed as needed and obtaining orders and notifying the on-call as applicable and attending Psychiatrist per the policy. Ensuring the one-hour face to face is performed by the appropriate discipline is also addressed in the policy and notifying the physician post assessment if performed by a qualified RN is discussed in length. Dating and timing all medical record entries is also discussed in length. Staff are taught that the charge nurse may need to re-assign some staff who have been involved with the incident to promote the patient feeling safe and to protect staff from any concerning perceptions the patient may feel towards the staff regardless of the intent. Timely Physician notification of all events/incidents, to ensure he/she thoroughly assess the patient and document any findings of injury.
The Abuse/Neglect policy review includes a discussion of patients' rights, staff responsibilities and reporting of actual or potential abuse and neglect. Staff may report concerns directly to their supervisors or directors and/or the internal compliance line developed on 7/20 of this year remains in place for patients and/or staff to report anonymously any clinical and non-clinical concerns including potential or actual abuse/neglect or complaints and grievances. Callers may call 412-247-2659 and report concerns. All concerns are routed to the administrator's office or leader designee and the patient Advocate. Patients/families/legal representatives are educated on admission when they receive the patient Handbook. The handbook had been revised on 7/19 and 9/21. All admissions Medical Records are reviewed/audited within 24 hrs. of admission or the next business day for compliance by the DON or designee. Leadership rounding remains in place and is performed 5 times a week including rounding on 1 night shift and 1 weekend shift. Leaders are assigned weekly timeframes and complete a report on any identified patient concerns, events, and complaints. All reports are forwarded to the administrator/designee within 24hrs or the next business day and monitored for compliance and discussed during administrative Flash meetings Monday through Friday.
Open communication is encouraged during the education sessions. Learners can ask and answer questions and actively participate throughout the sessions. Role playing and the game Jeopardy with specific questions regarding Abuse/Neglect, and Restraint/Seclusion have been added to the curriculum to promote understanding of the policies and procedures. The education is the responsibility of the hospital educator, interim DON, and CCM instructors and implemented on 12/4/23 and completed on 12/16/23.
Staff evaluations are collected after each session and reviewed by the DON and educator within one week of the session to identify any deficits or misunderstandings. All current clinical staff are scheduled to attend the full educational session and the program repeated during new hire orientation and annually during skills fair. The education will be the responsibility of the Interim Director of Nursing (DON), educator, and CCM instructors. The education for the current clinical employees began on 12/4/23 and completed on 12/16. Additional education on specific information and policy changes has been shared during shift huddles (DID you Know format) by the DON and charge nurses during the weeks of 12/4 and 12/11/23 and will remain ongoing as needed. Any current clinical employees who did not attend the educational session have been suspended and required to attend the next scheduled new hire orientation class. If the employee does not attend the scheduled class of new hire orientation the employee will be terminated. This information would be documented per the Progressive Discipline Policy.
All restraint/seclusion episodes are audited for documentation to include, description of the event, de- escalation techniques utilized prior to the restraint/seclusion, type of restraint, potential or actual injuries, timely physician notification and orders, staff and patient debriefings, Mass scores, 1 hour Face to Face assessments and notifications, and completing and submitting an incident report at the time of the event. The new audit tool has been developed and was implemented on 11/30/23 and is the responsibility of the DON or designee and/or the HIM director.
Staff are educated on the investigative process when any concerns are identified or reported. The procedure for implementing and completing a full investigation when actual or potential non-compliance has been identified that places patients at risk for harm has been reviewed and is the responsibility of the Human Resources Manager, Quality Manager, the interim Director of Nursing. Education was performed on 11/28/23. The education addressed immediate suspension pending the results of the investigation, video review, timely interviews and statements from all staff involved and the patient by the psychiatrist, and termination and regulatory entity reporting as needed. Policy HR029.01 Progressive Discipline has been revised to identify additional grounds for disciplinary actions up to and including termination i.e., Failure to document and enact non-physical interventions prior to restraint, speaking in a hallway or other patient care areas about a patient in an unprofessional manner, failure to report potential or actual abuse and neglect, and acting outside scope of license (MHT's or LVN's initiating a physical restraint without an RN or MD order) . The Abuse and Neglect policy had been revised to include staff accountability for inappropriate and non-compliant conduct during restraint/seclusion episodes and failure to report any potential or actual abuse. The revised policies were approved by MEC/GB on 12/4/2023.

