CONFIDENTIAL
DONorcon . uoNarsmIE
DO Ivar FILE m: MEDICAL Astana

(NW LOW Vii
IRM, IncIaenI we a 
IRM) SIgnIfIcance /Ssven(y ,7

IFMI UaIs Renewed 

BH DIV on~H

  
 
   

mom

P: 

           

 
 

EALTHCARE PEER REVIEW REPORT

 

 

      
  

   

Um Elm U'n Um

       

   

Iong mm permanenuy uI resul'ed In deem

  
 
 
   

angbuse 37, 
I DWImnge a Panenwm
DangI.Iea,caImmaI Emu 
warm I

El 

El Swag Gesmem

El Sume AIIempHs;

Afler DIC AnemplImI

Beam El 5mm:qu 
El News: I

     

mm mm (I 
nay Atevmn mam I  7 I
I I TIME: I DAN 35M 
DAV. 2% Elm Event: Nauflesk 

  

anylme Worslnegawenulcome 

I I: Oaseweduisv

PaIIenl Repuned - unobserved 
Founc on FIoor- Unobsewed (BI)
El O'J'ev IsbI

  

 

After DIsCharge Deam
El Huwmwam El smaeuzm I
I Medca' DeaMImz' Cl umermm
El Charge In Common um
I HaspIIaI InIecIIon I73:
I 
PIubIemIInmdenI the In 
MechamcaI ResIIaIm ancmr Samson II3I

El Duty to mm
El AMA DIscharqe 
SEXUAL ALLEGAIIONS I
MscawuusI DPWI Elm,
UyIangeIPLaz
I CI InIE'couIss 
I Elsnenga-IPI [as

DAssaqunzpaElPqus) DvIsvaPum}
Isa,
AOnFInnefly Aon Properly


Sexual M'scandum by PalIeflI toward sun Mam

I Baundaq Violation
VerhaI/ Non-Aggressive

 

I CI Wang LareIIsm
mm
MIA 5 hereI

D'I'Irung Memcamr IszI
Jestred 45'

 

 

HE.

LasI.pccmemsa El mm: mm
El Em
El 924mm

El omen>>

Found/Used

I O'eekec Med:-

EI Pvesc' more


 

  

Rear Frcbem I

 

     

.eaaum 42'
:4
Olher mm Descnbe

INFORMATION MANAGEMENT
El sveacn DIConfidenualIly 

El Breach II25I

El Consent ideas: aIInIo etc
mama AIqupEIIyGIven

I Key DSecu/Ily Breach :azI

 

Breach [Ian

I Key UHostagE mum
Returned MIssmg (M) on (JSI
D<30mmsIZIl I Bothemm]

an nuns 12mm) 24 hours (IEI

NoIReIumemm
ResuIl ASeanIMsauIt 
Found'm Unaumanzea Area IzzI Wm

LacaIInn

El Drug 
:1 MISCELLANEOUS IBBI

 

 

 

I 
Dower 8 
7 CUSTOMER THREAT 0F
CIMedcaIIcn ADRIJSI 
'ii' CompIaInam Nam 

[IO-name:


Re Asm 

 

Issne 
Daemmes Uiewcen'z'

I more Echam

 

Refer/ed In me

 

I TUIENTINJURED I

 

Hm I
AMIsuse Anna.
Enumen- Ina

3a Checked ReannIoFDA


P: Property El DzmageLZBI El 
DsmIenm) IIsm I
Hosp Prop El El I
El smIen Ilen' fl 
I FIrev El Accmem an El 5a Dy pauem 
El Damage by paIIentIKS) 
I PHYSICAL CONFRONTATICN
PIanacked El Sunny) PanemIIazI
VISllor (133)

Pt attacked by/ El Slafl (I34) I: (135)
InImed by El VIsItar (us) I


fiPaIIem 0M olCamroI (27)

 

I AwaIImcIIun aDIe

 

 

   
       
 

    

RE--INCIDENY MENTAL STATUS I an! Faramelers

     

 
  

    

 

SIeepmg(ID) I IsuIaImgIIn ConmsedIs, El cooperatweI Manna) El Impaired by SuosIancesIaI El Unconscmusm
I Cunperahvem El Sad/TearIuI MI Armous may i Aggrasswe IIBI El UseIaI El __fi
I WIthdIaWn mm I7) I L1 CombatIvsIZflI Nun-Cnmmumcahve (13] I 



 

BEHAVIORAL HEALTH DIVISION Heallhcare Peer Review P393 2
D. TYPE OF INJURY (Outcome)

    
 
  
  

  
       

 

.
AI'ParentIIeI A Exammed A No| Exzmmed Injury Involved 993'" 
'flfl! '3 Scramh El cm I2) El aumIIaI or I: Puncmre (15). by
BruIse andInr EI SpraIn (11) CI El Fracturem El DIsIocaIIan(mI El DIzzmesSIeI

