HospitalInspections.org

Based on clinical record review, observations and staff interview, the hospital failed to ensure that it developed policy /procedure for the safe operation and care of patients using the Emergency Department's (ED) "security holding room". This occurred in 1 of 1 sampled patients (Patient #1) using this room, in a total sample of 6 patients; and has the potential to affect any violent, combative or verbally disruptive patient(s), from the local community, coming into the ED.

Findings include:

The 7/11/13 clinical review record of Patient #1's ED stay documented that Patient #1 was brought into the ED per cart, restrained in 4 point (each extremity) leather restraints, after demonstrating threatening behaviors at a non-hospital based clinic that was located on the hospital campus. The triage assessment documents that Patient #1 is "...agitated, anxious, crying, restless, combative". This patient was taken to "Bed D1". The nursing "assessment" notes reflect that Patient #1 was taken into this room at 5:04 p.m. and remained in 4 point restraints until 6:15 p.m., when assisted to the commode.

At approximately 1:30 p.m. on 7/11/13, in interview with ED RN (Registered Nurse) F it was stated that Bed D1 is the "security room". RN F stated, at time/date of tour, that this was a "1:1 (patient to staff ratio) staff room for combative or screaming patients, or patients that would be disruptive to other ED patients.

At approximately 1:50 p.m. RN F provided a tour of the ED "security room". Observation of this room reflects that following: This room is segregated from the ED by double doors and a small corridor. The room is a approximate 12 x 12 feet concrete block room, which is surrounded by a larger anti-room space. The anti-room space contains a desk and chair situated by the security room's single viewing window, which can be used for viewing patient inside room. There is also a device for audio monitoring on this table. This room has a windowless door with no visible lock. In this security room there is a metal toilet with no visual privacy, and a metal and cloth covered office chair. The inside door latch, which is one continuous unit from top to bottom of the door, has a ledge on it's the top where something could be looped and held in place, and would not be considered suicide preventative. The chair in the room could easily be picked up and used as a weapon. The metal toilet has no lid, and it's edges could be used to inflict self-injury.

In interview with Director of Emergency G on 7/11/13 at approximately 2:30 p.m., the Director G was asked for a policy or procedure that directed staff on what types of patients would be appropriate for treatment in this room, what type of monitoring, assessment or supervision was required for ED patients put in this room, and who would be allowed to provide the monitoring, assessment or supervision. Director G stated that the hospital had no policy or procedure for patient monitoring in this "security room holding area".

Based on clinical record review, hospital policy review and staff interview, the hospital failed to implement hospital policy when using physical restraint for 1 of 3 violent patients (Patient #1) coming into the ED (Emergency Department). This occurred in a total sample of 6 ED patients (3 violent and 3 non-violent patients) using restraints while receiving ED care and services. This has the potential to affect the entire hospital community utilizing the ED.

Findings include:

The 7/11/13 review of Hospital "policy 04782-Restraints and Seclusion" under "D. Restraints /Seclusion for Violent or Self-Destructive Behavior" documents under
"1. Before a restraint is applied, attempted alternative are considered or have been attempted and are documented.
a. Document behavior or events leading to restraint and the alternatives attempted.
b. Document patient instructions regarding the rationale for restraint and criteria for release.
c. Continuous direct supervision (1:1) is required for any patient in restraints for VSD (Violent or Self -Destructive) behavior.
2. Initial Order
a. LIP ( Licensed Independent Practitioner) does a face-to-face evaluation as evidenced by their signature on the restraint form: Restraint /Seclusion for Violent or Self -destructive behavior.
i. The LIP's order must be time limited as follows:
i. Adults 4 hours...
b. In an emergency, an RN (Registered Nurse) may initiate restraints based on patient assessment.
i. After assuring the patient's safety, as soon as possible AND within one (1) hour, the RN will consult with the LIP about the patient's physical and psychological condition and obtain a written order.
c. LIP or educated RN or PA (Physician Assistant), must provide a face-to-face evaluation of the need for continued restraint within one hour after the initiation of the restraint and signing of restraint/seclusion for Violent or Self-Destructive behavior.
i. The mandated 1 hour assessment is still required if the intervention is ended prior to the 1 hour face -to-face timeframe.
d. Documentation will occur at least every 15 minutes or more frequently as the patient's condition warrants to assure patient safety.
i. Signs of any injury associated with the application of restraint.
ii. Nutrition /hydration are maintained.
iii. Circulation and range of motion in the extremities.
iv. Ensure stable vital signs.
v. Hygiene and elimination needs
vi. Physical and psychological status and comfort
vii. Readiness for discontinuation of restraint
3. Reassessment of Continued Use or Discontinuation of Restraint
a. Every hour and PRN (as needed), the RN or LIP must evaluate the need for continued restraint and document on the restraint flowsheet for VSD.
b. Every 2 hour vital sign monitoring is required...
i. Document the discontinuation on the Restraint Flowsheet."

