HospitalInspections.org

Based on medical record review, facility policy review and interview, the facility failed to notify one (1) of four (4) patient's family/legal guardian about the need for restraints.

The findings include:

The review of four (4) restraint records, revealed that Patient #6 was ordered and administrated Haldol (antipsychotic medication) 5 mg (milligrams) on May 4, 2025 at 10:21 PM, due to hospital onset delirium. Patient #6's medical record failed to contain documentation that the family/legal guardian were notified about the use of a chemical restraint. Patient #6 had three (3) family members listed as points of contact in their medical record.

A facility policy titled "Restraint and Seclusion Management- Most Restrictive Restraints", last revised February 20, 2024, was reviewed and revealed, in part, "...Restraint Application...17. Contact and educate patient and family/legal guardian, when possible about the need for restraints and document communication..."

During an interview in the afternoon of May 14, 2025, Staff Member #1, explained what "when possible" meant. Staff Member #1 indicated that this means that if staff are able, they will inform the family/legal guardian right away. If staff are unable to inform the family/legal guardian right away, it is expected that they will be informed as soon as possible and this will be documented in the patient's medical record.

Based on observations, medical record and facility document review, the facility failed to obtain a physician's order for physical restraint for one (1) of nine (9) patient included in the survey sample.

The findings include:

On May 13, 2025 at 3:15 PM, the surveyors and Staff Members #1 and #3 reviewed the facility's surveillance video footage (no sound included) from the Emergency Department (ED) on March 24, 2025.

The video footage revealed at 8:01 PM, Patient #2 with a security officer in the hallway of the facility's ED. Patient #2 was observed waving their arms in the air, jumping up and down and wandering through the hallway. The security guard was observed speaking to Patient #2 and gesturing with their arm and hand for Patient #2 to return to their room. Two (2) other security officers arrived to assist with the situation. Patient #2 was observed posturing their body in an aggressive manner towards the first security officer. The second security officer touched the left elbow of Patient #2's arm. Patient #2 reacted in an aggressive manner and all three (3) security officers placed their hands on Patient #2. The three (3) officers and Patient #2 went down to the floor as a struggle ensued in an attempt to restrain Patient #2. The three security officers were able to gain control and restrain Patient #2. One (1) security officer was observed rolling away from the struggle on the floor and was seen standing up and walking away. As the two (2) other security officers were restraining Patient #2 on the floor, a Respiratory Therapist (RT) entered the hallway walking towards the two (2) security officers and Patient #2 on the floor. The RT walked around the them, bent down and placed their hands on Patient #2's legs to further assist with restraining Patient #2. A Registered Nurse (RN) entered the hallway, bent down and placed their hands on Patient #2 to assist with the restraint. The two (2) security guards, the RT and the RN restrained Patient #2 on the floor until the local law enforcement arrived to the scene. Patient #2 was escorted back to their ED room.

Patient #2's ED timeline summary documented on March 24, 2025 at 8:14 PM, "Pt seen to be wandering around ER. Primary RN and RT attempted to redirect pt to (their) room. (Their) behavior became heightened and (they) began to be verbally aggressive. Security was called to try to redirect (them) as well. (They) became even more verbally aggressive and started to cuss at the staff member. Back -up security was called and while they were on the way, security attempted to use handle with care techniques to maintain patient and staff safety. Pt behavior heightened further and (they) continued yelling and cussing. AA called (local law enforcement) for back up. Upon their arrival, pt was escorted back to (their) room with security and PD assistance".

A review of the facility's policy "Restraint and Seclusion Management - Most Restrictive Restraints", last revised 2/20/2024, indicated in part: "Most Restrictive (Violent/Self-Destructive Behavior and/or any patients with 3-point, or 4-point, restraints): Any mechanical device utilized for the indication of excessive and unanticipated violent/self-destructive behavior, with intent to harm, which jeopardizes the immediate physical safety of the patient, a team member, or others...Examples include but not limited to...Physical Hold...Procedure: If Non-Restraint Intervention Fail: Caution: Restrain and/or seclude immediately...Notify physician immediately for an order...Restraint Ordering...10. Give the order for restraint an/or seclusion - Provider credentialed per Medical Staff Bylaws...11...Order must be written within minutes...".

Review of Patient #2's medical record related to this ED visit and subsequent hospitalization March 24 - March 25, 2025 revealed no evidence of a physician order for the above noted physical restraint.