Reddened Area II) El FamIed (5) El Seaman) ConcussIon (SI El Damaged 79997 115)
E1 Loss oIConscIousnessrduem an mm W, Oman") 7

     
        

I F. INCIDENT 
El ResmemIaI I: PanIaI mm mm: I
Day T'eanrenKIIZT, 

. IIan
SIudenI maI

 

I SOumatIenmzaI 7 7 7
Emer em I29 Pahenl'sRoommate/Olher 
9 PsIIenlNamas' 7 77

CI GIOUP Home ECT I: swam) aficgm'gg'sm

 

      
 
  

 

I
El PdIIenichm #anatwn {ma} EI may/Locauumm El Group Room 
El Bathroomum) HaIlway/LocaIIunImBI 3; El SchoaII a)
or El EI TherapyOI'IzcemI
'3 PIaygmundImaI EI Seclusianha) DncIur'sOmoemsI
EI CummunAreaIOs) El 
El OTIRecreauunaIImsI Nursmg SIBIIDMHS) omerm A

 

 

     

JURY cnussn a
I DAchdamIeI DSIBMI DEqqumenuEmImnmen

 

 

II IanIcted Home", zfi/AIzzI

 
   

 

TREATMENT 0R GIVEN

 

Tvealmem Reluscd I, a New my I: pIacec on I I II II may (10] Charges PRN Memcaum (232) ER mm 7 Pressed (OIhel (7) 7 TransIenu MedI'Swg (I2) I207 
A umt ResInctIcn Hosp fl [1 mum
EI Resm I manna": SeIecI ALI. IntenerI ms used Ior Im en! ram>>: LL Inlemnuans In 
MSleResIraInlmI EI MecnamcaI SeclusIDnIIE] EI ChemIcaI ResIreInI [21)

NameIsI or sun SpecIaI Trealmem IntervenImrIIs)

RamIndEv: PnysIcaI Ruslrainl/ Mechanical ResIraIm/ SecIusIon/ cnquI Rlitraint nquiws an Iom compleIed and submmed with HPR
4.7 uo-nncmou or mvsucmmuwnm: K. NAME or WITNESS AND 
Physician/LIP (23)

 

    
  
  
     
 

   

 

 

   

M. FAMILV:
A PaIIenl A FamIIy AnImde Aner Event:
mm EIAngryoBI
ndelslandmg CI Threatens Sun 43m
Conperawe um Other 

NAME 

 

   
    

     
     
 
    
 
 

Mainmunce (25)
Pulioe/Firl 

WFamily (2s) g74C777 

othur (7)
(22I

   
  

Administralmn (25)
ManagerIIszI
ngram/Unil [233) a m)
Czse Manager MIA 

DpatIemExammedmny AMedicaI "22,

PhysIcIan/LIF
swam (opqonamw Belem) No Response/'Irealmem Required (53)

 

 

 

 

 

 

 
   
  

 

 

7 Reviewed by Supervisor Risk Manager
RM Prim Nama'
Da|e Reviewed
RM qunamIe

  

 

 

 

Dale'  

Do NOT FILE THE MEDICAL RECORD EH "15619de

 

Shadow Mounmm Bchmim'nl Hcallh Swen. - 


mr,?wl if

   

 

   

 

5pm". 1 h" y":me

  
  

Twe Inukunun flma: 
\mem myDai'l'gfig Twigs}

moumm Swgnamrf 7 Daze 7 7 mm

IORB Psmuams:

 

RJN (Fim he done within 30mm)

fl (musk $110 3%
7secmmn 31/94 Egg 

CH :caUushficztxon furlmenertn Dangerm sar 
?p 133mm mm :d "41Turenennans Auempxed My 

flacOnnm actwu) prom-3mg

 

 

 

   
 
  

 

 

m'rume awn)

 

 

7 sum) ouemauon Que! um: Sumuhn redutnon
Msu'lcauan ordered durm; Php'vca} R:s:ramL'Seclusmn :(un Blue msmun order form) 
'7 dug" in Dos: mum-Jon 7 no: Rum: h'dxcaucv

 

   

R: mu;

Flume Mdumwnv

 

no lash mlervennuns :mempled 7 7 7 7 7

 

Mm flu; Proccs: filo mm! mm actinns mes beu'g combame
Verbal!) Comracrs for Satan \0 5ch Verbal 'Cunnacls far Safety to omers

 

 

for 
7 Cumpham uh rsquem

 
 

Pm cm ofcmena fur sc, 7.7/7? 7 7 

hues abuse Assues that uau'd unpack use afreslramr use" 7 Ye: 7/6
ph}5.tfll am: or tflr-dmmed 77 7 7

Tvme 

 

Am' dmb.
Dewbe scum) [am to was

i  77' Mqu

   
 

 

    

 

 

93H 

Slludo" Mountain Behavioral Heilkh 53318111
RNIminL'SL-clusion 
Page 2 on

GENDER 

 

3. LIP inimcnnon Euluanun (This nsVehsmeni to he cumplutd wlhin 1 hour or inicrvemionl:

a anon. sun H1 resiraim se

     

   

'isiur ur rehascd. etc) ,b

7% MM 7


u, Pniicm's reaction [0 imervenl' n: (posiu' 'negzuve bchavmrs, any adversc
.