The 7/11/13 clinical review record of Patient #1's ED stay documents under "assessment" that Patient #1 was brought into the ED per cart at 5:04 p.m. on 4/30/13, restrained in 4 point (each extremity) leather restraints, after demonstrating threatening behaviors at a non-hospital based clinic that was located on the hospital campus. The following "nurses note" under "assessment" are documented by RN L documents:
5:04 p.m. General: Patient was brought to security room per Charge Nurse N.
5:05 p.m. General: Patient arrived in security room with restraints placed.
5:20 p.m. General: Appears condition is unchanged, patient is laying on bed with restraints placed, writer is directly at bedside,capillary refill less than 3 seconds to all extremities.
5:50 p.m. General: Patient condition is unchanged, capillary refill less than 3 seconds to all extremities.
6 p.m. General: Appears patient stating I have to go to the bathroom (to spouse). Writer then asked (patient) if (patient) had to go to the bathroom and (patient) verbalized yes.
6:05 p.m. General: Writer consults with PA (Physician Assistant) J over the phone regarding removal of restraints, PA J approves removal of restraints.
6:05 p.m. General: Patient's condition is unchanged, capillary refill less than 3 seconds to all extremities.
6:15 p.m. General: Writer removes restraints with assistance of EST (Emergency Services Technician) M and assist to commode in room."

At 5:42 p.m. the "triage assessment" documented by RN L, who gives this patient a triage level of 3 (non-urgent), and continues to document:
" 5:50 p.m. General Appears uncomfortable , obese, Behavior is agitated, anxious, crying, restless, combative. Pain: Complains of pain in anterior aspect of right shoulder and posterior aspect of right shoulder pain does not radiate. Patient states "My right shoulder hurts".
5:50 p.m. Neuro: Level of Consciousness is awake, confused."

Under "Psych" RN L documents:
"5:50 p.m. Objective: Patient is uncooperative, aggressive, combative, defensive, speech is loud, patient continues to scream loudly with no apparent words or sentences...".

Under "Administered medications" RN L documents at 6 p.m. "Follow up: response: Patient begins to answer questions appropriately and states to writer that (patient) will cooperate with staff. Patient's voice is even, normal volume, and (patient) is making appropriate statements when answering questions."

The 7/11/13 review of the ED "Physician Note" PA J documents that "this patient was seen only by mid level provider" and that the patient was medically screened at 5:17 p.m. This patient was not given a definitive final diagnosis by PA J during the ED visit. The patient was discharged to home at 6:31 p.m. after PA J consulted with the patient's psychiatrist.

According to hospital policy, there was no evidenced documentation that Patient #1 received instructions regarding the rationale for restraint or criteria for their release. There was no documented evidence that the LIP did a face-to-face evaluation using the "Restraint/Seclusion for Violent or self -Destructive behavior" form and signed it as the hospital policy requires. There was no documented evidence that the LIP performed an additional face-to-face assessment within the one hour timeframe to justify the continued need for restraint, when it was documented that Patient #1 was physically restrained from 5:04 p.m. through 6:15 p.m. (1 hour and 11 minutes). The every 15 minute assessment documentation performed by RN L did not include all the components that were required as per hospital policy. There was no evidenced documentation of any signs of injury associated with restraint application (re: right shoulder injury). There was no evidenced documentation of nutrition or hydration being maintained. There was no evidenced documentation of physical or psychological status and comfort or readiness for discontinuation of restraint being assessed by RN L before 5:50 p.m. RN L documents under "assessment" that "there is no change in patient condition" and "patient condition is unchanged" but this documentation does not provide a objective description of what behaviors Patient #1 is demonstrating in the "security" room environment to justify the continued need for 4 point leather physical restraint before 5:50 p.m.

Interview with RN I on 7/11/13 at approximately 4 p.m., who provided medical records for the investigation stated that there was no documented evidence that ED staff used the required "Restraint/Seclusion for Violent or self -Destructive Behavior" form for this patient, and stated that when this form is used it should be scanned into the electronic medical records system. She stated that she could find no documented evidence that the above documentation was completed per hospital policy.

Based on clinical record review, hospital policy review and staff interview, the hospital failed to ensure that 1 of 6 sampled patients (Patient #1) requiring use of physical restraint in the hospital's emergency department had restraint orders written within the required federal timeframe; the hospital failed to ensure that it's policy that directed staff on restraint orders was updated to reflect federal regulatory guidelines. This has the potential to affect the entire community using this emergency department.

Findings include:

The 7/11/13 review of Patient #1's "nurses notes" document that Patient #1 was brought into the emergency department (ED) security room in 4 point leather restraints (restraints on both legs and arms to prevent movement) on 4/30/13 at 5:04 p.m. Nurses notes document that patient being restrained from 5:04 p.m. through 6:15 p.m., with PA (Physician Assistant) J writing orders for patient #1's discharge at 6:30 p.m.

The 7/11/13 review of Patient #1's "Physician Note" documents under "orders" that "4 point leather; ordered 4/30 7: 19 p.m. by RN (Registered Nurse) L". Medical orders for Patient #1's physical restraint were written/documented 49 minutes after patient discharge.

The 7/11/13 review of Hospital "policy 04782-Restraints and Seclusion" under "D. Restraints /Seclusion for Violent or Self-Destructive Behavior" documents under
"b. In an emergency, an RN (Registered Nurse) may initiate restraints based on patient assessment.
i. After assuring the patient's safety, as soon as possible AND within one (1) hour, the RN will consult with the LIP (Licensed Independent Practitioner) about the patient's physical and psychological condition and obtain a written order..." .

The above hospital policy does not reflect that current federal standard of writing a medical order for an emergency restraint within "a few minutes" after it is assessed that the application of restraint is warranted.

Interview with RN I on 7/11/13 at approximately 4 p.m., who provided medical records for the investigation stated that there was no documented evidence that ED staff wrote a timely order for physical restraint use after admission to the ED at 5:04 p.m.