HospitalInspections.org

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure physicians provided medical direction/supervision in the emergency department (ED) related to the use of physical restraints for 2 of 4 patients (P48 & P51) who's clinical records were reviewed.

Findings include:

Review of P48's clinical record indicated the patient was admitted to the ED on 2/10/18, at 4:17 a.m. and discharged on 2/10/18, at 4:20 p.m. The admitting diagnosis included restlessness, agitation, alcohol use and accidental drug overdose. A physician order was obtained on 2/10/18, at 4:24 a.m. to initiate 4 point soft restraints to extremities for violent behavior. The order included a duration of up to 4 hours. P48's initial admit behaviors included spitting, swearing, uncooperative and combative towards staff. P48's restraints were discontinued/ removed on 2/10/18, at 1:00 p.m. There were no renewal orders obtained by the physician after the initial 4 hour duration to continue the 4 point restraints. Review of C48's 15 minute monitoring log indicated the patient did not exhibit violent behaviors and had been sleeping from 6:30 a.m. to the time the restraints were discontinued at 1:00 p.m. P48 remained restrained during this time.

Review of P51's clinical record indicated the patient was admitted to the ED on 11/22/17, at 9:00 p.m. and discharged on 11/22/17, at 11:26 p.m. P51 was 17 years of age. The admitting diagnosis included restlessness, agitation, hallucinations and lysergide (LSD) poisoning. A nursing data flowsheet indicated 4 point soft restraints to extremities were initiated at 9:02 p.m. for violent behavior (aggressiveness). There were no physician orders found in the medical record for the use of restraints. P51's restraints were discontinued and removed on 11/22/17, at 10:15 p.m. /

Interview with the ED manager on 8/29/18, at 2:30 p.m. confirmed the above findings. The ED manager indicated physician orders should have been renewed with the continuation of physical restraints for P48 as well as orders for the initiation of restraints for P51. The ED manager further included all staff and physicians have been trained on the policy and procedures for the use of restraints/seclusion.

Review of the facility policy and procedure titled: Restraint or seclusion (undated) included guidelines for the appropriate use of restraints for violent/self-destructive behavior: (1) when a restraint is initiated a physician order is required and obtained within 1 hour of the application of the restraint; (2) a new physician order is obtained if the restraint is continued beyond the timeframe of the original order; (3) documentation of the restraint in the medical record includes notification of the use of restraint to the attending provider as well as obtaining orders for the use of the restraint; (4) review of the appropriate data is collected and obtained on the use of restraints and analyzed for compliance with the facility restraint policy.