 

response e2

   
 

 

 

C. hysicnl'medlcalslams:
Mam Aeniinng\x'NLfefimimonequaim ailenremities /Sku1|mzi:l

sys|em imach otor fimcimn equal [0 all exlremiucs

minds nninn narmal iimns 5p: Pulse 7 Resp Raul; Explain any areas nm WNL Am 

Complain! oflnjury sustained from iniervenuon Jesznfirpresenz, describe inJury and mmrventim<

 

 

 

 

 

1: Current mental slalus:
Mnod iEumymic iDepresacd iEuphonc __Anxmus  Imiabic Omar:
Affect Non-rial (fibile Restricted Blunted Flat iOthcr

o. ienzan'on in Jason M, Situation ilfnoL Cxplain
Insight 7 Quad our

E. 


7 Other
Undhle [0 control behavior 7 CombativciAssaumve i Resisiani Agnmd i Demanding, Vening
Selfrharm behavior cn mg, Guarded Other

 

 

 

5' Based upon systems review, behavinrsl and review oi recent Inhornory resulls, hismry, 
drug 111511"an mm any [actors (o patienvs violenl or minim?
No Yes 7 Ifyes describe.

 

 

 

 

i (medicaiian) ch- Giv: Ralionaie'

 

G, Continued nerd far restraint/seem A

 

 

Hi Guidance provided to sun in Idem")ng ways In help pa nt gain control: (6 7 Yes 7 describe

Tm I Ves RefzrredloTx

RN Signatur. Dateq Time 5 ED
wuh whom this evaiunnon was reVleWEd' '3 JEA
I:

Pin sman Tm

 

 

 
 
  

 

979-14 kid

 

Maumain Behzniv Hcahh 53mm

 

Reuraum
Pug>> 3 of 

 

clumm Urdu/Record

 

  

   

 

    

 

4 
Pazcm Farm 5 Membcr nomim' ohmcnenuon ./mn mm nonfird Mtg":
Anempied unab'c due 7 7,
Date una ofnulificaxion or unempx villg @007
7 Na E\p|am 7 Pa is niul' and no nonficanon mm
7 omer_ 
Altendng ph} man ufmtenenuon 7 Yes Dmer'ume 7
uhom 7
pmudm order and. or recewcd repun 

5 Termmalion/Pnn-lnlervL-miun Tm onenmnauon: row Tu'ne onmervenuon; :(fiu/ I

Behavmrramouonal mus at termination

SQW

 

     

Phwica slutusatlermmanon fun,>> unac: xCEulaKiUn good 

Am complaxmsohmunes orpaln anociaxed mm ch, umnbe InJur) and imenemion.

DaIs'Time all '4 5 $01)

 

 

 

9.944 

Shadow Mountain Bchmioral 535mm

0rd" Record
Page 4 M4

 

 

Patient Debriefing

be ramp/mud rifle! mmnm. mm mm mmed bm rm [mar Khan 24 hour;

  

Date [STune me
Famfly lmolvedmde'nuefin; fifi Yes Name' 

Panem's leading 10 mman


 
 

2) Pauem's of happened to mug: behzwom' L,
A 
,7   

 

unvercnuy.

 

 

 

a) Panem's perception mm mum have been 9;

0 .7 Z: 
4] DA pznem fee' hws/ncl wellrbemg. comfun and mm; m: mammned" No, explazn

 

7 Na Nye: amnbe 

 

5) m; any Imumanpenenced by putmm 

6) Strategies prevem repeat use ofmtervennon and/or to facmrs contributan inmdenx:

    
  
   

 

Strdieglesaddedlolreatme Ln '1 lfnox Xpiah
\cfing 
DaxeTxme L. 605'

thmeme 31'  

MHT Signalurc

1w Signature 7

979714 

Patient Record Staff Debriefing Form

Late of n; (NO Patient tdentitrer on Form) Gm" 
7th armada" tw n.  w.  
EzgleCreek HOPE ACE TRACE NW. South 

To Be Comntered av Stan Involved and On Duty 2t Ttme 
(I

rtEIiWiS ted to the senavrar'r "flan  




2 What behavterat escatattons were no pnor restraint/sectustun7
DPectn; Wettnreats anemandrn; 
the' .

3 What base need was the resident trying to have rnet7 a Safety Attentran a :1 Acceptance Center

:1 hurger Need Emotsonat need El ther
How was this need met? 0 

4 . e: cuu'd have prevented the restraint/sec'uston7
AM a tentathres were exsavsted El :t interventron s'afi' El onerrng time out
CI stgr's O'esca'attor' saoner Remuvtng the audience Cl .ent tn activity a patenter

:l Otne.

