HospitalInspections.org

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Based on interview, record review, and review of the hospital's policies and procedures, hospital staff failed to follow the policies and procedures by initiating physician's orders for seclusion and restraints for the management of violent self-destructive behaviors for 1 of 1 patient records reviewed (Patient #2) (Item #1), and to ensure that the physician's orders were complete, included documentation of the face to face assessment and authenticated for 1 of 1 patient records reviewed (Patient #2) (Item #2).

Failure to ensure that hospital staff follow the hospital's established policies and procedures for seclusion and restraint violates the rights of the patients and places the patients at risk for harm and loss of dignity.


ITEM #1 - Physician's Orders for the Use of Seclusion and Restraint

Findings included:

1. Document review of the hospital's policy titled, "Interdisciplinary Protocol for Seclusion and Restraint," no policy number, last dated 09/22, included the following:

a. The hospital initiates restraint or seclusion based on an individual order. The initiation of seclusion/restraint is by physician order.

b. If an emergency, the Registered Nurse (RN) may initiate seclusion or restraint. The RN must obtain a physician's order either during the emergency (if another RN is available) or immediately afterwards.

c. For renewal of the order, a telephone order is obtained at the 4th hour, and repeated as needed. Should seclusion/restraint still be necessary, a new order and face-to-face assessment is completed on or before the 25th hour.

Patient #2

2. On 05/03/23, the Investigator reviewed the medical record for Patient #2, a 63-year-old male admitted on 01/19/23 from Grant County Jail. The Patient was on a 15-day order for competency order and three 45-day competency restoration orders. Review of the Patient's seclusion and restraint documents in the medical record showed the following:

a. On 02/15/23 at 12:00 PM, Patient #2 was placed into seclusion after exhibiting aggressive, assaultive behavior. The RN documented that the Patient was agitated and threatening a peer in the dining room. The staff attempted several de-escalation techniques including redirection and active listening; however, the Patient continued to escalate and continued to threaten, and then assaulted a peer. The Patient was placed in seclusion at 12:00 PM.

b. On 02/15/23 at 8:18 PM, Patient #2 was released from seclusion. The Patient remained in the seclusion room with the door open. The Patient had been in seclusion for 8 hours 18 minutes.

c. Review of the Patient's medical record found no evidence that staff had written or obtained the initial provider order to initiate the seclusion, documented a face-to-face evaluation within one hour of initiating seclusion, or obtained provider orders every 4 hours to renew the seclusion, as directed by hospital policy. The medical record did not contain provider orders for the seclusion incident on 02/15/23 between 12:00 PM to 8:18 PM.

3. On 05/04/23 at 1:00 PM, during an interview with the Investigator, the Director of Quality (Staff #1) verified that some of the seclusion and restraint documents were missing from Patient #2's medical record. Staff #1 stated that it's possible that these documents had been thinned from the chart, however orders are not typically removed during thinning.


Item #2 - Complete and Authenticated Physician's Orders for Seclusion and Restraint

1. Document review of the hospital's policy titled, "Interdisciplinary Protocol for Seclusion and Restraint," no policy number, last dated 09/22, included the following:

a. The hospital initiates restraint or seclusion based on an individual order. The initiation of seclusion/restraint is by physician order.

b. Physician's orders for the use of restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, staff, or others, may be renewed every 4 hours for a maximum of 24 consecutive hours. At the 25th hour, a new order and face-to-face assessment is required.

c. The physician evaluates the patient, in person, within one hour of the initiation of the seclusion/restraint. This one-hour face-to-face evaluation is required. After the physicians' face to face assessment, the physician documents the date, time and signs the Seclusion and Restraint treatment order to continue seclusion (if appropriate), not to exceed 4 hours.

d. For renewal of the order, a telephone order is obtained at the 4th hour, and repeated as needed. Should seclusion/restraint still be necessary, a new order and face-to-face assessment is completed on or before the 25th hour.

e. NOTE: 24 hours of restraint or seclusion is an extreme measure with the potential for serious harm to the patient.

Patient #2

2. On 02/15/23 at 12:00 PM, Patient #2 was placed into seclusion after exhibiting aggressive, assaultive behavior. The Patient was placed in seclusion at 12:00 PM and released from seclusion on 02/15/23 at 8:18 PM. After the Patient had been released from seclusion and the seclusion door was opened, the Patient remained in the seclusion room. At 8:45 PM, the Patient's behavior began to escalate when he crawled out from under the blue mat that he was lying under and grabbed his sandwich and two cups of juice and threw them at the staff. The Patient was once again placed in seclusion. The door was locked, and an order was obtained to place the Patient in seclusion at 8:45 PM.

3. Patient #2 remained in seclusion from 02/15/23 at 8:45 PM until 02/17/23 at 7:45 AM, 35 hours later. Review of the medical record showed that an initial provider was obtained to initiate seclusion, and a subsequent order was written every 4 hours to renew the seclusion order.

4. Staff failed to document a provider order and face-to-face assessment after the Patient had been in seclusion for 24 hours. The required assessment was due to be completed no later than 02/16/23 by 8:45 PM.

5. After the Patient was released from seclusion, and the door was unlocked at 7:45 AM on 02/17/23, the patient remained in the seclusion room. Staff entered the seclusion room to clean the bathroom as the Patient had smeared feces over the walls. The Patient became agitated and aggressive and threatened staff. The seclusion room door was locked, and seclusion was initiated again at 7:50 AM on 02/17/23. The Patient remained in seclusion until 02/18/23 at 5:45 PM, 34 hours later. There were no missing provider's orders from this seclusion and restraint incident.

6. The Investigator reviewed the provider's orders for seclusion and restraint to ensure that all the required components were included, such as the "criteria for discharge, order for continued seclusion or revision to order, and provider signature." The seclusion and restraint order review showed the following:

a. The "criteria for discharge" is documented every 24 hours. The review found that for 3 of 4 orders, the providers had failed to document this required information.

b. The selection to "continue the seclusion" or "revise the order" was a component of each order renewing the seclusion. The review found that for 5 of 10 orders, the providers had failed to indicate what the renewal order was for.

c. The Investigator found that 5 of 10 orders failed to contain a provider signature.

d. Additionally, as previously mentioned, the medical records did not contain any provider orders for the seclusion and restraint incident from 02/15/23 at 12:00 PM through 02/15/23 at 8:18 PM.

7. On 05/03/23 at 2:45 PM, during an interview with the Investigator, the Chief Medical Officer (CMO) (Staff 5) verified that the provider's seclusion and restraint orders were incomplete and missing key components. The CMO reported that he would be following up with the providers immediately.

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