During the educational sessions regarding restraint/seclusion, the policy is reviewed and discussed in length with the class to ensure staff understand the policy and the step-by-step procedures to be followed anytime a restraint/seclusion is required. The class emphasizes that the processes for the use of any restraint/seclusion including physical holds is only performed when "Imminent danger" of harm is identified that could affect the patients and/or others. de-escalation techniques, including verbal de-escalation, time out rooms, and giving patients space and room to breathe. prior to implementing escorts and physical holds. The use of "The Modified Agitation Scale Score" (MASS) is discussed in length to include purpose, procedure, documentation, and requirements on admission, during each shift assessment, and as needed during inappropriate patient behavior, and prior, during and after all restraint seclusion episodes. Staff also discuss non-pharmacological and pharmacological interventions utilized according to the MASS score to prevent the need for restraint/seclusion. Staff are educated on the roles of the team members if restraint/seclusion is implemented. The rules and regulations defined in the policy are discussed in length. Timely notification of the psychiatrist is stressed, and the need to notify and document the attending psychiatrist as soon as possible if the on-call psychiatrist was notified at the time of the event is stressed. Restraint documentation is reviewed and has been updated and approved by MEC and Governing Board on 12/4 that allows the staff to identify all procedures i.e., obtaining orders, 1 hour face to face by appropriate discipline, and timely notification of all required physicians, The form prompts staff to perform and document the required elements of event. The education is the responsibility of the hospital educator, interim DON, and CCM instructors and implemented on 12/4/23 and completed on 12/16/23. All restraint/seclusion episodes are audited for documentation to include, description of the event, de- escalation techniques utilized prior to the restraint/seclusion, type of restraint, potential or actual injuries, timely physician notification and orders, staff and patient debriefings, Mass scores, 1 hour Face to Face assessments and notifications, date and time and completing and submitting an incident report at the time of the event. The new audit tool was implemented on 11/30/23 and is the responsibility of the DON or designee and/or the HIM director. Staff are held accountable per the "Progressive discipline policy. The HIM manager or designee audits charts for physician documentation compliance and failure to comply with policy and rules and regulations of regulatory entities, Non-compliance is addressed per the Medical Staff bylaws. Audits are performed Monthly, with delinquency alerts are sent bi-weekly.

The restraint and seclusion education curriculum developed in 11/28 includes a policy review which is discussed in length with the class to ensure staff understand the policy and the step-by-step procedures to be followed anytime a restraint/seclusion is required. The class emphasizes that the processes for the use of any restraint/seclusion including physical holds is only performed when "Imminent danger " or harm is identified that could affect the patients and/or others. Per the policy only a psychiatrist or RN may implement a manual physical restraint (physical holds/Escorts) and if the patient does not require any additional restraint/seclusion interventions a qualified RN may perform the 1-hour face to face. The psychiatrist is notified at the time of the restraint event if the intervention was ordered by a RN and post the 1-hour face to face the qualified RN performing the task must notify the physician (Psychiatrist) of the post assessment and status of the patient's condition. Documentation of any orders obtained during the notification including date and time is also discussed. The timeline for performing the 1-hour face to face is stressed during the education. The education is the responsibility of the hospital educator, interim DON, and CCM instructors and implemented on 12/4/23 and completed on 12/16/23. All restraint/seclusion episodes are audited for documentation to include, description of the event, de- escalation techniques utilized prior to the restraint/seclusion, type of restraint, potential or actual injuries, timely physician notification and orders, staff and patient debriefings, Mass scores, 1 hour Face to Face assessments and notifications, date and time and completing and submitting an incident report at the time of the event. The new audit tool was implemented on 11/30/23 and is the responsibility of the DON or designee and/or the HIM director. Staff are held accountable per the "Progressive discipline policy. The HIM manager or designee audits charts for physician documentation compliance and failure to comply with policy and rules and regulations of regulatory entities, Non-compliance is addressed per the Medical Staff bylaws. Audits are performed Monthly, with delinquency alerts are sent bi-weekly.

The restraint and seclusion education curriculum developed in 11/28 includes a policy review which is discussed in length with the class to ensure staff understand the policy and the step-by-step procedures to be followed anytime a restraint/seclusion is required. The class emphasizes that the processes for the use of any restraint/seclusion including physical holds is only performed when "Imminent danger" or harm is identified that could affect the patients and/or others. Per the policy only a psychiatrist or RN may implement a manual physical restraint (physical holds/Escorts) and if the patient does not require any additional restraint/seclusion interventions a qualified RN may perform the 1-hour face to face. The psychiatrist is notified at the time of the restraint event if the intervention was ordered by a RN and after the 1-hour face to face the qualified RN performing the task must notify the physician (Psychiatrist) of the completed post assessment and status of the patient's condition. Documentation of any orders obtained during the notification including date and time is also discussed. The timeline for performing the 1-hour face to face and notifying the psychiatrist of the post assessment is stressed during the education. The education is the responsibility of the hospital educator, interim DON, and CCM instructors and implemented on 12/4/23 and completed on 12/16/23. All restraint/seclusion episodes are audited for documentation to include, description of the event, de- escalation techniques utilized prior to the restraint/seclusion, type of restraint, potential or actual injuries, timely physician notification and orders, staff and patient debriefings, Mass scores, 1 hour Face to Face assessments and notifications, date and time and completing and submitting an incident report at the time of the event. The new audit tool was implemented on 11/30/23 and is the responsibility of the DON or designee and/or the HIM director. Staff are held accountable per the "Progressive discipline policy. The HIM manager or designee audits charts for physician documentation compliance and failure to comply with policy and rules and regulations of regulatory entities, Non-compliance is addressed per the Medical Staff bylaws. Audits are performed Monthly, with delinquency alerts are sent bi-weekly.