Jgfierventtons used before managemenUseclusron
Processed with patient mega use at Contng tdentrred on PC z'flage Patient to Engage Retaxamn

0 Encourage Sett~TtmeOut Remavetrom Stimuh thmternetrveserrpesm

Staff Directed Time Out Dtversiun/Redtrecl Attention Medtcattun
DUnaate to draw tess attematrves dde tn sudden unset atdangeruvs patient benavror

6 What coutd have been done during the restratnt'sectuston to make the pattentdeescatate more mare it end

sooner or be tess 0 Not to obscenrtres/msutts El Havetusi one person talk to the patrent/afiotmng
argung the patent Change start member to the paltent Remove the atovaktng strmutr Other

 

 

        

 

 

 

7 Did the restratn'vsectusion eflecttveiy prevent patient from further harming setflothersHow did this impact the unit and other patients? '2 tncreased cnadsan UNI tncreased orsaretvtor peers EIMade
peers teer frightened Peers staned acting out as wettaflas removed and unttsetited Other

 

9 three attematives that could have been utitrzed instead of the SIR

 

 

 

 

 

 

A


Partici 
Name W'flfi Date 0'49"; Trme' ISOC)
Name Date Time
Name Date' Time
Name Time

 

Signature at staff campteting the debriefing (Mm:

Administrative Reviewer:

sumo" mom-uh BEHAVIORAL HEALTH SYSTEM

AUDIT TOOL

DENTIAL 7 NOT PAW OF THE FA HEM RECORD - DO NOT COPY

ee- 
Typeollntervemian.' Wcamestramt mm"?

Time! Time Tnanlmefinmmutesp:
{9 
Unillegrim'

5 
To be comp'eked (or each episode 0' sec'uslonhesuaml by the UM Manager/swarms: and 10Mald (0 We PV depl when oompVEte

 

 

 

 

 

 

Name on

 

 

 

 

REQUIRED ELEMENTS Yes No MA Commerfl
Documentanon reflects that pahent was an senor omevs 
2 Documentauon mdmaxes lhaHess meaeuves lavled orweve not 9/ a
3 Documentation desennes me penenx beneder 
4 descnees stafl mtawenlvon max led \0 me sec'uswon ov vesdamt at me [we we 
5 The erdeuenens (he 2/0 
5 Was me auendmg named dune episode 
7 The panem was evaxdmedvaeexo laceby {a 
a The up completely dommenled me assessmem on me One Hour Face to Face Evemdudn Ednn 9/ 
9 Appmpuale checks were documemd every '5 mmules on me Secluslon a. Restraint Documenlahon 

to The panem was assessed ton

a Humhun/hydvafiun

vital signs

hygxene elimma'mn 

a A stews

readmess dxscanlmualion 0f restraml seduslon

1 Signs wry/pan
11, creay (elease mend documented p/ 
12, Dues documenlainn dearly railed need '0 wulmue 01 discontinue "5&7 3/ a
13 Order dmainea worn MD to conunde res|ramvsedusion at the end no me ongma' ovder 41/
UP conducts another facerlorlace evalualmn ll'he duration exceeds 7 ,6
15, Panenrs lamny or guardian notified 
16 demeth was cummeled 
17 Pauenr debnefing was competed 24 hours ot me epwsode if" E, 
18 Hospdal Leadersmp nas been nauned we pauenr has 2 or more SIR mtervenllons 2A hours 9/  
'9 Make 2 copy 0' me Reslramt form In put in chart Mark as fl/ 

,Revvewed by Date

Revxsed 6/2013

 

mam: 1y
SECLUSI OB

   

 

 

   

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MUST BE MAENT En DURING 0R 
15 Mmma 
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"rams n: ma spam alumnuufibe In: pan-m 1' 
Em: hnmarmry 1s Inlan am by 1:1 um 15
was: sum! tie-"Wu! 5191.. . '5 mm mm
'Mmia n15 mama-m. an mun-slugs - i a a (an - a1 mailman-u
Min-n: plflanl(Inn-.15)
1 nus-:1 wary 1 haur 1/553 (if

 
    

 

 

 




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